Transfusion and haemoglobin changes in primary THR

Published Date: 19th July 2016

Publication Authors: Raftery S, Yoxall PF

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Joint replacement surgery causes a significant burden on national blood stocks accounting for approximately 10% of hospital transfusions [1]. Allogenic blood transfusions are associated with increased morbidity and mortality [2]. There is a wide variation in transfusion rates in UK trusts, for primary total hip replacement (THR), with a reported national average of 25% [3]. The DoH has published guidance to reduce transfusions by introducing blood conservation strategies including cell salvage and use of pharmacological agents [4]. Our trust had no such guidelines and practice was variable. We aimed to look at our peri operative blood transfusion rates, whether we used any of the suggested conservation strategies and analysed the impact on length and cost of stay.

Methods

We retrospectively audited all 248 primary THR in 2012, assessing transfusion rates (including cell salvage), haemoglobin changes (96 h post-operatively), intra-operative fluid and tranexamic acid (TXA) use and length and cost of stay. The primary audit highlighted there was no standard practice in our trust. One clinician used TXA regularly and we found those patients had a reduction in transfusion rates. We implemented a protocol for our primary THRs that included guidance on TXA use. We prospectively re-audited in 2014 to determine whether practice and outcomes have changed.

Results

Our initial audit demonstrated a transfusion rate below the national average of 21% (n = 52), 117 units RBC at 0.47 units per patient (n = 248) peri operatively in primary THR. Following protocol introduction there was a significant transfusion rate reduction 12.3% (n = 9), 19 units RBC at 0.26 units per patient (n = 73). The overall transfusion rate for those receiving TXA is almost half that of those that didn’t 10.6% vs 20.3%. 2012 data highlights an increased length of stay for patients that received a transfusion (11.3 days vs 5.9 days). This conveyed an estimated additional cost of £183 000 for the trust. On statistical analysis of the whole data set (ANOVA) there was no evidence (p = 0.74) that TXA doses have an influence on length of stay per se but there was strong evidence (p < 0.0001) that TXA doses has an influence on change in haemoglobin (average drop g/l 2.8 vs 3.6).

Discussion

Following implementation of change we have achieved a 50% reduction in our transfusion rates for patients undergoing primary THR. Whilst TXA has a statistically significant effect on reducing Hb drops, its use does not convey a statistically significant reduction in length of stay. The reasons for increased length of stay associated with transfusion are likely multifactorial. We have now implemented a standardised protocol that includes guidance on peri-operative blood conservation.

England, E; Yoxall, P; Raftery, S. (2014).  A completed audit of transfusion and haemoglobin changes in primary THR and the relationship with length of stay and tranexamic acid use . Anaesthesia. 69 (Suppl 4), 56.

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