Transfusion Thresholds for Major Orthopedic Surgery: A Systematic Review and Meta-analysis

Blood Transfusion in the Age of Tranexamic Acid: Who Needs a Type and Screen Before Total Hip Arthroplasty?

BACKGROUND

Modern surgical protocols, particularly the use of tranexamic acid (TXA), have reduced, but not eliminated, blood transfusions surrounding total hip arthroplasty (THA). Identifying patients at risk for transfusion remains important for risk reduction and to determine type and screen testing.

METHODS

We reviewed 6,405 patients who underwent primary, unilateral THA between January 2014 and January 2023 at a single academic institution, received TXA, and had preoperative hemoglobin (Hgb) values. We compared demographics, baseline hemoglobin levels, and surgical details between patients who were and were not transfused. Data were analyzed utilizing multivariate regression and receiver operating characteristic (ROC) curve analysis.

RESULTS

The overall perioperative and intraoperative transfusion rates were 3.4 and 1.0%, respectively. Patients who were older, women, and American Society of Anesthesiologists (ASA) class >II demonstrated an increased risk of transfusion. Risk of transfusion demonstrated an inverse correlation with preoperative Hgb levels, a bimodal association with Body Mass Index (BMI), and a direct correlation with age, surgical time, and estimated blood loss on multivariate analysis. The Receiver Operating Characteristic (ROC) analysis demonstrated a preoperative Hgb cutoff of 12 g/dL for predicting any transfusion. Above the threshold of 12 g/dL, total and intraoperative transfusions were rare, with rates of 1.7 and 0.3%, respectively. Total and intraoperative transfusion rates with Hgb between 11 and 12 g/dL were 14.3 and 4.6%, respectively. Below 11 g/dL, total and intraoperative transfusion rates were 27.5 and 10.1%, respectively.

CONCLUSION

In the age of TXA, blood transfusion is rare in THA when preoperative Hgb is > 12 g/dL, challenging the need for universal type and screening. Conversely, patients who have hemoglobin < 11.0 g/dL, remain at substantial risk for transfusion. Between hemoglobin 11 and 12 g/dL, patient age, sex, BMI, ASA classification, anticipated estimated blood loss (EBL), and surgical time may help predict transfusion risk and the need for a perioperative type and screen.

Correlation Between Anesthesia Methods and Adverse Short-Term Postoperative Outcomes Depending on Frailty: A Prospective Cohort Study

Purpose

This study aims to investigate how the type of anesthesia used during major orthopedic surgery may impact adverse short-term postoperative outcomes depending on frailty.

Methods

To conduct this investigation, we recruited individuals aged 65 years and older who underwent major orthopedic surgery between March 2022 and April 2023 at a single institution. We utilized the FRAIL scale to evaluate frailty. The primary focus was on occurrences of death or the inability to walk 60 days after the surgery. Secondary measures included death within 60 days; inability to walk without human assistance at 60 days; death or the inability to walk without human assistance at 30 days after surgery, the first time out of bed after surgery, postoperative blood transfusion, length of hospital stay, hospital costs, and the occurrence of surgical complications such as dislocation, periprosthetic fracture, infection, reoperation, wound complications/hematoma.

Results

In a study of 387 old adult patients who had undergone major orthopedic surgery, 41.3% were found to be in a frail state. Among these patients, 262 had general anesthesia and 125 had neuraxial anesthesia. Multifactorial logistic regression analyses showed that anesthesia type was not linked to complications. Instead, frailty (OR 4.04, 95% CI 1.04 to 8.57, P< 0.001), age (OR 1.05, 95% CI 1.00-1.10, P= 0.017), and aCCI scores, age-adjusted Charlson Comorbidity Index, (OR 1.36, 95% CI 1.12 to 1.66, P= 0.002) were identified as independent risk factors for death or new walking disorders in these patients 60 days after surgery. After adjusting for frailty, anesthesia methods was not associated with the development of death or new walking disorders in these patients (P > 0.05).

Conclusion

In different frail populations, neuraxial anesthesia is likely to be comparable to general anesthesia in terms of the incidence of short-term postoperative adverse outcomes.

Disparities Associated With Total Joint Arthroplasty Transfusion Rates

BACKGROUND

Infections, readmissions, and mortalities after total joint arthroplasty (TJA) are serious complications, and transfusions have been associated with increased complication rates following TJA. Certain populations, including women, Black patients, patients who have public insurance and older adults have higher risks of transfusion. Recently, there has been a decline in transfusion rates and a greater emphasis on equity in medicine. This study examined whether disparities in transfusion rates still exist and what variables influence rates over time.

METHODS

We used a health care system database to identify 5,435 total knee arthroplasty (TKA) and 2,105 total hip arthroplasty (THA) patients from 2013 to 2021. Transfusion rates were 2.9 and 3.1% in the TKA and THA arthroplasty groups, respectively. White race represented 67.1 and 69.8% of the TKA and THA groups, respectively. Fisher exact and Wilcoxon rank sum tests were used to compare categorical and continuous variables. Multivariable logistic regressions were performed to predict transfusion rates within 5 days of surgery and adjust for potential confounders.

RESULTS

Transfusion rates declined over time. However, Black patients had a higher rate of transfusion than White patients despite similar hemoglobin levels, 5.1 versus 1.8% (P < .001) in the TKA group and 4.1 versus 2.7% (P = .103) in the THA group. Following adjustment, the biggest factor associated with a higher transfusion risk in the TKA group was being Black (adjusted odds ratio = 2.2, 95% confidence interval = 1.55 to 3.13).

CONCLUSIONS

Transfusion rates for TJA patients are declining; however, Black patients continued to receive transfusions at higher rates in patients receiving TKA.

Trends, complications, and readmission of allogeneic red blood cell transfusion in primary total hip arthroplasty in china: a national retrospective cohort study

INTRODUCTION

Decrease in allogenic red blood cell (RBC) transfusion rates following total hip arthroplasty (THA) has been reported in the United States, but whether other countries share the same trend remains unclear. Additionally, the relation of allogenic RBC transfusion to the risk of complications in THA remains controversial. Using the Chinese national inpatient database, the current study aimed to examine trends, complications, charges, and readmission patterns of allogeneic RBC transfusion in THA.

MATERIALS AND METHODS

Patients undergoing primary THA between 2013 and 2019 were included, and then stratified into the transfusion and the non-transfusion group based on the database transfusion records. A generalized estimating equation model was used to investigate trends in transfusion rates. After propensity-score matching, a logistic regression model was used to compare the complications, rates and causes of 30-day readmission between two groups.

RESULTS

A total of 10,270 patients with transfusion and 123,476 patients without transfusion were included. Transfusion rates decreased from 19.11% in 2013 to 9.94% in 2019 (P for trend < 0.001). After matching, no significant differences in the risk of of in-hospital death (odds ratio [OR], 4.00; 95% confidence interval [CI] 0.85-18.83), wound infection (OR 0.72; 95%CI 0.45-1.17), myocardial infarction (OR 1.17; 95%CI 0.62-2.19), deep vein thrombosis (OR 1.25; 95%CI 0.88-1.78), pulmonary embolism (OR 2.25; 95%CI 0.98-5.17), readmission rates (OR 1.07; 95%CI 0.88-1.30) and readmission causes were observed between two groups. However, the transfusion group had higher hospitalization charges than the non-transfusion group (72,239.89 vs 65,649.57 Chinese yuan [CNY], P < 0.001).

CONCLUSIONS

This study found that allogeneic RBC transfusion in THA was not associated with the increased risk of complications and any-cause readmission. However, the currently restrictive transfusion policy should be continued because excessive blood transfusion may increase the socioeconomic burden.

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

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

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Acute Postoperative Anemia After Unilateral Primary Total Joint Arthroplasty: Restrictive Transfusion Thresholds are Safe for Discharge Regardless of Delta Hemoglobin

BACKGROUND

Primary unilateral total joint arthroplasty (TJA) is associated with acute postoperative anemia that may require blood transfusion. Clinicians may worry about discharging patients after surgery who experience substantial decreases in hemoglobin (Hgb), even if their Hgb is above restrictive transfusion thresholds. The purpose of this study was to determine whether differences between preoperative and postoperative Hgb values (Delta) correlate with 90-day readmission in patients who did not receive perioperative transfusions.

METHODS

A retrospective review of patients undergoing primary unilateral TJA between 2015 and 2020 was performed. The primary outcome was whether a specific cutoff delta Hgb was predictive of readmission within 90 days due to anemia-related causes. Secondary outcomes included the presence of acute postoperative anemia and transfusion during readmission.

RESULTS

Six thousand seven hundred and ninety one patients had a median delta Hgb of 2.80. In total, 268 patients (3.95%) were readmitted within 90 days postoperatively, with two patients requiring transfusion during readmission. A significantly higher rate of readmission was found in patients with cardiovascular disease (5.16% versus 3.68%; P = .020). When constructing receiver operating characteristic curves, a cutoff value of 3.20 resulted in an area under curve of 0.595 (0.486-0.704). In patients with cardiovascular disease, a cutoff value of 3.10 resulted in an area under curve of 0.626 (0.466-0.787).

CONCLUSION

The magnitude of Hgb change was not predictive of anemia-related readmission within 90 days in patients who did not receive a perioperative transfusion. Patients experiencing higher delta Hgb values but remaining above the transfusion threshold may have a greater physiologic reserve.

Unicompartmental Knee Arthroplasty in Octogenarians: A National Database Analysis Including Over 700 Octogenarians

Background

Material and methods

Results

Conclusion

Transfusion Avoidance in Severely Anemic Total Hip and Total Knee Arthroplasty Patients: An Analysis of Risk

Background

Material and methods

Results

Conclusion

Simultaneous Bilateral Total Hip Arthroplasty With Contemporary Blood Management is Associated With a Low Risk of Allogeneic Blood Transfusion

BACKGROUND

There is a paucity of data on blood loss and the risk of allogeneic blood transfusion after simultaneous bilateral total hip arthroplasty (SBTHA) with contemporary blood management including neuraxial anesthesia, routine tranexamic acid use, and a restrictive transfusion protocol. As such, we sought to determine the in-hospital outcomes of SBTHA, specifically analyzing blood loss and the rate and risk factors for transfusion.

METHODS

We identified 191 patients who underwent SBTHA at a single institution from 2016 to 2019. No drains were utilized and no patients donated blood preoperatively. Mean age was 59 years with 96 females (50.3%). The surgical approach was posterior in 138 (72.3%) and direct anterior in 53 (27.7%) patients. We analyzed blood loss, the rate of allogeneic blood transfusions, and in-hospital thromboembolic complications. We analyzed risk factors for transfusion with a logistic regression analysis.

RESULTS

Twenty-two patients (11.5%) underwent allogeneic blood transfusion. All transfused patients were female. Univariate analysis revealed female gender as a transfusion risk factor since it had statistically significant higher proportion in the transfusion group than the nontransfusion group (100% vs 43.5%, respectively, P < .001). We did not identify any other singular significant risk factors for transfusion in a multivariable regression analysis. However, females with a preoperative Hb <12 had an elevated risk of transfusion at 37.5% (15/40 patients).

CONCLUSION

With contemporary perioperative blood management protocols, there is a relatively low (11.5%) risk of a blood transfusion after SBTHA. Females with a lower preoperative Hb (<12 g/dL) had the highest risk of transfusion at 37.5%.

Predictors and Outcomes of Postoperative Hemoglobin of <8 g/dL in Total Joint Arthroplasty

BACKGROUND

Restrictive transfusion practices have decreased transfusions in total joint arthroplasty (TJA). A hemoglobin threshold of <8 g/dL is commonly used. Predictors of this degree of postoperative anemia in TJA and its association with postoperative outcomes, independent of transfusions, remain unclear. We identified predictors of postoperative hemoglobin of <8 g/dL and outcomes with and without transfusion in TJA.

METHODS

Primary elective TJA cases performed with a multimodal blood management protocol from 2017 to 2018 were reviewed, identifying 1,583 cases. Preoperative and postoperative variables were compared between patients with postoperative hemoglobin of <8 and ≥8 g/dL. Logistic regression and receiver operating characteristic curves were used to assess predictors of postoperative hemoglobin of <8 g/dL.

RESULTS

Positive predictors of postoperative hemoglobin of <8 g/dL were preoperative hemoglobin level (odds ratio [OR] per 1.0-g/dL decrease, 3.0 [95% confidence interval (CI), 2.4 to 3.7]), total hip arthroplasty (OR compared with total knee arthroplasty, 2.1 [95% CI, 1.3 to 3.4]), and operative time (OR per 30-minute increase, 2.0 [95% CI, 1.6 to 2.6]). Negative predictors of postoperative hemoglobin of <8 g/dL were tranexamic acid use (OR, 0.42 [95% CI, 0.20 to 0.85]) and body mass index (OR per 1 kg/m2 above normal, 0.90 [95% CI, 0.86 to 0.94]). Preoperative hemoglobin levels of <12.4 g/dL in women and <13.4 g/dL in men best predicted postoperative hemoglobin of <8 g/dL. Overall, 5.2% of patients with postoperative hemoglobin of 7 to 8 g/dL and 95% of patients with postoperative hemoglobin of <7 g/dL received transfusions. Patients with postoperative hemoglobin of <8 g/dL had longer hospital stays (p < 0.001) and greater rates of emergency department visits or readmissions (p = 0.001) and acute kidney injury (p < 0.001). Among patients with postoperative hemoglobin of <8 g/dL, patients who received transfusions had a lower postoperative hemoglobin nadir (p < 0.001) and a longer hospital stay (p = 0.035) than patients who did not receive transfusions.

CONCLUSIONS

Postoperative hemoglobin of <8 g/dL after TJA was associated with worse outcomes, even for patients who do not receive transfusions. Optimizing preoperative hemoglobin levels may mitigate postoperative anemia and adverse outcomes.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical practice for outpatients that are chronically red cell dependent: A survey in the Netherlands

BACKGROUND AND OBJECTIVES

Limited data are available to guide physicians on how to determine the red blood cell (RBC) transfusion regimen in chronically transfusion-dependent patients. The lack of clarity on thresholds and targets to be used for transfusion could easily result in either under or over transfusion in these patients. The aim of our survey is to investigate (1) transfusion thresholds; (2) number of RBC units given per transfusion episode; (3) interval between transfusions and (4) patient factors, like decreased cardiac function modulating the former.

MATERIALS AND METHODS

We sent a web-based 44-question survey to members of the Dutch Haematology Association.

RESULTS

Fifty physicians responded between June and October 2020 (response rate 30%), well-distributed between community and academic hospitals. A wide variation in transfusion strategies was reported: Most patients have transfused 1-2 RBC units (range: 0-3 units) every 2-4 weeks (range: 1-12 weeks) with a median threshold of 8.0 g/dl ranging from 6.4 to 9.6 g/dl. Patient-specific clinical factors that are most frequently reported to influence the transfusion strategy are angina pectoris, cardiac failure and dyspnoea, softer parameters that are of influence are the quality of life and self-sustainability.

CONCLUSION

The results of this survey indicate a broad variation in RBC transfusion strategies in Dutch patients with chronic transfusion dependency. While the current variation in transfusion strategies may be unavoidable in an individualized approach, randomized trials and better defined usable parameters to evaluate the effect of transfusion strategies are required to reach a consensus on how to determine the transfusion strategy.

Transfusion in orthopaedic surgery : a retrospective multicentre cohort study

Aims

Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.

Methods

We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma.

Results

Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon.

Conclusion

Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies.

Cite this article: Bone Jt Open 2021;2(10):850–857.

Allogeneic Red Blood Cell Transfusion Rate and Risk Factors After Hemiarthroplasty in Elderly Patients With Femoral Neck Fracture

Objective

This study aimed to determine the rate and risk factors of allogeneic red blood cell transfusions (ABT) after hemiarthroplasty (HA) in elderly patients with femoral neck fracture (FNF).

Methods

The subjects of the study were elderly patients (≥65 years old) who were admitted to the geriatric trauma orthopedics ward of Beijing Jishuitan Hospital between March 2018 and June 2019 for HA treatment due to an FNF. The perioperative data were collected retrospectively, and univariate and multivariate stepwise logistic regression analyses were performed to determine the post-operative ABT rate and its risk factors.

Results

There were 445 patients in the study, of whom 177 (39.8%) received ABT after surgery. Multivariate stepwise logistic regression analysis showed that preoperative low hemoglobin (Hb), high intraoperative blood loss (IBL), advanced age, and a low body mass index (BMI) are independent risk factors of ABT after HA in elderly FNF patients.

Conclusion

ABT after HA is a common phenomenon in elderly patients with FNF. Their post-operative ABT needs are related to preoperative low Hb, high IBL, advanced age, and low BMI. Therefore, ABT can be reduced by taking these factors into account. When the same patient had three risk factors (preoperative low hemoglobin, advanced age, and low BMI), the risk of ABT was very high (78.3%). Also, when patients have two risk factors of preoperative low hemoglobin and low BMI, the risk of ABT was also high (80.0%).

Patient characteristics, outcomes, and trends in extremity sarcoma management by surgeon specialty

BACKGROUND

Extremity soft tissue sarcoma is managed by oncological trained general or orthopedic surgeons, but limited data exist comparing patient characteristics and outcomes between the 2 specialties.

METHODS

Patients were identified from the 2008 to 2017 National Surgical Quality Improvement Program who underwent limb-sparing resection of extremity soft tissue sarcoma by either general surgeons or orthopedic surgeons. Multivariable logistic regression analysis identified factors associated with general surgeons compared with OS. Length of stay was assessed using Poisson regression. Procedure annual percent change was analyzed using Joinpoint Regression.

RESULTS

The majority of extremity soft tissue sarcoma cases were performed by general surgeons (N = 304, 69.4%), but general surgeons' resections significantly decreased (35.2%) over the study period (annual percent change -5.8, P < .0001). General surgeons' patients were less likely to receive neoadjuvant chemotherapy (2.0% vs 3.7%, P < .01), and more likely to receive neoadjuvant radiation (9.9% vs 5.2%, P < .01) and have normal preoperative white blood cell counts (77.0% vs. 66.4%, P = .02). Orthopedic surgeons' cases were more often performed under regional anesthesia (9.7% vs. 2.3%, P = .01), and orthopedic patients were more likely to receive postoperative transfusions (5.2% vs 0.3%, P < .01) and had a longer median length of stay (2 vs 1 days, P < .01). Thirty-day overall morbidity (7.2% general surgeon vs 9.7% orthopedic surgeon, P = .38) and all-cause mortality (0.3% general surgeon vs 0% orthopedic surgeon, P = .51) did not differ by specialty.

CONCLUSION

Although postoperative outcomes for extremity soft tissue sarcoma are comparable between general and orthopedic surgeons, treatment and perioperative management differences exist. Future investigation focused on understanding these differences in perioperative management across specialties may help identify areas for quality improvement in care of patients with extremity soft tissue sarcoma.

Simultaneous Bilateral Primary Total Knee Arthroplasty With TXA and Restrictive Transfusion Protocols: Still a 1 in 5 Risk of Allogeneic Transfusion

BACKGROUND

Historically, there was up to a 60% risk of blood transfusion for patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA). As such, the goal of this study was to analyze the rate and risk factors for allogeneic blood transfusions in patients undergoing SBTKA with tranexamic acid (TXA).

METHODS

We retrospectively identified 475 patients who underwent SBTKA with a double dose TXA regimen at a single institution from 2016 to 2019. Mean age was 65 years. Two hundred fifty-seven patients (54%) were female. Mean body mass index was 30 kg/m². Drains were utilized in 143 patients (30%). Mean preoperative hemoglobin (Hgb) was 13.7 g/dL. Multivariate logistic regression analysis adjusting for age ≥70 years, sex, body mass index, drain use, and preoperative Hgb of <12.5 g/dL was utilized to identify risk factors for transfusion.

RESULTS

One hundred six patients (22%) received an allogeneic transfusion, including 28 patients (6%) who received ≥2 units. Multivariate analysis showed that preoperative Hgb <12.5 (OR = 3.99, P < .0001), female sex (OR = 2.34, P = .002), and drain use (OR = 2.13, P = .004) were risk factors for transfusion. Forty-two patients (42/83, 51%) with a preoperative Hgb <12.5 received a transfusion compared with 64 patients (64/392, 16%) with a Hgb ≥12.5 (P < .001).

CONCLUSION

Patients undergoing SBTKA with contemporary blood management still have a 1 in 5 rate of allogeneic transfusion. Drain use independently increases transfusion risk by 2-fold and should be avoided. Patients with a preoperative Hgb <12.5 have a transfusion rate of 50% and, as such, should either not undergo SBTKA or have extensive perioperative blood optimization.

Tranexamic acid in patients with current or former cancer undergoing hip and knee arthroplasty

BACKGROUND AND OBJECTIVES

While tranexamic acid (TXA) is an excellent mechanism to reduce blood loss in arthroplasty, its safety in cancer patients-who could potentially benefit the most from blood conservation-is unknown.

METHODS

A multicenter, retrospective review of current or former cancer patients undergoing hip/knee arthroplasty from 2014 to 2019 was performed. The use of intravenous TXA, indication (oncologic/degenerative), cancer state, cancer type, surgical factors, demographics, and comorbidities were collected. The association between TXA use and 90-day/1-year complications was analyzed with multivariable logistic regressions.

RESULTS

We identified 282 patients with current (87.9%) or former (12.1%) malignancies undergoing arthroplasty (73.0% oncologic/27.0% degenerative). About 74 (26.2%) patients received TXA (52.7% had oncologic indications, 74.3% had active cancer). In adjusted analysis, TXA was not associated with increased risk of venous thromboembolism within 90-days (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.16-2.16, p = 0.43) or 1-year (OR 0.47; 95%CI 0.15-1.44, p = 0.19), with a trend towards lower risk. Similar results were seen for mortality and wound complications, and when stratifying by indication.

CONCLUSION

TXA was not associated with increased complications in current or former cancer patients undergoing arthroplasty. Future randomized studies of TXA in arthroplasty should include cancer patients; in the interim, clinicians should weigh the theoretical risks of TXA with the known benefits of reduced blood loss in oncology patients.

Variation in prophylactic tranexamic acid administration among anesthesiologists and surgeons in orthopedic surgery: a retrospective cohort study

PURPOSE

Tranexamic acid (TXA) reduces red blood cell transfusion in various orthopedic surgeries, yet the degree of practice variation in its use among anesthesiologists and surgeons has not been described. To target future knowledge transfer and implementation strategies, and to better understand determinants of variability in prophylactic TXA use, our primary objective was to evaluate the influence of surgical team members on the variability of prophylactic TXA administration.

METHODS

This was a retrospective cohort study of all adult patients undergoing primary total hip arthroplasty (THA), hip fracture surgery, and spine fusion ± vertebrectomy at two Canadian hospitals between January 2014 and December 2016. We used Canadian Classification of Health Interventions procedure codes within the Discharge Abstract Database which we linked to the Ottawa Data Warehouse. We described the percentage of patients that received TXA by individual surgery, the specifics of TXA dosing, and estimated the effect of anesthesiologists and surgeons on prophylactic TXA using multivariable mixed-effects logistic regression analyses.

RESULTS

In the 3,900 patients studied, TXA was most commonly used in primary THA (85%; n = 1,344/1,582), with lower use in hip fracture (23%; n = 342/1,506) and spine fusion surgery (23%; n = 186/812). The median [interquartile range] total TXA dose was 1,000 [1,000-1,000] mg, given as a bolus in 92% of cases. Anesthesiologists and surgeons added significant variability to the odds of receiving TXA in hip fracture surgery and spine fusion, but not primary THA. Most of the variability in TXA use was attributed to patient and other factors.

CONCLUSION

We confirmed the routine use of TXA in primary THA, while observing lower utilization with more variability in hip fracture and spine fusion surgery. Further study is warranted to understand variations in use and the barriers to TXA implementation in a broader population of orthopedic surgical patients at high risk for transfusion.

Rationale Therapie mit Erythrozytenkonzentraten – Update 2020

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

Defining postoperative transfusion thresholds in liver transplant recipients: A novel retrospective approach

BACKGROUND

The optimal transfusion threshold for most patient populations has been defined as hematocrit (HCT) <21%. However, some specific patient populations are known to benefit from higher transfusion thresholds. To date, the optimal postoperative transfusion threshold for patients undergoing liver transplant has not been determined. To define the ideal transfusion threshold for liver transplant patients, we designed a retrospective study of 496 liver transplant recipients.

METHODS

Using HCT prior to discharge as a surrogate marker for transfusion thresholds we grouped patients into three groups of transfusion thresholds (HCT <21%, <24%, and >30%). Transfusion rates (intra- and postoperative), graft and patient survival, and complications requiring readmission were compared between groups.

RESULTS

Ninety-two percent of patients were transfused during their hospital stay. Graft survival, patient survival, and rates of readmission within 30 days of discharge were no different between the three discharge HCT groups. Patients discharged with HCT >30% were less likely to be readmitted with infectious complications; however, this group also had the lowest model of end-stage liver (MELD) score at time of transplantation and were less likely to have received a transfusion during their hospital stay.

CONCLUSION

Transfusion thresholds of HCT <24%, and potentially as low as 21% are acceptable in postoperative liver transplant recipients. The conduct of a randomized clinical trial, as supported by these data, will be necessary to support the use of lower thresholds.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Cell salvage within adult and pediatric idiopathic scoliosis surgery: A random cross-sectional study

INTRODUCTION

This study aimed to evaluate the use of a cell savage and its impact on the amount of allogenic blood transfused to the patients during idiopathic scoliosis surgery.

METHODS

A total of 142 randomly selected patients with scoliosis had been included in this study. The adult group consisted of 78 patients, and the pediatric group, 64 patients. Both groups were divided into subgroups (pre-cell saver era and cell saver era). Data on the following parameters were collected: amount of blood transfused intraoperatively, within 24 h postoperatively, and overall. The number of patients who received transfusion was counted as the number of patients who avoided any transfusion. For statistical purposes, we performed unpaired student t-test, chi-square test, and Mann-Whitney test.

RESULTS

There was no significant difference in adult groups perioperatively. In the pediatric group, there was a statistically significant difference intraoperatively. Economic analysis of blood management showed positive numbers for both groups, where more than 1 unit of blood was transfused.

CONCLUSIONS

Statistical analysis showed the cost-effectiveness of the perioperative use of cell salvage during pediatric scoliosis surgery. Overall, the use of cell salvage during scoliosis surgery had a positive impact on both blood management and patient recovery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

PROSPERO CRD42019120503.

Long-Term Sustainability of a Quality Initiative Program on Transfusion Rates in Total Joint Arthroplasty: A Follow-Up Study

BACKGROUND

There are significant variations in transfusion rates among institutions performing total joint arthroplasty. We previously demonstrated that implementation of an educational program to increase awareness of the American Association of Blood Banks' transfusion guidelines led to an immediate decrease in transfusion rates at our facilities. It remained unclear how this initiative would endure over time. We report the long-term success and sustainability of this quality program.

METHODS

We reviewed the Michigan Arthroplasty Collaborative Quality Initiative data from 2012 through 2017 of all patients undergoing primary hip and knee arthroplasty at our institutions for preoperative and postoperative hemoglobin level, transfusion status, and number of units transfused and transfusions outside of protocol to identify changes surrounding our blood transfusion educational initiative. We calculated the transfusions prevented and cost implications over the course of the study.

RESULTS

We identified 6645 primary hip and knee arthroplasty patients. There was a significant decrease in transfusion rate and overall transfusions in each group when compared to pre-education values. Subgroup analysis of TKA and THA independently showed significant decreases in both transfusion rate and overall transfusions. Over the final 3 years of the study, only 2 patients were transfused outside of the American Association of Blood Banks protocol. We estimate prevention of 519 transfusions over the study period.

CONCLUSION

Application of this quality initiative was an effective means of identifying opportunities for quality improvement. The program was easily initiated, had significant early impact, and has been shown to be sustainable.

Preoperative embolization in surgical treatment of long bone metastasis: a systematic literature review

Surgery of long bone metastases is associated with a significant risk of perioperative blood loss, which may necessitate blood transfusion.

Successful embolization (> 70% obliteration of vascularity) can be achieved in 36–75% of cases.

The reported rate of embolization-related complications is 0–9%.

Three out of six level III evidence studies showed a reduction in perioperative blood loss and/or blood transfusion requirement after preoperative embolization of renal cell carcinoma metastasis in long bones; three out of six studies did not.

One level III evidence study did not show a reduction in perioperative blood loss and/or transfusion requirement after preoperative embolization of hepatocellular carcinoma metastases in long bones.

There were no studies found that support preoperative embolization of thyroid metastases or other frequent long bone metastases (e.g. mamma carcinoma, lung carcinoma, or prostate carcinoma).

The clinical level of evidence of the studies found is low and randomized studies taking into account primary tumour, location of metastases and type of surgery are therefore desired.

Cite this article: EFORT Open Rev 2020;5:17-25. DOI: 10.1302/2058-5241.5.190013

A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures

INTRODUCTION

In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population.

METHODS

In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation.

RESULTS

After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival.

DISCUSSION

A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Intraoperative cell salvage use reduces the rate of perioperative allogenic blood transfusion in patients undergoing periacetabular osteotomy

Blood loss during periacetabular osteotomy (PAO) is variable, with losses ranging from 100 to 3900 ml in published series. Perioperative allogenic blood transfusion is frequently utilized although is associated with significant risk of morbidity. Cell salvage (CS) is a common blood conservation tool; however, evidence supporting its use with PAO is lacking. Our aim was to assess whether CS affects perioperative allogenic blood transfusion rate in patients undergoing PAO. The clinical records of 58 consecutive PAOs in 54 patients (median age 24.7 years, interquartile range 17.8–29.4 years) performed by a single surgeon between 1 January 2016 and 30 April 2018 were reviewed. Autologous blood pre-donation and surgical drains were not used. Due to variable technician availability, CS was intermittently used during the study period. PAOs were allocated into a CS group or no cell salvage group (NCS group), according to whether an intraoperative CS system was used. There was no significant difference in patient age, gender, body mass index, dysplasia severity, regional anesthetic technique, tranexamic acid administration, surgical duration or estimated blood loss (all P > 0.05) between the two groups. The CS group had a lower preoperative hemoglobin compared to the NCS group (median, 13.4 g/dl versus 14.4 g/dl, P = 0.006). The incidence of allogenic blood transfusion was significantly lower in the CS group compared to the NCS group (2.5% versus 33.3% patients transfused, P = 0.003). Multivariate modeling showed CS use to be protective against allogenic blood transfusion (P = 0.003), with an associated 80-fold reduction in the odds of transfusion (odds ratio, 0.01; 95th% CI, 0–0.57). To our knowledge, this is the first study to assess the effect of CS use on allogenic transfusion rate in patients undergoing PAO. Our results demonstrate CS to be a mandatory component of blood conservation for all patients undergoing PAO.

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

INTRODUCTION

There has been a significant increase in the number of systematic reviews and meta-analyses of randomised controlled trials investigating thresholds for red blood cell transfusion. To systematically collate, appraise and synthesise the results of these systematic reviews and meta-analyses, we will conduct an overview of systematic reviews.

METHODS AND ANALYSIS

This is a protocol for an overview of systematic reviews. We will search five databases: MEDLINE, Embase, Web of Science Core Collection, PubMed (for prepublication, in process and non-Medline records) and Google Scholar. We will consider systematic reviews and meta-analyses of randomised controlled trials evaluating the effect of haemoglobin thresholds for red blood cell transfusion on mortality. Two authors will independently screen titles and abstracts retrieved in the literature search and select studies meeting the eligibility criteria for full-text review. We will extract data onto a predefined form designed to summarise the key characteristics of each review. We will assess the methodological quality of included reviews and the quality of evidence in included reviews.

ETHICS AND DISSEMINATION

Formal ethics approval is not required for this overview as we will only analyse published literature. The findings of this study will be presented at relevant conferences and submitted for peer-review publication. The results are likely to be used by clinicians, policy makers and developers of clinical guidelines and will inform suggestions for future systematic reviews and randomised controlled trials.

PROSPERO REGISTRATION NUMBER

CRD42019120503.

Pre-operative transfusions are associated with numerous post-operative complications in total hip arthroplasty

Primary total hip arthroplasty (THA) is among the most common surgical procedures and known to potentially cause significant blood loss. In total, 74,814 patients from the National Surgical Quality Improvement Project Database were studied. Complications were divided into post-operative and non-operative complications. Pre-operative transfusion in THA patients was found to be an independent predictor of infection (OR: 5.41), pneumonia (OR: 2.66), failure to wean (OR: 13.84), urinary tract infection (OR: 3.42), cardiac arrest (OR: 5.83), and transfusion post-operatively (OR: 5.94). Future medical decisions in primary THA cases should entail a careful risk-benefit and close monitoring in order to prevent complications.

Semiautomatic intermittent pneumatic compression device applied to deep vein thrombosis in major orthopedic surgery

Objective

To investigate the effect of additional semiautomatic intermittent pneumatic compression device (IPCD) in the prevention of deep vein thrombosis (DVT) of lower extremity in these patients undergoing major orthopedic surgery, when compared with the conventional graduated compression stockings alone.

Methods

The data of 112 patients undergoing major orthopedic surgery were retrospectively analyzed. 51 patients who ever received IPCD and graduated compression stockings during major orthopedic surgery were taken as the experimental group, and 61 patients who only received the conventional graduated compression stockings during surgery were taken as the observation group. The Doppler sonography was utilized to detect the presence of DVT and pulmonary embolism pre- and postoperatively. Besides, the mean and peak velocity of blood flow in femoral vein were recorded before and after surgery. And then, the comparisons between the two groups were made, respectively.

Results

When compared with the conventional graduated compression stockings alone, the intraoperative application of IPCD and stockings contributed the significant reduction of DVT (3.92%, 2/51 versus 9.84%, 6/61, X² = 5.632, P = 0.034). In terms of the mean and peak velocity of blood flow in femoral vein, the postoperative difference was higher in the observation group than those in the control group (149.56 ± 26.35 versus 130.15 ± 22.56 mm/s, P < 0.05). With respect to perioperative blood loss, the difference between the two groups was statistically significant (800.5 ± 320.7 versus 950.1 ± 305.9 ml, P = 0.031).

Conclusions

Intraoperative application of IPCD could promote blood circulation of lower limbs, and significantly decrease the incidence of potentially fatal DVT in patients undergoing major orthopedic surgery, when compared with the conventional graduated compression stockings.

Mortality, Morbidity and Related Outcomes Following Perioperative Blood Transfusion in Patients with Major Orthopaedic Surgery: A Systematic Review

Background

Benefits and risks of liberal and restrictive transfusion regimens are under on-going controversial discussion. This systematic review aimed at assessing both regimens in terms of pre-defined outcomes with special focus on patients undergoing major orthopaedic surgery.

Methods

We performed a literature search for mortality, morbidity and related outcomes following peri-operative blood transfusion in patients with major orthopaedic surgery in electronic databases. Combined outcome measure estimates were calculated within the scope of meta-analyses including randomised clinical trials comparing restrictive versus liberal blood transfusion regimens (e.g. MH risk ratio, Peto odds ratio).

Results

A total of 880 publications were identified 15 of which were finally included (8 randomised clinical trials (RCTs) with 3,693 patients and 6 observational studies with 4,244,112 patients). Regarding RCTs, no significant differences were detected between the transfusion regimes for all primary outcomes (30-day mortality, thromboembolic events, stroke/transitory ischaemic attack, myocardial infarction, wound infection and pneumonia) and a secondary outcome (length of hospital stay), whereas there was a significantly reduced risk of receiving at least one red blood concentrate under a restrictive regimen.

Conclusion

The results of this systematic review do not suggest an increased risk associated with either a restrictive or a liberal transfusion regimen in patients undergoing major orthopaedic surgery.