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Dr. John M. Keggi JOHN M. KEGGI
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Although not all patients require a blood transfusion with total joint replacement or resurfacing surgery, there is always a chance that you might need a blood transfusion during or after the surgery.

We make every effort to reduce or eliminate the need for blood transfusion. Blood pressure is lowered during surgery, for example, and we use various cautery devices to eliminate bleeding during the surgery. Incisions are smaller than they were in the past, and minimally invasive techniques have led to a reduction in blood loss. For large, revision surgeries or complex surgeries in which significant blood loss is anticipated, a capture circuit is utilized in which blood suctioned from the field is centrifuged and given back to the patient. All patients are typically placed on iron for a few weeks after surgery, which also increases the body's production of red blood cells. This is usually discontinued a few weeks later since a common side effect of the iron is constipation. Vitamin C and folic acid also help with blood cell production.

For many patients, a transfusion may not even be needed for primary (first-time) joint replacements after all of the above measures are taken. However, having a revision or complex surgery, or bilateral surgeries (e.g., both knees or hips at the same time), increases the odds of requiring a transfusion. It is also more important to transfuse older patients or patients with a known history of heart disease or stroke, since it is the red blood cells that carry oxygen to the tissues, and these patients are at higher risk for complications if they remain very anemic. Younger and healthier patients, as a rule, usually can better tolerate a low hemoglobin (blood count) without the need for blood.

For some patients, we know ahead of time that there will be no transfusion, even in the event of an emergency (e.g., Jehovah's Witnesses who have documented their refusal to accept blood products). In those instances, we may use medications preoperatively like erythropoeitin which stimulates the body's own mechanisms to produce more red blood cells. We do not use these methods routinely, however, because there is some concern of side effects and because these treatments are very expensive.

Blood Bank - Donated Blood

If blood is required, there are two sources that are usually employed. The first is the blood bank. Blood samples taken during preadmission testing are matched to samples donated by blood donors; in this way, a sample can be matched very closely. Given enough time, even difficult matches for rare blood types can usually be made by obtaining blood from other banks throughout the state. (Some people are difficult matches because of antibodies, usually generated from multiple previous transfusions.)

The blood bank today is quite safe. Twenty years ago there was much concern because of infections that were transmitted, mainly hepatitis and HIV (which causes AIDS). For the past two decades, tests have been developed and deployed to extensively test blood samples. As a result, the odds of getting an infection via the blood bank are often estimated in the range of 1 in a million or better.

The principal problem with receiving donated blood today is the small chance of an imperfect match and a transfusion reaction. In most cases, this simply results in a mild fever and the transfusion is stopped, but rarely it can cause a more serious reaction.

The second problem is that of availability; today, the blood supply is dependent on the good will of donors at churches, schools, and work place blood drives. At some times of the year, blood shortages can occur in which transfusions are rationed by need. It is very rare for a shortage to result in someone not getting the blood they need for life-threatening conditions, but we may not be able to fully transfuse someone to desired hemoglobin levels, resulting in their being fatigued for a few weeks until the body regenerates red blood cells.

Autologous Donation

An alternative to receiving donated blood is autologous (self) donation. Patients have the option to donate their own blood a few weeks before surgery if they are in good enough health. This has the advantage of always being available and having essentially zero risk of a transfusion reaction or infection.

However, there are some disadvantages to self donation. The principal problem is that it does actually make patients more anemic prior to surgery, and for older or less healthy patients, they make not fully make it up before surgery. Studies have shown that patients are more likely to be anemic after surgery if they donate beforehand.

There is not a set age limit to self donation, although I generally recommend against it for my own patients over the age of 75, preferring the blood bank instead because it leaves them anemic. However, some surgeons recommend it for all ages. In the end, the option is left up to the patient as long as you are not too anemic (most surgeons use a cut-off hemoglobin level of 11 gm/dl).

If you donate your own blood, usually one or two units of blood (if you have an adequate supply without being anemic already) are taken and stored in a liquid state. The blood is then good for 6 weeks. While it is possible to actually freeze the blood and store it longer, this is not typically done because it requires that the blood is frozen at the time of donation (e.g., it cannot be frozen if it was previously stored in liquid state, as in the case when surgery will unexpectedly be delayed for some other temporary medical issue such as a pneumonia).

Directed Donation

Patients often ask if a relative or spouse can donate blood for them. The short answer is yes, it is possible, but we rarely use it in practice because it still must be matched and go through the same processing that other donated blood goes through. It is also screened for transmittable viruses the same as any other donated blood. Additionally, even a close family member may not be a compatible match. This process typically takes days or weeks, but it is possible.

If a patient is interested in directed donation, we refer them to the American Red Cross for arrangements and will use the tagged blood

Please remember the information on this site is for educational purposes only and should not be used to make a decision on a condition or a procedure. All decisions should be made in conjunction with your surgeon and your primary care provider.