Blood transfusion may be beneficial and life saving in particular clinical situations. However, transfusions do carry some risks. Blood is a limited resource and liable to shortage at times of peak demand. Total hip replacement surgery accounts for 4.6% of blood used in hospitals and studies have shown a wide variation in transfusion practice for this procedure. A pre-operative haemoglobin (Hb) of less than 12 g/dl increases the likelihood of transfusion threefold.
NHS Blood and Transplant, in collaboration with the Royal College of Physicians, carry out a series of ‘national comparative audits’ on transfusion practice, acknowledged by the Healthcare Commission. These audits evaluate safety of transfusion and appropriateness of blood usage. The aim of this prospective audit was to measure transfusion practice in ‘primary total hip replacement’ surgery (THR) against two performance indicators and four practice standards. The audit report highlighted deficiencies in practice nationally and made recommendations to improve transfusion practice.
Two hundred and twenty-three hospitals submitted data for 7465 patients who underwent THR. Nationally, 25% of patients were transfused and the transfusion rate among hospitals varied from 0 to 100%. The audit found that, nationally, 29% of patients did not have a Hb estimation pre-operatively, and 15% went for surgery with a Hb less than 12 g/dl. To minimise the likelihood of patients receiving blood transfusions, preoperative anaemia should be corrected as far as possible. Hospitals should have a written policy for identification and management of anaemia in pre-assessment clinics. Surgeons seeing patients at initial consultation must ensure that patients have a full blood count, and that patients with anaemia are investigated and steps are taken to correct the anaemia before surgery. GPs referring patients for surgery should take measures to optimise the haemoglobin.
Studies have shown that previously undiagnosed anaemia is identified in more than 30% of patients undergoing elective surgery and a third of these are due to iron deficiency. This anaemia in the absence of chronic blood loss responds well to oral iron. It takes several weeks to optimise the haemoglobin and there may not be sufficient time to correct the anaemia in the pre-assessment before surgery. Therefore, we propose that at the point when a GP decides that a patient is likely to need arthroplasty, tests are done to identify anaemia and where necessary treat with haematinics before the initial orthopaedic consultation.
- © British Journal of General Practice, 2008.
