Search

Background: In patients undergoing total knee replacement (TKR), most blood loss occurs post-operatively, and the return of unwashed filtered shed blood (USB) from post-operative drainage may represent an alternative to allogeneic blood transfusion (ABT). We evaluated the impact of USB return on the cellular immune response (CIR) after TKR. Patients and methods: Forty TKR patients, intended to receive post-operative USB, entered the study. Blood samples were obtained before and 6 h, 24 h, 72 h and 7 days after surgery, and from USB, after it had been passed through a 40-mm filter. Full blood cell counts, lymphocyte subsets and immunoglobulins (IgA, IgG, IgM) were measured in all samples. A set of clinical data was collected from each patient. Results: Twenty-four of the 25 patients received a mean of 1.2 USB units and did not need additional ABT (USB group). Twelve of the 15 remaining patients who received neither USB nor ABT served as a control group for the post-operative CIR study. All patients showed a post-operative decrease in T-cell and natural killer (NK) cell counts, but not B-cell counts, and there were no significant differences between the groups with regard to CIR parameters, post-operative infection or hospital stay. Conclusions: Post-operative salvage and return of USB after TKR does not seem to increase the post-operative infection rate or hospital stay, and does not modify CIR induced by surgery. These findings add to the clinical experience that post-operative USB return, as a source of autologous blood, is safe, and questions the beneficial effect of blood washing.

Postoperative nosocomial infection (PNI) is a severe complication in surgical patients. Known risk factors of PNI such as allogeneic blood transfusions (ABTs), anemia, and iron deficiency are manageable with perioperative intravenous (IV) iron therapy. To address potential concerns about IV iron and the risk of PNI, we studied a large series of orthopedic surgical patients for possible relations between IV iron, ABT, and PNI.Pooled data on ABT, PNI, 30-day mortality, and length of hospital stay (LHS) from 2547 patients undergoing elective lower-limb arthroplasty (n = 1186) or hip fracture repair (n = 1361) were compared between patients who received either very-short-term perioperative IV iron (200-600 mg; n = 1538), with or without recombinant human erythropoietin (rHuEPO; 40,000 IU), or standard treatment (n = 1009).Compared to standard therapy, perioperative IV iron reduced rates of ABT (32.4% vs. 48.8%; p = 0.001), PNI (10.7% vs. 26.9%; p = 0.001), and 30-day mortality (4.8% vs. 9.4%; p = 0.003) and the LHS (11.9 days vs. 13.4 days; p = 0.001) in hip fracture patients. These benefits were observed in both transfused and nontransfused patients. Also in elective arthroplasty, IV iron reduced ABT rates (8.9% vs. 30.1%; p = 0.001) and LHS (8.4 days vs.10.7 days; p = 0.001), without differences in PNI rates (2.8% vs. 3.7%; p = 0.417), and there was no 30-day mortality.Despite known limitations of pooled observational analyses, these results suggest that very-short-term perioperative administration of IV iron, with or without rHuEPO, in major lower limb orthopedic procedures is associated with reduced ABT rates and LHS, without increasing postoperative morbidity or mortality.

Requirements for allogeneic red cell transfusion after total knee arthroplasty are still high (20-50%), and salvage and reinfusion of unwashed, filtered post-operative shed blood is an established method for reducing transfusion requirements following this operation. We performed a cost analysis to ascertain whether this alternative is likely to be cost-effective.Data from 1,093 consecutive primary total knee arthroplasties, managed with (reinfusion group, n=763) or without reinfusion of unwashed salvaged blood (control group, n=330), were retrospectively reviewed. The costs of low-vacuum drains, shed blood collection canisters (Bellovac ABT, Wellspect HealthCare and ConstaVac CBC II, Stryker), shed blood reinfusion, acquisition and transfusion of allogeneic red cell concentrate, haemoglobin measurements, and prolonged length of hospital stay were used for the blood management cost analysis.Patients in the reinfusion group received 152±64 mL of red blood cells from postoperatively salvaged blood, without clinically relevant incidents, and showed a lower allogeneic transfusion rate (24.5% vs. 8.5%, for the control and reinfusion groups, respectively; p =0.001). There were no differences in post-operative infection rates. Patients receiving allogeneic transfusions stayed in hospital longer (+1.9 days [95% CI: 1.2 to 2.6]). As reinfusion of unwashed salvaged blood reduced the allogeneic transfusion rate, both reinfusion systems may provide net savings in different cost scenarios (€ 4.6 to € 106/patient for Bellovac ABT, and € -51.9 to € 49.9/patient for ConstaVac CBCII).Return of unwashed salvaged blood after total knee arthroplasty seems to save costs in patients with pre-operative haemoglobin between 12 and 15 g/dL. It is not cost-saving in patients with a pre-operative haemoglobin15 g/dL, whereas in those with a pre-operative haemoglobin12 g/dL, although cost-saving, its efficacy could be increased by associating some other blood-saving method.

Background Salvage and return of unwashed shed blood (USB) after total knee replacement (TKR) is an established blood-saving technique, but some authors question its efficacy and safety and suggest that the shed blood be washed before returning. We evaluated a colloid-based sedimentation method for improving and standardizing the quality of USB collected after TKR without the need for washing. Methods Experiments were performed to find the optimal colloid dose and sedimentation time using diluted donated venous blood. USB samples (n=52) were drawn from the reinfusion bag and mixed with hydroxyethyl starch or gelatine solutions (15−30%, colloid solution volume/total volume×100). USB red blood cells (RBCs) were allowed to settle by gravity for 30 min, supernatant was evacuated from the syringe, and RBC concentrate was analysed. RBC recovery and other blood cell and chemical removal were calculated according to changes in USB volume and haematocrit. Twenty-five samples from leucodepleted packed RBCs were analysed as a comparator group. Results Mean haemoglobin (Hb) of USB was 10.9 g dl−1. After colloid treatment, 90% of RBCs were recovered, and USB Hb was similar to that of leucodepleted packed RBCs (n=25) (18.9 vs 19.6 g dl−1, respectively; P=NS). In addition, the procedure reduced USB content of leucocytes (60%), platelets (48%), total protein (76%), cytokines (70–77%), and plasma-free haemoglobin (53%), without major differences between colloids. Conclusions Sedimentation of USB with colloid solutions provides a low-cost alternative for improving and standardizing the quality of salvaged USB after TKR.

Background: In patients undergoing total knee replacement (TKR) most blood loss occurs postoperatively and return of unwashed filtered shed blood (USB) from postoperative drainage may represent an alternative to allogeneic blood transfusion (ABT). We evaluated the impact of USB return, with or without leucocytes, on the acute-phase response (APR) after TKR. Patients and methods: Forty-eight TKR patients, intended to receive postoperative USB, entered the study. Blood samples were obtained before and 6, 24, 72 h and 7 days after surgery, and from the USB before and after it passed through a 40-mm filter (Group F40) or a leucocyte-reduction filter (Group LRF). Haematimetric parameters, APR proteins (albumin, prealbumin, ceruloplasmin, haptoglobin, C-reactive protein), complement C3 and C4, and cytokines (IL-1b, IL-6, IL-8, IL-10, and TNF-a) were measured in all samples. Results: Twenty-eight patients (Group F40 ¼ 14, Group LRF ¼ 14) received a mean of 1.2 USB units, without any clinically relevant incident, and did not need additional ABT. Sixteen out of the 20 remaining patients who received neither USB nor ABT served as a control group for the postoperative APR study. All patients showed the typical postoperative APR profile and there were no significant differences between groups for APR parameters, postoperative complications, or hospital stay. Conclusions: Postoperative blood salvage and return, with or without a LRF, after TKR does not present any clinically relevant side-effects and does not modify APR induced by surgery. These findings seem to confirm the clinical experience that postoperative USB return is safe and questions the beneficial effect of using LRF.

In patients undergoing total knee replacement (TKR), most of the measured blood loss occurs during the postoperative period, and 30-50% of these patients receive allogeneic blood transfusion (ABT). For this reason, the salvage and return of unwashed filtered shed blood (USB) from postoperative drainage may represent an alternative to ABT in these patients. We have, therefore, evaluated the clinical utility of USB return in TKR patients, with a special focus on patients with mild anaemia.Data from 200 TKR patients (group 2) receiving USB within the first 6 postoperative hours (ConstaVac CBC II, Sryker) were prospectively collected. A retrospective series of 100 TRK patients served as the control group (group 1).USB return was possible in 162 patients who received a mean of 0.98+/-0.4 U/pte, without any clinically relevant incident. Return of USB decreased both the percentage of patients with ABT (48% vs 11%, for groups 1 and 2, respectively; p0.01) and the ABT units/patient index (1.31+/-1.27 vs 0.29+/-0.87 units/patient, respectively; p0.01). A transfusion protocol was not established, but there was no difference between groups with respect to either perioperative Hb levels or overall transfusion index, indicating that the transfusion criteria were uniform. However, for the subgroups of patients who needed ABT, the preoperative Hb level was 1 g/dL lower in those receiving USB (13.4+/-1.4 vs 12.4+/-1.2 g/dL; p0.05). There was no difference in the postoperative complication rate, and patients in group 2 recovered the ability to walk 1 day earlier, and their hospital stay was 3 days shorter than in group 1 (p0.01).Return of USB after TKR seems to shorten the hospital stay and effectively reduce postoperative requirements for ABT, especially in patients with preoperative Hbor = 13 g/dL. For patients with preoperative Hb13 g/dL, although the return of USB also decreased the requirements for ABT, a further reduction will probably be obtained with the addition of another blood-saving method.