Rationale

Anemia is common in perioperative patients. It is important to understand how orthopedic patients compare, and if these trends are changing over time.

Clinical comment

Approximately one‐third of patients are found to be anemic at their preoperative assessment.¹ In addition, perioperative anemia is an independent risk factor for increased length of stay in hospital, increased time in intensive care, perioperative complications, and mortality.² Patient blood management (PBM) is an evidence‐based approach to reducing the need for transfusions, and, when necessary, making transfusions safer and more effective.³ In order to implement PBM principles effectively, it is important to know how frequent the need for transfusion is among orthopedic surgery patients.

Available literature and quality of evidence

Mazzeffi et al. performed a retrospective review of the National Surgical Quality Improvement Program (NSQIP) over a five‐year period comparing various surgical specialties, including orthopedic surgery (2018, level III).⁴ Slover et al. performed a database study (2017, level III) looking at 59 038 patients undergoing total joint arthroplasty and analyzed transfusion rates among this population.⁵ Sherrod et al. analyzed the NSQIP Pediatric database for 1184 patients undergoing surgery for hip dysplasia to examine transfusion rates (2018, level III).⁶ Soleimanha et al. performed a prospective study (2016, level II) to analyze transfusion rates among 872 patients at a trauma centre.⁷

Findings

In their retrospective review of NSQIP data, Mazzeffi et al. identified an interesting trend in transfusion rates across five different surgical specialties (orthopedics, vascular, gynecology, neurosurgery, and thoracic surgery). In the first year of the study (2011), orthopedic surgery had the highest rate of transfusions among the various specialties (22.4%). By the final year of the study (2015), this rate was down to 6.3%, and was lower than vascular and gynecological surgery (2018, level III).⁴ In their large database study of nearly 60 000 patients, Slover et al. found that 18% of patients undergoing total joint arthroplasty required transfusion (2017, level III).⁵ In their NSQIP pediatric database study, Sherrod et al. found 22.4% of patients undergoing surgery for hip dysplasia required transfusions (2018, level III).⁶ Finally, in their study of orthopedic trauma patients, Soleimanha et al. found that 36.5% of patients required a transfusion in the perioperative period (2016, level II).⁷

Resolution of clinical scenario

• Based on large database studies, transfusion rates in orthopedic surgery range from between 20 and 35%, compared to 5–15% in other surgical specialties.
  
• Based on a longitudinal study, transfusion rates in orthopedic surgery have been on the decline more recently and are now comparable to other surgical specialties.

Rationale

Transfusion of blood products is both expensive and has numerous associated risks. Thus, it is important to identify evidence‐based perioperative strategies that can reduce transfusion rates.

Clinical comment

Over one hundred million units of blood are collected worldwide annually.⁸ Transfusion is one of the only therapeutic interventions available to increase oxygen delivery to tissues; however, transfusion is expensive and not without risk. The total cost of a single unit of allogenic blood – including acquisition, storage, and personnel – is close to CAD$700.⁹ Blood transfusion safety is continuously improving, but adverse events including transfusion‐related acute lung injury (TRALI), cardiac overload, hemolysis, and infection do continue to occur.¹⁰ A number of well‐studied PBM strategies have been described, including (i) iron therapy, (ii) erythropoietin (EPO) administration, (iii) cell salvage, and (iv) antifibrinolytic therapy.

Available literature and quality of the evidence

Four separate randomized controlled trials (RCTs) (all level I) have analyzed the effectiveness of intravenous (IV) iron therapy in orthopedic surgery patients. The four studies, conducted between 2006 and 2016, randomized between 31 and 306 patients to IV iron, control, and in some cases IV iron plus EPO groups.¹¹–¹⁴

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