Transfusion drains versus suction drains in total knee replacement: meta-analysis

Changes in perioperative hemoglobin and hematocrit in patients undergoing total knee arthroplasty: a prospective observational study of optimal timing of measurement

Objective

This study was performed to depict the patterns of change in the perioperative hemoglobin (Hb) concentration and hematocrit (Hct) and to identify the optimal timing of Hb and Hct measurement in patients undergoing total knee arthroplasty (TKA).

Methods

This prospective observational study involved 302 consecutive patients who underwent TKA. The patients were kept in hospital for 1 full week postoperatively. Hb and Hct measurements were performed preoperatively and on days 1 to 7 postoperatively and then during clinic visits at 1, 3, and 6 months postoperatively.

Results

The Hb concentration and Hct decreased during the first few days postoperatively and reached a nadir on postoperative day 4 and 3, respectively; they then recovered in the following days. Significant differences in the Hb concentration and Hct were detected between the preoperative period and day 1, between days 1 and 2, between days 2 and 3, between day 7 and 1 month, and between 1 and 3 months. A significant difference in the Hct was also detected between 3 and 6 months.

Conclusion

The optimal timing of Hb and Hct measurement is on postoperative day 3 or 4. This timing accurately reflects ongoing hidden blood loss to better guide blood transfusions.

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

BACKGROUND AND PURPOSE

Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research.

METHODS AND MATERIALS

We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital.

RESULTS

Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction.

CONCLUSION

The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.

No benefit of autologous transfusion drains in total knee arthroplasty

PURPOSE AND HYPOTHESIS

Autologous blood transfusion drains are commonly used to reduce allogeneic blood transfusion rate after total knee arthroplasty. There is conflicting evidence as to whether autologous transfusion drains (ABT drains) were effective when restrictive transfusion triggers were used. The aim of our study was to ascertain where, as a part of a blood management protocol, autologous blood transfusion drains reduce the allogeneic blood transfusion rate after total knee arthroplasty.

METHODS

Two-hundred total knee arthroplasty patients were included in the prospective randomized controlled study. After implantation, a Redon drain without vacuum assistance (control, n = 100) or an autologous blood transfusion drain (ABT group, n = 100) was used. Demographic and operative data were collected. The blood loss, total blood loss, blood values and transfusion rate were documented.

RESULTS

The blood loss in the drains was significantly increased for the ABT group (409 vs. 297 ml, p < 0.001). There was a non-significant trend towards a higher total blood loss for ABT patients (1844 vs. 1685 ml, n.s.). The allogeneic blood transfusion rate was similar for both groups (8 vs. 9%, n.s.). Similarly, the number of transfused blood units was comparable between both groups (0.2U/patient vs. 0.17U/patient n.s.).

CONCLUSION

In combination with restrictive blood transfusion triggers, ABT drains had no positive effect on the allogeneic blood transfusion rate. The blood loss in ABT drains was higher. As a consequence, the use of ABT drains was discontinued.

LEVEL OF EVIDENCE

I.

What is the optimal approach for tranexamic acid application in patients with unilateral total hip arthroplasty?

PURPOSE

In the total hip arthroplasty (THA), the optimal administration route of tranexamic acid (TXA) remains controversial. This study was designed to investigate the impact of topical injection of TXA on blood loss during primary unilateral THA as well as short-term safety and adverse side effects compared with intravenous administration of TXA.

MATERIAL AND METHODS

In this study, 75 patients who underwent unilateral THA were randomly divided into 3 groups receiving intra-articular TXA (IA group), intravenous TXA (IV group) or no TXA (control group C). Blood loss, postoperative drainage, covert blood loss, total blood volume, the number of blood transfusions after surgery and transfusion rate, incidence of deep venous thrombosis and pulmonary embolism were recorded and evaluated in the three groups after 1 week and 1 month.

RESULTS

There were significant differences in the quantity of postoperative drainage, covert blood loss, total blood volume, the number of blood transfusions after surgery and transfusion rates between the three groups (P < 0.05), but blood loss during surgery showed no significant differences among the three groups (P > 0.05). In the IV group, 1 patient suffered from deep venous thrombosis of the lower limbs and in the C group, 2 patients suffered from superficial venous thrombosis of the lower limbs 2 and 4 days after surgery, respectively. In the IA group no complications occurred during the follow-up period.

CONCLUSION

Preoperative intravenous TXA and postoperative topical TXA significantly reduced postoperative blood loss and transfusion rates among the patients who underwent primary unilateral THA and the short-term safety was good. The data suggest that topical injection of TXA is safer and more effective, without postoperative complications.

Application of postoperative autotransfusion in total joint arthroplasty reduces allogeneic blood requirements: a meta-analysis of randomized controlled trials

Background

Total joint arthroplasty is associated with significant blood loss and often requires blood transfusion. However, allogeneic blood transfusion (ABT) may lead to severe problems, such as immunoreaction and infection. Postoperative autotransfusion, an alternative to ABT, is controversial. We conducted a meta-analysis to evaluate the ability of postoperative autotransfusion to reduce the need for ABT following total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Methods

Systematic literature searches for randomized controlled trials were performed using PubMed, Embase, and the Cochrane Library until February 2016. Relative risks (RRs) and weighted mean differences with 95% confidence intervals (CIs) were calculated using fixed-effect or random-effect models; we also evaluated publication bias and heterogeneity.

Results

Seventeen trials with a total of 2314 patients were included in the meta-analysis. The pooled RRs of ABT rate between autotransfusion and the regular drainage/no drainage groups for TKA and THA were 0.446 (95% CI = 0.287, 0.693; p < 0.001) and 0.757 (95% CI = 0.599, 0.958; p = 0.020), respectively. In the subgroup analysis performed in TKA patients according to control interventions, the pooled RRs were 0.377 (95% CI = 0.224, 0.634; p < 0.001) (compared with regular drainage) and 0.804 (95% CI = 0.453, 1.426, p = 0.456) (compared with no drainage). In the subgroup analysis performed for THA, the pooled RRs were 0.536 (95% CI = 0.379, 0.757, p < 0.001) (compared with regular drainage) and 1.020 (95% CI = 0.740, 1.405, p = 0.904) (compared with no drainage).

Conclusions

Compared to regular drainage, autotransfusion reduces the need for ABT following TKA and THA. This reduction is not present when comparing autotransfusion to no drainage. However, the reliability of the meta-analytic results concerning TKA was limited by significant heterogeneity in methods among the included studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1710-2) contains supplementary material, which is available to authorized users.

The efficacy and safety of autologous blood transfusion drainage in patients undergoing total knee arthroplasty: a meta-analysis of 16 randomized controlled trials

Background

Autologous blood transfusion drainage (ABTD) has been used for many years to reduce blood loss in total knee arthroplasty (TKA). We evaluate the current evidence concerning the efficiency and safety of ABTD used in TKA compared with conventional suction drainage (CSD).

Methods

We performed a systematic literature search of the PubMed, Embase, Cochrane Library and four Chinese databases. All randomized controlled trials (RCTs) that compared the effects of ABTD versus CSD in TKA were included in the meta-analysis.

Results

Sixteen RCTs involving 1534 patients who compared the effects of ABTD versus CSD were included. Five of the RCTs were performed in Asia, ten in Europe, and one in North America. Patients in the ABTD group had a lower blood transfusion rate (OR: 0.25 [0.13, 0.47]; Z = 4.27, P < 0.0001) and fewer units transfused per patient (WMD: −0.68 [−0.98, −0.39]; Z = 4. 52, P < 0.00001) than did patients in the CSD group. Wound complications, deep vein thrombosis, febrile complications, post-operative hemoglobin days 5–8, drainage volume, and length of hospital stay did not differ significantly between the two types of drainage systems.

Conclusion

This meta-analysis suggests that ABTD is a safe and effective method that yields a lower blood transfusion rate and fewer units transfused per patient in TKA compared with CSD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1301-7) contains supplementary material, which is available to authorized users.

Comparison Between Closed Suction Drainage and No Drainage Following Total Knee Arthroplasty in a Tertiary Care Setting in Pakistan

BACKGROUND

Total knee arthroplasty is associated with hematoma formation and extensive blood loss up to 1.5 liters. The placement of a closed suction drain to control this complication is controversial. The purpose of this study is to determine the efficacy between total knee arthroplasty without a drain and with a closed suction drain.  Methods: A retrospective cohort study was conducted between January 2014 and December 2015 on 100 patients to assess the hemoglobin and hematocrit levels, the rate of allogeneic blood transfusion, and the length of hospital stay in patients with a closed suction drain versus no suction post-total knee arthroplasty.

RESULTS

Fifty-six units of packed red blood cells were transfused in 36 out of 50 patients (72%) in the closed suction group compared to 21 units of packed red blood cells in 18 out of 50 patients (36%) in the no suction group after 24 hours post-surgery. The hemoglobin levels at multiple intervals were lower in the closed suction group (p < 0.05). The closed suction group also had an extra one-day stay in the hospital (p = 0.0492, 95% CI = 0.70 - 0.94).

CONCLUSION

 Closed suction drain placement is associated with low hemoglobin levels, an increased rate of allogeneic blood transfusion, and a longer hospital stay.

Comparison between autologous blood transfusion drainage and closed-suction drainage/no drainage in total knee arthroplasty: a meta-analysis

Background

Autologous blood transfusion (ABT) drainage system is a new unwashed salvaged blood retransfusion system for total knee replacement (TKA). However, whether to use ABT drainage, closed-suction (CS) drainage or no drainage in TKA surgery remains controversial. This is the first meta-analysis to assess the clinical efficiency, safety and potential advantages regarding the use of ABT drains compared with closed-suction/no drainage.

Methods

PubMed, Embase, and the Cochrane Library were comprehensively searched in March 2015. Fifteen randomized controlled trials (RCTs) were identified and pooled for statistical analysis. The primary outcome evaluated was homologous blood transfusion rate. The secondary outcomes were post-operative haemoglobin on days 3–5, length of hospital stay and wound infections after TKA surgery.

Results

The pooled data included 1,721 patients and showed that patients in the ABT drainage group might benefit from lower blood transfusion rates (16.59 % and 37.47 %, OR: 0.28 [0.14, 0.55]; 13.05 % and 16.91 %, OR: 0.73 [0.47,1.13], respectively). Autologous blood transfusion drainage and closed-suction drainage/no drainage have similar clinical efficacy and safety with regard to post-operative haemoglobin on days 3–5, length of hospital stay and wound infections.

Conclusions

Autologous blood transfusion drainage offers a safe and efficient alternative to CS/no drainage with a lower blood transfusion rate. Future large-volume high-quality RCTs with extensive follow-up will affirm and update this system review.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0993-z) contains supplementary material, which is available to authorized users.

Intravenous iron supplementation with intra-articular administration of tranexamic acid reduces the rate of allogeneic transfusions after simultaneous bilateral total knee arthroplasty

BACKGROUND

Peri-operative intravenous administration of iron supplementation seems a good option to reduce allogeneic blood transfusion in major orthopaedic surgery. However, its efficacy in simultaneous bilateral total knee arthroplasty has not been studied.

MATERIALS AND METHODS

From December 2014 to May 2015, a total of 72 consecutive patients underwent simultaneous bilateral total knee arthroplasty and received peri-operative intravenous iron supplementation (iron isomaltoside 1000: 600 mg pre-operatively and 400 mg 1 week post-operatively) and intra-articular tranexamic acid (2 g in 20 mL saline at the end of surgery), and were managed with a restrictive transfusion trigger (haemoglobin <7 g/dL). Post-operatively, we observed patients closely for symptoms of anaemia and checked their haemoglobin levels on days 1, 6 and 13 after surgery.

RESULTS

The mean baseline haemoglobin level was 13.1 g/dL. The levels remained above 7.0 g/dL on post-operative days 1, 6 and 13 (mean, 11.4 g/dL, 9.9 g/dL and 10.4 g/dL, respectively) in all but one patient who experienced melaena and required allogeneic blood transfusion.

DISCUSSION

Intravenous iron supplementation combined with intra-articular administration of tranexamic acid seems to be an effective strategy for reducing the rate of allogeneic blood transfusion in patients undergoing simultaneous bilateral total knee arthroplasty managed with a restrictive transfusion trigger.

Postoperative autotransfusion drain after total hip arthroplasty: a meta-analysis of randomized controlled trials

The use of a postoperative autotransfusion drain (PATD) to reduce allogenic blood transfusions in total hip arthroplasty (THA) remains controversial. Therefore, we conducted a meta-analysis to evaluate the efficacy and safety of this technique. Randomized controlled trials (RCTs) were identified from PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL). Thirteen RCTs (1,424 participants) were included in our meta-analysis. The results showed that PATD reduced the rate of allogenic transfusions (RR = 0.56; 95% CI [0.40, 0.77]) and total blood loss (MD = -196.04; 95% CI [-311.01, -81.07]). Haemoglobin (Hb) levels were higher in the PATD group on postoperative day 1 (MD = 0.28; 95% CI [0.06, 0.49]), but no significant differences on postoperative days 2 or 3 (MD = 0.29; 95% CI [-0.02, 0.60]; MD = 0.26; 95% CI [-0.04, 0.56]; respectively). There were no differences in length of hospital stay (MD = -0.18; 95% CI [-0.61, 0.25]), febrile reaction (RR = 1.26; 95% CI [0.95, 1.67]), infection (RR = 0.95; 95% CI [0.54, 1.65]), wound problems (RR = 1.07; 95% CI [0.87, 1.33]), or serious adverse events (RR = 0.59; 95% CI [0.10, 3.58]). Our findings suggest that PATD is effective in reducing the rate of allogenic transfusion. However, the included studies are inadequately powered to conclusively determine the safety of this technique.

No clear benefit or drawback to the use of closed drainage after primary total knee arthroplasty: a systematic review and meta-analysis

Background

Closed drainage after primary total knee arthroplasty (TKA) has been used routinely for many decades, but controversies have arisen in recent years. The purposes of this study were to compare the clinical outcomes of closed drainage with nondrainage after primary TKA; and to assess the benefit and drawback of closed drainage.

Methods

Electronic databases (PubMed/Medline, CENTRAL, Embase and Web of Science) were systematically searched for randomised controlled trials (RCTs) that investigated the efficacy and risks of closed drainage after primary TKA. Two investigators independently reviewed studies for eligibility, assessed the risk of bias and extracted the data. A meta-analysis was then performed using Review Manager Software.

Results

Twelve RCTs totalling 889 TKAs were identified. No significant differences in infection rate or blood loss were found between the closed drainage and nondrainage TKAs, and there was also no significant difference in haematoma formation, deep venous thrombosis, postoperative VAS score or range of motion between the two groups.

Conclusions

There appears to be no clear benefit or drawback to the use of closed drainage after primary TKA. Improving the use of closed drainage might provide better outcomes.

Short duration and low suction pressure drain versus no drain following total knee replacement

PURPOSE

To compare the short-term outcome in patients with or without a drain (short duration and low suction pressure) following total knee replacement (TKR).

METHODS

A consecutive series of 106 women and 48 men (mean age, 69 years) underwent unilateral TKR. The first 77 patients used a low suction pressure (200 mm Hg) drain following TKR for 24 hours, and the next 77 patients used no drain.

RESULTS

The 2 groups were comparable in terms of preoperative characteristics, the proportion of patients with pharmacological prophylaxis for deep vein thrombosis, the tourniquet time, and mode of anaesthesia. The mean drain output in the drain group was 221 ml. The time to achieve straight-leg-raising was earlier in the drain group (3.1 vs. 4.2 days, p<0.001).

CONCLUSION

The use of a short duration, low suction pressure drain following TKR enabled an earlier return of quadriceps power, without increasing haemoglobin drop and transfusion rate.

Efficacy and Safety of Tranexamic Acid in Bilateral Total Knee Replacement: A Meta-Analysis and Systematic Review

Background

Tranexamic acid (TXA) has been well documented to reduce blood loss and transfusion requirements in patients undergoing unilateral total knee arthroplasty (TKA). However, the efficacy and safety of TXA in simultaneous bilateral TKA have not been clearly defined. The aim of our study was to systematically review the existing evidence regarding the role of TXA in patients undergoing simultaneous bilateral TKA.

Material/Methods

A systematic search of all studies published through June 2014 was performed using Medline, EMBASE, OVID, and other databases. All studies that compared the efficacy and safety of TXA administration in simultaneous bilateral TKA patients were identified. The data from the included trials were extracted and analyzed regarding blood loss and transfusion rates. The evidence quality levels of the selected articles were evaluated using a grading system.

Results

Six studies were included, in which a total of 245 patients received TXA and 271 patients were controls. Overall, the results demonstrated that the use of TXA significantly reduced total blood loss by a mean of 371.1 ml (95% confidence interval (CI)=−412.12 to −330.09; p<0.001) and reduced the number of patients requiring blood transfusion (risk ratio (RR)=0.16; 95% CI=0.10 to 0.28; p<0.001). No significant differences in adverse effects such as deep vein thrombosis (DVT) or pulmonary embolism (PE) were noted in any group.

Conclusions

The intravenous use of TXA in patients undergoing simultaneous bilateral TKA is effective and safe and results in significantly reduced estimated blood loss and transfusion rates. No significant difference was observed in the incidence of side effects. Due to the limitations in the evidence quality of current meta-analyses, well-conducted, larger, high-quality randomized controlled trials (RCTs) are required.

Is postoperative cell salvage necessary in total hip or knee replacement? A meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this study was to determine whether there are hematological or clinical differences with the use of postoperative cell salvage after total knee (TKR) and hip replacement (THR).

METHODS

A systematic literature review based on PubMed, EMBASE, the Cochrane Library Database in any language regarding postoperative cell salvage following TKR or THR was performed. High quality of randomized controlled trials were identified. The data was analyzed using Rev Man 5.2.

RESULTS

19 randomized controlled trials (12 in TKR, 4 in THR and 3 in both) about 3482 patients were identified and included in this meta-analysis. Postoperative cell salvage significantly reduced the allogeneic blood transfusion requirement after TKR (RR = 0.46, 95% CI = 0.30 to 0.72) and THR (RR = 0.46, 95%CI = 0.32 to 0.68). It also demonstrated a higher level of postoperative Hemoglobin (MD = 0.26 g/dL, 95%CI = 0.15 to 0.37) with the use of postoperative cell salvage. No significant differences were detected regarding length of hospital stay, the incidence of febrile reaction, wound infection and deep vein thrombosis.

CONCLUSION

The results strengthen the fact that postoperative cell salvage is effective and safe to reduce the rate of transfusion after TKR and THR. As the relatively poor methodological quality and heterogeneity, further research is needed to confirm its safety and cost-effectiveness.

Cell Salvage in Hip and Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Cell salvage is used to reduce allogeneic red blood-cell (RBC) transfusions in total hip arthroplasty (THA) and total knee arthroplasty (TKA). We performed a meta-analysis to assess the effectiveness of cell salvage to reduce transfusions in THA and TKA separately, and to examine whether recent trials change the conclusions from previous meta-analyses.

METHODS

We searched MEDLINE through January 2013 for randomized clinical trials evaluating the effects of cell salvage in THA and TKA. Trial results were extracted using standardized forms and pooled using a random-effects model. Methodological quality of the trials was evaluated using the Cochrane Collaboration's tool for risk-of-bias assessment.

RESULTS

Forty-three trials (5631 patients) were included. Overall, cell salvage reduced the exposure to allogeneic RBC transfusion in THA (risk ratio [RR], 0.66; 95% confidence interval [CI], 0.51 to 0.85) and TKA (RR, 0.51; 95% CI, 0.39 to 0.68). However, trials published in 2010 to 2012, with a lower risk of bias, showed no significant effect of cell salvage in THA (RR, 0.82; 95% CI, 0.66 to 1.02) and TKA (RR, 0.91; 95% CI, 0.63 to 1.31), suggesting that the treatment policy regarding transfusion may have changed over time.

CONCLUSIONS

Looking at all trials, cell salvage still significantly reduced the RBC exposure rate and the volume of RBCs transfused in both THA and TKA. However, in trials published more recently (2010 to 2012), cell salvage reduced neither the exposure rate nor the volume of RBCs transfused in THA and TKA, most likely explained by changes in blood transfusion management.

Blood management protocol for total knee arthroplasty to reduce blood wastage and unnecessary transfusion

PURPOSE

To compare outcomes of 2 cohorts of patients who underwent total knee arthroplasty (TKA) before and after the introduction of a blood management protocol.

METHODS

Records of 97 and 96 consecutive patients who underwent unilateral TKA before and after introduction of the blood management protocol, respectively, were reviewed. Before introduction of the protocol, patients were cross-matched for blood before surgery. Transfusion after surgery was at the discretion of the surgeons or the on-call doctors. After introduction of the protocol, only patients with a preoperative haemoglobin level of <110 g/l underwent 'type and screening' of blood group. 2 units of blood were cross-matched preoperatively when multiple red-cell antibodies were identified or postoperatively when blood transfusion was required. Only patients with a postoperative haemoglobin level of <80 g/l or being symptomatic received blood transfusion until the haemoglobin level reached >100 g/l. Those with a postoperative haemoglobin level of 80 to 100 g/l were given iron sulphate 300 mg twice daily for a month.

RESULTS

The 2 groups did not differ significantly in age, sex ratio, pre- and post-operative haemoglobin levels, and drain output. Comparing outcome before and after introduction of the protocol, the transfusion rate (10.3% vs. 3.1%, p=0.046), crossmatch rate (100% vs. 3.1%, p<0.001), and crossmatch to transfusion ratio (9.7:1 vs. 1:1, p<0.001) decreased. Among transfused patients, the decreased postoperative haemoglobin level indicated a lower transfusion trigger point (100 g/l vs. 75 g/l, p<0.006) No patient developed infection, cardiovascular or cerebrovascular complications within 30 days.

CONCLUSION

The blood management protocol for TKA is effective in reducing unnecessary allogeneic blood transfusions and wastage of unused blood, without an increase in postoperative complications.

Comparison of therapeutic effects between drainage blood reinfusion and temporary clamping drainage after total knee arthroplasty in patients with rheumatoid arthritis

OBJECTIVE

To compare the therapeutic effects between drainage blood reinfusion and temporary clamping drainage after total knee arthroplasty in patients with rheumatoid arthritis to provide a basis for clinical practice.

METHODS

Data from 83 patients with rheumatoid arthritis undergoing total knee arthroplasty were retrospectively analyzed. The 83 patients were divided into a drainage blood reinfusion group (DR group, n = 45) and a temporary clamping drainage group (CD group, n = 38). In the DR group, postoperative drainage blood was used for autotransfusion. In the CD group, closed drainage was adopted, and the drainage tube was clamped for 2 h postoperatively followed by patency. The postoperative drainage amount, hemoglobin level, rate and average volume of allogeneic blood transfusion, swelling and ecchymosis of the affected knee joint, time to straight-leg raising and range of active knee flexion were compared between the two groups.

RESULTS

The total drainage volume was higher in the DR group than in the CD group (P = 0.000). The average volume of postoperative allogeneic blood transfusion (P = 0.000) and the decrease in the hemoglobin level 24 h after total knee arthroplasty (P = 0.012) were lower in the DR group than in the CD group. Swelling and ecchymosis of the affected knee joint, time to straight-leg raising and the range of active knee flexion were improved in the DR group compared with the CD group (all P<0.05).

CONCLUSION

Compared with temporary clamping drainage, drainage blood reinfusion after total knee arthroplasty can reduce the allogeneic blood transfusion volume and is conducive to early rehabilitation in patients with rheumatoid arthritis.

Modern Patient Blood Management in Arthroplasty

One of the oldest and still commonest procedures in clinical practice, allogeneic blood transfusion (ABT), is not fully supported by available evidence. In the last few decades, increasing concerns about unfavorable outcomes associated with ABT, anticipation of future insufficient blood supply, and awareness of the cost (direct and indirect) of transfusion have led to the promotion of patient blood management (PBM) as a cost-effective strategy, beneficial for patients as well as for society (Shander et al. 2010). PBM programs utilize a series of measures with a proven ability to reduce ABT and to be cost-effective. Despite that the impact of PBM on patient clinical outcomes needs to be fully defined and future studies are needed, PBM should be adopted as a new standard of care.

De-implementation of expensive blood saving measures in hip and knee arthroplasties: study protocol for the LISBOA-II cluster randomized trial

Background

Despite evidence that erythropoietin and intra- and postoperative blood salvage are expensive techniques considered to be non-cost-effective in primary elective total hip and knee arthroplasties in the Netherlands, Dutch medical professionals use them frequently to prevent the need for allogeneic transfusion. To actually change physicians’ practice, a tailored strategy aimed at barriers that hinder physicians in abandoning the use of erythropoietin and perioperative blood salvage was systematically developed. The study aims to examine the effectiveness, feasibility and costs of this tailored de-implementation strategy compared to a control strategy.

Methods/Design

A cluster randomized controlled trial including an effect, process and economic evaluation will be conducted in a minimum of 20 Dutch hospitals. Randomisation takes place at hospital level. The hospitals in the intervention group will receive a tailored de-implementation strategy that consists of four components: interactive education, feedback in educational outreach visits, electronically sent reports on hospital performance (all aimed at orthopedic surgeons and anesthesiologists), and information letters or emails aimed at other involved professionals within the intervention hospital (transfusion committee, OR-personnel, pharmacists). The hospitals in the control group will receive a control strategy (i.e., passive dissemination of available evidence). Outcomes will be measured at patient level, using retrospective medical record review. This will be done in all hospitals at baseline and after completion of the intervention period. The primary outcome of the effect evaluation is the percentage of patients undergoing primary elective total hip or knee arthroplasty in which erythropoietin or perioperative blood salvage is applied. The actual exposure to the tailored strategy and users’ experiences will be assessed in the process evaluation. In the economic evaluation, the costs of the tailored strategy and the control strategy in relation to the difference in their effectiveness will be compared.

Discussion

This study will show whether a systematically developed tailored strategy is more effective for de-implementation of non-cost-effective blood saving measures than the control strategy. This knowledge can be used in national and international initiatives to make healthcare more efficient. It also provides more generalized knowledge regarding de-implementation strategies.

Trial registration

This trial is registered at the Dutch Trial Register NTR4044.

Evaluation of the efficacy and safety of tranexamic acid for reducing blood loss in bilateral total knee arthroplasty

Tranexamic acid (TA) has been reported to reduce blood loss after total joint arthroplasty; however, the literature is sparse in evaluating its efficacy in simultaneous bilateral total knee arthroplasty (TKA). In this retrospective study of consecutive patients, TA use in bilateral TKA was associated with a significant reduction in perioperative serum hemoglobin drop, as well as allogeneic blood transfusion needs from 50% to 11% of patients. No autologous blood donation or drains were used. There were no venous thromboembolic events reported. Implementation of a systematic intravenous TA protocol in simultaneous bilateral TKA appears highly effective in reducing transfusion requirements, potentially reducing healthcare resource utilization as well as the morbidity and complications associated with allogeneic blood transfusions.

Delayed drainage versus autotransfusion drainage and routine drainage after total knee arthroplasty: a comparative study

BACKGROUND

The purpose of this research is to compare the clinical results of different drainage methods in total knee arthroplasty (TKA).

METHODS

This retrospective comparative study included 55 patients who accepted primary unilateral TKA between October 2010 and November 2012. The patients were classified according to the drainage method used: 25 patients in the autotransfusion drainage group, 12 patients in the delayed drainage group, and 18 patients in the routine drainage group. Otherwise, the same operative procedures and postoperative care were applied to all patients. The variables recorded included total amount of postoperative drainage (including intraoperative blood loss); cases of allogenic blood transfusion; body temperatures on postoperative days 1, 3, and 7; and pre- and postoperative hemoglobin level. Some other elements such as postoperative swelling, range of motion, and wound healing were also compared.

RESULTS

Patients who underwent autotransfusion were found to have an amount of drainage (799.2 ± 196.7 mL) significantly greater than that in the routine drainage group (666.1 ± 155.0 mL), which in turn was significantly greater than that in the delayed drainage group (381.7 ± 129.2 mL). The postoperative hemoglobin level in the delayed drainage group (91.5 ± 7.9 g/L) was similar to that in the autotransfusion group (92.0 ± 9.6 g/L), while that in the routine drainage group (81.3 ± 9.9 g/L) was significantly lower. The patients in the autotransfusion group were observed to have higher body temperatures than those in the other two groups. In the routine drainage group, eight cases accepted allogenic blood transfusion, and the percentage (44.4%) was significantly higher than that in the other two groups. There were no significant between-group differences in swelling, healing qualities, and range of motion.

CONCLUSIONS

Delayed postoperative drainage may reduce blood loss and the chance of allogenic blood transfusion compared with routine drainage and may also reduce the chance of postoperative fever and extra costs compared with autotransfusion.