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Pavenski K, Ward SE, Hare GMT, Freedman J, Pulendrarajah R, Pirani RA, Sheppard N, Vance C, White A, Lo N, Waddell JP, Ho A, Schemitsch EH, Kataoka M, Bogoch ER, Saini K, David Mazer C, Baker JE. A rationale for universal tranexamic acid in major joint arthroplasty: overall efficacy and impact of risk factors for transfusion. Transfusion 2018; 59:207-216. [PMID: 30383292 DOI: 10.1111/trf.14995] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) therapy is effective in reducing postoperative red blood cell (RBC) transfusion in total joint arthroplasty (TJA), yet uncertainty persists regarding comparative efficacy and safety among specific patient subgroups. We assessed the impact of a universal TXA protocol on RBC transfusion, postoperative hemoglobin (Hb), and adverse outcomes to determine whether TXA is safe and effective in TJA, both overall and in clinically relevant subgroups. STUDY DESIGN AND METHODS A retrospective observational study was performed on patients undergoing TJA at our institution spanning 1 year before and after the implementation of a universal protocol to administer intravenous (IV) TXA. The primary outcome was percentage of patients transfused, and secondary outcomes were perioperative Hb and occurrence of adverse events (death, myocardial infarction, stroke, seizure, pulmonary embolism, deep vein thrombosis, and acute kidney injury ). Outcomes were compared in pre- and post-protocol groups with χ2 analysis. Logistic regression compared risk of transfusion in pre- and post-protocol subgroups of patients with differing risk for transfusion (anemia, body mass index [BMI], and sex). RESULTS No differences were found in baseline patient characteristics across pre- and post-protocol groups (n = 1084 and 912, respectively). TXA use increased from 32.3% to 92.2% while transfusion rates decreased from 10.3% to 4.8% (p < 0.001). Postoperative Day 3 Hb increased from 95.8 to 101.4 g/L (p < 0.001). Logistic regression demonstrated reduced transfusion in post-protocol subgroups regardless of sex, anemia, or BMI (p < 0.001). No increase in adverse events was observed (p = 0.8451). CONCLUSIONS Universal TXA was associated with a reduction of RBC transfusion, overall and in clinically relevant subgroups, strengthening the rationale for universal therapy.
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Affiliation(s)
- Katerina Pavenski
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, Ontario, Canada
| | - Sarah E Ward
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gregory M T Hare
- St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, Ontario, Canada.,Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - John Freedman
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Ontario Transfusion Coordinators (ONTraC), Toronto, Ontario, Canada
| | - Robisa Pulendrarajah
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Razak A Pirani
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas Sheppard
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Colm Vance
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alexander White
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nick Lo
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James P Waddell
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alex Ho
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Emil H Schemitsch
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark Kataoka
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Earl R Bogoch
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kiran Saini
- Department of Pharmacy, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - James E Baker
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Müller S, Oberle D, Drechsel-Bäuerle U, Pavel J, Keller-Stanislawski B, Funk MB. Mortality, Morbidity and Related Outcomes Following Perioperative Blood Transfusion in Patients with Major Orthopaedic Surgery: A Systematic Review. Transfus Med Hemother 2018; 45:355-367. [PMID: 30498414 DOI: 10.1159/000481994] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/29/2017] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Susanne Müller
- Division Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Langen, Germany
| | - Doris Oberle
- Division Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Langen, Germany
| | - Ursula Drechsel-Bäuerle
- Division Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Langen, Germany
| | - Jutta Pavel
- Division Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Langen, Germany
| | | | - Markus B Funk
- Division Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Langen, Germany
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3
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Mao T, Gao F, Han J, Sun W, Guo W, Li Z, Wang W. Restrictive versus liberal transfusion strategies for red blood cell transfusion after hip or knee surgery: A systematic review and meta-analysis. Medicine (Baltimore) 2017. [PMID: 28640148 PMCID: PMC5484258 DOI: 10.1097/md.0000000000007326] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Red blood cell (RBC) transfusions are commonly used in surgical patients, but accompanied by many risks such as metabolic derangement, and allergic and febrile reactions. Indications for transfusion in patients after hip or knee surgery have not been definitively evaluated and remain controversial. We performed a meta-analysis to compare the benefits and harms of restrictive versus liberal transfusion strategies in patients after hip or knee surgery. METHODS The PubMed, EMBASE, and Cochrane Library databases were searched for relevant studies through September 2015. The main clinical outcomes reported in randomized controlled trials (RCTs) included 30-day mortality, infection rate, cardiogenic complications, and length of hospital stay. The meta-analysis program of the Cochrane Collaboration (RevMan version 5.3.0) was used for data analysis. Statistical heterogeneity was assessed by both Cochran chi-squared test (Q test) and I test. Begg and Egger test were used to assess potential publication bias. RESULTS We identified 10 eligible RCTs, involving 3788 patients in total. In patients undergoing hip or knee surgery, we found no differences in mortality, or the incidence rates of pneumonia, wound infection, myocardial infarction, or congestive heart failure, between restrictive and liberal thresholds for RBC transfusion (P > .05). CONCLUSION Restrictive transfusion has no advantage over the liberal strategy. However, considerably less patients received blood transfusion via the restrictive strategy than with the liberal counterpart. Due to variations in the included studies, additional larger scale and well-designed studies are required to validate these conclusions.
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Affiliation(s)
- Tianli Mao
- Peking University China–Japan Friendship School of Clinical Medicine
| | - Fuqiang Gao
- Department of Orthopedic Surgery, China–Japan Friendship Hospital, Beijing, China
| | - Jun Han
- Peking University China–Japan Friendship School of Clinical Medicine
| | - Wei Sun
- Department of Orthopedic Surgery, China–Japan Friendship Hospital, Beijing, China
| | - Wanshou Guo
- Department of Orthopedic Surgery, China–Japan Friendship Hospital, Beijing, China
| | - Zirong Li
- Department of Orthopedic Surgery, China–Japan Friendship Hospital, Beijing, China
| | - Weiguo Wang
- Department of Orthopedic Surgery, China–Japan Friendship Hospital, Beijing, China
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4
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Noh JH, Lee JW, Nam YJ, Choi KY. Is Intraoperative Use of QuikClot Combat Gauze Effective for Hemostasis after Total Knee Arthroplasty? Clin Orthop Surg 2017; 9:43-49. [PMID: 28261426 PMCID: PMC5334026 DOI: 10.4055/cios.2017.9.1.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 10/11/2016] [Indexed: 11/29/2022] Open
Abstract
Background To assess the hemostatic effect of QuikClot Combat Gauze (QCG) compared to that of standard gauze during cruciate-retaining total knee arthroplasty (TKA). Methods Sixty knees underwent TKA using a pneumatic tourniquet in this prospective randomized study. After implantation of the femoral and tibial components and hardening of the bone cement, the tourniquet was deflated and QCG (group 1) or standard gauze (group 2) was packed into the joint cavity for 5 minutes for hemostasis. Perioperative bleeding volume and blood transfusion volume were compared between two groups. Results The mean intraoperative bleeding volume was 64.7 ± 12.7 mL in group 1 and 63.9 ± 9.2 mL in group 2 (p = 0.808). The mean postoperative blood drainage was 349.0 ± 170.6 mL in group 1 and 270.1 ± 136.3 mL in group 2 (p = 0.057). The average postoperative blood transfusion volume was 323.7 ± 325.9 mL in group 1 and 403.6 ± 274.8 mL in group 2 (p = 0.314). Conclusions QCG was not significantly effective for reducing perioperative bleeding volume or the blood transfusion rate compared with standard gauze during TKA.
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Affiliation(s)
- Jung Ho Noh
- Department of Orthopaedic Surgery, Kangwon National University Hospital, Chuncheon, Korea
| | - Jae Woo Lee
- Department of Orthopaedic Surgery, Kangwon National University Hospital, Chuncheon, Korea
| | - Young Joon Nam
- Department of Orthopaedic Surgery, Kangwon National University Hospital, Chuncheon, Korea
| | - Ki Yong Choi
- Department of Orthopaedic Surgery, Kangwon National University Hospital, Chuncheon, Korea
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5
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Hochreiter J, Hejkrlik W, Emmanuel K, Hitzl W, Ortmaier R. Blood loss and transfusion rate in short stem hip arthroplasty. A comparative study. INTERNATIONAL ORTHOPAEDICS 2016; 41:1347-1353. [PMID: 27942850 DOI: 10.1007/s00264-016-3365-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/28/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE Little scientific evidence on blood loss and transfusion rates after short-stem hip arthroplasty exists. The hypothesis of this study was that the blood loss and transfusion rate is lower in short stems compared to straight stems. METHODS We compared 124 patients who underwent total hip arthroplasty (THA) using a short-stem design (group 1) and 141 patients using a straight-stem design (group 2). All patients were operated on by the same surgeon, and both groups were similar in age, gender, affected side, body mass index, and ASA score. RESULTS The calculated blood loss was 1139 ml in group 1 and 1358 ml in group 2 (p < 0.001). The transfusion rate was 8% in group 1 and 15.6% in group 2 (p < 0.001). There was no significant difference between groups 1 and 2 regarding complications and operation time (p > 0.05). CONCLUSION Compared to patients after straight stem THA, both blood loss and blood transfusion rates were lower in patients after short stem THA.
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Affiliation(s)
- Josef Hochreiter
- Department of Orthopaedic Surgery, St. Vincent Hospital Linz, Seilerstätte 4, A-4020, Linz, Austria
| | - Wilfried Hejkrlik
- Department of Orthopaedic Surgery, St. Vincent Hospital Linz, Seilerstätte 4, A-4020, Linz, Austria
| | - Katja Emmanuel
- Department of Orthopaedic Surgery, St. Vincent Hospital Linz, Seilerstätte 4, A-4020, Linz, Austria
- Department of Orthopaedics and Traumatology, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria
| | - Wolfgang Hitzl
- Department of Biostatistics, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria
| | - Reinhold Ortmaier
- Department of Orthopaedic Surgery, St. Vincent Hospital Linz, Seilerstätte 4, A-4020, Linz, Austria.
- Department of Orthopaedics and Traumatology, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
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Eka A, Chen AF. Patient-related medical risk factors for periprosthetic joint infection of the hip and knee. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:233. [PMID: 26539450 DOI: 10.3978/j.issn.2305-5839.2015.09.26] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite advancements and improvements in methods for preventing infection, periprosthetic joint infection (PJI) is a significant complication following total joint arthroplasty (TJA). Prevention is the most important strategy to deal with this disabling complication, and prevention should begin with identifying patient-related risk factors. Medical risk factors, such as morbid obesity, malnutrition, hyperglycemia, uncontrolled diabetes mellitus, rheumatoid arthritis (RA), preoperative anemia, cardiovascular disorders, chronic renal failure, smoking, alcohol abuse and depression, should be evaluated and optimized prior to surgery. Treating patients to get laboratory values under a specified threshold or cessation of certain modifiable risk factors can decrease the risk of PJI. Although significant advances have been made in past decades to identify these risk factors, there remains some uncertainty regarding the risk factors predisposing TJA patients to PJI. Through a review of the current literature, this paper aims to comprehensively evaluate and provide a better understanding of known medical risk factors for PJI after TJA.
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Affiliation(s)
- Aleeson Eka
- Rothman Institute, Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Antonia F Chen
- Rothman Institute, Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
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7
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Abstract
Periprosthetic joint infection (PJI) has moved into the first place as the cause of failure following total knee arthroplasty (TKA). Recent studies have shown that PJI results in higher mortality in patients than many cancers. The economic burden of treating PJI is likely to exceed $1 billion this year in the US. Thus, it is paramount that all efforts are invested to prevent this dreaded complication after total joint arthroplasty (TJA). This article summarizes some of the most effective and proven strategies for prevention of PJI. It is hoped that the article will be of benefit to the readers of the journal.
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8
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Carling MS, Jeppsson A, Eriksson BI, Brisby H. Transfusions and blood loss in total hip and knee arthroplasty: a prospective observational study. J Orthop Surg Res 2015; 10:48. [PMID: 25889413 PMCID: PMC4383080 DOI: 10.1186/s13018-015-0188-6] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 03/16/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is a high prevalence of blood product transfusions in orthopedic surgery. The reported prevalence of red blood cell transfusions in unselected patients undergoing hip or knee replacement varies between 21% and 70%. We determined current blood loss and transfusion prevalence in total hip and knee arthroplasty when tranexamic acid was used as a routine prophylaxis, and further investigated potential predictors for excessive blood loss and transfusion requirement. METHODS/MATERIALS In total, 193 consecutive patients undergoing unilateral hip (n = 114) or knee arthroplasty (n = 79) were included in a prospective observational study. Estimated perioperative blood loss was calculated and transfusions of allogeneic blood products registered and related to patient characteristics and perioperative variables. RESULTS Overall transfusion rate was 16% (18% in hip patients and 11% in knee patients, p = 0.19). Median estimated blood loss was significantly higher in hip patients (984 vs 789 mL, p < 0.001). Preoperative hemoglobin concentration was the only independent predictor of red blood cell transfusion in hip patients while low hemoglobin concentration, body mass index, and operation time were independent predictors for red blood cell transfusion in knee patients. CONCLUSIONS The prevalence of red blood cell transfusion was lower than previously reported in unselected total hip or knee arthroplasty patients. Routine use of tranexamic acid may have contributed. Low preoperative hemoglobin levels, low body mass index, and long operation increase the risk for red blood cell transfusion.
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Affiliation(s)
- Malin S Carling
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, SE 413 45, Sweden. .,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden. .,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Bengt I Eriksson
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, SE 413 45, Sweden. .,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, SE 413 45, Sweden. .,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Stoicea N, Bergese SD, Ackermann W, Moran KR, Hamilton C, Joseph N, Steiner N, Barnett CJ, Smith S, Ellis TJ. Current status of blood transfusion and antifibrinolytic therapy in orthopedic surgeries. Front Surg 2015; 2:3. [PMID: 25729751 PMCID: PMC4325662 DOI: 10.3389/fsurg.2015.00003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 01/22/2015] [Indexed: 01/28/2023] Open
Affiliation(s)
- Nicoleta Stoicea
- Department of Anesthesiology, Wexner Medical Center, Ohio State University , Columbus, OH , USA
| | - Sergio D Bergese
- Department of Anesthesiology, Wexner Medical Center, Ohio State University , Columbus, OH , USA ; Department of Neurological Surgery, Wexner Medical Center, Ohio State University , Columbus, OH , USA
| | - Wiebke Ackermann
- Department of Anesthesiology, Wexner Medical Center, Ohio State University , Columbus, OH , USA
| | - Kenneth R Moran
- Department of Anesthesiology, Wexner Medical Center, Ohio State University , Columbus, OH , USA
| | - Charles Hamilton
- Department of Anesthesiology, Wexner Medical Center, Ohio State University , Columbus, OH , USA
| | - Nicholas Joseph
- Department of Neuroscience, Ohio State University , Columbus, OH , USA
| | - Nathan Steiner
- Drexel University College of Medicine , Philadelphia, PA , USA
| | | | - Stewart Smith
- College of Medicine, Wexner Medical Center, Ohio State University , Columbus, OH , USA
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Serghini I, Qamouss Y, Zoubir M, Lalaoui JS, Koulali IK, Boughalem M. [Anesthesia for total hip prosthesis: report of 50 cases]. Pan Afr Med J 2015; 22:379. [PMID: 27047619 PMCID: PMC4796777 DOI: 10.11604/pamj.2015.22.379.6938] [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: 04/29/2015] [Accepted: 05/27/2015] [Indexed: 11/17/2022] Open
Abstract
La chirurgie de la prothèse totale de la hanche (PTH) est une chirurgie fonctionnelle qui consiste en un remplacement d'une articulation endommagée afin d'améliorer la qualité de vie du patient. L'anesthésie pour PTH exige une préparation rigoureuse à l'intervention, la consultation d'anesthésie sera donc la clef de cette réussite. Nous avons réalisé une étude rétrospective concernant 60 arthroplasties totales de la hanche implantées chez 50 patients adultes, colligée au sevice de Traumatologie et de chirurgie orthopédique à l'Hôpital Militaire Avicenne de Marrakech sur une période étalée de Janvier 2010 au Décembre 2012. Nous avons évalué la prise en charge anesthésique: pré, per et postopératoire des patients opérés pour une PTH. La moyenne d’âge était de 56,5 ans, le sex-ratio était de 1,63 en faveur des hommes. L'indication prédominante était la coxarthrose primitive. L'anesthésie générale était la technique anesthésique la plus utilisée (66% des cas), l'intubation difficile était rencontrée chez 6% de nos patients. La durée moyenne de l'acte chirurgical était de 114 +/- 25,33 mn. 12% de nos patients ont présenté une hypotension artérielle peropératoire. L'incidence de la transfusion homologue perop était de 14%. Nous avons noté 08 cas de complications postop: 03 cas d'infection de la PTH 15 jours après l'intervention, 03 cas de descellement aseptique, 01 cas de luxation de PTH et 01 cas de descellement septique avec un recul moyen de 54 mois.
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Affiliation(s)
- Issam Serghini
- Pôle Anesthésie- Réanimation, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
| | - Youssef Qamouss
- Pôle Anesthésie- Réanimation, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
| | - Mohamed Zoubir
- Pôle Anesthésie- Réanimation, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
| | - Jaafar Salim Lalaoui
- Pôle Anesthésie- Réanimation, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
| | - Idrissi Khalid Koulali
- Pôle de Traumatologie et Orthopédie, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
| | - Mohamed Boughalem
- Pôle Anesthésie- Réanimation, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
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Kim TK, Chang CB, Koh IJ. Practical issues for the use of tranexamic acid in total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 2014; 22:1849-58. [PMID: 23542923 DOI: 10.1007/s00167-013-2487-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 03/22/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE This systematic review was undertaken to answer three specific questions relating to the clinical values of tranexamic acid (TNA) in total knee arthroplasty (TKA): (1) Whether there are differences in blood-saving effects between the systemic and topical administrations; (2) Whether blood-saving effects of TNA differ by doses and timings of administration; and (3) Whether the use of TNA is safe at all reported doses, timings, and routes of administration with respect to the incidences of symptomatic deep-vein thrombosis (DVT) and pulmonary embolism (PE). METHODS A systematic review was carried out with 28 randomised controlled trials to evaluate the efficacy and safety of TNA use in TKA identified from the literature. RESULTS Both systemic and topical administrations reduced blood loss after TKA, but transfusion reducing effects varied in studies whether systemic or topical administrations. The effects of TNA were influenced by doses and timings of administration. No increased incidences of symptomatic DVT and PE were found for all reported doses, timings, and routes of TNA administration. CONCLUSION Surgeons can consider incorporating the use of TNA to their blood-saving protocols in TKA without serious concern of adverse events but need to adopt optimal doses, timings, and routes of TNA administrations.
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Affiliation(s)
- Tae Kyun Kim
- Joint Reconstruction Center, Seoul National University Bundang Hospital, 166 Gumiro, Bundanggu, Seongnamsi, Gyeonggi-do, 463-707, Republic of Korea,
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12
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Kim TK, Chang CB, Kang YG, Seo ES, Lee JH, Yun JH, Lee SH. Clinical value of tranexamic acid in unilateral and simultaneous bilateral TKAs under a contemporary blood-saving protocol: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2014; 22:1870-8. [PMID: 23592025 DOI: 10.1007/s00167-013-2492-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 12/04/2012] [Indexed: 12/28/2022]
Abstract
PURPOSE Despite the documented blood-saving effects of tranexamic acid (TNA) in total knee arthroplasty (TKA), the question whether clinical values of TNA are identical in unilateral and bilateral TKAs remains unclear. This study was undertaken to determine the clinical values of TNA in unilateral and simultaneous bilateral TKAs under a contemporary blood-saving protocol in terms of efficacy (total blood loss and transfusion rate) and safety (the incidences of symptomatic deep vein thrombosis and pulmonary embolism). METHODS One hundred and eighty unilateral and 146 bilateral TKA patients were randomized into TNA group or control group. In unilateral TKA patients, TNA (10 mg/kg) was administered intravenously 20 min before tourniquet deflation and repeated 3 h after surgery. In bilateral TKA patients, one more dose (10 mg/kg) was given before tourniquet deflation in the second TKA. A contemporary blood-saving protocol was applied to all patients. The TNA and control groups were compared separately in unilateral and bilateral TKA patients for the efficacy and safety variables. RESULTS In unilateral TKA patients, the TNA group had less total blood loss (905 vs. 1,018 mL, p = 0.018) than the control group, but there was no difference in the allogenic transfusion rate (1 vs. 7 %, n.s.). In bilateral TKA patients, the TNA group showed no differences in total blood loss (1,282 vs. 1,379 mL, n.s.), but a significant reduction in the allogenic transfusion rate (7 vs. 27 %, p = 0.002). No symptomatic deep vein thrombosis or pulmonary embolism was found in all patients. CONCLUSION This study demonstrates that the use of TNA reduces total blood loss, but the effects on the transfusion rate can differ depending on the type of TKAs (unilateral vs. bilateral) and the blood-saving protocols.
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Affiliation(s)
- Tae Kyun Kim
- Joint Reconstruction Center, Seoul National University Bundang Hospital, 166 Gumiro, Bundanggu, Seongnamsi, 463-707, Gyeonggido, Republic of Korea,
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Baek SH. Identification and preoperative optimization of risk factors to prevent periprosthetic joint infection. World J Orthop 2014; 5:362-367. [PMID: 25035840 PMCID: PMC4095030 DOI: 10.5312/wjo.v5.i3.362] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 05/16/2014] [Indexed: 02/06/2023] Open
Abstract
Despite significant improvements over the past several decades in diagnosis, treatment and prevention of periprosthetic joint infection (PJI), it still remains a major challenge following total joint arthroplasty. Given the devastating nature and accelerated incidence of PJI, prevention is the most important strategy to deal with this challenging problem and should start from identifying risk factors. Understanding and well-organized optimization of these risk factors in individuals before elective arthroplasty are essential to the ultimate success in reducing the incidence of PJI. Even though some risk factors such as demographic characteristics are seldom changeable, they allow more accurate expectation regarding individual risks of PJI and thus, make proper counseling for shared preoperative decision-making possible. Others that increase the risk of PJI, but are potentially modifiable should be optimized prior to elective arthroplasty. Although remarkable advances have been achieved in past decades, many questions regarding standardized practice to prevent this catastrophic complication remain unanswered. The current study provide a comprehensive knowledge regarding risk factors based on general principles to control surgical site infection by the review of current literature and also share own practice at our institution to provide practical and better understandings.
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Blood management may have an impact on length of stay after total hip arthroplasty. HSS J 2014; 10:124-30. [PMID: 25050095 PMCID: PMC4071463 DOI: 10.1007/s11420-014-9384-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 03/18/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The steady rise in demand for total hip arthroplasty constitutes a significant and increasing burden on health care resources. The biggest contributors to the total cost of hip replacement procedures other than the price of the implant are hospital stay and postoperative rehabilitation. Blood management is one of the most adjustable factors that can impact length of stay and cost-efficiency while improving patient safety. QUESTIONS/PURPOSES The primary purpose of this retrospective study was to assess the potential impact of blood management interventions on length of hospital stay after primary unilateral total hip arthroplasty. This was achieved by first identifying which patient and surgical factors are associated with an increased risk of prolonged hospital stay. Subsequently, the significant factors were controlled for through a multivariate regression analysis to quantify the association between blood transfusions and increased hospital stay. METHODS Retrospectively, the study included 2,104 primary total hip replacements. Eight hundred eighty-eight procedures were performed on males and 1,216 on females, with a mean age of 64 years at the time of the surgery (range 18-94 years) and BMI of 28.6 kg/m(2) (range 12-51.5 kg/m(2)). The correlation between each factor and length of stay was analyzed separately using univariate regression analysis. Those variables with p ≤ 0.05 in the univariate model were selected for inclusion in the multivariate logistic regressions. Multiple linear regression was used to analyze the effect of each significant factor and derive odds ratios with adjustment for the other variables. RESULTS Multivariate Poisson regression revealed that increased length of stay was significantly correlated to patient age (p = 0.05), the use of coumadin (p = 0.02) or lovenox/heparin (p = 0.007) as opposed to aspirin for anticoagulation, and allogeneic blood transfusion (p < 0.0001). The data shows that allogeneic blood transfusion is associated with a longer hospital stay regardless of absolute drop in hemoglobin level postoperatively or at discharge or the number of units transfused (OR = 1.18, 95% CI = 1.09 to 1.28, p < 0.001). CONCLUSION Transfusion of allogeneic blood is independently associated with increased hospital stay after total hip arthroplasty. Blood management modalities that can significantly reduce transfusion risk could impact length of stay as well as the total cost of hip replacement procedures.
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Mohanlal PK, Sandiford N, Skinner JA, Samsani SR. Comparision of blood loss between computer assisted and conventional total knee arthroplasty. Indian J Orthop 2013; 47:63-6. [PMID: 23532765 PMCID: PMC3601237 DOI: 10.4103/0019-5413.106906] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bleeding during total knee arthroplasty (TKA) can cause significant morbidity and mortality. One proposed benefit of computer assisted TKA is decreased bleeding as the femoral canal is not invaded. This study assessed blood loss between computer assisted surgery (CAS) and conventional TKA. MATERIALS AND METHODS 73 consecutive patients (37 males, 36 females) underwent primary TKA between 2006 and 2009. Thirty eight patients underwent navigated TKA and 35 underwent conventional TKA for symptomatic osteoarthritis of the knee. These patients were matched for age, gender, and body mass index (BMI). Average age was 70.3 years (range 47-91 years). Mean BMI was 30 (range 17-49). Average preoperative hemoglobin was 13.26 g/dL (range 8.7-18.4 g/dL) in the navigated group and 13.47 g/dL (range 9.6-15.8 g/dL) in the conventional group (P = 0.9). Average tourniquet time was 110 min (range 90-150 min) in the navigated group and 96.7 min (range 60-145 min) in the conventional group (P = 0.77). RESULTS Average postoperative hemoglobin in the navigated group was 10.34 g/dL (range 7.5-14.8 g/dL) and in the conventional group was 10.03 g/dL (range 7.5-12.2 g/dL) (P = 0.17). Six patients in both groups required blood transfusions. The mean drain collection was 599 mL (range 150-1370 mL) in the navigated group and 562 mL (range 750-1000 mL) in the conventional group (P = 0.1724). These results suggest that there is no significant reduction in blood loss in CAS TKA. CONCLUSION These results suggest that there is no significant difference in blood loss in CAS TKA and conventional TKA. This study also highlights the heterogeneity of methods used in studies related to CAS TKA. We believe that there is a need for a large multicenter prospective randomized controlled trial to be performed before a consensus can be reached on the influence of CAS techniques on blood loss during primary TKA.
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Affiliation(s)
- Paras Kumar Mohanlal
- Department of Trauma and Orthopaedics, Medway Maritime Hospital, Gillingham, Kent, ME7 5NY, UK
| | - Nemandra Sandiford
- Department of Trauma and Orthopaedics, Medway Maritime Hospital, Gillingham, Kent, ME7 5NY, UK,Address for correspondence: Mr. N. Sandiford, 3 Eynswood, Sidcup, Kent, UK. E-mail:
| | - John A Skinner
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, UK
| | - SR Samsani
- Department of Trauma and Orthopaedics, Medway Maritime Hospital, Gillingham, Kent, ME7 5NY, UK
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Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop Relat Res 2012; 470:130-7. [PMID: 21874391 PMCID: PMC3237966 DOI: 10.1007/s11999-011-2043-3] [Citation(s) in RCA: 304] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of specific baseline comorbid conditions on the relative risk of postoperative mortality and periprosthetic joint infection (PJI) in elderly patients undergoing TKA has not been well defined. QUESTIONS/PURPOSES We calculated the relative risk of postoperative mortality and PJI associated with 29 comorbid conditions in Medicare patients undergoing TKA. PATIENTS AND METHODS The Medicare 5% sample was used to calculate the relative risk of 90-day postoperative mortality and PJI as a function of 29 preexisting comorbid conditions in 83,011 patients who underwent primary TKA between 1998 and 2007. RESULTS The independent risk factors for 90-day postoperative mortality (in decreasing order of significance) were congestive heart failure, metastatic cancer, renal disease, peripheral vascular disease, cerebrovascular disease, lymphoma, cardiac arrhythmia, dementia, pulmonary circulation disorders, and chronic liver disease. The independent risk factors for PJI (in decreasing order of significance) were congestive heart failure, chronic pulmonary disease, preoperative anemia, diabetes, depression, renal disease, pulmonary circulation disorders, obesity, rheumatologic disease, psychoses, metastatic tumor, peripheral vascular disease, and valvular disease. CONCLUSIONS We believe this information important when counseling elderly patients regarding the risks of mortality and PJI after TKA and risk-adjusting publicly reported TKA patient outcomes.
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Barr PJ, Donnelly M, Cardwell C, Alam SS, Morris K, Parker M, Bailie KEM. Drivers of transfusion decision making and quality of the evidence in orthopedic surgery: a systematic review of the literature. Transfus Med Rev 2011; 25:304-16.e1-6. [PMID: 21640550 DOI: 10.1016/j.tmrv.2011.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Reasons for variation in transfusion practice in orthopedic surgery are not well understood. This systematic review identified and appraised the quality of the literature in this area to assess the impact of factors associated with the use of allogeneic red blood cell (RBC) transfusion in orthopedic procedures. MEDLINE and EMBASE databases were searched for relevant English language publications. Articles containing a range of MeSH and text terms regarding "blood transfusion," "predictors," and "multiple logistic regression" were retrieved. Articles that focused on patients undergoing orthopedic procedures and that met prespecified inclusion criteria were appraised in terms of potential bias and the appropriateness of statistical approach. A total of 3641 citations were retrieved, and 29 met the inclusion criteria for the review. Articles reported on a range of orthopedic procedures including total hip arthroplasty; total knee arthroplasty, total shoulder arthroplasty, and spinal surgery. Most studies were conducted in the United States (n = 12) or Canada (n = 5). Study quality was moderate; 50% or more of the quality criteria were assessed in 15 articles. Particular areas of concern were the lack of prospective studies, lack of clarity in defining the time interval between risk factor assessment and transfusion outcome, and lack of model validation. A narrative synthesis found that 2 factors consistently influenced the use of RBC transfusion-decreased hemoglobin (n = 25) and increased patient age (n = 18). Increased surgical complexity (n = 12), low body weight (n = 9), presence of additional comorbidities (n = 9), and female sex (n = 7) were also important factors. The general quality of the studies in the field is weak. However, low hemoglobin and increasing age were consistently identified as independent risk factors for RBC transfusion in orthopedic practice. Additional or alternative analytical approaches are required to obtain a more comprehensive, holistic understanding of the decision to transfuse RBCs to patients undergoing orthopedic surgery.
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Affiliation(s)
- Paul James Barr
- Centre for Excellence in Public Health, Queen's University Belfast, Northern Ireland, UK.
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Revision total hip replacement: predictors of blood loss, transfusion requirements, and length of hospitalisation. J Orthop Traumatol 2010; 11:159-65. [PMID: 20835744 PMCID: PMC2948129 DOI: 10.1007/s10195-010-0105-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Accepted: 08/12/2010] [Indexed: 11/08/2022] Open
Abstract
Background Revision total hip replacement (THR) is associated with increased blood loss and extended hospitalization. Materials and methods We reviewed 146 patients who underwent revision THR to identify predictors of blood loss, transfusion requirements, and length of hospitalization. Results Blood loss was greater with increasing age and in men. Femoral and dual-component revision and revision of cemented hip components were also associated with greater blood loss. Transfusion requirements were greater in patients who had lower preoperative hemoglobin concentration and in patients undergoing dual-component revision. Length of hospitalization was significantly increased in patients who received transfusion but less in patients who underwent isolated acetabular-component hip revision. Conclusions This study shows significantly greater blood loss in men, older patients, revision surgery of cemented implants, and dual-component revisions. More complex revision surgery and preoperative anemia are clearly associated with increased transfusion requirements and length of hospitalization. Identification and treatment of patients at higher risk of transfusion may guide likely transfusion requirements, shorten the length of hospitalization, and reduce the overall cost of treatment.
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Alternative procedures for reducing allogeneic blood transfusion in elective orthopedic surgery. HSS J 2010; 6:190-8. [PMID: 21886535 PMCID: PMC2926355 DOI: 10.1007/s11420-009-9151-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 12/01/2009] [Indexed: 02/07/2023]
Abstract
Perioperative blood loss is a major problem in elective orthopedic surgery. Allogeneic transfusion is the standard treatment for perioperative blood loss resulting in low postoperative hemoglobin, but it has a number of well-recognized risks, complications, and costs. Alternatives to allogeneic blood transfusion include preoperative autologous donation and intraoperative salvage with postoperative autotransfusion. Orthopedic surgeons are often unaware of the different pre- and intraoperative possibilities of reducing blood loss and leave the management of coagulation and use of blood products completely to the anesthesiologists. The goal of this review is to compare alternatives to allogeneic blood transfusion from an orthopedic and anesthesia point of view focusing on estimated costs and acceptance by both parties.
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Subcutaneous versus intraarticular indwelling closed suction drainage after TKA: a randomized controlled trial. Clin Orthop Relat Res 2010; 468:2168-76. [PMID: 20127212 PMCID: PMC2895852 DOI: 10.1007/s11999-010-1243-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Accepted: 01/14/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND TKA can involve substantial bleeding, and the issue regarding whether vacuum drainage should be used during TKA continues to be debated as both methods have disadvantages. QUESTIONS/PURPOSES We therefore asked whether subcutaneous indwelling vacuum drainage is advantageous over intraarticular indwelling vacuum drainage in terms of blood drainage, bleeding-related complications, and functional outcomes in primary TKA. PATIENTS AND METHODS We randomized 111 patients undergoing TKAs to have either a subcutaneous indwelling or an intraarticular indwelling catheter and compared the two groups for blood loss (hemoglobin decrease, transfusion requirements, hypotension episode), incidence of wound problems (requirements for dressing reinforcement, oozing, hematoma, hemarthrosis, ecchymosis, infection), and functional outcomes (recovery of motion arc, American Knee Society, WOMAC, and SF-36 scores) at 12 months after surgery. RESULTS The mean vacuum drainage volume was less in the subcutaneous indwelling group than in the intraarticular indwelling group (140 mL versus 352 mL). The groups were similar in terms of decreases in hemoglobin after 2 and 5 days (3.0 versus 3.3 g/dL and 3.3 versus 3.7 g/dL, respectively), allogenic transfusion requirements (4% versus 11%), incidence of wound problems, and functional scores. CONCLUSIONS The data suggest subcutaneous indwelling closed-suction drainage is a reasonable alternative to intraarticular indwelling closed-suction drainage and to no suction drainage. LEVEL OF EVIDENCE Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Yang C, Zhu Q, Han Y, Zhu J, Wang H, Cong R, Zhang D. Minimally-invasive total hip arthroplasty will improve early postoperative outcomes: a prospective, randomized, controlled trial. Ir J Med Sci 2009; 179:285-90. [DOI: 10.1007/s11845-009-0437-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2009] [Accepted: 09/16/2009] [Indexed: 10/20/2022]
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Beyer J, Wessela S, Hakenberg OW, Kuhlisch E, Halbritter K, Froehner M, Wirth MP, Schellong SM. Incidence, risk profile and morphological pattern of venous thromboembolism after prostate cancer surgery. J Thromb Haemost 2009; 7:597-604. [PMID: 19143928 DOI: 10.1111/j.1538-7836.2009.03275.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is the most common non-surgical complication after major pelvic surgery. Little is known about the risk factors or the time of development of postoperative venous thrombosis. METHODS A cohort of 523 consecutive patients undergoing radical prostatectomy with lymphadenectomy was prospectively assessed by complete compression ultrasound at days -1, +8 and +21. RESULTS Complete data were available in 415 patients, while four patients had VTE before surgery and were excluded from the analysis. In the remaining 411 patients, 71 VTE events were found in 69 patients (16.8%). Most were limited to calf muscle veins (56.5%), followed by deep calf vein thrombosis (23.2%), proximal deep vein thrombosis (DVT, 14.5%) and pulmonary embolism (PE, 5.8%). Of the 14 patients with proximal DVT/PE, 11 patients (78.6%) developed VTE between days 8 and 21. Risk factors for VTE were a personal history of VTE (OR 3.0), pelvic lymphoceles (LCs) impairing venous flow (OR 2.8) and necessity of more than two units of red blood cells (OR 2.6). CONCLUSION Venous thromboembolism is common after radical prostatectomy. A significant proportion develops after day 8, suggesting that prolonged heparin prophylaxis should be considered. Since LCs with venous flow reduction result in higher rates of VTE, hemodynamically relevant lymphoceles should be surgically treated.
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Affiliation(s)
- J Beyer
- Division of Vascular Medicine, Department of Medicine, Technical University Dresden, Dresden, Germany.
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23
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Reinfusion of unwashed salvaged blood after total knee arthroplasty in patients with rheumatoid arthritis. INTERNATIONAL ORTHOPAEDICS 2008; 33:1615-8. [PMID: 18853156 DOI: 10.1007/s00264-008-0661-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Revised: 08/06/2008] [Accepted: 08/06/2008] [Indexed: 10/21/2022]
Abstract
Autotransfusion with unwashed salvaged blood (USB) is effective for avoiding allogeneic blood transfusion (ABT) in patients undergoing total knee arthroplasty (TKA). We performed a retrospective study to determine the percentage of patients receiving ABT and the volume of postoperative blood drainage after introduction of autotransfusion with USB for patients with rheumatoid arthritis (RA) undergoing TKA. In 100 patients without autotransfusion (group 1) and 100 patients receiving autotransfusion of USB (group 2), we compared the number of patients who required ABT, as well as the postoperative drainage volume, ABT volume, and autotransfusion volume. In group 1, 83% of the patients received ABT, while only 47% received ABT in group 2, and there was a significant decrease (p < 0.001). However, the postoperative drainage volume was significantly increased in group 2 (p < 0.001).
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Regis D, Corallo F, Franchini M, Rosa R, Ricci M, Bartolozzi P. Preoperative autologous blood donation in primary total knee arthroplasty: critical review of current indications. ACTA ACUST UNITED AC 2008; 91:41-4. [PMID: 18320372 DOI: 10.1007/s12306-007-0007-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2006] [Accepted: 11/02/2007] [Indexed: 11/29/2022]
Abstract
Preoperative autologous blood donation (PABD) is a well established transfusion practice in elective orthopaedic surgery, involving immunologic and infective advantages but also involving exposure to not negligible risks, and costs as well. The aim of this study was to assess the real need for blood transfusions in primary total knee arthroplasty (TKA). Between January 2000 and July 2005, 214 patients underwent primary unilateral TKA. Altogether, 416 autologous blood units were collected, however only 47 (11.3%) were transfused. Thirty-eight patients (17.8%) received autologous blood, while 4 of them (10.5%) also received allogeneic blood. Based on the results of this study, PABD should be recommended in well selected patients undergoing TKA: older female patients with a low basal haemoglobin level.
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Affiliation(s)
- Dario Regis
- Department of Orthopaedic Surgery, University Hospital of Verona, Verona, Italy.
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25
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Dowsey MM, Choong PFM. Obesity is a major risk factor for prosthetic infection after primary hip arthroplasty. Clin Orthop Relat Res 2008; 466:153-8. [PMID: 18196388 PMCID: PMC2505299 DOI: 10.1007/s11999-007-0016-3] [Citation(s) in RCA: 207] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2007] [Accepted: 10/03/2007] [Indexed: 01/31/2023]
Abstract
UNLABELLED The incidence of obesity and the number of hip arthroplasties being performed in Australia each year are increasing. Although uncommon, periprosthetic infection after surgery can have a devastating effect on patient outcomes. We therefore asked whether obesity correlated with periprosthetic infection after primary hip arthroplasty. We further asked whether variables such as patient comorbidities, operative time, blood transfusions, use of drains, and cementation practices correlated with periprosthetic infection. We hypothesized obesity was an independent risk factor for the development of acute periprosthetic infection after primary hip arthroplasty. We reviewed 1207 consecutive primary hip arthroplasties separating patients into four weight groups, normal, overweight, obese, and morbidly obese, and compared for incidence of periprosthetic infection between the groups. We observed a considerably higher infection rate in obese patients; the correlation was independent of patient comorbidities such as diabetes and cardiovascular disease. We also observed a correlation between infection rates and using a posterior approach in obese patients. The incidence of periprosthetic infection was not influenced by operative time, transfusion requirements, use of drains, and cementation practices. In this series, obesity was an independent risk factor for acute periprosthetic infection after primary hip arthroplasty. LEVEL OF EVIDENCE Level II, prognostic study.
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Affiliation(s)
- Michelle M. Dowsey
- Department of Orthopaedics, St Vincent’s Hospital, Melbourne University, PO Box 2900, Fitzroy 3065 Melbourne, Victoria Australia ,Department of Surgery, St Vincent’s Hospital, Melbourne, Australia
| | - Peter F. M. Choong
- Department of Orthopaedics, St Vincent’s Hospital, Melbourne University, PO Box 2900, Fitzroy 3065 Melbourne, Victoria Australia ,Department of Surgery, St Vincent’s Hospital, Melbourne, Australia
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Mirza SB, Campion J, Dixon JH, Panesar SS. Efficacy and economics of postoperative blood salvage in patients undergoing elective total hip replacement. Ann R Coll Surg Engl 2007; 89:777-84. [PMID: 17999819 DOI: 10.1308/003588407x209310] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Patients undergoing total hip replacement (THR) regularly receive allogenic blood transfusions. The infusion of allogenic blood exposes the recipient to significant risks including the transmission of infection, anaphylactic and haemolytic reactions. The purpose of this study was to determine the effect of introducing a system to retransfuse salvaged drainage blood in patients undergoing primary THR. PATIENTS AND METHODS We reviewed records of 109 consecutive patients who underwent THR following the introduction of the ABTrans autologous retransfusion system at our institution in January 2000. For comparison, we reviewed the medical records of 109 patients who underwent the same procedure immediately before the introduction of the retransfusion system. RESULTS Overall, 9% of patients treated with blood salvage and 30% treated without blood salvage required allogenic blood transfusions. Patients treated with the salvage system had significantly smaller haemoglobin drops in the peri-operative period (difference 0.56 g/dl; P = 0.001). The overall cost of using the retransfusion system was similar to that of routine vacuum drainage when the savings of reduced allogenic blood transfusion were taken into account. CONCLUSIONS The retransfusion of postoperative drainage blood is a simple, effective and safe way of providing autologous blood for patients undergoing primary THR.
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Affiliation(s)
- Saqeb B Mirza
- Department of Orthopaedics, Weston General Hospital, Weston-super-Mare, Somerset, UK.
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Guay J. Postoperative Pain Significantly Influences Postoperative Blood Loss in Patients Undergoing Total Knee Replacement. PAIN MEDICINE 2006; 7:476-82. [PMID: 17112361 DOI: 10.1111/j.1526-4637.2006.00236.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Although hypertension has long been recognized as a factor that might increase intraoperative blood losses in major orthopedic surgery, the effects of postoperative pain-induced hypertension on blood losses have not so far been evaluated. The aim of this study was to evaluate the effect of pain on perioperative blood losses of patients undergoing primary total knee replacement (TKR). METHODS Data from patients participating in a randomized clinical trial comparing intravenous patient-controlled analgesia (PCA) (N = 20) with PCA plus continuous femoral nerve (three-in-one) block (N = 20) or PCA plus continuous posterior lumbar plexus (psoas compartment) block (N = 20) were prospectively and retrospectively collected. Correlations between relevant variables and measured and calculated blood loss, number of transfused unit, and late (96 hours) postoperative hemoglobin were tested by linear regressions. Stepwise regressions for each of the four above-mentioned goals were constructed using a probability to enter of 0.25 and to leave of 0.1. A P < 0.05 was considered significant. RESULTS At the stepwise regressions there was a significant positive correlation between measured blood losses and morphine consumption from 12 to 18 hours (P = 0.006); between calculated blood loss and preoperative mean arterial blood pressure (P = 0.01) and preoperative hemoglobin value (P = 0.02); and between late postoperative hemoglobin and body weight (P = 0.047). CONCLUSION In patients undergoing TKR, there is a significant correlation between measured blood loss and morphine consumption from 12 to 18 hours. It is concluded that postoperative pain significantly influences postoperative blood loss in patients undergoing TKR.
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Affiliation(s)
- Joanne Guay
- Department of Anesthesiology, Maisonneuve-Rosemont Hospital, University of Montreal, 5415 L'Assomption Boulevard, Montreal, Quebec, Canada.
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Deutsch A, Spaulding J, Marcus RE. Preoperative epoetin alfa vs autologous blood donation in primary total knee arthroplasty. J Arthroplasty 2006; 21:628-35. [PMID: 16877146 DOI: 10.1016/j.arth.2005.12.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Accepted: 12/02/2005] [Indexed: 02/01/2023] Open
Abstract
This prospective randomized trial compared preoperative autologous blood donation (PAD) with epoetin alfa in patients undergoing primary total knee reconstruction. Fifty adult patients with pretreatment hemoglobin level of 100 to 130 g/L were randomized to either epoetin alfa 40,000 U at preoperative days 14 and 7 or to a standard PAD protocol. Patient characteristics and operative blood loss were similar between groups. Baseline hematological parameters for epoetin alfa vs PAD were not significantly different; however, by the day of surgery the epoetin alfa group had significantly higher hemoglobin (130 vs 114 g/L; P < .001), hematocrit (0.408 vs 0.352; P < .001), and reticulocyte count (3.4 vs 2.1 x 10(9) cells per liter; P < .001). These differences remained significant for 1 to 2 days postoperatively. There was no significant difference in the incidence of allogeneic transfusions between groups (28% for epoetin alfa vs 8% for PAD; P = .1383). Both treatments were generally well tolerated. Epoetin alfa appears to be a safe alternative to PAD in patients who are at risk for transfusion in the perioperative period following total knee arthroplasty.
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Affiliation(s)
- Allen Deutsch
- Department of Orthopedic Surgery, Kelsey-Seybold Clinic, Baylor College of Medicine, Houston, Texas 77025, USA
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Franchini M, Regis D, Gandini G, Corallo F, de Gironcoli M, Aprili G. Preoperative autologous blood donation in primary total knee arthroplasty: a single-centre experience on 214 consecutive patients. Vox Sang 2006; 90:191-4. [PMID: 16507019 DOI: 10.1111/j.1423-0410.2006.00750.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Although preoperative autologous blood donation (PABD) is a widespread practice in elective orthopedic surgery, it is controversial whether this procedure avoids allogeneic blood transfusions in patients undergoing total knee arthroplasty (TKA). PATIENTS AND METHODS We performed a retrospective study on 214 consecutive patients undergoing PABD before elective primary TKA. RESULTS Thirty-eight patients (17.8%) were transfused with autologous red blood cells (RBC), while four of them (10.5% of those requiring transfusions, 1.9% of all patients) also received allogeneic RBC. The transfused patients were, in most cases, female and had significantly lower basal and preoperative haemoglobin levels. CONCLUSIONS Based on the results of this study, PABD is not necessary in most patients undergoing TKA, although older female patients with low basal haemoglobin levels could benefit from a predeposit programme and/or erythropoietin support in order to reduce the risk of exposure to allogeneic blood.
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Affiliation(s)
- M Franchini
- Servizio di Immunoematologia e Trasfusione, Azienda Ospedaliera di Verona, Verona, Italy.
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Gasparini G, Papaleo P, Pola P, Cerciello S, Pola E, Fabbriciani C. Local infusion of norepinephrine reduces blood losses and need of transfusion in total knee arthroplasty. INTERNATIONAL ORTHOPAEDICS 2006; 30:253-6. [PMID: 16521017 PMCID: PMC2532120 DOI: 10.1007/s00264-005-0050-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 11/29/2005] [Indexed: 10/24/2022]
Abstract
Blood loss after total knee arthroplasty (TKA) is often associated with cardiovascular complications and a high transfusion rate of allogenic blood. In our study we focused our attention on developing a new intra-surgical procedure that appears safe, easy to perform and effective in the reduction of bleeding in TKA. We evaluated 84 patients who underwent TKA and met our inclusion criteria; they were assigned to two groups: 55 controls in which a saline solution was used to wash the surgical field before tourniquet release, and a second group of 29 patients, in which a saline solution containing a low dose of norepinephrine was locally applied before tourniquet release. The local administration of a low dose of norepinephrine has induced a significant reduction of perioperative blood loss and blood transfusion requirements; in addition, this method was characterised by the absence of complications or adverse effects. In conclusion, our data suggest that intraoperative local administration of a low dose of norepinephrine could represent an effective and safe method of reducing blood loss and preventing blood transfusions in patients with TKA.
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Affiliation(s)
- G. Gasparini
- Department of Orthopedics, A. Gemelli University Hospital, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - P. Papaleo
- Department of Medicine, A. Gemelli University Hospital, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
- Istituto di Patologia Speciale Medica e Semeiotica Medica, A. Gemelli University Hospital, L.go A. Gemelli 8, 00168 Rome, Italy
| | - P. Pola
- Department of Medicine, A. Gemelli University Hospital, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - S. Cerciello
- Department of Orthopedics, A. Gemelli University Hospital, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - E. Pola
- Department of Orthopedics, A. Gemelli University Hospital, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - C. Fabbriciani
- Department of Orthopedics, A. Gemelli University Hospital, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
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Rosencher N, Poisson D, Albi A, Aperce M, Barré J, Samama CM. Two injections of erythropoietin correct moderate anemia in most patients awaiting orthopedic surgery. Can J Anaesth 2005; 52:160-5. [PMID: 15684256 DOI: 10.1007/bf03027722] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The primary objective of this study was to assess the number of erythropoietin (EPO) injections required to reach a hematocrit (Ht) of 40% in moderately anemic patients. The secondary objective was to compare this strategy with autologous blood donation (ABD) in elective orthopedic surgery in terms of red blood cell (RBC) production. STUDY DESIGN AND METHODS 93 patients with a baseline Ht between 30 and 39% were randomized into two groups the day of the preoperative assessment. In the EPO group, patients received 40,000 UI/week sc until they reached a maximal Ht of 40%. In the ABD group, a RBC pack was collected every week as long as the Ht was above 33%. RESULTS Two EPO injections were necessary to reach a 40% Ht in 63% of the patients. It was possible to collect two RBC packs in 45% of the patients in the ABD group. Volume of RBC production was significantly higher in the EPO group: 268 +/- 142 mL vs 141 +/- 129 (P = 0.0001). In the EPO group, Ht was significantly higher on days one and three after surgery and at discharge. The energy score was better in the EPO group. In the ABD group, 12.6% patients vs 6.5% in the EPO group received allogeneic transfusion (ns). CONCLUSION Only two EPO injections were sufficient to reach a Ht of 40% in the majority of patients. Therefore, to improve cost/effectiveness, the number of EPO injections should be related to baseline Ht instead of the four injections recommended in the product monograph.
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Affiliation(s)
- Nadia Rosencher
- Paris M5 University-Cochin Hospital, 27 rue du Faubourg St Jacques, 75014 Paris, France.
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Khanna MP, Hébert PC, Fergusson DA. Review of the clinical practice literature on patient characteristics associated with perioperative allogeneic red blood cell transfusion. Transfus Med Rev 2003; 17:110-9. [PMID: 12733104 DOI: 10.1053/tmrv.2003.50008] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There is evidence to suggest that there exists considerable variation in red blood cell (RBC) transfusion practices, especially in the surgical specialties. This is in large part related to difficulties in defining specific transfusion threshold criteria, given that there is no minimum acceptable hemoglobin threshold concentration and there is variability in assigning importance to patient factors. The purpose of this study is to identify patient-related factors that might be associated with the need for allogeneic RBC transfusion in surgical patients. We systematically identified, selected, and reviewed all observational or interventional studies describing patient-specific or related variables associated with the need for allogeneic RBC transfusion in the surgical patient population. We also evaluated the methodological characteristics of the individual studies. Sixty-two studies met our inclusion criteria and were analyzed for this review. Most of these studies were conducted in patients undergoing cardiac surgery (n = 30) and orthopedic surgery (n = 16). Decreased preoperative red cell reserve was most frequently associated with RBC transfusions, being identified as a significant variable in 46 studies. The other factors commonly associated with transfusion were advancing age (n = 28), female gender (n = 21), and small body size (n = 14). Only 2 studies attempted to prospectively validate a predictive model for RBC transfusion based on the variables identified. This systematic review shows that preoperative anemia, advancing age, female gender, and small body size are often associated with perioperative allogeneic RBC transfusion. However, the retrospective nature of most of the studies and the small sample sizes make it difficult to formulate a clinically useful prediction rules regarding allogeneic RBC transfusion. Ongoing research in designing large prospective cohort studies evaluating transfusion patterns are needed to further elucidate how patient characteristics impact the transfusion threshold.
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Affiliation(s)
- Madhu Priya Khanna
- Centre for Transfusion Research/Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
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DiGioia AM, Plakseychuk AY, Levison TJ, Jaramaz B. Mini-incision technique for total hip arthroplasty with navigation. J Arthroplasty 2003; 18:123-8. [PMID: 12629599 DOI: 10.1054/arth.2003.50025] [Citation(s) in RCA: 240] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
This prospective study compares a mini-incision technique and traditional posterior approach for total hip arthroplasty (THA). Thirty-three patients who had undergone a mini-incision THA were matched by diagnosis, gender, average age, and preoperative Harris Hip Score (HHS) to 33 patients who had undergone THA using the traditional posterior approach. The average length of the incision for group 1 was 11.7 cm (range, 7.3-13.0) and for group 2 was 20.2 cm (range, 14.8-26.0). At the 3-month follow-up, patients in the mini-incision group had significant improvement in limp (P<.05) and ability to climb stairs (P <.01) compared with the traditional group. At the 6 month follow-up, the mini-incision group was significantly better in terms of limp (P <.05), distance walked (P<.001), and stairs (P < 0.001). There was no significant difference between groups for pain, function, or range of motion at the 1-year follow-up examination.
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Affiliation(s)
- Anthony M DiGioia
- Institute for Computer Assisted Orthopaedic Surgery, The Western Pennsylvania Hospital, Pittsburgh, Pennsylvania 15242, USA
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Borghi B, Casati A, Iuorio S, Celleno D, Michael M, Serafini P, Pusceddu A, Fanelli G. Frequency of hypotension and bradycardia during general anesthesia, epidural anesthesia, or integrated epidural-general anesthesia for total hip replacement. J Clin Anesth 2002; 14:102-6. [PMID: 11943521 DOI: 10.1016/s0952-8180(01)00362-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE To evaluate the frequency of hypotension and bradycardia during integrated epidural-general anesthesia as compared with general anesthesia or epidural anesthesia alone. DESIGN Prospective, randomized, open, multicenter study. SETTING Inpatient anesthesia at 7 University or Hospital Departments of anesthesia. PATIENTS 210 ASA physical status I, II, and III patients undergoing elective total hip replacement. INTERVENTIONS Using a balanced randomization method, each hospital enrolled 30 consecutive patients who received integrated epidural-general anesthesia, epidural anesthesia, or general anesthesia. MEASUREMENTS AND MAIN RESULTS Occurrence of clinically relevant hypotension (systolic arterial blood pressure (BP) decrease >30% from baseline), or bradycardia (heart rate (HR) <45 bpm) requiring pharmacologic treatment were recorded, as well as routine cardiovascular parameters. Clinically relevant hypotension during induction of nerve block was reported in 13 patients receiving epidural block (18%) and 16 patients receiving epidural-general anesthesia (22%) (p = 0.67). Subsequently, 22 of the remaining 54 patients in the epidural-general anesthesia group (41%) developed hypotension after the induction of general anesthesia, as compared with 16 patients of the general anesthesia group (23%) (p = 0.049). No differences in HR or in frequency of bradycardia were observed in the three groups. CONCLUSIONS The induction of general anesthesia in patients with an epidural block up to T10 increased the odds of developing clinically relevant hypotension as compared with those patients who received no epidural block, and was associated with a twofold increase of the odds of hypotension as compared with the use of epidural anesthesia alone.
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