Perioperative protocol to reduce blood transfusions in total knee o hip replacement patients
DOI:
https://doi.org/10.31053/1853.0605.v78.n2.30134Keywords:
arthroplasty replacement, blood transfusion, anemia, Tranexamic AcidAbstract
Introduction
Patient Blood Management (PBM) programs improve patient care and reduce health costs. It includes detection of presurgical anemia, reduction of blood loss and improvement of patient-specific anemic reserve. The aim of this study is to assess the effect of a PBM program on transfusion rate, length of stay (LOS) and adverse events.
Methods
We developed a retrospective observational study. We included patients who underwent total hip (THR) o knee replacement (TKR). Our PBM involved preoperative assessment, administration of 2 doses of tranexamic acid, application of restrictive transfusion criteria and use of IV iron. We compared results between the group of patients before and the one after the PBM implementation.
Results
We included 179 patients (80 TKR and 99 THR) who underwent surgery before PBM implementation from January to December 2014 (Group A), and 187 patients (103 TKR and 84 THR) who underwent arthroplasty after PBM application from January to November 2016 (Group B). In Group A, hemoglobin drop was larger than in Group B, for TKR (5.1±1.2 vs. 4.2±1.2 g/dl; p<0,05) and for THR (4.7±1.3 vs. 3.8±1.3 g/dl; p<0,05). In group A, more patients were transfused (31.8% vs. 2.7%; p<0.001). LOS was longer for patients in group A, in both surgeries (for TKA, 3.98±1.4days vs. 2.99±0.95 days; p<0.0001; for THA 3.68±1.06days vs. 2.88±0.75days; p<0.0001). No significant differences were found regarding adverse events.
Conclusion
Our PBM program saved transfusions after primary TKR and THR and lowered LOS, without risking patients to higher number of complications or death.
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References
Zhu S, Qian W, Jiang C, Ye C, Chen X. Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis. Postgrad Med J. 2017 Dec;93(1106):736-742. doi: 10.1136/postgradmedj-2017-134991.
Soffin EM, YaDeau JT. Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. Br J Anaesth. 2016 Dec;117(suppl 3):iii62-iii72. doi: 10.1093/bja/aew362.
Goodnough LT, Shander A. Patient blood management. Anesthesiology. 2012 Jun;116(6):1367-76. doi: 10.1097/ALN.0b013e318254d1a3. Erratum in: Anesthesiology. 2013 Jan;118(1):224.
Theusinger OM, Kind SL, Seifert B, Borgeat L, Gerber C, Spahn DR. 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 Transfus. 2014 Apr;12(2):195-203. doi: 10.2450/2014.0306-13.
Jans Ø, Jørgensen C, Kehlet H, Johansson PI; Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group. Role of preoperative anemia for risk of transfusion and postoperative morbidity in fast-track hip and knee arthroplasty. Transfusion. 2014 Mar;54(3):717-26. doi: 10.1111/trf.12332.
Muñoz M, Gómez-Ramírez S, García-Erce JA. Implementing Patient Blood Management in major orthopaedic procedures: orthodoxy or pragmatism? Blood Transfus. 2014 Apr;12(2):146-9. doi: 10.2450/2014.0050-14.
Wu WC, Schifftner TL, Henderson WG, Eaton CB, Poses RM, Uttley G, Sharma SC, Vezeridis M, Khuri SF, Friedmann PD. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA. 2007 Jun 13;297(22):2481-8. doi: 10.1001/jama.297.22.2481.
Padhi S, Kemmis-Betty S, Rajesh S, Hill J, Murphy MF. Blood transfusion: summary of NICE guidance. BMJ. 2015 Nov 18;351:h5832–h5832.
Carson JL, Guyatt G, Heddle NM, Grossman BJ, Cohn CS, Fung MK, Gernsheimer T, Holcomb JB, Kaplan LJ, Katz LM, Peterson N, Ramsey G, Rao SV, Roback JD, Shander A, Tobian AA. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA. 2016 Nov 15;316(19):2025-2035. doi: 10.1001/jama.2016.9185.
Xie J, Hu Q, Huang Q, Ma J, Lei Y, Pei F. Comparison of intravenous versus topical tranexamic acid in primary total hip and knee arthroplasty: An updated meta-analysis. Thromb Res. 2017 May;153:28-36. doi: 10.1016/j.thromres.2017.03.009.
De Napoli G, Ottolenghi J, Melo LM. Comparación de sangrado y transfusiones en artroplastias primarias de cadera y rodilla con monodosis de ácido tranexámico frente a placebo en un hospital universitario. Estudio prospectivo. Rev Colomb Ortop y Traumatol. 2016 Sep;30(3):101–6. doi: 10.1016/j.rccot.2016.10.004.
Dauria A, Depetris HM. Uso tópico de ácido tranexámico en reemplazo total de rodilla primario. [Topical administration of tranexamic acid in primary total knee replacement.]. Rev la Asoc Argentina Ortop y Traumatol. 2018 Feb 15;83(1):05-11. doi: 10.15417/697.
Pujol-Nicolas A, Morrison R, Casson C, Khan S, Marriott A, Tiplady C, Kotze A, Gray W, Reed M. Preoperative screening and intervention for mild anemia with low iron stores in elective hip and knee arthroplasty. Transfusion. 2017 Dec;57(12):3049-3057. doi: 10.1111/trf.14372.
Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, Nemo G, Dragert K, Beaupre L, Hildebrand K, Macaulay W, Lewis C, Cook DR, Dobbin G, Zakriya KJ, Apple FS, Horney RA, Magaziner J; FOCUS Investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011 Dec 29;365(26):2453-62. doi: 10.1056/NEJMoa1012452.
Goodnough LT, Levy JH, Murphy MF. Concepts of blood transfusion in adults. Lancet. 2013 May 25;381(9880):1845-54. doi: 10.1016/S0140-6736(13)60650-9.
Duncan CM, Gillette BP, Jacob AK, Sierra RJ, Sanchez-Sotelo J, Smith HM. Venous thromboembolism and mortality associated with tranexamic acid use during total hip and knee arthroplasty. J Arthroplasty. 2015 Feb;30(2):272-6. doi: 10.1016/j.arth.2014.08.022.
Sun Y, Jiang C, Li Q. A systematic review and meta-analysis comparing combined intravenous and topical tranexamic acid with intravenous administration alone in THA. PLoS One. 2017 Oct 10;12(10):e0186174. doi: 10.1371/journal.pone.0186174.
Xie J, Ma J, Yue C, Kang P, Pei F. Combined use of intravenous and topical tranexamic acid following cementless total hip arthroplasty: a randomised clinical trial. Hip Int. 2016 Jan-Feb;26(1):36-42. doi: 10.5301/hipint.5000291.
May JH, Rieser GR, Williams CG, Markert RJ, Bauman RD, Lawless MW. The Assessment of Blood Loss During Total Knee Arthroplasty When Comparing Intravenous vs Intracapsular Administration of Tranexamic Acid. J Arthroplasty. 2016 Nov;31(11):2452-2457. doi: 10.1016/j.arth.2016.04.018.
Goyal N, Chen DB, Harris IA, Rowden NJ, Kirsh G, MacDessi SJ. Intravenous vs Intra-Articular Tranexamic Acid in Total Knee Arthroplasty: A Randomized, Double-Blind Trial. J Arthroplasty. 2017 Jan;32(1):28-32. doi: 10.1016/j.arth.2016.07.004.
North WT, Mehran N, Davis JJ, Silverton CD, Weir RM, Laker MW. Topical vs Intravenous Tranexamic Acid in Primary Total Hip Arthroplasty: A Double-Blind, Randomized Controlled Trial. J Arthroplasty. 2016 May;31(5):1022-6. doi: 10.1016/j.arth.2015.11.003.
Poeran J, Rasul R, Suzuki S, Danninger T, Mazumdar M, Opperer M, Boettner F, Memtsoudis SG. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ. 2014 Aug 12;349:g4829. doi: 10.1136/bmj.g4829.
Xu K, Chan NC, Ibrahim Q, Kruger P, Sinha S, Bhagirath V, Ginsberg J, Bangdiwala S, Guyatt G, Eikelboom J, Hirsh J. Reduction in Mortality following Elective Major Hip and Knee Surgery: A Systematic Review and Meta-Analysis. Thromb Haemost. 2019 Apr;119(4):668-674. doi: 10.1055/s-0039-1677732.
Chornenki NLJ, Um KJ, Mendoza PA, Samienezhad A, Swarup V, Chai-Adisaksopha C, Siegal DM. Risk of venous and arterial thrombosis in non-surgical patients receiving systemic tranexamic acid: A systematic review and meta-analysis. Thromb Res. 2019 Jul;179:81-86. doi: 10.1016/j.thromres.2019.05.003.
Malviya A, Martin K, Harper I, Muller SD, Emmerson KP, Partington PF, Reed MR. Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop. 2011 Oct;82(5):577-81. doi: 10.3109/17453674.2011.618911.
Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. The Efficacy of Tranexamic Acid in Total Hip Arthroplasty: A Network Meta-analysis. J Arthroplasty. 2018 Oct;33(10):3083-3089.e4. doi: 10.1016/j.arth.2018.06.023.
Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. The Efficacy of Tranexamic Acid in Total Knee Arthroplasty: A Network Meta-Analysis. J Arthroplasty. 2018 Oct;33(10):3090-3098.e1. doi: 10.1016/j.arth.2018.04.043.
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