Sunday, June 7, 2015

Shoulder joint replacement arthroplasty - blood transfusion- the 4 Ps

Blood transfusion in primary total shoulder arthroplasty: incidence, trends, and risk factors in the United States from 2000 to 2009.

These authors used the National Inpatient Sample between 2000 and 2009 to assess the overall blood transfusion rate as well as trends in transfusion patterns over time and the patient and hospital characteristics that independently influenced the likelihood that a given patient undergoes allogeneic blood transfusion. They found that the overall blood transfusion rate (ie, the proportion of patients who received at least 1 transfusion of any kind) was 6.7%. This rate increased over time, from 4.9% in 2000 to 7.1% in 2009 (P < .001).

With respect to the 4 Ps, the risk of allogeneic blood transfusion was increased for patients over 85 years of age, women, non-white patients, patients with other than private insurance, patients with comorbidities and provider hospitals with low case loads and hospitals in the Northeast.

Comment: There are many factors that influence the use of blood transfusion. This study would have been stronger had a multivariate analysis been carried out to determine the most influential factors among those studied. However, other factors could not be identified in such a study, such as the individual surgeon's threshold for transfusion (?based on hematocrit or symptoms?), the time of surgery, the attention to hemostasis, the use of topical thrombin, the time of implementation of motion after surgery, the method of fixation of the components and many more. 

Our approach has been to attempt to minimize the use of blood so that it is saved for those whose life depends on it. We strive for short wound times and excellent hemostasis. We reserve transfusion for those patients with symptoms of anemia, such as orthostatic hypotension that does not respond to fluids, and for those at high risk for complications related to diminished arterial oxygenation.

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