[Indications for blood transfusion during orthopedic surgery]

Intraarticular use of tranexamic acid reduces blood loss and transfusion rate after primary total knee arthroplasty

BACKGROUND

Tranexamic acid (TXA) is effective in reduction of hemorrhage after major surgical procedures. In total joint replacement it is commonly administered intravenously. Despite various studies regarding the safety of its antifibrinolytic effect there are contraindications for systemic use. In total knee arthroplasty (TKA) TXA can also be administered intraarticular. However, there is a lack of studies focusing on dosage, effectiveness and complications of this local treatment. This study aimed to evaluate if blood loss and transfusion rate can be reduced in primary TKA by local application of TXA.

METHODS

We included a total of 202 consecutive primary, unilateral TKA patients, 101 without and 101 with intraartricular application of 2 g TXA. Surgery was conducted after a standardized protocol. Blood loss, transfusion and complication rates were evaluated until three months after surgery. Blood loss was estimated using the hematocrit-value (Hk) prior and five days after surgery by Rosenecher's and Mercuriali's formula.

RESULTS

By the use of TXA a significant reduction of blood loss (Rosencher average 1220 ml vs 1900 ml, Mercuriali average 430 ml vs 700 ml p < 0,001) and transfusion rate (0% vs 24.75% of patients, p < 0,001) was observed. There were no differences regarding complication rates. Due to the lower cost of TXA compared to applied erythrocyte concentrates a side effect of the treatment was a cost reduction of € 1.609 within this cohort.

CONCLUSIONS

The intraarticular application of 2 g TXA resulted in a significant reduction of blood loss and transfusion rate after primary TKA without increased complication rates. This method therefore seems to be a safe and cost effective instrument to reduce perioperative blood loss. However, it has to be considered that this is an off-label use.

Randomized Controlled Study on Safety and Feasibility of Transfusion Trigger Score of Emergency Operations

Background:

Due to the floating of the guideline, there is no evidence-based evaluation index on when to start the blood transfusion for patients with hemoglobin (Hb) level between 7 and 10 g/dl. As a result, the trigger point of blood transfusion may be different in the emergency use of the existing transfusion guidelines. The present study was designed to evaluate whether the scheme can be safely and effectively used for emergency patients, so as to be supported by multicenter and large sample data in the future.

Methods:

From June 2013 to June 2014, patients were randomly divided into the experimental group (Peri-operative Transfusion Trigger Score of Emergency [POTTS-E] group) and the control group (control group). The between-group differences in the patients’ demography and baseline information, mortality and blood transfusion-related complications, heart rate, resting arterial pressure, body temperature, and Hb values were compared. The consistency of red blood cell (RBC) transfusion standards of the two groups of patients with the current blood transfusion guideline, namely the compliance of the guidelines, utilization rate, and per-capita consumption of autologous RBC were analyzed.

Results:

During the study period, a total of 72 patients were recorded, and 65 of them met the inclusion criteria, which included 33 males and 32 females with a mean age of (34.8 ± 14.6) years. 50 underwent abdomen surgery, 4 underwent chest surgery, 11 underwent arms and legs surgery. There was no statistical difference between the two groups for demography and baseline information. There was also no statistical differences between the two groups in anesthesia time, intraoperative rehydration, staying time in postanesthetic care unit, emergency hospitalization, postoperative 72 h Acute Physiologic Assessment and Chronic Health Evaluation II scores, blood transfusion-related complications and mortality. Only the POTTS-E group on the 1^st postoperative day Hb was lower than group control, P < 0.05. POTTS-E group was totally (100%) conformed to the requirements of the transfusion guideline to RBC infusion, which was higher than that of the control group (81.25%), P < 0.01. There were no statistical differences in utilization rates of autologous blood of the two groups; the utilization rates of allogeneic RBC, total allogeneic RBC and total RBC were 48.48%, 51.5%, and 75.7% in POTTS-E group, which were lower than those of the control group (84.3%, 84.3%, and 96.8%) P < 0.05 or P < 0.01. Per capita consumption of intraoperative allogeneic RBC, total allogeneic RBC and total RBC were 0 (0, 3.0), 2.0 (0, 4.0), and 3.1 (0.81, 6.0) in POTTS-E groups were all lower than those of control group (4.0 [2.0, 4.0], 4.0 [2.0, 6.0] and 5.8 [2.7, 8.2]), P < 0.05 or P < 0.001.

Conclusions:

Peri-operative Transfusion Trigger Score-E evaluation scheme is used to guide the application of RBC. There are no differences in the recent prognosis of patients with the traditional transfusion guidelines. This scheme is safe; Compared with doctor experience-based subjective assessment, the scoring scheme was closer to patient physiological needs for transfusion and more reasonable; Utilization rate and the per capita consumption of RBC are obviously declined, which has clinical significance and is feasible. Based on the abovementioned three points, POTTS-E scores scheme is safe, reasonable, and practicable and has the value for carrying out multicenter and large sample clinical researches.

[Analgaesia, anaesthesia, and rehabilitation for minimally invasive total knee arthroplasty]

Compared with conventional total knee arthroplasty, rehabilitation after a minimally invasive procedure is faster. Flexion to 90 degrees is reached in a few days in most patients. Coordination exercises, stair climbing, and mobilisation with one or no crutches are achieved rapidly, and patients can usually return more quickly to their activities of daily living as well as professional and leisure-time activities. This progress is based on new surgical techniques that protect muscles and tendons. To optimize these results, analgaesia protocols and anaesthesia procedures could be improved, and rehabilitation programs should be individualised. Patient education is best started weeks before surgery because a well-motivated patient supports an excellent clinical outcome. New surgical techniques give us the possibility to think about routinely used perioperative procedures and improve them. The aim is to offer a concept of minimally invasive surgical technique and optimized protocols for perioperative anaesthesia, analgaesia, and rehabilitation.

[Tolerance to perioperative anemia. Mechanisms, influencing factors and limits]

Die zu erwartende Kostensteigerung im Transfusionswesen (steigender Fremdblutbedarf bei gleichzeitig rückläufiger Spendebereitschaft, Behandlungspflicht transfusionsassoziierter Folgeerkrankungen) erhöht den sozioökonomischen Stellenwert der Entwicklung institutionsspezifischer Transfusionsprogramme. Ein wesentlicher Bestandteil hierbei ist – neben einer schonenden Operationstechnik und der konsequenten perioperativen Anwendung fremdblutsparender Maßnahmen – die Ausschöpfung der natürlicherweise vorhandenen „Anämietoleranz“ des menschlichen Organismus (Toleranz größerer Blutverluste durch Verlust von „verdünntem“ Blut, Hinauszögern des Transfusionsbeginns bis nach chirurgischer Blutstillung, Gewinnung von autologem Blut). In der vorliegenden Übersicht werden die Mechanismen, Einflussgrößen und Grenzen dieser natürlichen Anämietoleranz für den Gesamtorganismus und für einzelne Organsysteme zusammengefasst und die sich daraus ergebende Indikation zur Erythrozytentransfusion abgeleitet. Unter kontrollierten Bedingungen (Narkose, strikte Aufrechterhaltung von Normovolämie, komplette Muskelrelaxierung, Hyperoxämie, Hypothermie) werden von kardiopulmonal gesunden Individuen kurzzeitig auch extreme Grade der Verdünnungsanämie [Hämoglobin- (Hb-)Wert <3 g/dl (<1,86 mmol/l)] ohne Transfusion toleriert. In der klinischen Routine bleibt diese Situation – nicht zuletzt in Ermangelung eines adäquaten Monitorings – jedoch auf spezielle Sonderfälle beschränkt (z. B. unerwartete große Blutverluste bei Zeugen Jehovahs, unerwarteter Engpass bei der Bereitstellung von Fremdblut). Die derzeit geltenden Empfehlungen verschiedener Expertenkommissionen decken sich dahingehend, dass perioperativ (1) bis zu einer Hb-Konzentration von 10 g/dl (6,21 mmol/l) auch bei alten Patienten und Patienten mit kardiopulmonalen Begleiterkrankungen eine Transfusion von Erythrozyten in der Regel nicht notwendig ist und (2) eine Transfusion bei jungen, gesunden Patienten ohne kardiopulmonale Vorerkrankungen (einschließlich Schwangeren und Kindern) erst ab einer Hb-Konzentration von <6 g/dl (<3,72 mmol/l) notwendig wird. Auch beatmete Intensivpatienten mit Polytrauma und Sepsis scheinen nicht von einer Transfusion auf Hb-Konzentration >9 g/dl (>5,59 mmol/l) zu profitieren. Bei massiven Blutverlusten und diffuser Blutungsneigung scheint ein Hb von 10 g/dl (6,21 mmol/l) zur Stabilisierung der Blutgerinnung beizutragen.

[Tolerance to perioperative anemia. Mechanisms, influencing factors and limits]

Die zu erwartende Kostensteigerung im Transfusionswesen erhöht den sozioökonomischen Stellenwert der Entwicklung institutionsspezifischer Transfusionsprogramme. Ein wesentlicher Bestandteil hierbei ist – neben einer schonenden Operationstechnik und der konsequenten perioperativen Anwendung fremdblutsparender Maßnahmen – die Ausschöpfung der natürlichen „Anämietoleranz“ des menschlichen Organismus. Im vorliegenden Beitrag werden die Mechanismen, Einflussgrößen und Grenzen dieser Anämietoleranz für den Gesamtorganismus und für einzelne Organsysteme zusammengefasst und die sich daraus ergebende Indikation zur Erythrozytentransfusion abgeleitet. Die derzeit geltenden Empfehlungen decken sich dahingehend, dass bis zu einer Hämoglobinkonzentration von 10 g/dl (6,21 mmol/l) auch bei alten Patienten oder kardiopulmonalen Begleiterkrankungen eine perioperative Transfusion in der Regel nicht notwendig ist und bei jungen, gesunden Patienten ohne kardiopulmonale Vorerkrankungen (einschließlich Schwangeren und Kindern) erst ab <6 g/dl (<3,72 mmol/l) notwendig wird. Auch beatmete Intensivpatienten mit Polytrauma und Sepsis scheinen nicht von einer Transfusion auf eine Hämoglobinkonzentration >9 g/dl (>5,59 mmol/l) zu profitieren. Bei massiven Blutverlusten und diffuser Blutungsneigung scheint ein Wert von 10 g/dl (6,21 mmol/l) zur Stabilisierung der Blutgerinnung beizutragen.