Preoperative moderate renal impairment is an independent risk factor of transfusion in elderly patients undergoing hip fracture surgery and receiving low-molecular-weight heparin for thromboprophylaxis

Factors affecting the need of postoperative blood transfusion in elderly patients with intertrochanteric hip fracture

INTRODUCTION

We investigated the risk factors that increased the frequency of blood transfusions in elderly patients with intertrochanteric hip fractures to determine blood transfusion risk before surgery and to take selective precautionary measures in the group at high risk for transfusion to ensure safe surgery.

MATERIALS AND METHODS

We retrospectively reviewed the electronic medical records of 203 patients who underwent surgical fixation of intertrochanteric hip fractures from January 2015 to December 2020. We hypothesized that patient sex, age, body mass index, preoperative hemoglobin, preoperative platelet count, glomerular filtration rate (GFR), preoperative albumin level, American Society of Anesthesiologist score, intraoperative blood loss, duration of surgery, method of anesthesia, and time from injury to surgery would affect the need for blood transfusion. Student's t-test, Chi-squared test, and the one-way analysis of variance test were used to determine whether differences between variables in the transfusion and non-transfusion groups were significant.

RESULTS

Unstable fractures (P = 0.002), general anesthesia (P = 0.028), lower preoperative hemoglobin levels (P < 0.001), and lower GFRs (P < 0.001) were identified as related to blood transfusions in univariate analysis. In multivariate logistic analysis, the need for allogeneic blood transfusion in unstable fractures was approximately 2.949 times higher than in stable fractures (P = 0.009). The risk in general anesthesia patients was about 2.953 times higher than in spinal anesthesia patients (P = 0.007). In addition, the need for allogeneic blood transfusion increased by about 1.293 times as preoperative hemoglobin levels decreased by 1 g/dL (P = 0.017) and increased by about 1.017 times as the GFR decreased by 1 mL/min/1.7m2 (P = 0.006).

CONCLUSION

Low preoperative hemoglobin levels, low GFRs, general anesthesia, and unstable fractures in elderly patients with intertrochanteric hip fractures increased the risk of blood transfusion.

Can Total Joint Arthroplasty Be Safely Performed in Patients with Chronic Kidney Disease?

BACKGROUND

Patients suffering from chronic kidney disease are at greater risk of perioperative and postoperative complications. There is no systematic review study demonstrating whether total joint arthroplasty can be safely performed in patients with chronic kidney disease.

METHODS

A literature search was performed in the PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and Cochrane Library databases for information from the earliest date of data collection to September of 2018. Studies comparing the perioperative and postoperative outcomes of no-chronic kidney dysfunction (CKD) patients with those of CKD patients were included. Statistical heterogeneity was quantitatively evaluated by means of the χ2 test, with significance set at P < .10 or I2 > 50%.

RESULTS

Three articles consisting of 38,209 patients were included (35,363 no-CKD patients and 2,846 CKD patients). The results showed that CKD was related to a greater increase in postoperative infection rate, deep vein thrombosis, readmission, and mortality (P < .1). No differences in length of surgery, length of stay, pulmonary embolism, or revision were observed (P > .10).

CONCLUSIONS

Compared with no-CKD patients, CKD patients demonstrated an increased risk of perioperative and postoperative complications.

An analysis of postoperative hemoglobin levels in patients with a fractured neck of femur

Objectives

The aim of this study was to analyze the changes in hemoglobin level and to determine a suitable timeline for post-operative hemoglobin monitoring in patients undergoing fixation of femoral neck fracture.

Patients and methods

Patients who underwent either dynamic hip screw (DHS) fixation (n = 74, mean age: 80 years) or hip hemiarthroplasty (n = 104, mean age: 84 years) for femoral neck fracture were included into the study. The hemoglobin level of the patients was monitored perioperatively.

Results

Analysis found a statistically and clinically significant mean drop in hemoglobin of 31.1 g/L over time from pre-operatively (D0) to day-5 post-operatively (p < 0.001), with significant reductions from D0 to day-1 and day-1 to day-2 (p < 0.001). At each post-operative time point, DHS patients had lower hemoglobin values over hemiarthroplasty patients (p = 0.046).

Conclusion

The decrease in hemoglobin in the first 24-h post-operative period (D0 to day-1) is an underestimation of the ultimate lowest value in hemoglobin found at day-2. Relying on the day-1 hemoglobin could be detrimental to patient care. We propose a method of predicting patients likely to be transfused, and recommend a protocol for patients undergoing femoral neck fracture surgery to standardize postoperative hemoglobin monitoring.

Level of evidence

Level IV Prognostic study.

The Doppler renal resistive index for early detection of acute kidney injury after hip fracture

BACKGROUND

Postoperative acute kidney injury (AKI) is linked to an increase in morbidity and mortality, particularly in elderly populations. This study's aim was to assess the accuracy of the Doppler renal resistive index (RI) in detecting AKI at an early stage after hip fracture surgery.

METHODS

This prospective single-centre study included 48 patients suffering hip fractures requiring surgery and who presented risk factors for the development of AKI. The RI was calculated preoperatively and postoperatively in patients without pain and with haemodynamic and respiratory stability. The occurrence of AKI was determined by measurements of serum creatinine according to AKIN criteria.

RESULTS

Twenty-nine patients (60%) developed AKI during the first five postoperative days, without need for dialysis. The RI was increased in patients who developed postoperative AKI 0.68 (0.67-0.71) vs. 0.72 (0.7-0.73); P=0.014 for the preoperative index; and 0.6 (0.58-0.68) vs. 0.74 (0.71-0.76); P<0.0001 for the postoperative index. A postoperative index superior or equal to 0.706 is a marker for the early detection of AKI with a high sensitivity and a high specificity (76% and 89%, respectively).

CONCLUSION

The calculation of the RI during the perioperative periods of hip fracture surgery predicts early and effectively the postoperative occurrence of AKI, thus allowing treatment to be anticipated so as to improve patient prognosis.

Routine pre-operative group cross-matching in total knee arthroplasty: A review of this practice in an Asian population

BACKGROUND

Routine pre-operative group cross-match (GXM) and post-operative haemoglobin level measurements are performed for all total knee arthroplasty (TKA) patients in many institutions. We aimed to determine whether this practice is justified, and to identify predictors for post-operative transfusion.

MATERIALS AND METHODS

A retrospective review was performed on 226 TKA procedures performed between Jan. 2011 and Dec. 2013. Patients' demographics and clinical details including co-morbidities, pre-operative laboratory results, type of anaesthesia, surgery duration, post-operative haemoglobin level and transfusion requirement were reviewed.

RESULTS

Overall transfusion rate was 10.6% (n=24). Cross-match to transfusion ratio was 6.5. The cross-match to transfusion ratio (C:T ratio) was measured as the ratio of number of units of blood cross-matched to units of blood transfused. In females, relative risk of transfusion between patients with pre-operative haemoglobin below 12.0 and those above or equal to 12.0 was significant at 4.53 (Confidence interval (CI) 2.16 to 9.53). The relative risk of transfusion between patients above 65 years of age compared to those below 65 years of age was 1.13 (CI 1.03 to 1.23). Multivariate analysis revealed advancing age (p=0.044) and lower preoperative haemoglobin (p<0.001) as significant variables associated with post-operative transfusion.

CONCLUSION

Post-operative transfusion rates are low and excessive pre-operative GXM and post-operative haemoglobin checks are contributing to unnecessary medical costs. Predictors of blood transfusion risk in unilateral TKA in our cohort of Asian population were advancing age and lower pre-operative haemoglobin level. Type and screen tests should be performed for all other patients. LEVEL OF SCIENTIFIC EVIDENCE: 3.

The effect of chronic kidney disease on total hip arthroplasty

Patients with chronic kidney disease (CKD) undergoing total hip arthroplasty (THA) were evaluated for risk of revision, surgical site infection (SSI), thromboembolic events, mortality and readmission. 20,720 primary TKA cases were included (smaller sample for readmission evaluation, N = 9322). The prevalence of CKD among THA patients was 6.1% (N = 1269). After adjustment for age, gender, race, general health, and diabetes, CKD patients were at 1.4 (95% confidence interval 1.1-1.8) increased risk of readmission within 90 days. The adjusted risks for revision (overall, aseptic, and septic), SSI (deep and superficial), deep vein thrombosis, pulmonary embolism, and mortality (30-day, 90-day, ever) were not significantly different between patients with CKD and those without CKD. However, increased risk for 90-day readmission underscores that CKD patients are a fundamentally different population of patients.

Can total knee arthroplasty be safely performed in patients with chronic renal disease?

BACKGROUND AND PURPOSE

The prevalence of chronic renal disease (CRD) is rising worldwide. Patients with CRD are more likely to have associated medical problems and are at greater risk of postoperative morbidity and mortality. We evaluated patient characteristics and risk of early revision, surgical site infection (SSI), thromboembolic events, mortality, and re-admission of patients with CRD undergoing total knee arthroplasty (TKA). We hypothesized that this patient population would have higher rates of complications.

PATIENTS AND METHODS

We conducted a retrospective analysis of data that had been prospectively collected by a Total Joint Replacement Registry. All primary TKAs performed from 2005 through 2010 were included. 41,852 primary TKA cases were evaluated, of which 2,686 (6.4%) TKA procedures had been performed in CRD patients. Patient characteristics, comorbidities, and general health status were evaluated. Cox proportional hazard regressions and logistic regressions were used to evaluate the association of CRD with outcomes while adjusting for confounding variables. Results - The mean age of the CRD cohort was 67 years and approximately two-thirds of the patients were female. The median follow-up time was 2.1 years. Compared to TKA patients without CRD the CRD patients were older, had poorer general health, and had a higher prevalence of comorbidities. They had a higher incidence of deep SSI (0.9% vs. 0.7%), superficial SSI (0.5% vs. 0.3%), deep vein thrombosis (0.6% vs. 0.4%), any-time mortality (4.7% vs. 2.4%), 90-day mortality (0.4% vs. 0.2%), and 90-day re-admission (10% vs. 6.0%) than patients without CRD. However, after adjustment for confounding variables, CRD patients were at 1.9 times (95% CI: 1.1-3.5) increased risk of superficial SSI, 1.3 times (CI: 1.1-1.6) increased risk of re-admission within 90 days, and 1.5 times (CI: 1.2-1.8) increased risk of mortality at any point after the procedure. The risks of all other complications were not statistically significantly different in patients with CRD compared to patients without CRD.

CONCLUSIONS

CRD patients undergoing TKA have more comorbidities and a higher risk for superficial SSI, 90-day re-admission, and any-time mortality.