Orthopaedic surgeons have always been interested in limiting blood loss when it comes to major procedures. No procedures are more representative of that effort than hip and knee arthroplasty. A well-done meta-analysis by van Bodegan-Vos et al. in the June 17, 2015 JBJS looks at blood conservation through cell salvage—the perioperative suctioning, collection, concentration, and re-infusion of a patient’s own blood.
The authors report that cell salvage significantly protected patients from the need for allogeneic blood transfusions based on well-performed RCTs prior to 2010, but they found no significant effect in similar trials performed after 2010. What changed? Among other things, the surgical community adopted stricter transfusion-trigger criteria in uncomplicated cases, from a hemoglobin concentration of <10 g/dL to a hemoglobin concentration between 7 and 8 g/dL.
From my point of view, cell salvage is an example of technology that was developed to meet a clinical “standard” that was incompletely examined in prior research. There are many other clinical standards that we use in daily practice that have been inadequately evaluated; ordering blood cultures for febrile episodes and imposing BMI limits for surgery center-based procedures are just two examples.
It would certainly be preferable to examine the actual clinical validity and public health implications of these so-called standards before we develop expensive interventions, such as cell salvage, to respond to them. In that way the orthopaedic community can expand our role in meeting the goals of the Institute for Healthcare Improvement’s Triple Aim: better care for individuals, improved population health, and lower per capita health care costs.
Marc Swiontkowski, MD
JBJS Editor in Chief