Bloodless surgery in geriatric surgery

Blood Management for the Orthopaedic Surgical Patient

Prevention and management of anemia and blood loss in the orthopaedic patient undergoing surgery is a major concern for healthcare providers and patients. Although transfusion technology can be lifesaving, there are risks to blood products that have led to increased awareness of blood management and development of hospital patient blood management programs. Use of patient blood management can be effective in addressing preoperative anemia, a major modifiable risk factor in patients undergoing surgery. In this informational article, evidence-based practice guidelines for perioperative blood management are addressed. A case scenario is introduced focusing on a patient whose religious preference is Jehovah's Witness having "no blood wishes" undergoing elective orthopaedic surgery. Orthopaedic nurses can facilitate optimal patient blood management through multidisciplinary collaboration.

Bloodless Management of the Anemic Patient in the Emergency Department

Anemia is a commonly encountered condition in emergency medicine; transfusion of packed red blood cells is commonly performed for anemic patients in the emergency department (ED), but some patients are unable to accept transfusion of blood products due to medical or religious concerns. The unique, acute, and time-sensitive nature of emergency medicine practice requires that physicians maintain an enhanced awareness of bloodless medicine treatment modalities. Identification of bloodless medicine patient preferences in the ED can help guide physicians in the recommendation of acceptable methods of treating anemia in this patient population. A focus on early hemostasis and resuscitation, instead of attempts to convince the patient to accept blood transfusion, can be lifesaving in patients with acute bleeding. Treatment strategies including the use of methods to reduce unnecessary blood loss, enhance red blood cell production, and increase the oxygen-carrying capacity of blood should also be considered early in patient presentation. Timely involvement of the Hospital Liaison Committee can help facilitate successful interpersonal communication and shared decisionmaking between emergency physicians and bloodless medicine patients. By embracing an understanding of bloodless medicine patient needs as well as available treatment strategies, ED physicians can contribute to optimal overall outcomes for anemic bloodless medicine patients.

Blood transfusion rates and predictors following geriatric hip fracture surgery

BACKGROUND

Postoperative blood product transfusions in elderly hip fracture patients cause concern for morbidity and mortality. The purpose of this study was to identify predictors and short-term sequelae of postoperative transfusion following geriatric hip fracture surgery.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify geriatric (⩾65 years) patients who sustained operative femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to determine risk-adjusted odds ratios (OR) of associated perioperative risk factors and sequelae of postoperative transfusion.

RESULTS

In total, 8416 geriatric hip fracture patients were identified of whom 28.3% had documented postoperative transfusion. In multivariate analysis, age (OR 1.03 [1.02-1.04], p < 0.001), preoperative anaemia (OR 4.69 [3.99-5.52], p = 0.001), female sex (OR 1.61 [1.39-1.87], p < 0.001), lower BMI (OR 0.97 [0.96-0.98], p < 0.001), American Society of Anesthesiologists (ASA) classification (OR 1.14 [1.01-1.27], p = 0.031), COPD (OR 1.30 [1.06-1.59], p = 0.011), hypertension (OR 1.17 [1.01-1.35], p = 0.038), increased OR time (OR 1.02 [1.01-1.03], p < 0.001), and intertrochanteric (OR 2.99 [2.57-3.49], p < 0.001) and subtrochanteric femur fractures (OR 5.07 [3.84-6.69], p < 0.001) were independent risk factors for receiving postoperative blood transfusion. Patients with postoperative transfusion had a significantly higher risk-adjusted 30-day mortality (8.4% vs. 6.4%, OR 1.29 [1.02-1.64], p = 0.035), hospital readmission rate (9.4% vs. 7.7%, OR 1.27 [1.04-1.55], p = 0.018), and total hospital LOS (7.3 vs. 6.3 days, p < 0.001).

CONCLUSIONS

Postoperative transfusion is a common occurrence in geriatric fragility hip fractures with multiple risk factors. Careful preoperative planning and multidisciplinary management efforts are warranted to reduce use of postoperative transfusions.

Feasibility of Hip Fracture Surgery Using a No Transfusion Protocol in Elderly Patients: A Propensity Score-Matched Cohort Study

OBJECTIVES

To determine whether hip fracture surgery (HFS) without transfusion affects postoperative mortality and complications in elderly patients.

DESIGN

Retrospective comparative study.

PATIENTS

Three hundred fourteen patients ≥65 years of age who underwent HFS between May 2003 and December 2014. Patients were divided into 2 groups: those who consented to blood transfusion if needed and those who did not. One-to-one propensity score matching generated 50 matched pairs of patients.

INTERVENTION

Patients underwent HFS with or without blood transfusion. In the no transfusion group, simultaneous administration of erythropoietin and iron was used as an alternative.

MAIN OUTCOME MEASUREMENTS

The primary outcome was postoperative mortality (90-day, 1-year, overall). The secondary outcomes were hemoglobin change and the incidence of postoperative complications.

RESULTS

HFS using a no transfusion protocol was not associated with increased mortality at any time point. Mean hemoglobin levels were significantly different between the 2 groups on postoperative day 1 (11.0 ± 1.3 vs. 10.5 ± 1.6, P = 0.002) but levels completely recovered within 2 weeks in both groups. There was also no difference in postoperative complication rates between the 2 groups, and overall hospital stays and charges were similar.

CONCLUSIONS

An HFS protocol without blood transfusion was not associated with increased mortality or complications in elderly patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.