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Zhou JJ, Hemphill C, Walker CT, Farber SH, Uribe JS. Adverse Effects of Perioperative Blood Transfusion in Spine Surgery. World Neurosurg 2021; 149:73-79. [PMID: 33540100 DOI: 10.1016/j.wneu.2021.01.093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Perioperative blood transfusion is often necessary during spine surgery because of blood loss from the surgical field during and after surgery. However, blood transfusions are associated with a small but significant risk of causing several adverse events including hemolytic transfusion reactions and transfusion-associated circulatory overload. Moreover, many prior publications have noted increased rates of perioperative morbidity and worsened outcomes in spine surgery patients who received blood transfusions. We performed a systematic review of the literature to better characterize the effects of blood transfusion on spine surgery outcomes. METHODS The PubMed/MEDLINE database was queried using the composite key word "transfus∗ AND 'spine surgery.'" A title and abstract review were performed to identify articles for final inclusion. RESULTS A title and abstract review of the resulting 372 English-language articles yielded 13 relevant publications, which were subsequently incorporated into this systematic review. All included studies were retrospective, nonrandomized analyses. CONCLUSIONS Overall, prior literature indicates a relationship between perioperative blood transfusion and worsened outcomes after spine surgery. However, the available data represent level IV evidence at best. In the future, prospective, randomized, controlled studies may help define the effects of perioperative blood transfusion on spine surgery outcomes.
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Affiliation(s)
- James J Zhou
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Courtney Hemphill
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - S Harrison Farber
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Soffin EM, YaDeau JT. Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. Br J Anaesth 2018; 117:iii62-iii72. [PMID: 27940457 DOI: 10.1093/bja/aew362] [Citation(s) in RCA: 181] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols produce significant clinical and economic benefits in a range of surgical subspecialties. There is a long tradition of applying clinical pathways to the perioperative care of joint arthroplasty patients. Enhanced recovery after surgery represents the next step in the evolution of standardized care. To date, reports of full ERAS pathways for hip or knee arthroplasty are lacking. In this narrative review, we present the evidence base that can be usefully applied to constructing ERAS pathways for hip or knee arthroplasty. The history and rationale for applying ERAS to joint arthroplasty are explained. Evidence demonstrates improved outcomes after joint arthroplasty when a standardized approach to care is implemented. The efficacy of individual ERAS components in hip or knee replacement is considered, including preoperative education, intraoperative anaesthetic techniques, postoperative analgesia, and early mobilization after joint arthroplasty. Interventions lacking high-quality evidence are identified, together with recommendations for future research. Based on currently available evidence, we present a model ERAS pathway that can be applied to perioperative care of patients undergoing hip or knee arthroplasty.
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Affiliation(s)
- E M Soffin
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
| | - J T YaDeau
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
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Do autologous blood transfusion systems reduce allogeneic blood transfusion in total knee arthroplasty? Knee Surg Sports Traumatol Arthrosc 2017; 25:2957-2966. [PMID: 27085359 DOI: 10.1007/s00167-016-4116-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 03/29/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To study whether autologus blood transfusion systems reduce the requirement of allogneic blood transfusion in patients undergoing total knee arthroplasty. METHODS A comprehensive search of the published literature with PubMed, Scopus and Science direct database was performed. The following search terms were used: (total knee replacement) OR (total knee arthroplasty) OR (TKA) AND (blood transfusion) OR (autologous transfusion) OR (autologous transfusion system). Using search syntax, a total of 748 search results were obtained (79 from PubMed, 586 from Science direct and 83 from Scopus). Twenty-one randomized control trials were included for this meta-analysis. RESULTS The allogenic transfusion rate in autologus blood transfusion (study) group was significantly lower than the control group (28.4 and 53.5 %, respectively) (p value 0.0001, Relative risk: 0.5). The median units of allogenic blood transfused in study control group and control group were 0.1 (0.1-3.0) and 1.3 (0.3-2.6), respectively. The median hospital stay in study group was 9 (6.7-15.6) days and control group was 8.7 (6.6-16.7) days. The median cost incurred for blood transfusion per patient in study and control groups was 175 (85.7-260) and 254.7 (235-300) euros, respectively. CONCLUSION This meta-analysis demonstrates that the use of auto-transfusion systems is a cost-effective method to reduce the need for and quantity of allogenic transfusion in elective total knee arthroplasty. LEVEL OF EVIDENCE Level I.
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De Fine M, Traina F, Giavaresi G, Leo E, Sanzarello I, Perna F, Dattola R, Faldini C. Effect of different postoperative flexion regimes on the outcomes of total knee arthroplasty: randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2017; 25:2972-2977. [PMID: 27056697 DOI: 10.1007/s00167-016-4119-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 03/29/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE A consistent limb position strategy could be an attractive and easier alternative to reduce blood loss and increase range of motion following total knee arthroplasty. The aim of this study was to understand the proper amount of flexion required to improve functional outcomes with limited patients' discomfort. METHODS Eighty-five patients undergoing total knee arthroplasty were randomly assigned to receive mild (30° of knee flexion) or high-flexion protocol (70° of knee flexion), 48 h after surgery. The same daily rehabilitation scheme was followed. Total blood loss, hidden blood loss, haemoglobin and haematocrit levels, fixed flexion deformity, range of motion and limb circumference at the superior patellar pole were evaluated preoperatively and 7 days after surgery. RESULTS Demographics, blood parameters and preoperative range of motion did not show any significant difference between the two groups. No complications were recorded in both groups. High-flexion group had greater rate of dropout due to excessive patients' discomfort. A significantly lower Hb at day 1 was found in the high-flexion group. No differences were recorded regarding the remaining parameters. CONCLUSION No significant differences were found between the high-flexion and mild-flexion protocols; however, mild-flexion protocol was better tolerated by patients. We therefore recommend a 30° flexion protocol to be routinely used 48 h postoperatively after total knee arthroplasty. This is an easy strategy to improve functional outcomes, which is a fundamental issue considering the steady increase in knee prostheses utilization. LEVEL OF EVIDENCE Randomized controlled trial, Level II.
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Affiliation(s)
- Marcello De Fine
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy.
| | - Francesco Traina
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy
| | - Gianluca Giavaresi
- Laboratory of Preclinical and Surgical Studies, Rizzoli Orthopedic Institute, Bologna, Italy
- Laboratory of Tissue Engineering - Innovative Technology Platforms for Tissue Engineering, Rizzoli Orthopedic Institute, Palermo, Italy
| | - Eugenio Leo
- Rehabilitation Service, University of Messina, Messina, Italy
| | - Ilaria Sanzarello
- Section of Orthopaedics and Traumatology, Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Fabrizio Perna
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy
| | - Roberto Dattola
- Rehabilitation Service, University of Messina, Messina, Italy
| | - Cesare Faldini
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy
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5
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Liu D, Dan M, Martinez Martos S, Beller E. Blood Management Strategies in Total Knee Arthroplasty. Knee Surg Relat Res 2016; 28:179-87. [PMID: 27595070 PMCID: PMC5009041 DOI: 10.5792/ksrr.2016.28.3.179] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/21/2015] [Accepted: 01/18/2016] [Indexed: 01/09/2023] Open
Abstract
A perioperative blood management program is one of a number of important elements for successful patient care in total knee arthroplasty (TKA) and surgeons should be proactive in its application. The aims of blood conservation are to reduce the risk of blood transfusion whilst at the same time maximizing hemoglobin (Hb) in the postoperative period, leading to a positive effect on outcome and cost. An individualized strategy based on patient specific risk factors, anticipated blood loss and comorbidities are useful in achieving this aim. Multiple blood conservation strategies are available in the preoperative, intraoperative and postoperative periods and can be employed in various combinations. Recent literature has highlighted the importance of preoperative Hb optimization, minimizing blood loss and evidence-based transfusion guidelines. Given TKA is an elective procedure, a zero allogenic blood transfusion rate should be the aim and an achievable goal.
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Affiliation(s)
- David Liu
- Gold Coast Centre for Bone and Joint Surgery, Queensland, Australia
| | - Michael Dan
- John Hunter Hospital, New South Wales, Australia
| | | | - Elaine Beller
- Centre for Research in Evidence-Based Practice Bond University, Queensland, Australia
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Hong KH, Pan JK, Yang WY, Luo MH, Xu SC, Liu J. Comparison between autologous blood transfusion drainage and closed-suction drainage/no drainage in total knee arthroplasty: a meta-analysis. BMC Musculoskelet Disord 2016; 17:142. [PMID: 27476506 PMCID: PMC4968028 DOI: 10.1186/s12891-016-0993-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Kun-Hao Hong
- Department of Orthopedic Surgery, Guangdong Second Traditional Chinese Medicine Hospital, No. 60 Hengfu Road, Guangzhou, Guangdong, 510095, China
| | - Jian-Ke Pan
- Department of Orthopedic Surgery, Second School of Clinical Medicine, Guangzhou University of Chinese Medicine, No. 111 Dade Road,, Guangzhou, Guangdong, 510120, China
| | - Wei-Yi Yang
- Department of Orthopedic Surgery, Second School of Clinical Medicine, Guangzhou University of Chinese Medicine, No. 111 Dade Road,, Guangzhou, Guangdong, 510120, China
| | - Ming-Hui Luo
- Department of Orthopedic Surgery, Second School of Clinical Medicine, Guangzhou University of Chinese Medicine, No. 111 Dade Road,, Guangzhou, Guangdong, 510120, China
| | - Shu-Chai Xu
- Department of Orthopedic Surgery, Second School of Clinical Medicine, Guangzhou University of Chinese Medicine, No. 111 Dade Road,, Guangzhou, Guangdong, 510120, China
| | - Jun Liu
- Department of Orthopedic Surgery, Second School of Clinical Medicine, Guangzhou University of Chinese Medicine, No. 111 Dade Road,, Guangzhou, Guangdong, 510120, China.
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7
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Dan M, Liu D, Martos SM, Beller E. Intra-operative blood salvage in total hip and knee arthroplasty. J Orthop Surg (Hong Kong) 2016; 24:204-8. [PMID: 27574264 DOI: 10.1177/1602400217] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To review records of 371 patients who underwent total hip or knee arthroplasty (THA or TKA) with intra-operative blood salvage to determine the allogeneic blood transfusion rate and the predictors for allogeneic blood transfusion. METHODS Records of 155 male and 216 female consecutive patients aged 17 to 95 (mean, 70) years who underwent primary THA or TKA by a single surgeon with the use of intra-operative blood salvage were reviewed. RESULTS The preoperative haemoglobin level was <120 g/dl in 15% of THA patients and 5% of TKA patients; the allogeneic transfusion rate was 24% in THA patients and 12% in TKA patients. Despite routine use of intra-operative blood salvage, only 59% of THA patients and 63% of TKA patients actually received salvaged blood, as a minimum of 200 ml blood loss was required to activate blood salvage. In multivariable analysis, predictors for allogeneic blood transfusion were female gender (adjusted odds ratio [OR]=2.8, p=0.02), age >75 years (adjusted OR=5.9, p<0.001), and preoperative haemoglobin level <120 g/l (adjusted OR=30.1, p<0.001), despite the use of intra-operative blood salvage. Patients who received allogeneic blood transfusion had a longer hospital stay and greater complication rate. CONCLUSION Intra-operative blood salvage is not effective in preventing allogeneic blood transfusion in patients with a preoperative haemoglobin level <120 g/l. It should be combined with preoperative optimisation of the haemoglobin level or use of tranexamic acid.
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Affiliation(s)
- M Dan
- John Hunter Hospital, NSW, Australia & Department of Medicine, Bond University, Gold Coast, Queensland Australia
| | - D Liu
- Gold Coast Centre for Bone and Joint Surgery, Gold Coast, Australia
| | - S M Martos
- Gold Coast Centre for Bone and Joint Surgery, Gold Coast, Australia
| | - E Beller
- Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland, Australia
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Athanasoulias V, Mavrogenis AF, Sdrenias CV, Mitsiokapa EA, Lourikas V, Papagelopoulos PJ, Christodoulou NA. Post-operative Blood Salvage and Retransfusion in Total Hip and Knee Arthroplasty. J Int Med Res 2016; 35:268-75. [PMID: 17542414 DOI: 10.1177/147323000703500211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This retrospective study evaluated the safety and efficacy of post-operative blood salvage and retransfusion in 430 patients undergoing total hip arthroplasty and 530 patients undergoing total knee arthroplasty. Volumes of autologous blood retransfused (mean ± SD) were 525 ± 75 and 660 ± 95 ml in the hip and knee replacement groups, respectively. Overall, 230 patients (24%) also required allogeneic blood transfusion. In a subgroup of 150 randomly selected patients, the values of free haemoglobin in the allogeneic, autologous and patients' blood at the time of surgery were 0.568 ± 0.112, 0.272 ± 0.067 and 0.032 ± 0.011 g/l, respectively. On the first and third post-operative days, the levels in patients' blood were 0.092 ± 0.039 and 0.057 ± 0.028 g/l, respectively. There were no major complications; transient chills and fever were reported in 99 (10.3%) and 115 patients (12.0%), respectively. In conclusion, post-operative blood salvage and retransfusion is a safe way to reduce the need for allogeneic blood transfusion in patients undergoing elective orthopaedic surgery.
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Affiliation(s)
- V Athanasoulias
- Department of Anaesthesiology, General Hospital of Karpenissi, Evrytania, Greece.
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Tió MM, Sánchez-Etayo G, Bergé R, Salazar F, Basora M, Sala-Blanch X. Cost-effectiveness of post-operative cell salvage in total knee arthroplasty. Should we continue to recommend its use today? ACTA ACUST UNITED AC 2016; 63:444-50. [PMID: 26782288 DOI: 10.1016/j.redar.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- M M Tió
- Departamento de Anestesiología y Reanimación, Hospital Clínic, Barcelona, España.
| | - G Sánchez-Etayo
- Departamento de Anestesiología y Reanimación, Hospital Clínic, Barcelona, España
| | - R Bergé
- Departamento de Anestesiología y Reanimación, Hospital Clínic, Barcelona, España
| | - F Salazar
- Departamento de Anestesiología y Reanimación, Hospital Clínic, Barcelona, España
| | - M Basora
- Departamento de Anestesiología y Reanimación, Hospital Clínic, Barcelona, España
| | - X Sala-Blanch
- Departamento de Anestesiología y Reanimación, Hospital Clínic, Barcelona, España
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Postoperative Autologous Reinfusion in Total Knee Replacement. JOURNAL OF BLOOD TRANSFUSION 2015; 2015:826790. [PMID: 26442168 PMCID: PMC4579317 DOI: 10.1155/2015/826790] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/10/2015] [Accepted: 08/24/2015] [Indexed: 12/03/2022]
Abstract
Surgeries for total knee replacement (TKR) are increasing and in this context there is a need to develop new protocols for management and use of blood transfusion therapy. Autologous blood reduces the need for allogeneic blood transfusion and the aim of the present study was to verify the safety and the clinical efficacy. An observational retrospective study has been conducted on 124 patients, undergoing cemented total knee prosthesis replacement. Observed population was stratified into two groups: the first group received reinfusion of autologous blood collected in the postoperative surgery and the second group did not receive autologous blood reinfusion. Analysis of data shows that patients undergoing autologous blood reinfusion received less homologous blood bags (10.6% versus 30%; p = 0.08) and reduced days of hospitalization (7.88 ± 0.7 days versus 8.96 ± 2.47 days for the control group; p = 0.03). Microbiological tests were negative in all postoperatively salvaged and reinfused units. Our results emphasize the effectiveness of this procedure and have the characteristics of simplicity, low cost (€97.53 versus €103.79; p < 0.01), and easy reproducibility. Use of autologous drainage system postoperatively is a procedure that allows reducing transfusion of homologous blood bags in patients undergoing TKR.
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Post-operative limb position can influence blood loss and range of motion after total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 2015; 23:852-9. [PMID: 24682489 DOI: 10.1007/s00167-013-2732-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE A consistent post-operative limb positioning regime could be an attractive, simple and cost-effective alternative to improve patient's outcomes after total knee arthroplasty (TKA). The aim of this study was to perform a systematic review of the available literature in order to understand whether a consistent post-operative limb positioning regime could affect blood loss and range of motion (ROM) after TKA. METHODS A search was performed using the keywords "total knee replacement/knee prosthesis" in combination with "post-operative management", "blood loss", "range of motion", "leg position", "flexion", "extension" and "splinting" regardless of the year of publication. The scientific databases have been accessed in order to identify papers dealing with post-operative limb positioning regimes after TKA. RESULTS Seven articles matching the inclusion criteria were selected. Blood loss and ROM were both investigated in all but one paper, in which only blood loss was evaluated. There were six randomized controlled trials and one prospective comparative study. A 48-72 h post-operative knee flexion protocol seems to be effective in reducing blood loss and increasing ROM following TKA. We did also find no benefit in using extension splints in the immediate post-operative period. CONCLUSIONS Based on the studies undertaken to date, a 48-72 h post-operative knee flexion protocol should be implemented as an easy and inexpensive method of reducing blood loss and increasing ROM following TKA. Shorter flexion regimes failed to influence these parameters.
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Effectiveness of an autologous transfusion system following cemented and non-cemented revisions of total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2014; 38:1603-8. [PMID: 24817099 DOI: 10.1007/s00264-014-2359-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 04/10/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The goal of this study was to analyse the efficacy of blood autotransfusion using a continuous autologous transfusion system in revisions of total hip arthroplasty (THA). We looked at whether administration of allogeneic blood units was reduced in these cases and if there is a difference between cemented and non-cemented revisions. METHODS Between January 2011 and December 2011, patients being treated with revision THA were included (n = 411). The following parameters were analysed: patient age, gender, weight (kg), height (cm), body mass index (BMI, kg/m(2)), surgical diagnosis, treatment and American Society of Anesthesiologists (ASA) classification score. The difference between pre- and post-operative haemoglobin (Hb, g/dl), amount of peri-operative blood loss (ml), amount of retransfused washed shed blood and amount of allogeneic and/or autologous transfusion (ml) were recorded. RESULTS In both the cemented and non-cemented revision THA groups, there was no significant difference between pre- and post-operative Hb with or without using an autotransfusion system. In 92 of 186 cemented cases using an autologous transfusion system (49.5%) and 38 of 117 non-cemented cases using an autologous transfusion system (32.5%), allogeneic blood transfusion (ABT) was required. Cemented procedures using an autologous transfusion system got significantly more ABTs than non-cemented procedures using an autologous transfusion system (p = 0.0042, odds ratio = 2.035). CONCLUSIONS Use of an autologous transfusion system did not reduce the amount of ABT in revision THA in the patient cohort reported here. In our opinion, general blood management is required before and during surgery to reduce administration of ABT.
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Kim GH, Park SW, Kim JH, In Y. The efficacy of unilateral use of a blood reinfusion device in one-stage bilateral total knee arthroplasty. Knee Surg Relat Res 2014; 26:7-12. [PMID: 24639941 PMCID: PMC3953528 DOI: 10.5792/ksrr.2014.26.1.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/22/2014] [Accepted: 01/24/2014] [Indexed: 11/02/2022] Open
Abstract
PURPOSE To assess the efficacy of unilateral use of a blood reinfusion device in one-stage bilateral total knee arthroplasty (TKA). MATERIALS AND METHODS We carried out a retrospective cohort study on 100 patients having one-stage bilateral TKA. In 50 of these patients (study group), a blood reinfusion device was applied on one knee and a standard suction drain on the other, and they were compared with 50 matched controls who received bilateral suction drains (control group). The hemoglobin (Hb) level, the hematocrit (Hct) and the platelet count were checked preoperatively, immediately postoperatively, and the third and seventh days postoperatively. The total drain output and the amount of allogeneic blood transfusion were also compared. RESULTS There were no significant differences in the total drain output and required amount of allogeneic blood transfusions between groups (p>0.05). However, the study group had significantly lower Hb and Hct values by the first day postoperatively and significantly lower platelet count values by the third day postoperatively than the control group (p<0.05). CONCLUSIONS Compared with use of bilateral suction drains, unilateral use of reinfusion device was not advantageous in reducing allogeneic transfusion in one-stage bilateral TKA.
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Affiliation(s)
- Geon-Hyeong Kim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Se-Wook Park
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jong-Ho Kim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yong In
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Cip J, Widemschek M, Benesch T, Waibel R, Martin A. Does single use of an autologous transfusion system in TKA reduce the need for allogenic blood?: a prospective randomized trial. Clin Orthop Relat Res 2013; 471:1319-25. [PMID: 23229426 PMCID: PMC3586038 DOI: 10.1007/s11999-012-2729-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 11/26/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Mechanical autotransfusion systems for washed shed blood (WSB) were introduced to reduce the need for postoperative allogenic blood transfusions (ABTs). Although some authors have postulated decreased requirements for ABT by using autologous retransfusion devices, other trials, mostly evaluating retransfusion devices for unwashed shed blood (USB), verified a small or no benefit in reducing the need for postoperative ABT. Because of these contradictory findings it is still unclear whether autologous retransfusion systems for WSB can reduce transfusion requirements. QUESTIONS/PURPOSES We therefore asked whether one such autologous transfusion system for WSB can reduce the requirements for postoperative ABT. METHODS In a prospective, randomized, controlled study, we enrolled 151 patients undergoing TKA. In Group A (n=76 patients), the autotransfusion system was used for a total of 6 hours (intraoperatively and postoperatively) and the WSB was retransfused after processing. In Control Group B (n=75 patients), a regular drain without suction was used. We used signs of anemia and/or a hemoglobin value less than 8 g/dL as indications for transfusion. If necessary, we administered one or two units of allogenic blood. RESULTS Twenty-three patients (33%) in Group A, who received an average of 283 mL (range, 160-406 mL) of salvaged blood, needed a mean of 2.1 units of allogenic blood, compared with 23 patients (33%) in Control Group B who needed a mean of 2.1 units of allogenic blood. CONCLUSIONS We found the use of an autotransfusion system did not reduce the rate of postoperative ABTs. LEVEL OF EVIDENCE Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Johannes Cip
- />Department of Orthopaedic Surgery, Academic Teaching Hospital, Medical University of Innsbruck, Carinagasse 47, A-6800 Feldkirch, Austria
| | - Mark Widemschek
- />Department of Orthopaedic Surgery, Academic Teaching Hospital, Medical University of Innsbruck, Carinagasse 47, A-6800 Feldkirch, Austria
| | - Thomas Benesch
- />Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Roman Waibel
- />Sport Orthopaedic Clinic Bern, Münsingen, Switzerland
| | - Arno Martin
- />Department of Orthopaedic Surgery, Academic Teaching Hospital, Medical University of Innsbruck, Carinagasse 47, A-6800 Feldkirch, Austria
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Muñoz M, Ariza D, Campos A, Martín-Montañez E, Pavía J. The cost of post-operative shed blood salvage after total knee arthroplasty: an analysis of 1,093 consecutive procedures. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 11:260-71. [PMID: 23149145 PMCID: PMC3626479 DOI: 10.2450/2012.0139-12] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 08/06/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Requirements for allogeneic red cell transfusion after total knee arthroplasty are still high (20-50%), and salvage and reinfusion of unwashed, filtered post-operative shed blood is an established method for reducing transfusion requirements following this operation. We performed a cost analysis to ascertain whether this alternative is likely to be cost-effective. MATERIALS AND METHODS Data from 1,093 consecutive primary total knee arthroplasties, managed with (reinfusion group, n=763) or without reinfusion of unwashed salvaged blood (control group, n=330), were retrospectively reviewed. The costs of low-vacuum drains, shed blood collection canisters (Bellovac ABT, Wellspect HealthCare and ConstaVac CBC II, Stryker), shed blood reinfusion, acquisition and transfusion of allogeneic red cell concentrate, haemoglobin measurements, and prolonged length of hospital stay were used for the blood management cost analysis. RESULTS Patients in the reinfusion group received 152±64 mL of red blood cells from postoperatively salvaged blood, without clinically relevant incidents, and showed a lower allogeneic transfusion rate (24.5% vs. 8.5%, for the control and reinfusion groups, respectively; p =0.001). There were no differences in post-operative infection rates. Patients receiving allogeneic transfusions stayed in hospital longer (+1.9 days [95% CI: 1.2 to 2.6]). As reinfusion of unwashed salvaged blood reduced the allogeneic transfusion rate, both reinfusion systems may provide net savings in different cost scenarios (€ 4.6 to € 106/patient for Bellovac ABT, and € -51.9 to € 49.9/patient for ConstaVac CBCII). DISCUSSION Return of unwashed salvaged blood after total knee arthroplasty seems to save costs in patients with pre-operative haemoglobin between 12 and 15 g/dL. It is not cost-saving in patients with a pre-operative haemoglobin >15 g/dL, whereas in those with a pre-operative haemoglobin <12 g/dL, although cost-saving, its efficacy could be increased by associating some other blood-saving method.
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Affiliation(s)
- Manuel Muñoz
- GIEMSA, Facultad de Medicina, School of Medicine, University of Málaga, Málaga, Spain.
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16
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Haien Z, Yong J, Baoan M, Mingjun G, Qingyu F. Post-operative auto-transfusion in total hip or knee arthroplasty: a meta-analysis of randomized controlled trials. PLoS One 2013; 8:e55073. [PMID: 23372816 PMCID: PMC3555861 DOI: 10.1371/journal.pone.0055073] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 12/18/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Total hip or knee arthroplasty is an elective procedure that is usually accompanied by substantial blood loss, which may lead to acute anemia. As a result, almost half of total joint arthroplasty patients receive allogeneic blood transfusions (ABT). Many studies have shown that post-operative auto-transfusion (PAT) significantly reduces the need for ABT, but other studies have questioned the efficacy of this method. METHODS The protocol for this trial and supporting CONSORT checklist are available as supporting information; see Checklist S1. To evaluate the efficacy of PAT, we conducted a Cochrane systematic review that combined all available data from randomized controlled trials. Data from the six included trials were pooled for analysis. We then calculated relative risks with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences with 95% CIs for continuous outcomes. FINDINGS AND CONCLUSION To our knowledge, this is the first meta-analysis to compare the clinical results between PAT and a control in joint replacement patients. This meta-analysis has proven that the use of a PAT reinfusion system reduced significantly the demand for ABT, the number of patients who require ABT and the cost of hospitalization after total knee and hip arthroplasty. This study, together with other previously published data, suggests that PAT drains are beneficial. Larger, sufficiently powered studies are necessary to evaluate the presumed reduction in the incidence of infection as well as DVT after joint arthroplasty with the use of PAT.
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Affiliation(s)
- Zhao Haien
- Department of Orthopaedic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Jiang Yong
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi’an, China
| | - Ma Baoan
- Department of Orthopaedic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Guo Mingjun
- Department of Orthopaedic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Fan Qingyu
- Department of Orthopaedic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
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Thomassen BJW, Pilot P, Scholtes VAB, Grohs JG, Holen K, Bisbe E, Poolman RW. Limit allogeneic blood use with routine re-use of patient's own blood: a prospective, randomized, controlled trial in total hip surgery. PLoS One 2012; 7:e44503. [PMID: 23028549 PMCID: PMC3441549 DOI: 10.1371/journal.pone.0044503] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 08/08/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There are risks related to blood incompatibility and blood-borne diseases when using allogeneic blood transfusion. Several alternatives exist today, one of which, used for autologous blood salvage perioperatively, is the Sangvia Blood Management System. This study was designed to investigate the efficacy of the system and to add data to previously reported safety results. METHODOLOGY/PRINCIPAL FINDINGS Two hundred sixteen patients undergoing primary or revision total hip arthroplasty (THA) were enrolled in this randomized, controlled, assessor-blinded multicenter study. Randomization was either autologous blood transfusion (Sangvia group) or no use of autologous blood (Control group), both in combination with a transfusion protocol for allogeneic transfusion. Patients were followed during hospital stay and at two months after discharge. The primary outcome was allogeneic blood transfusion frequency. Data on blood loss, postoperative hemoglobin/hematocrit, safety and quality of life were also collected. The effectiveness analysis including all patients showed an allogeneic blood transfusion rate of 14% in both groups. The efficacy analysis included 197 patients and showed a transfusion rate of 9% in the Sangvia group as compared to 13% in the Control group (95%CI -0.05-0.12, p = 0.5016). A mean of 522 mL autologous blood was returned in the Sangvia group and lower calculated blood loss was seen. 1095 mL vs 1285 mL in the Control group (95%CI 31-346, p = 0.0175). No differences in postoperative hemoglobin was detected but a lower hematocrit reduction after surgery was seen among patients receiving autologous blood. No relevant differences were found for safety parameters or quality of life. CONCLUSIONS/SIGNIFICANCE General low use of allogeneic blood in THA is seen in the current study of the Sangvia system used together with a transfusion protocol. The trial setting is under-powered due to premature termination and therefore not able to verify efficacy for the system itself but contributes with descriptive data on safety. TRIAL REGISTRATION Clinicaltrials.gov NCT00822588.
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Affiliation(s)
- Bregje J W Thomassen
- Department of Orthopaedic Surgery, Medical Center Haaglanden, The Hague, The Netherlands.
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SCHNEIDER SO, BIEDLER AE, BEHMENBURG F, VOLK T, RENSING H. Impact of shed blood products on stimulated cytokine release in an in vitro model of transfusion. Acta Anaesthesiol Scand 2012; 56:724-9. [PMID: 22571497 DOI: 10.1111/j.1399-6576.2012.02704.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Blood transfusion is reported to suppress the recipient's immune system. To avoid allogenic transfusion, post-operative shed blood retransfusion is a commonly used method. The aim of this study was to investigate the dose-related impact of post-operatively collected shed blood products on the stimulated cytokine release in an in vitro model of transfusion. METHODS Venous blood samples obtained from 20 patients undergoing hip arthroplasty were mixed with post-operatively collected unprocessed, processed, and irradiated shed blood as well as normal saline as a control. Shed blood was processed by centrifugation and separating the cellular fraction from the soluble fraction and washing the cellular fraction with phosphate buffered saline to eliminate any cell fragments and other substances. Mixing ratios were 1:3, 1:1, and 3:1. Endotoxin-stimulated release of Tumor Necrosis Factor-alpha (TNF-α) was measured after 24 h of culture by enzyme-linked immunosorbent assay. RESULTS Unprocessed, irradiated shed blood and the soluble fraction caused a significant suppression of stimulated TNF-α release compared to control. The addition of the cellular shed blood fraction had no significant influence on the TNF-α release compared to control. CONCLUSION Shed blood and its components caused a dose-independent immunomodulation as indicated by a suppressed stimulated TNF-α release. Leukocytes seem to play a minor role, as we observed a sustained suppression after transfusion of γ-irradiated shed blood. Only the elimination of soluble factors by centrifugation and followed by an additional washing step prevented the observed suppression of TNF-α. Thus, we assume that washing of shed blood can prevent potential detrimental effects.
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Affiliation(s)
- S. O. SCHNEIDER
- Department for Anaesthesiology; Critical Care Medicine and Pain Therapy; Saarland University Hospital; Homburg; Germany
| | - A. E. BIEDLER
- Department for Anaesthesiology; Critical Care Medicine and Pain Therapy; Saarland University Hospital; Homburg; Germany
| | - F. BEHMENBURG
- Department for Anaesthesiology; Critical Care Medicine and Pain Therapy; Saarland University Hospital; Homburg; Germany
| | - T. VOLK
- Department for Anaesthesiology; Critical Care Medicine and Pain Therapy; Saarland University Hospital; Homburg; Germany
| | - H. RENSING
- Department for Anaesthesiology; Critical Care Medicine and Pain Therapy; Saarland University Hospital; Homburg; Germany
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19
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Alberca I, Asuero MS, Bóveda JL, Carpio N, Contreras E, Fernández-Mondéjar E, Forteza A, García-Erce JA, García de Lorenzo A, Gomar C, Gómez A, Llau JV, López-Fernández MF, Moral V, Muñoz M, Páramo JA, Torrabadella P, Quintana M, Sánchez C. [The "Seville" Consensus Document on Alternatives to Allogenic Blood Transfusion. Sociedades españolas de Anestesiología (SEDAR), Medicina Intensiva (SEMICYUC), Hematología y Hemoterapia (AEHH), Transfusión sanguínea (SETS) Trombosis y Hemostasia (SETH)]. Med Clin (Barc) 2011; 127 Suppl 1:3-20. [PMID: 17020674 DOI: 10.1157/13093075] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The Consensus Document on Alternatives to Allogenic Blood Transfusion (AABT) has been drawn up by a panel of experts from 5 scientific societies. The Spanish Societies of Anesthesiology (SEDAR), Critical Care Medicine and Coronary Units (SEMICYUC), Hematology and Hemotherapy (AEHH), Blood Transfusion (SETS) and Thrombosis and Hemostasis (SETH) have sponsored and participated in this Consensus Document. Alternatives to blood transfusion have been divided into pharmacological and non-pharmacological, with 4 modules and 12 topics. The main objective variable was the reduction of allogenic blood transfusions and/or the number of transfused patients. The extent to which this objective was achieved by each AABT was evaluated using the Delphi method, which classifies the grade of recommendation from A (supported by controlled studies) to E (non-controlled studies and expert opinion). The experts concluded that most of the indications for AABT were based on middle or low grades of recommendation, "C", "D", or "E", thus indicating the need for further controlled studies.
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20
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion management of patients in the peri-operative period. III. The post-operative period. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:320-35. [PMID: 21627922 PMCID: PMC3136601 DOI: 10.2450/2011.0076-10] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Giancarlo Maria Liumbruno
- Units of Immunohaematology, Transfusion Medicine and Clinical Pathology, San Giovanni Calibita Fatebenefratelli Hospital, Rome.
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21
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Noyes M, Coffey MJ, Brown DM, Mesghali H. Acute compartment syndrome of the forearm following autologous blood reinfusion: a case report. Hand (N Y) 2010; 5:303-6. [PMID: 19866241 PMCID: PMC2920398 DOI: 10.1007/s11552-009-9237-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Accepted: 10/09/2009] [Indexed: 11/30/2022]
Abstract
Compartment syndrome is a condition with multiple reported etiologies, and permanent disability may ensue if not treated in a timely fashion. We report the first case, to our knowledge, of acute forearm compartment syndrome caused by intravenous autologous blood reinfusion. The patient underwent forearm fasciotomy, and hematoma was encountered deep to the superficial volar fascia, presumably extravasated from the reinfusion catheter. With the rise in the number of knee and hip arthroplasties, surgeons need a heightened awareness of the possible complications and morbidity associated with a presumed increase in autologous blood reinfusion.
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Affiliation(s)
- Matthew Noyes
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St, Suite 2200, Dayton, OH 45409 USA
| | - Michael J. Coffey
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St, Suite 2200, Dayton, OH 45409 USA
| | - Dennis M. Brown
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St, Suite 2200, Dayton, OH 45409 USA ,Good Samaritan Hospital/Montgomery Orthopaedic Surgeons, Dayton, OH USA
| | - Homayoun Mesghali
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St, Suite 2200, Dayton, OH 45409 USA ,Good Samaritan Hospital/Montgomery Orthopaedic Surgeons, Dayton, OH USA
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Subcutaneous versus intraarticular indwelling closed suction drainage after TKA: a randomized controlled trial. Clin Orthop Relat Res 2010; 468:2168-76. [PMID: 20127212 PMCID: PMC2895852 DOI: 10.1007/s11999-010-1243-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Accepted: 01/14/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND TKA can involve substantial bleeding, and the issue regarding whether vacuum drainage should be used during TKA continues to be debated as both methods have disadvantages. QUESTIONS/PURPOSES We therefore asked whether subcutaneous indwelling vacuum drainage is advantageous over intraarticular indwelling vacuum drainage in terms of blood drainage, bleeding-related complications, and functional outcomes in primary TKA. PATIENTS AND METHODS We randomized 111 patients undergoing TKAs to have either a subcutaneous indwelling or an intraarticular indwelling catheter and compared the two groups for blood loss (hemoglobin decrease, transfusion requirements, hypotension episode), incidence of wound problems (requirements for dressing reinforcement, oozing, hematoma, hemarthrosis, ecchymosis, infection), and functional outcomes (recovery of motion arc, American Knee Society, WOMAC, and SF-36 scores) at 12 months after surgery. RESULTS The mean vacuum drainage volume was less in the subcutaneous indwelling group than in the intraarticular indwelling group (140 mL versus 352 mL). The groups were similar in terms of decreases in hemoglobin after 2 and 5 days (3.0 versus 3.3 g/dL and 3.3 versus 3.7 g/dL, respectively), allogenic transfusion requirements (4% versus 11%), incidence of wound problems, and functional scores. CONCLUSIONS The data suggest subcutaneous indwelling closed-suction drainage is a reasonable alternative to intraarticular indwelling closed-suction drainage and to no suction drainage. LEVEL OF EVIDENCE Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Vincent HK, Omli MR, Vincent KR. Absence of combined effects of anemia and bilateral surgical status on inpatient rehabilitation outcomes following total knee arthroplasty. Disabil Rehabil 2010; 32:207-15. [PMID: 20001826 DOI: 10.3109/09638280903071875] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To examine the effects of anemia on inpatient rehabilitation outcomes following unilateral and bilateral total knee arthroplasty (TKA). METHOD This was a multicenter, retrospective study from 15 inpatient rehabilitation facilities. Patients (N = 5421) with very low hematocrit (Hct <30%), low Hct (30-36% women, 30-41% men), or normal Hct (>36% women, 41% men) were included. Inpatient rehabilitation occurred following TKA. Functional independence measure (FIM) scores, length of stay (LOS), itemized hospital charges, discharge destination were main outcomes. RESULTS LOS was 13% longer and hospital charges were 12.5-18.0% higher in the very low Hct than remaining groups (p = 0.0001). The FIM score and subscores for walking, stair climbing, bathing, transfers, and dressing changes were comparable for all Hct groups for the overall score. Hct <30% did not correspond to worse outcomes in patients with bilateral surgeries compared with unilateral surgeries; total FIM scores improved 47-53% across all Hct groups, regardless of bilateral surgical status. Discharge to home ranged 92.6-94.7% across all Hct groups (p > 0.05). CONCLUSIONS Rehabilitation teams can expect comparable functional improvements and discharge to home in anemic and non-anemic patients with either unilateral or bilateral surgeries without hematologic correction in the rehabilitation setting, but might need an additional day to accomplish these outcomes.
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Affiliation(s)
- Heather K Vincent
- Department of Orthopaedics and Rehabilitation, UF&Shands Orthopaedics and Sports Medicine Institute, University of Florida, PO Box 112727, Gainesville, FL 32611, USA.
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Muñoz M, Ariza D, Florez A, Campos A. Reinfusion drains reduce postoperative transfusion requirements after primary total knee replacement surgery. Transfus Med 2009; 18:269-71. [PMID: 18783587 DOI: 10.1111/j.1365-3148.2008.00867.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Muñoz M, García-Erce JA, Villar I, Thomas D. Blood conservation strategies in major orthopaedic surgery: efficacy, safety and European regulations. Vox Sang 2009; 96:1-13. [DOI: 10.1111/j.1423-0410.2008.01108.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Reinfusion of unwashed salvaged blood after total knee arthroplasty in patients with rheumatoid arthritis. INTERNATIONAL ORTHOPAEDICS 2008; 33:1615-8. [PMID: 18853156 DOI: 10.1007/s00264-008-0661-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Revised: 08/06/2008] [Accepted: 08/06/2008] [Indexed: 10/21/2022]
Abstract
Autotransfusion with unwashed salvaged blood (USB) is effective for avoiding allogeneic blood transfusion (ABT) in patients undergoing total knee arthroplasty (TKA). We performed a retrospective study to determine the percentage of patients receiving ABT and the volume of postoperative blood drainage after introduction of autotransfusion with USB for patients with rheumatoid arthritis (RA) undergoing TKA. In 100 patients without autotransfusion (group 1) and 100 patients receiving autotransfusion of USB (group 2), we compared the number of patients who required ABT, as well as the postoperative drainage volume, ABT volume, and autotransfusion volume. In group 1, 83% of the patients received ABT, while only 47% received ABT in group 2, and there was a significant decrease (p < 0.001). However, the postoperative drainage volume was significantly increased in group 2 (p < 0.001).
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del Trujillo MM, Carrero A, Muñoz M. The utility of the perioperative autologous transfusion system OrthoPAT in total hip replacement surgery: a prospective study. Arch Orthop Trauma Surg 2008; 128:1031-8. [PMID: 17828546 DOI: 10.1007/s00402-007-0440-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Indexed: 02/09/2023]
Abstract
BACKGROUND Total hip replacement (THR) is associated with a significant perioperative blood loss, and 30-50% of these patients receive allogeneic blood transfusion (ABT). We evaluated the clinical utility of washed shed blood (WSB) return to reduce ABT in THR patients. STUDY DESIGN AND METHODS Data from 108 consecutive THR patients were prospectively collected. WSB salvage and reinfusion (OrthoPAT) was intended for 60 (Reinfusion group), whereas the remaining 48 patients served as control group. Patients received ABT if haemoglobin <8 g/dl or clinical signs and symptoms of acute anemia. RESULTS WSB return was possible in 49 patients (205 +/- 151 ml of erythrocyte/patient), without any clinically relevant incident. Return of WSB decreased both the ABT rate (48 vs. 15%, for control and reinfusion groups, respectively; P = 0.001) and the ABT index (371 +/- 154 ml RBC vs. 53 +/- 117 ml RBC, respectively; P = 0.001), without differences between cemented and uncemented THR. In addition, patients from reinfusion group showed a trend to lower postoperative infection rate (10 vs. 2%, respectively; P = 0.086). CONCLUSIONS Perioperative salvage and return of WSB in THR seems to effectively reduce the requirements for ABT. However, for patients with preoperative Hb < 13 g/dl, some additional blood saving method should be associated to WSB return.
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Vincent HK, Vincent KR. Influence of Admission Hematocrit on Inpatient Rehabilitation Outcomes After Total Knee and Hip Arthroplasty. Am J Phys Med Rehabil 2007; 86:806-17. [PMID: 17885313 DOI: 10.1097/phm.0b013e318151fe19] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine admission hematocrit (Hct) status on inpatient rehabilitation outcomes after total knee (TKA) and hip arthroplasty (THA). DESIGN This study was a retrospective, exploratory analysis. Patients (n = 400) were stratified by admission hematocrit levels: normal (Hct >or=36-41%, World Health Organization criteria for normal Hct in women and men), low (Hct between the operational 30% cutoff and 36-41%), and very low (Hct <30%). Functional Independence Measure (FIM) scores and specific lower-body FIM motor scores, FIM efficiency, length of stay (LOS), and total hospital charges were analyzed. RESULTS Regardless of arthroplasty joint, all improved total FIM score, motor FIM score, and specific lower-body activity FIM scores (walking, wheelchair, dressing, transfers, stairs) by discharge (all P < 0.05). LOS was 28.9-31% longer in the TKA-very low Hct and THA-very low Hct groups than in the normal Hct groups (P = 0.026). Total hospital charges were 32.6-45.6% higher in the TKA-very low Hct and THA-very low Hct groups than in the normal Hct groups (P < 0.05). Hct was a significant contributor to the variance of linear regression models for LOS and total charges (P < 0.05). CONCLUSIONS Although very low Hct at admission does not impede functional gains, it is related to longer LOS and greater hospital charges. Rehabilitation teams should consider this when preparing plans of care, rehabilitation goals, and plans for discharge.
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MESH Headings
- Activities of Daily Living
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/rehabilitation
- Arthroplasty, Replacement, Knee/rehabilitation
- Comorbidity
- Female
- Hematocrit
- Humans
- Length of Stay
- Linear Models
- Male
- Osteoarthritis, Hip/blood
- Osteoarthritis, Hip/epidemiology
- Osteoarthritis, Hip/surgery
- Osteoarthritis, Knee/blood
- Osteoarthritis, Knee/epidemiology
- Osteoarthritis, Knee/surgery
- Recovery of Function
- Retrospective Studies
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Affiliation(s)
- Heather K Vincent
- UF & Shands Orthopaedics and Sports Medicine Institute, Department of Orthopaedics and Rehabilitation, Gainesville, FL 32608, USA
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Muñoz M, García-Erce JA, Cuenca J, Bisbe E. Pharmacological management of perioperative anaemia: our experience with intravenous iron in orthopaedic surgery. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1751-2824.2007.00081.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Muñoz M, García-Erce JA, Campos A, Fernando Barrios L. [Legal framework for the use of autologous blood and other alternatives to allogenic transfusion]. Med Clin (Barc) 2007; 128:256-62. [PMID: 17335739 DOI: 10.1157/13099250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Manuel Muñoz
- GIEMSA, Medicina Transfusional, Facultad de Medicina, Universidad de Málaga, Málaga, España.
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Muñoz M, Kühlmorgen B, Ariza D, Haro E, Marroquí A, Ramirez G. Which patients are more likely to benefit from postoperative shed blood salvage after unilateral total knee replacement? An analysis of 581 consecutive procedures. Vox Sang 2007; 92:136-41. [PMID: 17298576 DOI: 10.1111/j.1423-0410.2006.00868.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Requirements for allogeneic blood transfusion (ABT) after total knee replacement (TKR) are still high (30-50%), and salvage of unwashed filtered postoperative shed blood (USB) may represent an alternative to ABT. We evaluated that patients are more likely to benefit of USB reinfusion after TKR. PATIENTS AND METHODS Data from 581 consecutive primary TKR, managed with (reinfusion group, n = 382) or without (control group, n= 199) reinfusion of USB, were retrospectively reviewed. RESULTS Patients from reinfusion group received 119 +/- 88 ml of red blood cells from USB, without clinically relevant incidents, and showed a lower ABT rate (30.6% vs. 8.4%, for control and reinfusion groups, respectively; P = 0.001) (transfusion trigger, haemoglobin [Hb] < 9 g/dl). Differences in ABT rate between groups were significant for all preoperative Hb levels, except for Hb < or = 12 g/dl. A lower transfusion threshold (Hb < 8 g/dl) might have further decreased ABT rate (14.6% vs. 5.2%, respectively; P < 0.001), with differences being significant for preoperative Hb between 12 and 15 g/dl. There were no differences with respect to postoperative infection rate, but patients from reinfusion group had a shorter length of hospital stay (11 +/- 4 vs. 13 +/- 4 days, respectively; P= 0.001). CONCLUSIONS Return of USB after TKR seems to reduce the need for ABT, especially in patients with preoperative Hb between 12 and 15 g/dl. There is little benefit of USB reinfusion for patients with preoperative Hb > 15 g/dl, whereas patients with preoperative Hb < 12 g/dl would probably benefit from the combination of USB with some other blood-saving method.
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Affiliation(s)
- M Muñoz
- GIEMSA, School of Medicine, University of Málaga, Campus de Teatinos s/n, 19071 Málaga, Spain.
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García-Erce JA, Cuenca J, Martínez F, Cardona R, Pérez-Serrano L, Muñoz M. Perioperative intravenous iron preserves iron stores and may hasten the recovery from post-operative anaemia after knee replacement surgery. Transfus Med 2006; 16:335-41. [PMID: 16999756 DOI: 10.1111/j.1365-3148.2006.00682.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In unilateral total knee replacement (TKR), perioperative blood loss, low transfusion thresholds and short hospital stay result in patients being discharged with low haemoglobin (Hb). We assessed the effects of perioperative administration of intravenous iron, with or without erythropoietin, plus a restrictive transfusion threshold (Hb < 80 g L(-1)) both on transfusion rate and recovery from post-operative anaemia. TRK patients received iron sucrose (2 x 200 mg per 48 h, iv) (Group IVI, n = 129). Patients with admission Hb < 130 g L(-1), also received erythropoietin (1 x 40 000 IU, sc) (Group EPO, n = 19). Perioperative clinical and laboratory data were obtained. Mean Hb loss was 36 g L(-1), but only seven patients were transfused (5%). Pre-operatively, 66 (45%) patients did not have enough stored iron to compensate Hb loss. At post-operative day 30, only 15% were anaemic, 70% of Hb loss and 92% of pre-operative Hb were recovered and ferritin increased by 73 microg L(-1) (P < 0.01), although erythropoietic response was higher in patients receiving erythropoietin (P < 0.05). No adverse effects of iron sucrose or erythropoietin were witnessed. This protocol seems to reduce allogeneic blood transfusion rate and may hasten the recovery from post-operative anaemia in TKR patients, without depleting iron stores. Further studies are needed to ascertain which patients may benefit of extended intravenous iron and/or erythropoietin administration.
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Affiliation(s)
- J A García-Erce
- Department of Haematology, University Hospital, Miguel Servet, Zaragoza, Spain
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Cuenca J, García-Erce JA, Martínez F, Pérez-Serrano L, Herrera A, Muñoz M. Perioperative intravenous iron, with or without erythropoietin, plus restrictive transfusion protocol reduce the need for allogeneic blood after knee replacement surgery. Transfusion 2006; 46:1112-9. [PMID: 16836557 DOI: 10.1111/j.1537-2995.2006.00859.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Unilateral total knee replacement (TKR) results in a substantial blood loss and 30 to 50 percent of patients receive allogeneic blood transfusion (ABT). Therefore, the effectiveness of a restrictive transfusion trigger (hemoglobin [Hb] level < 8 g/dL) plus stimulation of erythropoiesis was evaluated, with or without blood salvage, for reducing ABT in TKR patients. STUDY DESIGN AND METHODS A series of 139 consecutive of primary TKR patients received perioperative iron sucrose (2 x 200 mg/48 hr, intravenously [IV]), plus preoperative erythropoietin (EPO; 1 x 40.000 UI, sc) if preoperative Hb level was less than 130 g per L (Group A). This protocol was applied to another series of 173 consecutive TKR patients who also received postoperative unwashed shed blood (USB) if preoperative Hb level was less than 130 g per L (Group B). Perioperative clinical and laboratory data were gathered. RESULTS No adverse effects of iron sucrose, EPO, or USB administration were witnessed, and only 13 patients received ABT overall (4%). No major differences in perioperative blood counts or iron metabolism variables were observed between groups, but stimulation of erythropoiesis seemed to be more pronounced in those patients receiving EPO (p < 0.05). There were no differences in postoperative complications between groups, but length of hospital stay for patients with a preoperative Hb level of less than 130 g per L was shorter in Group B (p < 0.05). CONCLUSION This blood saving protocol seems to be effective for reducing ABT in TKR patients. Which patients are more likely to benefit from either perioperative iron administration or selective addition of postoperative blood salvage to pharmacologic treatment, however, needs to be further evaluated.
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Affiliation(s)
- Jorge Cuenca
- Department of Orthopedic and Trauma Surgery, University Hospital "Miguel Servet," Zaragoza, Spain
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Zacharopoulos A, Apostolopoulos A, Kyriakidis A. The effectiveness of reinfusion after total knee replacement. A prospective randomised controlled study. INTERNATIONAL ORTHOPAEDICS 2006; 31:303-8. [PMID: 16810542 PMCID: PMC2267590 DOI: 10.1007/s00264-006-0173-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Revised: 04/19/2006] [Accepted: 05/10/2006] [Indexed: 11/29/2022]
Abstract
The purpose of our study was to determine the effectiveness of a postoperative autologous blood reinfusion system as an alternative to homologous, banked blood transfusions in total knee arthroplasty. We carried out a prospective randomised controlled study on 60 patients having unilateral total knee replacements. In all these patients, the same surgical team applied the same surgical technique, and all patients followed the same rehabilitation program. In 30 of these patients (group A), a reinfusion system of unwashed salvaged blood was applied, and they were supplemented postoperatively with banked blood transfusions when required. A control group of 30 patients (group B), in whom standard suction drains were used, received one unit of homologous banked blood transfusion intraoperatively and additional blood transfusions postoperatively when required. The administration of banked blood transfusion was determined by the haemoglobin value (<9 mg/dl) and/or clinical signs (blood pressure, pulse, etc.). The values of haemoglobin, haematocrit and platelets were recorded preoperatively and the first, fifth and 15th postoperative days, respectively. Five patients of group A required nine units of homologous blood (0.3 units/patient) postoperatively. Ten patients of group B required an additional 15 banked blood units postoperatively (in total 45 banked blood units for group B; 1.5 units/patient). In the study group, the total homologous blood requirements were reduced by 80%, while the postoperative blood requirements were reduced by 50%. There was no significant difference in the postoperative haematocrit and haemoglobin values between the two groups. The cost of the blood management in the study group was reduced by 36%. The use of an autologous blood reinfusion system reduces highly effectively the demands of homologous banked blood transfusion in total knee arthroplasty.
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Affiliation(s)
- A. Zacharopoulos
- Orthopaedic Department, General Hospital of Amfissa, Oikismos Drosochoriou, 33100 Amfissa, Greece
| | - A. Apostolopoulos
- Orthopaedic Department, General Hospital of Amfissa, Oikismos Drosochoriou, 33100 Amfissa, Greece
| | - A. Kyriakidis
- Orthopaedic Department, General Hospital of Amfissa, Oikismos Drosochoriou, 33100 Amfissa, Greece
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Cuenca J, García-Erce JA, Martínez F, Cardona R, Pérez-Serrano L, Muñoz M. Preoperative haematinics and transfusion protocol reduce the need for transfusion after total knee replacement. Int J Surg 2006; 5:89-94. [PMID: 17448971 DOI: 10.1016/j.ijsu.2006.02.003] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Revised: 02/07/2006] [Accepted: 02/13/2006] [Indexed: 12/25/2022]
Abstract
BACKGROUND Unilateral total knee replacement (TKR) can result in a substantial blood loss and 30-50% of these patients receive allogeneic blood transfusion (ABT), this transfusion rate may be even higher among anaemic patients. PATIENTS AND METHODS We assessed the requirements for ABT in 156 consecutive patients undergoing surgery for primary TKR, who received iron ferrous sulphate (256 mg/day; 80 mg of Fe(2+)), vitamin C (1000 mg/day) and folic acid (5mg/day) during the 30-45 days preceding surgery, and who were transfused if Hb <80 g/L and/or clinical signs/symptoms of acute anaemia/hypoxemia (Group 2). A previous series of 156 TKR patients serves as a control group (Group 1). RESULTS Compared to those in Group 1, patients in Group 2 presented a lower transfusion rate (5.8% vs. 32%, for Group 2 and Group 1, respectively; p<0.01), and a lower transfusion index (1.78+/-0.44 vs. 2.22+/-0.65 units per transfused patient, respectively; p<0.05). After patient's stratification according to a preoperative Hb above or below 130 g/L, the differences in transfusion rate remained significant, although 19% of patients from Group 2 still needed ABT if their preoperative Hb <130 g/L. CONCLUSION This protocol seems to be effective for avoiding ABT in non-anaemic TKR patients, whereas for anaemic patients another blood saving strategy, such us preoperative erythropoietin administration or postoperative blood salvage, should be added to further increase its effectiveness.
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Affiliation(s)
- Jorge Cuenca
- Department of Orthopaedic and Trauma Surgery, University Hospital Miguel Servet, Zaragoza, Spain
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Muñoz M, Cobos A, Campos A, Ariza D, Muñoz E, Gómez A. Post-operative unwashed shed blood transfusion does not modify the cellular immune response to surgery for total knee replacement. Acta Anaesthesiol Scand 2006; 50:443-50. [PMID: 16548856 DOI: 10.1111/j.1399-6576.2006.00977.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients undergoing total knee replacement (TKR), most blood loss occurs post-operatively, and the return of unwashed filtered shed blood (USB) from post-operative drainage may represent an alternative to allogeneic blood transfusion (ABT). We evaluated the impact of USB return on the cellular immune response (CIR) after TKR. PATIENTS AND METHODS Forty TKR patients, intended to receive post-operative USB, entered the study. Blood samples were obtained before and 6 h, 24 h, 72 h and 7 days after surgery, and from USB, after it had been passed through a 40-microm filter. Full blood cell counts, lymphocyte subsets and immunoglobulins (IgA, IgG, IgM) were measured in all samples. A set of clinical data was collected from each patient. RESULTS Twenty-four of the 25 patients received a mean of 1.2 USB units and did not need additional ABT (USB group). Twelve of the 15 remaining patients who received neither USB nor ABT served as a control group for the post-operative CIR study. All patients showed a post-operative decrease in T-cell and natural killer (NK) cell counts, but not B-cell counts, and there were no significant differences between the groups with regard to CIR parameters, post-operative infection or hospital stay. CONCLUSIONS Post-operative salvage and return of USB after TKR does not seem to increase the post-operative infection rate or hospital stay, and does not modify CIR induced by surgery. These findings add to the clinical experience that post-operative USB return, as a source of autologous blood, is safe, and questions the beneficial effect of blood washing.
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Affiliation(s)
- M Muñoz
- GIEMSA, School of Medicine, University of Málaga, Malaga, Spain.
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MUNOZ MANUEL, CAMPOS ARTURO, MUNOZ ENCARNACION, CARRERO ANTONIO, CUENCA JORGE, GARCIA-ERCE JOSEANTONIO. Red cell salvage in orthopedic surgery. ACTA ACUST UNITED AC 2006. [DOI: 10.1111/j.1778-428x.2006.00007.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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