Abstract
Total Joint Arthroplasty (TJA) is associated with significant blood loss and allogeneic transfusion rates over 20% nationally. However, there are significant risks associated with allogeneic blood transfusion. Such risks include viral disease transmission, transfusion reactions, fluid overload, cost to the healthcare system, and prosthetic joint infection (PJI). As such, avoidance of transfusion is advised.
Minimising transfusion rates begins in the pre-operative phase and continues during the operative and post-operative phases. A lower pre-operative hemoglobin level is the strongest predictor for the potential need of allogeneic blood transfusion after TJA. Other risk factors include the use of general anesthesia, higher Charlson comorbidity index, female gender, and longer duration of surgery.
We present a comprehensive blood management strategy that encompasses all three phases. In the pre-operative phase, the most important intervention is screening for the presence of, and correcting, any preexisting anemia. During the operative phase, the use of hypotensive regional anesthesia is utilised when appropriate. In addition, tranexamic acid (TXA) is liberally utilised, either topically or intravenously. In the post-operative phase, transfusion triggers are carefully scrutinised. Only patients with symptomatic anemia despite fluid resuscitation are considered for blood transfusion. The threshold for transfusion is individualised for each patient, and is not merely based on a laboratory value.
Utilising this approach, we have decreased our transfusion rates from over 20% to just over 10%, even with a relatively unhealthy population at a tertiary referral center. The main driver of this reduction was the introduction of TXA as the standard of care for all TJA patients. TXA has been shown in multiple studies to be both safe and effective.
