An individualized pre-operative blood saving protocol can increase pre-operative haemoglobin levels and reduce the need for transfusion in elective total hip or knee arthroplasty

Effect of erythropoietin on perioperative blood transfusions in primary total hip arthroplasty: A systematic review

BACKGROUND

Primary total hip arthroplasty (THA) often requires blood transfusion. Transfusions are undesirable due to risks of infectious and noninfectious complications. This systematic review therefore studied the effectiveness of erythropoietin (EPO) in reducing allogeneic transfusion rate during THA.

METHODS

Using the MESH terms "Erythropoietin" AND "Total Hip" with restrictions to 'Randomized Controlled Trial', 'Clinical Trial', 'Humans', and 'English', a literature search was performed in PubMed and CINAHL. Articles were scanned by both authors and retained for further review if eligibility was met according to the inclusion criteria defined by the PICOS (population, intervention, comparator, outcomes, study design) configuration. Risk of bias was assessed using the Cochrane risk of bias criteria. Data extracted include patient demographics, intervention versus comparator arm, outcomes, laboratory data, and individual study characteristics. The primary outcome of focus was rate or amount of allogeneic blood transfusions intra- or postoperatively. In 6/8 studies, data permitted calculations of absolute risk reduction (ARR) in transfusion rate (%) and number needed to treat (NNT) to evade transfusions.

RESULTS

A total of 8 studies met all eligibility criteria and were retained for data extraction; risk of bias was low-moderate in 7/8 and high in 1/8. Allogeneic transfusion exposure was lowered by the intervention in 7/8 studies with ARR from 9.6% to 33.5% and NNT from 4 to 10.

CONCLUSIONS

In the blood conservation systems described, the addition of EPO was effective in reducing allogeneic transfusions. The studies included spanned a nearly 30-year period. Earlier studies incorporated preoperative autologous donation, a now outdated modality.

Routine Preoperative Group Crossmatching and Postoperative Check Hemoglobin Is not Necessary in Patients Undergoing Total Knee Arthroplasty

This study aims to find out if routine preoperative group crossmatch and postoperative check hemoglobin for total knee arthroplasty (TKA) patients is necessary. A retrospective analysis was performed on patients who underwent unilateral TKAs for osteoarthritis from January 1, 2004 to December 31, 2014. The main outcome measures were postoperative hemoglobin levels and transfusion requirements. Patients' demographics, comorbidities, laboratory results, and surgical details were analyzed. A total of 955 TKAs were included in this study (males = 207, females = 748; mean age = 66.1 years, standard deviation [SD] = 7.7). A total of 79 (8.27%) cases required postoperative blood transfusion, and the crossmatch-transfusion ratio was 17.5. Significant predictors for postoperative transfusion included lower preoperative hemoglobin levels (p < 0.001) and advanced age (p < 0.001). Receiver operating characteristic (ROC) curve and Youden's Index analyses identified the preoperative hemoglobin cut-off value for females to be 12.1 g/dL (relative risk (RR): 5.65, p < 0.001) in predicting postoperative blood transfusion requirement, and 12.4 g/dL (RR: 11.71, p < 0.001) for males. For age, the identified cut-off value was 68 years (RR: 3.18, p < 0.001). The largest decline in hemoglobin levels was noted on postoperative day (POD) 3 (31.8%), and smallest on POD 1 (18.8%). The postoperative transfusion requirements in TKA are low and do not justify routine perioperative blood investigations. However, these investigations should be reserved for patients with the identified risk factors, in particular advancing age (68 years and above) and lower preoperative hemoglobin (below or equal to 12.1 and 12.4 g/dL for females and males, respectively). In the event that postoperative hemoglobin level needs to be checked, it should be performed beyond the first POD.

Efficacy and Safety of Intravenous Ferric Carboxymaltose in Patients with Postoperative Anemia Following Same-Day Bilateral Total Knee Arthroplasty: A Randomized Controlled Trial

(1) Background: The purpose of this study was to evaluate the efficacy and safety of intravenous (IV) ferric carboxymaltose (FCM) to treat acute postoperative anemia following same-day bilateral total knee arthroplasty (TKA). (2) Methods: A total of 118 patients who underwent same-day bilateral TKA were randomly assigned to two groups: an FCM group (FCM infusion, 58 patients) and a Control group (placebo with normal saline, 60 patients). The primary endpoint was the number of responders with a Hb increase of two or more points by the second postoperative week. The secondary endpoints were Hb level, iron metabolism variables and blood transfusion rate at 2, 6 and 12 weeks after surgery. (3) Results: The FCM group had more Hb responders than the Control group (62.1% vs. 31.6%, p < 0.001). The Hb level was significantly higher in the FCM group during 12 weeks after surgery (all p < 0.05). Ferritin, iron and transferrin saturation levels were significantly higher in the FCM group from 2 to 12 weeks postoperatively (all p < 0.05). There was no difference in transfusion rate after surgery (p > 0.05). (4) Conclusion: In patients with postoperative anemia after same-day bilateral TKA, IV FCM infusion significantly improved Hb response two weeks after surgery without severe adverse events compared to placebo. In contrast, transfusion rate and various parameters of quality of life assessment up to 12 weeks did not vary between these groups. Level of evidence: Level I.

Does subcutaneous administration of recombinant human erythropoietin increase thrombotic events in total hip arthroplasty? A prospective thrombelastography analysis

BACKGROUND

Anemia is one of severe complications in the perioperative period of total hip arthroplasty (THA). Erythropoietin (EPO) has been considered to improve patients' anemia state, but its efficiency and safety remains controversial.

METHODS

A total of 152 patients who underwent total hip arthroplasty from January 2017 to March 2019 were randomized to 2 groups. Recombinant human erythropoietin (rHu-EPO) group was treated with rHu-EPO subcutaneous injection 10000 IU after operation and once daily in the next week, while control group was treated with none extra treatment. Routine hematologic examination and thrombelastography (TEG) performed at different time point respectively. Doppler ultrasound for bilateral lower limbs was performed 1 day before surgery and 7 days after surgery. Auxiliary examination outcomes, blood transfusions outcomes, and postoperative complications were recorded as assessment indicators.

RESULTS

The difference in the relevant indexes of traditional coagulation and TEG values between two groups were not significantly. No significant difference was observed in the incidence of thromboembolism events and other complications between two groups during postoperative period. The amount of intraoperative blood loss was similar between the two groups. However, the postoperative use and dosage of allogeneic blood in the rHu-EPO group were lower than those in the control group. The hemoglobin and hematocrit level in the rHu-EPO group were higher than that in the control group after surgery.

CONCLUSION

Postoperative subcutaneous injection of rHu-EPO can improve hematological anemia-related parameters, reduce the use and dosage of allogeneic blood transfusions (ABTs), and has no significant influence on the formation of thrombosis and other complications in patients undergoing total hip arthroplasty in short term.

Preoperative iron treatment in anaemic patients undergoing elective total hip or knee arthroplasty: a systematic review and meta-analysis

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.

A randomised trial evaluating the effect of intraoperative iron administration

Perioperative anaemia increases postoperative morbidity and mortality, and iron deficiency is anaemia’s most common cause in surgical patients. Preoperative intravenous iron increases postoperative haemoglobin; however, data regarding intraoperative intravenous iron’s effectiveness are inadequate. This study examined intraoperative intravenous iron’s effects on postoperative haemoglobin levels in adults. Fifty-seven healthy subjects (aged 19–40 years) scheduled for bimaxillary orthognathic surgery were assigned randomly to the iron (n = 28) or control (n = 29) groups. The iron group received intravenous ferric derisomaltose (1,000 mg) after anaesthetic induction. The control group received an identical volume of intravenous normal saline. The primary outcome was postoperative haemoglobin level. Secondary outcomes included other postoperative haematologic and iron parameters. Laboratory data were obtained preoperatively and at 1 day, 2 weeks, and 4 weeks postoperatively. Haemoglobin was higher in the iron group 2 weeks postoperatively (12.9 g/dL vs. 12.2 g/dL), but the between-group difference was not significant after adjustment for multiple testing. However, the reticulocyte production index was significantly higher in the iron group 2 weeks postoperatively. Intraoperative intravenous iron maintains postoperative haemoglobin values in patients undergoing bimaxillary orthognathic surgery by increasing haematopoietic function and iron bioavailability and therefore appears to be a useful strategy for blood management.

Effectiveness of iron supplementation in the perioperative management of total knee arthroplasty: a systematic review

Introduction/purpose

The purpose of this systematic review was to evaluate the effect of iron supplementation during total knee arthroplasty (TKA): (1) Is the iron supplementation necessary during TKA? (2) When is the optimal timing of iron supplementation? (3) Which is better, between orally and intravenously administered iron supplementation? And (4) What is the optimal dose of iron supplementation?

Materials and methods

A rigorous and systematic approach was used and each of the selected studies was evaluated for methodological quality. Data about study design, total number of cases enrolled, iron administration method, timing, and dose were extracted. Change in hemoglobin and transfusion rates were extracted to evaluate the effectiveness of iron supplementation.

Results

Eleven studies were included in the final analysis. Most of studies reported that hemoglobin change between iron and control group did not show any difference. Only one study reported that iron supplementation could reduce the decrease in hemoglobin. However, transfusion rate showed a decrease in the iron supplementation group compared with the control group. There was no clear consensus on the optimum timing and dose of iron supplementation and intravenously administered iron was more effective than orally administered iron, especially in anemic patients.

Conclusion

Iron supplementation is not clear as a way to raise hemoglobin levels after TKA, but an effective treatment for lowering transfusion rate, especially in patients with anemia. We could not determine the optimal timing and dose of the iron. Intravenously administered iron was similar to, or better than, orally administered iron for improving hemoglobin levels and transfusion rate.

Clinical effectiveness of 3 days preoperative treatment with recombinant human erythropoietin in total knee arthroplasty surgery: a clinical trial

AIMS

The purpose of study is to evaluate the effect and complication of preoperative short-term daily recombinant human erythropoietin (rhEPO) treatment for blood-saving in patients undergoing unilateral primary total knee arthroplasty (TKA).

METHODS

This three-arm randomized clinical trial compared three different rhEPO-based treatment protocols for unilateral primary TKA. Group A: application of daily doses of rhEPO combined with iron supplement starting 3 days before surgery; Group B: application of daily doses of rhEPO combined with iron supplement starting the day of surgery; Group C: iron supplement alone. Perioperative hemoglobin (Hb) level gaps, total perioperative blood loss, reticulocyte levels and treatment-related complications were studied.

RESULTS

A total of 102 patients were included (35, 35 and 32 patients in Groups A, B and C, respectively). Total blood loss (TBL) in Groups A, B and C was 490.84, 806.76 and 924.21 ml, respectively. Patients in Group A had a significant lower TBL than Groups B and C (A vs. B: P = 0.010; A vs. C: P < 0.001). There was no difference as for TBL between Groups B and C (P = 0.377). Group A patients had significant smaller Hb decline than Group C on the third and fifth postoperative day (P = 0.049, P = 0.037), as well as than Group B on the fifth postoperative day (P = 0.048). There was no difference as for Hb decline between Groups B and C. No difference was shown in levels of inflammatory biomarkers or blood-saving protocol-related complications among three groups.

CONCLUSIONS

Daily dose of rhEPO combined with iron supplement administered 3 days before TKA procedures could significantly decrease perioperative blood loss and improve postoperative Hb levels, without significantly elevating risks of complication, when compared with admission of rhEPO on the day of surgery and iron supplement alone. Preoperative daily rhEPO treatment could be a more effective blood-saving protocol in TKA procedures.

Transfusions in the Emergency department: More than a blood transfusion

Increasing haemoglobin and haematocrit levels with blood transfusions has been the gold standard for treating severe anaemia; however, the indication for transfusing concentrated red blood cells is based merely on a few laboratory markers, such as haemoglobin and haematocrit levels, rather than based on the symptoms according to clinical practice guidelines, the implementation of legal regulations and the consensus achieved by the hospitals' transfusion committees. The aim of this multicentre study was to reassess the suitability of the indication for transfusing concentrated red blood cells and the volumes transfused in emergency departments. We established an observational, multicentre, cross-sectional design with 2 participating centres: the La Paz University Hospital and the Hospital of Salamanca. In total, we obtained data from 381 patients, 220 (57.74%) of whom were men with an average age of 71.4±14.0 years and 161 (42.26%) of whom were women with an average age of 75.3±15.3 years (P<.001). The most prevalent underlying diseases in the patients who underwent transfusions were heart disease, which included haemorrhaging due to antiplatelet or anticoagulant therapy (57.7%), haemato-oncologic (15.3%) diseases and neurological disease. Only 54.9% (209/381) of the prescriptions for transfusion were considered appropriate, with significant differences according to the indication.

The Effect of Intraoperative Ferric Carboxymaltose in Joint Arthroplasty Patients: A Randomized Trial

This study assessed the efficacy of intraoperative high-dose intravenous iron therapy in facilitating recovery from postoperative anemia and reducing the transfusion rate in patients with total knee and total hip arthroplasty. This prospective randomized controlled study involved 58 subjects. Group F received 1000 mg intravenous ferric carboxymaltose and Group C received normal saline. The changes in hemoglobin (Hb), hematocrit, iron metabolism variables, transfusion rates, and the arterial partial pressure of oxygen and the fraction of oxygen (PaO2/FiO2) ratio were recorded. There were 29 patients of each group. The change in Hb levels from baseline to 1 month post-surgery was higher in Group F than in Group C (0.3 ± 1.0 g/dl vs. -0.8 ± 0.8 g/dl, p < 0.001). Functional iron deficiency occurred more frequently in Group C (0% vs. 48.3%, p < 0.001) after the operation. The incidence of postoperative anemia, transfusion rate and P/F ratio did not significantly differ between the two groups. This study suggests that intraoperative high-dose ferric carboxymaltose during lower limb total arthroplasty can facilitate the recovery from postoperative anemia. Although it could not prevent the occurrence of postoperative anemia or the administration of transfusion, this treatment seemed to overcome surgery-related decrease of iron availability.

Efficacy of perioperative intravenous iron therapy for transfusion in orthopedic surgery: A systematic review and meta-analysis

Perioperative anemia frequently occurs in patients undergoing orthopedic surgery. We aimed to evaluate the efficacy of perioperative intravenous iron therapy (IVIT) on transfusion and recovery profiles during orthopedic surgery. We searched PubMed, Embase, Cochrane, and Google Scholar for eligible clinical trials (randomized controlled trials, RCTs; case-control studies, CCSs) in comparing IVIT and no iron therapy, up to September 2018. Primary outcomes were the effects of IVIT on the proportion of patients transfused and units of red blood cells (RBCs) transfused perioperatively. Secondary outcomes were the effects of IVIT on recovery profiles, such as length of hospital stay (LOS), post-operative infection, and mortality. Subgroup analysis was performed based on iron dose (low: ≤ 300 mg, high: > 400 mg), IVIT period (pre-operative, post-operative, perioperative), and study design. We identified 12 clinical trials (4 RCTs with 616 patients and 8 CCSs with 1,253 patients). IVIT significantly reduced the proportion of patients transfused by 31% (RR, 0.69; P = 0.0002), and units of RBCs transfused by 0.34 units/person (MD, -0.34; P = 0.0007). For subgroup analysis by iron dose, low- or high-dose IVIT significantly reduced the proportion of patients transfused (RR, 0.73, P = 0.005; RR, 0.68, P = 0.008), and RBC units transfused (MD, -0.47, P < 0.0001; MD, -0.28, P = 0.04). For subgroup analysis by period, IVIT administered post-operatively significantly reduced the proportion of patients transfused (post-operative: RR, 0.60, P = 0.002; pre-operative: RR, 0.74, P = 0.06) and RBC units transfused (post-operative: MD, -0.44, P <0.00001; pre-operative: MD, -0.29, P = 0.06). For subgroup analysis by study design, IVIT decreased the proportion of patients transfused and RBC units transfused in the group of CCSs, but IVIT in the group of RCTs did not. IVIT significantly shortened LOS by 1.6 days (P = 0.0006) and reduced post-operative infections by 33% (P = 0.01). IVIT did not change mortality. Perioperative IVIT during orthopedic surgery, especially post-operatively, appears to reduce the proportion of patients transfused and units of RBCs transfused, with shorter LOS and decreased infection rate, but no change in mortality rate. These were only found in CCSs and not in RCTs due to the relatively small number of RCTs with low to high risk of bias.

Oral vs intravenous tranexamic acid in total-knee arthroplasty and total hip arthroplasty: A systematic review and meta-analysis

BACKGROUND

This study aimed to compare the efficacy and safety of oral tranexamic acid (TXA) with intravenous (IV) TXA in reducing perioperative blood loss in total-knee arthroplasty (TKA) and total-hip arthroplasty (THA).

METHODS

PubMed, Web of Science, Embase, and Cochrane Library were fully searched for relevant studies. Studies comparing the efficacy and safety of oral TXA with IV TXA in TKA and THA were included in this research. Odds ratio (OR) or risk difference (RD) was applied to compare dichotomous variables, while mean difference (MD) was used to compare continues variables.

RESULTS

A total of 7 studies (5 randomized controlled trials and 2 retrospective studies) were included into this study. As for patients undergoing TKA or THA, there were no obvious differences between oral TXA group and IV TXA group in hemoglobin (Hb) drop (MD = 0.06, 95% confidence interval [CI] = -0.01 to 0.13, P = .09), transfusion rate (OR = 0.78, 95% CI = 0.54-1.13, P = .19), total blood loss (MD = 16.31, 95% CI = -69.85 to 102.46, P = .71), total Hb loss (MD = 5.18, 95% CI = -12.65 to 23.02, P = .57), length of hospital stay (MD = -0.06, 95% CI = -0.30 to 0.18, P = .63), drain out (MD = 21.04, 95% CI = -15.81 to 57.88, P = .26), incidence of deep vein deep vein thrombosis (RD = 0.00, 95% CI = -0.01 to 0.01, P = .82) or pulmonary embolism (RD = 0.00, 95% CI = -0.01 to 0.01, P = .91). The sample size of this study was small and several included studies were with relatively low quality.

CONCLUSION

Oral TXA is equivalent to IV TXA in reducing perioperative blood loss and should be recommended in TKA and THA. More high-quality studies are needed to elucidate this issue.

Clinical standards for patient blood management and perioperative hemostasis and coagulation management. Position Paper of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new "standard of care" so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period.

A meta-analysis and systematic review evaluating the use of erythropoietin in total hip and knee arthroplasty

Purpose

The debate is still ongoing on the effectiveness and safety of erythropoietin (EPO) treatment in orthopedic surgeries. Specifically, previous studies have not compared the dynamic change of hemoglobin (Hb) levels between different transfusion methods. Besides, complications or side effects of this alternative have not been quantitatively analyzed. We conducted a meta-analysis and systemic review to evaluate the efficacy of EPO on Hb levels observed during the whole perioperative period as well as the volume of allogeneic blood transfusion (ABT), the risk of venous thromboembolism, and application frequency of ABT in hip and knee surgery.

Materials and methods

PubMed, Embase, Web of Science, and the Cochrane library were systematically searched from inception to November 2017. The data from randomized controlled trials were extracted and the risk of bias assessed using Cochrane’s Collaboration’s tool.

Results

Twenty-five randomized controlled trials involving 4,159 patients were included in this meta-analysis. EPO could reduce exposure to allogeneic blood transfused (odds ratio [OR] =0.42, P=0.001) and reduce the average volume of allogeneic blood transfused (OR = −0.28, P=0.002). When EPO and preoperative autologous blood donation (PABD) were compared, the use of EPO was associated with lower exposure to ABT (OR =0.48, P=0.03), but no significant decrease in the average volume of allogeneic blood transfused (OR = −0.23, P=0.32). The use of EPO was associated with a higher level of Hb with or without use of PABD at all the 4 time points (preoperation, 24–48 hours postoperation, 3–5 days postoperation, discharge of last observation) (P<0.0001), which means EPO could increase the level of Hb significantly during the perioperative period. The results also indicated EPO does not increase the risk of a venous thromboembolism event.

Conclusion

Preoperative administration of EPO was shown to generally increase Hb levels during the whole perioperative period; however, the extent of the positive effects varies with time points. Additionally, EPO minimizes the need for transfusion significantly in patients undergoing hip or knee surgery without increasing the chance of developing thrombotic complications. Therefore, EPO offers an alternative blood management strategy in total hip arthroplasty and total knee arthroplasty.

Current misconceptions in diagnosis and management of iron deficiency

The prevention and treatment of iron deficiency is a major public health goal. Challenges in the treatment of iron deficiency include finding and addressing the underlying cause and the selection of an iron replacement product which meets the needs of the patient. However, there are a number of non-evidence-based misconceptions regarding the diagnosis and management of iron deficiency, with or without anaemia, as well as inconsistency of terminology and lack of clear guidance on clinical pathways. In particular, the pathogenesis of iron deficiency is still frequently not addressed and iron not replaced, with indiscriminate red cell transfusion used as a default therapy. In our experience, this imprudent practice continues to be endorsed by non-evidence-based misconceptions. The intent of the authors is to provide a consensus that effectively challenges these misconceptions, and to highlight evidence-based alternatives for appropriate management (referred to as key points). We believe that this approach to the management of iron deficiency may be beneficial for both patients and healthcare systems. We stress that this paper solely presents the Authors' independent opinions. No pharmaceutical company funded or influenced the conception, development or writing of the manuscript.

Preoperative optimisation of anaemia for primary total hip arthroplasty: a systematic review

BACKGROUND

The 2009 NHS Blood and Transplant national comparative audit on blood use following primary total hip arthroplasty (THR) highlighted that preoperative anaemia was common and undertreated. They recommended that hospitals have a written policy for treating anaemia preoperatively. In our centre, we found that preoperative optimisation of anaemia, significantly reduced blood transfusion rate to <5%. The 2015 national audit showed that even though 48% of patients received tranexamic acid, 85% of patients required transfusion. By conducting a systematic review of literature on blood management for preoperative anaemia in primary THR; we aimed to validate the recommendations of the national audit and increase its awareness in the orthopaedic community.

METHODS

A PubMed Search was performed to identify suitable literature limited to randomised controlled trials, cohort studies, meta-analyses and systematic reviews involving primary THR. We excluded any THRs performed for trauma and revision arthroplasty. Our exclusion criteria for the intervention was the use of autologous methods such as cell salvage techniques and preoperative autologous blood donation.

RESULTS

Analysis of 13 publications showed widespread study heterogeneity, which precluded meta-analysis. Preoperative blood management (PBM) interventions included the use of recombinant human erythropoietin and oral iron supplementation in 12/13 and 11/13 studies respectively. There were significant differences in transfusion rates between PBM and control groups in 12/13 studies.

CONCLUSIONS

The findings overwhelmingly support preoperative optimisation of anaemia. The main barrier to wider implementation remains the cost effectiveness. We recommend using our validated protocol, which has shown to significantly reduce transfusion rates, length of stay and remain cost effective.

Preoperative screening and intervention for mild anemia with low iron stores in elective hip and knee arthroplasty

BACKGROUND

Preoperative anemia in patients undergoing elective hip and knee arthroplasty is associated with increased postoperative morbidity and mortality, red blood cell (RBC) transfusion, and length of stay (LOS). The aim of this study was to assess the effect of optimizing hemoglobin (Hb) levels before elective primary hip and knee arthroplasty.

STUDY DESIGN AND METHODS

This is a prospective comparative cohort study of patients who underwent elective hip and knee arthroplasty before (control) and after (intervention) the launch of a Hb optimization program. Patients with anemia followed an agreed upon algorithm dependent on their medical history and blood variables taken on listing for surgery. The primary outcome for this study was the requirement for allogenic RBC transfusion. Secondary outcomes included hospital LOS, admission to critical care, readmission, medical complications, incidence of thromboembolic events, mortality, and costs.

RESULTS

A total of 1814 control patients operated between February 2012 and February 2013 were compared to 1622 intervention patients operated between February 2013 and May 2014. In the intervention group transfusion was significantly reduced (108 [6%] vs. 63 [4.1%], p = 0.005) as well as readmission (81 [4.5%] vs. 48 [2.3%], p= 0.020) and critical care admission (23 [1.3%] vs. 9 [0.5%], p = 0.030). LOS was significantly reduced from 3.9 days to 3.6 days (p = 0.017). The saving for the cohort was £263,000 ($342,000).

CONCLUSIONS

Algorithm-led preoperative anemia screening and management in elective arthroplasty was associated with reduced RBC transfusion, readmission, critical care admission, LOS, and costs.

Is There a Role for Preoperative Iron Supplementation in Patients Preparing for a Total Hip or Total Knee Arthroplasty?

BACKGROUND

Several treatment modalities exist for the treatment of perioperative anemia. We determined the effect of oral iron supplementation on preoperative anemia, and the use of blood-conserving interventions before total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

A total of 3435 total joint arthroplasties (1461 THAs and 1974 TKAs) were analyzed during 2 phases of a blood conservation program. The first phase used erythropoietin alfa (EPO) or intravenous (IV) iron for patients at risk for perioperative anemia. The second phase included these interventions, as well as preoperative iron supplementation. The effect on preoperative hemoglobin (Hb) and serum ferritin, as well as EPO and IV iron utilization, was determined.

RESULTS

Oral iron therapy increased preoperative Hb level by 6 g/L (P < .001) and 7 g/L (P < .001) in the hip and knee cohorts, respectively. Serum ferritin level rose by 80 μg/L (P < .001) and 52 μg/L (P < .001) in the hip and knee cohorts, respectively. The number of patients with an Hb level <130 g/L was significantly reduced (P < .001 for both cohorts), as were patients with serum ferritin levels <35 μg/L (P = .002 for hip and P < .001 for knee cohorts). Utilization of EPO reduced from 16% to 6% (P < .001) and 18% to 6% (P < .001) in the hip and knee cohorts, respectively. Utilization of IV iron reduced from 4% to 2% (P = .05) and 5% to 2% (P < .001) in the hip and knee cohorts, respectively.

CONCLUSION

Oral iron therapy reduced the burden of perioperative anemia and reduced utilization of other blood-conserving therapies before THA and TKA. Future research should delineate the cost-effectiveness of oral iron therapy.

Optimal Timing for Hemoglobin Concentration Determination after Total Knee Arthroplasty: Day 1 versus Day 2

Purpose

Postoperative hemoglobin (Hb) determination remains an essential parameter for quantifying blood loss following total knee replacement (TKR) surgery and guiding transfusion practice. In this study we aimed to ascertain the optimal timing for Hb determination postoperatively and assess its relationship to serum hematocrit (Hct).

Materials and Methods

This was a retrospective cohort analysis of 61 consecutive patients undergoing preoperative, day 1 and day 2 Hb and Hct concentration determination following TKR surgery. This was a single centre study in the United Kingdom.

Results

The mean fall in Hb concentration at day 1 was 2.9 g/dL in comparison to 3.3 g/dL at day 2. This indicated a significant difference of 0.39 g/dL (p=0.023). A total of 5 patients required blood transfusions following day 2 Hb determination. Postoperative Hct values varied in close relation with the Hb concentration with no significant differences demonstrated. Our study reveals a significant change between day 1 and day 2 Hb concentrations following TKR surgery, with no significant differing information provided through Hct determination.

Conclusions

Our results support the use of delayed routine testing at day 2 following surgery as it is likely to more accurately reflect ongoing hidden blood loss into the joint cavity and within soft tissue planes.

Preoperative haemoglobin cut-off values for the prediction of post-operative transfusion in total knee arthroplasty

PURPOSE

The purpose of this study is to determine preoperative haemoglobin cut-off values that could accurately predict post-operative transfusion outcome in patients undergoing primary unilateral total knee arthroplasty (TKA). This will allow surgeons to provide selective preoperative type and screen to only patients at high risk of transfusion.

METHODS

A total of 1457 patients diagnosed with osteoarthritis and underwent primary unilateral TKA between January 2012 and December 2014 were retrospectively reviewed. Logistic regression analyses were applied to identify factors that could predict transfusion outcome.

RESULTS

A total of 37 patients (2.5 %) were transfused postoperatively. Univariate analysis revealed preoperative haemoglobin (p < 0.001), age (p < 0.001), preoperative haematocrit (p < 0.001), and preoperative creatinine (p < 0.001) to be significant predictors. In the multivariate analysis with patients dichotomised at 70 years of age, preoperative haemoglobin remained significant with adjusted odds ratio of 0.33. Receiver operating characteristic curve identified the preoperative haemoglobin cut-off values to be 12.4 g/dL (AUC = 0.86, sensitivity = 87.5 %, specificity = 77.2 %) and 12.1 g/dL (AUC = 0.85, sensitivity = 69.2 %, specificity = 87.1 %) for age above and below 70, respectively.

CONCLUSIONS

The authors recommend preoperative haemoglobin cut-off values of 12.4 g/dL for age above 70 and 12.1 g/dL for age below 70 to be used to predict post-operative transfusion requirements in TKA. To maximise the utilisation of blood resources, the authors recommend that only patients with haemoglobin level below the cut-off should receive routine preoperative type and screen before TKA.

LEVEL OF EVIDENCE

IV.

Peri-articular tranexamic acid injection in total knee arthroplasty: a randomized controlled trial

Background

Intravenous tranexamic acid (IV TXA) is one of the most effective agents in use for reducing blood loss following total knee arthroplasty (TKA) but its safety regarding venous thromboembolic events (VTEs) remains in question. The direct, local application of TXA may reduce systemic toxicity whilst maintaining good or better bleeding control compared to IV TXA. The topical application of TXA via Hemovac drains has been reported previously with good results. However, there are no data on peri-articular TXA injections during TKA.

Methods

We conducted an open randomized, pilot study of peri-articular vs. IV TXA in 60 patients undergoing TKA. 30 patients received either: (i) 750 mg peri-articular TXA into the medial, lateral capsules and the quadriceps tendon prior to capsular closure and tourniquet deflation (group1), or (ii) 750 mg of IV TXA just before tourniquet deflation. Blood loss in the hemovac drain and hemoglobin (Hb) concentrations were measured at 24 and 48 h (h), and the number of blood transfusions and leg circumference measurements were recorded.

Results

At 48 h, the total blood loss in the hemovac drain was 445 mL in group 1 vs. 520 mL in group 2 (p = 0.081) and the corresponding declines in Hb were 1.85 g/dL vs. 1.87 g/dL (p = 0.84). 16 patients received blood transfusions: 9 vs. 7 in groups 1 and 2, respectively (p = 0.928). There were no differences in thigh and lower leg circumferences, pain scores, knee flexion at discharge date and lengths of hospital stay. There were no clinically detected venous thromboembolic events.

Conclusion

This pilot study has shown promising results for peri-articular TXA during TKA. Additional, larger studies are needed to confirm our results and be powered to show differences in efficacy and safety of peri-articular vs. IV TXA.

Trial registration

ClinicalTrials.gov Identifier NCT02829346. Retrospectively registered: 07/11/2016.

Routine pre-operative group cross-matching in total knee arthroplasty: A review of this practice in an Asian population

BACKGROUND

Routine pre-operative group cross-match (GXM) and post-operative haemoglobin level measurements are performed for all total knee arthroplasty (TKA) patients in many institutions. We aimed to determine whether this practice is justified, and to identify predictors for post-operative transfusion.

MATERIALS AND METHODS

A retrospective review was performed on 226 TKA procedures performed between Jan. 2011 and Dec. 2013. Patients' demographics and clinical details including co-morbidities, pre-operative laboratory results, type of anaesthesia, surgery duration, post-operative haemoglobin level and transfusion requirement were reviewed.

RESULTS

Overall transfusion rate was 10.6% (n=24). Cross-match to transfusion ratio was 6.5. The cross-match to transfusion ratio (C:T ratio) was measured as the ratio of number of units of blood cross-matched to units of blood transfused. In females, relative risk of transfusion between patients with pre-operative haemoglobin below 12.0 and those above or equal to 12.0 was significant at 4.53 (Confidence interval (CI) 2.16 to 9.53). The relative risk of transfusion between patients above 65 years of age compared to those below 65 years of age was 1.13 (CI 1.03 to 1.23). Multivariate analysis revealed advancing age (p=0.044) and lower preoperative haemoglobin (p<0.001) as significant variables associated with post-operative transfusion.

CONCLUSION

Post-operative transfusion rates are low and excessive pre-operative GXM and post-operative haemoglobin checks are contributing to unnecessary medical costs. Predictors of blood transfusion risk in unilateral TKA in our cohort of Asian population were advancing age and lower pre-operative haemoglobin level. Type and screen tests should be performed for all other patients. LEVEL OF SCIENTIFIC EVIDENCE: 3.

Cost Analysis of Tranexamic Acid in Anemic Total Joint Arthroplasty Patients

BACKGROUND

Preoperative anemia is present in 20% of total joint arthroplasty patients. Current preoperative treatment options, including iron supplementation (FE) and erythropoietin (EPO), are expensive. Tranexamic acid (TXA) has been adopted as an intraoperative adjunct to decrease blood loss. Our hypothesis is that TXA is a cost-effective treatment compared to FE and EPO in anemic patients.

METHODS

In this study, a cost analysis was performed, comparing the material costs of TXA and packed red blood cells (PRBCs) to the theoretical administration and material costs of FE and EPO per standard preoperative anemia protocol.

RESULTS

A total of 243 patients were included in the study. Of this group, 18.5% (45/243) had preoperative anemia. The rate of transfusion was 6.7% (3/45), and 5 units of PRBCs was transfused. The combined cost of TXA and PRBCs was $5317.08. Even assuming a best-case scenario with FE or EPO treatment without a postoperative PRBC requirement, the cost of treatment would range from 2 to 17 times more than treatment with TXA. An additional 50 units of PRBC (1.1 units per patient) would need to be transfused for the cost of TXA treatment to be equivalent to FE or EPO treatment.

CONCLUSION

Tranexamic acid is significantly less expensive than FE or EPO as a treatment option for total joint arthroplasty patients presenting with preoperative anemia. It is a cost-effective adjunct for limiting transfusion rates in this patient population. We recommend that new preoperative anemia levels that necessitate preoperative intervention be established.

Preoperative anemia and postoperative outcomes after hepatectomy

BACKGROUND

Preoperative anaemia is associated with adverse outcomes after surgery but outcomes after liver surgery specifically are not well established. We aimed to analyze the incidence of and effects of preoperative anemia on morbidity and mortality in patients undergoing liver resection.

METHODS

All elective hepatectomies performed for the period 2005-2012 recorded in the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database were evaluated. We obtained anonymized data for 30-day mortality and major morbidity (one or more major complication), demographics, and preoperative and perioperative risk factors. We used multivariable logistic regression models to assess the adjusted effect of anemia, which was defined as (hematocrit <39% in men, <36% in women), on postoperative outcomes.

RESULTS

We obtained data for 12,987 patients, of whom 4260 (32.8%) had preoperative anemia. Patients with preoperative anemia experienced higher postoperative major morbidity and mortality rates compared to those without anemia. After adjustment for predefined variables, preoperative anemia was an independent risk factor for postoperative major morbidity (adjusted OR 1.21, 1.09-1.33). After adjustment, there was no significant difference in postoperative mortality for patients with or without preoperative anemia (adjusted OR 0.88, 0.66-1.16).

CONCLUSION

Preoperative anemia is independently associated with an increased risk of major morbidity in patients undergoing hepatectomy. Therefore, it is crucial to readdress preoperative blood management in anemic patients prior to hepatectomy.

Patient Blood Management in Hip Replacement Arthroplasty

Perioperative blood transfusions are common in total hip arthroplasty because of preoperative anemia and perioperative blood loss. Perioperative anemia and the need for allogeneic blood transfusion are related with increased morbidity. To reduce perioperative allogeneic blood transfusion, keeping the preoperative hemoglobin level above 12.0 g/dL is important in orthopedic patients. By using the anti-fibrinolytic agent or perioperative cell salvage, reduce intraoperative blood loss is very important for the reduction of perioperative blood loss. As a transfusion trigger, low hemoglobin is another important target to reduce the transfusion rate. Because blood management is closely connected with prognosis, it has become a new challenge in orthopedic surgery.

[Optimization of preoperative hemoglobin levels in patients without anemia and/or patients who undergo surgery with high blood loss]

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.

Can tranexamic acid change preoperative anemia management during total joint arthroplasty?

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.

Blood transfusion in hip arthroplasty: a laboratory hematic curve must be the single predictor of the need for transfusion?

Objective

to determine whether the laboratory hematic curve must be the single predictor of postoperative blood transfusion in total hip arthroplasty.

Methods

the laboratory blood samples of 78 consecutive patients undergoing total hip arthroplasty was analyzed during five distinct moments: one preoperative and four postoperative. There was a count of hemoglobin, hematocrit and platelets of the patients samples. Other catalogued variables ascertain possible risk factors related to transfusional practice. They characterized the anthropometric, behavioral and co morbidities data in this population. The study subjects were divided and categorized into two groups: those who received blood transfusion during or after surgery (Group 1, G1), and those who did not accomplish blood transfusion (Group 2, G2). Transfusion rules were lead by guidelines of American Academy of Anesthesiology and the British Society of Hematology.

Results

a total of 27 (34.6%) patients received blood transfusions. The curves of hemoglobin, hematocrit and platelet transfusions between G1 and G2 were similar (p > 0.05). None of the analyzed risk factors modified the rate of transfusion rate in their analysis with p value > 0.05, except the race. The sum of clinical co morbidities associated with patients in G1 was a median of 3 (95% CI 2.29–3.40), while in G2 the median was 2 (95% CI 1.90–2.61) with p = 0.09.

Conclusion

the curve in red blood cells has limited reliability when used as sole parameter. The existence of tolerant patients hematimetric curve variations assumes that their assessments of clinical, functional evaluation and co-morbidities are parameters that should influence the decision to transfusion red blood cells.

Comprehensive Look at Blood Transfusion Utilization in Total Joint Arthroplasty at a Single Academic Medical Center under a Single Surgeon

The utilization of autologous and allogeneic transfusions in total joint arthroplasties was to characterize patients who may benefit from giving preoperative blood donations. We conducted a retrospective chart review of 525 patients to document preoperative hematocrit, estimated blood loss, length of stay, transfusions, and medical comorbidities. Results of our review showed that total hip arthroplasty revision (THA-R) had the highest prevalence of transfusions (60%) followed by total hip arthroplasty (THA, 53%), total knee arthroplasty-revision (TKA-R, 33%), and total knee arthroplasty (TKA, 23%). There was significant waste of autologous donations: 92% of TKA patients, 64% of THA, and 33% of THA-R patients wasted on average 1.527, 1.321, and 1.5 autologous units, respectively. Pre-operative hematocrit was the strongest predictor of future transfusion need across all procedures, and primary THA had additional predictors in age and gender.

Anaemia in the older surgical patient: a review of prevalence, causes, implications and management

This review provides the clinician with a summary of the causes, implications and potential treatments for the management of anaemia in the older surgical patient. The prevalence of anaemia increases with age and is frequently identified in older surgical patients. Anaemia is associated with increased postoperative morbidity and mortality. Allogenic blood transfusion is commonly used to treat anaemia but involves inherent risks and may worsen outcomes. Various strategies for the correction of pre- and postoperative anaemia have evolved. These include correction of nutritional deficiencies and the use of intravenous iron and erythropoesis stimulating therapy. Clear differences exist between the elective and emergency surgical populations and the translation of research findings into these individual clinical settings requires more work. This should lead to a standardized approach to the management of this frequently encountered clinical scenario.

Increased preoperative collection of autologous blood with recombinant human erythropoietin therapy in tertiary care hospitals of Jammu

Introduction:

To study whether the administration of recombinant human erythropoietin increases the amount of autologous blood that can be collected before orthopaedic surgery.

Materials and Methods:

We conducted a randomized controlled trial of recombinant human erythropoietin in 68 adults scheduled for elective orthopedic procedures. The patients received either erythropoietin 600 units/kg of body weight or placebo intravenously every 5^th day prior to each phlebotomy for 21 days during which time up to 5 units of blood was collected. Patients were excluded from donation when their hematocrit values were less than 33%. All patients received iron sulphate 325mg orally 3 times daily. The mean number of units collected per patient was 4.33 ± 0.4 for erythropoietin group and 3.05± 0.71 for the placebo group.

Results:

The mean packed red cell volume donated by patients who received erythropoietin was 32% greater than that donated by patients who received placebo (196.3 vs. 169.4 ml, p<0.05). 68% in the placebo group and 9% of patients treated with erythropoietin were unable to donate ≥4 units. No adverse effects were attributed to erythropoietin. While participating in the study, complications developed in 2 patients one in each group necessitating their removal from the study.

Conclusion:

We conclude that recombinant human erythropoietin increases the ability of the patients about to undergo elective surgery to donate autologous blood units.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?» All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

Results of primary total knee arthroplasty in Jehovah's Witness patients

Total knee arthroplasty can be challenging in Jehovah's Witnesses, as these patients do not accept blood transfusions. We reported our experiences with a special blood management protocol for these patients who underwent total knee arthroplasty. There were 124 self-reported Jehovah's Witnesses who had a mean age of 64 years and who underwent total knee arthroplasties between 1998 and 2009. Mean follow-up was 60 months (range, 24-120 months). Implant survivorship, with revision for aseptic component failure as an end point, was 98%. At the final follow-up, mean Knee Society objective and function score improved to 91 and 81 points, respectively. The authors believe that this blood management protocol was responsible for performing safe and transfusion-free total knee arthroplasties that can ultimately lead to excellent outcomes.

Predicting need for allogeneic transfusion after total knee arthroplasty

Total knee arthroplasty (TKA) can lead to substantial blood loss. To avoid the high costs of autologous blood predonation programs and efficiently allocate limited blood resources, we sought to identify preoperative and intraoperative factors associated with allogeneic blood transfusion (AllTx) after primary TKA and, subsequently, develop a model to predict patients who will require AllTx. We analyzed 31 independent variables in 644 primary unilateral TKAs without autologous blood predonation for requirement of AllTx. Seventy-one procedures (11.0%) required AllTx. Age, comorbid anemia, preoperative hemoglobin concentration, and surgical time were significant predictors for requiring AllTx. When applied to an independent cohort, our model for predicting the need for AllTx after TKA was 90% sensitive and 52.5% specific.

The Use of Preoperative Epoetin-α in Revision Hip Arthroplasty

Purpose:

To evaluate the efficacy of preoperative epoetin-α on the revision hip arthroplasty patient. We hypothesized that epoetin-α will reduce blood transfusion. A pertinent review of the literature is provided.

Methods:

Forty-six patients were retrospectively reviewed. Sixteen patients received epoetin-α. Patients were case matched by age, preoperative hemoglobin, surgery, gender, and BMI. The clinical triggers for blood transfusion during or after the procedure were determined based on peri- and postoperative hemoglobin levels, ASA score, and/or clinical symptoms consistent with anemia. Blood salvage was not used.

Results:

Blood transfusion and length of stay were decreased in the epoetin-α group. Hemoglobin in the intervention group increased from 12.0 to 14.5, preoperatively. Patients who received epoetin-α were 0.78 (RR=0.225) times as likely to receive a transfusion. Number Needed to Treat (NNT) to avoid one allogeneic transfusion was 1.84. Age, Gender, BMI, ASA, total and hidden blood loss, preoperative Iron supplements, preop Hct, preop PLT, PT, PTT, and INR were similar. One (6.0%) patient developed an uncomplicated deep venous thrombosis in the intervention group.

Conclusions:

The mildly anemic revision hip arthroplasty patient is at increased risk for transfusion. Epoetin-α increased preoperative hemoglobin counts and reduced transfusions in this study; it also decreased patient length of hospital stay likely allowing for an earlier readiness to resume normal activities and/or meet short-term milestones. A randomized study to evaluate the direct and indirect costs of such a treatment methodology in the mildly anemic revision patient may be warranted.

Reducing noninfectious risks of blood transfusion

As screening for transfusion-associated infections has improved, noninfectious complications of transfusion now cause the majority of morbidity and mortality associated with transfusion in the United States. For example, transfusion-related acute lung injury, transfusion-associated circulatory overload, and hemolytic transfusion-reactions are the first, second, and third leading causes of death from transfusion, respectively. These complications and others are reviewed, and several controversial methods for prevention of noninfectious complications of transfusion are discussed, including universal leukoreduction of erythrocyte units, use of male-only plasma, and restriction of erythrocyte storage age.