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Hourlier H, Fricault G, Fennema P. Blood management protocol for baseline anemic patients undergoing hip arthroplasty. Arch Orthop Trauma Surg 2025; 145:143. [PMID: 39853461 DOI: 10.1007/s00402-025-05764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Accepted: 01/15/2025] [Indexed: 01/26/2025]
Abstract
INTRODUCTION Patients undergoing total hip arthroplasty (THA) with preoperative anemia are at higher risk for transfusion. Blood-conserving interventions can reduce perioperative transfusions. This retrospective study evaluates the efficacy and safety of a patient blood management (PBM) protocol in elective primary THA patients with preoperative anemia. MATERIALS AND METHODS We analyzed data from a prospectively collected database of THAs performed consecutively from January 2013 to October 2023. The patients were grouped based on baseline hemoglobin (Hb) levels, as follows: <12 g/dL (group 1) and ≥ 12 g/dL (group 2). The PBM protocol included optimized preoperative epoetin (EPO) for Hb < 11 g/dL, bleeding reduction measures, and restrictive transfusion thresholds. Blood loss was measured using a bleeding index (BI-7), accounting for Hb decrease from admission to the 7th postoperative day and total transfused units. Multiple linear regression was used to assess the differences in BI-7. RESULTS Of the 1,442 patients, 104 (7%) had Hb < 12 g/dL (group 1). Among these, 46 (45%) received EPO, with none requiring transfusion in the first week. The mean adjusted BI-7 was 2.3 g/dL (95% CI, 2.1 to 2.6) in group 1 and 2.7 g/dL (95% CI, 2.6 to 2.7) in group 2, showing a significant difference (-0.4 g/dL; 95% CI, -0.6 to -0.1; p < 0.001). CONCLUSIONS THA patients with baseline Hb < 12 g/dL had a zero-transfusion rate and significantly lower blood loss than those with Hb ≥ 12 g/dL. Optimizing preoperative Hb levels above 12 g/dL is not necessary for patients undergoing standard THA. Optimizing preoperative Hb may not be necessary for patients with baseline anemia due to their low blood loss. The PBM protocol was effective in conserving blood, time, and resources, offering a viable alternative for blood conservation in elective hip arthroplasty.
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Affiliation(s)
| | | | - Peter Fennema
- AMR Advanced Medical Research, Männedorf, Switzerland
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Kalra SK, Auron M. Anemia and Transfusion Medicine. Med Clin North Am 2024; 108:1065-1085. [PMID: 39341614 DOI: 10.1016/j.mcna.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
Peri-operative anemia is a common condition encountered in adult surgical patients. It is increasingly recognized as a predictor of post-operative morbidity and mortality. Evaluation and treatment of anemia pre-operatively can reduce transfusion needs and potentially improve outcomes in surgical patients. This article discusses anemia optimization strategies in peri-operative setting with special focus on use of intravenous iron therapy. Additionally, the authors describe the role of transfusion medicine and best practices around red blood cell, platelet, and plasma transfusions.
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Affiliation(s)
- Smita K Kalra
- UCI Hospitalist Program, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA.
| | - Moises Auron
- Department of Hospital Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Cai L, Chen L, Zhao C, Han G, Wang Q, Kang P. Do Patients with Borderline Anemia Need Treatment before Total Hip Arthroplasty? A Propensity Score-Matched Cohort Study. Orthop Surg 2024; 16:123-131. [PMID: 38049380 PMCID: PMC10782264 DOI: 10.1111/os.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 12/06/2023] Open
Abstract
OBJECTIVE Preoperative anemia has been identified as a modifiable risk factor for multiple adverse outcomes. In real clinical practice, considering treatment of anemia would increase costs and delay surgery. Patients undergoing total hip arthroplasty (THA) with mild anemia are usually neglected and still underdiagnosed or inadequately treated. This study investigated the effects of preoperative borderline anemia and anemia intervention before THA on perioperative outcomes. METHODS We screened 706 patients from those receiving THA at our hospital from January 2020 to January 2022, with 112 in the borderline anemia group and 594 in the non-anemia group. The cohort for this retrospective study was created by using propensity score matching (PSM) and subgroup analysis. The primary outcome was perioperative blood loss, while secondary outcomes were the rate of allogeneic blood transfusion and human serum albumin transfusion, perioperative laboratory indicators, postoperative length of stay, and complications. The independent sample t-test and the Mann-Whitney U-test were used to analyze continuous data, and the Pearson χ2 -test or the Fisher exact test was used to analyze categorical variables. RESULTS After PSM, there was no significant difference in perioperative blood loss between patients in the borderline anemia group and the non-anemia group. The primary outcomes of hidden (p = 0.004) and total (p = 0.005) blood loss were significantly lower in the intervention group than in the control group. No statistical differences were found in allogeneic blood transfusion, human serum albumin transfusion, postoperative length of stay, or complications (p > 0.05). CONCLUSIONS Anemia treatments for patients with borderline anemia before THA significantly reduced hidden blood loss and total blood loss in the perioperative period and decreased the drop of hemoglobin and hematocrit without increasing postoperative complications.
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Affiliation(s)
- Lijun Cai
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduPeople's Republic of China
| | - Liyile Chen
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduPeople's Republic of China
| | - Chengcheng Zhao
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduPeople's Republic of China
| | - Guangtao Han
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduPeople's Republic of China
| | - Qiuru Wang
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduPeople's Republic of China
| | - Pengde Kang
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduPeople's Republic of China
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Yu W, Liu C, Bi Z. Effect of recombinant human erythropoietin combined with iron sucrose on postoperative hemoglobin in patients undergoing artificial joint replacement. Sci Rep 2023; 13:18919. [PMID: 37919317 PMCID: PMC10622435 DOI: 10.1038/s41598-023-41887-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/01/2023] [Indexed: 11/04/2023] Open
Abstract
With the aging of the population, an increasing number of elderly patients are opting for artificial joint replacement, leading to the exploration of various rapid rehabilitation programs in the perioperative period. In this study, we aimed to investigate the effectiveness of combining recombinant human erythropoietin and iron sucrose in altering the range and trend of postoperative hemoglobin in patients undergoing arthroplasty. Specifically, we will examine whether this combination can effectively alter the rise and fall of postoperative haemoglobin, identify the inflection point of haemoglobin change or recovery after arthroplasty, and assess the effect of treatment on serum iron in postoperative blood. We conducted a retrospective study of 138 patients who underwent unilateral total joint arthroplasty by the same surgeon in the same hospital before July 2022. The results of this study may provide valuable insights for the development of effective rehabilitation programs for patients undergoing arthroplasty.
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Affiliation(s)
- Wenjiang Yu
- Department of Orthopedics, Linyi People's Hospital, Linyi, Shandong, China
| | - Chengyan Liu
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhiguo Bi
- Department of Orthopedics, The First Hospital of Jilin University, Changchun, Jilin, China.
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Warren JA, McLaughlin JP, Molloy RM, Higuera CA, Schaffer JL, Piuzzi NS. Blood Management in Total Knee Arthroplasty: A Nationwide Analysis from 2011 to 2018. J Knee Surg 2022; 35:997-1003. [PMID: 33241545 DOI: 10.1055/s-0040-1721414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Both advances in perioperative blood management, anesthesia, and surgical technique have improved transfusion rates following primary total knee arthroplasty (TKA), and have driven substantial change in preoperative blood ordering protocols. Therefore, blood management in TKA has seen substantial changes with the implementation of preoperative screening, patient optimization, and intra- and postoperative advances. Thus, the purpose of this study was to examine changes in blood management in primary TKA, a nationwide sample, to assess gaps and opportunities. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify TKA (n = 337,160) cases from 2011 to 2018. The following variables examined, such as preoperative hematocrit (HCT), anemia (HCT <35.5% for females and <38.5% for males), platelet count, thrombocytopenia (platelet count < 150,000/µL), international normalized ration (INR), INR > 2.0, bleeding disorders, preoperative, and postoperative transfusions. Analysis of variances were used to examine changes in continuous variables, and Chi-squared tests were used for categorical variables. There was a substantial decrease in postoperative transfusions from high of 18.3% in 2011 to a low of 1.0% in 2018, (p < 0.001), as well as in preoperative anemia from a high of 13.3% in 2011 to a low of 9.5% in 2016 to 2017 (p < 0.001). There were statistically significant, but clinically irrelevant changes in the other variables examined. There was a HCT high of 41.2 in 2016 and a low of 40.4 in 2011 to 2012 (p < 0.001). There was platelet count high of 247,400 in 2018 and a low of 242,700 in 201 (p < 0.001). There was a high incidence of thrombocytopenia of 5.2% in 2017 and a low of low of 4.4% in 2018 (p < 0.001). There was a high INR of 1.037 in 2011 and a low of 1.021 in 2013 (p < 0.001). There was a high incidence of INR >2.0 of 1.0% in 2012 to 2015 and a low of 0.8% in 2016 to 2018 (p = 0.027). There was a high incidence of bleeding disorders of 2.9% in 2013 and a low of 1.8% in 2017 to 2018 (p < 0.001). There was a high incidence of preoperative transfusions of 0.1% in 2011 to 2014 and a low of <0.1% in 2015 to 2018 (p = 0.021). From 2011 to 2018, there has been substantial decreases in patients receiving postoperative transfusions after primary TKA. Similarly, although a decrease in patients with anemia was seen, there remains 1 out 10 patients with preoperative anemia, highlighting the opportunity to further improve and address this potentially modifiable risk factor before surgery. These findings may reflect changes during TKA patient selection, optimization, or management, and emphasizes the need to further advance multimodal approaches for perioperative blood management of TKA patients. This is a Level III study.
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Affiliation(s)
- Jared A Warren
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Robert M Molloy
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Carlos A Higuera
- Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | | | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Yuan M, Tao Q, Wang D, Wang H, Zhou Z. Finding the optimal regimen for short-term daily recombinant human erythropoietin treatment for blood-saving purpose in patients undergoing unilateral primary total hip arthroplasty: a double-blinded randomized placebo-controlled trial. BMC Musculoskelet Disord 2022; 23:243. [PMID: 35279105 PMCID: PMC8917634 DOI: 10.1186/s12891-022-05184-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 03/04/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose To find the best short-term daily recombinant human erythropoietin (rhEPO)-based treatment protocols for blood-saving purpose in THA. Method The patients were randomized to 1 of 3 interventions: Patients in group A received 10,000 IU (150 IU/kg) of subcutaneous rhEPO (1 ml) daily from 5 days preoperatively to 3 days postoperatively (9 doses in total); Patients in group B received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to 3 days preoperatively and then 10,000 IU (150 IU/kg) of subcutaneous rhEPO daily until 3 days postoperatively (6 doses in total). Patients in group C received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to one day preoperatively and then 10,000 IU (150 IU/kg) of subcutaneous rhEPO daily from the day of surgery to 3 days postoperatively (4 doses in total). Results One hundred eighty patients were included. On postoperative day one, patients in the group A showed significantly higher Hb level (108.4 ± 11.4 g/L) than group C (103.9 ± 8.8 g/L). Group B (107.8 ± 8.4 g/L) also showed significantly higher Hb level than group C (103.9 ± 8.8 g/L) (p < 0.05). On postoperative day 3, no significant difference was found between group B and group C in Hb level (98.7 ± 10.5 and 94.9 ± 8.7 g/L, respectively) (p = 0.094), but the Hb level in group A (103.6 ± 11.0 g/L) was still markedly higher than in group B and the Hb level in group A was also markedly higher than in group C. In terms of blood loss, no markedly difference was found in intraoperative blood loss among group A, B and C (78.3 ± 22.4, 84.6 ± 29.1, and 80.3 ± 23.9 ml, respectively) (p = 0.381), but on postoperative day one, the mean blood loss in group C (522.4 ± 189.4 ml) was significantly more than group B (371.2 ± 124.6 ml), and group B was also significantly more than group A (284.8 ± 112.9 ml) with 95% confidence interval, and group B had significantly less blood loss than group C (p < 0.001). With respect to the total blood loss, the total blood loss in group C (881.6 ± 314.9 ml) was significantly more than group B (642.6 ± 232.9 ml), and group B was also significantly more than group A (514.5 ± 204.6 ml) with 95% confidence interval (Table 2). Only 2 patients in each group received allogeneic blood transfusion and each patient received 2 units of red blood cells, so, the transfusion requirements among the three groups were comparable. Conclusions Daily small-dose of subcutaneous rhEPO administered from 5 days before THA could significantly decrease perioperative blood loss and improve postoperative Hb levels, without increasing risks of complications, when compared with the application of rhEPO from 3 days before THA or from the day of surgery. However, surgeons should choose the regimen individually according to different patients’ personal circumstances.
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Kim TW, Park HJ, Chang MJ, Kang SY, Kang KS, Chang CB, Kang SB. Effect of severity and cause of preoperative anemia on the transfusion rate after total knee arthroplasty. Sci Rep 2022; 12:4083. [PMID: 35260783 PMCID: PMC8904493 DOI: 10.1038/s41598-022-08137-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 02/18/2022] [Indexed: 11/09/2022] Open
Abstract
This study aimed to (1) evaluate the preoperative Hb cut-off value for transfusion after unilateral and bilateral staged (1 week apart) TKAs, respectively, and (2) determine whether cause of preoperative anemia can affect transfusion rate after TKA. A total of 951 patients who underwent TKA (unilateral: 605, bilateral staged: 346) from 2016 to 2019 were reviewed retrospectively. Patient demographics, comorbidities, preoperative Hb level, surgery types, and cause of anemia were evaluated as possible risk factors. The cut-off values for preoperative Hb level to reduce transfusion after TKA were evaluated in each surgery type. Preoperative Hb level, surgery type, and cardiac disease were identified as the risk factors for transfusion after TKA, and preoperative Hb levels of 11.8 (AUC 0.88) and 12.8 (AUC 0.76) were the cut-off values for transfusion after unilateral and staged bilateral TKAs, respectively. Although transfusion rate was higher in anemia with iron deficiency (ID) group than anemia without ID group, preoperative Hb level was also lower in anemia with ID group than anemia without ID group. Single use of preoperative Hb level with different cut-offs depending on the surgery types can be useful indicator for preoperative optimization regardless of cause of anemia.
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Affiliation(s)
- Tae Woo Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, South Korea
| | - Hyung Jun Park
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, South Korea
| | - Moon Jong Chang
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, South Korea
| | - Sang Yoon Kang
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Kee Soo Kang
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Chong Bum Chang
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
- Seoul National University College of Medicine, Seoul, South Korea
| | - Seung-Baik Kang
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, South Korea.
- Seoul National University College of Medicine, Seoul, South Korea.
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Jakuscheit A, Schaefer N, Roedig J, Luedemann M, von Hertzberg-Boelch SP, Weissenberger M, Schmidt K, Holzapfel BM, Rudert M. Modifiable Individual Risks of Perioperative Blood Transfusions and Acute Postoperative Complications in Total Hip and Knee Arthroplasty. J Pers Med 2021; 11:jpm11111223. [PMID: 34834575 PMCID: PMC8622846 DOI: 10.3390/jpm11111223] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/08/2021] [Accepted: 11/15/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The primary aim of this study was to identify modifiable patient-related predictors of blood transfusions and perioperative complications in total hip and knee arthroplasty. Individual predictor-adjusted risks can be used to define preoperative treatment thresholds. METHODS We performed this retrospective monocentric study in orthopaedic patients who underwent primary total knee or hip arthroplasty. Multivariate logistic regression models were used to assess the predictive value of patient-related characteristics. Predictor-adjusted individual risks of blood transfusions and the occurrence of any perioperative adverse event were calculated for potentially modifiable risk factors. RESULTS 3754 patients were included in this study. The overall blood transfusion and complication rates were 4.8% and 6.4%, respectively. Haemoglobin concentration (Hb, p < 0.001), low body mass index (BMI, p < 0.001) and estimated glomerular filtration rate (eGFR, p = 0.004) were the strongest potentially modifiable predictors of a blood transfusion. EGFR (p = 0.001) was the strongest potentially modifiable predictor of a complication. Predictor-adjusted risks of blood transfusions and acute postoperative complications were calculated for Hb and eGFR. Hb = 12.5 g/dL, BMI = 17.6 kg/m2, and eGFR = 54 min/mL were associated, respectively, with a 10% risk of a blood transfusion, eGFR = 59 mL/min was associated with a 10% risk of a complication. CONCLUSION The individual risks for blood transfusions and acute postoperative complications are strongly increased in patients with a low preoperative Hb, low BMI or low eGFR. We recommend aiming at a preoperative Hb ≥ 13g/dL, an eGFR ≥ 60 mL/min and to avoid a low BMI. Future studies must show if a preoperative increase of eGFR and BMI is feasible and truly beneficial.
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Affiliation(s)
- Axel Jakuscheit
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97070 Wuerzburg, Germany; (N.S.); (J.R.); (M.L.); (S.P.v.H.-B.); (M.W.); (M.R.)
- Correspondence:
| | - Nina Schaefer
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97070 Wuerzburg, Germany; (N.S.); (J.R.); (M.L.); (S.P.v.H.-B.); (M.W.); (M.R.)
| | - Johannes Roedig
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97070 Wuerzburg, Germany; (N.S.); (J.R.); (M.L.); (S.P.v.H.-B.); (M.W.); (M.R.)
| | - Martin Luedemann
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97070 Wuerzburg, Germany; (N.S.); (J.R.); (M.L.); (S.P.v.H.-B.); (M.W.); (M.R.)
| | - Sebastian Philipp von Hertzberg-Boelch
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97070 Wuerzburg, Germany; (N.S.); (J.R.); (M.L.); (S.P.v.H.-B.); (M.W.); (M.R.)
| | - Manuel Weissenberger
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97070 Wuerzburg, Germany; (N.S.); (J.R.); (M.L.); (S.P.v.H.-B.); (M.W.); (M.R.)
| | - Karsten Schmidt
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany;
| | - Boris Michael Holzapfel
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich, Marchionistr. 15, 81377 Munich, Germany;
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97070 Wuerzburg, Germany; (N.S.); (J.R.); (M.L.); (S.P.v.H.-B.); (M.W.); (M.R.)
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Avau B, Van Remoortel H, Laermans J, Bekkering G, Fergusson D, Georgsen J, Manzini PM, Ozier Y, De Buck E, Compernolle V, Vandekerckhove P. Lack of Cost-Effectiveness of Preoperative Erythropoiesis-Stimulating Agents and/or Iron Therapy in Anaemic, Elective Surgery Patients: A Systematic Review and Updated Analysis. PHARMACOECONOMICS 2021; 39:1123-1139. [PMID: 34235646 PMCID: PMC8476458 DOI: 10.1007/s40273-021-01044-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES For anaemic elective surgery patients, current clinical practice guidelines weakly recommend the routine use of iron, but not erythrocyte-stimulating agents (ESAs), except for short-acting ESAs in major orthopaedic surgery. This recommendation is, however, not based on any cost-effectiveness studies. The aim of this research was to (1) systematically review the literature regarding cost effectiveness of preoperative iron and/or ESAs in anaemic, elective surgery patients and (2) update existing economic evaluations (EEs) with recent data. METHODS Eight databases and registries were searched for EEs and randomized controlled trials (RCTs) reporting cost-effectiveness data on November 11, 2020. Data were extracted, narratively synthesized and critically appraised using the Philips reporting checklist. Pre-existing full EEs were updated with effectiveness data from a recent systematic review and current cost data. Incremental cost-effectiveness ratios were expressed as cost per (quality-adjusted) life-year [(QA)LY] gained. RESULTS Only five studies (4 EEs and 1 RCT) were included, one on intravenous iron and four on ESAs + oral iron. The EE on intravenous iron only had an in-hospital time horizon. Therefore, cost effectiveness of preoperative iron remains uncertain. The three EEs on ESAs had a lifetime time horizon, but reported cost per (QA)LY gained of 20-65 million (GBP or CAD). Updating these analyses with current data confirmed ESAs to have a cost per (QA)LY gained of 3.5-120 million (GBP or CAD). CONCLUSIONS Cost effectiveness of preoperative iron is unproven, whereas routine preoperative ESA therapy cannot be considered cost effective in elective surgery, based on the limited available data. Future guidelines should reflect these findings.
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Affiliation(s)
- Bert Avau
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium.
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
| | - Jorien Laermans
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
| | - Geertruida Bekkering
- Center for Evidence-Based Medicine, Leuven, Belgium
- Cochrane Belgium, Leuven, Belgium
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Canadian Blood Services, Ottawa, Canada
| | - Jørgen Georgsen
- South Danish Transfusion Service, Odense University Hospital, Odense, Denmark
| | - Paola Maria Manzini
- SC Banca del Sangue Servizio di Immunoematologia, University Hospital Città della Salute e della Scienza di Torino, Torino, Italy
| | - Yves Ozier
- University Hospital of Brest, Brest, France
| | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
- Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Veerle Compernolle
- Blood Services, Belgian Red Cross, Mechelen, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Philippe Vandekerckhove
- Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Belgian Red Cross, Mechelen, Belgium
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Hussey P, Onodera Y, Reddy S, Samuelson B, Subramani S, Siddapura Ranganath Y, Jaradat T, Hanada S. Need for preoperative anemia management clinics in Japan: initiatives at a university hospital in the USA. J Anesth 2021; 35:710-722. [PMID: 34338863 DOI: 10.1007/s00540-021-02979-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/21/2021] [Indexed: 12/26/2022]
Abstract
Untreated preoperative anemia increases the risk of morbidity and mortality and there is increasing evidence that early intervention for preoperative anemia improves outcomes after major surgery. Accordingly, anemia management clinics have been established in various institutions in the USA. As an example, the University of Iowa Hospitals and Clinics outpatient clinic treats pre-surgical anemic patients, who undergo major surgery with anticipated blood loss of more than 500 mL, by providing effective standardized care in a timely manner. This standardized care is an integral part of patient blood management to reduce perioperative blood transfusion and improve patient outcomes. The importance of preoperative anemia management has not yet been sufficiently recognized in Japan. Timely intervention for preoperative anemia should be incorporated into routine pre-surgical patient care in Japan.
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Affiliation(s)
- Patrick Hussey
- Department of Anesthesia, School of Medicine, University of Alabama at Birmingham, 619 19th Street S, Birmingham, AL, 35226, USA
| | - Yoshiko Onodera
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA.,Surgical Operation Department, Asahikawa Medical University Hospital, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Sundara Reddy
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Blain Samuelson
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Sudhakar Subramani
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Yatish Siddapura Ranganath
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Tariq Jaradat
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Satoshi Hanada
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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Lin J, Wang C, Liu J, Yu Y, Wang S, Wen A, Wu J, Zhang L, Sun F, Guo X, Liu F, Li H, Li N, Wang H, Lv Y, Jia Z, Li X, Zhang J, Li Z, Liu S, Zhong S, Yang J, Ma S, Zhou L, Guan X, Ma C, Cheng S, Chen S, Xu Z, Li G, Wang D. Prevalence and intervention of preoperative anemia in Chinese adults: A retrospective cross-sectional study based on national preoperative anemia database. EClinicalMedicine 2021; 36:100894. [PMID: 34041460 PMCID: PMC8144738 DOI: 10.1016/j.eclinm.2021.100894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/15/2021] [Accepted: 04/22/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Preoperative anemia is an important pillar of perioperative patient blood management. However, there was no literature comprehensively described the current situation of preoperative anemia in China. METHODS We conducted a national retrospective cross-sectional study to assess the prevalence and intervention of preoperative anemia in Chinese adults. Data were from the National Preoperative Anemia Database based on hospital administration data from January 1, 2013 to December 31, 2018. FINDINGS A total of 797,002 patients were included for analysis. Overall, 27.57% (95% CI 27.47-27.67) of patients had preoperative anemia, which varied by gender, age, regions, and type of operation. Patients who were female, age over 60 years old, from South China, from provinces with lower per capita GDP, underwent operations on the lymphatic and hematopoietic system, with laboratory abnormalities were more likely to have a high risk of preoperative anemia. Among patients with preoperative anemia, 5.16% (95% CI 5.07-5.26) received red blood cell transfusion, 7.79% (95% CI 7.67-7.91) received anemia-related medications such as iron, erythropoietin, folic acid or vitamin B12, and 12.25% (95% CI 12.10-12.40) received anemia-related therapy (red blood cell transfusion or anemia-related medications) before operation. The probability of preoperative RBC transfusion decreased by 54.92% (OR 0.46, 95% CI 0.46-0.47) as each 10-g/L increase in preoperative hemoglobin. Patients with preoperative hemoglobin less than 130 g/L was associated with longer hospital stay and more hospital costs. Patients with severe preoperative anemia given iron preoperatively had lower intra/post-operative RBC transfusion rate, shorter length of stay and less hospitalization costs, but no similar correlation was found in patients with mild and moderate preoperative anemia and patients given erythropoietin preoperatively. INTERPRETATION Our present study shows that preoperative anemia is currently a relatively prevalent problem that has not been fully appreciated in China. More researches will be required to optimize the treatment of preoperative anemia. FUNDING National Natural Science Foundation of China and the Logistics Support Department of the Central Military Commission.
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Affiliation(s)
- Jie Lin
- Department of Transfusion Medicine, The First Medical Center of PLA General Hospital, Beijing, China
| | - Chao Wang
- Institute of Statistics and Information, Beijing Center for Diseases Control and Prevention, Beijing, China
| | - Junting Liu
- Department of Transfusion Medicine, The First Medical Center of PLA General Hospital, Beijing, China
| | - Yang Yu
- Department of Transfusion Medicine, The First Medical Center of PLA General Hospital, Beijing, China
| | - Shufang Wang
- Department of Transfusion Medicine, The First Medical Center of PLA General Hospital, Beijing, China
| | - Aiqing Wen
- Department of Blood Transfusion, Daping Hospital, Army Medical University, Chongqing, China
| | - Jufeng Wu
- Department of Blood Transfusion, Hainan Provincial People's Hospital, Haikou, Hainan, China
| | - Long Zhang
- Department of Blood Transfusion, Affiliated Hospital of Chifeng University, Inner Mongolia Autonomous Region, China
| | - Futing Sun
- Department of Blood Transfusion, Weifang People's Hospital, Shandong, China
| | - Xiaojun Guo
- Department of Blood Transfusion, The First Hospital of Shanxi Medical University, Shanxi, China
| | - Fenghua Liu
- Department of Blood Transfusion, The First Affiliated Hospital of Harbin Medical University, Heilongjiang, China
| | - Hailan Li
- Department of Blood Transfusion, The People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Zhuang Autonomous Region, China
| | - Na Li
- Department of Blood Transfusion, General Hospital of Easter Theater Command, Jiangsu, China
| | - Haibao Wang
- Department of Blood Transfusion, Hainan Hospital of PLA General Hospital, Hainan, China
| | - Yi Lv
- Clinical Laboratory Medicine Center, Zhengzhou Yihe Hospital Affiliated to Henan University, Henan, China
| | - Zhonghua Jia
- Department of Blood Transfusion, Gaoan People's Hospital, Jiangxi, China
| | - Xiaoyan Li
- Department of Blood Transfusion, Baoji Central Hospital, Shaanxi, China
| | - Jun Zhang
- Department of Blood Transfusion, The First Affiliated Hospital of Bengbu Medical College, Anhui, China
| | - Zunyan Li
- Department of Blood Transfusion, Affiliated Hospital of Beihua University, Jilin, China
| | - Shanshan Liu
- Department of Blood Transfusion, The First People's Hospital of GuiYang, Guizhou, China
| | - Shuhuai Zhong
- Department of Blood Transfusion, Guizhou Provincial People's Hospital, Guizhou, China
| | - Jun Yang
- Department of Blood Transfusion, Zigong Fourth People's Hospital, Sichuan, China
| | - Shuxuan Ma
- Department of Blood Transfusion, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Lingling Zhou
- Department of Transfusion Medicine, The First Medical Center of PLA General Hospital, Beijing, China
| | - Xiaozhen Guan
- Department of Transfusion Medicine, The First Medical Center of PLA General Hospital, Beijing, China
| | - Chunya Ma
- Department of Transfusion Medicine, The First Medical Center of PLA General Hospital, Beijing, China
| | | | | | - Zhenhua Xu
- HealSci Technology Co., Ltd, Beijing, China
| | - Gang Li
- Institute of Statistics and Information, Beijing Center for Diseases Control and Prevention, Beijing, China
| | - Deqing Wang
- Department of Transfusion Medicine, The First Medical Center of PLA General Hospital, Beijing, China
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12
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Ruan RX, Bai CW, Zhang L, Huang CR, Pan S, Zhang XC, Zhu ZY, Zheng X, Guo KJ. Does subcutaneous administration of recombinant human erythropoietin increase thrombotic events in total hip arthroplasty? A prospective thrombelastography analysis. J Orthop Surg Res 2020; 15:546. [PMID: 33213494 PMCID: PMC7678274 DOI: 10.1186/s13018-020-02083-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Anemia is one of severe complications in the perioperative period of total hip arthroplasty (THA). Erythropoietin (EPO) has been considered to improve patients' anemia state, but its efficiency and safety remains controversial. METHODS A total of 152 patients who underwent total hip arthroplasty from January 2017 to March 2019 were randomized to 2 groups. Recombinant human erythropoietin (rHu-EPO) group was treated with rHu-EPO subcutaneous injection 10000 IU after operation and once daily in the next week, while control group was treated with none extra treatment. Routine hematologic examination and thrombelastography (TEG) performed at different time point respectively. Doppler ultrasound for bilateral lower limbs was performed 1 day before surgery and 7 days after surgery. Auxiliary examination outcomes, blood transfusions outcomes, and postoperative complications were recorded as assessment indicators. RESULTS The difference in the relevant indexes of traditional coagulation and TEG values between two groups were not significantly. No significant difference was observed in the incidence of thromboembolism events and other complications between two groups during postoperative period. The amount of intraoperative blood loss was similar between the two groups. However, the postoperative use and dosage of allogeneic blood in the rHu-EPO group were lower than those in the control group. The hemoglobin and hematocrit level in the rHu-EPO group were higher than that in the control group after surgery. CONCLUSION Postoperative subcutaneous injection of rHu-EPO can improve hematological anemia-related parameters, reduce the use and dosage of allogeneic blood transfusions (ABTs), and has no significant influence on the formation of thrombosis and other complications in patients undergoing total hip arthroplasty in short term.
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Affiliation(s)
- Ru-Xin Ruan
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Chao-Wen Bai
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Le Zhang
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Chao-Ran Huang
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Sheng Pan
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Xing-Chen Zhang
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Zheng-Ya Zhu
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Xin Zheng
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China.
| | - Kai-Jin Guo
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China.
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13
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Cost-Effectiveness of Arthroplasty Management in Hip and Knee Osteoarthritis: a Quality Review of the Literature. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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Warner MA, Shore-Lesserson L, Shander A, Patel SY, Perelman SI, Guinn NR. Perioperative Anemia. Anesth Analg 2020; 130:1364-1380. [DOI: 10.1213/ane.0000000000004727] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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15
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Cao SL, Ren Y, Li Z, Lin J, Weng XS, Feng B. Clinical effectiveness of 3 days preoperative treatment with recombinant human erythropoietin in total knee arthroplasty surgery: a clinical trial. QJM 2020; 113:245-252. [PMID: 31605493 DOI: 10.1093/qjmed/hcz261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/23/2019] [Indexed: 12/19/2022] Open
Abstract
AIMS The purpose of study is to evaluate the effect and complication of preoperative short-term daily recombinant human erythropoietin (rhEPO) treatment for blood-saving in patients undergoing unilateral primary total knee arthroplasty (TKA). METHODS This three-arm randomized clinical trial compared three different rhEPO-based treatment protocols for unilateral primary TKA. Group A: application of daily doses of rhEPO combined with iron supplement starting 3 days before surgery; Group B: application of daily doses of rhEPO combined with iron supplement starting the day of surgery; Group C: iron supplement alone. Perioperative hemoglobin (Hb) level gaps, total perioperative blood loss, reticulocyte levels and treatment-related complications were studied. RESULTS A total of 102 patients were included (35, 35 and 32 patients in Groups A, B and C, respectively). Total blood loss (TBL) in Groups A, B and C was 490.84, 806.76 and 924.21 ml, respectively. Patients in Group A had a significant lower TBL than Groups B and C (A vs. B: P = 0.010; A vs. C: P < 0.001). There was no difference as for TBL between Groups B and C (P = 0.377). Group A patients had significant smaller Hb decline than Group C on the third and fifth postoperative day (P = 0.049, P = 0.037), as well as than Group B on the fifth postoperative day (P = 0.048). There was no difference as for Hb decline between Groups B and C. No difference was shown in levels of inflammatory biomarkers or blood-saving protocol-related complications among three groups. CONCLUSIONS Daily dose of rhEPO combined with iron supplement administered 3 days before TKA procedures could significantly decrease perioperative blood loss and improve postoperative Hb levels, without significantly elevating risks of complication, when compared with admission of rhEPO on the day of surgery and iron supplement alone. Preoperative daily rhEPO treatment could be a more effective blood-saving protocol in TKA procedures.
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Affiliation(s)
- S-L Cao
- Department of Orthopaedic Surgery, Peking Union Medical College, Beijing 100730, China
| | - Y Ren
- Department of Orthopaedic Surgery, Peking Union Medical College, Beijing 100730, China
| | - Z Li
- Department of Orthopaedic Surgery, Peking Union Medical College, Beijing 100730, China
| | - J Lin
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing 100730, China
| | - X-S Weng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing 100730, China
| | - B Feng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing 100730, China
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17
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Chang X, Li Q, Tang H. Use of preoperative erythropoietin therapy to facilitate autologous blood donation in orthopedic surgery: A meta-analysis. Medicine (Baltimore) 2020; 99:e18577. [PMID: 31914036 PMCID: PMC6959933 DOI: 10.1097/md.0000000000018577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Autologous blood transfusion helps to avoid or reduce the need for allogenic blood transfusion in patients undergoing major surgery. We examined the value of erythropoietin therapy to support preoperative autologous blood donation (PABD) in patients undergoing orthopedic surgery. METHODS For this systematic review and meta-analysis, Medline, Cochrane, EMBASE, and Google Scholar databases were searched from October 26th, 1989 until September 30th, 2017. Primary outcomes were percentages of patients able to donate ≥4 units of blood for autologous transfusion, amount of allogeneic blood transfused, changes in hematocrit and hemoglobin levels from before PABD to immediately before surgery, and adverse events. RESULTS Of 256 studies identified, 18 studies met the inclusion criteria with a total of 1914 patients (mean age 51-69 years), of whom 1153 were treated with erythropoietin. Erythropoietin was associated with a greater percentage of patients able to donate ≥4 units of blood for autologous use compared to controls (OR = 6.00, 95% CI = 3.97 to 9.09, P < .001). Patients receiving preoperative erythropoietin had significantly less of a reduction in hematocrit and hemoglobin levels from before PABD to immediately before surgery compared with controls (hematocrit: mean differences = -1.438, 95% CI = -2.14 to -0.73, P < .001; hemoglobin: mean differences = -1.426, 95% CI = -1.78 to -1.07, P < .001). No significant differences were observed in the amount of allogenic blood transfused between patients receiving erythropoietin and controls (difference in means = -0.220, 95% CI = -0.536 to 0.097, P = .174). Patients who received erythropoietin were less likely to experience dizziness than controls, but the incidence of nausea or fatigue were similar between groups. CONCLUSION Erythropoietin therapy during the PABD period results in less of a reduction in hematocrit and hemoglobin levels and an increase in the percentage of patients able to donate blood preoperatively.
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18
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Surgical prescription of epoetin alfa in contemporary total hip arthroplasty: a prospective comparative study. INTERNATIONAL ORTHOPAEDICS 2019; 44:261-266. [PMID: 31468111 PMCID: PMC6969013 DOI: 10.1007/s00264-019-04399-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/16/2019] [Indexed: 11/05/2022]
Abstract
Purpose Pre-operative anaemia treatment has been associated with reduced morbidity in joint arthroplasty. This study examined the impact of a surgical prescription of epoetin (EPO) in contemporary total hip arthroplasty (THA). Methods We conducted a comparative study in a series of 1402 primary THAs performed in patients all having a pre-operative haemoglobin (Hb) level documented four to eight weeks before THA surgery. In group A (647 hips), one subcutaneous injection of 40,000 IU EPO once a week for four weeks was prescribed at the discretion of anaesthetist during the pre-operative visit in patients with pre-operative Hb between 10 and 13 g/dl. In group S comprising the remaining 755 hips, an amended EPO therapy including two injections of 20,000 to 40,000 IU was prescribed by the surgeon in patients with Hb less than 12 g/dl deemed at high risks to be transfused following THA. Primary study endpoint was the bleeding index (BI). Results EPO therapy was delivered in 43 patients (6.7%) in group A and in 26 patients (3.4%) in group S (p = 0.006). The mean total dose of EPO administrated was 115,349 IU in group A versus 75,200 IU in group S (p < 0.001). The mean BI were 2.7 ± 1.0 in group A and 2.8 ± 1.0 g/dl in group S (p = 0.375). No patient was blood-transfused up to post-operative day seven in group S versus five patients in group A (p = 0.021). Conclusions The amended protocol does not lead to increased peri-operative bleeding. Advances in intra-operative methods to reduce the bleeding allow changing indications of EPO in patients undergoing THA with a low level of Hb.
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19
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Pennestrì F, Maffulli N, Sirtori P, Perazzo P, Negrini F, Banfi G, Peretti GM. Blood management in fast-track orthopedic surgery: an evidence-based narrative review. J Orthop Surg Res 2019; 14:263. [PMID: 31429775 PMCID: PMC6701001 DOI: 10.1186/s13018-019-1296-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research. METHODS AND MATERIALS We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital. RESULTS Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction. CONCLUSION The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.
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Affiliation(s)
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Fisciano, Italy. .,San Giovanni di Dio e Ruggi D'Aragona Hospital "Clinica Orthopedica" Department, Hospital of Salerno, Salerno, Italy. .,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, London, England.
| | - Paolo Sirtori
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Paolo Perazzo
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Francesco Negrini
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Giuseppe Banfi
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy.,Vita-Salute San Raffaele University, Scientific Direction, Milan, Italy
| | - Giuseppe M Peretti
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy.,University of Milan, Department of Biomedical Sciences for Health, Milan, Italy
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20
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Mueller MM, Van Remoortel H, Meybohm P, Aranko K, Aubron C, Burger R, Carson JL, Cichutek K, De Buck E, Devine D, Fergusson D, Folléa G, French C, Frey KP, Gammon R, Levy JH, Murphy MF, Ozier Y, Pavenski K, So-Osman C, Tiberghien P, Volmink J, Waters JH, Wood EM, Seifried E. Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference. JAMA 2019; 321:983-997. [PMID: 30860564 DOI: 10.1001/jama.2019.0554] [Citation(s) in RCA: 406] [Impact Index Per Article: 67.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs. OBJECTIVE To develop a set of evidence-based recommendations for patient blood management (PBM) and for research. EVIDENCE REVIEW The scientific committee developed 17 Population/Intervention/Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018. FINDINGS From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization. CONCLUSIONS AND RELEVANCE The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.
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Affiliation(s)
- Markus M Mueller
- German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Kari Aranko
- European Blood Alliance (EBA), Amsterdam, the Netherlands
| | - Cécile Aubron
- Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
| | | | - Jeffrey L Carson
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | | | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
- Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Dana Devine
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Departments of Medicine, Surgery, Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Gilles Folléa
- Société Française de Transfusion Sanguine (SFTS), Paris, France
| | - Craig French
- Intensive Care, Western Health, Melbourne, Australia
| | | | | | - Jerrold H Levy
- Department of Cardiothoracic Intensive Care Medicine, Duke University Medical Centre, Durham, North Carolina
| | - Michael F Murphy
- National Health Service Blood and Transplant and University of Oxford, Oxford, United Kingdom
| | - Yves Ozier
- Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
| | | | - Cynthia So-Osman
- Sanquin Blood Bank, Leiden and Department of Haematology, Groene Hart Hospital, Gouda, the Netherlands
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
| | | | - Jimmy Volmink
- Department of Clinical Epidemiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jonathan H Waters
- Departments of Anesthesiology and Bioengineering, University of Pittsburgh Medical Centre, Pittsburgh, Pennsylvania
| | - Erica M Wood
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Erhard Seifried
- German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
- European Blood Alliance (EBA), Amsterdam, the Netherlands
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
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Zainul-Abidin S, Amanatullah DF, Anderson MB, Austin M, Barretto JM, Battenberg A, Bedard NA, Bell K, Blevins K, Callaghan JJ, Cao L, Certain L, Chang Y, Chen JP, Cizmic Z, Coward J, DeMik DE, Diaz-Borjon E, Enayatollahi MA, Feng JE, Fernando N, Gililland JM, Goodman S, Goodman S, Greenky M, Hwang K, Iorio R, Karas V, Khan R, Kheir M, Klement MR, Kunutsor SK, Limas R, Morales Maldonado RA, Manrique J, Matar WY, Mokete L, Nung N, Pelt CE, Pietrzak JRT, Premkumar A, Rondon A, Sanchez M, Novaes de Santana C, Sheth N, Singh J, Springer BD, Tay KS, Varin D, Wellman S, Wu L, Xu C, Yates AJ. General Assembly, Prevention, Host Related General: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S13-S35. [PMID: 30360983 DOI: 10.1016/j.arth.2018.09.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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22
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Yaghmour KM, Atkinson S, Chisari E, McDonnell SM, Khan W. Effectiveness and safety of tranexamic acid in total joint arthroplasty. J Perioper Pract 2019; 29:356-360. [PMID: 30650055 DOI: 10.1177/1750458919825812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Total joint arthroplasty is associated with significant blood loss, that could result in the need of blood transfusions. Several techniques are being utilised to limit the volume of blood loss, in order to avoid transfusion. In this review, we look at blood loss in total joint arthroplasty and the perioperative strategies to limit the loss of blood. With the use of tranexamic acid gaining popularity, we analyse the published literature on its use in patients undergoing total joint arthroplasty. We have found that published studies favour using tranexamic acid in total joint arthroplasty as a safe and effective method of reducing blood loss.
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Affiliation(s)
- Khaled M Yaghmour
- Division of Trauma & Orthopaedics Surgery Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Sam Atkinson
- Division of Trauma & Orthopaedics Surgery Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Emanuele Chisari
- Division of Trauma & Orthopaedics Surgery Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico, University of Catania, Catania, Italy
| | - Stephen M McDonnell
- Division of Trauma & Orthopaedics Surgery Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Wasim Khan
- Division of Trauma & Orthopaedics Surgery Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Derzon J, Alford A, Clarke N, Gross I, Shander A, Thurer R. Anemia Management and Audit Feedback Practices for Reducing Overuse of RBC Transfusion: A Laboratory Medicine Best Practice Systematic Review and Meta-Analysis. Am J Clin Pathol 2019; 151:18-28. [PMID: 30357323 DOI: 10.1093/ajcp/aqy123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives To evaluate the effectiveness of anemia management and audit with feedback practices in reducing overuse of RBC transfusion. Methods This review follows the Centers for Disease Control and Prevention's Laboratory Medicine Best Practice Systematic Review (A-6) method. We searched the literature and solicited unpublished studies on practices to reduce overuse of RBC transfusions as measured by reductions in units transfused and proportion of patients transfused. Results Thirteen studies on preoperative anemia management and three studies on audit feedback practices met inclusion criteria. Strength of evidence was high to moderate for reducing the number of units and proportion of patients transfused. Conclusions Preoperative anemia management reduces the proportion of patients transfused and units of RBCs transfused. Audit with feedback across cases, physicians, and/or service areas, as part of a continuous quality improvement practice, reduces the proportion of patients and units of RBCs transfused.
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Affiliation(s)
- James Derzon
- RTI International, Social, Statistical, and Environmental Sciences, Washington, DC
| | - Aaron Alford
- National Network of Public Health Institutes, Research and Evaluation, Washington, DC
| | | | | | - Aryeh Shander
- Englewood Hospital and Medical Center, Englewood, NJ
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Association of preoperative anaemia with postoperative morbidity and mortality: an observational cohort study in low-, middle-, and high-income countries. Br J Anaesth 2018; 121:1227-1235. [DOI: 10.1016/j.bja.2018.08.026] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 07/09/2018] [Accepted: 08/02/2018] [Indexed: 01/01/2023] Open
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25
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Voorn VMA, van Bodegom-Vos L, So-Osman C. Towards a systematic approach for (de)implementation of patient blood management strategies. Transfus Med 2018; 28:158-167. [PMID: 29508467 DOI: 10.1111/tme.12520] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/26/2018] [Accepted: 02/12/2018] [Indexed: 12/14/2022]
Abstract
Despite the increasing availability of evidence in transfusion medicine literature, this evidence does not automatically find its way into practice. This is also applicable to patient blood management (PBM). It may concern the lack of implementation of effective new techniques or treatments, or it may apply to the (over)use of techniques and treatments (e.g. inappropriate transfusions) that have proven to be of limited benefit for patients (low-value care) and could be abandoned (de-implementation). In PBM literature, the implementation of restrictive transfusion thresholds and the de-implementation of inappropriate transfusions are described. However, most implementation strategies were not preceded by the identification of relevant barriers, and the used strategies were not often supported by literature on behavioural changes. In this article, we describe implementation vs de-implementation, highlight the current situation of (de)implementation in PBM and describe a systematic approach for (de)implementation illustrated by an example of a PBM de-implementation study regarding '(cost-) effective patient blood management in total hip and knee arthroplasty'. The systematic approach used for (de)implementation is based on the implementation model of Grol, which consists of the following five steps: the detection of improvement goals, a problem analysis, the selection of (de)implementation strategies, the execution of the (de)implementation strategy and an evaluation. Based on the description of the current situation and the experiences in our de-implementation study, we can conclude that de-implementation may be more difficult than expected as other factors may play a role in effective de-implementation compared to implementation.
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Affiliation(s)
- V M A Voorn
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.,Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - L van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - C So-Osman
- Unit Transfusion Medicine, Sanquin, Leiden, The Netherlands.,Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
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Lu Q, Peng H, Zhou G, Yin D. Perioperative Blood Management Strategies for Total Knee Arthroplasty. Orthop Surg 2018; 10:8-16. [PMID: 29424017 PMCID: PMC6594499 DOI: 10.1111/os.12361] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/24/2017] [Indexed: 01/28/2023] Open
Abstract
Total knee arthroplasty (TKA) often causes a significant amount of blood loss with an accompanying decline in hemoglobin and may increase the frequency of allogeneic blood transfusion rates. Unfortunately, allogeneic blood transfusions have associated risks including postoperative confusion, infection, cardiac arrhythmia, fluid overload, increased length of hospital stay, and increased mortality. Other than reducing the need for blood transfusions, reducing perioperative blood loss in TKA may also minimize intra-articular hemorrhage, limb swelling, and postoperative pain, and increase the range of motion during the early postoperative period. These benefits improve rehabilitation success and increase patients' postoperative satisfaction. Preoperative anemia, coupled with intraoperative and postoperative blood loss, is a major factor associated with higher rates of blood transfusion in TKA. Thus, treatment of preoperative anemia and prevention of perioperative blood loss are the primary strategies for perioperative blood management in TKA. This review, combined with current evidence, analyzes various methods of blood conservation, including preoperative, intraoperative, and postoperative methods, in terms of their effectiveness, safety, and cost. Because many factors can be controlled to reduce blood loss and transfusion rates in TKA, a highly efficient, safe, and cost-effective blood management strategy can be constructed to eliminate the need for transfusions associated with TKA.
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Affiliation(s)
- Qiang Lu
- Department of OrthopaedicsRenmin Hospital of Wuhan UniversityWuhanChina
| | - Hao Peng
- Department of OrthopaedicsRenmin Hospital of Wuhan UniversityWuhanChina
| | - Guan‐jin Zhou
- Department of Orthopaedics, Puai Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Dong Yin
- Department of OrthopaedicsThe People’s Hospital of Guangxi Zhuang Autonomous RegionNanningChina
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Lee H, Yuh YJ. A Paradigm Shift: Perioperative Iron and Erythropoietin Therapy for Patient Blood Management. ACTA ACUST UNITED AC 2018. [DOI: 10.7599/hmr.2018.38.1.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Hyesun Lee
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Young Jin Yuh
- Department of Internal Medicine, Inje University Paik Hospital, Seoul, Korea
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Preoperative optimisation of anaemia for primary total hip arthroplasty: a systematic review. Hip Int 2017; 27:515-522. [PMID: 28605004 DOI: 10.5301/hipint.5000530] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND The 2009 NHS Blood and Transplant national comparative audit on blood use following primary total hip arthroplasty (THR) highlighted that preoperative anaemia was common and undertreated. They recommended that hospitals have a written policy for treating anaemia preoperatively. In our centre, we found that preoperative optimisation of anaemia, significantly reduced blood transfusion rate to <5%. The 2015 national audit showed that even though 48% of patients received tranexamic acid, 85% of patients required transfusion. By conducting a systematic review of literature on blood management for preoperative anaemia in primary THR; we aimed to validate the recommendations of the national audit and increase its awareness in the orthopaedic community. METHODS A PubMed Search was performed to identify suitable literature limited to randomised controlled trials, cohort studies, meta-analyses and systematic reviews involving primary THR. We excluded any THRs performed for trauma and revision arthroplasty. Our exclusion criteria for the intervention was the use of autologous methods such as cell salvage techniques and preoperative autologous blood donation. RESULTS Analysis of 13 publications showed widespread study heterogeneity, which precluded meta-analysis. Preoperative blood management (PBM) interventions included the use of recombinant human erythropoietin and oral iron supplementation in 12/13 and 11/13 studies respectively. There were significant differences in transfusion rates between PBM and control groups in 12/13 studies. CONCLUSIONS The findings overwhelmingly support preoperative optimisation of anaemia. The main barrier to wider implementation remains the cost effectiveness. We recommend using our validated protocol, which has shown to significantly reduce transfusion rates, length of stay and remain cost effective.
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Boutsiadis A, Reynolds RJ, Saffarini M, Panisset JC. Factors that influence blood loss and need for transfusion following total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:418. [PMID: 29201870 DOI: 10.21037/atm.2017.08.11] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Blood loss during total knee arthroplasty (TKA) remains a concern, as many patients require blood transfusions, which increase risks of allergic reactions, disease transmission, and thromboembolisms. The purpose was to determine factors associated with blood loss and need for transfusion in patients receiving routine TKA. Methods The authors prospectively analyzed 150 consecutive uncemented TKAs for age, gender, body mass index (BMI), anticoagulant medication, type of anesthesia, tranexamic acid (TXA) administration, tourniquet inflation, drain placement, pre- and post-operative Haemoglobin (Hb) level (g/dL), and whether transfusion was necessary. Univariable and multivariable regression analyses were performed to identify factors associated with Hb loss and need for transfusion with significance level set at P value<0.05. Results The cohort comprised 92 women and 58 men, aged 69.5±8.9 years. The mean Hb loss was 3.7±1.3 g/dL. The 20 patients (13%) who had transfusions also had lower preoperative Hb (12.6±1.2 g/dL) compared to the remaining patients (14.3±1.2 g/dL). Hb loss was significantly associated with preoperative Hb, TXA, and gender, but multivariable regression identified gender as a confounder and indicated that TXA reduced Hb loss by 0.92 g/dL. Multivariable regression revealed the need for transfusion was only significantly associated with preoperative Hb and indicated that a decrease of preoperative Hb by 1 g/dL nearly quadrupled the chances of needing transfusion. Conclusions Hb loss was significantly associated with preoperative Hb levels and use of TXA, while the need for transfusion was only associated with preoperative Hb levels. These findings could help identify patients at risk for blood transfusions. Level of evidence: level III, prospective case series.
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Affiliation(s)
- Achilleas Boutsiadis
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | | | - Mo Saffarini
- Medical Technology, ReSurg SA, Nyon, Switzerland
| | - Jean-Claude Panisset
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
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Themistoklis T, Theodosia V, Konstantinos K, Georgios DI. Perioperative blood management strategies for patients undergoing total knee replacement: Where do we stand now? World J Orthop 2017; 8:441-454. [PMID: 28660135 PMCID: PMC5478486 DOI: 10.5312/wjo.v8.i6.441] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/20/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Total knee replacement (TKR) is one of the most common surgeries over the last decade. Patients undergoing TKR are at high risk for postoperative anemia and furthermore for allogeneic blood transfusions (ABT). Complications associated with ABT including chills, rigor, fever, dyspnea, light-headedness should be early recognized in order to lead to a better prognosis. Therefore, perioperative blood management program should be adopted with main aim to reduce the risk of blood transfusion while maximizing hemoglobin simultaneously. Many blood conservation strategies have been attempted including preoperative autologous blood donation, acute normovolemic haemodilution, autologous blood transfusion, intraoperative cell saver, drain clamping, pneumatic tourniquet application, and the use of tranexamic acid. For practical and clinical reasons we will try to classify these strategies in three main stages/pillars: Pre-operative optimization, intra-operative and post-operative protocols. The aim of this work is review the strategies currently in use and reports our experience regarding the perioperative blood management strategies in TKR.
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Voorn VMA, Marang-van de Mheen PJ, van der Hout A, Hofstede SN, So-Osman C, van den Akker-van Marle ME, Kaptein AA, Stijnen T, Koopman-van Gemert AWMM, Dahan A, Vliet Vlieland TPMM, Nelissen RGHH, van Bodegom-Vos L. The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial. Implement Sci 2017; 12:72. [PMID: 28558843 PMCID: PMC5450044 DOI: 10.1186/s13012-017-0601-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/16/2017] [Indexed: 01/07/2023] Open
Abstract
Background Perioperative autologous blood salvage and preoperative erythropoietin are not (cost) effective to reduce allogeneic transfusion in primary hip and knee arthroplasty, but are still used. This study aimed to evaluate the effectiveness of a theoretically informed multifaceted strategy to de-implement these low-value blood management techniques. Methods Twenty-one Dutch hospitals participated in this pragmatic cluster-randomized trial. At baseline, data were gathered for 924 patients from 10 intervention and 1040 patients from 11 control hospitals undergoing hip or knee arthroplasty. The intervention included a multifaceted de-implementation strategy which consisted of interactive education, feedback on blood management performance, and a comparison with benchmark hospitals, aimed at orthopedic surgeons and anesthesiologists. After the intervention, data were gathered for 997 patients from the intervention and 1096 patients from the control hospitals. The randomization outcome was revealed after the baseline measurement. Primary outcomes were use of blood salvage and erythropoietin. Secondary outcomes included postoperative hemoglobin, length of stay, allogeneic transfusions, and use of local infiltration analgesia (LIA) and tranexamic acid (TXA). Results The use of blood salvage (OR 0.08, 95% CI 0.02 to 0.30) and erythropoietin (OR 0.30, 95% CI 0.09 to 0.97) reduced significantly over time, but did not differ between intervention and control hospitals (blood salvage OR 1.74 95% CI 0.27 to 11.39, erythropoietin OR 1.33, 95% CI 0.26 to 6.84). Postoperative hemoglobin levels were significantly higher (β 0.21, 95% CI 0.08 to 0.34) and length of stay shorter (β −0.36, 95% CI −0.64 to −0.09) in hospitals receiving the multifaceted strategy, compared with control hospitals and after adjustment for baseline. Transfusions did not differ between the intervention and control hospitals (OR 1.06, 95% CI 0.63 to 1.78). Both LIA (OR 0.0, 95% CI 0.0 to 0.0) and TXA (OR 0.3, 95% CI 0.2 to 0.5) were significantly associated with the reduction in blood salvage over time. Conclusions Blood salvage and erythropoietin use reduced over time, but not differently between intervention and control hospitals. The reduction in blood salvage was associated with increased use of local infiltration analgesia and tranexamic acid, suggesting that de-implementation is assisted by the substitution of techniques. The reduction in blood salvage and erythropoietin did not lead to a deterioration in patient-related secondary outcomes. Trial registration www.trialregister.nl, NTR4044 Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0601-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Veronique M A Voorn
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.,Department of Orthopedic Surgery, Groene Hart Hospital, Bleulandweg 10, 2803, HH, Gouda, The Netherlands
| | - Perla J Marang-van de Mheen
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Anja van der Hout
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.,Department of Clinical Psychology, Vrije Universiteit Amsterdam, Van der Boechorststraat 1-3, 1081, BT, Amsterdam, The Netherlands
| | - Stefanie N Hofstede
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Cynthia So-Osman
- Department of Transfusion Medicine, Sanquin Blood Supply, Plesmanlaan 1a, 2333, BZ, Leiden, The Netherlands.,Department of Internal Medicine, Groene Hart Hospital, Bleulandweg 10, 2803, HH, Gouda, The Netherlands
| | - M Elske van den Akker-van Marle
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Ad A Kaptein
- Department of Medical Psychology, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Theo Stijnen
- Department of Medical Statistics & Bioinformatics, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | | | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Thea P M M Vliet Vlieland
- Department of Orthopedics, Leiden University Medical Center, J11-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Rob G H H Nelissen
- Department of Orthopedics, Leiden University Medical Center, J11-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
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Lee GW, Park KS, Kim DY, Shin YR, Yoon TR. New strategy of closed suction drainage after primary total hip arthroplasty. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:223-226. [PMID: 28336196 PMCID: PMC6197411 DOI: 10.1016/j.aott.2017.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/06/2016] [Accepted: 07/03/2016] [Indexed: 12/02/2022]
Abstract
Objective The purpose of this study was to evaluate the effect of late applied negative pressure on postoperative drain output after primary total hip arthroplasty (THA). Patients and methods 100 patients (100 hips) were treated by closed suction drainage applying negative pressure immediately after THA (group I). The remaining 100 patients (100 hips) were treated by the same drainage system, but the negative pressure was not applied in the first 24 h after THA and then negative pressure was applied (group II). Results The mean total drain output was different between the two groups (group I: 597 ± 200.1 mL, group II: 403 ± 204.1 mL; p < 0.05). Reported drain output from immediate postoperative to postoperative day one was 369 ± 125.5 ml in group I and 221 ± 141.3 ml in group II (p < 0.05). The change of hemoglobin from immediate postoperative to 24 h after THA was lower in group II (group I: 1.5 ± 0.62 g/dL, group II: 1.1 ± 0.73 g/dL; p = 0.004). The mean unit number of blood transfusions was 1.0 (range, 0.0–5.0) in group I and 0.3 (range, 0.0–2.0) in group II (p < 0.05). There was no difference in Harris hip score between the two groups at postoperative 1 year or last follow-up (p = 0.073). Conclusion The minor change in drain system management can reduce postoperative blood loss after primary THA and the need for transfusion. Level of evidence: Level III, Therapeutic study
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Rosique RG, Rosique MJF, Rabelo MQ. Does Postoperative Erythropoietin Reduce Transfusions and Hemodynamic Instability Following Liposuction, Either Alone or Associated with Abdominoplasty or Mammaplasty? A Comparative, Prospective Study of 50 Consecutive Patients. Aesthetic Plast Surg 2017; 41:98-101. [PMID: 28039503 DOI: 10.1007/s00266-016-0748-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/18/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Erythropoietin (EPO) is a hematopoietic growth factor and an alternative to avoid blood transfusion in high-blood-loss surgeries. We evaluate EPO efficacy to reduce clinically relevant anemia and dehydration in patients undergoing liposuction. METHODS We prospectively evaluated 50 consecutive patients subjected to liposuction greater than 2.5 L and alternately assigned into two comparable groups (25 patients each), except for the postoperative administration of erythropoietin (4000 UI per day subcutaneously) during five consecutive days. Incidence data for blood transfusion or parenteral hydration were collected. Statistical analyses were performed with significance at p value <5%. RESULTS There was no significant difference between groups related to any preoperative feature or the incidence of dehydration (p = 0.1099) or transfusion (p = 1.0). CONCLUSION Postoperative erythropoietin administration was not effective in preventing blood transfusion for anemia or parenteral hydration for hemodynamic instability in patients undergoing major liposuction. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.
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Affiliation(s)
- Rodrigo G Rosique
- Rosique Plastic Surgery, Antonio Diederichsen Street, 400, Suite 1204, Ribeirão Preto, São Paulo, 14020-250, Brazil.
| | - Marina J F Rosique
- Rosique Plastic Surgery, Antonio Diederichsen Street, 400, Suite 1204, Ribeirão Preto, São Paulo, 14020-250, Brazil
| | - Mariana Quintino Rabelo
- Rosique Plastic Surgery, Antonio Diederichsen Street, 400, Suite 1204, Ribeirão Preto, São Paulo, 14020-250, Brazil
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Correction of iron-deficiency anaemia in colorectal surgery reduces perioperative transfusion rates: A before and after study. Int J Surg 2017; 38:1-8. [DOI: 10.1016/j.ijsu.2016.12.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/06/2016] [Accepted: 12/10/2016] [Indexed: 11/23/2022]
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Styron JF, Klika AK, Szubski CR, Tolich D, Barsoum WK, Higuera CA. Relative efficacy of tranexamic acid and preoperative anemia treatment for reducing transfusions in total joint arthroplasty. Transfusion 2016; 57:622-629. [DOI: 10.1111/trf.13955] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 11/05/2016] [Accepted: 11/06/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Joseph F. Styron
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Alison K. Klika
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Caleb R. Szubski
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Deborah Tolich
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Wael K. Barsoum
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
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Phruetthiphat OA, Gao Y, Anthony CA, Pugely AJ, Warth LC, Callaghan JJ. Incidence of and Preoperative Risk Factors for Surgical Delay in Primary Total Hip Arthroplasty: Analysis From the American College of Surgeons National Surgical Quality Improvement Program. J Arthroplasty 2016; 31:2432-2436. [PMID: 27381373 DOI: 10.1016/j.arth.2016.05.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 04/25/2016] [Accepted: 05/25/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total joint arthroplasty is a proven treatment for osteoarthritis of the knee and hip that has failed conservative treatment. While most of total joint arthroplasty is considered elective with surgery on the day of admission, a small subset of patients may require delay in surgery past the day of admission. Recently, surgical delay for primary total knee arthroplasty has been identified. However, the incidence, outcomes, and risk factors for delay in surgery before total hip arthroplasty (THA) have not been previously defined. QUESTIONS/PURPOSE In patients undergoing THA, we sought to define (1) the incidence of and risk factors for delay in surgery, (2) the postoperative complications between surgical delay and no surgical delay cohorts, and (3) association of the Charlson comorbidity index (CCI) in patients with delay of surgery. METHODS We retrospectively queried the National Surgical Quality Improvement Program database using Current Procedural Terminology billing codes and identified 7890 THAs performed between 2006 and 2010. Univariate and subsequent multivariate logistic regression analysis were then used to identify risk factors for surgical delay. Correlation between CCI and surgical delay in THA was evaluated. RESULTS One-hundred seventy-nine patients (2.31%) were identified as experiencing a surgical delay before THA. Multivariate analysis identified congestive heart failure (CHF) (P = .0038), bleeding disorder (P < .0001), sepsis (P < .0001), prior operation in past 30 days (P = .0001), dependent functional status (P < .0001), American Society of Anesthesiologists class 3 (P = .0001), American Society of Anesthesiologists class 4 (P = .0023), significant weight loss (P = .0109), and hematocrit <38% (P < .0001) as independent risk factors for delay in surgery. Compared with the nondelay cohort, those experiencing surgical delay before THA had higher rates of postoperative surgical (8.9% vs 3.1%, P < .0001) and medical complications (23.5% vs 10.1%, P < .0001). Mean CCI was higher in the THA surgical delay cohort (3.16 vs 2.24, P < .0001) compared with the nondelay group. CONCLUSION Surgical delay in patients undergoing THA may cause undue disruption in surgeon and hospital resource utilization. In an era of quality assessment and cost consciousness, it is important to understand that the short-term outcomes of elective, same day THA differ dramatically from those hospitalized for medical necessity before surgery. Surgeons should consider thorough medical evaluation in those with CHF, bleeding disorders, sepsis, significant weight loss, and hematocrit <38% before hospital admission.
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Affiliation(s)
- Ong-Art Phruetthiphat
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa; Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Yubo Gao
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa
| | - Chris A Anthony
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa
| | - Andrew J Pugely
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa
| | - Lucian C Warth
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa
| | - John J Callaghan
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa
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Affiliation(s)
- James T Ninomiya
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Combination of erythropoietin and tranexamic acid in bilateral simultaneous total hip arthroplasty: a randomised, controlled trial. Hip Int 2016; 26:331-7. [PMID: 27102553 DOI: 10.5301/hipint.5000356] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/01/2016] [Indexed: 02/05/2023]
Abstract
INTRODUCTION This study aimed to evaluate whether the combination of erythropoietin (EPO) and tranexamic acid (TXA) exerted any additional benefits on the number of blood transfusions required and haematological parameters compared with TXA alone following primary bilateral simultaneous total hip arthroplasty. MATERIALS AND METHODS We conducted a single-centre, prospective, randomised, and controlled trial at our hospital. Group EPO + TXA (n = 30) received daily subcutaneous injections EPO (10,000 IU) on preoperative days 1-4 and postoperative days 1-3. Additionally, these patients were administered TXA (15 mg/kg) 10 min prior to the incision. Group TXA (n = 32) received only TXA (15 mg/kg) 10 min prior to the incision. The primary outcomes were the haematological parameters and number of blood transfusions required. The secondary outcomes were total blood loss, drainage volume, and postoperative complications. RESULTS The total amount of blood transfusion and mean blood transfusion per patient was lower in group EPO + TXA than in group TXA (p = 0.039, p = 0.023; respectively). In the postoperative period, patients in group EPO + TXA had higher haematological parameters (haemoglobin, haematocrit, and reticulocyte count) than patients in group TXA. No significant differences were found in total blood loss, drainage volume, and DVT or PE between the 2 groups. CONCLUSIONS This study showed that administrating EPO + TXA in combination can increase haematological parameters and reduce the need for blood transfusion without increasing the risk of DVT or PE compared with TXA alone.
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Zhao Y, Jiang C, Peng H, Feng B, Li Y, Weng X. The effectiveness and safety of preoperative use of erythropoietin in patients scheduled for total hip or knee arthroplasty: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2016; 95:e4122. [PMID: 27399121 PMCID: PMC5058850 DOI: 10.1097/md.0000000000004122] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Because allogeneic blood transfusion carries a risk of serious complications, erythropoietin (EPO) has been used in patients scheduled for total hip or knee arthroplasty in an effort to reduce the need for allogeneic blood transfusion; however, its efficacy, cost-effectiveness, and safety are still controversial. The purpose of this review was to determine the hematopoiesis-promoting effect and potential complications, as well as the cost-effectiveness, of preoperative use of EPO in patients scheduled for total hip or knee arthroplasty. METHODS We searched MEDLINE, EMBASE, Cochrane, and ClinicalTrials.gov databases for relevant literature from 2000 to 2015. Risk of bias was assessed for all included studies and data were extracted and analyzed. RESULTS Preoperative use of EPO was associated with lower exposure to allogeneic blood transfusion (odds ratio = 0.41) and higher hemoglobin concentration after surgery (standardized mean difference = 0.86, P < 0.001). Complications were not generally reported, but there was no significant difference between the group with and without EPO based on given data. Cost-effectiveness was also summarized but was not conclusive. CONCLUSION Preoperative administration of EPO reduces the requirement for allogeneic blood transfusion and increases hemoglobin level after surgery. The studies of cost-effectiveness were not conclusive. Further studies and guidelines specific to blood management in the perioperative stage of total knee and hip arthroplasty are expected.
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Affiliation(s)
| | | | | | | | | | - Xisheng Weng
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China
- Correspondence: Xisheng Weng, MD, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing 100730, China (e-mail: )
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Li J, Zhao J, He C, Tong W, Zou Y, Xu W. Comparison of Blood Loss After Total Hip Arthroplasty Between Ankylosing Spondylitis and Osteoarthritis. J Arthroplasty 2016; 31:1504-9. [PMID: 27006146 DOI: 10.1016/j.arth.2015.12.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/12/2015] [Accepted: 12/17/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study was conducted to compare the blood loss during primary total hip arthroplasty (THA) between ankylosing spondylitis (AS) and hip osteoarthritis (OA). METHODS We reviewed 120 THAs in 68 patients comprising 3 groups: AS with total bony ankylosis of the hips (ASB), AS with stiff hips (ASS), and OA. Demographics, perioperative laboratory values, intraoperative data, blood loss, transfusion rate, transfusion reactions, surgical complications, hospitalization cost, and length of stay (LOS) were collected and analyzed among ASB, ASS, and OA groups. RESULTS The patients of the ASB and ASS groups were much younger and thinner than those of the OA group. There were no significant differences in the preoperative values of activated partial thromboplastin time, prothrombin time, and international normalized ratio among the 3 groups (all P > .05). The intraoperative blood loss, volume of drainage, hidden blood loss, transfusion rate, transfusion reactions, and hospitalization cost in the ASB group were significantly higher than in the other 2 groups, although not significantly different between the ASS and OA groups (P > .05). CONCLUSION Both AS and OA can cause hyperosteogeny to the hips, but ASB patients have more serious symptoms in their affected hips. This may cause more blood loss in THA surgery because of bone surface bleeding. The reason that ASB patients suffered more blood loss may be related to the high difficulty and long duration of the operation.
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Affiliation(s)
- Jia Li
- Department of Orthopedics, Changhai Hospital Affiliated to the Second Military Medical University, Shanghai, China
| | - Jinzhu Zhao
- Department of Orthopedics, No. 401 Hospital, Jinan Military Region of PLA, Qingdao, Shandong, China
| | - Chongru He
- Department of Orthopedics, Changhai Hospital Affiliated to the Second Military Medical University, Shanghai, China
| | - Wenwen Tong
- Department of Orthopedics, Changhai Hospital Affiliated to the Second Military Medical University, Shanghai, China
| | - Yuming Zou
- Department of Orthopedics, Changhai Hospital Affiliated to the Second Military Medical University, Shanghai, China
| | - Weidong Xu
- Department of Orthopedics, Changhai Hospital Affiliated to the Second Military Medical University, Shanghai, China
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Voorn VMA, Hout A, So‐Osman C, Vliet Vlieland TPM, Nelissen RGHH, Akker‐van Marle ME, Dahan A, Marang‐van de Mheen PJ, Bodegom‐Vos L. Erythropoietin to reduce allogeneic red blood cell transfusion in patients undergoing total hip or knee arthroplasty. Vox Sang 2016; 111:219-225. [DOI: 10.1111/vox.12412] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/14/2016] [Accepted: 03/30/2016] [Indexed: 01/28/2023]
Affiliation(s)
- V. M. A. Voorn
- Department of Medical Decision Making Leiden University Medical Center Leiden The Netherlands
| | - A. Hout
- Department of Medical Decision Making Leiden University Medical Center Leiden The Netherlands
| | - C. So‐Osman
- Department of Transfusion Medicine and Centre for Clinical Transfusion Research Sanquin Blood Supply Foundation Leiden The Netherlands
- Department of Internal Medicine Groene Hart Hospital Gouda The Netherlands
| | | | - R. G. H. H. Nelissen
- Department of Orthopaedics Leiden University Medical Center Leiden The Netherlands
| | - M. E. Akker‐van Marle
- Department of Medical Decision Making Leiden University Medical Center Leiden The Netherlands
| | - A. Dahan
- Department of Anaesthesiology Leiden University Medical Center Leiden The Netherlands
| | | | - L. Bodegom‐Vos
- Department of Medical Decision Making Leiden University Medical Center Leiden The Netherlands
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Bernabeu‐Wittel M, Romero M, Ollero‐Baturone M, Aparicio R, Murcia‐Zaragoza J, Rincón‐Gómez M, Monte‐Secades R, Melero‐Bascones M, Rosso CM, Ruiz‐Cantero A. Ferric carboxymaltose with or without erythropoietin in anemic patients with hip fracture: a randomized clinical trial. Transfusion 2016; 56:2199-211. [DOI: 10.1111/trf.13624] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 03/08/2016] [Accepted: 03/17/2016] [Indexed: 12/11/2022]
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Phan DL, Ani F, Schwarzkopf R. Cost Analysis of Tranexamic Acid in Anemic Total Joint Arthroplasty Patients. J Arthroplasty 2016; 31:579-82. [PMID: 26601635 DOI: 10.1016/j.arth.2015.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 09/30/2015] [Accepted: 10/02/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Preoperative anemia is present in 20% of total joint arthroplasty patients. Current preoperative treatment options, including iron supplementation (FE) and erythropoietin (EPO), are expensive. Tranexamic acid (TXA) has been adopted as an intraoperative adjunct to decrease blood loss. Our hypothesis is that TXA is a cost-effective treatment compared to FE and EPO in anemic patients. METHODS In this study, a cost analysis was performed, comparing the material costs of TXA and packed red blood cells (PRBCs) to the theoretical administration and material costs of FE and EPO per standard preoperative anemia protocol. RESULTS A total of 243 patients were included in the study. Of this group, 18.5% (45/243) had preoperative anemia. The rate of transfusion was 6.7% (3/45), and 5 units of PRBCs was transfused. The combined cost of TXA and PRBCs was $5317.08. Even assuming a best-case scenario with FE or EPO treatment without a postoperative PRBC requirement, the cost of treatment would range from 2 to 17 times more than treatment with TXA. An additional 50 units of PRBC (1.1 units per patient) would need to be transfused for the cost of TXA treatment to be equivalent to FE or EPO treatment. CONCLUSION Tranexamic acid is significantly less expensive than FE or EPO as a treatment option for total joint arthroplasty patients presenting with preoperative anemia. It is a cost-effective adjunct for limiting transfusion rates in this patient population. We recommend that new preoperative anemia levels that necessitate preoperative intervention be established.
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Affiliation(s)
- Duy L Phan
- University of California, Irvine School of Medicine, Irvine, California
| | - Fiyinfoluwa Ani
- University of California, Irvine School of Medicine, Irvine, California
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
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McGoldrick NP, O’Connor EM, Davarinos N, Galvin R, Quinlan JF. Cost benefit analysis of the use of tranexamic acid in primary lower limb arthroplasty: A retrospective cohort study. World J Orthop 2015; 6:977-982. [PMID: 26716094 PMCID: PMC4686445 DOI: 10.5312/wjo.v6.i11.977] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/14/2015] [Accepted: 10/08/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine the cost benefit conferred by the perioperative administration of intravenous tranexamic acid (TXA) in lower limb arthroplasty.
METHODS: This study evaluates the use of TXA in 200 consecutive lower limb arthroplasties performed in a single surgeon series. The initial 100 patients (control group) underwent surgery without perioperative administration of TXA while the subsequent 100 patients (TXA group) all received 1 g TXA at the time of induction of anaesthesia. Pre- and post-operative haemoglobin, platelet count, haematocrit, the use of blood product post-operatively, length of stay were examined. A financial analysis of both groups was then undertaken.
RESULTS: The mean age of patients in both groups was 63 ± 13 years. There were no significant differences between groups in terms of gender (P = 0.47), proportion of total hip replacement to total knee replacement (P = 0.25) or pre-operative haemoglobin (P = 0.43). In the control group, the transfusion rate was 22%. In the TXA group, the transfusion rate dropped to 2% (P < 0.001). The mean post-operative haemoglobin was 10.82 ± 1.55 g/dL in the control group vs 11.33 ± 1.27 g/dL in the TXA group (P = 0.01). The total cost of transfused blood products was €11055 and €603 respectively. The mean length of stay in the control group was 6.53 ± 5.93 d vs 5.47 ± 4.26 d in the TXA group (P = 0.15) leading to an estimated financial saving of €114586. There was one pulmonary embolus in the control group and one deep venous thrombosis in the TXA group.
CONCLUSION: Intravenous TXA reduces blood loss in lower limb arthroplasty. This leads to lower transfusion rates, shorter length of stay in hospital and significant financial savings.
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Guinn NR, Guercio JR, Hopkins TJ, Grimsley A, Kurian DJ, Jimenez MI, Bolognesi MP, Schroeder R, Aronson S. How do we develop and implement a preoperative anemia clinic designed to improve perioperative outcomes and reduce cost? Transfusion 2015; 56:297-303. [DOI: 10.1111/trf.13426] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 10/15/2015] [Accepted: 10/15/2015] [Indexed: 12/16/2022]
Affiliation(s)
| | - Jason R. Guercio
- North American Partners in Anesthesia; Hospital of Central Connecticut; New Britain Connecticut
| | | | | | | | | | - Michael P Bolognesi
- Department of Surgery; Duke University Medical Center; Durham North Carolina
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What Are Risk Factors for 30-day Morbidity and Transfusion in Total Shoulder Arthroplasty? A Review of 1922 Cases. Clin Orthop Relat Res 2015; 473:2099-105. [PMID: 25524429 PMCID: PMC4419001 DOI: 10.1007/s11999-014-4107-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/09/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Total shoulder arthroplasty (TSA) is an effective treatment for end-stage glenohumeral joint pathology with good long-term results. Previous descriptions of morbidity and blood transfusion in TSA are limited by preoperative risk factors and postoperative complications considered and single-center studies. QUESTIONS/PURPOSES The purpose of this study was to define in a group of patients undergoing TSA (1) the type and incidence of complications; (2) the frequency of and risk factors for both minor and major complications; and (3) the risk factors for bleeding resulting in transfusion. METHODS We retrospectively queried the National Surgical Quality Improvement Program database using Current Procedural Terminology billing codes and identified 1922 cases of TSA performed between 2006 and 2011. Postoperative outcomes were divided into one of four categories: any complication, major morbidity (systemic life-threatening event or a substantial threat to a vital organ) or mortality, minor morbidity (localized to the operative upper extremity or not posing a major systemic threat to the patient), or bleeding resulting in transfusion. Univariate and multivariate analyses were then used to identify risk factors for complications. RESULTS There were a total of 155 complications (8% of the 1922 patients identified). The most common complication was bleeding resulting in transfusion (82 patients [4.26%]) followed by urinary tract infections (27 patients [1.40%]), return to the operating room (14 patients [0.73%]), pneumonia (10 patients [0.52%]), and peripheral nerve injury (nine patients [0.47%]). The incidence of major morbidity was 2% (44 patients), which included five patients (0.26%) who died; the incidence of any minor morbidity was 7% (136 patients). After controlling for likely confounding variables, we found steroid use (odds ratio [OR], 3; 95% confidence interval [CI], 2-6), hematocrit < 38% (OR, 2; 95% CI, 1-3), American Society of Anesthesiologists (ASA) Class 4 (OR, 3; 95% CI, 1-7), and operating time > 2 hours (OR, 2; 95% CI, 1-3) as independent predictors of complication and congestive heart failure (OR, 12; 95% CI, 1-106) as an independent risk factor for major morbidity or mortality. Hematocrit < 38% (OR, 3; 95% CI, 2-6), resident involvement (OR, 3; 95% CI, 2-5), steroid use (OR, 3; 95% CI, 1-6), and ASA Class 3 versus 1 or 2 (OR, 2; 95% CI, 1-5) were independent risk factors for bleeding resulting in transfusion. CONCLUSIONS Short-term morbidity after TSA is higher than previously reported. The prevalence of complications within 30 days of surgery and our outlined risk factors should guide surgeon-driven preoperative patient evaluation, management, and counseling. Surgeons who perform TSA should be aware operative time > 2 hours is associated with increased complications. Patients with preoperative hematocrit < 38%, history of steroid use, ASA Class > 2, and patients with congestive heart failure should receive medical optimization before TSA. LEVEL OF EVIDENCE Level III, therapeutic study.
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Styron JF, Higuera CA, Klika AK, Molloy R. The role of tranexamic acid in a comprehensive blood management protocol for total hip and knee arthroplasty patients. ACTA ACUST UNITED AC 2015. [DOI: 10.1053/j.sart.2015.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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