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Using a prospective audit, we have evaluated the efficacy of an integrated autotransfusion regimen which comprised predepositing and intra- and postoperative blood salvage in major orthopaedic surgery. We examined prospectively the records of 1785 patients (1198 females, 5867 males, mean age 62 (range 16-90) yr, preoperative haemoglobin concentration 13.4 (SD 1.4) g dl-1) undergoing total hip arthroplasty (THA, 1229 patients), THA after removal of internal fixation devices (RFD + THA, 18 patients), total knee arthroplasty (TKA, 263 patients), revision surgery of the hip (HR cup + stem revision, 197 patients; cup revision, 53 patients; stem revision, 16 patients) and total knee revision (TKR, nine patients). We estimated that the number of predonations (MSBOS = maximum surgery blood order schedule) was 2 u. for THA, TKA and TKR, and 3 u. for partial or total hip revision and total hip arthroplasty with fixation removal. We found that it was possible to obtain the MSBOS in 1597 patients (89.5%). Homologous red blood cell (HRBC) transfusions were carried out in 131 patients (7.3%). We found that the need to use HRBC was significantly associated with failure to meet the number of MSBOS, female sex, lower preoperative haemoglobin concentration, use of calcium heparin for antithrombosis prophylaxis, more extensive surgery, higher ASA rating and co-existing diseases such as coronary artery disease.

With regard to increasing reservations as to homologous transfusions and the objective risks that they involve, since 1984 we have been using an autotransfusion technique in total hip arthroplasty constituting blood predeposit for hemodilution, and intra- and postoperative blood recovery. When this method was used postoperative complications were not very significant even when patients were high-risk (cardiopathic); furthermore, the use of homologous transfusions was required in 2.2% of the patients in 1994 as compared to 90% in 1985. The use of our orthopaedic protocol allows for rapid recovery of movement in the patient thus reducing time bed-ridden and related risks (DVT and/or PTE); the transfusion protocol allows for a return to normal of hemodynamic conditions a few days after surgery. Finally, the reduced incidence of complications caused by homologous transfusions (hepatitis, AIDS...) constitutes a financial saving for the government.

The anaesthesiologist plays a central role in co-ordinating the combined application of the various blood saving techniques. In fact, to carry out transfusion therapy correctly, the anaesthesiologist must plan the right number of units of predeposit blood during the first examination, estimate the salvage of intra and post operative blood loss and spread the infusion of the units over the first three days in order to keep the patient in a state of haemodilution. From January 1992 to June 1994 in the department of anaesthesia and the intensive care unit, 980 patients were treated for total joint replacement: 714 total hips (7 after removal of plates and screws) 145 revisions, and 121 total knee prostheses. Basal Hb was 13.4 +/- 1.4 g/dl (range 6.7-17.9 g/dl). Homologous transfusions were carried out in 6.3% of these patients. The need to use homologous transfusions was negatively influenced by female sex, coronary heart disease (p = 0.005), length of surgery and type of antithromboembolic prophylaxis (indobufen has a significantly low incidence-p = 0.0001--compared to calcium heparin or low molecular weight heparin).