Patient blood management strategies in total hip and knee arthroplasty

Factors associated with increased risk of postoperative blood transfusion in patients undergoing total hip arthroplasty at an Irish University Hospital

INTRODUCTION

Approximately 7000 total hip arthroplasty (THA) surgeries occur in Ireland each year. A number of preoperative factors have been identified that increase the risk of postoperative blood transfusion after THA, including anaemia. The ability to identify patients at risk may allow preoperative management strategies to reduce blood transfusions. Data from Irish orthopaedic patients is currently lacking.

AIM

To investigate if preoperative anaemia and other factors are associated with postoperative blood transfusions in patients who undergo THA.

METHODS

A retrospective cohort study of all patients who underwent THA in 2019 in SIVUH, Cork, using medical chart review.

RESULTS

In total, 350 charts met the inclusion criteria, with 291 charts reviewed. 8.9% of the patients who underwent THA had preoperative anaemia. Among these, 19.2% had a postoperative blood transfusion, compared to 1.5% of patients who were not anaemic preoperatively. The odds of receiving a blood transfusion was 15.5 times greater in the preoperative anaemia group compared to the non-anaemic group. Increasing age and higher ASA scores were associated with preoperative anaemia and postoperative blood transfusions. Length of stay was increased by 2.2 days (p < 0.00016) if blood transfusion was required.

CONCLUSION

Preoperative anaemia was common in an Irish orthopaedic population undergoing THA. Preoperative anaemia predisposes patients to the greatest increased risk of postoperative blood transfusions. The other factors associated with the need for postoperative transfusion were ASA grade 3 or more and age greater than 65 years. Patients who received postoperative blood transfusions had a significantly increased length of hospital stay.

Acute kidney injury in the context of staged revision arthroplasty and the use of antibiotic-laden cement spacers: a systematic review

BACKGROUND

The most common cause of revision arthroplasty is prosthetic joint infection (PJI). Chronic PJI is commonly treated with two-stage exchange arthroplasty involving the placement of antibiotic-laden cement spacers (ACS) in the first stage, often containing nephrotoxic antibiotics. These patients often have significant comorbidity burdens and have higher rates of acute kidney injury (AKI). This systematic review aims to assess the current literature to identify (1) AKI incidence, (2) associated risk factors, and (3) antibiotic concentration thresholds in ACS that increase AKI risk following first-stage revision arthroplasty.

METHODS

An electronic search was performed of the PubMed database of all studies involving patients undergoing ACS placement for chronic PJI. Studies assessing AKI rates and risk factors were screened by two authors independently. Data synthesis was performed when possible. Significant heterogeneity prevented meta-analysis.

RESULTS

Eight observational studies consisting of 540 knee PJIs and 943 hip PJIs met inclusion criteria. There were 309 (21%) cases involving AKI. The most commonly reported risk factors included perfusion-related factors (lower preoperative hemoglobin, transfusion requirement, or hypovolemia), older age, increased comorbidity burden, and nonsteroidal anti-inflammatory drug consumption. Only two studies found increased risk with greater ACS antibiotic concentration (> 4 g vancomycin and > 4.8 g tobramycin per spacer in one study, > 3.6 g of vancomycin per batch or > 3.6 g of aminoglycosides per batch in the other); however, these were reported from univariate analyses not accounting for other potential risk factors.

DISCUSSION

Patients undergoing ACS placement for chronic PJI are at an increased risk for AKI. Understanding the risk factors may lead to better multidisciplinary care and safer outcomes for chronic PJI patients.

LEVEL OF EVIDENCE III

The safety of tranexamic acid administration in total knee arthroplasty: a population-based study from Taiwan

Tranexamic acid is an effective treatment to reduce blood loss. We performed a retrospective observational study to evaluate safety in unilateral total knee arthroplasty. We utilised Taiwan's national health insurance database to identify relevant patients and to retrieve information on peri-operative blood transfusions and tranexamic acid administration within 60 days of follow-up. We examined changes in the rate of transfusions and adverse events with respect to tranexamic acid administration using logistic regression. We observed a total of 226,719 knee arthroplasty cases during 2010-2019. Transfusion and tranexamic acid administration rates were 38.9% (88,258) and 42.9% (97,237), respectively. Tranexamic acid was associated with a 50% decrease in blood transfusions (RR: 0.50, 95%CI: 0.48-0.51). After propensity-score matching, tranexamic acid was not associated with pulmonary embolism; deep vein thromboembolism; artery vein thromboembolism; acute myocardial infarction; ischaemic stroke; or in-hospital mortality, but was significantly associated with acute kidney injury. Patients with existing chronic kidney disease suffered a high absolute risk of kidney injury irrespective of tranexamic acid administration (832 per 10,000, 95%CI 797-869). Tranexamic acid was also associated with surgical site infection. There was strong interaction between blood transfusion; tranexamic aid administration; and development of surgical site infection. In conclusion, tranexamic acid use was associated with decreased blood transfusion and was not associated with thromboembolic events. However, careful consideration is required before use in patients with pre-existing renal disease. Further, our observed interaction between patients given tranexamic acid who subsequently require transfusion requires careful consideration with respect to enhanced prophylaxis against surgical site infection.

Blood loss and transfusion rates following total hip arthroplasty: a multivariate analysis

This study aimed to identify factors that inde- pendently predict increased rates of transfusion following total hip arthroplasty (THA) surgery. A retrospective analysis of all patients undergoing THA surgery over 12 months was performed. Electronic operative records were analysed to determine the following patient factors: American Society of Anesthesiologists (ASA) grade, body mass index (BMI), co-morbidities, indication for surgery, surgical technique, type of implant used, haematological markers, hospital length of stay (LOS) and complications. A total of 244 patients were included. There were 141 females (58%) and 103 males (42%). The median age was 65±12. The median pre-operative blood volume was 4500mls (IQR; 4000-5200). The median blood loss was 1069mls (IQR; 775-1390). The total number of patients requiring transfusion was 28 (11%), with a median of two units being transfused. Pre-operative haemoglobin (p<0.001) level, haematocrit (p<0.001) level and weight (p=0.016) were found to be predictive of transfusion requirement as well as ASA grade (p=0.005). Application of an intra-operative surgical drain was associated with higher rates of transfusion (p<0.001). Our study strengthens the evidence that pre-operative haemoglobin and haematocrit levels are valuable predictors of patients requiring transfusion. Additionally, ASA grade may be viewed as a helpful factor in predicting risk of transfusion. A strategy incorporating pre-operative optimisation of modifiable factors may reduce rates of transfusion requirement.

Intraoperative and Postoperative Iron Supplementation in Elective Total Joint Arthroplasty: A Systematic Review

INTRODUCTION

Postoperative anemia is associated with substantial morbidity and mortality in total joint arthroplasty (TJA). Our primary objective was to determine whether perioperative iron supplementation improves postoperative hemoglobin levels in TJA. Secondary objectives were to determine the effects of perioperative iron on adverse events, quality of life, and functional measures in TJA.

METHODS

We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using six databases. We included English-language, randomized controlled trials investigating intraoperative or postoperative iron supplementation in elective TJA that reported postoperative hemoglobin levels in patients aged 18 years or older. Seven eligible studies were identified, among which substantial heterogeneity was noted. Bias risk was low in four studies, unclear in two studies, and high in one study. Three studies assessed oral iron supplementation, three assessed intravenous iron supplementation, and one compared oral and intravenous iron supplementation. All intravenous iron was administered intraoperatively, except in the oral versus intravenous comparison.

RESULTS

Postoperative oral iron supplementation had no effect on postoperative hemoglobin levels. Intraoperative and postoperative intravenous iron supplementation was associated with higher postoperative hemoglobin levels and greater increases in hemoglobin levels. Two studies reported rates of anemia and found that intraoperative and postoperative intravenous iron supplementation reduced rates of postoperative anemia at postoperative day 30. No adverse events were associated with iron supplementation. One study found that intravenous iron improved quality of life in TJA patients with severe postoperative anemia compared with those treated with oral iron. Perioperative iron had no effects on functional outcomes.

DISCUSSION

We found no evidence that postoperative oral iron supplementation improves hemoglobin levels, quality of life, or functional outcomes in elective TJA patients. However, intraoperative and postoperative intravenous iron supplementation may accelerate recovery of hemoglobin levels in these patients.

LEVEL OF EVIDENCE

Level I, systematic review of randomized controlled trials.

Preoperative blood transfusion associated with increased length of stay and increased postoperative complications after revision total knee arthroplasty

Currently, the impact of preoperative transfusion on postoperative morbidity following revision total knee arthroplasty (TKA) is unknown. A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was performed and included patients who underwent revision TKAs. Postoperative complications were analyzed. A total of 6,849 patients were included. Patients who received a preoperative blood transfusion were found to have an increased risk of developing 3 of 17 adverse events. Although overall complication rates remain relatively low, orthopedic surgeons should counsel their patients on the implications of preoperative blood transfusions on post-operative outcomes.