Intraoperative autologous transfusion in orthopaedic patients by mikesanye


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Intraoperative autologous transfusion in orthopaedic patients
JA Goulet, TJ Bray, LA Timmerman, DR Benson and WL Bargar
J Bone Joint Surg Am. 1989;71:3-8.

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Publisher Information         The Journal of Bone and Joint Surgery
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                                                                                         Copyright          1989      byThe     Journal         of Botie   and     Joint        Surge,v.    Incorporated

       Intraoperative                                                         Autologous                                                   Transfusion                                                 in         Orthopaedic                               Patients*
       BY JAMES                A.          GOULET,                  M.D.t,            ANN            ARBOR,                   MICHIGAN,          TIMOTHY                   J.       BRAY,     M.D.t,            LAURA    A.   TIMMERMAN,            M.D.,

                                      DANIEL                 R.      BENSON,                 M.D.,                 AND          WILLIAM                    L.      BARGAR,                   M.D.,                       CALIFORNIA

                                                              From           the Department                 of Orthopaedics,                          University           of California               at Davis,      Sacramento

       ABSTRACT:            The cases          of 175 consecutive            patients         prebanked             and intraoperative                          autologous                blood        is rec-
who had intraoperative                       autologous         transfusion           during ommended               for all orthopaedic                          procedures               in which           ho-
revision       total hip arthroplasty,                  an elective         operation        on
                                                                                              mologous            blood        may be needed.
the spine,         repair      of trauma          to the spine,          or open reduc-
tion of a fracture                of the acetabulum                 were reviewed               to Orthopaedic                surgical          procedures              frequently            necessitate
evaluate         the applicability               of this technique                in ortho-   replacement            of a substantial                   amount          of lost blood.                 The ad-
paedic       operations.           A separate           group      of forty-one           con-verse      effects        of homologous                       blood        transfusion,               including
secutive       patients        who had open reduction                       of a fracture transmission                 of disease isoimmunization                             and hemolytic,                ,                              ,

of the acetabulum                 or the spine           before       the introduction febrile,             and anaphylactic                  reactions,            have been documented7.
of the autotransfuser                  was reviewed            and compared              with has been estimated
                                                                                              It                                        that the incidence                     of post-transfusion
the group         that had autotransfusion.                  An autologous             bloodhepatitis          is 1 per cent               per unit of blood                     that is transfused,
predeposit          program was used for twenty-five                       of fifty-two       and that most              cases       of post-transfusion                      hepatitis          are caused
patients       who had a procedure                     on the hip and for fifty- the non-A,   by                           non-B          hepatitis           virus7.        Chronic            hepatitis        of
one of fifty-five            patients       who had an elective                 procedure some           form      has been            observed             in as many              as 67 per cent of
on the spine.                                                                                 patients        who have            had homologous                      blood        transfusion26.              By
       The mean             rate of red blood-cell                salvage        using      the
                                                                                              the      middle        of 1985,        transfusion-associated                      acquired             im-
autotransfuser             was 60 per cent over-all.                 The mean trans-munodeficiency                           syndrome               had         been        reported            in 194 pa-
fusion      requirements             were significantly              less < (p 0.001)         tients,      or approximately                    1 per cent             of all patients                 who had
in all groups           of patients        in whom        the autotransfuser               wasacquired        immunodeficiency                      syndrome              whose         cases       had been
used.      Use of the autotransfuser                       reduced         the mean           re-
                                                                                              reported         at that time1035.                 Although              the risk of contracting
quirement           for banked          blood in patients              who had a frac-        acquired          immunodeficiency                        syndrome              has been              low,      and
ture of the acetabulum                   from 3.8 to 2.3 units per patient, may be reduced                                    further         by antibody                screening’4              and donor
and significantly               reduced         the mean           need       for bankedself-deferral35,                  the perceived                  risk is much                higher,          and the
blood      in individuals            who had trauma                to the spine          from consequences               of the disease                   are grave420.               In addition,             the
2.7 to 1.8 units per patient                   (p < 0.01).       The use of pre- question                       of the         liability         of the physician                        in transfusion-
banked        autologous           blood      further      reduced         the mean          re-
                                                                                              related       acquired          immunodeficiency                        syndrome               recently         has
quirement            for homologous               blood     from        2.4 to 0.8 unit       been      suggested          in court,           and settlements                  against          physicians
per patient           in those       who had revision               total hip arthro-and hospitals                      could        be the result33.
plasty      (p < 0.005),        and from 3.6 to 0.4 unit per patient                                   A byproduct              of the epidemic                     of acquired               immunode-
in those who had an elective                         procedure          on the spine ficiency   (p            syndrome             has been              closer       scrutiny            and       wider      ac-
<   0.01).                                                                                    ceptance           of autologous                  transfusion.                If used            in place           of
       No statistically             significant differences             between        the homologous                transfusion           autotransfusion                  decreases             the risk  ,

hematocrit            values that       were       measured           preoperatively          of exposure             to potentially                  infectious            agents         and       excludes
and in the recovery                   room      and the lowest              recorded         he- risk of isoimmunization
                                                                                              the                                                    to foreign            red blood-cell,                plate-
matocrit        values could be established                  for any ofthe           groups let, and leukocyte                    antigens.             Other       advantages              include         con-
that were studied,                 and no complications                    were encoun- servation               of blood           products,             acceptance             by some             members
tered in this study.                                                                          of religious           groups          that consider                 homologous                  blood       to be
       In the absence                of infection          or tumor,                            of
                                                                               the use unacceptable,                     and potential                 financial          savings26’.
                                                                                                                                                                 The     increase                      in transfusion         of prebanked          autologous
                                                                                                                                                        blood       during      the                  past decade        has occurred        for many         of the
       *    No      benefits          in    any      form         have       been     received         or     will       be     received              from
a commercial      party related directly          or indirectly      to the subject                                           ofthis           article.
                                                                                                                                                        same        theoretical                       reasons      that    prompted       increased         use of
No funds     were     received      in support       of this study.                                                                                    intraoperative                        autologous         transfusion.        After     the patient                    is
     t Section      ofOrthopaedic           Surgery,      University       ofMichigan,                                                    TC      2912,
Ann   Arbor,      Michigan        48 109-0328.
                                                                                                                                                       found       to be                    medically      eligible        for autologous         transfusion
     1: Reno Orthopaedic            Clinic, 555 North Arlington             Avenue,                                            Reno,            Ne-    and informed                         consent     has been         obtained,      blood    is collected
vada       89520.
       §    Department                 of      Orthopaedics,                    University            of      California                  at     Davis,
                                                                                                                                                       and stored.    The rate of donation                                         of     blood       is limited         prin-
2230       Stockton            Boulevard,                   Sacramento,              California              95817.                                    cipally  by the donor  patient’s  ability                                        to regenerate        and       main-

VOL.       71-A,       NO.       1.    JANUARY                    1989                                                                                                                                                                                             3
4                                                                                                                           J. A.        GOULET             ET         AL.

tam an adequate    red blood-cell   mass.      As many as ten unitstrauma-related            problem        involving       the spine,       and open      re-
of blood    have   been    stored   preoperatively        using   this
                                                                   duction       of thirty-four        fractures       of the acetabulum.        For com-
method36, although    we have limited     the amount               parison with
                                                       to four units                       the     groups         that    had   intraoperative        auto-
in      our         practice.                  Technically,                       the       only            requirement                      in transfusion,
                                                                                                                                                  ad-                                 the cases     of forty-one                                   additional  consecutive
dition  to those                         of standard   blood-banking                                     techniques                              patients
                                                                                                                                            is spe-                          who         had  seven    fractures                                 of the acetabulum         and
cial identification                          and segregation         of                              the donor’s                         blood thirty-four
                                                                                                                                                    to                             procedures                 for      a trauma-related                           problem                   involv-
ensure              that       it is appropriately                                   and         safely           redirected                    to ing the spine,
                                                                                                                                                    the                 which                           were          done          by the same                   surgeons                  during
person             from        whom it was taken2’.                              The         use of preoperatively                                 a twenty-seven-month                                 period              before           the         introduction                     of the
stored      blood      for autologous                                      transfusion                      has        been           well         doc-
                                                                                                                                                     autotransfuser                      at our              institution,                 were           reviewed                 separately.
umented         in the orthopaedic                                         literature’     3.31           .32.36.37#{149}                            An autologous                       blood              predeposit               program                was available                        only
        Intraoperative            autologous                                    transfusion                     initially                was          for
                                                                                                                                                     as- non-trauma      patients  and was used in twenty-five                                                                             of fifty-
sociated        with      serious        risks,                               including                    disseminated                               two operations
                                                                                                                                                  intra-                on the hip, in eighteen  oftwenty-two                                                                           elective
vascular                 coagulation,                     fatal          air      embolism,                       hemoglobinemia,                     procedures     on the spine     that were not done       for                                                                    scoliosis,
and hemolytic                            nephrotoxicity22226.                              While             the automation                          and
                                                                                                                                                     of       in all of the                     procedures                    for      scoliosis.
autotransfusion                             using      the   Bentley                               reservoir                        with     roller   The   surgeon                               and          the       anesthesiologist                           determined                      the
pumps,         which                       was    introduced        by                           KlebanofP,                            marked amounta     of blood                               that          needed               to be transfused                              intraopera-
great          advance,       the                    vent    system      allowed    air to enter tively,
                                                                                                    the       on the                                                                   basis           of the patient’s     preoperative                                       hematocrit,
patient          if the level                       of blood       in the reservoir     was not con- estimated
                                                                                                  the                                                                                   loss          of blood     at operation,         and                                 the patient’s
tinually           monitored,                       and severe       coagulopathies     and fatal cardiovascular
                                                                                                   air                                                                                   status Replacement
                                                                                                                                                                                                  .                                       of blood              products              during
emboli               still         were    reported                      with  its use’’2.    With                                    the        intro-
                                                                                                                                                     the      operation,                     in general,                 closely          paralleled                        the       estimated
duction              ofthe           Haemonetics                        Cell Saver   (Haemonetics,                                             Brain-loss      of blood.                     Postoperatively,                         the amount                       of         blood       to          be
tree,          Massachusetts)                                     in      1974             and,             later,             the          Didecotransfused               was                determined        by                   the surgeon                      on the basis      of
Autotrans                    (Electromedics,                             Englewood,                          Colorado),                            serial
                                                                                                                                               which               postoperative                     hematocrit                       values,    loss                  of blood    from
was     used                 in this      study,                       many    of the                      problems                   that        were
                                                                                                                                                   drains,     and the hemodynamic                                                  status          of     the        patient.
associated                   with           intraoperative                        autologous                      transfusion                   have       For each patient,   the                                     type         of procedure,                      age,           sex,         and
been eliminated.                                Intraoperatively,                            lost          blood              is     suctioned estimated       loss of blood       were                                             recorded.    The                     intraoperative
into          an      extracorporeal                         system,                   where              the        blood             cells areloss    of blood      was   estimated                                                by measuring                          blood       in the
separated                from             the debris                   and the serum     through                                      a centrif-suction    apparatus,     by weighing                                                 sponges,    and                    by adding        the
ugation              process.               The final                  product is washed      autologous                                              surgeon’s
                                                                                                                                                     red                       estimate               of      unaccounted                     loss         of     blood              on       drapes
blood              cells          that    are suspended                         in      a saline                solution,                 which and              off         the      field.           Estimates                were             recorded                   separately                    by
is pumped                     into             a reinfusion                     bag         and           is available                      for      im-
                                                                                                                                                     circulating                    nurses         and          anesthesiologists,                              and         the           larger          of
mediate                  reinfusion2’.                      Although                       the       rate          of         collection             theof two estimates                          was used                    for this study.      Transfusions                                           of
blood  by aspiration   varies   with the rate of blood    loss,                                                                                      the
                                                                                                                                                     homologous       and                      autologous                    blood    were  recorded        separately
volume   of blood that is needed    to process one unit of packedas                                                                                    units    that were                                given   intraoperatively                                     and           postopera-
cells         may            be      aspirated                within                 ten     minutes                  when            extensive tively.      The volume                                 of blood     that was                             delivered                 by the au-
loss of blood                        has occurred    without    major                                              cellular   damage. totransfuser                                    was    recorded.                     The              hematocrit                 values                 of       ten
Centrifugation                         and  washing     of the cells                                              to prepare          consecutive
                                                                                                                                  a unit                                             specimens         of              blood              that were               delivered                   by      the
for reinfusion                        can  be completed       within                                              an additional        ten
                                                                                                                                      autotransfuser                                     were               measured,                 and          the      average                0.55.
minutes.                                                                                                                                             Using             0.55         as the        average               hematocrit                   of the blood                         that     was
        Although                         intraoperative                        autologous                     transfusions                     haveobtained                   for     intraoperative                     autologous                      transfusion                  and          0.65
been           well            documented                          in          general              and            thoracic                        as
                                                                                                                                            surgical the               average               hematocrit                 of packed                   red      blood                cells          at our
applications’’2’922242634,             reports     of its use in orthopaedic      institution,    this value       was converted       to units      of 225 milli-
surgery        have    been     limited        to small  series   of patients    who
                                                                                  liters ofpacked      red blood        cells, which  facilitated      comparison
had an elective          procedure        on the spine     or hip or an operation with homologous         transfusions.        The number        of units of plate-
for scoliosis’6’22832.                                   The           present              study           was             performed            to
                                                                                                                                                  lets and fresh-frozen       plasma      that were          administered        to each
provide               a critical                  assessment                      of       the       applicability                        of  intra-
                                                                                                                                                  patient    also was recorded.        Hematocrit          values      that were    mea-
operative                   autologous                    transfusion                      in       patients                 who                    an
                                                                                                                                          have sured preoperatively          and in the recovery              room      and the lowest
orthopaedic                        procedure.                                                                                                     value   that was obtained       during     hospitalization            were recorded
                                                                                                                                                     to enable                 comparison                      of     thresholds                   for      transfusion                      in each
                                          Materials                    and           Methods                                                         group.
           The             cases          of     175       consecutive                      patients                who            had         an or-           Data          were        analyzed                  initially          by obtaining                     the mean                   and
thopaedic                   procedure                    in which                 the       autotransfuser                           was          used,
                                                                                                                                                      standard               deviation                for      each         variable               in each            group.               The        use
during             the       twenty-four-month                                  period            between                      of
                                                                                                                              and blood
                                                                                                                            July      1983  products     in all patients                                                              in whom        the autotransfuser
June          1985,          were              reviewed                 retrospectively.                    The operations was employed              was     compared                                                                with     that   in the patients                                       in
included                   fifty-two               revision                total           hip       replacements,       thirty-
                                                                                                                               whom     it was not.    Single-variant                                                                analysis      was accomplished
three          spinal              fusions           for       scoliosis,                   twenty-two                       elective             pro-
                                                                                                                                                     through                 the      Student t test.    The                         use of blood                           products    in
cedures                  involving                 the       spine,                thirty-four                    procedures                      forpatients
                                                                                                                                                         a                   who      had intraoperative                             autotransfusion                          and in those

                                                                                                                                                                                                      THE       JOURNAL              OF      BONE         AND       JOINT           SURGERY
                                                               INTRAOPERATIVE                       AUTOLOGOUS                    TRANSFUSION                     IN     ORTHOPAEDIC                 PATIENTS                                                         5

who         did           not             was           compared                  within            the      groups              that         were
                                                                                                                                                spine,        prebanked                  autologous               blood           was    available  for all of
operated    on for trauma     to the spine                                                    and for a fracture         of the thirty-three
                                                                                                                             the                patients      who had scoliosis                                                             and for eighteen
acetabulum.     The    groups     that had                                                   an elective       operation    ofon the twenty-two      patients     who did not.                                                             The mean loss of
the hip or spine      using    intraoperative                                                    autotransfusion            blood (1570 milliliters;
                                                                                                                          were                              standard  deviation,                                                             1479 milliliters)
subdivided                      further    into                        patients            who    had             or     had     not             in
                                                                                                                                               been the group      that had scoliosis      was                                    skewed     upward   by large
enrolled                 in      an autologous                               blood          predeposit                  program,                and
                                                                                                                                                 losses   of blood     from eight patients       who had a neuromuscular
these        groups                     were           then          compared.               Multivariate                  analysis             be-
                                                                                                                                                disorder.     In these     eight patients,    the mean   loss of blood                                                         was
tween    groups        was achieved      using    a BMBP          I-R program 3490 milliliters.       The  average    loss     of blood    from      the re-
(BMDP      Statistical    Software,     Los Angeles,        California)    withmaining    twenty-five     patients,   including      both   children     and
the assistance        of the University        of California,       Davis,    sta-
                                                                               adults, was 910 milliliters.         A mean       of 2. 1 units of blood
tistical           laboratory.                                                                                                                  was        recovered               for        each      of     the      patients            who        had      scoliosis.
                                                                                                                                                The mean                 amounts        of prebanked    autologous     blood                                    and ho-
                                                                     Results                                                                    mologous                banked        blood   that were transfused       were                                    2. 1 and
           The           over-all                     rate       of red           blood-cell                salvage           using             1
                                                                                                                                               the.4 units,             respectively,       in this group.     The estimated                                       loss of
autotransfuser                     was   60 per      cent.    When     the autotransfuser blood  from                                                                      the     patients          who         did        not     have     scoliosis          who            had
was used,                     a mean   of 1 .9 units      of red blood    cells per patient elective
                                                                                          an                                                                            operation    on the spine                                 averaged 800 milliliters
was        salvaged,                          and      a mean              of     1 .7 units            of banked                 blood         per
                                                                                                                                                for the           patients     in whom   prebanked                                   autologous       blood                 was
patient  was transfused.                                           This  rate              was 40 per cent           used
                                                                                                             less than                                     and         775       milliliters            for    those          in whom             it was        not       used.
the mean    of 2.9 units                                         of banked                 blood that was transfused The                                  mean           amount           of intraoperatively                        recovered            autologous
for each     patient     in whom     the autotransfuser             was not used,  blood was not significantly    different between       the two groups
and      the  difference      was   highly     significant       < (p0.001).       (0.9 unit in the group that had scoliosis,        compared     with 1.2
Thirty-four       (83 per cent)   of the forty-one          patients     for whom  units  in the group   that did not have    scoliosis).     However,    in
the autotransfuser         was not used    needed         homologous         blood,the patients  who did not have scoliosis,         only three of eigh-
compared                      with              only           eighty-two                  (47       per       cent)         of         the     teen patients
                                                                                                                                                 175                 in whom prebanked           autologous        blood was used
patients             for whom   the autotransfuser                                                was         used.                             needed       banked       homologous       blood     (mean,       0.4 unit per pa-
        An           analysis of the patients      who                                            had         an operation                     for
                                                                                                                                                tient),     whereas        all of the four patients             who did not have
trauma              to        the             spine           that       was      done           with        or        without            use prebanked
                                                                                                                                                   of             autologous         blood    needed       banked       homologous
the autotransfuser       provided    an opportunity        to compare                                                                        twoblood     (mean,        3.6 units per patient)        <(p 0.01).
well matched       groups.     No prebanked       autologous     blood                                                                       was        In the fifty-two        patients who had a total hip procedure,
available     for these    patients.   When     the autotransfuser                                                                              the
                                                                                                                                              was mean estimated               loss of blood was 940 milliliters.                In this
used,        a mean        of 2.5                            units    of blood    was recovered    and                                          group,
                                                                                                                                           trans-            twenty-five        of the fifty-two        procedures         were done
fused        intraoperatively.                                   Although      the mean   loss of blood                                         using
                                                                                                                                              was          both     the autotransfuser          and prebanked              autologous
greater            in the                 group               in which               the      autotransfuser                     was        usedblood.      There      were no statistically        significant      differences       in
(1530         milliliters,                          compared               with        1090       milliliters              in the group
                                                                                                                                      age,                 loss        of blood,              or recovery              of     intraoperative                 autologous
in which     it was     not used),        significantly                                                      less banked                       blood
                                                                                                                                           blood         between      the group  of patients                                            in whom   prebanked
was   needed     during     hospitalization             for                                                the patients                        autologous
                                                                                                                                         in this                blood    was used (mean,                                             2.4 units  per patient)
group   (mean,       1 .8 units,     compared       with 2.7 units for and the group
                                                                         the                    of patients      in whom                                                                                                           it was not used.     In the
group  in which the autotransfuser             was not used < [p 0.01]). first group,      only    six of twenty-five        patients    needed       homol-
      When the autotransfuser              was not used,                 ogous blood products
                                                             only five (15                                (mean,    0.8 unit per patient),         whereas
per cent)     of thirty-four       patients     received   no homologous twenty-two        of twenty-seven          patients     in the second          group
blood   products,       whereas      fourteen     (41 per cent) of thirty-
                                                                         received      banked       homologous         blood    (mean,     2.4     units     per
four patients     avoided     banked      blood when the autotransfuser patient).     The difference         in the amount       of banked      blood that
was        used.               There                  was        no       statistically              significant              difference was               required              for     each        group             was         highly         significant     <       (p
between                  the ages of the patients    or the hematocrit                                                                      0.005).
(measured                   preoperatively and in the recovery  room,                                                                and the      No               statistically               significant             differences             between            the       he-
lowest             recorded                     hematocrit)                     in the        two         groups       <   (p
                                                                                                                            0.05).              matocrit               values          that      were         measured                preoperatively                  and         in
A similar                     trend,                although               not       statistically                significant,                   the
                                                                                                                                                was recovery   room and the lowest recorded    hematocrit  values
seen     in          the                group    of patients                           who          had        a fracture                     of could be established
                                                                                                                                                   the                 in any of the groups    that were studied.
acetabulum,                             in which    a mean                        of    2.3         units       of banked                        Only seven of the patients
                                                                                                                                              blood                           in the entire study needed trans-
was        needed                       for      patients               for      whom            the        autotransfuser                      was
                                                                                                                                                fusions           of platelets            or fresh            frozen         plasma,         and       no significant
used,   compared        with a mean         of 3.8 units for patients       differences
                                                                            for                between    these variables        could be established    in
whom      it was not used.          When      the autotransfuser     was the groups.
                                                                            not                  No complications       that were related       to air em-
used,   two (29 per cent) of seven               patients    avoided  homol-bolism,       coagulopathy,        or renal    failure    were recognized     in
ogous    transfusions,      whereas     fifteen    (44 per cent) of thirty-any of the patients.
four patients        for whom       the technique         was used   avoided
banked     blood.                                                                                           Discussion
      Of the patients       who had an elective            operation  on the        Intraoperative      autologous       transfusion      and prebanked

VOL.       71-A,         NO.        ,   IJANUARY                1989
6                                                                                                     J. A.         GOULET            ET    AL.

autologous                   transfusion               have         been        proved         to be        safe,              Furthermore,
                                                                                                                         facile,                              although,   due to the phlebotomy,                         the patients
and effective                   methods            of reducing                  the need         for homologous               in each             group          in which    prebanked   autologous                        blood    was
blood           in      patients           who          have         a general             surgical              procedure. used had              a slightly            lower     preoperative       hematocrit     than those
Smaller               series         of     patients            have            shown          similarly             positivein whom                prebanked                autologous        blood    was     not used,     the
results         of intraoperative                      autologous                transfusion           in operations difference                      was         not    significant.
on       the         spine        or the hip and                      in procedures         for                  scoliosis’6    In our series,                           approximately    60 per cent of the esti-           This       study confirmed                      previous    findings,                      extended mated    loss of red                          blood    cells was recovered  using the au-
indications         for intraoperative                               autologous        transfusion                       to totransfuser.
                                                                                                                              in-                   This                   compares              favorably             with         other
dude        orthopaedic        trauma                           patients,       and     demonstrated                         series’624’253#{176} and
                                                                                                                              the                        in                 part    it    reflects       technical            advances,
efficacy       of combining         the                       two methods           of autologous                            which
                                                                                                                           the high rates of hemolysis
                                                                                                                         blood           have overcome                      that oc-
transfusion         when     it is possible          to do so.                          curred when the earlier autotransfusion                         devices      were used.
        In this series, significant            differences         in the amount      ofCharted     estimates       of loss of blood,                which      were made            by
homologous           banked      blood      that was transfused               were foundthe anesthesia        staff and circulating              nurses,       were the deter-
between        patients     in whom        the autotransfuser              was used and minants     of loss of blood            in this study.           An underestimation
those       in whom        it was not used.                In patients        who had ofan loss of blood         might     contribute         to an apparently             high rate
operation        for trauma        to the spine,            a mean       of 2.7 units ofof salvage.      The figures        for estimated           loss and intraoperative
banked        blood     was transfused            when the autotransfuser             was
                                                                                        recovery     of blood       in each       group,       however,         were     similar       to
not employed,            compared        with a mean of 1 .8 units when those in previouslyit                         recorded        series of operations             on the hip
was used.          This significant          difference       < (p 0.01)     between    and spine       in which         intraoperative           autologous          transfusion
well matched            cohorts      occurred          in spite of a significantly was used,            and the figures            facilitate      comparison           with     those
greater              loss      of    blood         (p
                                                    <     0.05)            in    the     patients           in      whom     series.
the autotransfuser                           was         used.             Similarly,               fewer     thrombocytopenia,
                                                                                                                    units      of Severe        disseminated            intravascular
banked       blood     were      transfused         in the patients           who                                                a
                                                                                                                         had coagulopathy,
                                                                                                                   infection,          microemboli,           hemoglobinopathy,
fracture     of the acetabulum              for whom the autotransfuser                   and nephrotoxicity
                                                                                        was                                have been mentioned                  as potential          corn-
employed        than in those for whom                 it was not. In both groupsplications                of autotransfusion22226,                   but they          have     not pre-
of patients,       a benefit of the autotransfuser                 was demonstrated sented          difficult      clinical       problems        in recent      series2’6’9’2529’32.
in terms of reducing            the need for homologous                   banked     trans-
                                                                                          These     problems           seem to have been largely                        eliminated          by
fusions.                                                                                  technical      advances           in the autotransfuser.               Although          we did
        In patients     who had an elective                 procedure,        prebanked not systematically                look for thrombocytopenia,                        hypofibrin-
autologous        blood was available             for many of those for whomogenemia,                       or hypercoagulability,                  no hematological,                renal,
the autotransfuser          also was used. In patients                  who had a total infectious
                                                                                          or                    disorders         were noted clinically.                Another        con-
hip replacement,              significantly           less     homologous          bankedcern that is unique                  to orthopaedic           surgery        relates      to large
blood      was needed       when        prebanked          autologous        blood     wasamounts       of bone debris               that have been collected                   with sal-
used,     with     an average         of 0.8 homologous                 unit needed       vaged blood.
                                                                                            for                  However,           in a laboratory          study,      there was no
the patients       in whom prebanked               autologous         blood was used,histological             evidence          of bone       or cartilage          in the tissues           of
compared        with an average           of 2.4 homologous              units for those  dogs that were given autologous                       transfusion        for an operation
in whom        it was not used (p 0.005). In patients
                                          <                                 who had on the spine” and we noted no clinical                                , evidence          of partic-
an      elective              operation            on         the     spine,           prebanked              autologous ulate             emboli             in our      patients.
blood           also         was     associated              with transfusion                       of significantly  Autologous                                    blood   may provide    advantages                     other than
less          homologous                   blood          (p 0.01)
                                                           <           (mean,                       0.4 unit per those directly                                 related   to infection  and reactions                     to transfu-
patient          for         those        in whom              prebanked               autologous                blood       was
                                                                                                                              sion.         Some              studies         suggested       that     fewer         pulmonary              mi-
used,          compared              with        3.6     units        per patient   in whom for those
                                                                                            croernbolic          complications               developed           when        autotransfused
it was not used).           The results         in these      patients        clearly        blood
                                                                                          show         was used3,           and that autotransfused                       blood      has better
the advantage          of prebanked           autologous          blood        in reducing oxygen-transport                  capacities3’             than      does        banked          blood.
the exposure         to homologous           banked      blood and its attendant “Chromium-labeling                                studies        have shown             that the survival
risks.                                                                                       of intraoperatively              processed           autologous           red blood         cells in
       An analysis         of hematocrit          values      that were measured patients                 who have an orthopaedic                      operation         is equal or nearly
preoperatively          and in the recovery               room,          and the lowest      equal to the survival                of normal          red blood cells and is about
recorded       value during the patient’s             hospitalization,             provided the same as or slightly                   better than that of frozen,                     processed
a standard        for assessing        fluid     management.               The mean          autologous
                                                                                           pre-                  red blood            cells      or processed              homologous            red
operative       hematocrit        for each group             ranged         from 0.35 blood   to       cells’7”23.
0.40;      the hematocrit          that was measured                    in the recovery             The       cost-effectiveness                 of autotransfusion                  in
room,       from 0.30 to 0.35;             and the lowest              recorded        hemat-paedic     operations          is related         to the amount              of blood        that can
ocrit,    from 0.26 to 0.29.             The fact that there was no signif- recovered        be                    preoperatively             or intraoperatively.               Cost-benefit
icant difference          between      any of these groups                   demonstrates analysis          in some        series       has variously              estimated         that a loss
that the same standards             of care were applied                 to each patient, of 700 to 7500               milliliters          of blood        justifies        the use of the
regardless       of the mechanism              of transfusion             that was used.     autotransfuser’9’21’24’#{176}. At the time of writing,                            the costs at

                                                                                                                                                                        ThE     JOURNAL     OF BONE AND        JOINT    SURGERY
                                                  INTRAOPERATIVE                      AUTOL000US                    TRANSFUSION                     IN     ORTHOPAEDIC                      PATIENTS                                                     7
our institution      were $160.50        for the first unit of homologous               In our series of 175 patients               who had an orthopaedic
blood and $125.00           for each additional           unit. The charges     for
                                                                                operation,       the use of prebanked             autologous           blood    and in-
preoperatively        banked     autologous        blood       were actually    traoperative
                                                                              less                  autologous     blood      was shown            to be safe, eco-
than those for homologous              blood,     with a cost of $67.00         nomical,
                                                                               per            and effective      in significantly         reducing        the need for
unit collected               1
                     and $20.00 for freezing           if the shelf life was additional          homologous        (banked)       blood       as well as the as-
anticipated       to be more than thirty-five            days. The cost of use  sociated     immunological         and infectious          complications.         These
of the autotransfuser          was$47500      regardless        of the amount   methods       are effective     individually,         but they are even more
of blood       that was recovered,          and there were no additional effective            when       they are jointly       utilized.       In the absence          of
costs        for personnel.               In this series,  the average                               loss of blood infection     or tumor,       we recommend      the use                                                        of intraoperative
from         patients    for              whom     the autotransfuser                                 was used was autologous        transfusion       in all orthopaedic                                                               procedures                   in
1200 milliliters.                                                                                                  which      homologous         blood   may be needed.

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  2. BELL,         WILLIAM:            The      Hematology                of Autotransfusion.                      84:
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  3. BENNETT,            S. H. ; GEELHOED,                 G. W. ; TERRILL,              R. E. ; and HOYE,               R. C. : Pulmonary                    Effects       of Autotransfused                    Blood.          A Comparison                of Fresh
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      SCHONBERGER,              L. B.; SPIRA, 1. J.; ALEXANDER,                           W. J.; SWINGER,               GARY;        AMMANN,              ARTHUR;          SOLOMON,              STEVEN;           AUERBACH,               DAVID;         MILDVAN,
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1 1 . DORANG,           L. A. ; KLEBANOFF,                      GERALD; and KEMMERER,                     W. T. : Autotransfusion                   in Long-Segment                   Spinal         Fusion.          An Experimental                   Model        to
      Demonstrate             the Efficacy             of Salvaging              Blood       Contaminated              with Bone            Fragments           and Marrow.                          J.
                                                                                                                                                                                           Am. , 123: Surg.  686-688,              1972.
12. DUNCAN,             S. E.; KLEBANOFF,                  GERALD;          and ROGERS,           WAID:         A Clinical         Experience             with Intraoperative                  Autotransfusion.                  Ann. Surg. , 180:       296-
      304,     1974.
13. ECKARDT,             J. J.; GOSSETT,           T. C.; and AMSTUTZ,                    H. C.: Autologous                  Transfusion             and Total           Hip Arthroplasty.                  Clin.        Orthop.,          132:     39-45,         1978.
14. FEORINO,           P. M. ; JAFFE, H. W. ; PALMER,                         ERSKINE;         PETERMAN, T. A. ; FRANCIS,                   D. P.; KALYANARAMAN,                         V. S. ; WEiNSTEIN,              R. A. ; STONEBURNER,
      R. L.; ALEXANDER,                  W. J.; RAEVSKY,                   CATHY;        GETCHELL, J. P. ; WARFIELD,                       DONNA;           HAVERKOS, H. W. ; KILBOURNE,                          B. W. ; NICHOLSON,                  J. K.
      A. ; and CURRAN,              J. W.: Transfusion-Associated                        Acquired           Immunodeficiency                  Syndrome.             Evidence          for Persistent              Infection          in Blood         Donors.          New
      England          J. Med.,          312:       1293-1296,              1985.
15. FERRERA,            B. E.: Autotransfusion:                        Its Use in Acute               Hemothorax.             Southern          Med.         J., 50: 516-519,                  1957.
16. FLYNN,          J. C.; METZGER,                C. R.; and CSENCSITZ,                   T. A.: Intraoperative                   Autotransfusion                (IAT)       in Spinal           Surgery.          Spine,         7: 432-435,             1982.
17. FLYNN,          J. C.; RAY,            J. M.;         and BIERMAN,             A. H.: Intraoperative                   Autotransfusion.                  A Five-Year              Update           of Its Use             (in Vivo          Survival         Study      of
      Processed         RBC’s         during       Major         Orthopaedic            Procedures            Using      IAT).       Orthop.           8:
                                                                                                                                                     ,Trans.500,      1984.
18. FLYNN,          J. C.; RAY, J. M. ; and BIERMAN,                              A. H.: Erythrocyte                  Survival         following           Intraoperative            Autotransfusion                   in Spinal Vivo  An
      Comparative              Study.        Orthop. Trans. , 9: 1 19, 1985.
19. GILL0rr,              ANTHONY,          and THOMAS,                J. M. : Clinical            Investigation            Involving           the Use          of the Haemonetic                      Cell      Saver         in Elective           and Emergency
      Vascular          Operations.           Am. Surg. 50: 609-612,
                                                              ,                            1984.
20. HEALTH             AND      PUBLIC          POLICY          COMMITTEE,              AMERICAN             COLLEGE          OF PHYSICIANS,     and THE INFECTIOUS                      DISEASES            SOCIETY            OF AMERICA: Position
      Paper.       Acquired           Immunodeficiency                     Syndrome.           Ann.       Intern.       Med., 575-581,
                                                                                                                                    104:           1986.
21. IANNACONE,              W. M.; HEPPENSTALL,                        R. B.; STEINBERG,               M. E.; and CRAWFORD-GAMBLE,                              P. E.: Intraoperative                     Autologous              Transfusion            in Adult
      Orthopaedic             Surgery          of the Hip               and     Femur.        Poster       exhibit       at the Annual                Meeting          of The         American             Academy               of Orthopaedic                Surgeons,         New
      Orleans,         Louisiana,           Feb.       20,      1986.
22. JACOBS,          L. M. , and HSIEH,               J. W.: A Clinical                  Review         of Autotransfusion                  and Its Role             in Trauma.             J. Am.         Med. , 215: 3283-3287,
                                                                                                                                                                                                                        Assn.                        1984.
23. JONES, R. B.; PROPST-PROCTOR,                                S. L.; MCDOUGALL,                   I. R.; YHAP,           E. 0.; BLECK,              E. E.; and RINSKY,                   L. A.: Erythrocyte                      Survival        following
      Intraoperative             Autotransfusion                  in Orthopaedic              Surgery.         Orthop.          8:
                                                                                                                             ,Trans. 381 , 1984.
24. JURKOVICH,             G. J.; MOORE,              E. E.; and MEDINA,                  GEORGIA: Autotransfusion                   in Trauma.           A Pragmatic            Analysis.            Am.       J. Surg. 148: 782-785,
                                                                                                                                                                                                                         ,                              1984.
25. KEELING,            M. M. ; GRAY,              L. A. , JR. ; BRINK, M. A. ; HILLERICH,                               V. K. ; and          BLAND,        K. I.: Intraoperative                    Autotransfusion.                  Experience            in 725
      Consecutive             Cases.        Ann.        Surg. 197: 536-541
                                                            ,                         , 1983.
26. KLEBANOFF,                GERALD:        Early Clinical             Experience         with a Disposable                Unit for the Intraoperative                       Salvage         and Reinfusion                of Blood          Loss (Intraoperative
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27. KORETZ,            R. L. ; STONE,             OLIVE;           MOUSA,          MARIAM; and GITNICK,                G. L. : Non-A,                Non-B         Post-Transfusion                 Hepatitis A Decade
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       enterology,           88:     1251-1254,              1985.
28.    KRUGER,     L. , and COLBERT,         J.: Intraoperative           Autologous          Transfusion        in Children       Undergoing           Spinal   Surgery.                     Trans.
                                                                                                                                                                                Orthop. , 7: 571-572,           1983.
29.    KRUGER,     L. M. , and COLBERT,            J. M.: Intraoperative             Autologous           Transfusion        in Children        Undergoing         Spinal     Surgery.       J. Pediat. , 5: 330-
     332,    1985.
30. LEHNER,        J. T.; VAN PETEGHEM,             P. K. ; LEATHERMAN,             K. D.; and BRINK,           M. A. : Experience            in Intraoperative         Autogenous          Blood     Recovery        System
     in Scoliosis        and Spinal       Surgery.             6
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31 . MALLORY,         T. H., and KENNEDY,               MELANIE:       The Use of Banked              Autologous         Blood    in Total        Hip Replacement            Surgery.        Clin.     , 117:
                                                                                                                                                                                                     Orthop.     254-
     257, 1976.
32. MARMOR,          L. ; BERKUS,      D. ; ROBERTSON,            J. D. ; WILSON,         J. ; and MEESKE,          K. A. : Banked           Autologous         Blood      in Total      Hip Replacement.                Surg.,
     Gynec.       and Obstet. , 145:       63-64,       1977.
33. MILLER,       P. J.; O’CONNELL,             JEFFREY;       LEIPOLD,        ANDREW;          and WENZEL,R. P. : Potential            Liability      for Transfusion-Associated         AIDS.      J. Am.       Med.
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35. PETERMAN,          T. A. ; JAFFE,     H. F. ; FEORINO,           P. M.; GETCHELL,             J. P. ; WARFIELD,         D. T. ; HAVERKOS,           H. W. ; STONEBURNER,              R. L. ; and CURRAN,
     J. W.: Transfusion-Associated                Acquired         Immunodeficiency              Syndrome         in the United        States.      J. Am.                Assn.
                                                                                                                                                                Med. , 254: 2913-2917,               1985.

VOL.      71-A,      NO.      I, JANUARY              1989
8                                                                                                         J. A.      GOULET              ET       AL.

36.   THOMSON,             J. D.; CALLAGHAN,      J. J.; SAVORY,       C. G.; STANTON,       R. P.; and PIERCE,                                                R.      N.:         Prior     Deposition            of      Autologous              Blood         in Elective
      Orthopaedic            Surgery. J. Bone    and Joint     Surg., 69-A:   320-324,     March     1987.
37.   WOOLSON,             S. T.; MARSH,     J. S.; and TANNER,           J. B.: Transfusion       of Previously                                                Deposited                  Autologous              Blood           for    Patients         Undergoing            Hip-
      Replacement             Surgery.   J. Bone     and Joint     Surg.
                                                                     , 69-A:    325-328,     March     1987.

                                                                                    Copyright     1989 by The Journal     of Bone and   Joint     Surgers.          Incorporated

                                                          Intraoperative                                             Autologous                                              Transfusion
                                                               in         Revision                            Total                     Hip                   Arthroplasty*t
                                                         BY     MAJOR            WILLIAM        J.   WILSON,               MEDICAL                CORPS,                UNITED                 STATES          ARMY

                                           From       The       Swedish          Hospital       Medical       Center.       Seattle.        and       the      Madigan                Army       Medical           Center.           Tacoma

        ABSTRACT:            The records             ofninety-eight                patients        (100 acceptably              high         incidence             of renal          failure,            fatal       air
hips) who had revision                          total hip arthroplasty                         were re-   embolism,          and severe             coagulopathy3”6”.            With        the intro-
viewed        to evaluate             the efficacy            of intraoperative                   autolo- duction,        however,             of the Haemonetics                     Cell       Saver         (Hae-
gous        transfusion                 in reducing                   homologous                   blood-monetics,           Braintree,             Massachusetts)                 and        the     Sorenson
transfusion           requirements.                                                                       Autotransfusion                System          (Sorenson           Research,              Salt       Lake
        In the fifty hips in the study                             group,          a mean 685 of City, Utah) in the mid-1970’s,                                    most of the shortcomings                        of
milliliters         of autologous                  blood,         or 47 per cent of earlier               the        systems         were remedied,               thus rendering             intraoperative
estimated        loss of blood,              was transfused                 intraoperatively.             autologous         transfusion           safe and effective20.
During         the entire           course       of hospitalization,                    the mean of Intraoperative                          autologous          transfusion          has been used in
the total           homologous                 blood-transfusion                     requirements patients               who      had       a major         orthopaedic            reconstructive                pro-
was 795 milliliters                in thirty-nine                study-group          patients,           cedure       at the Swedish                 Hospital         Medical          Center,           Seattle,
compared           with 1 160 milliliters                   in forty-six           control-group          Washington,            since the middle                  of 1984. This report                      is the
patients       who did not have autologous                                  transfusion.             Thisresult      of a retrospective                 analysis        of the first fifty revision
difference             was statistically                    significant            < (p 0.029).           total hip arthroplasties                using the Haemonetics                     Cell Saver III
Eleven        patients         in the study              group         and four patients                  at this facility.
                                                                                                           in                         A control          group       of fifty similar             patients,         in
the control           group          did not receive                 homologous              blood. whom revision                    total hip arthroplasty                was performed                without
        Over-all,          the use of intraoperative                     autologous             trans- intraoperative               autologous            transfusion,           was       used        for corn-
fusion       was directly              responsible             for a 42 per cent reduc-parison.
tion in the total amount                           of homologous                  blood        that was
transfused.                                                                                                                           Materials           and Methods
                                                                                                                  The records            of ninety-eight              patients       who had re- 100
        The concept               of autologous               transfusion            was first pro-       vision     total hip arthroplasties,                  performed           by fifteen         different
posed by Blundell,                     in 1818,           as a potentially                  life-saving surgeons          between          October          1983 and September                       were
                                                                                                                                                                                                   1985                                                     ,

technique          for patients              who       had      a massive              hemorrhage’7. reviewed.             The first fifty hips in which total hip revision                                     was
Crude early attempts                    met with varied                success         until Kleban- performed              using the Haemonetics                      Cell Saver III comprised
off,     in the early            1970’s,        modified           the Bentley             Cardiotomy the study            group.         There       were twenty-four                 women           (twenty-
Reservoir          with       systems for aspiration,                  filtration,        and infu- six hips)             and twenty-four                  men      (twenty-four            hips).         In both
sion.      The     result       was the Bentley                   Autotransfusion                 System, patients      who had bilateral                arthroplasty,          the stages were sev-
Model         ATS-100            (Bentley           Laboratories,              Santa       Ana,       Cali-
                                                                                                          eral weeks          apart.       These       two patients            were       considered             four
fornia),      an important               technical         advance           that demonstrated            for statistical        purposes.          The ages ranged                 from thirty-two                to
the feasibility           of intraoperative               autologous            transfusion.           Un-seventy-nine           years         (mean,        61 .8 years).            Both        the femoral
fortunately,          the Bentley             system        was associated                with an Un-     and the acetabular                  component             were     revised          in thirty         hips;
       *   No   benefits           in any         form        have   been      received         or will   be received            the
                                                                                                                              from         femoral                  component                    only,          in      sixteen             hips;          and      the        ace-
a commercial        party         related     directly           or indirectly         to the subject       ofthis      article. tabular            component                          only,          in    four           hips.
No funds        were            received          in support         of this       study.
       t The   views      expressed       in this article      are those     of the author     and do
                                                                                                          The                                           control                group            consisted               of the             final      fifty         patients
not reflect   the official        policy    or position      of the Department                     in
                                                                                      of the Army, whom                                                      revision                total      hip        arthroplasty                   was        performed                 im-
the Department         of Defense,         or the United        States   Government.
       : Box    819,      Madigan        Army       Medical     Center,     Tacoma,     Washington mediately                                                  before     the                 Cell Saver                    came    into use for intra-
98431-5819.        Please     address      requests      for reprints    to Major    Wilson.       operative                                                  autologous                     transfusion                    at this institution This        .

                                                                                                                                                                                      THE      JOURNAL             OF BONE               AND    JOINT           SURGERY

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