Practical recommendations for patient blood management and the reduction of perioperative transfusion in joint replacement surgery Warwick Bruce,* David Campbell,† David Daly‡ and James Isbister§ *Concord Repatriation General Hospital, Sydney, New South Wales, Australia †Wakefield Orthopaedic Clinic, Adelaide, South Australia, Australia ‡Alfred Hospital, Melbourne, Victoria, Australia and §Royal North Shore Hospital and Sydney Medical School, Sydney, New South Wales, Australia Key words anaemia, antifibrinolytic agent, arthroplasty, blood transfusion, joint replacement surgery, normothermia, patient blood management. Correspondence Professor Warwick Bruce, Hip and Knee Clinic at Sydney Olympic Park Retail 4, 8 Australia Avenue, Sydney Olympic Park, Sydney, NSW 2127, Australia. Email: prof.bruce@hipandkneeclinic.com.au W. Bruce MBBS, FRACS; D. Campbell BMBS, FRACS; D. Daly MBBS, FANZCA; J. Isbister MBBS, FRACP. Accepted for publication 29 September 2012. doi: 10.1111/ans.12000 Abstract Data from the Australian Better Safer Transfusion programme show that about one- third of patients undergoing hip or knee arthroplasty receive perioperative blood transfusions, placing them at increased risk for adverse clinical outcomes. Other concerns associated with allogeneic blood transfusion include the quality of stored red cell concentrates, the cost of provision of blood and the predicted local demographics, which mean that fewer donors will need to support a greater number of recipients. In view of the multiple challenges associated with allogeneic blood transfusion and its provision, we developed practical management recommendations for perioperative bleeding in joint replacement surgery, based on available evidence and expert consen- sus opinion, that aim to promote a new, responsible approach to transfusion manage- ment. Key recommendations are as follows. Patients’ medical health, including haemoglobin and iron levels, needs to be evaluated and optimized preoperatively. Anticoagulant and antiplatelet therapy should be stopped if possible, unless indicated for secondary cardiovascular prevention or coronary stent patency, in which case careful consideration is required. If substantial blood loss is anticipated, intraoperative management with antifibrinolytic agents is recommended for bleeding prophylaxis. Normothermia should be maintained. Pharmacological and non-pharmacological measures are recommended for post-operative thromboprophylaxis. A blood manage- ment programme should be instituted for haemodynamically stable patients. Introduction Joint replacement surgery can result in substantial perioperative blood loss, placing patients at increased risk of blood transfusions. 1 Data from the Australian Better Safer Transfusion (BeST) pro- gramme show a mean perioperative blood transfusion rate of 32% in patients undergoing elective orthopaedic surgery. 2 The mean trans- fusion rate was higher in total hip replacement (THR) than in total knee replacement (TKR), and higher in revision arthroplasty (THR: 60%; TKR: 47%) than in primary arthroplasty (THR: 37%; TKR: 20%). Transfusion rates varied widely between participating hospi- tals, ranging from 15% to 100% of patients undergoing surgery. Twelve per cent of patients were deemed to have been over- transfused. 2 The perioperative transfusion rates and inter-hospital variations captured by the BeST programme are comparable with those reported in other settings, including the UK. 3 A benchmarking of transfusion activity may be needed to help reduce transfusions that are not required or indicated, especially as the benefits of red cell transfusions are uncertain. Evidence is accumulating that transfu- sions are an independent risk factor for adverse clinical outcomes such as infection and immunomodulation. 4 Other concerns include the functional quality and efficacy of stored red cell concentrates; the increasing cost of ensuring sufficiency, quality and safety of the blood supply; and the predicted demographics, which mean that fewer donors will support a greater number of recipients. Reducing the need for allogeneic blood transfusion is an important goal in orthopaedic surgery. In view of the multiple challenges associated with allogeneic blood transfusion and its provision, we developed practical manage- ment recommendations for perioperative bleeding in joint replace- ment surgery, based on available evidence and expert consensus opinion, with the ultimate objective of promoting a new, responsible and viable approach to transfusion management. REVIEW ARTICLE ANZJSurg.com © 2012 The Authors ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons ANZ J Surg 83 (2013) 222–229