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Zhang FQ, Yang YZ, Li PF, Ma GR, Zhang AR, Zhang H, Guo HZ. Impact of preoperative anemia on patients undergoing total joint replacement of lower extremity: a systematic review and meta-analysis. J Orthop Surg Res 2024; 19:249. [PMID: 38637795 PMCID: PMC11027536 DOI: 10.1186/s13018-024-04706-y] [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: 10/04/2023] [Accepted: 03/29/2024] [Indexed: 04/20/2024] Open
Abstract
PURPOSE Preoperative anemia increases postoperative morbidity, mortality, and the risk of allogeneic transfusion. However, the incidence of preoperative anemia in patients undergoing total hip arthroplasty and total knee arthroplasty (TKA) and its relationship to postoperative outcomes has not been previously reported. METHODS We conducted a comprehensive literature search through PubMed, Cochrane Library, Web of Sincien, and Embase from inception to July 2023 to investigate the prevalence of preoperative anemia in patients undergoing Total Joint Arthroplasty, comorbidities between anemic and non-anemicpatients before surgery, and postoperative outcomes. postoperative outcomes were analyzed. Overall prevalence was calculated using a random-effects model, and heterogeneity between studies was examined by Cochran's Q test and quantified by the I2 statistic. Subgroup analyses and meta-regression analyses were performed to identify sources of heterogeneity. Publication bias was assessed by funnel plots and validated by Egger's test. RESULTS A total of 21 studies with 369,101 samples were included, all of which were retrospective cohort studies. 3 studies were of high quality and 18 studies were of moderate quality. The results showed that the prevalence of preoperative anemia was 22% in patients awaiting arthroplasty; subgroup analyses revealed that the prevalence of preoperative anemia was highest in patients awaiting revision of total knee arthroplasty; the highest prevalence of preoperative anemia was found in the Americas; preoperative anemia was more prevalent in the female than in the male population; and preoperative anemia with a history of preoperative anemia was more common in the female than in the male population. patients with a history of preoperative anemia; patients with joint replacement who had a history of preoperative anemia had an increased risk of infection, postoperative blood transfusion rate, postoperative blood transfusion, Deep vein thrombosis of the lower limbs, days in hospital, readmission within three months, and mortality compared with patients who did not have preoperative anemia. CONCLUSION The prevalence of preoperative anemia in patients awaiting total joint arthroplasty is 22%, and is higher in TKA and female patients undergoing revision, while preoperative anemia is detrimental to the patient's postoperative recovery and will increase the risk of postoperative complications, transfusion rates, days in the hospital, readmission rates, and mortality.
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Affiliation(s)
- Fu-Qiang Zhang
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China
| | - Yong-Ze Yang
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China.
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China.
| | - Peng-Fei Li
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China
| | - Guo-Rong Ma
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China
| | - An-Ren Zhang
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China
| | - Hui Zhang
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China
| | - Hong-Zhang Guo
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China.
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Uden H, Büttner F, von Heymann C, Krämer M, Kaufner L, Vorderwülbecke G, Hardt S, Kruppa J, Balzer F, Spies C. Allogeneic Blood Transfusion and Risk of Postoperative Complications in Patients with Mild and Moderate Anemia of Any Cause? A Retrospective Cohort Study in Total Revision Hip Surgery. Transfus Med Hemother 2024; 51:12-21. [PMID: 38314244 PMCID: PMC10836862 DOI: 10.1159/000530135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/26/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Patients undergoing revision total hip surgery (RTHS) have a high prevalence of mild and moderate preoperative anemia, associated with adverse outcomes. The aim of this study was to investigate the association of perioperative allogeneic blood transfusions (ABT) and postoperative complications in preoperatively mild compared to moderate anemic patients undergoing RTHS who did not receive a diagnostic anemia workup and treatment before surgery. Methods We included 1,765 patients between 2007 and 2019 at a university hospital. Patients were categorized according to their severity of anemia using the WHO criteria of mild, moderate, and severe anemia in the first Hb level of the case. Patients were grouped as having received no ABT, 1-2 units of ABT, or more than 2 units of ABT. Need for intraoperative ABT was assessed in accordance with institutional standards. Primary endpoint was the compound incidence of postoperative complications. Secondary outcomes included major/minor complications and length of hospital and ICU stay. Results Of the 1,765 patients, 31.0% were anemic of any cause before surgery. Transfusion rates were 81% in anemic patients and 41.2% in nonanemic patients. The adjusted risks for compound postoperative complication were significantly higher in patients with moderate anemia (OR 4.88, 95% CI: 1.54-13.15, p = 0.003) but not for patients with mild anemia (OR 1.93, 95% CI: 0.85-3.94, p < 0.090). Perioperative ABT was associated with significantly higher risks for complications in nonanemic patients and showed an increased risk for complications in all anemic patients. In RTHS, perioperative ABT as a treatment for moderate preoperative anemia of any cause was associated with a negative compound effect on postoperative complications, compared to anemia or ABT alone. Discussion ABT is associated with adverse outcomes of patients with moderate preoperative anemia before RTHS. For this reason, medical treatment of moderate preoperative anemia may be considered.
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Affiliation(s)
- Henning Uden
- Department of Anesthesia and Intensive Care Medicine, Sana Klinikum Lichtenberg, Berlin, Germany
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Franziska Büttner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian von Heymann
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael Krämer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berufsausübungsgemeinschaft Reinhardt/Krämer, Berlin, Germany
| | - Lutz Kaufner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Hardt
- Centre for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jochen Kruppa
- Hochschule Osnabrück – University of Applied Sciences, Osnabrück, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Heinrich S, Gratza S, Eckardt A, Ilchmann T. Stepwise implementation of an enhanced recovery pathway for elective total hip arthroplasty in a Swiss hospital: a cohort study. Swiss Med Wkly 2024; 154:3537. [PMID: 38579311 DOI: 10.57187/s.3537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Enhanced recovery programs after total hip arthroplasty have been shown to reduce hospital length of stay without compromising results, but yet there is a lack of data for the Swiss population. Therefore, this retrospective cohort study evaluated whether similar positive effects on clinical outcomes are present in the context of the Swiss healthcare system. METHODS Patients who underwent elective primary total hip arthroplasty were analysed. The baseline group comprised 50 patients treated consecutively by one surgeon in 2013 according to the clinical practice guidelines. Another surgeon implemented a new standardised treatment protocol in April 2014. In January 2018, this protocol was followed by an enhanced recovery program that integrated all care providers at the hospital. The data of the baseline group (series 0) and four series of 50 patients each, two treated with the standardised treatment protocol (series 1-2) and two treated with the enhanced recovery program (series 3-4), were analysed. All patients had follow-ups at 6 weeks and 3 months after surgery. The primary outcomes were length of stay and discharge destination; the secondary outcomes were admission on the day of surgery (instead of one day prior), the use of urinary catheters, the administration of opioids, the difference between pre- and postoperative haemoglobin, blood transfusions, and adverse events within 3 months of surgery. RESULTS The median length of stay was 10 days in the baseline group and only 5 days after the implementation of the standardised protocol and enhanced recovery program in series 4 (p <0.001). The percentage of patients discharged directly home was higher in series 4 than in the baseline group (84% vs. 66%, p = 0.085). Patients admitted to the hospital on the day of surgery increased from 2% in series 0 to 98% in series 4 (p <0.001). The use of urinary catheters was significantly higher in the baseline group (100% of patients) than in series 3 and 4 (0%) (p <0.001), and the number of patients who did not require opioids was significantly higher in series 4 than in series 0 (36% vs. 10%, p = 0.007). The median blood loss (500 ml vs. 300 ml, p <0.001), median difference in pre- and postoperative haemoglobin (29 g/dl vs. 25 g/dl, p = 0.145), and number of blood transfusions (5 vs. 2 p = 0.99) were higher in the baseline group than in series 4. The number of adverse events did not differ significantly between groups (p = 0.699). CONCLUSIONS Almost all parameters examined in this study showed improvement, whereas the rate of adverse events was not affected and remained low. The presented data can be used as a benchmark, but details of these findings need to be confirmed in larger cohorts.
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Affiliation(s)
| | - Simon Gratza
- University Hospital of Basel, Basel, Switzerland
| | - Anke Eckardt
- University Hospital of Basel, Basel, Switzerland
| | - Thomas Ilchmann
- Hirslanden Klinik Birshof, Endo Team, Münchenstein, Switzerland
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Sharma R, Huang Y, Dizdarevic A. Blood Conservation Techniques and Strategies in Orthopedic Anesthesia Practice. Anesthesiol Clin 2022; 40:511-527. [PMID: 36049878 DOI: 10.1016/j.anclin.2022.06.002] [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: 06/15/2023]
Abstract
Orthopedic surgery procedures involving joint arthroplasty, complex spine, long bone and pelvis procedure, and trauma and oncological cases can be associated with a high risk of bleeding and need for blood transfusion, making efforts to optimize patient care and reduce blood loss very important. Patient blood management programs incorporate efforts to optimize preoperative anemia, develop transfusion protocols and restrictive hemoglobin triggers, advance surgical and anesthesia practice, and use antifibrinolytic therapies. Perioperative management of anticoagulant therapies, a multidisciplinary decision-making task, weighs in risks and benefits of thromboembolic risk and surgical bleeding and is patient- and surgery-specific.
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Affiliation(s)
- Richa Sharma
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 West 168th Street, PH 5, New York, NY 10032, USA. https://twitter.com/Drsharma_richa
| | - Yolanda Huang
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 West 168th Street, PH 5, New York, NY 10032, USA
| | - Anis Dizdarevic
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 West 168th Street, PH 5, New York, NY 10032, USA.
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Fang Q, Zhang Z, Wang D, Wang L, Xiong W, Tang Y, Liu W, Wang G. Effect of Tranexamic Acid on Blood Management during a High Tibial Osteotomy: A Systematic Review and Meta-analysis. Orthop Surg 2022; 14:1940-1950. [PMID: 35913385 PMCID: PMC9483069 DOI: 10.1111/os.13407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 05/31/2022] [Accepted: 06/26/2022] [Indexed: 02/05/2023] Open
Abstract
This study aimed to evaluate the efficiency and safety of tranexamic acid for blood management during high tibial osteotomy (HTO). A systematic search was conducted in Medline, Embase, and the Cochrane library database. Six studies and 208 patients were included in this meta‐analysis using Review Manager V.5.3 and Stata 15.1 software. For primary outcomes, tranexamic acid lowered the total blood loss (WMD = –219.47, 95% CI [−355.61, −83.33], P = 0.002). For secondary outcomes, a significant reduction was found for decreased hemoglobin (POD1: WMD = –9.86, 95% CI [−13.45, −6.28], P < 0.05; POD2: WMD = –8.41, 95% CI [−11.50, −5.32], P < 0.05; POD5: WMD = –11.48, 95% CI [−14.56, −8.39], P < 0.05) and drainage (total: WMD = –105.93, 95% CI [−187.08, −24.78], P < 0.05; POD1: WMD = –122.195, 95% CI [−168.902, −75.488], P < 0.05). The sex difference (male/female ratio) was determined (total blood loss: P = 0.025; total drainage amount: p = 0.018) using meta‐regression analysis. Females benefited more from tranexamic acid in terms of total blood loss (M/F > 40%: WMD = –53.11, 95% CI [−100.16, −6.05], P = 0.03; 40% ≥ M/F ≥ 20%: WMD = –362.20, 95% CI [−423.96, −300.45], P < 0.05; M/F < 20%: WMD = –263.00, 95% CI [−277.17, −248.83], P < 0.05) and total drainage (M/F > 40%: WMD = –7.11, 95% CI [−10.75, −3.47], P < 0.05; 40% ≥ M/F ≥ 20%: WMD = –104.72, 95% CI [−155.36, −54.08], P < 0.05; M/F < 20%: WMD = –222.00, 95% CI [−297.42, −146.58], P < 0.05). No significant differences were found for drainage on POD2 and POD3, wound complications, orthromboembolic events. In conclusion, tranexamic acid is effective and safe for blood management during HTO. Females appeared to benefit more from it, and an additional postoperative dose is suggested fora better effect.
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Affiliation(s)
- Qian Fang
- West China Hospital, Sichuan University, Chengdu, China
| | - Zhen Zhang
- West China Hospital, Sichuan University, Chengdu, China
| | - Dong Wang
- West China Hospital, Sichuan University, Chengdu, China
| | - Limin Wang
- West China Hospital, Sichuan University, Chengdu, China
| | - Wei Xiong
- West China Hospital, Sichuan University, Chengdu, China
| | - Yunfeng Tang
- West China Hospital, Sichuan University, Chengdu, China
| | - Wenzheng Liu
- West China Hospital, Sichuan University, Chengdu, China
| | - Guanglin Wang
- West China Hospital, Sichuan University, Chengdu, China
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POLESE F, MANIA D, ARREGHINI N, MAZZAROL G, MALATESTA R, GESSONI G. Patient blood management negli interventi per protesi d'anca: una virtuosa partnership pubblico-privato. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2022. [DOI: 10.23736/s0393-3660.20.04476-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sicat CS, Muthusamy N, Singh V, Davidovitch RI, Slover JD, Schwarzkopf R. Impact of Preoperative Anemia Severity on Primary Total Hip Arthroplasty Outcomes. J Arthroplasty 2022; 37:721-726. [PMID: 34998908 DOI: 10.1016/j.arth.2021.12.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/20/2021] [Accepted: 12/29/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Preoperative anemia (POA) is a significant predictor for adverse outcomes in primary total hip arthroplasty (THA). Current literature has studied POA stratified by severity. This study aims to find a threshold preoperative hemoglobin (Hb) value for increased risk of adverse outcomes in THA. METHODS This is a retrospective analysis of primary THA patients with preoperative Hb values from 2014 to 2021 from an academic orthopedic specialty hospital. Demographics, surgical data, and postoperative outcomes were collected. Patients without preoperative Hb values within the electronic health record system or values acquired >30 days preoperatively were excluded. Patients were grouped based on POA severity using World Health Organization criteria. Secondary analysis using discrete preoperative Hb values was performed. P-values were calculated using analysis of variance/Kruskal-Wallis and chi-squared/Fisher's exact testing with P < .05 considered significant. RESULTS A total of 1347 patients were included: 771 (57.2%) patients with POA and 576 (42.8%) with normal preoperative Hb. In the POA group, 292 (37.9%) were mild, 445 (57.7%) moderate, and 34 (4.4%) severe. Increased length of stay was seen in moderate (3.9 ± 4.3 vs 2.4 ± 2.1, P < .001) and severe (5.0 ± 3.4 vs 2.4 ± 2.1, P < .0001) groups compared to control. The severe group had higher 90-day readmission and revision rates compared to control. Analysis by discrete Hb values showed increased length of stay in Hb values <11 g/dL and a greater proportion of patients with Hb values <12 g/dL were discharged to skilled nursing facilities. CONCLUSION Patients with preoperative Hb <12 g/dL should be assessed for other risk factors that may predispose them to postoperative complications. Further investigation is warranted to develop more robust perioperative management strategies for POA patients undergoing THA. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
| | | | - Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | | | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Neuwirth AL, Boddapati V, Held MB, Grosso MJ, Shah RP, Geller JA, Cooper HJ. Preoperative Anemia Is Associated With 30-Day Morbidity in Total Knee Arthroplasty. Orthopedics 2022; 45:e86-e90. [PMID: 34978512 DOI: 10.3928/01477447-20211227-06] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Given the heightened focus on decreasing length of stay and readmissions following total joint arthroplasty, meticulous preoperative optimization has become increasingly important. The goal of this study was to evaluate the association between preoperative anemia and postoperative morbidity and mortality at 30 days. We used the National Surgical Quality Improvement Program database to identify patients who underwent primary total knee arthroplasty (TKA) between 2006 and 2016. Cohorts were defined based on preoperative hemoglobin and were evaluated for 30-day complications as well as 30-day readmission and non-home discharge. The survey of the National Surgical Quality Improvement Program database yielded 198,233 patients who underwent TKA between 2006 and 2016. Preoperative anemia was found to be a risk factor for all complications (4.73% vs 3.22%, P<.001) as well as non-home discharge (37.0% vs 24.2%, P<.001) and unplanned readmission (4.99% vs 3.14%, P<.001) using both bivariate analysis and multivariate analysis. Meticulous optimization of patients at risk for complications is critical in the era of bundled care and increased focus on rapid transition from inpatient to outpatient care. Preoperative anemia was associated with the total postoperative complication rate at 30 days following TKA as well as non-home discharge and unplanned readmission. Surgeons should attempt to identify patients with preoperative anemia and correct underlying low blood levels to help minimize the rate of postoperative complications. [Orthopedics. 2022;45(2):e86-e90.].
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Optimization of Preoperative Anemia in Lower Limb Joint Replacement Surgery: Assessing the Rates of Allogenic Blood Transfusion and Duration of Hospital Stay. Orthop Nurs 2022; 41:15-20. [PMID: 35045537 DOI: 10.1097/nor.0000000000000815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Orthopaedic procedures such as total hip and total knee replacements carry a significant risk of postoperative anemia, necessitating allogenic blood transfusions (ABTs), and an increased hospital length of stay. AIM Our aim was to investigate whether the implementation of a local protocol designed to detect and treat preoperative anemia resulted in reduced ABT rates and a shorter duration of length of hospital stay (LOS). METHODS We retrospectively audited 683 patients undergoing primary hip and knee replacements. We collated data for all patients about hospital length of stay and blood transfusions received. Both descriptive statistics and univariate analysis were performed. RESULTS Approximately 21.6% of the cohort within the study who were anemic at preoperative clinic had a significantly increased median LOS of 2 days (p < .001) and an increased packed red cell transfusion rate compared with non-anemic patients (26.1% vs. 2.21%, p < 001). However, treatment of preoperative anemia did not show any significant difference in transfusion rates compared with patients who did not receive corrective treatment. The median LOS was higher by 1 day in the treated group compared with the nontreated cohort (p = .005). CONCLUSION There is significant evidence to suggest that preoperative anemia can increase LOS and increase the risk of requiring postoperative blood transfusions. However, anemia should be regarded as a characteristic that can add to the outcome in a cumulative manner, as opposed to an isolated factor. Further research is needed on how to better manage preoperative anemia in order to improve patients' outcomes.
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Fang Q, Zhang Z, Wang L, Xiong W, Tang Y, Wang G. Letter to editor regarding "The efficacy and safety of tranexamic acid in high tibial osteotomy: a systematic review and meta-analysis". J Orthop Surg Res 2021; 16:466. [PMID: 34301284 PMCID: PMC8305871 DOI: 10.1186/s13018-021-02616-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 02/08/2023] Open
Affiliation(s)
- Qian Fang
- West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zhen Zhang
- West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Limin Wang
- West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wei Xiong
- West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yunfeng Tang
- West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Guanglin Wang
- West China Hospital, Sichuan University, Chengdu, 610041, China.
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11
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How I treat anemia in the perisurgical setting. Blood 2021; 136:814-822. [PMID: 32556314 DOI: 10.1182/blood.2019003945] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/27/2020] [Indexed: 01/12/2023] Open
Abstract
Anemia is a common finding in the perioperative setting with significant untoward consequences including worsening of outcomes and diminished quality of life as well as increased risk of allogeneic blood transfusions. Here, we present 3 cases that illustrate how anemia can be perioperatively managed in patients undergoing cardiac, orthopedic, and oncology surgeries. Timely detection of anemia prior to high-blood loss surgeries can allow clinicians to manage it and optimize hemoglobin level, making patients better prepared for the surgery. Treatment of anemia should be guided by the etiology and may include erythropoietic agents, folic acid, B12, and iron preparations. Other blood management strategies geared toward reducing surgical blood loss such as autologous transfusion techniques and agents to optimize hemostasis are used during surgery and in the immediate postoperative period. Patients should be closely monitored following surgery for signs of ongoing bleeding in need of control. Finally, screening for and management of anemia should continue in the postoperative and postdischarge period, as persistence and recurrence of anemia can further undermine patient's outcomes.
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Role of preoperative erythropoietin in the optimization of preoperative anemia among surgical patients - A systematic review and meta-analysis. Hematol Transfus Cell Ther 2021; 44:76-84. [PMID: 33583767 PMCID: PMC8885371 DOI: 10.1016/j.htct.2020.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/02/2020] [Accepted: 12/07/2020] [Indexed: 11/23/2022] Open
Abstract
Preoperative anemia is a common finding. Preoperative allogeneic transfusion, iron therapy, vitamin supplementation and erythropoietin therapy are the current management strategies for preoperative anemia. Previous reviews regarding erythropoietin were limited to specialties, provided little evidence regarding the benefits and risks of erythropoietin in managing preoperative anemia and included non-anemic patients. The purpose of our systematic review was to determine the role of erythropoietin solely in preoperatively anemic patients and to investigate the complications of this treatment modality to produce a guideline for preoperative management of anemic patients for all surgical specialties. The PubMed/Medline, Google Scholar, and Cochrane Library were searched for randomized trials evaluating the efficacy of erythropoietin in preoperative anemia. The risk ratio (RR) and standardized mean difference (SMD) was used to pool the estimates of categorical and continuous outcomes, respectively. Allogeneic transfusion and complications and the 90-day mortality were the primary outcomes, while the postoperative change in hemoglobin, bleeding in milliliters and the number of red blood cell (RBC) packs transfused were the secondary outcomes. Results: Eight studies were included, comprising 734 and 716 patients in the erythropoietin group and non-erythropoietin group, respectively. The pooled estimate by RR for allogeneic transfusion was 0.829 (p = 0.049), while complications and the 90-day mortality were among the 1,318 (p = 0.18) patients. Conclusion: Preoperative erythropoietin provides better outcomes, considering the optimization of preoperative anemia for elective surgical procedures. The benefits of erythropoietin are significantly higher, compared to the control group, while the risks remain equivocal in both groups. We recommend preoperative erythropoietin in anemic patients.
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Scrimshire AB, Booth A, Fairhurst C, Kotze A, Reed M, McDaid C. Preoperative iron treatment in anaemic patients undergoing elective total hip or knee arthroplasty: a systematic review and meta-analysis. BMJ Open 2020; 10:e036592. [PMID: 33130561 PMCID: PMC7783611 DOI: 10.1136/bmjopen-2019-036592] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Preoperative anaemia is associated with increased risks of postoperative complications, blood transfusion and mortality. This meta-analysis aims to review the best available evidence on the clinical effectiveness of preoperative iron in anaemic patients undergoing elective total hip (THR) or total knee replacement (TKR). DESIGN Electronic databases and handsearching were used to identify randomised and non-randomised studies of interventions (NRSI) reporting perioperative blood transfusion rates for anaemic participants receiving iron before elective THR or TKR. Searches of CENTRAL, MEDLINE, Embase, PubMed and other databases were conducted on 17 April 2019 and updated on 15 July 2020. Two investigators independently reviewed studies for eligibility and evaluated risk of bias using the Cochrane risk of bias tool for randomised controlled trials (RCTs) and a modified Newcastle-Ottawa scale for NRSIs. Data extraction was performed by ABS and checked by AB. Meta-analysis used the Mantel-Haenszel method and random-effects models. RESULTS 807 records were identified: 12 studies met the inclusion criteria, of which 10 were eligible for meta-analyses (one RCT and nine NRSIs). Five of the NRSIs were of high-quality while there were some concerns of bias in the RCT. Meta-analysis of 10 studies (n=2178 participants) showed a 39% reduction in risk of receiving a perioperative blood transfusion with iron compared with no iron (risk ratio 0.61, 95% CI 0.50 to 0.73, p<0.001, I2=0%). There was a significant reduction in the number of red blood cell units transfused with iron compared with no iron (mean difference -0.37units, 95% CI -0.47 to -0.27, p<0.001, I2=40%); six studies (n=1496). Length of stay was significantly reduced with iron, by an average of 2.08 days (95% CI -2.64 to -1.51, p<0.001, I2=40%); five studies (n=1140). CONCLUSIONS Preoperative iron in anaemic, elective THR or TKR patients, significantly reduces the number of patients and number of units transfused and length of stay. However, high-quality, randomised trials are lacking. PROSPERO REGISTRATION NUMBER CRD42019129035.
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Affiliation(s)
- Ashley B Scrimshire
- Department of Health Sciences, University of York, York, UK
- Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Alison Booth
- Department of Health Sciences, University of York, York, UK
| | | | | | - Mike Reed
- Northumbria Healthcare NHS Foundation Trust, Ashington, UK
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Choi JT, Yoshida B, Jalali O, Hatch GF. Malnutrition in Orthopaedic Sports Medicine: A Review of the Current Literature. Sports Health 2020; 13:65-70. [PMID: 32639180 DOI: 10.1177/1941738120926168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
CONTEXT Malnutrition is well-studied in various aspects of the orthopaedic literature, most commonly in relation to arthroplasty, spine surgery, and trauma. However, the management of nutritional deficiencies is commonly overlooked among orthopaedic sports medicine providers. The purpose of this article is to analyze the available sports medicine literature to review the associations between malnutrition and the management of orthopaedic sports medicine patients from a treatment and performance standpoint. EVIDENCE ACQUISITION PubMed was searched for relevant articles published from 1979 to 2019. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS Few studies exist on the implications of macronutrient deficiencies specific to orthopaedic sports medicine procedures. Interestingly, micronutrient disorders-namely, hypovitaminosis D and iron deficiency-have been well studied and may lead to worse postoperative outcomes, injury rates, and athletic performance. Nutritional supplementation to correct such deficiencies has been shown to mitigate these effects, though further study is required. CONCLUSION Nutritional deficiencies are highly prevalent in orthopaedic sports medicine patients, and practitioners should be aware of their potential effects on treatment and performance outcomes. Management of such deficiencies and their effect on surgical patients remain an area of potential future research. Future studies are warranted in order to explore the potential therapeutic role of nutritional supplementation to prevent complications after common orthopaedic sports medicine procedures, improve athletic performance, and reduce injury rates.
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Affiliation(s)
- Jihoon T Choi
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon Yoshida
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Omid Jalali
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - George F Hatch
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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15
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16
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Shumborski S, Gooden B, Salmon LJ, O'Sullivan M, Pinczewski LA, Roe JP, Martina K, Chopra S, Maclean C, Lyons MC. Utility of preoperative blood screening before hip and knee arthroplasty. ANZ J Surg 2020; 90:350-354. [PMID: 31957206 DOI: 10.1111/ans.15676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/15/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is engrained in medical training that routine blood screening prior to arthroplasty is necessary for optimal patient care. There is little evidence to support their utility and the aggregate cost to the health system. The purpose of this study was to evaluate preoperative blood screening by identifying the frequency of an abnormal result and to examine the influence of age, gender and body mass index on the frequency of abnormal blood pathology. METHODS This is a retrospective review of 1000 patients from a single centre who underwent elective primary hip or knee arthroplasty from 2015 to 2017. Abnormal blood results were identified and clinically relevant intervals were created for routine markers. RESULTS A total of 939 patients had available pathology results with 84% identified as having an abnormal result and 47% having a clinically important range. Abnormal liver function tests and ferritin were most common. With increasing age, there was a significant increase in rates of abnormal clinically important range, renal dysfunction, abnormal haemoglobin and erythrocyte sedimentation rate. Males and patients with body mass index >40 had an increased rate of abnormal results, particularly liver function tests. CONCLUSION The ordering of preoperative investigations prior to lower limb arthroplasty is recommended by the National Institute for Health and Care Excellence guidelines, alleviating concern of post-operative complications and covering medicolegal issues. Our study determined a high frequency of abnormal results, justifying routine blood screening is recommended prior to surgery, particularly for the elderly, males and obese patients.
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Affiliation(s)
- Sarah Shumborski
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, New South Wales, Australia
| | - Benjamin Gooden
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, New South Wales, Australia
| | - Lucy J Salmon
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, New South Wales, Australia
| | - Michael O'Sullivan
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, New South Wales, Australia
| | - Leo A Pinczewski
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, New South Wales, Australia.,School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Justin P Roe
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, New South Wales, Australia
| | - Kaka Martina
- Orthopaedic Department, Mater Hospital, Sydney, New South Wales, Australia
| | - Sarthak Chopra
- School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Colin Maclean
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, New South Wales, Australia
| | - Matthew C Lyons
- North Sydney Orthopaedic and Sports Medicine Centre, Sydney, New South Wales, Australia
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Determinants of blood transfusion for elective surgical procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, 2017. Transfus Apher Sci 2019; 58:628-631. [PMID: 31521535 DOI: 10.1016/j.transci.2019.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Till date 80% of the world's population has access to only 20% of the world's safe blood that is properly collected and tested. Paradoxically, despite a severely inadequate supply, blood is often transfused unnecessarily and it will expose patients to complications. Despite lots of publication and investigation on the efficiency of blood usage, there is no clear demarcation which patients really need blood transfusion. OBJECTIVES To determine factors associated with blood transfusion in elective surgical procedures in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, 2017 G.C. METHODS Hospital based cross sectional study was conducted from February 1, 2017 to September 30, 2017 G.C at Tikur Anbessa specialized Hospital. Data was collected by using convenient sampling technique and structured checklist. Multivariate logistic regression analysis was conducted to identify significant predictors of transfusion based on p-value less than 0.05 with 95% confidence level. RESULTS Among all 387 elective surgical patients 88 (22.7%) of patients were transfused with prepared blood. The independent predictors of perioperative blood transfusion were neurosurgery (craniotomy) (p = 0.017), hemoglobin level < 11.0 g/dl (p < 0.001) and intraoperative blood loss ≥ 15% (P < 0 0.001). CONCLUSION neurosurgery, hemoglobin <11.0 g/dl and intraoperative blood loss ≥15% were the major determinants of blood transfusion.
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Zhao M, Geng X, Wang C, Zeng L, Tian H. The value of tranexamic acid for patients with preoperative anemia in primary total knee arthroplasty. Eur J Med Res 2019; 24:28. [PMID: 31405381 PMCID: PMC6689859 DOI: 10.1186/s40001-019-0387-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022] Open
Abstract
Background Preoperative anemia is relatively common in patients undergoing primary total knee arthroplasty (TKA), and is associated with higher medical costs due to blood transfusions. Methods We aimed to discuss the efficiency of tranexamic acid (TXA) administration for blood loss control in preoperatively anemic patients undergoing primary TKA. We retrospectively reviewed the clinical data regarding a consecutive series of primary unilateral TKA patients with preoperative anemia. Patients were divided into TXA group (received TXA peri-operatively) and control group (did not receive TXA). Outcome measures included drainage volume; hemoglobin, and hematocrit levels recorded preoperatively and over the first 5 days postoperatively; amount of allogeneic blood transfusion; and prevalence of thrombosis. Results Ninety-six patients from 996 cases were included in the study. Demographics, general health condition, and preoperative conditions were comparable between the two groups. However, significantly lower drainage volume (P < 0.001), hidden blood loss (P < 0.001), and allogeneic blood transfusion volume (χ = 4.00, P = 0.046) were noted in TXA group. The hemoglobin and hematocrit levels were significantly higher in TXA group on the first postoperative day (P = 0.006), but overall the drop in hemoglobin and hematocrit levels over the first 5 days postoperatively was similar between the groups (P = 0.763), as was the incidence of thromboembolism events (P = 0.794). Conclusion TXA has a positive role for patients with preoperative anemia in primary total knee arthroplasty. In patients with mild preoperative anemia, TXA decreases hidden blood loss and the need for allogeneic blood transfusion, which mainly appears effective on the first postoperative day of TKA.
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Affiliation(s)
- Minwei Zhao
- Department of Orthopedics, Peking University Third Hospital, No 49 Huayuan Road, Haidian District, Beijing, People's Republic of China
| | - Xiao Geng
- Department of Orthopedics, Peking University Third Hospital, No 49 Huayuan Road, Haidian District, Beijing, People's Republic of China
| | - Cheng Wang
- Department of Orthopedics, Peking University Third Hospital, No 49 Huayuan Road, Haidian District, Beijing, People's Republic of China
| | - Lin Zeng
- Epidemiology Center, Peking University Third Hospital, Beijing, People's Republic of China
| | - Hua Tian
- Department of Orthopedics, Peking University Third Hospital, No 49 Huayuan Road, Haidian District, Beijing, People's Republic of China.
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19
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Gómez-Ramirez S, Jericó C, Muñoz M. Perioperative anemia: Prevalence, consequences and pathophysiology. Transfus Apher Sci 2019; 58:369-374. [DOI: 10.1016/j.transci.2019.06.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Magill P, Cunningham EL, Hill JC, Beverland DE. Identifying the period of greatest blood loss after lower limb arthroplasty. Arthroplast Today 2018; 4:499-504. [PMID: 30569010 PMCID: PMC6288045 DOI: 10.1016/j.artd.2018.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/30/2018] [Accepted: 09/03/2018] [Indexed: 11/11/2022] Open
Abstract
Background The use of tranexamic acid (TXA) in total hip replacement (THR) typically reduces blood loss by approximately 400 mL, and typical total blood loss is still approximately 1 L. A barrier to harnessing the full potential of TXA is disagreement on the optimum timing of administration. To address this, we aimed to identify the period of greatest blood loss. Methods We analyzed the perioperative data of 870 patients who had undergone THR, total knee replacement, or unicompartmental knee replacement just before the introduction of TXA to our unit. Total blood loss was calculated on postoperative day (POD) 1 and POD2 using an equation based on change in hematocrit. Results Average total blood loss at POD2 was 1505, 1322, and 611 mL for THR, total knee replacement, and unicompartmental knee replacement, respectively. Between 86% and 96% of this blood loss occurred in the period between skin closure and POD1. Intraoperative loss did not correlate with total loss at POD2. Blood transfusion was more likely if the patient was female (odds ratio [OR], 6.8) or if they had preoperative anemia (OR, 8.3) than if there was a high-volume blood loss (OR, 1.6). Conclusions Approximately 90% of blood loss occurs between skin closure and the first postoperative 24 hours. “Intraoperative blood loss” and “transfusion rate” are not reliable markers of total blood loss. The full potential of TXA could be harnessed by using it during the period of greatest blood loss, that is, during the first postoperative 24 hours.
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Affiliation(s)
- Paul Magill
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland
| | - Emma L Cunningham
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland.,Centre for Public Health, Queen's University Belfast, Northern Ireland
| | - Janet C Hill
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland
| | - David E Beverland
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland
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21
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Polanco-García M, Capielo AM, Miret X, Chamero A, Sainz J, Revilla E, Guinjoan A, Arranz T. Effectiveness of a patient blood management protocol on reduction of allogeneic red blood cell transfusions in orthopedic surgery. Med Clin (Barc) 2018; 152:90-97. [PMID: 29887176 DOI: 10.1016/j.medcli.2018.04.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Patient blood management in orthopaedic surgery reduces transfusion risk. The best protocol is unknown. The effectiveness of a protocol based on the Seville Consensus on the reduction of transfusion risk is evaluated and a predictive transfusion equation is proposed in knee surgery. PATIENTS AND METHODS Cohort study in patients undergoing knee and hip arthroplasty from January 2014 to December 2015 at a second level complexity hospital in Vilafranca del Penedès (Barcelona). Patients with Hb between 10 and 13g/dL were classified as anaemic with or without iron deficiency and received iron or combination of iron and erythropoietin. On the day of surgery, tranexamic acid was administered, the Hb drop was measured the next day and the requirements and the transfusion lintel were measured during the stay. RESULTS A total of 334 patients were included in the study. The implementation of the programme decreased the transfusion risk from 41.5% to 14.8% at the end of the study. In hip surgery, transfused patients were significantly older, sicker and with lower preoperative Hb. Tranexamic acid did not decrease bleeding. In knee surgery, the administration of tranexamic acid was the variable that most decreased the transfusion risk followed by a high preoperative Hb. The equation predicts transfusion risk with a sensitivity of 55% and specificity of 95.7%. CONCLUSION The implementation of the programme reduces transfusion risk. The effectiveness of tranexamic acid varies according to surgery site. The use of iron and recombinant human erythropoietin is necessary to improve Hb.
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Affiliation(s)
- Mauricio Polanco-García
- Departamento de Anestesiología, Reanimación y Terapia del Dolor, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España.
| | - Ana María Capielo
- Departamento de Anestesiología, Reanimación y Terapia del Dolor, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Xavier Miret
- Departamento de Anestesiología, Reanimación y Terapia del Dolor, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Antonio Chamero
- Departamento de Anestesiología, Reanimación y Terapia del Dolor, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Julio Sainz
- Departamento de Anestesiología, Reanimación y Terapia del Dolor, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Elena Revilla
- Departamento de Hematología, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Antoni Guinjoan
- Departamento de Traumatología, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Teresa Arranz
- Departamento de Farmacia. Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
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Shin HJ, Min BH, Na HS. FIBTEM as a predictor of intra- and postoperative blood loss in revision total hip arthroplasty: A prospective observational study. Medicine (Baltimore) 2018; 97:e10929. [PMID: 29851830 PMCID: PMC6392916 DOI: 10.1097/md.0000000000010929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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
Revision total hip arthroplasty (THA) may cause intra- and postoperative massive bleeding. This prospective observational study evaluated if the maximum clot firmness of FIBTEM (MCFFIB) could act as a predictor of perioperative massive bleeding in revision THA.Fifty-eight adult patients undergoing revision THA were included. Pre- and postoperative MCFFIB, hematological and hemostatic laboratory data, as well as the amount of intra- and postoperative blood loss (IBL and PBL) were obtained.The change rate (MCFFIB-C) between the pre- and postoperative MCFFIB had a significant correlation with IBL (ρ = 0.431, P = .001). Moreover, PBL had a significant correlation with MCFFIB-C (ρ = 0.292, P = .026). The MCFFIB-C cut-off value of ≥ 29% showed the highest sensitivity and specificity for predicting IBL ≥ 1000 mL or PBL ≥500 mL. The incidence of red blood cell transfusion in the postoperative period was higher in patients showing MCFFIB-C ≥ 29% (34% vs 8%, P = .015).The change rate between pre- and postoperative MCFFIB values was correlated well with the amount of IBL or PBL. Moreover, particular change rate of MCFFIB could predict massive bleeding in revision THA.
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Jans Ø, Nielsen CS, Khan N, Gromov K, Troelsen A, Husted H. Iron deficiency and preoperative anaemia in patients scheduled for elective hip- and knee arthroplasty - an observational study. Vox Sang 2018; 113:260-267. [DOI: 10.1111/vox.12630] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/05/2017] [Accepted: 12/15/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Ø. Jans
- Section of Surgical Pathophysiology; Rigshospitalet; Copenhagen Denmark
- Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty; Rigshospitalet; Copenhagen Denmark
| | - C. S. Nielsen
- Department of Orthopaedic Surgery; Copenhagen University Hospital; Hvidovre Denmark
| | - N. Khan
- Department of Orthopaedic Surgery; Copenhagen University Hospital; Hvidovre Denmark
| | - K. Gromov
- Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty; Rigshospitalet; Copenhagen Denmark
- Department of Orthopaedic Surgery; Copenhagen University Hospital; Hvidovre Denmark
| | - A. Troelsen
- Department of Orthopaedic Surgery; Copenhagen University Hospital; Hvidovre Denmark
| | - H. Husted
- Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty; Rigshospitalet; Copenhagen Denmark
- Department of Orthopaedic Surgery; Copenhagen University Hospital; Hvidovre Denmark
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Zeng Y, Si H, Li C, Wu Y, Shen B. Effect of knee flexion position and combined application of tranexamic acid on blood loss following primary total knee arthroplasty: a prospective randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2018; 42:529-535. [PMID: 29396806 DOI: 10.1007/s00264-018-3808-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 01/23/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this study was to demonstrate the association between tranexamic acid (TXA)-combined application and knee flexion in the first 24 hour post-operatively that could reduce total blood loss and transfusion need in patients undergoing total knee arthroplasty (TKA), without sacrificing safety. METHODS Ninety TKA patients were divided into three groups randomly: the flexion group: the knee was in 90° flexion position for the first 12 hour post-surgery and kept at 60°for the next 12 hour, combined with 1 g TXA topical and 1 g TXA intravenous application. The extension group: the knee was in fully extension position post-operatively, combined with topical and intravenous TXA application. The controlled group: the knee was in fully extension position post-operatively combined with single intravenous TXA application. The primary outcomes included blood loss variables and transfusion values. The secondary outcomes included post-operative hospital stay, knee flexion degree, complication rate, and hospital charge. RESULTS The total blood loss and transfusion needs in the flexion group were significantly reduced in comparison with that in the extension group and controlled group. The post-operative knee flexion motion was significant higher in the flexion group than the other two groups. There was no difference among the three groups with regard to the rates of complications. CONCLUSIONS Keeping the knee in flexion position combined with topical and intravenous TXA application in patients undergoing primary unilateral TKA significantly reduced post-operative bleeding and the transfusion rate compared with what was found after treatment with extension knee position or single intravenous TXA application. LEVEL OF EVIDENCE Therapeutic Level I.
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Affiliation(s)
- Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Haibo Si
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Canfeng Li
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China.
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Preoperative Anaemia and Associated Postoperative Outcomes in Noncardiac Surgery Patients in Central Region of Ghana. Anesthesiol Res Pract 2017; 2017:7410960. [PMID: 29375620 PMCID: PMC5742513 DOI: 10.1155/2017/7410960] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/30/2017] [Accepted: 11/14/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction Several studies suggest that preoperative anaemia (PA) is associated with adverse postoperative outcomes, but little is known about these outcomes in the Central Region of Ghana. This study aims to determine the prevalence of PA among noncardiac surgical patients and its implications for their postoperative outcomes. Methods This study was designed as an observational study; data including demographics and clinical and laboratory results were collected from the patients' records and through interviews. Results A total of 893 inpatient surgical cases undergoing elective and emergency operations, aged 15 years and above with mean age of 44.2 ± 17.0 yrs, were enrolled. The prevalence of PA was 54.3%, mostly microcytic with or without hypochromia (57.2%). The prevalence was higher in females than males (p ≤ 0.001). Preoperative anaemia was significantly associated with prolonged length of hospital stay (OR: 2.12 (95% CI: 1.49–3.10)). Allogeneic blood transfusion significantly prolonged the length of hospital stay (OR 4.48 (95% CI: 2.67–7.51)). 15.5% of the anaemic patients received oral iron supplements compared to 2.2% of nonanaemic patients (p ≤ 0.001). Conclusion Preoperative anaemia is common among noncardiac surgical patients. It is independently and significantly associated with prolonged hospital stay leading to the use of increased healthcare resources. It is also the main predictor for perioperative allogeneic blood transfusions and the use of haematinics.
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Hong FS, Sieradzki N, Pollock C, Nasra F, Mo A, Willcox A, Churilov L, Ho WK, Smith C. Prevalence and causes of preoperative anaemia in elective major surgery patients. Intern Med J 2017; 47:1400-1404. [DOI: 10.1111/imj.13613] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 08/01/2017] [Accepted: 08/27/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Frank S. Hong
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Nicole Sieradzki
- Department of Anaesthesia; Austin Health; Melbourne Victoria Australia
| | - Claire Pollock
- Department of Anaesthesia; Austin Health; Melbourne Victoria Australia
| | - Faye Nasra
- Department of Anaesthesia; Austin Health; Melbourne Victoria Australia
| | - Allison Mo
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Abbey Willcox
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform; Florey Institute of Neuroscience and Mental Health; Melbourne Victoria Australia
- School of Science; RMIT University; Melbourne Victoria Australia
| | - Wai Khoon Ho
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Carole Smith
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
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What Should Define Preoperative Anemia in Primary THA? Clin Orthop Relat Res 2017; 475:2683-2691. [PMID: 28786087 PMCID: PMC5638743 DOI: 10.1007/s11999-017-5469-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/01/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of tranexamic acid (TXA) in THA decreases the risk of transfusion after surgery. However, nearly 10% of patients still undergo a transfusion, which has been independently associated with an increased risk of complications. Preoperative anemia has been proven to be a strong predictor of transfusion after THA, but the ideal "cutoff" values in today's population that maximize sensitivity and specificity to predict transfusion have yet to be established. QUESTIONS/PURPOSES (1) Which preoperative factors are associated with postoperative transfusion in the setting of TXA use? (2) If preoperative hemoglobin (Hgb) remains associated with transfusion, what are the best-supported preoperative Hgb cutoff values associated with increased transfusion after THA? METHODS A retrospective chart analysis was performed from January 1, 2013, to January 1, 2015, on 558 primary THAs that met prespecified inclusion criteria. A multivariable logistic regression analysis model was used to identify independent factors associated with transfusion. Area under the receiver-operator curve (AUC) was used to determine the best-supported preoperative Hgb cut point across all participants, as well as adjusted by sex and TXA use. Overall, 60 patients with a blood transfusion were included and compared with 498 control subjects (11% risk of transfusion). RESULTS After controlling for potential confounding variables such as age, sex, American Society of Anesthesiologist score, intravenous TXA (IV TXA) use, and preoperative Hgb, we found that patients with lower preoperative Hgb (g/dL per 1-unit decrease, odds ratio [OR], 2.6; 95% CI, 2.0-3.5; p < 0.001), female sex (vs male, OR, 4.2; 95% CI, 1.7-10.3; p = 0.002), and those unable to receive IV TXA (topical TXA/no TXA, OR, 13.5; 95% CI, 6.3-28.6; p < 0.001) were more likely to receive a transfusion. Of these, preoperative Hgb was found to be the variable most highly associated with transfusion (AUC, 0.876). A preoperative Hgb cutoff value of 12.6 g/dL maximized the AUC (0.876) for predicting transfusion across all patients unadjusted for baseline characteristics (sensitivity = 83, specificity = 84) with values of 12.5 g/dL (sensitivity = 85, specificity = 77) and 13.5 g/dL (sensitivity = 92, specificity = 77) for women and men, respectively. CONCLUSIONS The 1968 WHO definitions of anemia (preoperative Hgb < 13 g/dL for men and < 12 g/dL for women) used currently may underestimate patients at risk of transfusion after THA today. Further studies are needed to see if blood conservation referral decreases the risk of transfusion with preoperative treatment of anemia. LEVEL OF EVIDENCE Level III, therapeutic study.
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Preciado Mora M, Azparren Cabezón G, Escudero Rodríguez J, Esteban Garcia C, Font Gual A, Moral García V. La anemia como factor de riesgo quirúrgico en cirugía vascular. Algoritmos de diagnóstico y tratamiento. ANGIOLOGIA 2017. [DOI: 10.1016/j.angio.2016.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
The prevalence of preoperative anemia in major orthopedic surgery is high and is the main predictive factor for allogeneic blood transfusion. The scheduling of a preoperative visit with sufficient notice (at least 3 weeks before surgery), with a blood count test and a basic iron metabolism study, enables us to treat the anemia and/or improve preoperative hemoglobin levels, thereby reducing the need for transfusion and the risks associated with transfusions. Intravenous iron and/or erythropoietin are treatments for optimizing preoperative anemia, with good levels of scientific evidence.
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Affiliation(s)
- E Bisbe Vives
- Servicio de Anestesiología y Reanimación, Hospital del Mar, IMIM ((Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, España.
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Peri-operative treatment of anaemia in major orthopaedic surgery: a practical approach from Spain. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 15:296-306. [PMID: 28151388 DOI: 10.2450/2017.0177-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/31/2016] [Indexed: 12/16/2022]
Abstract
In patients undergoing major orthopaedic surgery, pre-operative anaemia, peri-operative bleeding and a liberal transfusion policy are the main risk factors for requiring red blood cell transfusion (RBCT). The clinical and economic disadvantages of RBCT have led to the development and implementation of multidisciplinary, multimodal, individualised strategies, collectively termed patient blood management, which aim to reduce RBCT and improve patients' clinical outcome and safety. Within a patient blood management programme, low pre-operative haemoglobin is one of the few modifiable risk factors for RBCT. However, a survey among Anaesthesia Departments in Spain revealed that, although pre-operative assessment was performed in the vast majority of hospitals, optimisation of haemoglobin concentration was attempted in <40% of patients who may have benefitted from it, despite there being enough time prior to surgery. This indicates that haemoglobin optimisation takes planning and forethought to be implemented in an effective manner. This review, based on available clinical evidence and our experience, is intended to provide clinicians with a practical tool to optimise pre-operative haemoglobin levels, in order to minimise the risk of patients requiring RBCT. To this purpose, after reviewing the diagnostic value and limitations of available laboratory parameters, we developed an algorithm for the detection, classification and treatment of pre-operative anaemia, with a patient-tailored approach that facilitates decision-making in the pre-operative assessment. We also reviewed the efficacy of the different pharmacological options for pre-operative and post-operative management of anaemia. We consider that such an institutional pathway for anaemia management could be a viable, cost-effective strategy that is beneficial to both patients and healthcare systems.
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Esteban Gracia C, Escudero Rodríguez J, Preciado Mora M, Moral García V, Rodríguez Cabeza P, Clarà Velasco A, Fernández Heredero A, Botas Velasco M, Fernández Alonso S, Mateos Otero F, Salmerón Febres L, Estallo Laliena L, Ibrahim Z, Miralles Hernández M. Prevalencia de anemia en pacientes sometidos a cirugía vascular electiva y su influencia en el postoperatorio. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2016.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kearney B, To J, Southam K, Howie D, To B. Anaemia in elective orthopaedic surgery - Royal Adelaide Hospital, Australia. Intern Med J 2016; 46:96-101. [DOI: 10.1111/imj.12945] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/03/2015] [Accepted: 10/25/2015] [Indexed: 11/29/2022]
Affiliation(s)
- B. Kearney
- Site Clinical Director, Royal Adelaide Hospital; SA Pathology; Adelaide Australia
- Clinical Haematology Service; Royal Adelaide Hospital; Modbury Australia
| | - J. To
- Division of Aged Care; Rehabilitation and Palliative Care, Modbury Hospital; Adelaide Australia
| | - K. Southam
- Royal Adelaide Hospital; Orthopaedic Surgery and Trauma; Adelaide Australia
| | - D. Howie
- Department of Orthopaedic Surgery and Trauma; University of Adelaide, Royal Adelaide Hospital; Australia
| | - B. To
- Clinical Haematology Service; Royal Adelaide Hospital; Modbury Australia
- Clinical Section; Royal Adelaide Hospital Department of Haematology, SA Pathology; Adelaide South Australia Australia
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Colomina MJ, Basora Macaya M. [Optimization of preoperative hemoglobin levels in patients without anemia and/or patients who undergo surgery with high blood loss]. ACTA ACUST UNITED AC 2015; 62 Suppl 1:35-40. [PMID: 26320342 DOI: 10.1016/s0034-9356(15)30005-0] [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: 11/28/2022]
Abstract
To minimize allogeneic blood transfusions (ABTs) during complex surgery and surgery with considerable blood loss risk, various blood-sparing techniques are needed (multimodal approach). All surgical patients should be assessed with sufficient time to optimize hemoglobin levels and iron reserves so that the established perioperative transfusion strategy is appropriate. Even if the patient does not have anemia, improving hemoglobin levels to reduce the risk of ABT is justified in some cases, especially those in which the patient refuses a transfusion. Treatment with iron and/or erythropoietic agents might also be justified for cases that need a significant autologous blood reserve to minimize ABT during surgery with considerable blood loss.
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Affiliation(s)
- M J Colomina
- Servicio de Anestesiología y Reanimación, Área de Traumatología, Hospital Universitario Vall d'Hebron, Barcelona, España.
| | - M Basora Macaya
- Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
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Phan DL, Rinehart JB, Schwarzkopf R. Can tranexamic acid change preoperative anemia management during total joint arthroplasty? World J Orthop 2015; 6:521-527. [PMID: 26301181 PMCID: PMC4539475 DOI: 10.5312/wjo.v6.i7.521] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/24/2015] [Accepted: 06/16/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the postoperative transfusion and complication rates of anemic and nonanemic total joint arthroplasty patients given tranexamic acid (TXA).
METHODS: A cross-sectional prospective study was conducted of primary hip and knee arthroplasty cases performed from 11/2012 to 6/2014. Exclusion criteria included revision arthroplasty, bilateral arthroplasty, acute arthroplasty after fracture, and contraindication to TXA. Patients were screened prior to surgery, with anemia was defined as hemoglobin of less than 12 g/dL for females and of less than 13 g/dL for males. Patients were divided into four different groups, based on the type of arthroplasty (total hip or total knee) and hemoglobin status (anemic or nonanemic). Intraoperatively, all patients received 2 g of intravenous TXA during surgery. Postoperatively, allogeneic blood transfusion (ABT) was directed by both clinical symptoms and relative hemoglobin change. Complications were recorded within the first two weeks after surgery and included thromboembolism, infection, and wound breakdown. The differences in transfusion and complication rates, as well as the relative hemoglobin change, were compared between anemic and nonanemic groups.
RESULTS: A total of 232 patients undergoing primary joint arthroplasty were included in the study. For the total hip arthroplasty cohort, 21% (18/84) of patients presented with preoperative anemia. Two patients in the anemic group and two patients in the nonanemic group needed ABTs; this was not significantly different (P = 0.20). One patient in the anemic group presented with a deep venous thromboembolism while no patients in the nonanemic group had an acute complication; this was not significantly different (P = 0.21). For nonanemic patients, the average change in hemoglobin was 2.73 ± 1.17 g/dL. For anemic patients, the average change in hemoglobin was 2.28 ± 0.96 g/dL. Between the two groups, the hemoglobin difference of 0.45 g/dL was not significant (P = 0.13). For the total knee arthroplasty cohort, 18% (26/148) of patients presented with preoperative anemia. No patients in either group required a blood transfusion or had an acute postoperative complication. For nonanemic patients, the average change in hemoglobin was 1.85 ± 0.79 g/dL. For anemic patients, the average change in hemoglobin was 1.09 ± 0.58 g/dL. Between the two groups, the hemoglobin difference of 0.76 g/dL was significant (P < 0.001).
CONCLUSION: TXA administration results in low transfusion and complication rates and may be a useful adjunct for TJA patients with preoperative anemia.
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Pre-operative anaemia: prevalence, consequences and approaches to management. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:370-9. [PMID: 26192787 DOI: 10.2450/2015.0014-15] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/24/2015] [Indexed: 01/28/2023]
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Natera L, Roig XA, Rodriguez JCG, Gual AF, Llobet AB, Ces SV. Blood transfusion requirements in lower limb arthroplasties might be dramatically reduced if orthopaedic surgeons were concerned about preoperative anaemia. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s12570-015-0297-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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38
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Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 12:195-203. [PMID: 24931841 DOI: 10.2450/2014.0306-13] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 02/10/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND The aim of this study was to investigate the impact of the introduction of a Patient Blood Management (PBM) programme in elective orthopaedic surgery on immediate pre-operative anaemia, red blood cell (RBC) mass loss, and transfusion. MATERIALS AND METHODS Orthopaedic operations (hip, n=3,062; knee, n=2,953; and spine, n=2,856) performed between 2008 and 2011 were analysed. Period 1 (2008), was before the introduction of the PBM programme and period 2 (2009 to 2011) the time after its introduction. Immediate pre-operative anaemia, RBC mass loss, and transfusion rates in the two periods were compared. RESULTS In hip surgery, the percentage of patients with immediate pre-operative anaemia decreased from 17.6% to 12.9% (p<0.001) and RBC mass loss was unchanged, being 626±434 vs 635±450 mL (p=0.974). Transfusion rate was significantly reduced from 21.8% to 15.7% (p<0.001). The number of RBC units transfused remained unchanged (p=0.761). In knee surgery the prevalence of immediate pre-operative anaemia decreased from 15.5% to 7.8% (p<0.001) and RBC mass loss reduced from 573±355 to 476±365 mL (p<0.001). The transfusion rate dropped from 19.3% to 4.9% (p<0.001). RBC transfusions decreased from 0.53±1.27 to 0.16±0.90 units (p<0.001). In spine surgery the prevalence of immediate pre-operative anaemia remained unchanged (p=0.113), RBC mass loss dropped from 551±421 to 404±337 mL (p<0.001), the transfusion rate was reduced from 18.6 to 8.6% (p<0.001) and RBC transfusions decreased from 0.66±1.80 to 0.22±0.89 units (p=0.008). DISCUSSION Detection and treatment of pre-operative anaemia, meticulous surgical technique, optimal surgical blood-saving techniques, and standardised transfusion triggers in the context of PBM programme resulted in a lower incidence of immediate pre-operative anaemia, reduction in RBC mass loss, and a lower transfusion rate.
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Modern Patient Blood Management in Arthroplasty. PERIOPERATIVE MEDICAL MANAGEMENT FOR TOTAL JOINT ARTHROPLASTY 2015. [PMCID: PMC7123738 DOI: 10.1007/978-3-319-07203-6_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
One of the oldest and still commonest procedures in clinical practice, allogeneic blood transfusion (ABT), is not fully supported by available evidence. In the last few decades, increasing concerns about unfavorable outcomes associated with ABT, anticipation of future insufficient blood supply, and awareness of the cost (direct and indirect) of transfusion have led to the promotion of patient blood management (PBM) as a cost-effective strategy, beneficial for patients as well as for society (Shander et al. 2010). PBM programs utilize a series of measures with a proven ability to reduce ABT and to be cost-effective. Despite that the impact of PBM on patient clinical outcomes needs to be fully defined and future studies are needed, PBM should be adopted as a new standard of care.
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40
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Shah A, Stanworth SJ, McKechnie S. Evidence and triggers for the transfusion of blood and blood products. Anaesthesia 2014; 70 Suppl 1:10-9, e3-5. [DOI: 10.1111/anae.12893] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2014] [Indexed: 01/28/2023]
Affiliation(s)
- A. Shah
- Adult Intensive Care Unit; John Radcliffe Hospital; Oxford UK
| | - S. J. Stanworth
- Department of Haematology; John Radcliffe Hospital; Oxford UK
| | - S. McKechnie
- Department of Anaesthesia and Intensive Care; John Radcliffe Hospital; Oxford UK
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41
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Évaluation des pratiques transfusionnelles périopératoires aux cliniques universitaires de Kinshasa. Transfus Clin Biol 2014. [DOI: 10.1016/j.tracli.2014.08.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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42
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Bisbe E, Moltó L, Arroyo R, Muniesa J, Tejero M. Randomized trial comparing ferric carboxymaltose vs oral ferrous glycine sulphate for postoperative anaemia after total knee arthroplasty. Br J Anaesth 2014; 113:402-9. [DOI: 10.1093/bja/aeu092] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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43
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Baron D, Hochrieser H, Posch M, Metnitz B, Rhodes A, Moreno R, Pearse R, Metnitz P. Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients. Br J Anaesth 2014; 113:416-23. [DOI: 10.1093/bja/aeu098] [Citation(s) in RCA: 267] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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44
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[Perioperative anemia management: a systematic review and meta-analysis]. Wien Med Wochenschr 2014; 164:330-41. [PMID: 25168917 DOI: 10.1007/s10354-014-0293-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 06/25/2014] [Indexed: 01/23/2023]
Abstract
Anemia is a risk factor for increased postoperative morbidity and mortality. International guidelines, therefore, recommend preoperative diagnostic work up and causal treatment of anemia. Iron therapy, however, is suspected to negatively affect disease progression in patients with cancer-associated anemia. The objective of our systematic review was to assess the efficacy and safety of perioperative diagnosis and causal therapy of anemia, and to determine the effect of iron supplement on disease progression of cancer.We systematically searched multiple electronic databases. Two persons independently reviewed abstracts and full-text articles. We rated the risk of bias using the Cochrane Risk of Bias Tool and assessed the quality of the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Meta-Analyses were performed using the DerSimonian&Laird random effects method. Results indicate that preoperative therapy of anemia could reduce the need for blood transfusions (relative risk: 0,78; 95% confidence interval 0,61-1,02; number needed to treat: 6) For other patient-relevant outcomes the number of events were too small to detect clinically relevant differences. We could not find any evidence that iron supplements have an influence on the progression of tumors.
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Dilla A, Wisniewski MK, Waters JH, Triulzi DJ, Yazer MH. The effect of automated alerts on preoperative anemia management. Hematology 2014; 20:160-4. [DOI: 10.1179/1607845414y.0000000194] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Andrew Dilla
- School of MedicineUniversity of Pittsburgh, Pittsburgh, PA, USA
| | - Mary Kay Wisniewski
- The Donald D. Wolff Jr. Center for QualitySafety, and Innovation at UPMC, Pittsburgh, PA, USA
| | - Jonathan H. Waters
- Department of AnesthesiologyBioengineering and the McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Darrell J. Triulzi
- Department of PathologyUniversity of Pittsburgh, Pittsburgh, PA, USA
- Institute for Transfusion MedicinePittsburgh, PA, USA
| | - Mark H. Yazer
- Department of PathologyUniversity of Pittsburgh, Pittsburgh, PA, USA
- Institute for Transfusion MedicinePittsburgh, PA, USA
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Ackerman SJ, Tapia CI, Baik R, Pivec R, Mont MA. Use of a bipolar sealer in total hip arthroplasty: medical resource use and costs using a hospital administrative database. Orthopedics 2014; 37:e472-81. [PMID: 24810825 DOI: 10.3928/01477447-20140430-59] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/25/2013] [Indexed: 02/03/2023]
Abstract
Perioperative blood loss during total hip arthroplasty (THA) increases patient morbidity, length of stay (LOS), medical resource use (MRU), and costs. Minimizing blood loss may reduce postoperative anemia, the need for blood transfusions, and the increased risk of infections and longer hospital stays associated with blood transfusions. Pharmacologic agents and bipolar sealer devices can minimize perioperative bleeding. A retrospective, comparative cohort study in the US hospital setting was conducted to assess MRU and associated costs and the incidence of transfusion and complications among patients undergoing THA with or without the use of a bipolar sealer. Using a nationwide all-payer hospital administrative database, THA procedures from January 1, 2008, to March 31, 2011, were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure code 81.51. The bipolar sealer cohort (n=2683) and matched control cohort (n=2683) had a mean age of 65 years from 38 hospitals. The 2 groups had similar incidences of pre-operative anemia and medical comorbidities. Patients in the bipolar sealer group required significantly fewer blood transfusions (21.3% vs 23.8%; P=.0286) and had significantly lower incidence of hematomas (0.2% vs 0.9%; P=.0015) and significantly shorter LOS (2.90 vs 3.31 days; P<.0001) overall. The bipolar sealer group had higher supply costs, which were offset by reduced hospital inpatient room and board and operating room costs; there was no significant difference in total hospital costs between the 2 groups ($18,937 vs $18,734; P=.56). A bipolar sealer decreases postoperative blood transfusions and LOS during primary THA without increasing total hospital costs.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Blood Loss, Surgical/prevention & control
- Blood Loss, Surgical/statistics & numerical data
- Blood Transfusion/statistics & numerical data
- Cohort Studies
- Databases, Factual
- Female
- Health Care Costs/statistics & numerical data
- Hemostasis, Surgical/instrumentation
- Humans
- Length of Stay/statistics & numerical data
- Male
- Middle Aged
- Retrospective Studies
- United States/epidemiology
- Young Adult
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Reduced blood loss with ligation of medial circumflex pedicle during total hip arthroplasty with minimally invasive posterior approach. Orthop Traumatol Surg Res 2014; 100:237-8. [PMID: 24559883 DOI: 10.1016/j.otsr.2013.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/17/2013] [Accepted: 11/04/2013] [Indexed: 02/06/2023]
Abstract
A total hip arthroplasty procedure can lead to significant perioperative blood loss due to bleeding from the medial circumflex pedicle. When either the anterior or posterior approach is used, haemostasis of this pedicle, which is typically performed with electrocautery without dissection, can be inadequate. The purpose of this study was to evaluate the efficacy of a novel surgical technique in which the pedicleis is directly ligated. A single-centre, single-surgeon prospective study was performed to compare pedicle ligation to electrocautery (control group). In the ligation group, the pedicle was identified in front of the upper-third of the quadratus femoris and ligated. The mean postoperative blood loss in the ligation group (293.4±34.8 mL) was significantly less than in the control group (419.0±36.8 mL) (P<0.05). Pedicle ligation is a simple procedure that reduces blood loss during total hip arthroplasty.
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48
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Horstmann WG, Swierstra MJ, Ohanis D, Rolink R, Kollen BJ, Verheyen CCPM. Favourable results of a new intraoperative and postoperative filtered autologous blood re-transfusion system in total hip arthroplasty: a randomised controlled trial. INTERNATIONAL ORTHOPAEDICS 2014; 38:13-8. [PMID: 24077886 PMCID: PMC3890134 DOI: 10.1007/s00264-013-2084-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 08/11/2013] [Indexed: 01/02/2023]
Abstract
PURPOSE A new intraoperative filtered salvaged blood re-transfusion system has been developed for primary total hip arthroplasty (THA) that filters and re-transfuses the blood that is lost during THA. This system is intended to increase postoperative haemoglobin (Hb) levels, reduce perioperative net blood loss and reduce the need for allogeneic transfusions. It supposedly does not have the disadvantages of intraoperative cell-washing/separating re-transfusion systems, such as extensive procedure, high costs and need for specialised personnel. To re-transfuse as much as blood as possible, postoperatively drained blood was also re-transfused. METHODS A randomised, controlled, blinded, single-centre trial was conducted in which 118 THA patients were randomised to an intraoperative autologous blood re-transfusion (ABT) filter system combined with a postoperative ABT filter unit or high-vacuum closed-suction drainage. RESULTS On average, 577 ml of blood was re-transfused in the ABT group: 323 ml collected intraoperatively and 254 ml collected postoperatively. Hb level was higher in the ABT vs the high-vacuum drainage group: 11.4 vs. 10.8 g/dl, p = 0.02 on day one (primary endpoint) and 11.0 vs. 10.4 g/dl, p = 0.007 on day three. Total blood loss was less in the autotransfusion group: 1472 vs. 1678 ml, p = 0.03. Allogeneic transfusions were needed in 3.6 % of patients in the ABT group and 6.5 % in the drainage group, p = 0.68. CONCLUSION The use of a new intraoperative ABT filter system combined with a postoperative ABT unit resulted in higher postoperative Hb levels and less total blood loss compared with a high-vacuum drain following THA.
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Affiliation(s)
- Wieger G. Horstmann
- />Orthopedic Surgeon, Kennemer Gasthuis, Location E.G., Boerhaavelaan 22, 2035 RC Haarlem, P.O. Box 417, 2000 AK Haarlem, The Netherlands
| | | | - David Ohanis
- />Resident Orthopedic Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Rob Rolink
- />Resident Orthopedic Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Boudewijn J. Kollen
- />Epidemiologist, Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Ten-year follow-up on Dutch orthopaedic blood management (DATA III survey). Arch Orthop Trauma Surg 2014; 134:15-20. [PMID: 24276360 DOI: 10.1007/s00402-013-1893-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. This survey was conducted to assess the current use of perioperative blood-saving measures and to compare it with prior results. MATERIALS AND METHODS All departments of orthopaedic surgery at Dutch hospitals were sent a follow-up survey on perioperative blood-saving measures, and data were compared to the results of two surveys conducted 5 and 10 years earlier. RESULTS The response rate was 94 out of 108 departments (87%). Most departments used erythropoietin prior to hip and knee replacements at the expense of preoperative autologous blood donation. The use of intraoperative autologous retransfusion in revision hip (56 vs. 54%) as well as revision knee arthroplasty (26 vs. 24%), was virtually unchanged. Postoperative autologous retransfusion is still used by the majority of departments after both primary arthroplasty and revision of hip (58/53%) and knee (65/61%). CONCLUSIONS Currently, just as in 2007, the majority of Dutch orthopaedic departments uses erythropoietin, normothermia and postoperative autologous retransfusion with hip and knee arthroplasty. Intraoperative retransfusion is used mainly with hip revision arthroplasty. Other effective blood management modalities such as tranexamic acid have not been widely implemented.
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Tighten Your Belts! Reduce Your Transfusion Costs with Preoperative Management of Anemic Patients. Anesth Analg 2013. [DOI: 10.1213/ane.0b013e3182973498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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