Is a hemoglobin of 10 g/dL required for surgery?

Do Low Hemoglobin Levels Affect the Healing Process of Periprosthetic Joint Infection?

Background

Revision knee arthroplasty (RKA) is associated with low hemoglobin (Hb) levels after surgery, which results mostly from perioperative blood loss. Periprosthetic joint infection (PJI) is one of the common reasons for RKA. This study aimed to determine whether low Hb levels affect the healing process of PJI.

Methodology

This retrospective study included 69 patients who underwent two-stage revision for PJI between 2013 and 2016. Patients were divided into two groups according to the latest Hb levels (Hb < 10 and Hb > 10 g/dL) during hospitalization for the first-stage revision surgery. Laboratory parameters of infection were measured during the cement spacer retention period: C-reactive protein (CRP), sedimentation rate (SEDIM), and white blood cell (WBC) count. Treatment was evaluated in two periods: cement spacer retention period (between the first surgery and second surgery) and the first normal CRP period (between the first surgery with the first normal CRP level during the cement spacer retention period). Infection parameters in the two time periods and reoperation with cement spacer were compared between the groups.

Results

The mean patient age was 67.3 ± 7.94 (50-87) years, and the female-to-male ratio was 4:1. No difference was found in the postoperative first control CRP, SEDIM, and WBC between the groups (p = 0.953, p = 0.3341, and p = 0.444, respectively). CRP-SEDIM control curves were observed in parallel, and no significant difference was found. The cement spacer retention period was 60.3 ± 24.8 (17-123) days, and the first normal CRP period was 87.3 ± 28.4 (14-161) days; no statistical difference was found between the groups (p = 0.727, p = 0.754).

Conclusions

In RKA, as low Hb level was not a negative factor of infection, blood transfusion should be avoided as it has many complications.

Implementation of a restrictive blood transfusion protocol in a gynecologic oncology service

Objectives

The purpose of this study was to evaluate the impact of a restrictive blood transfusion protocol in a postoperative gynecologic oncology population. The primary objective was the rate of blood transfusions after surgery before and after implementation of a restrictive transfusion protocol (from July 1^st 2011 to December 30^th 2016). Secondary outcomes were patient morbidity and included rates of surgical site infection, pneumonia, sepsis, unplanned intubation, prolonged ventilator use, renal insufficiency, acute renal failure, urinary tract infection, cerebral vascular accident, cardiac complications, venous thromboembolism, and death within 30 days of surgery, readmissions and length of stay.

Methods

A restrictive blood transfusion protocol was implemented by the gynecologic oncology service at a National Comprehensive Cancer Network designated Comprehensive Cancer Center on January 1^st, 2014. The restrictive protocol required that no patient receive a blood transfusion for hemoglobin greater than 7.0 g/dL (or hematocrit greater than 21.0%) and that all red blood cells were administered in one unit increments followed by re-evaluation of blood parameters. Exceptions to this protocol were postoperative symptomatic anemia, intraoperative or day of surgery transfusion, active bleeding, postoperative severe sepsis, postoperative active coronary ischemia, and postoperative transfusion after 1.5 liter or greater blood loss.

Results

1482 patients were identified for this study (755 in the pre-protocol group and 727 in the post-protocol group). Patients treated under the restrictive protocol had decreased rates of red blood cell transfusion (11.0% vs 5.9% p<0.001), superficial surgical site infection (7.7% vs 4.1% p=0.005), deep surgical site infection (2.3% vs 0.7% p=0.02), and median length of stay (3.0 days vs 2.0 days p<0.001).

Conclusions

A restrictive blood transfusion protocol is associated with reductions in the rates of blood transfusions and postoperative morbidity with a 46.8% reduction in superficial surgical site infection and a 69.6% decrease in deep surgical site infection in the gynecologic oncology patient population.

A prospective study about the preoperative total blood loss in older people with hip fracture

Purpose

Our study is to confirm that hemoglobin (Hb) level is significantly reduced before operation in elderly patients with hip fracture and to specify potential amounts of bleeding and Hb decline in different types of fractures.

Methods

A prospective analysis was made on the clinical data of 349 patients with both a diagnosis of hip fracture and an operative delay of greater than 72 hours between April 2014 and February 2016. Hb concentration was measured on a daily basis before the surgery. Patients were grouped according to the type of fracture (intracapsular and extracapsular) for calculation of the total blood loss (TBL). All data analyses were done by SPSS version 21 software.

Results

There was a significant decrease preoperatively in the Hb concentration of nearly 21.55 g/L (standard error of the mean [SEM] 7.67) in patients with extracapsular hip fractures and nearly 15.63 g/L (SEM 6.01) in patients with intracapsular hip fractures. The preoperative TBL in patients with extracapsular fracture was significantly larger compared to that in patients with intracapsular fracture (790.3 mL and 581.7 mL, respectively, P<0.05 using Student’s t-test). We found no significant difference in the preoperative TBL between the male and female groups.

Conclusion

Hip fracture patients have an obvious blood loss after the injury, yet prior to the surgery the Hb levels were found to be normal. Anesthetic and orthopedic staff should pay additional attention to the problem of low preoperative Hb concentration, even if the initial Hb level was apparently normal.

On admission haemoglobin in patients with hip fracture

Several authors have identified on admission haemoglobin level as the most useful predictor of transfusion risk in patients with a hip fracture. A low postoperative haemoglobin unexplained by perioperative blood loss is not uncommon in these patients. The drop in haemoglobin after re-hydration prior to surgery should depend not only on the degree of dehydration but also on the amount of blood lost in the fracture.We could find no study in the English literature estimating the magnitude of this fall in haemoglobin after re-hydration prior to surgery.We conducted a prospective study to estimate the magnitude of fall in haemoglobin after rehydration prior to surgery by repeating the full blood count after at least 12 h of preoperative fluid resuscitation in 127 patients with hip fracture (75 consecutive at one centre and 52 consecutive at another).The average preoperative drop in haemoglobin was 2.23 gram/decilitre (g/dL) (p-value = 0.00) in subtrochanteric fractures, 1.1 g/dL (p-value = 0.001) in intertrochanteric fractures and 0.7 g/dL (p-value = 0.02) in intracapsular fractures. Fifteen patients with a haemoglobin level >9 g/dL on admission were found to have a haemoglobin level <9 g/dL on repeat test and were prevented from going to theatre without arrangements for perioperative transfusion during this study. Their predicted average postoperative haemoglobin without perioperative blood transfusion was calculated to be 6.5 g/dL.The on admission haemoglobin level was found to be falsely reassuring and could lead to a very low postoperative haemoglobin level. This could prove to be dangerous for many patients especially if remains undetected for several hours. We recommend that all patients with subtrochanteric fractures,and all patients with intertrochanteric or intracapsular fractures with a haemoglobin of less than 12 g/dL on admission have a repeat haemoglobin level performed prior to their surgery.

Risk analysis of blood transfusion requirements in emergency and elective spinal surgery

Spinal surgery has long been considered to have an elevated risk of perioperative blood loss with significant associated blood transfusion requirements. However, a great variability exists in the blood loss and transfusion requirements of differing patients and differing procedures in the area of spinal surgery. We performed a retrospective study of all patients undergoing spinal surgery who required a transfusion≥1 U of red blood cells (RBC) at the National Spinal Injuries Unit (NSIU) at the Mater Misericordiae University Hospital over a 10-year period. The purpose of this study was to identify risk factors associated with significant perioperative transfusion allowing the early recognition of patients at greatest risk, and to improve existing transfusion practices allowing safer, more appropriate blood product allocation. 1,596 surgical procedures were performed at the NSIU over a 10-year period. 25.9% (414/1,596) of these cases required a blood transfusion (n=414). Surgical groups with a significant risk of requiring a transfusion>2 U RBC included deformity surgery (RR=3.351, 95% CI 1.123-10.006, p=0.03), tumor surgery (RR=3.298, 95% CI 1.078-10.089, p=0.036), and trauma surgery (RR=2.444, 95% CI 1.183-5.050, p=0.036). Multivariable logistic regression analysis identified multilevel surgery (>3 levels) as a significant risk of requiring a transfusion>2 U RBC (RR=4.682, 95% CI 2.654-8.261, p<0.0001). Several risk factors in the spinal surgery patient were identified as corresponding to significant transfusion requirements. A greater awareness of the risk factors associated with transfusion is required in order to optimize patient management.

Strategies for blood management in orthopaedic and trauma surgery

Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.

Perioperative Anemia

Perioperative anemia is common and is associated with increased need for blood transfusion in the perioperative period. Perioperative anemia has also been linked to increased morbidity and mortality in surgical patients. Anemia may impede a patient's ability to recover fully and participate in postoperative rehabilitation. Pre-operative treatment of anemia is associated with a reduction in the need for blood transfusion in the perioperative period. Additional advances in surgical technology that reduce blood loss intraoperatively are associated with a reduction in postoperative anemia and should be used whenever possible. All strategies to prevent anemia in the perioperative period should be considered in an effort to minimize exposure of surgical patients to blood transfusion.

How low is too low? Cardiac risks with anemia

Despite the increasing availability of data supporting more restrictive transfusion practices, the risks and benefits of transfusing critically ill patients continue to evoke controversy. Past retrospective and observational studies suggested that liberal transfusion strategies were more beneficial in patients whose hematocrit levels fell below 30%. An expanding body of literature suggests that an arbitrary trigger for transfusion (the '10/30 rule') is ill advised. A recent randomized controlled trial provided compelling evidence that similar, and in some cases better, outcomes result if a restrictive transfusion strategy is maintained. The impact of this accumulating evidence on clinical practice is evident in large reports, which show that the average transfusion trigger in critically ill patients was a hemoglobin level in the range 8–8.5 g/dl. Based on the available evidence, transfusion in the critically ill patient without active ischemic heart disease should generally be withheld until the hemoglobin level falls to 7 g/dl. Transfusions should be administered as clinically indicated for patients with acute, ongoing blood loss and those who have objective signs and symptoms of anemia despite maintenance of euvolemia. The hemoglobin level at which serious morbidity or mortality occurs in critically ill patients with active ischemic heart disease is a subject of continued debate but it is likely that a set transfusion trigger will not provide an optimal risk–benefit profile in this population.

Blood saving protocol in elective total knee arthroplasty

BACKGROUND

To eliminate the need for allogeneic blood transfusion in patients undergoing elective total knee arthroplasty, we established and tried a protocol of combined methods, which is characterized by effectiveness, ease in application, and safety. It is based on perioperative administration of human recombinant erythropoietin plus iron and folic acid, mild acute normovolemic hemodilution, meticulous surgical technique, postoperative blood salvage through a closed-wound drainage system, and lower transfusion triggers.

DATA SOURCES

Sixty-one patients entered the protocol, and the results were retrospectively compared with the ones obtained from 58 consecutive patients who were operated on in the past before the use of any blood saving technique.

CONCLUSIONS

Only 5 patients of those who entered the protocol finally needed allogeneic blood transfusion, receiving a total number of 7 units, which is remarkable when compared with the 50 patients before the application of the protocol who required 111 units. Consequently, the utilization of allogeneic blood was reduced by 94%, a statistically quite significant result (P <0,001). We believe the protocol should be included in orthopedic surgeons' alternatives for blood saving in elective total knee arthroplasty.

Recognition and management of preoperative risk

Internists are frequently asked to do preoperative consultations and to manage perioperative complications. Realistic goals are to identify patient factors that increase the risk of surgery, to quantify this risk in order to make decisions about the appropriateness of and timing of the surgery, to provide recommendations on how to minimize the risk, to identify and manage coexisting medical conditions and their associated medication requirements, to monitor the patient for perioperative problems, and to make recommendations to deal with these problems when they occur. With few exceptions, nonselective imaging and laboratory screening tests have repeatedly been shown to be of little value when the history and physical do not suggest a problem. The risk associated with the planned surgery can be estimated, with the most common serious complications being cardiac events. Updated versions of Goldman's risk indices are particularly helpful for this. Clinical variables are optimally combined with selective stress testing to discern which patients will benefit from preoperative revascularization. This has been studied best in the setting of vascular surgery. A critical guiding principle is that the value of revascularization must be judged in terms of long term gains rather than just immediate perioperative benefit. Other interventions include the selective use of beta blockers, adequate analgesia for all, control of hypertension, and appropriate volume management, especially in the settings of preexisting CHF or valvular disease. It must also be recognized that perioperative ischemia and CHF often present atypically. An approach that combines aspects of both the ACC/AHA and the ACP guidelines seems optimal. A variety of noncardiac issues must also be addressed. Postoperative pulmonary complications are common, especially with preexisting pulmonary disease, thoracic and upper abdominal surgery, and obesity. PFTs and ABGs are indicated in selected patients. Stopping smoking, incentive spirometry, and selective use of bronchodilators and antibiotics are helpful. Patients with rheumatologic diseases have specific concerns based on systemic manifestations of disease including anemia, thrombocytopenia, pulmonary fibrosis, pericarditis, and hypercoagulability; medication effects particularly from steroids and nonsteroidal anti-inflammatory drugs; and specific joint problems including contractures and atlantoaxial joint instability. Diabetes increases the risk of infection and cardiac complications. Prevention of ketoacidosis and glucose control are necessary and can be achieved through a variety of approaches, depending on whether the patient suffers from Type 1 or Type 2 diabetes. The threshold for transfusion has increased in recent years, as has the use of erythropoietin and autologous blood donation. There is no longer an absolute hemoglobin that requires transfusion, although most require transfusion for hemoglobins less than 8 mg/dL, especially in the setting of cardiac disease and bloody surgery. The elderly require surgery at an increased rate and often do not do as well as younger patients. The primary issues are, however, not their age but their increased frequency of underlying disease and diminished reserve. The latter makes them prone to postoperative delirium, sensitivity to medications, and cardiac and pulmonary problems. Despite the many diseases that patients often have and the stresses of surgery itself, modern anesthetic and surgical techniques allow almost all patients to undergo necessary procedures at acceptable risk. The internist plays a critical role in minimizing this risk even further.

Anesthesia and surgery in pediatric patients with low hemoglobin values

A low preoperative hemoglobin (Hb) concentration creates a dilemma for the anesthetist to proceed or not. The authors prospectively studied the perioperative morbidity of 200 healthy infants and children (age range 3 mon-5 years) with preoperative Hb values > or = 7 g/dl, undergoing cleft lip and palate surgery under general anesthesia. The patients were later categorized according to preoperative Hb level group A: Hb 7-10 g/dl and group B: Hb > 10 g/dl and the results were compared. One or more episodes of hypoxemia (SpO2 < 91%) were recorded in 8 patients in group A and 6 in group B during airway management. All patients had stable cardiovascular parameters except for transient bradycardia during desaturations. Recovery was similar and rapid. There were no differences in perioperative morbidity between the two groups. However, the safety of general anesthesia in infants and children with difficult airways is questionable when the oxygen reserve is reduced in anemia.

The effects of stroma-free and dextran-conjugated hemoglobin on hemodynamics and carotid blood flow in hemorrhaged guinea pigs

Hemoglobin solutions are potential resuscitative fluids with volume expanding and oxygen delivery abilities developed to reduce the use of blood transfusion. Most hemoglobin solutions in clinical trials increase transiently arterial pressure by inhibiting nitric oxide-dependent vasodilation. Our objective was to compare the effects on central hemodynamics and carotid blood flow of two hemoglobin solutions after resuscitation from hemorrhage in anesthetized guinea pigs. After anesthesia and instrumentation, severe hemorrhage was induced by withdrawing 50% of the blood volume. Resuscitation was performed after 15 min of hypovolemia with 5% albumin, stroma-free hemoglobin, or hemoglobin conjugated to dextran-benzenetetracarboxylate (Dex-BTC-Hb). The mean arterial pressure (MAP), carotid blood flow (CBF), vascular resistance index and heart rate (HR) were monitored for 3 hours after resuscitation. After hemorrhage, MAP and CBF dropped to 57.6 +/- 4.4% and 58.9 +/- 3.7% of control values respectively. Albumin failed to maintain hemodynamics in the decompensatory phase of shock. Both hemoglobin solutions gave rise to a transient increase in MAP (35%); stroma-free hemoglobin increased the CBF (150%) and resistance index (24%) whereas Dex-BTC-Hb had no effect on CBF and vascular resistances. None of the solutions affected the HR. Modified hemoglobin has attenuated effects on CBF and resistance index compared to stroma-free hemoglobin. This may be due to a balance between the stimulation of nitric oxide synthesis by shear-stress and the inhibition of vasodilation by nitric oxide trapping.

Transfusion-free surgery is a treatment plan for all patients

Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal.

Evaluation of the HemoCue for measuring intra-operative haemoglobin concentrations: a comparison with the Coulter Max-M

We compared haemoglobin concentration values obtained using a portable haemoglobinometer, the HemoCue, in the operating theatre with the results obtained by the Coulter Max-M in the laboratory. Haemoglobin concentrations were measured on 52 arterial blood samples obtained from 13 patients during aortic surgery, in theatre with the HemoCue and again by the Coulter Max-M. Twenty routine samples from the laboratory were also analysed by both methods. There was no significant difference between results, with a mean of 10.94 g.dl-1 and 10.90 g.dl-1 for the HemoCue and Coulter, respectively (p = 0.12, t = -1.99, df = 70). The limits of agreement of the two methods (mean difference +/- 2 SD) were -0.37 and +0.45 g.dl-1. The coefficients of repeatability of the 20 samples analysed in duplicate on each device were 0.26 g.dl-1 and 0.33 g.dl-1, respectively. The coefficients of variance were 0.74% (HemoCue) and 0.93% (Coulter). With adequate training and monitoring, the HemoCue provides comparable haemoglobin results for near-patient testing in theatre.

Morbidity risk assessment in the surgically anemic patient

Clinicians have few data on which to base a decision to transfuse a surgical patient. We reviewed animal and human data to evaluate the effects that anemia and comorbidity have on surgical outcome. Experimental evidence consistently demonstrates increased cardiac output, decreased peripheral vascular resistance, and increased release of oxygen by red blood cells in response to anemia. Normal animals tolerate hemoglobin (Hb) levels down to approximately 5 g/dL. Below this level, cardiac ischemia and decreased ventricular function develop. In animals with experimental coronary artery stenosis, cardiac ischemia develops at Hb levels of 7-10 g/dL. Coexisting left ventricular hypertrophy, use of beta blockers, and hypoxemia also reduce animals' ability to tolerate anemia. The limited information on anemia tolerance of human surgical patients suggests that the presence of cardiac and pulmonary disease should influence transfusion decisions. A higher Hb threshold should be used in patients who have or are at risk of cardiac or pulmonary artery disease.