Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines

"Simplified International Recommendations for the Implementation of Patient Blood Management" (SIR4PBM)

BACKGROUND

More than 30% of the world's population are anemic with serious medical and economic consequences. Red blood cell transfusion is the mainstay to correct anemia, but it is also one of the top five overused procedures and carries its own risk and cost burden. Patient blood management (PBM) is a patient-centered and multidisciplinary approach to manage anemia, minimize iatrogenic blood loss, and harness tolerance to anemia in an effort to improve patient outcome. Despite resolution 63.12 of the World Health Organization in 2010 endorsing PBM and current guidelines which include evidence-based recommendations on the use of diagnostic/therapeutic resources to provide better health care, many hospitals have yet to implement PBM in routine clinical practice.

METHOD AND RESULTS

A number of experienced clinicians developed the following "Simplified International Recommendations for Patient Blood Management." We propose a series of simple, cost-effective, best-practice, feasible, and evidence-based measures that will enable any hospital to reduce both anemia prevalence on the day of intervention/surgery and anemia-related unnecessary transfusion in surgical and medical patients, including obstetrics and gynecology.

Anesthesia for Patients with Anemia

Anemia is a common and often ignored condition in surgical patients. Anemia is usually multifactorial and iron deficiency and inflammation are commonly involved. An exacerbating factor in surgical patients is iatrogenic blood loss. Anemia has been repeatedly shown to be an independent predictor of worse outcomes. Patient blood management (PBM) provides a multimodality framework for prevention and management of anemia and related risk factors. The key strategies in PBM include support of hematopoiesis and improving hemoglobin level, optimizing coagulation and hemostasis, use of interdisciplinary blood conservation modalities, and patient-centered decision making throughout the course of care.

Blood Transfusion Therapy

Transfusion of red blood cells (RBCs) is a balance between providing benefit for patients while avoiding risks of transfusion. Randomized, controlled trials of restrictive RBC transfusion practices have shown equivalent patient outcomes compared with liberal transfusion practices, and meta-analyses have shown improved in-hospital mortality, reduced cardiac events, and reduced bacterial infections. This body of level 1 evidence has led to substantial, improved blood utilization and reduction of inappropriate blood transfusions with implementation of clinical decision support via electronic medical records, along with accompanying educational initiatives.

Peri-operative treatment of anaemia in major orthopaedic surgery: a practical approach from Spain

In patients undergoing major orthopaedic surgery, pre-operative anaemia, peri-operative bleeding and a liberal transfusion policy are the main risk factors for requiring red blood cell transfusion (RBCT). The clinical and economic disadvantages of RBCT have led to the development and implementation of multidisciplinary, multimodal, individualised strategies, collectively termed patient blood management, which aim to reduce RBCT and improve patients' clinical outcome and safety. Within a patient blood management programme, low pre-operative haemoglobin is one of the few modifiable risk factors for RBCT. However, a survey among Anaesthesia Departments in Spain revealed that, although pre-operative assessment was performed in the vast majority of hospitals, optimisation of haemoglobin concentration was attempted in <40% of patients who may have benefitted from it, despite there being enough time prior to surgery. This indicates that haemoglobin optimisation takes planning and forethought to be implemented in an effective manner. This review, based on available clinical evidence and our experience, is intended to provide clinicians with a practical tool to optimise pre-operative haemoglobin levels, in order to minimise the risk of patients requiring RBCT. To this purpose, after reviewing the diagnostic value and limitations of available laboratory parameters, we developed an algorithm for the detection, classification and treatment of pre-operative anaemia, with a patient-tailored approach that facilitates decision-making in the pre-operative assessment. We also reviewed the efficacy of the different pharmacological options for pre-operative and post-operative management of anaemia. We consider that such an institutional pathway for anaemia management could be a viable, cost-effective strategy that is beneficial to both patients and healthcare systems.

[Patient blood management: Current state of the literature]

BACKGROUND

Preoperative anemia has a prevalence of approximately 30% and is one of the strongest predictors of perioperative red blood cell (RBC) transfusion. It is rarely treated although it is an independent risk factor for the occurrence of postoperative complications. Additionally, the high variability in the worldwide usage of RBC transfusions is alarming. Due to these serious deficits in patient care, in 2011 the World Health Organization recommended the implementation of a patient blood management (PBM).

OBJECTIVES

This article provides information about PBM as a multidimensional and interdisciplinary approach.

MATERIAL AND METHODS

A selective literature search was carried out in the Medline and Cochrane library databases including consideration of national and international guidelines.

RESULTS

A PBM promotes the medically and ethically appropriate use of all available resources, techniques and materials in favor of an optimized perioperative patient care. Patients' own resources should be specifically protected, strengthened and used and include (i) diagnosis and therapy of preoperative anemia, (ii) minimizing perioperative blood loss, (iii) blood-conserving surgical techniques, (iv) restriction of diagnostic blood sampling, (v) utilization of individual anemia tolerance, (vi) optimal coagulation and hemotherapy concepts and (vii) guideline-based, rational indications for the use of RBC transfusions.

CONCLUSION

A PBM should be advocated as an incentive to evaluate and critically optimize local conditions. An individual, interdisciplinarily structured bundle of different PBM measures has great potential to optimize the quality of patient care and to make it safer.

International consensus statement on the peri-operative management of anaemia and iron deficiency

Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.

Gender disparities in red blood cell transfusion in elective surgery: a post hoc multicentre cohort study

OBJECTIVES

A post hoc gender comparison of transfusion-related modifiable risk factors among patients undergoing elective surgery.

SETTINGS

23 Austrian centres randomly selected and stratified by region and level of care.

PARTICIPANTS

We consecutively enrolled in total 6530 patients (3465 women and 3065 men); 1491 underwent coronary artery bypass graft (CABG) surgery, 2570 primary unilateral total hip replacement (THR) and 2469 primary unilateral total knee replacement (TKR).

MAIN OUTCOME MEASURES

Primary outcome measures were the number of allogeneic and autologous red blood cell (RBC) units transfused (postoperative day 5 included) and differences in intraoperative and postoperative transfusion rate between men and women. Secondary outcomes included perioperative blood loss in transfused and non-transfused patients, volume of RBCs transfused, perioperative haemoglobin values and circulating red blood volume on postoperative day 5.

RESULTS

In all surgical groups, the transfusion rate was significantly higher in women than in men (CABG 81 vs 49%, THR 46 vs 24% and TKR 37 vs 23%). In transfused patients, the absolute blood loss was higher among men in all surgical categories while the relative blood loss was higher among women in the CABG group (52.8 vs 47.8%) but comparable in orthopaedic surgery. The relative RBC volume transfused was significantly higher among women in all categories (CABG 40.0 vs 22.3; TKR 25.2 vs 20.2; THR 26.4 vs 20.8%). On postoperative day 5, the relative haemoglobin values and the relative circulating RBC volume were higher in women in all surgical categories.

CONCLUSIONS

The higher transfusion rate and volume in women when compared with men in elective surgery can be explained by clinicians applying the same absolute transfusion thresholds irrespective of a patient's gender. This, together with the common use of a liberal transfusion strategy, leads to further overtransfusion in women.

Erythropoietin with iron supplementation for preoperative anaemia in non‐cardiac surgery

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

We aim to evaluate the efficacy and safety of preoperative erythropoietin (rHuEPO) with supplemental iron (parenteral or oral) in reducing perioperative allogeneic red blood cell transfusions in preoperatively anaemic people undergoing non‐cardiac surgery.

Anemia and iron deficiency in gastrointestinal and liver conditions

Iron deficiency anemia (IDA) is associated with a number of pathological gastrointestinal conditions other than inflammatory bowel disease, and also with liver disorders. Different factors such as chronic bleeding, malabsorption and inflammation may contribute to IDA. Although patients with symptoms of anemia are frequently referred to gastroenterologists, the approach to diagnosis and selection of treatment as well as follow-up measures is not standardized and suboptimal. Iron deficiency, even without anemia, can substantially impact physical and cognitive function and reduce quality of life. Therefore, regular iron status assessment and awareness of the clinical consequences of impaired iron status are critical. While the range of options for treatment of IDA is increasing due to the availability of effective and well-tolerated parenteral iron preparations, a comprehensive overview of IDA and its therapy in patients with gastrointestinal conditions is currently lacking. Furthermore, definitions and assessment of iron status lack harmonization and there is a paucity of expert guidelines on this topic. This review summarizes current thinking concerning IDA as a common co-morbidity in specific gastrointestinal and liver disorders, and thus encourages a more unified treatment approach to anemia and iron deficiency, while offering gastroenterologists guidance on treatment options for IDA in everyday clinical practice.

"Do not do" recommendations of the Spanish Society of Anaesthesiology, Critical Care and Pain Therapy. "Commitment to Quality by Scientific Societies" Project

In April 2013 the Ministry of Health (MSSSI) adopted the project called "Commitment to Quality by Scientific Societies in Spain", in response to social and professional demands for sustainability of the health system. The initiative is part of the activities of the Spanish Network of Agencies for Health Technology Assessment and Services of the National Health System, and is coordinated jointly by the Quality and Cohesion Department, the Aragon Institute of Health Sciences (IACS), and the Spanish Society of Internal Medicine (SEMI). All the scientific societies in Spain have been included in this project, and its main objective is to reduce the unnecessary use of health interventions in order to agree "do not do" recommendations, based on scientific evidence. The primary objective was to identify interventions that have not proven effective, have limited or doubtful effectiveness, are not cost-effective, or do not have priority. Secondary objectives were: reducing variability in clinical practice, to spread information between doctors and patients to guide decision-making, the appropriate use of health resources and, the promotion of clinical safety and reducing iatrogenesis. The selection process of the 5 "do not do" recommendations was made by Delphi methodology. A total of 25 panellists (all anaesthesiologists) chose between 15 proposals based on: evidence that supports quality, relevance, or clinical impact, and the people they affect. The 5 recommendations proposed were: Do not maintain deep levels of sedation in critically ill patients without a specific indication; Do not perform preoperative chest radiography in patients under 40 years-old with ASA physical status I or II; Do not systematically perform preoperative tests in cataract surgery unless otherwise indicated based on clinical history and physical examination; Do not perform elective surgery in patients with anaemia at risk of bleeding until a diagnostic workup is performed and treatment is given; and not perform laboratory tests (blood count, biochemistry and coagulation) prior to surgery in healthy or low risk patients (ASA I and II) with minimal estimated blood loss.

Impact of a blood management protocol on transfusion rates and outcomes following total hip and knee arthroplasty

Introduction Preoperative anaemia remains undertreated in the UK despite advice from national agencies to implement blood conservation measures. A local retrospective audit of 717 primary hip/knee replacements in 2008-2009 revealed 25% of patients were anaemic preoperatively. These patients experienced significantly increased transfusion requirements and length of stay. We report the results of a simple and pragmatic blood management protocol in a district general hospital. Methods Since 2010 patients at our institution who are found to be anaemic when listed for hip/knee replacement have been offered iron supplementation and/or erythropoietin depending on haemoglobin and ferritin levels. In this study, postoperative blood transfusions, length of stay and readmissions were assessed retrospectively for all patients undergoing elective primary hip/knee replacement in 2014 and compared with the baseline findings. Results During the 12-month study period, 406 patients were eligible for inclusion and none were excluded. Eighty-nine patients (22%) were anaemic preoperatively and sixty-five received treatment. The transfusion rate fell from the baseline levels of 23.0% and 6.7% to 4.3% and 0.5% for hip and knee replacements respectively (p<0.001). The median length of stay reduced from 6 to 3 days (p<0.001) for both hip and knee replacements. The rate for readmissions within 90 days fell from 13.5% to 8.9% (p<0.05). Conclusions Preoperative anaemia is common in patients listed for hip/knee replacement and it is associated strongly with increased blood transfusion. The introduction of a blood management protocol has led to significant reductions in transfusion and length of stay, sustained over a four-year period. This suggests that improved patient outcomes, conservation of blood stocks and cost savings can be achieved.

Blood transfusion and coagulation management

Despite impressive progress in surgical technique, aortic surgery is still associated with relatively high morbidity and mortality. One of the most important contributors to this phenomenon is the triad of bleeding, anemia, and transfusion. All three factors are known to influence the outcome of aortic surgery to a great extent. However, over the last few years a multidisciplinary, multimodal concept has been established, which enables the physician to avoid bleeding, anemia, and transfusion as much as possible. The concept of "patient blood management" combines several established measures with the potential to improve perioperative outcome. This chapter describes these measures with regard to aortic surgery and assesses their respective efficacy.

Understanding Perioperative Transfusion Practices in Gastrointestinal Surgery-a Practice Survey of General Surgeons

BACKGROUND

Despite guidelines recommending restrictive red blood cell transfusion (RBCT) strategies, perioperative transfusion practices still vary significantly. To understand the underlying mechanisms that lead to gaps in practice, we sought to assess the attitudes of surgeons regarding the perioperative management of anemia and use of RBCT in patients having gastrointestinal surgery.

METHODS

We conducted a self-administered Web-based survey of general surgery staff and residents, in a network of eight academic institutions at the University of Toronto. We developed a questionnaire using a systematic approach of items generation and reduction. We tested face and content validity and test-retest reliability. We administered the survey via emails, with planned reminders.

RESULTS

Total response rate was 48.1 % (62/125). Half (51.0 %) of respondents stated that they were unlikely to conduct a preoperative anemia work-up. About 54.0 % reported ordering preoperative oral iron supplementation for anemia. Most respondents indicated using a 70 g/L hemoglobin trigger (92.0 %) for transfusion. Factors increasing thresholds above 70 g/L included cardiac comorbidity (58.0 %), acute cardiac disease (94.0 %), symptomatic anemia (68.0 %), and suspected bleeding (58.0 %). With those factors, the transfusion threshold often increased above 90 g/L. Respondents perceived RBCTs to increase the postoperative morbidity (62 %), but not to impact the mortality (48 %) and cancer recurrence (52 %). Institutional protocols (68.0 %), blood conservation clinics (44.0 %), and clinical practice guidelines (84.0 %) were believed to encourage restrictive use of RBCTs.

CONCLUSION

Self-reported perioperative transfusion practices for GI surgery are heterogeneous. Few respondents investigated preoperative anemia. Stated use of RBCT indications varied from recommendations in published guidelines for patients with symptomatic anemia. Establishing team consensus and implementing local blood management guidelines appear necessary to improve uptake of evidence-based recommendations.

Patient Blood Management Bundles to Facilitate Implementation

More than 30% of the world's population are anemic with serious economic consequences including reduced work capacity and other obstacles to national welfare and development. Red blood cell transfusion is the mainstay to correct anemia, but it is also 1 of the top 5 overused procedures. Patient blood management (PBM) is a proactive, patient-centered, and multidisciplinary approach to manage anemia, optimize hemostasis, minimize iatrogenic blood loss, and harness tolerance to anemia. Although the World Health Organization has endorsed PBM in 2010, many hospitals still seek guidance with the implementation of PBM in clinical routine. Given the use of proven change management principles, we propose simple, cost-effective measures enabling any hospital to reduce both anemia and red blood cell transfusions in surgical and medical patients. This article provides comprehensive bundles of PBM components encompassing 107 different PBM measures, divided into 6 bundle blocks acting as a working template to develop institutions' individual PBM practices for hospitals beginning a program or trying to improve an already existing program. A stepwise selection of the most feasible measures will facilitate the implementation of PBM. In this manner, PBM represents a new quality and safety standard.

Implementing a patient blood management program in Norway: Where to start?

Norway has recently established a working group to implement a national patient blood management (PBM) program. Although benchmarking regarding blood usage is challenging in Norway due to legal barriers, a survey was sent to different hospitals to identify possible areas to be prioritized in the first phase of the PBM program. Among them, optimizing the patient's hemoglobin level before elective surgery and implementing electronic check-lists for the indication of transfusion when ordering blood products are two measures that may have a considerable impact on blood usage. The results of the survey also showed that patients may receive a red blood cell transfusion at hemoglobin levels that are higher than those internationally recommended. Since there are no national guidelines for the use of blood products, agreement regarding hemoglobin thresholds is essential to reduce variation in transfusion practice. To achieve these goals, the transfusion specialist plays a key role in promoting the principles behind the PBM concept at the local hospital.

Surgical site infection and transfusion rates are higher in underweight total knee arthroplasty patients

Background

Underweight (UW) patients undergoing total hip arthroplasty have exhibited higher complication rates, including infection and transfusion. No study to our knowledge has evaluated UW total knee arthroplasty (TKA) patients. We, therefore, conducted a study to investigate if these patients are at increased risk for complications, including infection and transfusion.

Methods

A case-control study was conducted using a prospectively collected institutional database. Twenty-seven TKA patients were identified as UW (body mass index [BMI] < 18.5 kg/m²) from 2000-2012 and were matched for age, gender, date of surgery, age-adjusted Charlson comorbidity index, rheumatoid arthritis, and diabetes. These patients were compared to 81 normal weight patients (BMI 18.5-24 kg/m²). Demographic variables were compared, along with wound complications, surgical site infection (SSI), blistering, deep vein thrombosis, pulmonary embolism, transfusion, revision, flexion contracture, hematoma formation, and patellar clunk.

Results

The average BMI was 17.1 kg/m² (range 12.8-18.4) for UW and 23.0 kg/m² (range 19.0-25.0) for normal weight patients (P < .001). UW TKA patients were more likely to develop SSIs (3/27, 11.1% vs 0/81, 0.0%, P = .01) and were more likely to require transfusions (odds ratio = 3.4, confidence interval 1.3-9.1; P = .02).

Conclusions

Our study demonstrates that UW TKA patients have a higher likelihood of developing SSI and requiring blood transfusions. The specific reasons are unclear, but we conjecture that it may be related to decreased wound healing capabilities and low preoperative hemoglobin. Investigation of local tissue coverage and hematologic status may be beneficial in this patient population to prevent SSI. Based on the results of this study, a prospective evaluation of these factors should be undertaken.

Strategies for the Management of Postoperative Anemia in Elective Orthopedic Surgery

Objective: To assess the use of oral iron, intravenous (IV) iron, and erythropoiesis-stimulating agents (ESAs) for the prevention and management of perioperative anemia in elective orthopedic surgery patients, and to provide a clinical algorithm for use. Data Sources: A PubMed and MEDLINE search was conducted from 1964 through March 2016 using the following search terms alone or in combination: orthopedic, surgery, elective, anemia, blood transfusion, iron, erythropoiesis-stimulating agents, and erythropoietin.Study Selection and Data Extraction: All English-language prospective and retrospective human studies and meta-analyses evaluating oral iron, IV iron, or ESA alone or in combination in elective orthopedic surgery patients were evaluated, provided they reported blood transfusion outcomes. Data Synthesis: A total of 9 prospective and retrospective studies and 1 meta-analysis were identified and included. In the preoperative setting, administration of oral iron, IV iron, or ESA alone or in combination to correct underlying anemia led to significantly reduced transfusion rates. Transfusion requirements were generally less with combination therapy (ESA + oral or IV iron). In the short-term perioperative or postoperative period, use of oral or IV iron led to conflicting results, with some reporting a statistically significant reduction in blood transfusions, whereas others reported none. Conclusions: In elective orthopedic surgery, IV or oral iron with or without an ESA may provide benefit in prevention of postoperative anemia and results in blood transfusion reduction without significantly increasing the risk of adverse events. These agents should be considered at the lowest effective dose with emphasis on administration prior to planned surgery.

The pre-operative levels of haemoglobin in the blood can be used to predict the risk of allogenic blood transfusion after total knee arthroplasty

Aims

The pre-operative level of haemoglobin is the strongest predictor of the peri-operative requirement for blood transfusion after total knee arthroplasty (TKA). There are, however, no studies reporting a value that could be considered to be appropriate pre-operatively. This study aimed to identify threshold pre-operative levels of haemoglobin that would predict the requirement for blood transfusion in patients who undergo TKA.

Patients and Methods

Analysis of receiver operator characteristic (ROC) curves of 2284 consecutive patients undergoing unilateral TKA was used to determine gender specific thresholds predicting peri-operative transfusion with the highest combined sensitivity and specificity (area under ROC curve 0.79 for males; 0.78 for females).

Results

Threshold levels of 13.75 g/dl for males and 12.75 g/dl for females were identified. The rates of transfusion in males and females, respectively above these levels were 3.37% and 7.11%, while below these levels, they were 16.13% and 28.17%. Pre-operative anaemia increased the rate of transfusion by 6.38 times in males and 6.27 times in females. Blood transfusion was associated with an increased incidence of early post-operative confusion (odds ratio (OR) = 3.44), cardiac arrhythmia (OR = 5.90), urinary catheterisation (OR = 1.60), the incidence of deep infection (OR = 4.03) and mortality (OR = 2.35) one year post-operatively, and increased length of stay (eight days vs six days, p < 0.001).

Conclusion

Uncorrected low pre-operative levels of haemoglobin put patients at potentially modifiable risk and attempts should be made to correct this before TKA. Target thresholds for the levels of haemoglobin pre-operatively in males and females are proposed. Take home message: Low pre-operative haemoglobin levels put patients at unnecessary risk and should be corrected prior to surgery. Cite this article: Bone Joint J 2016;98-B:490–7.

Association between frailty, cerebral oxygenation and adverse post-operative outcomes in elderly patients undergoing non-cardiac surgery: An observational pilot study

Background and Aims:

Although both frailty and low cerebral oxygen saturation increase the risk of post-operative complications, their relationship is yet to be investigated. The purpose of this observational study was to investigate the association between frailty, intraoperative cerebral oxygen saturation and post-operative complications in elderly patients undergoing non-cardiac surgery.

Methods:

After approval from the Institutional Review Board, 25 elderly patients (>65 years) undergoing non-cardiac major surgery were included in this study. Pre-operatively, all included patients were assessed for frailty and classified into frail and non-frail groups. All patients had routine intraoperative monitors, and a cerebral oximeter applied during anaesthesia. The ‘intraoperative’ anaesthesiologist and the post-operative study investigator were blinded to cerebral oximeter readings throughout the study. The incidence of significant intraoperative cerebral oxygen desaturation, adverse post-operative outcomes and length of hospital stay were compared. Statistical significance was defined as a value of P < 0.05.

Results:

We found that the frail group had more intraoperative cerebral desaturation (odds ratio [OR] [95% confidence interval [CI]]: 1.75 [1.11–2.75]) and longer median (interquartile range) length of hospital stay compared to the non-frail group (13.5 days [8.75–27.5] and 8 days [6–11], respectively). Furthermore, in patients with a low-baseline cerebral oxygen saturation (<55%), intraoperative cerebral desaturation (OR [95% CI]: 2.10 [1.00–4.42]), adverse post-operative outcomes (OR [95% CI]: 1.80 [1.00–3.23]) and median (interquartile range) length of hospital stay (15 days [9–31.5] vs. 9 days [6.25–13.75], P = 0.04) were significantly higher compared to subjects with higher baseline (≥55%) cerebral oxygen saturation.

Conclusions:

Frail patients have more intraoperative cerebral desaturation and longer lengths of hospital stay compared to non-frail patients.

Preoperative Anemia: Evaluation and Treatment

Previously undiagnosed anemia is often identified during routine assessment of surgical patients. Although studies suggest that perioperative anemia is associated with worse outcomes and a strong predictor for postoperative red cell transfusions, anemia is frequently ignored. Preoperative optimization of patients undergoing elective surgical procedures associated with significant blood loss, along with strategies to minimize intraoperative blood loss, shows promise for reducing postoperative transfusions and improving outcomes. In most situations, anemia can be corrected prior to elective surgeries and interventions. Future research should assess the timing and methods of optimization of preoperative anemia in surgery and which patients are best candidates for therapy.

Comparative Risk of Transfusion and Incremental Total Hospitalization Cost for Primary Unilateral, Bilateral, and Revision Total Knee Arthroplasty Procedures

BACKGROUND

This study evaluated the comparative risk of autologous and allogenic blood transfusion, inhospital complications, and incremental total hospitalization costs for primary unilateral, simultaneous bilateral, and revision total knee arthroplasty (TKA) procedures.

METHODS

Using the Premier Perspective database, we identified adults who underwent primary unilateral, simultaneous bilateral, or revision TKA procedures. Logistic regression, controlling for patient and hospital characteristics, was used to determine the risk of autologous or allogeneic blood transfusion. Controlling for the same factors, generalized linear models predicted incremental total hospitalization cost associated with transfusion.

RESULTS

Between January 2008 and June 2014, 513,558 primary unilateral, 33,977 bilateral, and 32,494 revision TKA patients met selection criteria. The overall percentage receiving a transfusion was 14.1% for unilateral, 36.3% for bilateral, and 20.0% for revision procedures. Logistic regression showed patients aged >65 years, female gender, Northeastern location, large hospitals, and higher Charlson score to be significantly associated with higher transfusion risk. Although overall risk of transfusion decreased over the study period, patients with Charlson score ≥3 were at 2.27 (primary unilateral), 1.88 (bilateral), and 2.44 (revision) greater odds of transfusion compared with healthy controls (Charlson score = 0). Generalized linear models showed an incremental total hospitalization cost among those receiving a transfusion of $2477, $4235, and $8594, respectively, compared with those without transfusion.

CONCLUSIONS

Transfusion risk remains a significant burden in select patient populations and procedures. The incremental cost of receiving a transfusion is significant, including not only direct costs but also staff time and increased hospital resource use.

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.

Minimizing Blood Transfusion in Total Hip and Knee Arthroplasty Through a Multimodal Approach

BACKGROUND

We introduced a multimodal, multidisciplinary approach to perioperative blood management aimed at reducing blood transfusions in primary knee (TKA) and hip (THA) arthroplasty. The protocol included (1) preoperative hemoglobin optimization through a multidisciplinary approach, (2) minimization of perioperative blood loss, and (3) adherence to evidence-based transfusion guidelines.

METHODS

Evaluation of 1010 consecutive patients undergoing primary TKA (488) or THA (522) was performed.

RESULTS

A significant reduction in the overall transfusion rate (1.4% vs 17.9%, P<.0001) resulted after algorithm introduction, when compared with the 1814 previous patients. Zero (0%) TKA and 4 (0.8%) THA patients adherent to protocol, and 4/488 (0.8%) TKA and 10/522 (1.9%) THA patients overall received transfusions.

CONCLUSION

Adoption of a multimodal blood management algorithm can significantly reduce blood transfusions in primary joint arthroplasty.

Intraoperative transfusion practices in Europe

BACKGROUND

Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe.

METHODS

We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013.

RESULTS

The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl(-1) and increased to 9.8 (1.8) g dl(-1) after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2).

CONCLUSION

Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl(-1)), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold.

CLINICAL TRIAL REGISTRATION

NCT 01604083.

Cost-effectiveness of post-operative cell salvage in total knee arthroplasty. Should we continue to recommend its use today?

OBJECTIVES

Total knee arthroplasty (TKA) has a high transfusion rate. In our protocol, the use of postoperative cell salvage is indicated in patients with contraindications to tranexamic acid (TA). An analysis was performed on the effect of post-operative cell salvage (POCS) regarding transfusion rate and costs in patients undergoing TKA.

MATERIAL AND METHODS

A prospective analysis was conducted on 518 patients, of whom 434 received TA, and 84 were contraindicated. The red cell mass, blood volume, and the percentage of lost blood volume were calculated. Incidents associated with the use of post-operative re-perfusion of drained blood and the rate of transfusion were recorded. An analysis was performed on the costs associated with allogeneic transfusion prevention methods.

RESULTS

A POCS drain was not inserted in 10 out of the 84 patients not candidates for TA. In the 74 in which it was placed, 158±72ml of red cell mass was reinfused. The allogeneic transfusion rate was 36%, and was 52% in those with no drain inserted. Relative risk of transfusion using POCS was 0.69 (0.41 to 1.16) with an absolute risk reduction of 16% (-8 to 40%). The number needed to treat to avoid allogeneic transfusion was 7. The direct costs to avoid allogeneic transfusion were €1,610. No complications associated with blood re-infusion were observed.

CONCLUSIONS

The use of POCS would be required in 7 patients after TKA to avoid one allogeneic transfusion with a cost over 10 times that of a transfusion of red cell concentrates.

Implementing a blood management protocol during the entire perioperative period allows a reduction in transfusion rate in major orthopedic surgery: a before-after study

BACKGROUND

Patient blood management (PBM) must be promoted in orthopedic surgery and relies on different strategies implemented during the entire perioperative period. Our aim was to assess whether the introduction of a pre-, intra-, and postoperative PBM protocol combining erythropoietin (EPO), ferric carboxymaltose (FCM), and tranexamic acid was effective in reducing perioperative transfusion and postoperative anemia.

STUDY DESIGN AND METHODS

In a two-phase prospective observational study, all patients admitted for total hip or knee arthroplasty were included the day before surgery. In Phase 1, use of EPO, iron, and tranexamic acid was left to the discretion of the anesthesiologists. In Phase 2, a protocol combining these treatments was implemented in the perioperative period. Perioperative hemoglobin levels and transfusion rates were recorded.

RESULTS

A total of 367 patients were included (184 and 183 in Phase 1 and 2, respectively). During Phase 2, implementing a PBM protocol allowed an increase in preoperative EPO prescription in targeted patients (i.e., with Hb < 13 g/dL; 18 [38%] vs. 34 [62%], p = 0.03) and in postoperative use of intravenous iron (12 [6%] vs. 32 [18%], p = 0.001) and tranexamic acid (157 [86%] vs. 171 [94%] patients, p = 0.02). In Phase 2, the number of patients who received transfusions (24 [13%] vs. 5 [3%], p = 0.0003) and of patients with a Hb level of less than 10 g/dL at discharge (46 [25%] vs. 26 [14%], p = 0.01) were reduced.

CONCLUSION

Introduction of a PBM protocol, using EPO, FCM, and tranexamic acid, reduces the number of perioperative transfusions and of patients with a Hb level of less than 10 g/dL at discharge.

Renal and Gastrointestinal Considerations in Patients Undergoing Elective Orthopaedic Surgery

To minimize perioperative complications after orthopaedic procedures, patients may undergo medical optimization, which includes an assessment of their renal function and gastrointestinal (GI) system. The GI and renal systems are complex, and their proper optimization in the preoperative period can influence the success of any procedure. Several factors can prevent complications and reduce morbidity, mortality, and the cost of care, including a thorough evaluation and screening, with particular emphasis on anemia and its renal and GI causes; management of medications that are metabolized by the liver and excreted by the kidneys; and careful attention to the patient's nutritional status.

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.