To the Editor:
The attached is a letter to the editor with questions
concerning the article bRisks Associated With Blood
Transfusion After Total Knee Arthroplasty Q by Bong
et al (J Arthroplasty 2004;19:281).
In 2003, our clinic acquired a NEN-EN-ISO
9001:2000 certificate for its blood management process
(, addendum). Any measure related to blood man-
agement follows standard operating procedures. There-
by, we can easily compare our policy with the blood
management processes of another hospital. Bong et al
present in their retrospective study [JArthroplasty.
2004;19:281-287] a recommendation to reduce allogen-
ic transfusions (and its risks) by proper use of autolo-
gous blood products. Their data show that allogenic
blood transfusions were required in 38% (no predona-
tion), 11% (predonation of 1 U autologous blood), and
7%, respectively (predonation of 2 U of autologous
blood). The article caught our attention because we do
not use any significant amount of allogenic transfusions
at all in total knee arthroplasty. Consequently, we
advise some simple adjustments in the blood manage-
ment procedures followed by our colleagues from the
Department of Orthopedic Surgery, NYU Hospital for
Joint Diseases, New York.
We summarize our recommendations:
1. Not only the anticoagulant drugs but also bclassicQ
nonselective nonsteroidal anti-inflammatory drugs have
to be stopped 24 hours before surgery. These drugs can
increase perioperative blood loss by 45% .
2. Erytropoetin should be prescribed in all cases
with a preoperative hemoglobin level between 100
and 130 g/L. As can be depicted from Table 3 of their
article, the transfusion rate is dramatically higher if the
preoperative hemoglobin level is below this level. It is
unclear to us why this treatment is not routinely used in
3. Maintaining normothermia during surgery is an
important measure in blood management. Studies on
major orthopedic surgery showed a 30% increase in
perioperative blood loss if the body temperature has
dropped just 1.68C [4,5].
4. Transfusion triggers are very important in control-
ling unnecessary allogenic transfusions. We have intro-
duced clear-cut triggers worked out by nurses. Leaving
the ultimate decision (transfusion or not) to orthopedic
surgeons or anesthesiologists will bring an avoidable
increase of homologous blood transfusions. Our transfu-
sion triggers are as follows: for patients with a cardiac
history, 88 g/L hemoglobin level; for patients older than
60 years, 80 g/L; and, for healthy patients younger than
60 years, 64 g/L.
5. Postoperative cell saving is especially applicable in
total knee surgery. The Bellovac ABT system (ABT
indicates autologous blood transfusion) concerns a type
of postoperative cell saving in which blood from the
surgical wound is collected, filtered, and thereafter
reinfused to the patient. Because most of the blood loss
occurs in the first 6 hours postoperatively, most can be
redonated. We propose that if a drain is put in, it should
connect to a cell saving system.
We trust that once the above simple measures are
introduced in their clinic, the use of allogenic blood
transfusions can be abandoned completely as is the waste
of autologous donated blood after total knee arthroplasty.
Moreover, they will find that allogenic blood is almost
Robert Slappendel, MD, PhD (Anaesthesiologist)
Nijmegen, The Netherlands
1. Slappendel R, Dirksen R, Weber EWG, et al. An
algorithm to reduce allogenic red blood cell transfusions
for major orthopedic surgery. Acta Orthop Scand 2003;
2. Slappendel R, Weber EW, Benraad B, et al. Does ibuprofen
increase perioperative blood loss during hip arthroplasty?Eur
J Anaesthesiol 2002;19:829.
3. Weber EWG, Slappendel R, Hemon Y, et al. Effects of
epoetine alfa on blood transfusions and postoperative recov-
ery in orthopaedic surgery. The European Epoetin Alfa
Surgery Trial (EEST). Eur J Anaesthesiol 2004;21:1.
4. Schmied H, Kurz A, Sassier DI, et al. Mild hypothermia
increases blood loss and transfusion requirements during
total hip arthroplasty. Lancet 1996;3:289.
5. Winkler M, Akca O, Birkenberg B, et al. Aggressive warming
reduces blood loss during hip arthroplasty. Anesth Analg
n 2005 Elsevier Inc. All rights reserved.
We would like to thank you for sending a copy of Dr
Slappendel’s letter in reference to our article bRisks
Associated With Blood Transfusion after Total Knee
Arthroplasty.Q As you know, we performed a retrospec-
tive observational study of total knee arthroplasties
conducted at our institution to identify specific risk
factors for allogenic blood transfusion.
Although Dr Slappendel’s experience has been that the
use of allogenic blood is almost completely avoidable, this
has not been the case at our institution. We appreciate
his recommendations, which may provide future direc-
tion for prospective studies to determine their efficacy
Matthew R. Bong, MD
Department of Orthopedic Surgery
NYU/Hospital for Joint Diseases
New York, New York
n 2005 Elsevier Inc. All rights reserved.
Letters to the Editor