Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Current Options and Approaches for Blood Management in Orthopaedic Surgery*†

Although the implementation of blood-screening measures has vastly reduced the risk of transmission of the human immunodeficiency virus through transfusion of donated blood products, several factors preclude the blood supply from achieving a zero-risk status. Patients who receive perioperative allogenic blood transfusions, for instance, have been reported to have higher rates of infection80,85,116 (although this finding remains controversial37,120) and perioperative blood loss, longer hospital stays26,40, more consecutive days of fever and administration of antibiotics, and a postoperative decrease in natural killer cells116. Furthermore, in a retrospective quantitative analysis of transfusion-associated immunomodulation, transfusion was the most important prognostic factor for postoperative infection13. Finally, the risk of transmission of infectious diseases, such as those caused by hepatitis-B and C viruses99 and to a lesser extent cytomegalovirus29 and Epstein-Barr virus129, as well as the risk of transfusion reactions, alloimmunization, and immunomodulation, remains substantive. Optimization of blood management is thus as important today as it was a decade ago, despite the markedly improved safety of allogenic blood.

Cost-management pressures in the 1990s and continued public concern about the safety of the blood supply have precipitated a concerted movement among the operative specialties to refine the existing blood-conservation measures as well as to develop new approaches67,110. These efforts have included development of transfusion practice standards; improvement in the techniques of operative hemostasis; perioperative blood salvage; promotion of preoperative autologous blood donation; and, more recently, development of blood substitutes or temporary oxygen carriers (currently under investigation)11,28,101 and clinical utilization of recombinant human erythropoietin (epoetin alfa) to stimulate erythropoiesis (Table I)16,26,32,34,40,70,77,125. …

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