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Schmidt-Braekling T, Sabri E, Kim PR, Gofton WT, Beaulé PE, Grammatopoulos G. Prevalence of anemia and association with outcome in joint arthroplasty - is there a difference between primary and revision cases? Arch Orthop Trauma Surg 2024; 144:2337-2346. [PMID: 38416136 DOI: 10.1007/s00402-024-05247-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 02/17/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE Anemia has been shown to be a modifiable pre-operative, patient factor associated with outcome following arthroplasty. The aims of this retrospective study were to (1) ascertain the prevalence of preoperative anemia in patients undergoing primary and revision hip and knee arthroplasty at a tertiary referral center and (2) to test the association with outcome and whether it differs between primary and revision cases. METHODS All hip and knee primary and revision arthroplasties performed at a Canadian academic, tertiary-care, arthroplasty center between 2012 and 2017 were included in this study. The study group consisted of 5944 patients, of which 5251 were primary Total Hip and Knee Arthroplasties or Hip Resurfacings and 693 were revision arthroplasties (65% hip revisions/35% knee revisions). Anemia was classified as per WHO definition (hemoglobin < 130 g/L for men and < 120 g/L for women). All anemic patients were grouped into mild, moderate or severe anemia. Length-of-stay, perioperative transfusion-rate, 90-day readmission, overall complication rate and reoperation rates were recorded. The effect of preoperative anemia and the effect of severity of the anemia was evaluated through multivariable regression analysis controlling for relevant covariates. RESULTS Preoperatively, 15% (786/5251) of the primary patients and 47% (322/693) of the revision arthroplasty patients were anemic preoperatively. Anemic revision patients were 3.1 times more likely (95% CI: 1.47-6.33) to obtain blood transfusions during the hospital stay, compared to a 4.9 times higher risk in primary patients. The odds ratio to sustain any postoperative complication if anemic was 1.5 times higher (95% CI: 0.73-3.16) in revision patients and 1.7 in primary cases. In addition, the 90-day readmission rate among both groups was 1.6 times higher in anemic patients. Furthermore, anemic revision patients had a 5.3 days longer length of stay (95% CI: 2.63-7.91), compared to only 1 additional day in anemic primary patients (95% CI: 0.69-1.34). CONCLUSION In this study cohort, the prevalence of anemia in patients awaiting revision arthroplasty was 3 times higher (46.6%) than in primary arthroplasty patients (18.7%). Preoperative anemia was associated with similarly, inferior outcomes in both groups. To reduce postoperative complications and the "burden" associated with anemia, these findings strongly recommend optimizing the preoperative hemoglobin in all arthroplasty patients. However, revision patients are affected more frequently, and particular attention must therefore be taken to this growing group in the future. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Tom Schmidt-Braekling
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Muenster, Germany
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Paul R Kim
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
| | - Wade T Gofton
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada.
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Jungwirth-Weinberger A, Bendich I, Westrich GH, Su EP, Valle AGD, Boettner F. Preoperative ferritin and hemoglobin levels are lower in patients with a history of COVID-19 but blood loss and transfusion requirements are not increased. Arch Orthop Trauma Surg 2023; 143:311-315. [PMID: 34302523 PMCID: PMC8308077 DOI: 10.1007/s00402-021-04082-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/18/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION A history of COVID-19 (Coronavirus Disease 2019), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may have an impact on hemoglobin and ferritin levels predisposing patients to increased blood transfusion requirements following total joint arthroplasty (TJA). The current study compares ferritin levels, hemoglobin levels, and transfusion rates between SARS-CoV-2 IgG positive and SARS-CoV-2 IgG negative TJA patients. MATERIALS AND METHODS Preoperative ferritin levels, pre- and postoperative hemoglobin levels, postoperative change in hemoglobin, and transfusion rates of 385 consecutive SARS-CoV-2 IgG positive patients undergoing TJA were compared to those of 5156 consecutive SARS-CoV-2 IgG negative patients undergoing TJA. RESULTS Preoperative hemoglobin levels were significantly lower in SARS-CoV-2 IgG positive patients [13.3 g/dL (range 8.9-17.7 g/dL)] compared to 13.5 g/dl (7.3-18.3 g/dL; p value 0.03). Ferritin levels were significantly lower in SARS-CoV-2 IgG positive patients (mean of 106.1 ng/ml (2.1-871.3.3 ng/ml) vs. 123.7 ng/ml (1.4-1985 ng/ml) (p value 0.02)). Hemoglobin on postoperative day (POD) one, after four-six weeks, and transfusion rates did not differ between the two groups. CONCLUSION Although preoperative hemoglobin and ferritin levels are lower in SARS-CoV2 IgG positive patients, there was no difference in hemoglobin on POD one, recovery of hemoglobin levels at four-six weeks postoperatively, and transfusion rates after surgery. Routine ferritin testing prior to TJA is not recommended in SARS-CoV-2 IgG positive patients.
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Affiliation(s)
- Anna Jungwirth-Weinberger
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,Cantonal Hospital Baden, Im Ergel 1, CH-5404 Baden, Switzerland
| | - Ilya Bendich
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | | | - Edwin P. Su
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | | | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Perez Alamino L, Tillet F, Bochatey E, Lopreite F. Optimización preoperatoria del paciente antes de una artroplastia de cadera o rodilla: parte 1. REVISTA DE LA ASOCIACIÓN ARGENTINA DE ORTOPEDIA Y TRAUMATOLOGÍA 2022. [DOI: 10.15417/issn.1852-7434.2022.87.5.1658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Las artroplastias de cadera y rodilla son estrategias que han demostrado ser efectivas en el tratamiento de la patología degenerativa articular. El reemplazo articular mejora la calidad de vida de la mayoría de los pacientes cuando el tratamiento conservador falla. Sin embargo, estas son cirugías mayores que conllevan un riesgo significativo de complicaciones, incluyendo la necesidad de una revisión. El propósito de este artículo es analizar los factores de riesgo modificables del paciente antes de la cirugía, a finde disminuir el riesgo de complicaciones posoperatorias. Estudios recientes han descripto ciertos factores de riesgo modificables, inherentes al paciente y que incrementan la posibilidad de complicaciones posoperatorias luego de un reemplazo articular de cadera o rodilla. Estos incluyen obesidad, malnutrición, tabaquismo, diabetes, anemia, deficiencia de vitamina D, consumo de opioides, artropatías inflamatorias, insuficiencia renal crónica y colonización por estafilococco meticilino-resistente. Si conseguimos optimizar estas condiciones durante el preoperatorio, reduciremos el riesgo de complicaciones posoperatorias.
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Warren JA, McLaughlin JP, Molloy RM, Higuera CA, Schaffer JL, Piuzzi NS. Blood Management in Total Knee Arthroplasty: A Nationwide Analysis from 2011 to 2018. J Knee Surg 2022; 35:997-1003. [PMID: 33241545 DOI: 10.1055/s-0040-1721414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Both advances in perioperative blood management, anesthesia, and surgical technique have improved transfusion rates following primary total knee arthroplasty (TKA), and have driven substantial change in preoperative blood ordering protocols. Therefore, blood management in TKA has seen substantial changes with the implementation of preoperative screening, patient optimization, and intra- and postoperative advances. Thus, the purpose of this study was to examine changes in blood management in primary TKA, a nationwide sample, to assess gaps and opportunities. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify TKA (n = 337,160) cases from 2011 to 2018. The following variables examined, such as preoperative hematocrit (HCT), anemia (HCT <35.5% for females and <38.5% for males), platelet count, thrombocytopenia (platelet count < 150,000/µL), international normalized ration (INR), INR > 2.0, bleeding disorders, preoperative, and postoperative transfusions. Analysis of variances were used to examine changes in continuous variables, and Chi-squared tests were used for categorical variables. There was a substantial decrease in postoperative transfusions from high of 18.3% in 2011 to a low of 1.0% in 2018, (p < 0.001), as well as in preoperative anemia from a high of 13.3% in 2011 to a low of 9.5% in 2016 to 2017 (p < 0.001). There were statistically significant, but clinically irrelevant changes in the other variables examined. There was a HCT high of 41.2 in 2016 and a low of 40.4 in 2011 to 2012 (p < 0.001). There was platelet count high of 247,400 in 2018 and a low of 242,700 in 201 (p < 0.001). There was a high incidence of thrombocytopenia of 5.2% in 2017 and a low of low of 4.4% in 2018 (p < 0.001). There was a high INR of 1.037 in 2011 and a low of 1.021 in 2013 (p < 0.001). There was a high incidence of INR >2.0 of 1.0% in 2012 to 2015 and a low of 0.8% in 2016 to 2018 (p = 0.027). There was a high incidence of bleeding disorders of 2.9% in 2013 and a low of 1.8% in 2017 to 2018 (p < 0.001). There was a high incidence of preoperative transfusions of 0.1% in 2011 to 2014 and a low of <0.1% in 2015 to 2018 (p = 0.021). From 2011 to 2018, there has been substantial decreases in patients receiving postoperative transfusions after primary TKA. Similarly, although a decrease in patients with anemia was seen, there remains 1 out 10 patients with preoperative anemia, highlighting the opportunity to further improve and address this potentially modifiable risk factor before surgery. These findings may reflect changes during TKA patient selection, optimization, or management, and emphasizes the need to further advance multimodal approaches for perioperative blood management of TKA patients. This is a Level III study.
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Affiliation(s)
- Jared A Warren
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Robert M Molloy
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Carlos A Higuera
- Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | | | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Are Risk Factors for Postoperative Significant Hemorrhage following Total Knee Arthroplasty Potentially Modifiable? A Retrospective Cohort Study. J Pers Med 2022; 12:jpm12030434. [PMID: 35330434 PMCID: PMC8949285 DOI: 10.3390/jpm12030434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 12/10/2022] Open
Abstract
Total knee arthroplasty (TKA) is the treatment of choice for end-stage osteoarthritis (OA) of the knee, because it alleviates pain and restores function of the knee. However, TKA-associated hemorrhage and subsequent anemia remain a concern. Most previous studies have defined meaningful postoperative bleeding as blood loss > 500 mL or hemoglobin (Hb) drop > 20 g/L. Therefore, we defined significant hemorrhage as a postoperative Hb drop more than 20 g/L in this study, and we investigated possible risk factors related to significant hemorrhage in TKA and whether these risk factors are modifiable. This retrospective study was conducted through a comprehensive review of the perioperative records of patients with OA of the knee who underwent TKA between January 2009 and December 2015 at our hospital. Patients were allocated into two groups: patients in Group A had their Hb drop ≤ 20 g/L; patients in Group B had their Hb drop > 20 g/L. Factors analyzed included sex, age, body mass index (BMI), the American Society of Anesthesiologists (ASA) classification, comorbidities, preoperative platelet count, use of tranexamic acid (TXA), operation time, and type of anesthesia. A total of 3350 patients met the criteria for analysis, with 1782 patients allocated to Group A and 1568 patients to Group B. Five independent risk factors for significant hemorrhage were identified: male sex (odds ratio(OR), 1.29; 95% confidence interval(CI), 1.08−1.53; p = 0.005), age (OR, 1.02; 95% CI, 1.01−1.03; p = 0.001), use of TXA (OR, 0.39; 95% CI, 0.34−0.45; p < 0.001), spinal anesthesia versus general anesthesia (OR, 0.71; 95% CI, 0.56−0.90; p = 0.004), and preoperative platelet count (OR, 0.96; 95% CI, 0.93−0.98; p = 0.001). Of these identified risk factors, preoperative platelet count, use of TXA, and spinal anesthesia are modifiable. These potentially modifiable risk factors need to be taken into consideration when making both the perioperative care and anesthesia plan by surgeons and anesthesiologists, especially in patients at risk of significant hemorrhage.
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Zhu J, Hu H, Deng X, Cheng X, Li Y, Chen W, Zhang Y. Risk factors analysis and nomogram construction for blood transfusion in elderly patients with femoral neck fractures undergoing hemiarthroplasty. INTERNATIONAL ORTHOPAEDICS 2022; 46:1637-1645. [PMID: 35166874 DOI: 10.1007/s00264-022-05347-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/10/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Elderly patients with femoral neck fractures (FNFs) undergoing hemiarthroplasty usually have poor physical condition. The main aim of this study was to identify risk factors for blood transfusion in these patients and construct a nomogram to intuitively predict the requirement of transfusion. The secondary purpose was to examine the relationship between blood transfusion and complications within 30 days post-operatively. Our hypothesis was that chronic kidney disease (CKD) and hypoalbuminemia may increase the requirement of transfusion. METHODS Data of 414 elderly patients undergoing hemiarthroplasty for FNFs were retrospectively collected. Univariate and multiple regression analysis were performed to identify independent risk factors for blood transfusion, which were used to construct a nomogram subsequently. The discrimination and calibration of the nomogram model were assessed with concordance index (C-index), the area under receiver operating characteristic curve (AUC), and calibration curve. Furthermore, the complications of blood transfusion within 30 days post-operatively were also analyzed. RESULTS Out of 414 patients, 127 (30.7%) received a blood transfusion. Independent risk factors for blood transfusion included CKD, hypoalbuminemia, pre-operative anaemia, general anaesthesia, higher American Society of Anesthesiologists score, more intraoperative blood loss, and longer surgical time. Increased hidden blood loss, deep vein thrombosis, superficial wound infection, and prolonged hospital stays were more common in transfused patients. The C-index of the nomogram model was 0.848 (95% CI = 0.811-0.885), and the AUC value was 0.859. The calibration curve showed a good consistency between the actual transfusion and the predicted probability. DISCUSSION We observed a transfusion rate of 30.7% in elderly FNF patients undergoing hemiarthroplasty. CKD and hypoalbuminemia were firstly identified as independent risk for blood transfusion. In addition, blood transfusion can increase the occurrence of early post-operative complications. CONCLUSION Targeted pre-operative intervention, such as optimizing CKD and correcting hypoalbuminemia is essential and highly regarded.
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Affiliation(s)
- Jian Zhu
- Shanxi Bethune Hospital, Shanxi Academy of Medical Science, No. 99, Longcheng Street, Taiyuan, 030032, Shanxi Province, China.,School of Medicine, Nankai University, Tianjin, 300071, People's Republic of China.,Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Hongzhi Hu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
| | - Xiangtian Deng
- School of Medicine, Nankai University, Tianjin, 300071, People's Republic of China.,Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Xiaodong Cheng
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yonglong Li
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Wei Chen
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yingze Zhang
- School of Medicine, Nankai University, Tianjin, 300071, People's Republic of China. .,Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China. .,Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China. .,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Intraoperative and Postoperative Iron Supplementation in Elective Total Joint Arthroplasty: A Systematic Review. J Am Acad Orthop Surg 2021; 29:e1200-e1207. [PMID: 33591126 DOI: 10.5435/jaaos-d-20-01171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/01/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Postoperative anemia is associated with substantial morbidity and mortality in total joint arthroplasty (TJA). Our primary objective was to determine whether perioperative iron supplementation improves postoperative hemoglobin levels in TJA. Secondary objectives were to determine the effects of perioperative iron on adverse events, quality of life, and functional measures in TJA. METHODS We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using six databases. We included English-language, randomized controlled trials investigating intraoperative or postoperative iron supplementation in elective TJA that reported postoperative hemoglobin levels in patients aged 18 years or older. Seven eligible studies were identified, among which substantial heterogeneity was noted. Bias risk was low in four studies, unclear in two studies, and high in one study. Three studies assessed oral iron supplementation, three assessed intravenous iron supplementation, and one compared oral and intravenous iron supplementation. All intravenous iron was administered intraoperatively, except in the oral versus intravenous comparison. RESULTS Postoperative oral iron supplementation had no effect on postoperative hemoglobin levels. Intraoperative and postoperative intravenous iron supplementation was associated with higher postoperative hemoglobin levels and greater increases in hemoglobin levels. Two studies reported rates of anemia and found that intraoperative and postoperative intravenous iron supplementation reduced rates of postoperative anemia at postoperative day 30. No adverse events were associated with iron supplementation. One study found that intravenous iron improved quality of life in TJA patients with severe postoperative anemia compared with those treated with oral iron. Perioperative iron had no effects on functional outcomes. DISCUSSION We found no evidence that postoperative oral iron supplementation improves hemoglobin levels, quality of life, or functional outcomes in elective TJA patients. However, intraoperative and postoperative intravenous iron supplementation may accelerate recovery of hemoglobin levels in these patients. LEVEL OF EVIDENCE Level I, systematic review of randomized controlled trials.
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Park HS, Bin SI, Kim HJ, Kim J, Kim H, Ro Y, Koh WU. Immediate intravenous iron administration improves anaemia recovery following total knee arthroplasty: A propensity-matched analysis. Vox Sang 2021; 117:243-250. [PMID: 34270101 DOI: 10.1111/vox.13181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/22/2021] [Accepted: 06/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients who undergo total knee arthroplasty (TKA) have a risk of postoperative anaemia. This observational study evaluated whether single-dose intravenous ferric carboxymaltose (FCM) administered immediately after TKA facilitates the correction of anaemia. MATERIALS AND METHODS We retrospectively analysed 722 patients who underwent primary TKA. The FCM group receiving 1000 mg intravenous FCM within one postoperative hour was compared with the non-FCM group that did not receive the medication. A propensity score matching with multiple logistic regression analysis was used to minimize intergroup differences in the baseline characteristics and postoperative blood loss. The rate and severity of postoperative anaemia were compared between the groups, along with haemoglobin (Hb) value, transfusion rate and complications. RESULTS After propensity score matching, 231 patients were included in each group. In the FCM group, the rate of anaemia at postoperative day (POD) 7 (p = 0.021) and postoperative week (POW) 5 (p < 0.001) and the transfusion rate were significantly lower (p = 0.008). The rate of moderate to severe anaemia at POW-5 was also significantly lower in the FCM group (p < 0.001). In patients without preoperative anaemia (n = 322), the transfusion rate and rate and severity of anaemia at POD-7 and POW-5 were significantly lower in the FCM group than in the non-FCM group. CONCLUSION Postoperative intravenous FCM administration facilitated recovery of surgery-related anaemia by improving Hb and may reduce the need for transfusion in TKA patients. Preoperative non-anaemic patients could also benefit from accelerated recovery by intravenous iron treatment.
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Affiliation(s)
- Hee-Sun Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong-Il Bin
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ha-Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jinsun Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Youngjin Ro
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Won Uk Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Ke C, Tian N, Zhang X, Chen M. Changes in perioperative hemoglobin and hematocrit in patients undergoing total knee arthroplasty: a prospective observational study of optimal timing of measurement. J Int Med Res 2020; 48:300060520969303. [PMID: 33203274 PMCID: PMC7683925 DOI: 10.1177/0300060520969303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Chenrong Ke
- Department of Orthopedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Orthopedic Surgery, Orthopedic Hospital in The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Naifeng Tian
- Department of Orthopedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiumeng Zhang
- Department of Orthopedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Orthopedic Surgery, Orthopedic Hospital in The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Mochuan Chen
- Department of Orthopedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Orthopedic Surgery, Orthopedic Hospital in The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Ruan RX, Bai CW, Zhang L, Huang CR, Pan S, Zhang XC, Zhu ZY, Zheng X, Guo KJ. Does subcutaneous administration of recombinant human erythropoietin increase thrombotic events in total hip arthroplasty? A prospective thrombelastography analysis. J Orthop Surg Res 2020; 15:546. [PMID: 33213494 PMCID: PMC7678274 DOI: 10.1186/s13018-020-02083-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Anemia is one of severe complications in the perioperative period of total hip arthroplasty (THA). Erythropoietin (EPO) has been considered to improve patients' anemia state, but its efficiency and safety remains controversial. METHODS A total of 152 patients who underwent total hip arthroplasty from January 2017 to March 2019 were randomized to 2 groups. Recombinant human erythropoietin (rHu-EPO) group was treated with rHu-EPO subcutaneous injection 10000 IU after operation and once daily in the next week, while control group was treated with none extra treatment. Routine hematologic examination and thrombelastography (TEG) performed at different time point respectively. Doppler ultrasound for bilateral lower limbs was performed 1 day before surgery and 7 days after surgery. Auxiliary examination outcomes, blood transfusions outcomes, and postoperative complications were recorded as assessment indicators. RESULTS The difference in the relevant indexes of traditional coagulation and TEG values between two groups were not significantly. No significant difference was observed in the incidence of thromboembolism events and other complications between two groups during postoperative period. The amount of intraoperative blood loss was similar between the two groups. However, the postoperative use and dosage of allogeneic blood in the rHu-EPO group were lower than those in the control group. The hemoglobin and hematocrit level in the rHu-EPO group were higher than that in the control group after surgery. CONCLUSION Postoperative subcutaneous injection of rHu-EPO can improve hematological anemia-related parameters, reduce the use and dosage of allogeneic blood transfusions (ABTs), and has no significant influence on the formation of thrombosis and other complications in patients undergoing total hip arthroplasty in short term.
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Affiliation(s)
- Ru-Xin Ruan
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Chao-Wen Bai
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Le Zhang
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Chao-Ran Huang
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Sheng Pan
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Xing-Chen Zhang
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Zheng-Ya Zhu
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China
| | - Xin Zheng
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China.
| | - Kai-Jin Guo
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, Xuzhou, Jiangsu Province, 221000, China.
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11
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Lee B, Kim EJ, Song J, Jung YS, Koo BN. A randomised trial evaluating the effect of intraoperative iron administration. Sci Rep 2020; 10:15853. [PMID: 32985539 PMCID: PMC7522208 DOI: 10.1038/s41598-020-72827-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022] Open
Abstract
Perioperative anaemia increases postoperative morbidity and mortality, and iron deficiency is anaemia’s most common cause in surgical patients. Preoperative intravenous iron increases postoperative haemoglobin; however, data regarding intraoperative intravenous iron’s effectiveness are inadequate. This study examined intraoperative intravenous iron’s effects on postoperative haemoglobin levels in adults. Fifty-seven healthy subjects (aged 19–40 years) scheduled for bimaxillary orthognathic surgery were assigned randomly to the iron (n = 28) or control (n = 29) groups. The iron group received intravenous ferric derisomaltose (1,000 mg) after anaesthetic induction. The control group received an identical volume of intravenous normal saline. The primary outcome was postoperative haemoglobin level. Secondary outcomes included other postoperative haematologic and iron parameters. Laboratory data were obtained preoperatively and at 1 day, 2 weeks, and 4 weeks postoperatively. Haemoglobin was higher in the iron group 2 weeks postoperatively (12.9 g/dL vs. 12.2 g/dL), but the between-group difference was not significant after adjustment for multiple testing. However, the reticulocyte production index was significantly higher in the iron group 2 weeks postoperatively. Intraoperative intravenous iron maintains postoperative haemoglobin values in patients undergoing bimaxillary orthognathic surgery by increasing haematopoietic function and iron bioavailability and therefore appears to be a useful strategy for blood management.
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Affiliation(s)
- Bora Lee
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Eun Jung Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Jaewoo Song
- Department of Laboratory Medicine, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young-Soo Jung
- Department of Oral & Maxillofacial Surgery, College of Dentistry, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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Postoperative Intravenous Iron Supplementation Does Not Improve Hemoglobin Level and Transfusion Rate Following Staged Bilateral Total Knee Arthroplasty. J Arthroplasty 2020; 35:2444-2450. [PMID: 32487501 DOI: 10.1016/j.arth.2020.04.086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/09/2020] [Accepted: 04/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We determined whether postoperative intravenous (IV) iron supplementation could reduce transfusion rate in patients undergoing staged bilateral total knee arthroplasty (TKA). Furthermore, we examined whether hemoglobin (Hb) levels and iron profile differed between patients with and without postoperative IV iron supplementation. METHODS This retrospective, comparative cohort study included 126 patients who underwent primary staged bilateral TKA during a single hospitalization. The second TKA was performed at a week's interval. Group iron (n = 65) received IV iron immediately after each surgery, while patients in group no-iron (n = 61) received no iron after surgery. Transfusion rate, change in Hb levels, and iron profile including serum iron, ferritin, total iron binding capacity, and transferrin saturation were evaluated preoperatively; on postoperative days 1, 2, and 4 after the first TKA; and postoperative days 1, 2, 4, and 7, 6 weeks, and 3 months after the second TKA. RESULTS There were no significant differences in Hb levels and transfusion rate following staged bilateral TKA between patients with and without postoperative IV iron supplementation although serum iron profiles were improved in patients with IV iron supplementation. CONCLUSION Postoperative IV iron supplementation immediately after acute blood loss caused by TKA was not effective in improving the transfusion rate. Therefore, surgeons should use protocols other than postoperative IV iron supplementation for reducing the transfusion rate in patients undergoing staged bilateral TKA in a single hospitalization. LEVEL OF EVIDENCE III.
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13
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Dlott CC, Moore A, Nelson C, Stone D, Xu Y, Morris JC, Gibson DH, Rubin LE, O'Connor MI. Preoperative Risk Factor Optimization Lowers Hospital Length of Stay and Postoperative Emergency Department Visits in Primary Total Hip and Knee Arthroplasty Patients. J Arthroplasty 2020; 35:1508-1515.e2. [PMID: 32113812 DOI: 10.1016/j.arth.2020.01.083] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The evaluation and management of outcomes risk has become an essential element of a modern total joint replacement program. Our multidisciplinary team designed an evidence-based tool to address modifiable risk factors for adverse outcomes after primary hip and knee arthroplasty surgery. METHODS Our protocols were designed to identify, intervene, and mitigate risk through evidence-based patient optimization. Nurse navigators screened patients preoperatively, identified and treated risk factors, and followed patients for 90 days postoperatively. We compared patients participating in our optimization program (N = 104) to both a historical cohort (N = 193) and a contemporary cohort (N = 166). RESULTS Risk factor identification and optimization resulted in lower hospital length of stay (LOS) and postoperative emergency department (ED) visits. Patients in the optimization cohort had a statistically significant decrease in mean LOS as compared to both the historical cohort (2.55 vs 1.81 days, P < .001) and contemporary cohort (2.56 vs 1.81 days, P < .001). Patients in the optimization cohort had a statistically significant decrease in 30- and 90-day ED visits compared to the historical cohort (P30-day = .042, P90-day = .003). When compared with the contemporary cohort, the optimization cohort had a statistically significant decrease in 90-day ED visits (21.08% vs 10.58%, P = .025). The optimization cohort had a statistically significant increase in the percentage of patients discharged home. We noted nonsignificant reductions in readmission rate, transfusion rate, and surgical site infections. CONCLUSION Optimization of patients before elective primary total hip arthroplasty and total knee arthroplasty reduced average LOS, ED visits, and drove telerehabilitation use. Our results add to the limited body of literature supporting this patient-centered approach.
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Affiliation(s)
- Chloe C Dlott
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Anne Moore
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Christen Nelson
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Dannielle Stone
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Yunshan Xu
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Jensa C Morris
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - David H Gibson
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Lee E Rubin
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Mary I O'Connor
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
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Engel JL, Gabra JN, Kane P, Kurtz WJ. Intravenous Iron May Improve Outcomes in Elderly Patients With Operative Hip Fractures. Geriatr Orthop Surg Rehabil 2020; 11:2151459320911844. [PMID: 32231863 PMCID: PMC7097875 DOI: 10.1177/2151459320911844] [Citation(s) in RCA: 3] [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: 12/12/2019] [Accepted: 02/03/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction: Hip fractures are common injuries with high morbidity and mortality rates. These patients often become anemic and require allogenic blood transfusion. Transfusions are costly with potential complications. This study examines the effect of intravenous (IV) iron on patients with hip fractures, undergoing surgery within 48 hours, and being treated with a highly restrictive transfusion protocol. Materials and Methods: A retrospective chart review performed on patients admitted to a level 1 tertiary care center with fractures of the proximal femur from December 2015 to December 2017 included 239 patients. Patients who received 300 mg of IV iron when their hemoglobin fell below 11 g/dL were compared to a control group of patients who never received IV iron with respect to transfusion rate, 30-day readmission rate, nosocomial infections, length of stay, and hospital costs. Results: There were no significant differences in transfusion rates (P = .118). There was a trend toward decreased length of stay (P = .063) and 30-day readmission rates (P = .051) with a 59% reduction in the odds of 30-day readmission when a patient received IV iron. There were no differences in nosocomial infection rates or cost of hospitalization. Discussion: This study presents a compelling argument for further research regarding the use of IV iron in elderly patients undergoing surgery for a hip fracture. Length of stay and transfusion rates are increased in patients with intertrochanteric fractures and undergoing intramedullary nailing. A higher number of these patients in the IV iron group may have falsely increased these rates. A prospective, randomized, controlled trial is needed to assess the true effects of perioperative IV iron. Conclusions: This study showed no significant benefit to IV iron use in elderly patients undergoing surgical treatment of hip fracture. The decrease in 30-day readmission rate should be further examined with a prospective randomized controlled trial.
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Affiliation(s)
- Jamie L Engel
- Department of Orthopaedic Surgery, Cleveland Clinic Akron General, OH, USA
| | - Joseph N Gabra
- Department of Research, Cleveland Clinic Akron General, OH, USA
| | - Patrick Kane
- Department of Orthopaedic Surgery, Cleveland Clinic Akron General, OH, USA
| | - William J Kurtz
- Department of Orthopaedic Surgery, Cleveland Clinic Akron General, OH, USA
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15
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Dao P, Massin P. Blood management in enhanced recovery after hip and knee replacement. Orthop Traumatol Surg Res 2020; 106:S1-S5. [PMID: 31836497 DOI: 10.1016/j.otsr.2019.05.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 04/30/2019] [Accepted: 05/10/2019] [Indexed: 02/02/2023]
Abstract
Enhanced recovery in orthopedic surgery is a global patient management strategy to achieve early functional recovery. Blood management is central to rehabilitation protocols after hip or knee replacement. Coagulation physiology in hip and knee replacement is now well described, showing aggravation of bleeding by hyperfibrinolysis. The present study approaches blood management via 3 questions. 1/How to anticipate and prevent transfusion risk preoperatively? Screening for predictive factors can target the at-risk population, enabling a strategy of preoperative hemoglobin level optimization. 2/How to improve intraoperative hemostasis so as to minimize blood loss? Anti-fibrinolytic and topical hemostatic agents have proven efficacy. Tranexamic acid plays a central role. The impact of the usual surgical techniques, such as pneumatic tourniquet and postoperative drainage, on bleeding needs assessment. 3/How to manage postoperative anemia? Anemia without signs of general intolerance is frequent at discharge, but has been little studied. This raises the question of the medical interest of correcting postoperative anemia. LEVEL OF EVIDENCE: Expert opinion, V.
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Affiliation(s)
- Pierre Dao
- CMC Ambroise-Paré, 25-27, boulevard Victor-Hugo, 92200 Neuilly-sur-Seine, France.
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16
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The Effect of Intraoperative Ferric Carboxymaltose in Joint Arthroplasty Patients: A Randomized Trial. J Clin Med 2019; 8:jcm8101674. [PMID: 31614940 PMCID: PMC6832232 DOI: 10.3390/jcm8101674] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/20/2019] [Accepted: 10/10/2019] [Indexed: 12/31/2022] Open
Abstract
This study assessed the efficacy of intraoperative high-dose intravenous iron therapy in facilitating recovery from postoperative anemia and reducing the transfusion rate in patients with total knee and total hip arthroplasty. This prospective randomized controlled study involved 58 subjects. Group F received 1000 mg intravenous ferric carboxymaltose and Group C received normal saline. The changes in hemoglobin (Hb), hematocrit, iron metabolism variables, transfusion rates, and the arterial partial pressure of oxygen and the fraction of oxygen (PaO2/FiO2) ratio were recorded. There were 29 patients of each group. The change in Hb levels from baseline to 1 month post-surgery was higher in Group F than in Group C (0.3 ± 1.0 g/dl vs. -0.8 ± 0.8 g/dl, p < 0.001). Functional iron deficiency occurred more frequently in Group C (0% vs. 48.3%, p < 0.001) after the operation. The incidence of postoperative anemia, transfusion rate and P/F ratio did not significantly differ between the two groups. This study suggests that intraoperative high-dose ferric carboxymaltose during lower limb total arthroplasty can facilitate the recovery from postoperative anemia. Although it could not prevent the occurrence of postoperative anemia or the administration of transfusion, this treatment seemed to overcome surgery-related decrease of iron availability.
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17
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Jiang T, Song K, Yao Y, Pan P, Jiang Q. Perioperative allogenic blood transfusion increases the incidence of postoperative deep vein thrombosis in total knee and hip arthroplasty. J Orthop Surg Res 2019; 14:235. [PMID: 31337430 PMCID: PMC6651957 DOI: 10.1186/s13018-019-1270-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/08/2019] [Indexed: 02/06/2023] Open
Abstract
Background Excessive blood loss caused by total joint arthroplasty (TJA) often increases the requirement for blood transfusion, which is associated with adverse outcomes. The purpose of this study was to determine the relationship between perioperative transfusion and postoperative DVT in TJA. Methods This retrospective study reviewed medical records of 715 patients, who consecutively underwent primary unilateral total knee arthroplasty (TKA) or total hip arthroplasty (THA) at our institution between September 2015 and March 2017. Demographic, clinical and surgical parameters were introduced into the univariate analysis to find risk factors for DVT within postoperative 30 days. In order to identify if allogenic blood transfusion was independently associated with DVT, a multivariate logistic regression analysis was conducted to adjust for gender, age, body mass index (BMI), diagnosis, and type of surgery. Results The incidence of perioperative allogenic blood transfusion was 12.4% (n = 89). Fifty-seven patients (8.0%) developed DVT after surgery. Univariate analysis demonstrated that there were differences between DVT group and non-DVT group in gender (P = 0.045), age (P < 0.001), BMI (P = 0.026), primary diagnosis (P = 0.001), type of surgery (P < 0.001), and transfusion rates (P = 0.040). After adjustment by using multivariate logistic regression analysis, transfusion appeared to be the independent risk factor for DVT in TJA (P = 0.001; OR = 3.9, 95%CI 1.8–8.4). Conclusion We found that perioperative allogenic blood transfusion was significantly associated with DVT following TJA. In order to reduce the risk of DVT and other adverse outcomes, methods to decrease transfusion rates should be used in clinical practice.
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Affiliation(s)
- Tao Jiang
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Sports Medicine and Adult Reconstructive Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, 210093, Jiangsu, People's Republic of China
| | - Kai Song
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Sports Medicine and Adult Reconstructive Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, 210093, Jiangsu, People's Republic of China
| | - Yao Yao
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Sports Medicine and Adult Reconstructive Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, 210093, Jiangsu, People's Republic of China
| | - Pin Pan
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Sports Medicine and Adult Reconstructive Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, 210093, Jiangsu, People's Republic of China
| | - Qing Jiang
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Sports Medicine and Adult Reconstructive Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China. .,Laboratory for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing, 210093, Jiangsu, People's Republic of China.
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18
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Gómez-Ramírez S, Bisbe E, Shander A, Spahn DR, Muñoz M. Management of Perioperative Iron Deficiency Anemia. Acta Haematol 2019; 142:21-29. [PMID: 30970362 DOI: 10.1159/000496965] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/16/2019] [Indexed: 01/28/2023]
Abstract
Preoperative anemia affects 30-40% of patients undergoing major surgery and is an independent risk factor for perioperative blood transfusion, morbidity, and mortality. Absolute or functional iron deficiency is its leading cause. Nonanemic hematinic deficiencies are also prevalent and may hamper preoperative hemoglobin optimization and/or recovery from postoperative anemia. As modifiable risk factors, anemia and hematinic deficiencies should be detected and corrected prior to major surgical procedures. Postoperative anemia is even more common (up to 80-90%) due to surgery-associated blood loss, inflammation-induced blunted erythropoiesis, and/or preexisting anemia. Preoperative oral iron may have a role in mild-to-moderate anemia, provided there is sufficient time (6-8 weeks) and adequate tolerance of oral preparations. Postoperative oral iron is of little value and rife with gastrointestinal adverse events. Intravenous iron should preferentially be used in cases of moderate-to-severe iron deficiency anemia, concomitant use of erythropoiesis-stimulating agents, short time to surgery or nonelective procedures, and for postoperative anemia management. Minor infusion reactions to intravenous iron are rare, the incidence of severe anaphylactic reactions is extremely low, and there is no increase in infections with intravenous iron. Currently available intravenous iron formulations allowing administration of large single doses are preferred.
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Affiliation(s)
- Susana Gómez-Ramírez
- Department of Internal Medicine, University Hospital Virgen de la Victoria, Málaga, Spain
| | - Elvira Bisbe
- Department of Anesthesiology, University Hospital Mar-Esperanza, Barcelona, Spain
| | - Aryeh Shander
- Departments of Anesthesiology, Critical Care, and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey, USA
- TeamHealth Research Institute, Englewood Health, Englewood, New Jersey, USA
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Manuel Muñoz
- Department of Surgical Specialties, Biochemistry, and Immunology, School of Medicine, University of Málaga, Málaga, Spain,
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Greco NJ, Manocchio AG, Lombardi AV, Gao SL, Adams J, Berend KR. Should postoperative haemoglobin and potassium levels be checked routinely following blood-conserving primary total joint arthroplasty? Bone Joint J 2019; 101-B:25-31. [PMID: 30648494 DOI: 10.1302/0301-620x.101b1.bjj-2018-0554.r1] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
AIMS Despite declining frequency of blood transfusion and electrolyte supplementation following total joint arthroplasty, postoperative blood analyses are still routinely ordered for these patients. This study aimed to determine the rate of blood transfusion and electrolyte restoration in arthroplasty patients treated with a perioperative blood conservation protocol and to identify risk factors that would predict the need for transfusion and electrolyte supplementation. PATIENTS AND METHODS Patients undergoing primary total joint arthroplasty of the hip or knee between July 2016 and February 2017 at a single institution were included in the study. Standard preoperative and postoperative laboratory data were collected and reviewed retrospectively. A uniform blood conservation programme was implemented for all patients. Need for blood transfusion or potassium supplementation was determined through a coordinated decision by the care team. Rates of transfusion and supplementation were observed, and patient risk factors were noted. RESULTS The overall rate of blood transfusion was 1.06% in the study population of 1132 total joint arthroplasties performed in 1023 patients. Of the 12 patients requiring transfusion, 11 were female, ten occurred in patients undergoing total hip arthroplasty, and all 12 patients had a preoperative haemoglobin level less than 130 g/l. Operative duration and surgical blood loss were significantly greater in those patients requiring blood transfusion. Nearly all patients requiring transfusion had a history of, or risk factors for, cardiovascular disease. Potassium supplementation was required in 15.5% of the study cohort; 72% of these patients receiving potassium presented with a potassium level less than 4 mmol/l during preoperative testing, while the remaining 28% had a past medical history of either significant anaemia, cardiopulmonary, cardiovascular, or renal diseases that had required substantial medical management. CONCLUSION A consistent blood-conserving perioperative strategy effectively minimized need for blood transfusion in total joint arthroplasty patients below previously reported rates in the literature. We suggest that postoperative full blood counts and basic metabolic panels should not routinely be ordered in these patients unless their preoperative haemoglobin and potassium is below 130 g/dl or 4 mmol/l respectively, and they have medical comorbidities.
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Affiliation(s)
- N J Greco
- Joint Implant Surgeons, Inc., White Fence Surgical Suites, and Mount Carmel Health System, New Albany, Ohio, USA
| | - A G Manocchio
- Department of Orthopedic Surgery, Grandview Medical Center, Dayton, Ohio, USA
| | - A V Lombardi
- Joint Implant Surgeons, Inc., White Fence Surgical Suites, and Mount Carmel Health System, New Albany, Ohio, USA and Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - S L Gao
- Department of Orthopedic Surgery, Grandview Medical Center, Dayton, Ohio, USA
| | - J Adams
- Joint Implant Surgeons, Inc., New Albany, Ohio, USA
| | - K R Berend
- Joint Implant Surgeons, Inc., White Fence Surgical Suites, and Mount Carmel Health System, New Albany, Ohio, USA
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20
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Blood conservation techniques in scoliosis surgery. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kumar L, Kumar AH, Grant SA, Gadsden J. Updates in Enhanced Recovery Pathways for Total Knee Arthroplasty. Anesthesiol Clin 2018; 36:375-386. [PMID: 30092935 DOI: 10.1016/j.anclin.2018.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Enhanced recovery after surgery (ERAS) programs for orthopedics involve a multidisciplinary approach to accelerating return to function, reducing pain, improving patient comfort and satisfaction, reducing complications from the surgical procedure, reducing hospital length of stay, and reducing costs. ERAS pathways for patients receiving total knee arthroplasty are different from those having intracavitary surgery; they are less focused on fluid homeostasis and gut motility than they are with optimizing systemic and local analgesics and providing a balance between the highest quality pain control and accelerated return to ambulation.
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Affiliation(s)
- Lisa Kumar
- Regional Anesthesiology and Acute Pain Medicine, Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Amanda H Kumar
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Stuart A Grant
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Jeff Gadsden
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.
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22
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Padmanabhan H, Siau K, Nevill AM, Morgan I, Cotton J, Ng A, Brookes MJ, Luckraz H. Intravenous iron does not effectively correct preoperative anaemia in cardiac surgery: a pilot randomized controlled trial. Interact Cardiovasc Thorac Surg 2018; 28:447-454. [DOI: 10.1093/icvts/ivy226] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/12/2018] [Accepted: 06/15/2018] [Indexed: 12/23/2022] Open
Affiliation(s)
- Hari Padmanabhan
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Keith Siau
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Alan M Nevill
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Wolverhampton, UK
| | - Ian Morgan
- Department of Cardiothoracic Surgery, Heart & Lung Centre, Wolverhampton, UK
| | - James Cotton
- Department of Cardiology, Heart & Lung Centre, Wolverhampton, UK
| | - Alex Ng
- Department of Cardiothoracic Anaesthesiology, Heart & Lung Centre, Wolverhampton, UK
| | - Matthew J Brookes
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Heyman Luckraz
- Department of Cardiothoracic Surgery, Heart & Lung Centre, Wolverhampton, UK
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Mistry JB, Gwam CU, Naziri Q, Pivec R, Abraham R, Mont MA, Delanois RE. Are Allogeneic Transfusions Decreasing in Total Knee Arthroplasty Patients? National Inpatient Sample 2009-2013. J Arthroplasty 2018; 33:1705-1712. [PMID: 29352682 DOI: 10.1016/j.arth.2017.12.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 11/23/2017] [Accepted: 12/13/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Allogeneic transfusions are commonly used for substantial blood loss in total knee arthroplasty (TKA), but have been associated with adverse effects and increased costs. The purpose of this study is to provide a detailed description of (1) trends of allogeneic blood transfusion; (2) risk factors and adverse events; and (3) discharge disposition, length-of-stay (LOS), and cost/charge analysis for primary TKA patients who received an allogeneic blood transfusion from 2009-2013. METHODS A cohort of 3,217,056 primary TKA patients was identified from the National Inpatient Sample database from 2009-2013. Demographic, clinical, economic, and discharge data were analyzed for patients who received allogeneic blood products, and for those who did not receive any type of blood transfusion. Other parameters analyzed include risk factors, adverse events, discharge disposition, and costs/charges. RESULTS There was a significant decline in use of allogeneic transfusion from 2009-2013 incidence (13.9%-7.3%; P < .001). All comorbidities examined were associated with significantly increased risk of receiving allogeneic transfusion with exception of patients with AIDS, metastatic cancer, and peptic ulcer disease. Allogeneic transfusion was associated with worse outcomes during hospitalization. Patients also had a greater likelihood of discharge to short-term care, greater LOS, and greater median costs/charges. Among TKA patients who received an allogeneic transfusion, costs varied based on hospital ownership and characteristics, primary-payer, region, and bed-size. CONCLUSION Given the poor outcomes and higher costs associated with allogeneic transfusions, efforts must be undertaken to minimize this risky practice. With the projected increase in demand for TKAs, orthopedists must understand effective blood management strategies.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Arthroplasty, Replacement, Knee/trends
- Blood Loss, Surgical
- Blood Transfusion/economics
- Blood Transfusion/statistics & numerical data
- Blood Transfusion/trends
- Comorbidity
- Databases, Factual
- Female
- Hospitalization
- Hospitals
- Humans
- Length of Stay/statistics & numerical data
- Male
- Middle Aged
- Patient Discharge
- Risk Factors
- Transplantation, Homologous/economics
- Transplantation, Homologous/statistics & numerical data
- Transplantation, Homologous/trends
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Affiliation(s)
- Jaydev B Mistry
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Qais Naziri
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Robert Pivec
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Roby Abraham
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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24
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Lee H, Yuh YJ. A Paradigm Shift: Perioperative Iron and Erythropoietin Therapy for Patient Blood Management. ACTA ACUST UNITED AC 2018. [DOI: 10.7599/hmr.2018.38.1.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Hyesun Lee
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Young Jin Yuh
- Department of Internal Medicine, Inje University Paik Hospital, Seoul, Korea
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