64 – Does the volume of intraoperative blood loss influence the incidence of post-operative VTE in patients undergoing orthopaedic procedures?

64 – Does the volume of intraoperative blood loss influence the incidence of post-operative VTE in patients undergoing orthopaedic procedures?

Alexander J. Acuña, Andy Kuo, Giedrius Kvederas, Atul F. Kamath.

Response/Recommendation: There is no concrete data related to this issue.  However, because of a potential association between allogeneic blood transfusion and postoperative venous thromboembolism (VTE), we recommend that strategies be in place to reduce intraoperative blood loss and the possible need for allogeneic blood transfusion.

Recommendation: Limited.

Rationale: Despite contemporary advancements in blood conservation strategies, patients undergoing major orthopaedic surgery may experience significant intraoperative blood loss necessitating perioperative blood transfusions1–5.  Notably, transfusion rates among modern cohorts undergoing complex total joint arthroplasty (TJA), spine surgery, or revision procedures may reach up to 20%6–13.  Despite ongoing efforts to limit perioperative blood loss, it remains unclear whether the incidence of postoperative VTE is influenced by the volume of intraoperative blood loss or by the receipt of blood transfusion in the perioperative period.

While Goel et al., recently analyzed the National Surgical Quality Improvement Program (NSQIP) database and reported a significantly higher risk of VTE among orthopaedic surgery patients receiving perioperative blood transfuions10, analyses on separate cohorts undergoing specific surgical procedures including TJA14–23, spine surgery24–37, pediatric trauma surgery38, and surgery for lower extremity and pelvic fractures39–44 have demonstrated inconsistent results.

There is some evidence from retrospective studies of patients undergoing TJA that a higher volume of blood loss and transfusion requirements may be associated with a higher incidence of VTE15,19,21,22.  Notably, in their analysis of 1’721,806 TJA patients, Parvizi et al., identified transfusion as an independent risk factor for postoperative VTE19.  However, these findings remain mixed in orthopaedic literature14,16–18,20, with other studies failing to identify an association after controlling for various patient and surgical factors, such as VTE prophylaxis18 and postoperative hemoglobin levels14.

Two meta-analyses27,28 evaluating the relationship between blood loss and postoperative VTE in spine surgery have presented contradictory findings.  While Xin et al., identified blood loss to be associated with VTE risk among patients undergoing spine surgery, the majority of included studies primarily conducted univariate analyses without adjusting for confounding factors28.  Additionally, while Zhang et al., did not identify a relationship between intraoperative blood loss and VTE incidence, their pooled analysis did identify transfusion as a risk factor for VTE27.  Similar to studies evaluating TJA, literature evaluating patients undergoing spine surgery have demonstrated inconsistent results when assessing both blood loss24–26,29–31 and transfusion24,29,30,37,45,46.

However, there is some evidence to suggest that the region of the spine being operated on may affect these relationships, with the majority of lumbar spine studies demonstrating a higher risk of VTE among transfused patients24,37,45,46.  Although, Aoude et al., did not find an association between transfusion and VTE incidence among thoracic spinal fusion patients, perioperative blood transfusion was associated with a significantly higher risk of pulmonary embolism (PE) and overall VTE in their lumbar fusion cohort46.

Analyses evaluating the impact of perioperative blood loss and transfusion on VTE risk in patients with lower extremity and pelvic fractures have also demonstrated varying results.  While patients suffering from postoperative VTE have been reported to have comparably higher blood loss40–42, it is unclear whether this independently affects the postoperative risk of VTE41,42.  Additionally, there is mixed data regarding the relationship between perioperative blood transfusion and deep venous thrombosis (DVT)39,40,43,44.  However, it is important to note that other studies utilizing multivariate analyses among patients without malignancy have demonstrated a higher risk of DVT among patients receiving transfusions39,40.

The inconsistencies demonstrated across included studies may be due to methodological limitations of the respective studies exploring this topic.  Of note, a large proportion of studies failed to control for patient- and procedure-related VTE risk factors as well as variations in implemented VTE prophylaxis protocols.  Similarly, variability in the use of tranexamic acid47–49 or tourniquets50 in certain procedures, as well as the accuracy of estimated blood loss51,52 may contribute to these inconsistent results.  Furthermore, although blood transfusion represents a surrogate measure of perioperative blood loss, there is some evidence that red blood cell transfusion itself may induce a hypercoagulable state53–56.

Based on the available literature, there is insufficient evidence to definitively conclude that the incidence of VTE is associated with the volume of intraoperative blood loss or the receipt of perioperative blood transfusions. However, the implementation of perioperative strategies to reduce blood loss and transfusion rates remain essential given their historic relationship with other perioperative complications3,5.


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2.         Sambandam B, Batra S, Gupta R, Agrawal N. Blood conservation strategies in orthopedic surgeries: A review. Journal of Clinical Orthopaedics and Trauma. 2013;4(4):164-170. doi:10.1016/j.jcot.2013.11.002

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15.       Jiang T, Song K, Yao Y, Pan P, Jiang Q. Perioperative allogenic blood transfusion increases the incidence of postoperative deep vein thrombosis in total knee and hip arthroplasty. Journal of Orthopaedic Surgery and Research. 2019;14(1):235. doi:10.1186/s13018-019-1270-2

16.       Hart A, Khalil JA, Carli A, Huk O, Zukor D, Antoniou J. Blood transfusion in primary total hip and knee arthroplasty. Incidence, risk factors, and thirty-day complication rates. Journal of Bone and Joint Surgery – American Volume. 2014;96(23):1945-1951. doi:10.2106/JBJS.N.00077

17.       Frisch NB, Wessell NM, Charters MA, Yu S, Jeffries JJ, Silverton CD. Predictors and complications of blood transfusion in total hip and knee arthroplasty. Journal of Arthroplasty. 2014;29(9 SUPPL.):189-192. doi:10.1016/j.arth.2014.03.048

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