Wound Drainage With or Without Blood Salvage? An Open, Prospective, Randomized and Single-Center Comparison of Blood Loss, Postoperative Hemoglobin Levels and Allogeneic Blood Transfusions After Major Hip Surgery

Robert Slappendel, MD, PhD; Wieger Horstmann, MD; Ris Dirksen, MD, PhD; Gijs G. Van Hellemondt, MD

Disclosures

Transfusion Alter Transfusion Med. 2008;10(4):174-181. 

In This Article

Discussion

No statistically significant difference between the Bellovac ABT group and the Medinorm group was observed with regard to blood loss during the first 24 hours after surgery, i.e. mean values were almost identical: 566 and 563 mL, respectively. In spite of this, postoperative hemoglobin concentrations were found to be higher in the Bellovac ABT group than in the Medinorm group at day 1. This finding indicates that a clinically relevant difference between the systems exists. This must, however, be further investigated in another clinical study. Hemoglobin concentrations were higher in the Bellovac ABT group at the other postoperative sampling occasions, but no statistically significant differences could be confirmed. This suggests either that there is no true difference between the treatment groups or that it is not possible to detect differences with the given sample. However, it is reasonable to believe that the higher hemoglobin values found in the Bellovac ABT group were caused by the reinfusion of autologous salvaged blood as no difference was observed in blood loss between the two groups. It also explains the lower incidence of allogeneic transfusions in the Bellovac ABT group.

The efficacy of postoperative blood salvage is well established in the literature in total knee and total hip surgery.[1,2,3,4,5,6,7,8] The efficacy (i.e. incidence of allogeneic transfusions) is expected to be higher in total knee surgery than in total hip surgery as the major blood loss occurs during the postoperative phase. In total hip surgery, the efficacy is often found to be lower as the majority of blood loss occurs during surgery. For example, Strümper et al.[1] described an allogeneic transfusion incidence of 6% for the Bellovac ABT drain, and 18% for the Medinorm drain in total knee surgery and the corresponding figures in total hip surgery were 34% and 47%, respectively. Moonen et al.[5] reported similar results, with an allogeneic transfusion rate of 2% for Bellovac ABT and 16% for another low-vacuum drain without autologous blood salvage in total knee surgery, and the lower-corresponding figures reported in total hip surgery were 11% and 21%, respectively.[5] However, the question of whether a lower efficacy of an autologous blood transfusion drainage system in total hip surgery outweighs its costs remains. In the present study, allogeneic transfusions were reduced by 6% in the Bellovac ABT group as compared with the Medinorm group. The total costs of Bellovac ABT for 100 patients would be around €6500, while the cost of the Medinorm AG drains is around €2000. The additional cost of €4500 must be weighed against the cost for allogeneic blood transfusion, i.e. calculated to approximately €1750 per unit at the study clinic, including costs for blood transfusions, cross matching, irregular antibodies, delivery, refrigerated storage, etc. Given these figures, the cost-effectiveness could be achieved by diminishing allogeneic transfusions by 3%. The present study was, however, too small to detect such a small difference between the two systems, as approximately 3800 patients would be required given the normal transfusion rate of 16% found in Medinorm group (80% power, 5% two-sided significance level).

In addition to a reduction of allogeneic blood, reduced immunosuppression associated with surgery and blood loss should also be considered as a potential benefit of autologous blood salvage. Gharehbaghian et al.[9] showed that immunosuppression could be reversed by transfusion of autologous salvaged blood, suggesting immunostimulating effects of autologous blood salvage. Accordingly, besides cost-effectiveness, autologous salvage blood could help to reduce the postoperative infection rate and wound disturbances that are often found after allogeneic transfusions in orthopedic surgery.[10,11]

No safety problems were observed in either the Bellovac ABT or the Medinorm AG system in the present study. The adverse events reported were common ones for this type of surgery and in general equally frequent in the two groups. In addition, more than 600,000 Bellovac ABT systems have been sold by the manufacturer, Astra Tech, without any reported of serious device-related adverse events in the literature. On the basis of this and the results reported by other authors, we conclude that the Bellovac ABT system is safe for clinical use in postoperative autologous blood transfusion.

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