Original Paper Vox Sang 1992;63:90-95
Lawrence Tim Goodnough Karl Vizmeg Ronald Sobecks Adam Schwarz Widu Soegiarso Department of Medicine and Ireland Cancer Center, University Hospitals of Cleveland, Case Western Reserve University, Ohio, USA
Prevalence and Classification of Anemia in Elective Orthopedic Surgery Patients: Implications for Blood Conservation Programs ................................................................................................. Abstract We audited 281 consecutive orthopedic patients scheduled for surgery for whom blood typekross-matching was requested over a 6-month period. One hundred and sixty-two patients predonated autologous blood at University Hospitals of Cleveland, and 34 (21%) of these were anemic [hematocrit (Hct) I 3 9 % ] at initial donation. Twelve (35%) of these 34 anemic autologous blood donors subsequently received homologous blood. In contrast, 18 (15%) of 128 nonanemic autologous blood donors received homologous blood (p = 0.05). In 119 patients who did not donate autologous blood, 39 (33%) were anemic at admission. Of these, 22 (56%) received homologous blood. In the 80 remaining nonanemic patients, 33 (41%) received homologous blood (p = 0.119). Analysis of discharge Hct indicates that 31 (12%) of 263 evaluable patients were possibly transfused inappropriately. The anemias of a cohort of 30 autologous donors were analyzed: 5 had rheumatoid arthritis without iron deficiency. Nine (30%) others had evidence of iron deficiency. Sixteen (53%) had an unclassified anemia of chronic disease. We conclude: (1) the high rates of homologous blood exposure indicate a need for innovative blood conservation strategies in anemic autologous blood donors; (2) the prevalence of anemia and the high rates of homologous blood exposure in anemic patients who did not donate autologous blood demonstrate a need for early recognition and treatment in order to procure autologous blood and reduce homologous blood exposure; (3) the presence of inappropriate autologous and homologous transfusions demonstrates a need for more effective physician education programs that emphasize ‘no blood transfusion’ as an alternative to enhance blood conservation effectiveness.
.....................
Introduction Autologous blood donation is a widely endorsed transfusion practice that has become, in terms of utilization and efficacy, a standard of practice in elective orthopedic sur-
This investigati(in was supported by Transfusion Medicine Acadcmic Award K-07-(HLO-lh2.5)from the National Heart. Lung. and Ulood Institirtc of the National Institutes of Hcalthy.
Received: August 2 5 199I Revised manuscript received: January 3. 1992 Accepted: January 4. 1992
gery [l]. However, subgroups of patients have been demonstrated to have less than optimal benefit from this blood conservation intervention. For example, patients undergoing hip replacement surgery at one program have been demonstrated to have an overall 18% likelihood of homo-
Lawrence Tim Goodnough, MD Laboratory Medicine Washington University Medical Center PO Box 81 18.660 South Euclid Avenue St.Inuin. MO 6311lI(USA)
Table 1. Clinical characteristics of patients undergoing elective orthopedic surgery
Autologous blood donors anemic Number of patients Females. % Age, years Hct. Yo' Estimated blood loss, nil'
'
'
'
nonanemic
Nonautologous blood donors anemic'
nonanemic
34 91 59.6k3.2 37.2+0.3
128 42 59.0f1.4 43.5 +O. 3
39 87 56.6k3.6 35.8f0.4
80 52 52.7k2.4 44.0k0.4
761k78
896+46
674k94
960k83
Hct 239%. MeankSEM.
logous blood exposure despite autologous blood donation [2]. Between one third [3] and one half of patients asked to donate 4 or more autologous blood units are unable to do so because of the anemia associated with serial blood donation; when this occurs, 40% of such patients subsequently receive homologous blood [4]. In addition to blunted efficacy, autologous blood donation programs may not achieve full utilization because of perceived limitations of blood donation in patients who are already anemic. Despite increased utilization of this transfusion practice [l, 4-61, up to 25% of hip and 35% of knee replacement patients do not predonate autologous blood even in aggressively promoted programs [7]; some of these patients may not be regarded as suitable canditates for autologous blood storage because of preexisting anemia. We have conducted a review of elective orthopedic surgical patients to define the prevalence of anemia and subsequent homologous blood exposure in order to determine implications for emerging blood conservation strategies in this patient population.
Methods A review of the medical records of orthopedic patients consecutively scheduled as outpatients for elective surgery was performed over 6 months. Of 671patients, 396 (59%) were cases in which a blood type and cross-matching was requested. Twelve patients had surgery canceled or postponed, and medical records for 19 patients were not available o r were incomplete. Of the remaining 365 patients audited, 84 predonated autologous blood at the regional Red Cross blood center and were excluded from analysis. The 162patients who predonatedautologous blood at University Hospitals of Cleveland, and the 119patientswhodidnotpredonate autologous blood for theirsurgery, from the basis of this report. A cohort of 30 anemic autologous blood donors was further analyzed for causes of anemia by evaluating iron
parameters (serum ferritin, iron, total iron-bindingcapacity, and iron saturation at time of initial blood donation and after final blood donation). stool blood test, and serum folate and B I Zlevels. I n this study, anemia was defined as a hematocrit (Hct) of 539% at first blood donation in autologous blood donors or at surgical admission in nonautologous blood donors. This level was chosen not as a determinant of general health but as a determinant for subsequent homologous blood transfusion, similar to that chosen for clinical trials of recombinant human erythropoietin therapy [2]. Estimated blood loss during surgical admission was calculated as described previously [ 81. Admission and discharge (last recorded) Hct percentage was multiplied by patient whole blood volume to determine the change in red blood cell (RBC) mass. Total RBC loss was then determined by the sum of RBC mass lost plus autologous (177 ml/unit) and homologous R B C mass (200 ml/unit) transfused 191. Our autologous blood donation program has been described previously [lo]. All patients are prescribed oral iron therapy (ferrous sulfate 325 mg) three times daily during the blood donation interval.
Results
The clinical characteristics of the patients audited are shown in table 1. Of 281 patients, 73 (26%) were classified as anemic (Hct 539%) determined at first blood donation (for autologous blood donors) or at surgical admission (for patients who did not donate autologous blood); 34 (21%) of 162 autologous blood donors and 39 (33%) of 119 patients who did not predonate autologous blood were anemic by these criteria. The percentage of female patients were higher (p
Lawrence Tim Goodnough Karl Vizmeg Ronald Sobecks Adam Schwarz Widu Soegiarso Department of Medicine and Ireland Cancer Center, University Hospitals of Cleveland, Case Western Reserve University, Ohio, USA
Prevalence and Classification of Anemia in Elective Orthopedic Surgery Patients: Implications for Blood Conservation Programs ................................................................................................. Abstract We audited 281 consecutive orthopedic patients scheduled for surgery for whom blood typekross-matching was requested over a 6-month period. One hundred and sixty-two patients predonated autologous blood at University Hospitals of Cleveland, and 34 (21%) of these were anemic [hematocrit (Hct) I 3 9 % ] at initial donation. Twelve (35%) of these 34 anemic autologous blood donors subsequently received homologous blood. In contrast, 18 (15%) of 128 nonanemic autologous blood donors received homologous blood (p = 0.05). In 119 patients who did not donate autologous blood, 39 (33%) were anemic at admission. Of these, 22 (56%) received homologous blood. In the 80 remaining nonanemic patients, 33 (41%) received homologous blood (p = 0.119). Analysis of discharge Hct indicates that 31 (12%) of 263 evaluable patients were possibly transfused inappropriately. The anemias of a cohort of 30 autologous donors were analyzed: 5 had rheumatoid arthritis without iron deficiency. Nine (30%) others had evidence of iron deficiency. Sixteen (53%) had an unclassified anemia of chronic disease. We conclude: (1) the high rates of homologous blood exposure indicate a need for innovative blood conservation strategies in anemic autologous blood donors; (2) the prevalence of anemia and the high rates of homologous blood exposure in anemic patients who did not donate autologous blood demonstrate a need for early recognition and treatment in order to procure autologous blood and reduce homologous blood exposure; (3) the presence of inappropriate autologous and homologous transfusions demonstrates a need for more effective physician education programs that emphasize ‘no blood transfusion’ as an alternative to enhance blood conservation effectiveness.
.....................
Introduction Autologous blood donation is a widely endorsed transfusion practice that has become, in terms of utilization and efficacy, a standard of practice in elective orthopedic sur-
This investigati(in was supported by Transfusion Medicine Acadcmic Award K-07-(HLO-lh2.5)from the National Heart. Lung. and Ulood Institirtc of the National Institutes of Hcalthy.
Received: August 2 5 199I Revised manuscript received: January 3. 1992 Accepted: January 4. 1992
gery [l]. However, subgroups of patients have been demonstrated to have less than optimal benefit from this blood conservation intervention. For example, patients undergoing hip replacement surgery at one program have been demonstrated to have an overall 18% likelihood of homo-
Lawrence Tim Goodnough, MD Laboratory Medicine Washington University Medical Center PO Box 81 18.660 South Euclid Avenue St.Inuin. MO 6311lI(USA)
Table 1. Clinical characteristics of patients undergoing elective orthopedic surgery
Autologous blood donors anemic Number of patients Females. % Age, years Hct. Yo' Estimated blood loss, nil'
'
'
'
nonanemic
Nonautologous blood donors anemic'
nonanemic
34 91 59.6k3.2 37.2+0.3
128 42 59.0f1.4 43.5 +O. 3
39 87 56.6k3.6 35.8f0.4
80 52 52.7k2.4 44.0k0.4
761k78
896+46
674k94
960k83
Hct 239%. MeankSEM.
logous blood exposure despite autologous blood donation [2]. Between one third [3] and one half of patients asked to donate 4 or more autologous blood units are unable to do so because of the anemia associated with serial blood donation; when this occurs, 40% of such patients subsequently receive homologous blood [4]. In addition to blunted efficacy, autologous blood donation programs may not achieve full utilization because of perceived limitations of blood donation in patients who are already anemic. Despite increased utilization of this transfusion practice [l, 4-61, up to 25% of hip and 35% of knee replacement patients do not predonate autologous blood even in aggressively promoted programs [7]; some of these patients may not be regarded as suitable canditates for autologous blood storage because of preexisting anemia. We have conducted a review of elective orthopedic surgical patients to define the prevalence of anemia and subsequent homologous blood exposure in order to determine implications for emerging blood conservation strategies in this patient population.
Methods A review of the medical records of orthopedic patients consecutively scheduled as outpatients for elective surgery was performed over 6 months. Of 671patients, 396 (59%) were cases in which a blood type and cross-matching was requested. Twelve patients had surgery canceled or postponed, and medical records for 19 patients were not available o r were incomplete. Of the remaining 365 patients audited, 84 predonated autologous blood at the regional Red Cross blood center and were excluded from analysis. The 162patients who predonatedautologous blood at University Hospitals of Cleveland, and the 119patientswhodidnotpredonate autologous blood for theirsurgery, from the basis of this report. A cohort of 30 anemic autologous blood donors was further analyzed for causes of anemia by evaluating iron
parameters (serum ferritin, iron, total iron-bindingcapacity, and iron saturation at time of initial blood donation and after final blood donation). stool blood test, and serum folate and B I Zlevels. I n this study, anemia was defined as a hematocrit (Hct) of 539% at first blood donation in autologous blood donors or at surgical admission in nonautologous blood donors. This level was chosen not as a determinant of general health but as a determinant for subsequent homologous blood transfusion, similar to that chosen for clinical trials of recombinant human erythropoietin therapy [2]. Estimated blood loss during surgical admission was calculated as described previously [ 81. Admission and discharge (last recorded) Hct percentage was multiplied by patient whole blood volume to determine the change in red blood cell (RBC) mass. Total RBC loss was then determined by the sum of RBC mass lost plus autologous (177 ml/unit) and homologous R B C mass (200 ml/unit) transfused 191. Our autologous blood donation program has been described previously [lo]. All patients are prescribed oral iron therapy (ferrous sulfate 325 mg) three times daily during the blood donation interval.
Results
The clinical characteristics of the patients audited are shown in table 1. Of 281 patients, 73 (26%) were classified as anemic (Hct 539%) determined at first blood donation (for autologous blood donors) or at surgical admission (for patients who did not donate autologous blood); 34 (21%) of 162 autologous blood donors and 39 (33%) of 119 patients who did not predonate autologous blood were anemic by these criteria. The percentage of female patients were higher (p
