Restrictive Versus Liberal Strategy for Red Blood-Cell Transfusion: A Systematic Review and Meta-Analysis in Orthopaedic Patients

Restrictive versus Liberal blood transfusion strategies for patients undergoing orthopedic surgery: a meta-analysis of randomised trials with trial sequential analysis

BACKGROUND

A meta-analysis was conducted to explore the prognostic differences of restrictive blood transfusion (RBT) versus liberal blood transfusion (LBT) strategies in orthopedic patients.

METHODS

A comprehensive search was performed in PubMed, Embase, Cochrane Central Register of Controlled Trials, Embase, and clinicaltrials.gov up to 20 October 2024. The quality of included studies was assessed according to Cochrane risk of bias, and quality of evidence was assessed using the GRADE system. We performed sensitivity and publication bias analyses and used trial sequential analysis (TSA) to assess the risk of random error in the analysis results.

RESULTS

19 studies involving 7833 patients were included in the analysis. Compared with LBT, RBT reduced transfusion rate and increased the occurrence of cardiovascular events (RR = 1.44; 95% CI: 1.15-1.80, P = 0.001; I2 = 0%), mainly increased myocardial infarction (RR = 1.70; 95% CI: 1.16-2.48, P = 0.006; I2 = 0%) rather than congestive heart failure. There were no significant differences between transfusion strategies in infection, thrombotic events, mortality, delirium and length of hospitalization. Results of subgroup analyses indicate that in patients at high risk for cardiovascular disease, RBT increases the risk of myocardial infarction and length of hospitalization. In addition, RBT are associated with lower overall infection rates and shorter length of hospitalization after joint replacement or revision surgery; and are associated with an increased risk of myocardial infarction after fracture repair surgery (RR = 1.79; 95% CI: 1.21-2.65, P = 0.004). The TSA results show that transfusion rate and mortality (≥ 60 days) have reached the required information size. However, the evidence regarding the efficacy for the remaining outcomes analyzed remains inconclusive, likely due to insufficient numbers of patients in the existing studies.

CONCLUSIONS

Compared with LBT, RBT increases the risk of cardiovascular events in orthopedic patients but does not affect adverse outcomes such as infection, thrombotic events, mortality, and delirium.

TRIAL REGISTRATION

No patients were involved in this study.

Blood transfusion in older surgical patients: the only option or is there a better approach?

Anemia is a common clinical condition that can significantly affect patient outcomes, particularly in those undergoing surgery. In older adults, the presence of anemia combined with cardiovascular disease can increase surgical morbidity and mortality, influencing surgical decisions and creating a cascade of complications that may negatively impact recovery. Blood transfusion remains the primary response to anemia in the perioperative setting, despite evidence suggesting potential adverse effects on survival and recovery. However, older adults present unique challenges due to age-related physiological changes anda reduced tolerance to anemia and blood loss. The debate between restrictive and liberal blood transfusion strategies in this population remains unresolved. Patient Blood Management (PBM) protocols have been developed to systematically address perioperative anemia. This review emphasizes the need for a nuanced approach to transfusion in older adults, suggesting that while a restrictive strategy may not be universally applicable, decisions should be guided by thorough clinical evaluations. These assessments should prioritize not only hemoglobin levels but also patient-specific factors, including life expectancy, comorbidities, and patient preferences, with the involvement of a multidisciplinary team to tailor the best approach for everyone.

Key Considerations for Frail Patients Undergoing Hip Fracture Surgery

Improving preoperative care for elderly patients with hip fractures is crucial for achieving the best outcomes. A multidisciplinary team that can improve overall care quality by addressing patient's medical conditions, analgesia, timely surgery, and early postoperative mobilization is required. This narrative review provides insights regarding the extent of preoperative optimization needed for hip fracture surgery.

Postoperative haemoglobin and anaemia-associated ischaemic events after major noncardiac surgery: A sex-stratified cohort study

STUDY OBJECTIVE

To determine the sex-specific associations between postoperative haemoglobin and mortality or complications reflecting ischaemia or inadequate oxygen supply after major noncardiac surgery.

DESIGN

A retrospective cohort study with prospective validation.

SETTING

A large university hospital health system in China.

PATIENTS

Men and women undergoing elective major noncardiac surgery.

INTERVENTIONS AND MEASUREMENTS

The primary exposure was nadir haemoglobin within 48 h after surgery. The outcome of interest was a composite of postoperative mortality or ischaemic events including myocardial injury, acute kidney injury and stroke within hospitalisation.

MAIN RESULTS

The study included 26,049 patients (15,757 men and 10,292 women). Low postoperative haemoglobin was a strong predictor of the composite outcome in both sexes, with the risk progressively increasing as the nadir haemoglobin concentration dropped below 130 g l-1 in men and 120 g l-1 in women (adjusted odds ratio [OR] 1.43, 95% CI 1.37-1.50 in men, and OR 1.45, 95% CI 1.35-1.55 in women, per 10 g l-1 decrease in postoperative nadir haemoglobin). Above these sex-specific thresholds, the change of nadir haemoglobin was no longer associated with odds of the composite outcome in either men or women. There was no significant interaction between patient sex and the association between postoperative haemoglobin and the composite outcome (Pinteraction = 0.673). Validation in an external prospective cohort (n = 2120) with systematic postoperative troponin and creatinine measurement confirmed our findings.

CONCLUSIONS

Postoperative haemoglobin levels following major noncardiac surgery were nonlinearly associated with ischaemic complications or mortality, without any clinically important interaction with patient sex.

Perioperative Transfusion Practices in Adults Having Noncardiac Surgery

Surgical patients are often transfused to manage bleeding and anemia. Best practices for red blood cell (RBC) transfusion administration in patient having noncardiac surgery remains controversial and a robust evaluation and description of perioperative transfusion practices is lacking. We characterized perioperative hemoglobin concentrations and transfusion practices from the prospective VISION cohort which included 39,222 patients aged ≥45 years who had inpatient noncardiac surgery. Variations in transfusion practices were analyzed using hierarchical mixed models, and associations with mortality and complications were evaluated using a nested frailty survival model. Within the cohort, 16.1% (n = 6296) were given perioperative RBC transfusions, with the fraction declining from 20% to 13% over the 6-year study period. The proportion of patients transfused varied by surgery type from 6.4% for low-risk operations (i.e., minor surgery) to 31.5% for orthopedic surgeries. Variations were largely associated with patient hemoglobin concentrations, but also with center (range: 3.7%-27.3%) and country (0.4%-25.3%). Even after adjusting for baseline hemoglobin, comorbidities and type of surgery, both center and country were significant sources of variation in transfusion practices. Among transfused participants, 60.4% (n = 3728/6170) had at least 1 hemoglobin concentration ≤80g/L and 86.0% (n = 5305/6170) had at least 1 hemoglobin concentration ≤90g/L, suggesting that relatively restrictive transfusion strategies were used in most. The proportion of patients receiving at least 1 RBC transfusion declined from 20% to 13% over 6 years. However, there was considerable unexplained variation in transfusion practices.

Consequences of anemia in geriatric hip fractures: how low is too low?

Background

The transfusion threshold for low hemoglobin (Hgb) in geriatric patients with hip fractures is widely debated. In certain populations, low Hgb is associated with poor outcomes. Our objective was to evaluate the relationship between lowest Hgb and outcome to identify the Hgb threshold where poor outcomes were more prevalent.

Methods

This retrospective cohort study included consecutive patients with hip fractures, aged ≥60 years, evaluated at two level 1 trauma centers from 2018 to 2021. Patients who did not undergo operative fixation or had a length of stay <1 day were excluded. The primary endpoint was adverse outcome defined as the composite of myocardial infarction, stroke, new-onset arrhythmia or death. We compared lowest Hgb and possible confounders between patients with and without adverse outcomes. Classification and regression tree (CART) analysis was performed to identify the threshold for Hgb where adverse outcomes were more prevalent. Multivariate analysis was performed.

Results

We evaluated 935 patients. Mean age was 80±10 years; admission Hgb was 12.5±1.7 g/dL. Diabetes was present in 20%, and 20% had coronary artery disease. Adverse outcomes were noted in 57 patients (6.1%). CART identified ≤7.1 g/dL as the Hgb threshold where adverse outcomes were more prevalent (15% vs. 4.1%, p<0.001). Additionally, a greater number of adverse outcomes were noted in the subgroup of patients having both a hemoglobin ≤7.1 g/dL and advanced age (age >79 years (22%)). After controlling for age, American Society of Anesthesiologist Physical Status Classification (ASA), antiplatelet medication, admission Hgb, time to operation and blood transfusions, lowest Hgb ≤7.1 g/dL remained a risk factor for adverse outcomes.

Conclusions

In geriatric patients with isolated hip fractures, Hgb ≤7.1 g/dL is associated with a significantly higher rate of adverse outcomes. This risk was most pronounced in patients older than 79 years; particular care should be taken in this demographic.

Level of evidence/study type

Level III/prognostic and epidemiological.

Allogeneic Blood Transfusion and Risk of Postoperative Complications in Patients with Mild and Moderate Anemia of Any Cause? A Retrospective Cohort Study in Total Revision Hip Surgery

Introduction

Patients undergoing revision total hip surgery (RTHS) have a high prevalence of mild and moderate preoperative anemia, associated with adverse outcomes. The aim of this study was to investigate the association of perioperative allogeneic blood transfusions (ABT) and postoperative complications in preoperatively mild compared to moderate anemic patients undergoing RTHS who did not receive a diagnostic anemia workup and treatment before surgery.

Methods

We included 1,765 patients between 2007 and 2019 at a university hospital. Patients were categorized according to their severity of anemia using the WHO criteria of mild, moderate, and severe anemia in the first Hb level of the case. Patients were grouped as having received no ABT, 1-2 units of ABT, or more than 2 units of ABT. Need for intraoperative ABT was assessed in accordance with institutional standards. Primary endpoint was the compound incidence of postoperative complications. Secondary outcomes included major/minor complications and length of hospital and ICU stay.

Results

Of the 1,765 patients, 31.0% were anemic of any cause before surgery. Transfusion rates were 81% in anemic patients and 41.2% in nonanemic patients. The adjusted risks for compound postoperative complication were significantly higher in patients with moderate anemia (OR 4.88, 95% CI: 1.54-13.15, p = 0.003) but not for patients with mild anemia (OR 1.93, 95% CI: 0.85-3.94, p < 0.090). Perioperative ABT was associated with significantly higher risks for complications in nonanemic patients and showed an increased risk for complications in all anemic patients. In RTHS, perioperative ABT as a treatment for moderate preoperative anemia of any cause was associated with a negative compound effect on postoperative complications, compared to anemia or ABT alone.

Discussion

ABT is associated with adverse outcomes of patients with moderate preoperative anemia before RTHS. For this reason, medical treatment of moderate preoperative anemia may be considered.

Preoperative Hemoglobin <10 g/DL Predicts an Increase in Major Adverse Cardiac Events in Patients With Hip Fracture Over 80 Years: A Retrospective Cohort Study

Background

Preoperative anemia has been associated with perioperative morbidity and mortality in patients undergoing cardiac and non-cardiac surgery. Preoperative anemia is common in elderly hip fracture patients. The primary objective of the study was to explore the relationship between preoperative hemoglobin levels and postoperative major adverse cardiovascular events (MACEs) in hip fracture patients over 80 years.

Methods

The retrospective study enrolled hip fracture patients over 80 years from January 2015 to December 2021 in our center. The data were collected from the hospital's electronic database after approval by the ethics committee. The primary objective of the study was to investigate MACEs, and the secondary objectives included in-hospital mortality, delirium, acute renal failure, ICU admission rate, and transfusion (>2 U).

Results

912 patients were entered for final analysis. Based on the restricted cubic spline, the risk of preoperative hemoglobin (<10 g/DL) was associated with an increased risk of postoperative complications. With univariable logistic analysis, a hemoglobin level <10 g/DL was associated with increased MACEs [OR 1.769, 95% CI (1.074, 2.914), P = .025], in-hospital mortality [OR 2.709, 95% CI (1.215, 6.039), P = .015] and transfusion >2 U risk [OR 2.049, 95% CI (1.56, 2.69), P < .001]. Even after adjustment for confounding factors, MACEs [OR 1.790, 95% CI (1.073, 2.985), P = .026], in-hospital mortality [OR 2.81, 95% CI (1.214, 6.514), P = .016] and transfusion >2 U rate [OR 2.002, 95% CI (1.516, 2.65), P < .001] were still higher in the lower hemoglobin level cohort. Moreover, a log-rank test showed increased in-hospital mortality in the cohort with a preoperative hemoglobin level of <10 g/DL. However, there was no difference in delirium, acute renal failure, and ICU admission rates.

Conclusions

In conclusion, for hip fracture patients over 80 years, preoperative hemoglobin levels <10 g/DL might be associated with increased postoperative MACEs, in-hospital mortality, and transfusion >2 U.

Analysis of inpatient complications in HIV/AIDS patients undergoing total hip arthroplasty - A propensity matched cohort study

Patients with human immunodeficiency virus (HIV) are at higher risk for orthopedic related diseases due to dysregulation in bone metabolism and metabolic effects related to their medication regimen. Furthermore, the rate of hip arthroplasty in HIV patients is increasing. With the recent changes in THA methodologies and improvements in HIV treatment, there is a need for updated research analyzing hip arthroplasty outcomes in this high-risk patient population. In this study, we used a national database to evaluate postoperative outcomes in HIV patients undergoing THA compared to THA patients without HIV. We use a propensity algorithm to create a cohort of 493 HIV negative patients for matched analysis. Among the 367,894 THA patients included in this study, 367,390 patients were HIV negative and 504 were HIV positive. The HIV cohort had a lower mean age (53.34 vs 65.88, p < 0.001), lower proportion of females (44% vs 76.4%, p < 0.001), lower incidence of diabetes without complications (5% vs 11.1%, p < 0.001) and a lower incidence of obesity (0.544 vs 0.875, p = 0.002). In the unmatched analysis, the incidence of acute kidney injury (4.8% vs 2.5%, p = 0.004), pneumonia (1.2% vs 0.2%, p = 0.002), periprosthetic infection (3.6% vs 1%, p < 0.001), and wound dehiscence (0.6% vs 0.1%, p = 0.009) were higher in HIV cohort, most likely due to inherent demographic variances present in the HIV population. In the matched analysis, the rates of blood transfusion (5.0% vs 8.3%, p = 0.041) were lower in the HIV cohort. Other post-operative variables, such as rates of pneumonia, wound dehiscence, and surgical site infections were not statistically significant between the HIV positive population and HIV negative matched cohort. Our study found similar rates of postoperative complications in HIV positive and HIV negative patients. The rate of blood transfusions in HIV positive patients was also noted to be lower. Our data suggests that THA is a safe procedure in patients infected with HIV.

Transfusion Thresholds Can Be Safely Lowered in the Hip Fracture Patient: A Consecutive Series of 1,496 Patients

INTRODUCTION

The purpose of this study is to identify optimal threshold hemoglobin (Hgb) and hematocrit (Hct) laboratory values to transfuse hip fracture patients.

METHODS

A consecutive series of hip fracture patients were reviewed for demographic, clinical, and cost data. Patients receiving an allogeneic transfusion of packed red blood cells (pRBCs) were grouped based on last Hct or Hgb (H&H) value before first transfusion. Multivariate logistic regressions of H&H quantile were performed to predict "good outcomes," a composite binary variable defined as admissions satisfying (1) no major complications, (2) length of stay below top tertile, (3) cost below median, (4) no mortality within 30 days, and (5) no readmission within 30 days. Odds ratios (OR) for "good outcomes" were calculated for each H&H quantile.

RESULTS

One thousand four hundred ninety-six hip fracture patients were identified, of which 598 (40.0%) were transfused with pRBCs. Patients first transfused at Hgb values from 7.55 to 7.85 g/dL ( P = 0.043, OR = 2.70) or Hct values from 22.7 to 23.8% ( P = 0.048, OR = 2.63) were most likely to achieve "good outcomes."

DISCUSSION

The decision to transfuse patients should be motivated by Hgb and Hct laboratory test results, given that transfusion timing relative to surgery has been shown to not affect outcomes among patients matched by trauma risk score. Surgeons should aim to transfuse hip fracture patients at Hgb levels between 7.55 g/dL and 7.85 g/dL or Hct levels between 22.7% and 23.8%. These transfusion thresholds have the potential to lower healthcare costs without compromising quality, ultimately resulting in less costly, efficacious care for the patient.

LEVEL OF EVIDENCE

Level III.

Prediction of red blood cell transfusion after orthopedic surgery using an interpretable machine learning framework

Objective

Postoperative red blood cell (RBC) transfusion is widely used during the perioperative period but is often associated with a high risk of infection and complications. However, prediction models for RBC transfusion in patients with orthopedic surgery have not yet been developed. We aimed to identify predictors and constructed prediction models for RBC transfusion after orthopedic surgery using interpretable machine learning algorithms.

Methods

This retrospective cohort study reviewed a total of 59,605 patients undergoing orthopedic surgery from June 2013 to January 2019 across 7 tertiary hospitals in China. Patients were randomly split into training (80%) and test subsets (20%). The feature selection method of recursive feature elimination (RFE) was used to identify an optimal feature subset from thirty preoperative variables, and six machine learning algorithms were applied to develop prediction models. The Shapley Additive exPlanations (SHAP) value was employed to evaluate the contribution of each predictor towards the prediction of postoperative RBC transfusion. For simplicity of the clinical utility, a risk score system was further established using the top risk factors identified by machine learning models.

Results

Of the 59,605 patients with orthopedic surgery, 19,921 (33.40%) underwent postoperative RBC transfusion. The CatBoost model exhibited an AUC of 0.831 (95% CI: 0.824-0.836) on the test subset, which significantly outperformed five other prediction models. The risk of RBC transfusion was associated with old age (>60 years) and low RBC count (<4.0 × 10¹²/L) with clear threshold effects. Extremes of BMI, low albumin, prolonged activated partial thromboplastin time, repair and plastic operations on joint structures were additional top predictors for RBC transfusion. The risk score system derived from six risk factors performed well with an AUC of 0.801 (95% CI: 0.794-0.807) on the test subset.

Conclusion

By applying an interpretable machine learning framework in a large-scale multicenter retrospective cohort, we identified novel modifiable risk factors and developed prediction models with good performance for postoperative RBC transfusion in patients undergoing orthopedic surgery. Our findings may allow more precise identification of high-risk patients for optimal control of risk factors and achieve personalized RBC transfusion for orthopedic patients.

Total Hip Arthroplasty Patients with Distinct Postoperative Fibrinolytic Phenotypes Require Different Antifibrinolytic Strategies

Bleeding patients exhibit different fibrinolytic phenotypes after injury, and the universal use of tranexamic acid (TXA) is doubted. We aimed to evaluate the efficacy of postoperative antifibrinolytic treatment in total hip arthroplasty (THA) patients with different fibrinolytic phenotypes. A retrospective analysis was conducted in 238 patients who underwent THA. Patients were divided into two groups by different fibrinolytic phenotypes (non-fibrinolytic shutdown and fibrinolytic shutdown), determined by the LY30 level on postoperative day 1 (POD1). The two groups were further stratified into four sub-groups based on different postoperative TXA regimens (Group A received no TXA postoperatively, while Group B did). Hidden blood loss (HBL), decline of hemoglobin (ΔHb), D-dimer (D-D), fibrinogen/fibrin degradation product (FDP), prothrombin time (PT), activated partial thromboplastin time (APTT), and demographics were collected and compared. The clinical baseline data were comparable between the studied groups. In patients who presented non-fibrinolytic shutdown postoperatively, Group B suffered significantly lower HBL and ΔHb than Group A on POD3 and POD5. In patients who presented postoperative fibrinolytic shutdown, Group B failed to benefit from the postoperative administration of TXA when compared to Group A. No difference was found in postoperative levels of D-D, FDP, PT, and APTT. Postoperative antifibrinolytic therapy is beneficial for THA patients who presented non-fibrinolytic shutdown postoperatively, while the efficacy and necessity should be considered with caution in those with fibrinolytic shutdown. LY30 is a promising parameter to distinguish different fibrinolytic phenotypes and guide TXA administration. However, further prospective studies are needed to confirm these findings.

The association between perioperative blood transfusions and venous thromboembolism risk following surgical management of hip fractures

Introduction

Despite high rates of transfusion reported among hip fracture patients in the perioperative period, the relationship between perioperative transfusions and VTE has not been thoroughly explored. Therefore, we used a national database to evaluate how perioperative transfusions among patients undergoing surgical management of hip fractures impacted 1) deep vein thrombosis (DVT) and 2) pulmonary embolism (PE) risk.

Methods

The Targeted Hip Fracture Database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients undergoing surgical management of hip fractures from 2016 to 2019. A multivariate logistic regression was conducted using various patient-specific variables to identify risk factors for DVT and PE. A nearest-neighbor propensity score matched (PSM) comparison between patients receiving and not receiving perioperative blood transfusions (1:1) was additionally conducted.

Results

Prior to our PSM, preoperative transfusions were not associated with DVT incidence (OR: 1.48, 95% CI: 0.80-2.50; p = 0.2). However, intra-operative/post-operative transfusions (OR: 1.26, 95% CI: 1.02-1.56; p = 0.00.30) as well as the receipt of both transfusion types (OR: 1.81, 95% CI: 1.10-2.81; p = 0.012) were associated with an increased risk of DVT. The latter of these findings remained significant following PSM (OR: 1.73, 95% CI: 1.04-2.73; p = 0.025). No relationship was demonstrated between PE risk and perioperative transfusion receipt.

Conclusion

Our findings emphasize the importance of perioperative blood management strategies among patients undergoing surgical repair of hip fracture. Specifically, orthopaedic surgeons should aim to optimize hip fracture patients prior to surgical intervention as well as intra-operatively to reduce transfusion incidence.

Effect of integrated management bundle on 1-year overall survival outcomes and perioperative outcomes in super elderly patients aged 90 and over with hip fracture: non-concurrent cohort study

BACKGROUND

Due to concomitant factors like frailty and comorbidity, super elderly (≥90 years) patients with hip fracture differ from patients aged 65-89 years in perioperative complications and mortality. The integrated management bundle referred to bundled application of multiple clinical measures. The aim of this study was to analyze effect of integrated management bundle on 1-year overall survival and perioperative outcomes in super elderly patients with hip fracture, with multidisciplinary management group serving as the control group.

METHODS

In this retrospective cohort study, super elderly patients with hip fracture were included from Jan 2017 to Nov 2020. Patients were retrospectively divided to multidisciplinary management group and integrated management bundle group. The primary outcome was 1- year overall survival, and the secondary outcome was perioperative outcomes. Kaplan-Meier methods was used to compare survival probability. Multivariable Cox's modeling was used to explain the effect of integrated bundle on 1-year overall survival adjusted for confounders. The perioperative outcomes including complications and in-hospital data of two groups were compared. The multivariable logistic regression was used to explain the effect of integrated bundle on the occurrence of perioperative complications adjusted for confounders. Prognostic factors related to survival was identified by multivariable Cox's regression analysis.

RESULTS

Ninety-seven patients comprised multidisciplinary management group, and 83 comprised integrated management bundle group. The Kaplan-Meier plots showed that the survival probability of integrated management bundle group was significantly better than multidisciplinary management group (HR:0.435, 95%CI:0.207-0.914, P = 0.039). Multivariable analysis after adjustment for confounders showed a 42.8% lower incidence of mortality integrated management bundle group than multidisciplinary management group (HR:0.428, 95%CI:0.186-0.986, P = 0.046). Incidence of hypoproteinemia, and electrolyte disturbance in integrated management bundle group was significantly lower than multidisciplinary management group (all P < 0.05). In addition, significant reduction was observed in length of stay (P < 0.05) in integrated management bundle group. Multivariable logistic regression showed integrated management bundle was independent protective factor of hypoproteinemia, and electrolyte disturbance. mECM score ≥ 6 and ASA score > 2 were independent risk factors of overall survival (HR: 1.940, 95%CI: 1.067-3.525,P = 0.030; HR: 2.281, 95%CI: 1.113-4.678,P = 0.024).

CONCLUSIONS

The integrated management bundle improved 1-year overall survival and played positive effects in improving perioperative outcomes. It might be a more suitable management modality for super elderly patients with hip fracture.

[Rational therapy with erythrocyte concentrates - Update 2022]

The use of red blood cell concentrates must follow the dictates of a rational indication. To further ensure this, the "Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives" 1 of the German Medical Association, published in 2009 and last revised in part in 2014, were systematically revised in 2020. This article presents them.

Fraturas intracapsulares do colo femoral no idoso

Currently, intracapsular femoral neck fracture (IFNF) is still a great challenge for orthopedists. In spite of the progress that has been made, a high mortality rate persists in the first year, especially in Brazil, where there is no awareness that such fractures in elderly patients should be treated as a medical emergency. The present article seeks to provide an update on the preoperative, surgical, and postoperative approaches.

Impact of restrictive red blood cell transfusion strategy on thrombosis-related events: A meta-analysis and systematic review

BACKGROUND AND OBJECTIVES

There is an ongoing controversy regarding the risks of restrictive and liberal red blood cell (RBC) transfusion strategies. This meta-analysis assessed whether transfusion at a lower threshold was superior to transfusion at a higher threshold, with regard to thrombosis-related events, that is, whether these outcomes can benefit from a restrictive transfusion strategy is debated.

MATERIALS AND METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials and Scopus from inception up to 31 July 2021. We included randomized controlled trials (RCTs) in any clinical setting that evaluated the effects of restrictive versus liberal RBC transfusion in adults. We used random-effects models to calculate the risk ratios (RRs) and 95% confidence intervals (CIs) based on pooled data.

RESULTS

Thirty RCTs involving 17,334 participants were included. The pooled RR for thromboembolic events was 0.65 (95% CI 0.44-0.94; p = 0.020; I²  = 0.0%, very low-quality evidence), favouring the restrictive strategy. There were no significant differences in cerebrovascular accidents (RR = 0.83; 95% CI 0.64-1.09; p = 0.180; I²  = 0.0%, very low-quality evidence) or myocardial infarction (RR = 1.05; 95% CI 0.87-1.26; p = 0.620; I²  = 0.0%, low-quality evidence). Subgroup analyses showed that a restrictive (relative to liberal) strategy reduced (1) thromboembolic events in RCTs conducted in North America and (2) myocardial infarctions in the subgroup of RCTs where the restrictive transfusion threshold was 7 g/dl but not in the 8 g/dl subgroup (with a liberal transfusion threshold of 10 g/dl in both subgroups).

CONCLUSIONS

A restrictive (relative to liberal) transfusion strategy may be effective in reducing venous thrombosis but not arterial thrombosis.

Novelle QLL 2020 – welche Auswirkungen haben die neu empfohlenen Hämoglobin-Transfusionstrigger auf die klinische Versorgung?

In der Gesamtnovelle der Querschnittsleitlinie (QLL) Hämotherapie der Bundesärztekammer (BÄK) 2020 wurde der Hämoglobin-Transfusionstrigger (Hb-Transfusionstrigger) bei akutem Blutverlust ohne zusätzliche Risikofaktoren aufgrund einer Neubewertung der internationalen Evidenz von 3,7 mmol/l (6 g/dl) auf 4,3 mmol/l (7 g/dl) angepasst. Ziel der vorliegenden Studie ist die retrospektive Analyse des Transfusionsverhaltens von EK bezüglich der Maßgaben der QLL. Zu diesem Zweck analysierten wir individuelle Prä- und Posttransfusions-Hb-Werte von Erythrozytenkonzentraten (EK), die im 4. Quartal 2019 (4946 EKs, 129 560 Hb-Werte) und 2020 (5502 EKs, 134 404 Hb-Werte) am Universitätsklinikum Leipzig (UKL) transfundiert wurden. Der mediane Hb-Wert vor der Transfusion betrug 4,3 mmol/l (7 g/dl) (680 medizinische Fälle, die 2724 EK in 1801 Transfusionen im Jahr 2019 erhielten). Von allen Transfusionen im Jahr 2019 zeigten 899 (49,9%) Transfusionen Hb-Werte < 4,3 mmol/l (7 g/dl) vor der Transfusion, während 152 (8,4%) Hb-Werte < 3,7 mmol/l (6 g/dl) aufwiesen. 2020 wurden jeweils vergleichbare Ergebnisse ermittelt. Wir zeigen, dass der mediane Hb-Anstieg nach der Transfusion eines EK 0,6 mmol/l (1 g/dl) betrug. 34,7% aller Transfusionen erreichten den erwarteten Anstieg von 0,6 mmol/l (1 g/dl) pro EK. Der absolute Anstieg nahm bei Transfusionen mit mehreren EK im Vergleich zu Transfusionen mit einem EK nicht linear zu. Der Grad der Hb-Erhöhung korrelierte invers mit dem Hb-Wert vor Transfusion. Der Hb-Wert nach der Transfusion wurde bei 96,3% der Fälle innerhalb von 24 Stunden nach Hämotherapie kontrolliert. Zusammenfassend spiegelt das Transfusionsverhalten generell die Empfehlungen der Leitlinie. Um ein optimiertes, individualisiertes und dennoch restriktives Transfusionsverhalten bei EK zu erreichen, schlagen wir die Implementierung eines klinischen Entscheidungsunterstützungssystems (CDSS) bei Verschreibung jeder einzelnen EK-Transfusion vor, welches Ärzte bei der Einhaltung der Transfusionsleitlinie unterstützt und über Abweichungen informiert.

Intraoperative transfusion practices and perioperative outcome in the European elderly: A secondary analysis of the observational ETPOS study

The demographic development suggests a dramatic growth in the number of elderly patients undergoing surgery in Europe. Most red blood cell transfusions (RBCT) are administered to older people, but little is known about perioperative transfusion practices in this population. In this secondary analysis of the prospective observational multicentre European Transfusion Practice and Outcome Study (ETPOS), we specifically evaluated intraoperative transfusion practices and the related outcomes of 3149 patients aged 65 years and older. Enrolled patients underwent elective surgery in 123 European hospitals, received at least one RBCT intraoperatively and were followed up for 30 days maximum. The mean haemoglobin value at the beginning of surgery was 108 (21) g/l, 84 (15) g/l before transfusion and 101 (16) g/l at the end of surgery. A median of 2 [1-2] units of RBCT were administered. Mostly, more than one transfusion trigger was present, with physiological triggers being preeminent. We revealed a descriptive association between each intraoperatively administered RBCT and mortality and discharge respectively, within the first 10 postoperative days but not thereafter. In our unadjusted model the hazard ratio (HR) for mortality was 1.11 (95% CI: 1.08-1.15) and the HR for discharge was 0.78 (95% CI: 0.74-0.83). After adjustment for several variables, such as age, preoperative haemoglobin and blood loss, the HR for mortality was 1.10 (95% CI: 1.05-1.15) and HR for discharge was 0.82 (95% CI: 0.78-0.87). Pre-operative anaemia in European elderly surgical patients is undertreated. Various triggers seem to support the decision for RBCT. A closer monitoring of elderly patients receiving intraoperative RBCT for the first 10 postoperative days might be justifiable. Further research on the causal relationship between RBCT and outcomes and on optimal transfusion strategies in the elderly population is warranted. A thorough analysis of different time periods within the first 30 postoperative days is recommended.

The application of patient-centered care bundle significantly reduces incidence of perioperative respiratory complications in hip fracture patients aged 80 and over

This study was designed as a pilot test to analyze the effect of patient-centered care (PCC) bundle intervention on perioperative respiratory complications and other outcomes in hip fracture patients aged ≥80. Between Jan 2018 and Dec 2019, 198 patients comprised the routine care group and 187 comprised the PCC bundle group. After propensity score matching, 151 remained in each group. Incidence of perioperative respiratory complications in the PCC bundle group was significantly lower than in the routine care group (all P < 0.05). Furthermore, significant reductions were observed in surgery delay, length of stay, incidence of arrhythmia, hypoproteinemia, and electrolyte disturbance (all P < 0.05) in the PCC bundle group. Age-Adjusted Charlson Comorbidity Index score was related, but only weakly, to length of stay and the number of perioperative complications. These results suggested that the PCC bundle might be a more suitable care modality for patients ≥80 with hip fracture.

Perioperative red blood cell infusion and deep vein thrombosis in patients with femoral and pelvic fractures: a propensity score matching

BACKGROUND

The relationship between perioperative red blood cell (RBC) infusion and deep vein thrombosis (DVT) has not been determined.

OBJECTIVES

To analyze the time-event relationship between perioperative RBC infusion and DVT in patients with femoral and pelvic fractures after adjusting for confounding factors and to provide reference for optimizing DVT risk factors.

METHODS

The clinical data of 569 patients with femoral and pelvic fractures who received surgical treatment from May 2018 to December 2019 were retrospectively analyzed. Propensity score matching (PSM) was performed on 20 covariates of DVT. With the formation or progression of DVT after RBC infusion as the end point, the time-event relationship between perioperative RBC infusion and DVT in patients was analyzed by binary logistic regression.

RESULTS

After 1:1 PSM of 569 patients included in this study, 126 patients were in the transfusion group and the non-transfusion group, respectively. Before PSM (P = 0.023, OR = 1.496 [95% CI, 1.058-2.115]), perioperative RBC infusion was associated with DVT formation for femoral and pelvic fractures. This conclusion was still obtained after PSM (P = 0.038, OR = 1.728, 95% CI = (1.031, 2.896)). The risk of DVT in patients with RBC infusion of 2-4U and > 4U is 1.833 and 2.667 times that of ≤ 2U, respectively. After excluding patients who received preoperative RBC infusion and had DVT formation or progression prior to RBC infusion, perioperative RBC infusion was still associated with the formation of DVT in femoral and pelvic fractures (P = 0.037, OR = 2.231 [95% CI, 1.049-4.745]).

CONCLUSION

Perioperative RBC infusion is one of the causes of DVT in patients with femoral and pelvic fractures, and the risk of DVT is positively correlated with the amount of RBC infusion.

Rationale Therapie mit Erythrozytenkonzentraten – Update 2020

Der Einsatz von Erythrozytenkonzentraten muss dem Gebot einer rationalen Indikation folgen. Um dies weiter zu gewährleisten, wurden die 2009 publizierten und zuletzt 2014 in Teilen revidierten „Querschnitts-Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten“ 1 der Bundesärztekammer 2020 einer systematischen Novellierung unterzogen. Der Artikel stellt sie vor.

Rethinking strategies for blood transfusion in hip fracture patients

OBJECTIVES

Most patients can tolerate a hemoglobin (Hgb) > 8 g per deciliter. In some cases, however, transfusion will delay physical therapy and hospital discharge. This study aims to review Hgb and transfusion data for a large volume of recent hip fracture patients in order to identify new opportunities for decreasing the length of hospital stay. Our hypotheses are that in some cases, earlier transfusion of more blood will be associated with shorter hospital stays, and that Hgb levels consistently decrease for more than 3 days postoperatively.

DESIGN

Retrospective chart review.

SETTING

Two academic medical centers with Geriatric Fracture Programs.

PATIENTS

Data was collected from patients 50 years and older with hip fractures April 2015 and October 2017.

INTERVENTION

Operative stabilization of the hip fractures according to standard of care for the fracture type and patient characteristics. Transfusion according to established standards.

MAIN OUTCOME MEASUREMENTS

Electronic records were retrospectively reviewed for demographic information, Hgb levels, and transfusion events.

RESULTS

One thousand fifteen patients with femoral neck or intertrochanteric hip fractures were identified. Eight hundred sixty met the inclusion criteria. The average length of hospital stay was 6.7 days. The mean patient age was 82 years. The average American Society of Anesthesiologists score was 2.9. The average Hgb level consistently decreased for 5 days postoperatively before beginning to increase on day 6. There was poor consistency between intraoperative Hgb levels and preoperative or postoperative Hgb levels. Three hundred sixty-eight (42.8%) patients were transfused an average of 1.9 (range 1-6) units. One hundred five patients required a transfusion on postoperative day (POD) 1: 72 received only 1 unit of blood: 36 (50%) of the 72 required a second transfusion in the following days, compared to 9 of 33 (27%) who received 2 units on POD 1 (χ2 = 3.8898; P < .05). Patients who received transfusions on POD 3 or later had an average length of stay >2.5 days longer than those who received a transfusion earlier (P = 0.005).

CONCLUSIONS

Our findings do not support earlier transfusion of more blood. Although in some cases, there is an association between earlier transfusion of more blood and shorter hospital stay, routine transfusion of more blood would incur higher transfusion risks in some patients who would not otherwise meet criteria for transfusion. After hip fracture surgery, the Hgb usually decreases for 5 days and does not begin to increase until POD 6. This information will provide utility in the population health management of hip fracture patients.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: an overview of systematic reviews

BACKGROUND

There are no overviews of systematic reviews investigating haemoglobin thresholds for transfusion. This is important as the literature on transfusion thresholds has grown considerably in recent years. Our aim was to synthesise evidence from systematic reviews and meta-analyses of the effects of restrictive and liberal transfusion strategies on mortality.

METHODS

This was a systematic review of systematic reviews (overview). We searched MEDLINE, Embase, Web of Science Core Collection, PubMed, Google Scholar, and the Joanna Briggs Institute EBP Database, from 2008 to 2018. We included systematic reviews and meta-analyses of randomised controlled trials comparing mortality in patients assigned to red cell transfusion strategies based on haemoglobin thresholds. Two independent reviewers extracted data and assessed methodological quality. We assessed the methodological quality of included reviews using AMSTAR 2 and the quality of evidence pooled using an algorithm to assign GRADE levels.

RESULTS

We included 19 systematic reviews reporting 33 meta-analyses of mortality outcomes from 53 unique randomised controlled trials. Of the 33 meta-analyses, one was graded as high quality, 15 were moderate, and 17 were low. Of the meta-analyses presenting high- to moderate-quality evidence, 12 (75.0%) reported no statistically significant difference in mortality between restrictive and liberal transfusion groups and four (25.0%) reported significantly lower mortality for patients assigned to a restrictive transfusion strategy. We found few systematic reviews addressed clinical differences between included studies: variation was observed in haemoglobin threshold concentrations, the absolute between group difference in haemoglobin threshold concentration, time to randomisation (resulting in transfusions administered prior to randomisation), and transfusion dosing regimens.

CONCLUSIONS

Meta-analyses graded as high to moderate quality indicate that in most patient populations no difference in mortality exists between patients assigned to a restrictive or liberal transfusion strategy.

TRIAL REGISTRATION

PROSPERO CRD42019120503.

Hip fracture clearance: How much optimisation is necessary?

Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. Long waiting times for surgery are associated with increased morbidity and mortality. The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery.

Coagulation monitoring and transfusion in major non-emergency orthopaedic surgery - An observational study

Objective

Perioperative coagulation monitoring and transfusions were evaluated.

Methods

70 cases were included. Time points: before (PRE), after surgery (POST), day 1, day 3, day 7. Standard and patient near tests were assessed. Groups were: Transfused (TG); Control (CG).

Results

23 patients were transfused (TG), 47 were not (CG). PRE haemoglobin was reduced, coagulation time (CT) was prolonged in TG. FIBTEM decrease was higher in TG. Leukocytes were elevated in TG. ASPI decreased, TRAP and ADP aggregability increased in both groups.

Conclusion

CT, haemoglobin and fibrinogen were associated with transfusion. TRAP and ADP aggregability increased and could account for thromboembolism.

Efficacy of a three-day prolonged-course of multiple-dose versus a single-dose of tranexamic acid in total hip and knee arthroplasty

Background

The application of tranexamic acid (TXA) in total hip arthroplasty (THA) and total knee arthroplasty (TKA) has brought momentous changes in blood management. However, the optimal regimen of TXA has not yet been identified. This study aimed to compare the efficacy of a three-day prolonged-course of multiple-dose of TXA with a single pre-operative dose of TXA in patients who undergo THA and TKA.

Method

We retrospectively analyzed two groups of consecutive patients who received primary unilateral THA and TKA from 2015 to 2017. One group received a three-day prolonged-course of multiple-dose of TXA, while another group received a single-dose of TXA. The primary outcomes included the changes in hemoglobin (Hb), estimated total blood loss (TBL), and transfusion rate; the secondary outcomes included the platelet (PLT) counts, inflammatory markers, and fibrinolysis parameters.

Results

A total of 193 THA and 166 TKA procedures were included for comparison. Compared with the patients who received a single-dose of TXA, the patients who received a three-day prolonged-course of multiple-dose of TXA had smaller post-operative drops in Hb levels, which led to consistently significantly higher Hb levels in both THA and TKA. Therefore, the use of multiple-dose of TXA was associated with significantly lower maximum Hb drops and estimated TBL in both THA (24.58±11.43 vs. 30.38±11.33 g/L, P=0.001; 685.88±412.02 vs. 968.94±479.9 mL, P<0.0001) and TKA (18.04±9.75 vs. 27.24±10.99 g/L, P<0.0001; 497.35±291.03 vs. 816.51±354.38 mL, P<0.0001), and marginally reduced transfusion requirements (THA: 1/65 vs. 10/128; TKA: 0/70 vs. 2/96). The multiple-dose group also showed higher PLT counts, continuously reduced inflammatory responses, and significantly and durably attenuated fibrinolytic responses.

Conclusions

A three-day prolonged-course of multiple-dose of TXA was consistently effective in reducing post-operative Hb drops, estimated TBL, inflammatory responses, and fibrinolytic responses, which could be recommended for clinical practice. However, these findings need to be confirmed by prospective studies.

Multicenter comparison of three intraoperative hemoglobin trend monitoring methods

Transfusion decisions are guided by clinical factors and measured hemoglobin (Hb). Time required for blood sampling and analysis may cause Hb measurement to lag clinical conditions, thus continuous intraoperative Hb trend monitoring may provide useful information. This multicenter study was designed to compare three methods of determining intraoperative Hb changes (trend accuracy) to laboratory determined Hb changes. Adult surgical patients with planned arterial catheterization were studied. With each blood gas analysis performed, pulse cooximetry hemoglobin (SpHb) was recorded, and arterial blood Hb was measured by hematology (tHb), arterial blood gas cooximetry (ABGHb), and point of care (aHQHb) analyzers. Hb change was calculated and trend accuracy assessed by modified Bland–Altman analysis. Secondary measures included Hb measurement change direction agreement. Trend accuracy mean bias (95% limits of agreement; g/dl) for SpHb was 0.10 (− 1.14 to 1.35); for ABGHb was − 0.02 (− 1.06 to 1.02); and for aHQHb was 0.003 (− 0.95 to 0.95). Changes more than ± 0.5 g/dl agreed with tHb changes more than ± 0.25 g/dl in 94.2% (88.9–97.0%) SpHb changes, 98.9% (96.1–99.7%) ABGHb changes and 99.0% (96.4–99.7%) aHQHb changes. Sequential changes in SpHb, ABGHb and aHQHb exceeding ± 0.5 g/dl have similar agreement to the direction but not necessarily the magnitude of sequential tHb change. While Hb blood tests should continue to be used to inform transfusion decisions, intraoperative continuous noninvasive SpHb decreases more than − 0.5 g/dl could be a good indicator of the need to measure tHb.

Restrictive versus liberal strategy for red blood-cell transfusion in hip fracture patients: A systematic review and meta-analysis

BACKGROUND

Most clinical guidelines recommend a restrictive red-blood-cell (RBC) transfusion threshold. However, indications for transfusion in patients with a hip fracture have not been definitively evaluated or remain controversial. We compared the pros and cons of restrictive versus liberal transfusion strategies in patients undergoing hip fracture surgery.

METHODS

Electronic databases were searched to identify randomized controlled trials (RCTs) and retrospective cohort studies (RCSs) to investigate the effects of a restrictive strategy versus its liberal counterpart in patients undergoing hip fracture surgery. The main clinical outcomes included delirium, mortality, infections, cardiogenic complications, thromboembolic events, cerebrovascular accidents, and length of hospital stay. The meta-analysis program of the Cochrane Collaboration (RevMan version 5.3.0) was used for data analysis. Statistical heterogeneity was assessed by both Cochran chi-squared test (Q test) and I test. Both Begg and Egger tests were used to assess potential publication bias.

RESULTS

We identified 7 eligible RCTs and 2 eligible RCSs, involving 3,575 patients in total. In patients undergoing hip fracture surgery, we found no differences in frequency of delirium, mortality, the incidence rates of all infections, pneumonia, wound infection, all cardiovascular events, congestive heart failure, thromboembolic events or length of hospital stay between restrictive and liberal thresholds for RBC transfusion (P >.05). However, we found that the use of restrictive transfusion thresholds is associated with higher rates of acute coronary syndrome (P <.05) while liberal transfusion thresholds increase the risk of cerebrovascular accidents (P <.05).

CONCLUSION

In patients undergoing hip fracture surgery, clinicians should evaluate the patient's condition in detail and adopt different transfusion strategies according to the patient's specific situation rather than merely using a certain transfusion strategy.

Application of thrombelastography (TEG) for safety evaluation of tranexamic acid in primary total joint arthroplasty

BACKGROUND

Questions remain, mainly concerning whether tranexamic acid (TXA) is truly safe since all available trials were underpowered to identify clinically important differences. The objective of this study is to evaluate the safety of TXA by using a novel technique-thromboelastography (TEG).

METHODS

A retrospective review was conducted on 359 consecutive patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) and received multiple-dose or single-dose of TXA at a tertiary academic center. TEG parameters, TEG coagulation status, conventional coagulation test parameters, and incidence of thrombotic events were used for safety evaluation.

RESULTS

Compared with single-dose cohort, patients who received multiple-dose of TXA had consistent statistically significant shortened R times on post-operative day 1 (POD1) and POD3 in both THA (POD1: 4.06 ± 0.71 s versus 4.45 ± 1.28 s, P = 0.011; POD3: 4.36 ± 0.83 s versus 5.12 ± 1.64 s, P < 0.0001) and TKA (POD1: 3.90 ± 0.73 s versus 4.29 ± 0.92 s, P = 0.011; POD3: 4.24 ± 0.94 s versus 4.65 ± 1.07 s, P = 0.023), while the K, α-angle, and MA values were similar during the perioperative period. TEG coagulation status analysis indicated that patients were significantly (P = 0.003) more likely with hypercoagulable status during the course of multiple-dose TXA. Conventional coagulation test parameters were similar. Only one patient developed calf vein thrombosis in the multiple-dose cohort.

CONCLUSIONS

Multiple-dose of TXA was associated with aggravated hypercoagulable state when compared with single-dose of TXA, but this prothrombotic state does not provoke thrombosis when combined with appropriate anticoagulant therapy. Therefore, multiple-dose of TXA remains safe and could be recommended for clinical practice. Potential benefits and possible risks should be trade-off when considering increasing the dosage and frequency of TXA on the present basis.

TRIAL REGISTRATION

ChiCTR1800015422 .

The Romanian Society of Internal Medicine's Choosing Wisely Campaign

Quality of care in medicine is not necessarily proportional to quantity of care and excess is often useless or even more, potentially detrimental to our patients. Adhering to the European Federation of Internal Medicine's initiative, the Romanian Society of Internal Medicine (SRMI) launched the Choosing Wisely in Internal Medicine Campaign, aiming to cut down diagnostic procedures or therapeutics overused in our country. A Working Group was formed and from 200 published recommendations from previous international campaigns, 36 were voted as most important. These were submitted for voting to the members of the SRMI and posted on a social media platform. After the two voting rounds, the top six recommendations were established. These were: 1. Stop medicines when no further benefit is achieved or the potential harms outweigh the potential benefits for the individual patient. 2. Don't use antibiotics in patients with recent C. difficile without convincing evidence of need. 3. Don't regularly prescribe bed rest and inactivity following injury and/or illness unless there is scientific evidence that harm will result from activity. Promote early mobilization. 4. Don't initiate an antibiotic without an identified indication and a predetermined length of treatment or review date. 5. Don't prescribe opioids for treatment of chronic or acute pain for sensitive jobs such as operating motor vehicles, forklifts, cranes or other heavy equipment. 6. Transfuse red cells for anemia only if the hemoglobin concentration is less than 7 g/dL or if the patient is hemodynamically unstable or has significant cardiovascular or respiratory comorbidity. Don't transfuse more units of blood than absolutely necessary.

The necessity of routine postoperative laboratory tests in enhanced recovery after surgery for primary hip and knee arthroplasty: A retrospective cohort study protocol

INTRODUCTION

Over the last few decades, the concepts of minimally invasive surgery and enhanced recovery after surgery (ERAS) protocols have been introduced into the field of total joint arthroplasty (TJA), and tranexamic acid (TXA) has been widely used in TJA. Modern-day surgical techniques and perioperative care pathways of TJA have experienced unexpected improvements. Recently, the necessity of the practice of ordering routine postoperative laboratory tests for patients undergoing primary TJA has been challenged, especially in the context of implementation of ERAS protocols in TJA. These studies have consistently suggested that routine postoperative laboratory tests are not necessary in modern-day primary, unilateral total hip arthroplasty (THA) or total knee arthroplasty (TKA), and laboratory tests after surgery should only be obtained for patients with risk factors. However, it remains unclear whether routine postoperative laboratory tests after THA and TKA remains justified in the Chinese patient population. Therefore, we developed this study to address this issue.

METHODS AND ANALYSIS

This retrospective cohort study will include adult patients who underwent primary unilateral THA or TKA and received multimodal perioperative care pathways according to ERAS protocols. The following patient data will be collected from the electronic medical record system: patients' demographics, preoperative and postoperative laboratory values, operation time, intraoperative blood loss, TXA use, tourniquet use, postoperative length of stay, and any medical intervention directly related to abnormal laboratory values. The main study outcomes are the incidence of acute anemia requiring transfusion and incidence of hypoalbuminemia requiring albumin supplementation. The secondary outcomes are the rates of acute kidney injury, incidence of abnormal serum sodium level, incidence of abnormal serum potassium level, and incidence of abnormal serum calcium level. These clinical data will be analyzed to determine the incidence of abnormal postoperative laboratory values following primary unilateral THA and TKA; to clarify the frequency of any medical intervention directly related to abnormal postoperative laboratory values; and to identify risk factors that predispose patients to have abnormal postoperative laboratory results.

STUDY REGISTRATION

Chinese Clinical Trial Registry (http://www.chictr.org.cn): ChiCTR1900020690.

Periprosthetic Joint Infection in Patients with Inflammatory Joint Disease: Prevention and Diagnosis

PURPOSE OF REVIEW

Periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint arthroplasty (TJA), causing significant morbidity and often requiring revision surgery. This goal of this manuscript is to review the current evidence for the prevention and diagnosis of PJI in patients with inflammatory arthritis.

RECENT FINDINGS

Patients with inflammatory arthritis have a higher risk of PJI after TJA; however, there are several preventive, diagnostic, and therapeutic measures that can be optimized to lower the burden of PJI in this population. This manuscript will review the current evidence and clinical practice recommendations that support specific features of preoperative evaluation, perioperative medication management, and surgical planning in inflammatory arthritis patients undergoing TJA. Evidence and recommendations for the diagnosis of PJI in this patient population will also be reviewed. Despite increased research efforts directed towards PJI, specific approaches directed at the inflammatory arthritis patient population remain surprisingly limited. Optimization strategies such as adequately managing disease-modifying medications, treating preoperative anemia, encouraging smoking cessation, and improving weight management are strongly encouraged before entering the perioperative period. If PJI does occur in the inflammatory arthritis patient, establishing the diagnosis is challenging, since guidelines were created from investigations of PJI in primarily patients without inflammatory arthritis. Future prospective research is required to better guide clinicians in preventing and diagnosing PJI in inflammatory arthritis patients undergoing TJA.