• Pranjal B Gupta, Vince M DeMario, Raj M Amin, Eric A Gehrie, Ruchika Goel, LeeK H KenKHK, William W Yang, Harpal S Khanuja, Robert S Sterling, Paul M Ness, and Steven M Frank.
• From the Department of Anesthesiology/Critical Care Medicine (V.M.D., S.M.F.) Department of Orthopaedic Surgery (R.M.A., H.S.K., R.S.S.) Department of Pathology (Transfusion Medicine; E.A.G., R.G., P.M.N.) The Johns Hopkins School of Medicine (P.B.G.), Baltimore, Maryland Simmons Cancer Institute at Southern Illinois University, Springfield, Illinois (R.G.) Armstrong Institute for Patient Safety and Quality (K.H.K.L., S.M.F.) The Johns Hopkins Health System Blood Management Program (S.M.F.), The Johns Hopkins Medical Institutions, Baltimore, Maryland Hofstra University School of Medicine, Hempstead, New York (W.W.Y.).
• Anesthesiology. 2018 Dec 1; 129 (6): 1082-1091.

What We Already Know About This TopicWHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopedic surgery patients require a higher hemoglobin transfusion threshold than other patient populations (8 g/dl vs. 7 g/dl). The authors tested the hypothesis in orthopedic patients that implementation of a patient blood management program encouraging a hemoglobin threshold less than 7 g/dl results in decreased blood use with no change in clinical outcomes.MethodsAfter launching a multifaceted patient blood management program, the authors retrospectively evaluated all adult orthopedic patients, comparing transfusion practices and clinical outcomes in the pre- and post-blood management cohorts. Risk adjustment accounted for age, sex, surgical procedure, and case mix index.ResultsAfter patient blood management implementation, the mean hemoglobin threshold decreased from 7.8 ± 1.0 g/dl to 6.8 ± 1.0 g/dl (P < 0.0001). Erythrocyte use decreased by 32.5% (from 338 to 228 erythrocyte units per 1,000 patients; P = 0.0007). Clinical outcomes improved, with decreased morbidity (from 1.3% to 0.54%; P = 0.01), composite morbidity or mortality (from 1.5% to 0.75%; P = 0.035), and 30-day readmissions (from 9.0% to 5.8%; P = 0.0002). Improved outcomes were primarily recognized in patients 65 yr of age and older. After risk adjustment, patient blood management was independently associated with decreased composite morbidity or mortality (odds ratio, 0.44; 95% CI, 0.22 to 0.86; P = 0.016).ConclusionsIn a retrospective study, patient blood management was associated with reduced blood use with similar or improved clinical outcomes in orthopedic surgery. A hemoglobin threshold of 7 g/dl appears to be safe for many orthopedic patients.

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