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Osman B, Devarajan J, Skinner A, Shapiro F. Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review. Curr Pain Headache Rep 2024; 28:971-983. [PMID: 38809403 DOI: 10.1007/s11916-024-01266-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures. RECENT FINDINGS Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.
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Affiliation(s)
- Brian Osman
- Department of Anesthesia, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Austin Skinner
- College of Osteopathic Medicine, Kansas City University, Joplin, MO, USA
| | - Fred Shapiro
- Massachusetts Eye and Ear, Massachusetts General Brigham, Boston, MA, USA.
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Lloyd TD, Geneen LJ, Bernhardt K, McClune W, Fernquest SJ, Brown T, Dorée C, Brunskill SJ, Murphy MF, Palmer AJ. Cell salvage for minimising perioperative allogeneic blood transfusion in adults undergoing elective surgery. Cochrane Database Syst Rev 2023; 9:CD001888. [PMID: 37681564 PMCID: PMC10486190 DOI: 10.1002/14651858.cd001888.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Concerns regarding the safety and availability of transfused donor blood have prompted research into a range of techniques to minimise allogeneic transfusion requirements. Cell salvage (CS) describes the recovery of blood from the surgical field, either during or after surgery, for reinfusion back to the patient. OBJECTIVES To examine the effectiveness of CS in minimising perioperative allogeneic red blood cell transfusion and on other clinical outcomes in adults undergoing elective or non-urgent surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers for randomised controlled trials (RCTs) and systematic reviews from 2009 (date of previous search) to 19 January 2023, without restrictions on language or publication status. SELECTION CRITERIA We included RCTs assessing the use of CS compared to no CS in adults (participants aged 18 or over, or using the study's definition of adult) undergoing elective (non-urgent) surgery only. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 106 RCTs, incorporating data from 14,528 participants, reported in studies conducted in 24 countries. Results were published between 1978 and 2021. We analysed all data according to a single comparison: CS versus no CS. We separated analyses by type of surgery. The certainty of the evidence varied from very low certainty to high certainty. Reasons for downgrading the certainty included imprecision (small sample sizes below the optimal information size required to detect a difference, and wide confidence intervals), inconsistency (high statistical heterogeneity), and risk of bias (high risk from domains including sequence generation, blinding, and baseline imbalances). Aggregate analysis (all surgeries combined: primary outcome only) Very low-certainty evidence means we are uncertain if there is a reduction in the risk of allogeneic transfusion with CS (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.59 to 0.72; 82 RCTs, 12,520 participants). Cancer: 2 RCTs (79 participants) Very low-certainty evidence means we are uncertain whether there is a difference for mortality, blood loss, infection, or deep vein thrombosis (DVT). There were no analysable data reported for the remaining outcomes. Cardiovascular (vascular): 6 RCTs (384 participants) Very low- to low-certainty evidence means we are uncertain whether there is a difference for most outcomes. No data were reported for major adverse cardiovascular events (MACE). Cardiovascular (no bypass): 6 RCTs (372 participants) Moderate-certainty evidence suggests there is probably a reduction in risk of allogeneic transfusion with CS (RR 0.82, 95% CI 0.69 to 0.97; 3 RCTs, 169 participants). Very low- to low-certainty evidence means we are uncertain whether there is a difference for volume transfused, blood loss, mortality, re-operation for bleeding, infection, wound complication, myocardial infarction (MI), stroke, and hospital length of stay (LOS). There were no analysable data reported for thrombosis, DVT, pulmonary embolism (PE), and MACE. Cardiovascular (with bypass): 29 RCTs (2936 participants) Low-certainty evidence suggests there may be a reduction in the risk of allogeneic transfusion with CS, and suggests there may be no difference in risk of infection and hospital LOS. Very low- to moderate-certainty evidence means we are uncertain whether there is a reduction in volume transfused because of CS, or if there is any difference for mortality, blood loss, re-operation for bleeding, wound complication, thrombosis, DVT, PE, MACE, and MI, and probably no difference in risk of stroke. Obstetrics: 1 RCT (1356 participants) High-certainty evidence shows there is no difference between groups for mean volume of allogeneic blood transfused (mean difference (MD) -0.02 units, 95% CI -0.08 to 0.04; 1 RCT, 1349 participants). Low-certainty evidence suggests there may be no difference for risk of allogeneic transfusion. There were no analysable data reported for the remaining outcomes. Orthopaedic (hip only): 17 RCTs (2055 participants) Very low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, or if there is any difference between groups for mortality, blood loss, re-operation for bleeding, infection, wound complication, prosthetic joint infection (PJI), thrombosis, DVT, PE, stroke, and hospital LOS. There were no analysable data reported for MACE and MI. Orthopaedic (knee only): 26 RCTs (2568 participants) Very low- to low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, and whether there is a difference for blood loss, re-operation for bleeding, infection, wound complication, PJI, DVT, PE, MI, MACE, stroke, and hospital LOS. There were no analysable data reported for mortality and thrombosis. Orthopaedic (spine only): 6 RCTs (404 participants) Moderate-certainty evidence suggests there is probably a reduction in the need for allogeneic transfusion with CS (RR 0.44, 95% CI 0.31 to 0.63; 3 RCTs, 194 participants). Very low- to moderate-certainty evidence suggests there may be no difference for volume transfused, blood loss, infection, wound complication, and PE. There were no analysable data reported for mortality, re-operation for bleeding, PJI, thrombosis, DVT, MACE, MI, stroke, and hospital LOS. Orthopaedic (mixed): 14 RCTs (4374 participants) Very low- to low-certainty evidence means we are uncertain if there is a reduction in the need for allogeneic transfusion with CS, or if there is any difference between groups for volume transfused, mortality, blood loss, infection, wound complication, PJI, thrombosis, DVT, MI, and hospital LOS. There were no analysable data reported for re-operation for bleeding, MACE, and stroke. AUTHORS' CONCLUSIONS In some types of elective surgery, cell salvage may reduce the need for and volume of allogeneic transfusion, alongside evidence of no difference in adverse events, when compared to no cell salvage. Further research is required to establish why other surgeries show no benefit from CS, through further analysis of the current evidence. More large RCTs in under-reported specialities are needed to expand the evidence base for exploring the impact of CS.
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Affiliation(s)
- Thomas D Lloyd
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | | | | | - Scott J Fernquest
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Tamara Brown
- School of Health, Leeds Beckett University, Leeds, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Michael F Murphy
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
- Blood and Transplant Research Unit in Data Driven Transfusion, NIHR, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Blood and Transplant Research Unit in Data Driven Transfusion, NIHR, Oxford, UK
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Blood management in total hip arthroplasty: a nationwide trend analysis from 2011 to 2018. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:45-50. [PMID: 34714392 DOI: 10.1007/s00590-021-03155-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 10/21/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE With the advent of practice changes surrounding preoperative patient optimization and postoperative protocols, a marked reduction has been reported in blood transfusion rates following total hip arthroplasty (THA). Thus, the purpose of this study was to examine differences in the prevalence of preoperative anemia, thrombocytopenia, elevated international normalized ratio (INR), bleeding disorders, and pre- and postoperative blood transfusions over the last decade. METHODS From 2011 to 2018, the American College of Surgeons National Quality Improvement Program database was queried for all primary THA procedures (n = 208,796). The following continuous variables were examined using analysis of variance: preoperative hematocrit (HCT), platelet count, and INR. The following categorical variables were analyzed by chi-squared tests: anemia (HCT < 35.5% for females and < 38.5% for males), thrombocytopenia (platelet count < 150,000/µL), INR > 2.0, bleeding disorders, preoperative transfusions, and postoperative transfusions. RESULTS There were decreases in preoperative anemia (2011: 16.2%; 2018: 11.4%, p < 0.001) and postoperative transfusions (2011: high = 22.2%; 2018: low = 1.3%, p < 0.001). Statistically significant but clinically irrelevant changes were observed in preoperative HCT (2011: low = 40.3, 2018: high = 41.1, p < 0.001), platelet count (2011: low = 248,700; 2018: high = 250,100, p < 0.001), thrombocytopenia (2011: high = 4.9%; 2018: low = 4.3%, p = 0.036), INR > 2.0 (2011: high = 1.1%; 2018: low = 0.7%, p = 0.001), bleeding disorders (2011: high = 2.9%; 2018: low = 2.0%, p < 0.001), and preoperative transfusions (2011: high = 0.2%; 2018: low = 0.1%, p = 0.007). CONCLUSION Large decreases in the number of patients with preoperative anemia and those receiving postoperative blood transfusion were observed during the study period. Future investigation is needed to ascertain whether this is due to patient optimization, practice changes, "cherry-picking" of healthy patients, or a combination of these factors. LEVEL OF EVIDENCE III.
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Tanaka KA, Pontikes AE, Van D, Vandyck K, Butt A, Mazzeffi MA, Thakral R, Stewart KE. Relationships Between Body Mass Index, Allogeneic Transfusion, and Surgical Site Infection After Knee and Hip Arthroplasty Surgery. Anesth Analg 2023; 136:123-129. [PMID: 35389377 DOI: 10.1213/ane.0000000000006036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Increased body mass index (BMI) is considered as an important factor that affects the need for total knee and hip arthroplasty (TKA/THA) and the rate of perioperative complications. Previous investigations have not fully established the relationship of BMI and perioperative transfusion with surgical site infection (SSI) or the relationship of BMI and perioperative transfusion after TKA or THA. METHODS The National Surgical Quality Improvement Program database was used to perform a retrospective cohort study involving 333,223 TKA and 41,157 THA cases between 2011 and 2018. Multivariable regression assessed the associations of BMI (5 standard categories) and transfusion with SSI. Odds ratio (OR) of SSI was calculated relative to a normal BMI (18.5-24.9 kg/m 2 ) after adjustment of potential confounding factors. RESULTS Perioperative transfusion decreased significantly over time for both TKA and THA; however, SSI rates remained steady at just under 1% for TKA and 3% for THA. In TKA, a higher OR for SSI was associated only with a BMI of 40+ (OR, 1.86; 95% confidence interval [CI], 1.60-2.18) compared to a referent BMI. In THA, increased ORs of SSI were seen for all BMI levels above normal and were highest for a BMI 40+ (OR, 3.08; 95% CI, 2.47-3.83). In TKA, ORs of transfusion decreased with increasing BMI and were lowest for a BMI 40+ (OR, 0.51; 95% CI, 0.47-0.54). In THA, ORs of transfusion began to increase slightly in overweight patients, reaching an OR of 1.36 (95% CI, 1.21-1.54) for a BMI 40+. CONCLUSIONS SSI incidence remained unchanged despite continuous reductions in blood transfusion in TKA and THA patients over 8 years. In TKA, ORs for SSI increased, but ORs for transfusion decreased with increasing BMI above normal. Conversely, in THA, ORs for SSI and transfusion both increased for a BMI 40+, but only OR for transfusion increased in underweight patients. These findings suggest the importance of controlling obesity in reducing SSI following TKA and THA.
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Affiliation(s)
- Kenichi A Tanaka
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Andrew E Pontikes
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - David Van
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kofi Vandyck
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Amir Butt
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Michael A Mazzeffi
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences
| | - Rishi Thakral
- Departments of Orthopedic Surgery and Rehabilitation
| | - Kenneth E Stewart
- Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Sinclair ST, Klika AK, Jin Y, Piuzzi NS, Higuera CA. The Impact of Surgeon Variability on Patient-Reported Outcomes in Total Hip Arthroplasty. J Arthroplasty 2022; 37:S479-S487.e1. [PMID: 35248750 DOI: 10.1016/j.arth.2022.02.100] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/16/2022] [Accepted: 02/23/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patient-related and surgery-related factors have been shown to be drivers of outcomes after total hip arthroplasty (THA); however, the impact of intersurgeon variability is poorly understood. The purpose of this study is to assess the following: (1) overall effect of surgeon on 1-year patient-reported outcome measures (PROMs), length of stay (LOS), discharge disposition, and 90-day readmission following THA; and (2) variability in 1-year PROMs among surgeons. METHODS A prospective cohort of 3,695 patients who underwent THA between 2016 and 2018 was included. Seventy-eight percent of patients completed 1-year follow-up. Thirty-one surgeons from a large healthcare system were included. Likelihood ratio tests analyzed the relationship among surgeon and 1-year Hip Disability and Osteoarthritis Outcome Score (HOOS)-Pain, HOOS-Physical Function Short-Form, HOOS-Joint Replacement, University of California, Los Angeles activity score, Patient Acceptable Symptom State, LOS, discharge disposition, and 90-day readmission. Mixed-effect proportional odds and logistic regression models were used to determine variable importance for each outcome. RESULTS In total, 90.5% of patients responded positively to 1-year Patient Acceptable Symptom State. There was a significant association among surgeon and 1-year PROMs, LOS, discharge disposition (P < .001), and readmission (P = .002). For HOOS-Pain, Physical Function Short-Form, and Joint Replacement, surgeon (Akaike information criterion increase: 34.6, 18.7, 17.1, respectively) was a greater contributor to outcome than patient-level factors, including age, gender, and comorbidity. Differences in the highest and lowest median probability of achieving any given score on 1-year PROMs ranged from 11% to 18.5%. Variability was not explained by approach (P = .431) or case volume (correlation coefficient, ρ = 0.19). CONCLUSION Surgeon-level variability appears to be a greater driver of 1-year PROMs than some patient-level characteristics. Incorporating surgeon as a variable is beneficial for model-fitting and important for increasing value in THA.
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Affiliation(s)
- SaTia T Sinclair
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Yuxuan Jin
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
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Wang X, Wang X, Liang F, Yu Y, Han R. Safety and efficacy of intravenous or topical tranexamic acid administration in surgery: a protocol for a systematic review and network meta-analysis. BMJ Open 2022; 12:e058093. [PMID: 35534082 PMCID: PMC9086642 DOI: 10.1136/bmjopen-2021-058093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) has become a widely used antifibrinolytic drug for reducing bleeding in surgery. However, adverse events, such as seizures, pulmonary embolism and deep vein thrombosis, limit its application. To date, insufficient attention has been devoted to determining the optimal dosage and administration route of TXA in the field of surgery. Thus, this study uses the network meta-analysis method, relying on its characteristics of combining direct comparison and indirect comparison, to analyse the safety and efficacy of different doses (high, medium, low) of intravenous injection or of topical application of TXA. METHODS AND ANALYSIS We will search the PubMed, Cochrane Central Register of Controlled Trials, Embase, Web of Science and China National Knowledge Internet databases using a strategy that combines the terms TXA, randomised controlled trials and embolism (or haemorrhage, blood transfusion, seizure, mortality). Two reviewers will independently screen all identified abstracts for eligibility and evaluate the risk-of-bias of the included studies using the Cochrane risk of bias tool for randomised controlled studies. We will conduct a systematic review and network meta-analysis. We plan to investigate heterogeneity by performing subgroup analysis and sensitivity analysis, and we will also consider the dose-response relationship between the optimal dose and a better routine. We will assess the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach ETHICS AND DISSEMINATION: No ethics approval will be sought, as no original data will be collected for this review. Findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER CRD42021281206.
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Affiliation(s)
- Xinyan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinxin Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fa Liang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yun Yu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Fan D, Ma J, Liu X, Zhang L. Peri-articular administration of tranexamic acid is an alternative route in total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:211. [PMID: 35392961 PMCID: PMC8991716 DOI: 10.1186/s13018-022-03095-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background As an antifibrinolytic agent, tranexamic acid (TXA) is increasingly used in total knee arthroplasty (TKA) to reduce blood loss. The administration of intravenous and intra-articular TXA has been well explored, but the most efficient way to administer TXA remains in question. Peri-articular injection (PAI) of TXA is a recently mentioned method. A meta-analysis of the efficacy of PAI TXA in patients after TKA should be performed.
Methods A systematic search was performed within PubMed, Embase, and the Cochrane Library up to November 8, 2021. Two authors independently screened studies for eligibility and extracted data for analysis. The primary outcome was haemoglobin change. The secondary outcomes were haematocrit change, total drainage volume, thromboembolic events, and blood transfusion. Results A total of ten studies were included in this meta-analysis. The results indicated that there was a significant decrease in haemoglobin change when using PAI TXA compared with no TXA (mean difference − 1.05; 95% CI − 1.28 to − 0.81; P < 0.00001; I2 = 0%), but it had no significant differences compared with IA and IV (mean difference − 0.01; 95% CI − 0.17 to − 0.14; P = 0.85; I2 = 39%). There were no significant differences between the TXA < 1.5 g subgroup (0.10, 95% CI − 0.27 to 0.46; P = 0.60; I2 = 0%) and the TXA ≥ 1.5 g subgroup (0.18, 95% CI − 0.12 to 0.48; P = 0.24; I2 = 74%). In addition, the combined group (PAI plus IV or IA) was superior to the IV or IA group in terms of haemoglobin change (mean difference − 0.51; 95% CI − 0.76 to − 0.27; P < 0.0001; I2 = 19%). Regarding haematocrit change, the pooled result showed it was significantly less in the PAI group than the non-TXA group. Similarly, comparing it against the IV subgroup, the result revealed a difference in favour of the PAI group, with a mean difference of − 1.89 g/dL (95% CI − 2.82 to − 0.95; P < 0.0001; I2 = 67%). For total drainage volume, the pooled result was in favour of PAI TXA over no TXA (297 ml, 95% CI − 497.26 to − 97.23; P = 0.004; I2 = 87%), but it had no significant difference compared with IA and IV (mean difference − 37.98; 95% CI − 115.68 to 39.71; P = 0.34; I2 = 95%). There was no significant difference in thromboembolic events (OR 0.74; 95% CI 0.25 to 2.21; P = 0.59; I2 = 0%). Blood transfusion was not significantly different between the PAI group and the non-TXA group (OR 0.50; 95% CI 0.23 to 1.06; P = 0.07; I2 = 21%), and there was no significant difference between PAI and the other two TXA injection methods (OR 0.72; 95% CI 0.41 to 1.25; P = 0.24; I2 = 19%). Conclusion PAI has comparable effects to IV and IA injections. PAI is an alternative injection route of TXA for patients who have undergone TKA.
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Affiliation(s)
- DingYuan Fan
- Department of Joint Surgery and Sports Medicine, Wangjing Hospital, China Academy of Chinese Medical Sciences, No. 6, South Zhonghuan Road, Chaoyang district, Beijing, 100102, People's Republic of China.,Beijing University of Chinese Medicine (BUCM), Beijing, People's Republic of China
| | - Jia Ma
- Department of Joint Surgery and Sports Medicine, Wangjing Hospital, China Academy of Chinese Medical Sciences, No. 6, South Zhonghuan Road, Chaoyang district, Beijing, 100102, People's Republic of China
| | - XiaoHua Liu
- Department of Joint Surgery and Sports Medicine, Wangjing Hospital, China Academy of Chinese Medical Sciences, No. 6, South Zhonghuan Road, Chaoyang district, Beijing, 100102, People's Republic of China
| | - Lei Zhang
- Department of Joint Surgery and Sports Medicine, Wangjing Hospital, China Academy of Chinese Medical Sciences, No. 6, South Zhonghuan Road, Chaoyang district, Beijing, 100102, People's Republic of China.
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Xu C, Wu M, Wang Z, Liu Y, Zhou P, Guan J. Efficacy of repeated intravenous tranexamic acid in reducing perioperative bleeding of acetabular fractures. Clin Hemorheol Microcirc 2021; 79:567-573. [PMID: 34151780 DOI: 10.3233/ch-211203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Application of tranexamic acid (TXA) in the treatment of acetabular fractures could reduce intraoperative and postoperative blood loss. OBJECTIVE To investigate the effect of single and repeated intravenous infusion of TXA on blood loss of acetabular fractures. METHODS 120 patients with acetabular fractures admitted to our hospital from January 2017 to September 2020 were retrospectively divided into three groups: Patients accepted 1g TXA at preoperative 30 minutes were defined as single TXA group (n = 40); Patients accepted 1g TXA at preoperative 30 minutes and 1g TXA at 3 hours after the start of surgery were defined as repeated TXA group (n = 40); Patients accepted normal saline at preoperative 30 minutes were defined as control group (n = 40). RESULTS The total blood loss in single TXA group and repeated TXA group were significantly lower than control group, and the total blood loss in the repeated TXA group was significantly lower than single TXA group (P < 0.05). The hidden blood loss from surgery to postoperative 1 day in repeated TXA group was significantly lower than single TXA group and the control group(P < 0.05). No significant differences were observed in the operative time, postoperative transfusion rate and thrombosis rate among the three groups (P > 0.05). CONCLUSION Repeated TXA is more recommended during acetabular fracture surgery since it can reduce the total blood loss without increasing the operative time, postoperative transfusion rate and thrombosis rate compared with single TXA.
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Affiliation(s)
- Chen Xu
- Department of Orthopedics, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Min Wu
- Department of Orthopedics, Bengbu Medical University Affiliated to First Hospital, Bengbu, Anhui Province, China
| | - Zhaodong Wang
- Department of Orthopedics, Bengbu Medical University Affiliated to First Hospital, Bengbu, Anhui Province, China
| | - Yajun Liu
- Department of Orthopedics, Bengbu Medical University Affiliated to First Hospital, Bengbu, Anhui Province, China
| | - Pinghui Zhou
- Department of Orthopedics, Bengbu Medical University Affiliated to First Hospital, Bengbu, Anhui Province, China
| | - Jianzhong Guan
- Department of Orthopedics, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China.,Department of Orthopedics, Bengbu Medical University Affiliated to First Hospital, Bengbu, Anhui Province, China
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Teoh WY, Tan TG, Ng KT, Ong KX, Chan XL, Hung Tsan SE, Wang CY. Prophylactic Topical Tranexamic Acid Versus Placebo in Surgical Patients: A Systematic Review and Meta-analysis∗. Ann Surg 2021; 273:676-683. [PMID: 32282377 DOI: 10.1097/sla.0000000000003896] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Perioperative bleeding remains a major concern to all clinicians caring for perioperative patients. Due to the theoretical risk of thromboembolic events associated with tranexamic acid (TXA) when administered intravenously, topical route of TXA has been extensively studied, but its safety and efficacy profile remain unclear in the literature. The primary aim of this review was to assess the effect of topical TXA on incidence of blood transfusion and mortality in adults undergoing surgery. DATA SOURCES EMBASE, MEDLINE, CENTRAL, and ISI Web of Science were systematically searched from their inception until May 31, 2019. REVIEW METHODS Parallel-arm randomized controlled trials were included. RESULTS Seventy-one trials (7539 participants: orthopedics 5450 vs nonorthopedics 1909) were included for quantitative meta-analysis. In comparison to placebo, topical TXA significantly reduced intraoperative blood loss [mean difference (MD) -36.83 mL, 95% confidence interval (CI) -54.77 to -18.88, P < 0.001], total blood loss (MD -319.55 mL, 95% CI -387.42 to -251.69, P < 0.001), and incidence of blood transfusion [odds ratio (OR) 0.30, 95% CI 0.26-0.34, P < 0.001]. Patients who received topical TXA were associated with a shorter length of hospital stay (MD -0.28 days, 95% CI -0.47 to -0.08, P = 0.006). No adverse events associated with the use of topical TXA were observed, namely mortality (OR 0.78, 95% CI 0.45-1.36, P = 0.39), pulmonary embolism (OR 0.73, 95% CI 0.27-1.93, P = 0.52), deep vein thrombosis (OR 1.07, 95% CI 0.65-1.77, P = 0.79), myocardial infarction (OR 0.79, 95% CI 0.21-2.99, P = 0.73), and stroke (OR 0.85, 95% CI 0.28-2.57, P = 0.77). Of all included studies, the risk of bias assessment was "low" for 20 studies, "unclear" for 26 studies and "high" for 25 studies. CONCLUSIONS In the meta-analysis of 71 trials (7539 patients), topical TXA reduced the incidence of blood transfusion without any notable adverse events associated with TXA in adults undergoing surgery. PROSPERO CRD 42018111762.
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Affiliation(s)
- Wan Yi Teoh
- University of Liverpool, School of Medicine, Cedar House, Liverpool, United Kingdom
| | - Tun Giap Tan
- Basingstoke and North Hampshire Hospital, Hampshire, United Kingdom
| | - Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Jalan University, Kuala Lumpur, Malaysia
| | - Ke Xin Ong
- University of Warwick, Gibbet Hill Road, Coventry, United Kingdom
| | - Xue Lin Chan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Jalan University, Kuala Lumpur, Malaysia
| | - Samuel Ern Hung Tsan
- Faculty of Medicine and Health Sciences, University of Malaysia Sarawak, Sarawak, Malaysia
| | - Chew Yin Wang
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Jalan University, Kuala Lumpur, Malaysia
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Mazzeffi M, Taneja M, Porter S, Chow JH, Jackson B, Fontaine M, Frank SM, Tanaka K. Anemia, sex, and race as predictors of morbidity or mortality after knee arthroplasty surgery. Transfusion 2020; 60:2877-2885. [PMID: 33017478 DOI: 10.1111/trf.16111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Anemia is associated with poor outcome after major joint replacement surgery, but it is unclear whether sex and race modify its impact on outcome. We hypothesized that anemia would be associated with increased morbidity or mortality after knee arthroplasty surgery and that sex and race would be effect modifiers for this relationship. STUDY DESIGN AND METHODS We performed a retrospective cohort study of elective knee arthroplasty patients between 2013 and 2018 using data from the National Surgical Quality Improvement Program. Morbidity or mortality after surgery was compared between patients without anemia, with mild anemia, and with moderate to severe anemia. Multivariable logistic regression was used to determine adjusted odds for morbidity or mortality with anemia. Interaction terms were entered into the model to test for effect modification by sex and race. RESULTS 243 491 patients were included and 30 135 patients (12.4%) were anemic. Morbidity or mortality occurred in 3.7% of patients without anemia, 5.2% of patients with mild anemia, and 7.1% of patients with moderate to severe anemia (P < .001). After adjustment for confounding variables, mild anemia OR = 1.36 (95% CI = 1.28-1.45), and moderate to severe anemia OR = 1.92 (95% CI = 1.72-2.13) were associated with increased odds of morbidity or mortality. Sex, but not race, was a significant effect modifier with men having a greater increase in morbidity or mortality when anemic (P = .02). CONCLUSIONS Anemia is associated with increased morbidity or mortality after knee arthroplasty surgery and men have a greater increase in perioperative risk than women when anemic.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Monica Taneja
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Steven Porter
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Jonathan H Chow
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bryon Jackson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Magali Fontaine
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Palmer AJR, Gagné S, Fergusson DA, Murphy MF, Grammatopoulos G. Blood Management for Elective Orthopaedic Surgery. J Bone Joint Surg Am 2020; 102:1552-1564. [PMID: 32558663 DOI: 10.2106/jbjs.19.01417] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Antony J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom
| | | | | | - Michael F Murphy
- NHS Blood and Transplant and Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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12
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Henze K, Herten M, Haversath M, Busch A, Brandau S, Hackel A, Flohé SB, Jäger M. Surgical vacuum filter-derived stromal cells are superior in proliferation to human bone marrow aspirate. Stem Cell Res Ther 2019; 10:338. [PMID: 31753037 PMCID: PMC6868799 DOI: 10.1186/s13287-019-1461-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/16/2019] [Accepted: 10/18/2019] [Indexed: 01/11/2023] Open
Abstract
Background During joint replacement, surgical vacuum suction guarantees a sufficient overview on the situs. We assume high concentrations of mesenchymal stromal cells (MSCs) on surgical vacuum filters. We compared the in vitro proliferative and differentiation potency of cells from the following: (i) bone marrow (BM), (ii) cancellous bone (CB), (iii) vacuum filter (VF), and (iv) cell saver filtrate reservoir (SF) in 32 patients undergoing elective total hip replacement. Methods Mononuclear cells (MNC) were isolated, and cell proliferation and colony-forming units (CFU) were measured. Adherent cells were characterized by flow cytometry for MSC surface markers. Cells were incubated with osteogenic, adipogenic, and chondrogenic stimuli. Cells were cytochemically stained and osteoblastic expression (RUNX-2, ALP, and BMP-2) investigated via qPCR. Results Dependent on the source, initial MNC amount as well as CFU number was significantly different whereas generation time did not vary significantly. CFU numbers from VF were superior to those from SR, BM, and CB. The resulting amount of MSC from the respective source was highest in the vacuum filter followed by reservoir, aspirate, and cancellous bone. Cells from all groups could be differentiated into the three mesenchymal lines demonstrating their stemness nature. However, gene expression of osteoblastic markers did not differ significantly between the groups. Conclusion We conclude that surgical vacuum filters are able to concentrate tissue with relevant amounts of MSCs. A new potent source of autologous regeneration material with clinical significance is identified. Further clinical studies have to elucidate the regenerative potential of this material in an autologous setting.
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Affiliation(s)
- Katharina Henze
- Department of Orthopaedics and Trauma Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Monika Herten
- Department of Orthopaedics and Trauma Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Marcel Haversath
- Department of Orthopaedics and Trauma Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - André Busch
- Department of Orthopaedics and Trauma Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Sven Brandau
- Department of Otorhinolaryngology, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Alexander Hackel
- Department of Otorhinolaryngology, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Stefanie B Flohé
- Department of Orthopaedics and Trauma Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Marcus Jäger
- Department of Orthopaedics and Trauma Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany. .,Department of Orthopaedics, Trauma and Reconstructive Surgery, University of Duisburg Essen & St. Marien Hospital Mülheim an der Ruhr / Contilia, Kaiserstrasse 50, 45468, Mülheim/Ruhr, Germany.
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Tranexamic Acid Use in Open Reduction and Internal Fixation of Fractures of the Pelvis, Acetabulum, and Proximal Femur: A Randomized Controlled Trial. J Orthop Trauma 2019; 33:371-376. [PMID: 30939507 DOI: 10.1097/bot.0000000000001480] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the safety and efficacy of tranexamic acid (TXA) use in fractures of the pelvic ring, acetabulum, and proximal femur. DESIGN Prospective, randomized controlled trial. SETTING Single Level 1 trauma center. PATIENTS Forty-seven patients were randomized to the study group, and 46 patients comprised the control group. INTERVENTION The study group received 15 mg/kg IV TXA before incision and a second identical dose 3 hours after the initial dose. MAIN OUTCOME MEASUREMENTS Transfusion rates and total blood loss (TBL) [via hemoglobin-dilution method and rates of venous thromboembolic events (VTEs)]. RESULTS TBL was significantly higher in the control group (TXA = 952 mL, no TXA = 1325 mL, P = 0.028). The total transfusion rates between the TXA and control groups were not significantly different (TXA 1.51, no TXA = 1.17, P = 0.41). There were no significant differences between the TXA and control groups in inpatient VTE events (P = 0.57). CONCLUSION The use of TXA in high-energy fractures of the pelvis, acetabulum, and femur significantly decreased calculated TBL but did not decrease overall transfusion rates. TXA did not increase the rate of VTE. Further study is warranted before making broad recommendations for the use of TXA in these fractures. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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14
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Kolte D, Beale C, Aronow HD, Kennedy KF, Apostolidou E, Sellke FW, Sharaf BL, Gordon PC, Abbott JD, Ehsan A. Trends and outcomes of red blood cell transfusion in patients undergoing transcatheter aortic valve replacement in the United States. J Thorac Cardiovasc Surg 2019; 159:102-111.e11. [PMID: 31014667 DOI: 10.1016/j.jtcvs.2019.03.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/20/2019] [Accepted: 03/11/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine temporal trends, predictors, and outcomes of red blood cell (RBC) transfusion in patients undergoing transcatheter aortic valve replacement (TAVR) in the United States. METHODS We used the National Inpatient Sample databases to identify TAVR procedures performed between January 2012 and September 2015 in the United States. Patients were propensity matched (within the strata of overt and no bleeding) on the likelihood of receiving RBC transfusion, and in-hospital outcomes were compared between the 2 groups in the matched cohort. RESULTS Among 46,710 TAVR procedures performed during the study period, rates of RBC transfusion were 17.3% (95% confidence interval [CI], 16.1%-18.5%). RBC transfusion rates decreased significantly from 29.5% during the first quarter of 2012 to 10.8% during the third quarter of 2015 (P < .001). Older age, female sex, peripheral vascular disease, chronic kidney disease, anemia, coagulopathy, and fluid/electrolyte disorders were associated with increased odds, whereas elective admission, obesity, and endovascular access were associated with decreased odds of RBC transfusion. In the propensity-matched cohort (7995 pairs with and without RBC transfusion), RBC transfusion was associated with increased risk of in-hospital mortality, infection, and transient ischemic attack/stroke in patients without bleeding (odds ratio [OR]Mortality, 2.29; 95% CI, 1.31-4.02; ORInfection, 2.13; 95% CI, 1.03-4.39; ORTransient ischemic attack/Stroke, 3.36; 95% CI, 1.52-7.45), but not in those with overt bleeding (ORMortality, 1.10; 95% CI, 0.68-1.48; ORInfection, 0.80; 95% CI, 0.45-1.45; ORTransient ischemic attack/Stroke, 1.16; 95% CI, 0.74-1.85); Pinteraction < .05 for all. CONCLUSIONS RBC transfusion is associated with worse clinical outcomes in TAVR patients without bleeding, but not in those with overt bleeding. The utility and optimal threshold for RBC transfusion in TAVR patients, especially among those with overt bleeding, warrants further prospective investigation.
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Affiliation(s)
- Dhaval Kolte
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | - Charles Beale
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | - Herbert D Aronow
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | | | - Eirini Apostolidou
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | - Frank W Sellke
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | - Barry L Sharaf
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | - Paul C Gordon
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | - J Dawn Abbott
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | - Afshin Ehsan
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI.
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15
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Wang D, Wang HY, Luo ZY, Pei FX, Zhou ZK, Zeng WN. Finding the Optimal Regimen for Oral Tranexamic Acid Administration in Primary Total Hip Arthroplasty: A Randomized Controlled Trial. J Bone Joint Surg Am 2019; 101:438-445. [PMID: 30845038 DOI: 10.2106/jbjs.18.00128] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Previous studies have confirmed that, compared with intravenous and intra-articular formulations, oral tranexamic acid (TXA) provides equivalent reduction in blood loss, at a substantially reduced cost and greater ease of administration. However, the optimal oral dosage regimen to achieve maximum blood-loss reduction remains unclear. The aim of this study was to assess the efficacy of a regimen of multiple doses of oral TXA on blood loss in primary total hip arthroplasty. METHODS In this randomized controlled trial, 200 patients were randomized to 1 of 4 interventions. Group A received a single dose of 2.0 g of TXA orally at 2 hours preoperatively. In addition to this same preoperative dose, Group B received 1.0 g of TXA orally at 3 hours postoperatively, Group C received 1.0 g of TXA orally at 3 and 9 hours postoperatively, and Group D received 1.0 g of TXA orally at 3, 9, and 15 hours postoperatively. All patients received a 1.0-g topical dose of TXA. The primary outcome was total blood loss. Secondary outcomes included hemoglobin reduction, transfusion rate, thromboembolic complications, and adverse events. RESULTS The mean total blood loss (and standard deviation) was significantly less in Groups B, C, and D (792.2 ± 293.0, 630.8 ± 229.9, and 553.0 ± 186.1 mL, respectively) than in Group A (983.6 ± 286.7 mL) (p < 0.001). Moreover, Groups C and D had a lower mean reduction in hemoglobin than did Groups A and B. However, no differences were identified between Groups C and D for blood loss and hemoglobin reduction. Additionally, no differences were observed among the groups regarding thromboembolic complications and transfusions. CONCLUSIONS The multiple postoperative doses of oral TXA further reduced blood loss compared with a single preoperative bolus. The regimen of a preoperative dose and 3 postoperative doses of oral TXA produced maximum effective reduction of blood loss in total hip arthroplasty. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Duan Wang
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Hao-Yang Wang
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Ze-Yu Luo
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Fu-Xing Pei
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Zong-Ke Zhou
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Wei-Nan Zeng
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China
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16
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Sun Q, Li J, Chen J, Zheng C, Liu C, Jia Y. Comparison of intravenous, topical or combined routes of tranexamic acid administration in patients undergoing total knee and hip arthroplasty: a meta-analysis of randomised controlled trials. BMJ Open 2019; 9:e024350. [PMID: 30696680 PMCID: PMC6352808 DOI: 10.1136/bmjopen-2018-024350] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE This study aimed to compare the effects of intravenous, topical and combined routes of tranexamic acid (TXA) administration on blood loss and transfusion requirements in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). DESIGN This was a meta-analysis of randomised controlled trials (RCT) wherein the weighted mean difference (WMD) and relative risk (RR) were used for data synthesis applied in the random effects model. Stratified analyses based on the surgery type, region, intravenous and topical TXA dose and transfusion protocol were also conducted. The main outcomes included intraoperative and total blood loss volume, transfusion rate, low postoperative haemoglobin (Hb) level and postoperative Hb decline. However, the secondary outcomes included length of hospital stay (LOS) and/or occurrence of venous thromboembolism (VTE). SETTING We searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration. PARTICIPANTS Patients undergoing TKA or THA. INTERVENTIONS Intravenous, topical or combined intravenous and topical TXA. RESULTS Twenty-six RCTs were selected, and the intravenous route did not differ substantially from the topical route with respect to the total blood loss volume (WMD=30.92, p=0.31), drain blood loss (WMD=-34.53, p=0.50), postoperative Hb levels (WMD=-0.01, p=0.96), Hb decline (WMD=-0.39, p=0.08), LOS (WMD=0.15, p=0.38), transfusion rate (RR=1.08, p=0.75) and VTE occurrence (RR=1.89, p=0.15). Compared with the combined-delivery group, the single-route group had significantly increased total blood loss volume (WMD=198.07, p<0.05), greater Hb decline (WMD=0.56, p<0.05) and higher transfusion rates (RR=2.51, p<0.05). However, no significant difference was noted in the drain blood loss, postoperative Hb levels and VTE events between the two groups. The intravenous and topical routes had comparable efficacy and safety profiles. CONCLUSIONS The combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.
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Affiliation(s)
- Qi Sun
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jinyu Li
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jiang Chen
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chenying Zheng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chuyin Liu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yusong Jia
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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17
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Isidoro REC, Silva KFND, Oliveira JFD, Barichello E, Pires PDS, Barbosa MH. BLOOD ORDERS AND PREDICTORS FOR HEMOTRANSFUSION IN ELECTIVE FEMUR FRACTURE REPAIR SURGERY. TEXTO & CONTEXTO ENFERMAGEM 2019. [DOI: 10.1590/1980-265x-tce-2018-0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: to estimate the incidence of red blood cell concentrate orders in elective femur fracture repair surgeries and to identify predictors for hemotranfusion. Method: retrospective cohort study conducted with 271 patients submitted to femur fracture repair surgery between July 2013 and July 2016. Surgical and transfusion data were obtained from patient charts and the Transfusion Management System. Association between sociodemographic and clinical variables related to the surgical procedure and the occurrence of red blood cell concentrate transfusion was analyzed using descriptive statistics, the chi-squared test, relative risk, and odds ratio. Multivariate analysis was performed using binomial logistic regression. Results: the incidence of blood orders for patients undergoing femur fracture repair surgery was 87%. Ninety-one (33.6%) patients received red blood cell concentrate transfusions. Even though placing blood orders is recommended, given the possibility of intra- or postoperative transfusions, only 52 (47.2%) blood transfusions occurred in the preoperative period. The variables female sex, low preoperative hemoglobin levels and procedure lasting longer than 120 minutes presented statistical significance (p<0.05) and were considered predictors for hemototransfusion. Conclusion: Perioperative nursing must be aware of the importance of blood orders for all patients undergoing femur fracture repair surgery, including in the preoperative period, with special attention to patients who are female, previously anemic and submitted to long-lasting procedures.
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18
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Wang D, Luo ZY, Yu ZP, Liu LX, Chen C, Meng WK, Yu QP, Pei FX, Zhou ZK, Zeng WN. The antifibrinolytic and anti-inflammatory effects of multiple doses of oral tranexamic acid in total knee arthroplasty patients: a randomized controlled trial. J Thromb Haemost 2018; 16:2442-2453. [PMID: 30430724 DOI: 10.1111/jth.14316] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Indexed: 02/05/2023]
Abstract
Essentials Perioperative blood loss and inflammatory response can significantly affect recovery after surgery. We studied the effects of multiple-dose oral tranexamic acid on blood loss and inflammatory response. A postoperative four-dose regimen brought about maximum reduction in postoperative blood loss. A postoperative four-dose regimen reduced inflammatory response and promoted early rehabilitation. SUMMARY: Background Tranexamic acid (TXA) can reduce blood loss and the inflammatory response at multiple doses in total knee arthroplasty patients. However, the optimal regimen has not been determined. Objectives To identify the most effective regimen for achieving maximum reductions in blood loss and the inflammatory response. Patients/Methods Two hundred and seventy-five patients were randomized to receive a placebo (group A), a single 2-g oral dose of TXA 2 h preoperatively followed by 1 g of oral TXA 3 h postoperatively (group B), a single dose followed by 1 g of oral TXA 3 h and 7 h postoperatively (group C), a single dose followed by 1 g of oral TXA 3 h, 7 h and 11 h postoperatively (group D), or a single dose followed by 1 g of oral TXA 3 h, 7 h, 11 h and 15 h postoperatively (group E). The primary outcome was total blood loss on postoperative day (POD) 3. Secondary outcomes included a decrease in the hemoglobin level, coagulation parameters, inflammatory marker levels, and thromboembolic complications. Results Groups D and E had significantly lower blood loss and smaller decreases in hemoglobin level than groups A, B, and C, with no significant difference on POD 3 between groups D and E. Significantly enhanced coagulation was identified for the four multiple-dose regimens; however, all thromboelastographic parameters remained within normal ranges. Group E had the lowest inflammatory marker levels and pain, and the greatest range of motion. No thromboembolic complications were identified. Conclusion The four-dose regimen yielded the maximum reductions in blood loss and inflammatory response, improved analgesia, and promoted early rehabilitation. Further studies are required to ensure that these findings are reproducible.
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Affiliation(s)
- D Wang
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Z-Y Luo
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Z-P Yu
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - L-X Liu
- Department of Neuroscience, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - C Chen
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - W-K Meng
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Q-P Yu
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chengdu, China
| | - F-X Pei
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Z-K Zhou
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - W-N Zeng
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chengdu, China
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19
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Xie J, Hu Q, Huang Z, Zhou Z, Pei F. Comparison of three routes of administration of tranexamic acid in primary unilateral total knee arthroplasty: Analysis of a national database. Thromb Res 2018; 173:96-101. [PMID: 30500676 DOI: 10.1016/j.thromres.2018.11.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 11/11/2018] [Accepted: 11/22/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The ideal route for the administration of tranexamic acid (TXA) remains undecided. This study aimed to compare the efficacy and safety of three routes of TXA following primary total knee arthroplasty (TKA). MATERIALS AND METHODS We prospectively collected patients' data through the National Health Database from January 2013 to September 2017. The patients were divided into a control group, intravenous group, topical group, and combined group according to the different routes of TXA. The primary outcome was the incidence of transfusion, and secondary outcomes were total blood loss, hemoglobin level and extent of hemoglobin decrease on postoperative day 3, and incidence of complications. RESULTS Of the total of 7133 primary TKA procedures collected, 4201 employed TXA and 2932 did not. The transfusion rate was 19.8% in the control group and 7.5% in the topical group, significantly higher than that in the intravenous (4.0%, p < 0.001) and combined (4.2%, p < 0.01) groups. The topical group had higher blood loss (0.97 ± 0.47 L), greater reduction in hemoglobin level (31.2 ± 10.1 g/L), and lower hemoglobin level (102.6 ± 12.7 g/L) on postoperative day 3, compared with the intravenous and combined groups (p < 0.05 for all). The differences between the intravenous and combined groups were not significant (p > 0.05). The incidence of deep vein thrombosis in the topical group (1.1%) was significantly higher than that in the control (0.4%, p = 0.007) and intravenous groups (0.3%, p = 0.003). CONCLUSION Intravenous and combined administration of TXA was equivalent in reducing blood loss and transfusion requirement, and superior to topical routes.
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Affiliation(s)
- Jinwei Xie
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Qinsheng Hu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China.
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China.
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Palmer A, Chen A, Matsumoto T, Murphy M, Price A. Blood management in total knee arthroplasty: state-of-the-art review. J ISAKOS 2018. [DOI: 10.1136/jisakos-2017-000168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Total blood loss from primary total knee arthroplasty may exceed 2 L with greater blood loss during revision procedures. Blood loss and allogeneic transfusion are strongly associated with adverse outcomes from surgery including postoperative mortality, thromboembolic events and infection. Strategies to reduce blood loss and transfusion rates improve patient outcomes and reduce healthcare costs. Interventions are employed preoperatively, intraoperatively and postoperatively. The strongest predictor for allogeneic blood transfusion is preoperative anaemia. Over 35% of patients are anaemic when scheduled for primary and revision knee arthroplasty, defined as haemoglobin <130 g/L for men and women, and the majority of cases are secondary to iron deficiency. Early identification and treatment of anaemia can reduce postoperative transfusions and complications. Anticoagulation must be carefully managed perioperatively to balance the risk of thromboembolic event versus the risk of haemorrhage. Intraoperatively, tranexamic acid reduces blood loss and is recommended for all knee arthroplasty surgery; however, the optimal route, dose or timing of administration remains uncertain. Cell salvage is a valuable adjunct to surgery with significant expected blood loss, such as revision knee arthroplasty. Autologous blood donation is not recommended in routine care, sealants may be beneficial in select cases but further evidence of benefit is required, and the use of a tourniquet remains at the discretion of the surgeon. Postoperatively, restrictive transfusion protocols should be followed with a transfusion threshold haemoglobin of 70 g/L, except in the presence of acute coronary syndrome. Recent studies report no allogeneic transfusions after primary knee arthroplasty surgery after employing blood conservation strategies. The current challenge is to select and integrate different blood conserving interventions to deliver an optimal patient pathway with a multidisciplinary approach.
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Klein AA, Bailey CR, Charlton AJ, Evans E, Guckian-Fisher M, McCrossan R, Nimmo AF, Payne S, Shreeve K, Smith J, Torella F. Association of Anaesthetists guidelines: cell salvage for peri-operative blood conservation 2018. Anaesthesia 2018; 73:1141-1150. [DOI: 10.1111/anae.14331] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 01/03/2023]
Affiliation(s)
- A. A. Klein
- Department of Anaesthesia and Intensive Care; Royal Papworth Hospital; Cambridge UK
| | - C. R. Bailey
- Department of Anaesthesia, Guys and St; Thomas' NHS Foundation Trust; London UK
| | - A. J. Charlton
- NHS Blood and Transplant; Newcastle upon Tyne NHS Foundation Trust; Newcastle UK
| | - E. Evans
- Department of Obstetric Anaesthesia; St George's University Hospitals NHS Foundation Trust; London UK
| | - M. Guckian-Fisher
- Immediate Past President; The Association for Peri-operative Practice (AFPP); UK
| | - R. McCrossan
- Northern School of Anaesthesia; Royal Victoria Infirmary; Newcastle upon Tyne NHS Foundation Trust; Newcastle UK
| | - A. F. Nimmo
- Department of Anaesthesia; Royal Infirmary of Edinburgh; Edinburgh UK
| | | | - K. Shreeve
- Better Blood Transfusion Team; Welsh Blood Service; Co-chair of UK Cell Salvage Action Group; UK
| | - J. Smith
- Department of Paediatric Cardiothoracic Anaesthesia and Intensive Care; Freeman Hospital; Newcastle upon Tyne NHS Foundation Trust; Newcastle UK
| | - F. Torella
- Liverpool Vascular and Endovascular Service; Liverpool UK
- School of Physical Sciences; University of Liverpool; Liverpool UK
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22
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Decline in allogeneic blood transfusion usage in total hip arthroplasty patients: National Inpatient Sample 2009 to 2013. Hip Int 2018; 28:382-390. [PMID: 29218687 DOI: 10.5301/hipint.5000590] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Although total hip arthroplasty (THA) is an effective treatment for end-stage arthritis, it is also associated with substantial blood loss that may require allogeneic blood transfusion. However, these transfusions may increase the risk of certain complications. The purpose of our study is to evaluate: (i) the incidence/trends of allogeneic blood transfusion; (ii) the associated risk factors and adverse events; and (iii) the discharge disposition, length of stay (LOS), and costs for these patients between 2009 and 2013. METHODS The National Inpatient Sample database was used to identify 1,542,366 primary THAs performed between 2009 and 2013. Patients were stratified based on demographics, economic data, hospital characteristics, comorbidities, and whether or not allogeneic transfusion was received. Logistic regression was performed to evaluate the risk factors for transfusion and postoperative complications. RESULTS From 2009 to 2013, allogeneic transfusions were used in 16.9% of primary THAs, with a declining annual incidence. Except for obesity, all comorbidities were associated with increased likelihood of receiving a transfusion. Allogeneic transfusion patients were more likely to experience surgical site infections or pulmonary complications (p<0.001 for all). These patients were more likely to be discharged to a short-term care facility (p<0.001). Additionally, they had a greater mean LOS (p<0.001) and higher median hospital costs and charges when compared to their non-transfused counterparts. CONCLUSIONS While the observed decline in allogeneic transfusion usage is encouraging, further efforts should focus on preoperative patient optimisation. Given the projected increase in demand for primary THAs, orthopaedic surgeons must be familiar with safe and effective blood conservation protocols.
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Mazzeffi MA, See JM, Williams B, Richards J, Zimmerman D, Galvagno S, Fontaine M, Tanaka K. Five-year trends in perioperative red blood cell transfusion from index cases in five surgical specialties: 2011 to 2015. Transfusion 2018. [PMID: 29542136 DOI: 10.1111/trf.14559] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Red blood cell (RBC) transfusion can be life-saving; however, the risks of RBC transfusion have been increasingly recognized, and current guidelines recommend restrictive transfusion in most patients. We hypothesized that RBC transfusions are decreasing in surgical patients. STUDY DESIGN AND METHODS A retrospective review of the National Surgical Quality Improvement Program database was performed from 2011 to 2015. Index cases in five surgical specialties were studied: neurosurgery, thoracic surgery, gynecologic surgery, orthopedic surgery, and vascular surgery. Patient characteristics, preoperative laboratory values, and surgery details were compared between years. The study's primary outcome was perioperative RBC transfusion, which was compared over the 5-year period for each specialty. Secondary outcomes were myocardial infarction and renal failure after surgery. In addition, trends in RBC transfusion between low-risk and high-risk patients and between emergency and elective surgery were examined. RESULTS RBC transfusion decreased in all surgical specialties except for thoracic and gynecologic surgery. RBC transfusion decreased substantially in orthopedic surgery, falling from 22.4% in 2011 to 6.3% in 2015 (p ≤ 0.0001). High-risk patients had greater reductions in the receipt of RBC transfusion than low-risk patients, and there were no increases in myocardial infarction or renal failure after surgery in any specialty. CONCLUSION RBC transfusion appears to be decreasing across multiple surgical specialties, with no apparent increase in myocardial infarctions or renal failure. This likely represents an important improvement in patient care. Continued efforts are needed to develop patient blood management programs and further reduce RBC transfusion.
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Affiliation(s)
- Michael A Mazzeffi
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - John M See
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brittney Williams
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Justin Richards
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Darin Zimmerman
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Samuel Galvagno
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Magali Fontaine
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenichi Tanaka
- Departments of Anesthesiology and Pathology, University of Maryland School of Medicine, Baltimore, Maryland
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Xie J, Hu Q, Ma J, Huang Q, Pei F. Multiple boluses of intravenous tranexamic acid to reduce hidden blood loss and the inflammatory response following enhanced-recovery primary total hip arthroplasty: a randomised clinical trial. Bone Joint J 2017; 99-B:1442-1449. [PMID: 29092982 DOI: 10.1302/0301-620x.99b11.bjj-2017-0488.r1] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/25/2017] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to examine the efficacy and safety of multiple boluses of intravenous (IV) tranexamic acid (TXA) on the hidden blood loss (HBL) and inflammatory response following primary total hip arthroplasty (THA). PATIENTS AND METHODS A total of 150 patients were allocated randomly to receive a single bolus of 20 mg/kg IV TXA before the incision (group A), a single bolus followed by a second bolus of 1 g IV-TXA three hours later (group B) or a single bolus followed by two boluses of 1 g IV-TXA three and six hours later (group C). All patients were treated using a standard peri-operative enhanced recovery protocol. Primary outcomes were HBL and the level of haemoglobin (Hb) as well as the levels of C-reactive protein (CRP) and interleukin-6 (IL-6) as markers of inflammation. Secondary outcomes included the length of stay in hospital and the incidence of venous thromboembolism (VTE). RESULTS The mean HBL was significantly lower in group C (402.13 ml standard deviation (sd) 225.97) than group A (679.28 ml sd 277.16, p < 0.001) or B (560.62 ml sd 295.22, p = 0.010). The decrease in the level of Hb between the pre-operative baseline and the level on the third post-operative day was 30.82 g/L (sd 6.31 g/L) in group A, 27.16 g/L (sd 6.83) in group B and 21.98 g/L (sd 3.72) in group C. This decrease differed significantly among the three groups (p < 0.01). The mean level of CRP was significantly lower in group C than in the other two groups on the second (p ≤ 0.034) and third post-operative days (p ≤ 0.014). The levels of IL-6 were significantly lower in group C than group A on the first three post-operative days (p = 0.023). The mean length of stay was significantly lower in group C than group A (p = 0.023). No VTE or other adverse events occurred. CONCLUSION Multiple boluses of IV-TXA can effectively reduce HBL following primary THA. A regime of three boluses leads to a smaller decrease in the level of Hb, less post-operative inflammation and a shorter length of stay in hospital than a single bolus. Cite this article: Bone Joint J 2017;99-B:1442-9.
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Affiliation(s)
- J Xie
- Sichuan University, 37 Guoxue Road, Chengdu, Sichuan Province 610041, China
| | - Q Hu
- Sichuan University, 37 Guoxue Road, Chengdu, Sichuan Province 610041, China
| | - J Ma
- Sichuan University, 37 Guoxue Road, Chengdu, Sichuan Province 610041, China
| | - Q Huang
- Sichuan University, 37 Guoxue Road, Chengdu, Sichuan Province 610041, China
| | - F Pei
- Sichuan University, 37 Guoxue Road, Chengdu, Sichuan Province 610041, China
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Naqvi SY, Rabiei AH, Maltenfort MG, Restrepo C, Viscusi ER, Parvizi J, Rasouli MR. Perioperative Complications in Patients With Sleep Apnea Undergoing Total Joint Arthroplasty. J Arthroplasty 2017; 32:2680-2683. [PMID: 28583758 DOI: 10.1016/j.arth.2017.04.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/05/2017] [Accepted: 04/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study aims to evaluate the effect of sleep apnea (SA) on perioperative complications after total joint arthroplasty (TJA) and whether the type of anesthesia influences these complications. METHODS Using the ninth and tenth revisions of the International Classification of Diseases, coding systems, we queried our institutional TJA database from January 2005 to June 2016 to identify patients with SA who underwent TJA. These patients were matched in a 1:3 ratio based on age, gender, type of surgery, and comorbidities to patients who underwent TJA but were not coded for SA. Perioperative complications were identified using the same coding systems. Multivariate analysis was used to test if SA is an independent predictor of perioperative complications and if type of anesthesia can affect these complications. RESULTS A total of 1246 patients with SA were matched to 3738 patients without SA. Pulmonary complications occurred more frequently in patients with SA (1.7% vs 0.6%; P < .001), confirmed using multivariate analysis (odds ratio = 2.91; 95% confidence interval, 1.58-5.36; P = .001). Use of general anesthesia increased risk of all but central nervous system complications and mortality (odds ratio = 15.88; 95% confidence interval, 3.93-64.07; P < .001) regardless of SA status compared with regional anesthesia. Rates of pulmonary and gastrointestinal complications, acute anemia, and mortality were lower in SA patients when regional anesthesia was used (P < .05). CONCLUSION SA increases risk of postoperative pulmonary complications. The use of regional anesthesia may reduce risk of pulmonary complications and mortality in SA patients undergoing TJA.
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Affiliation(s)
- Syed Y Naqvi
- Department of Internal Medicine, Pennsylvania Hospital of the University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Amin H Rabiei
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mitchell G Maltenfort
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Camilo Restrepo
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Eugene R Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mohammad R Rasouli
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania; Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Mufarrih SH, Qureshi NQ, Ali A, Malik AT, Naim H, Noordin S. Total knee Arthroplasty: risk factors for allogeneic blood transfusions in the South Asian population. BMC Musculoskelet Disord 2017; 18:359. [PMID: 28830388 PMCID: PMC5568396 DOI: 10.1186/s12891-017-1728-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 08/16/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is the recommended treatment for end-stage knee osteoarthritis. Considering the various risks associated with intra and postoperative blood transfusions, better understanding is required with respect to the risk factors contributing to a greater possibility of blood transfusion during or after surgery. Although literature highlights several such factors, our study is among the first to identify these risk factors in the South Asian population which differs from other populations in several ways. METHODS The study consists of a review of 658 patients undergoing TKA from 2005 to 2015. Data was obtained from patient medical records and was analysed using logistic regression analysis. The relationship between each predictor and the outcome variable was calculated as an Odds ratio (OR), the threshold of significance for which was p = 0.25 and p = 0.05 for univariate and multivariable analysis respectively. RESULTS The mean age of the patient population was 63 years (78% female), 25% of whom received one or more blood transfusions. Multivariable analysis revealed 5 significant independent predictors for increased risk of blood transfusions including bilateral knee surgery (OR:5.51), preoperative anemia (OR:4.15), higher ASA (American Society of Anaesthesiologists) status (3-4) (OR:1.92), female sex (OR:3.44) and BMI (Body mass index) ≤30 (OR:1.79) while increasing co-morbidities and age (>60) were found to be insignificant. CONCLUSIONS The factors identified for the South Asian population are largely similar to those for other populations. Identification of high risk patients will permit the application of an international multipronged approach which not only targets the modifiable risk factors but also the decision making process and blood management protocols in order to minimize the transfusion associated risks for a patient undergoing a TKA.
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Affiliation(s)
| | | | - Arif Ali
- Aga Khan University Hospital, Karachi, Pakistan
| | | | - Huda Naim
- Dow International Medical College, Karachi, Pakistan
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Frazier SK, Higgins J, Bugajski A, Jones AR, Brown MR. Adverse Reactions to Transfusion of Blood Products and Best Practices for Prevention. Crit Care Nurs Clin North Am 2017; 29:271-290. [PMID: 28778288 DOI: 10.1016/j.cnc.2017.04.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Transfusion, a common practice in critical care, is not without complication. Acute adverse reactions to transfusion occur within 24 hours and include acute hemolytic transfusion reaction, febrile nonhemolytic transfusion reaction, allergic and anaphylactic reactions, and transfusion-related acute lung injury, transfusion-related infection or sepsis, and transfusion-associated circulatory overload. Delayed transfusion adverse reactions develop 48 hours or more after transfusion and include erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and, with long-term transfusion, iron overload. Clinical strategies may reduce the likelihood of reactions and improve patient outcomes.
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Affiliation(s)
- Susan K Frazier
- PhD Program, RICH Heart Program, College of Nursing, University of Kentucky, CON Building, Office 523, 751 Rose Street, Lexington, KY 40536-0232, USA.
| | - Jacob Higgins
- College of Nursing, University of Kentucky, CON Building, 751 Rose Street, Lexington, KY 40536-0232, USA
| | - Andrew Bugajski
- College of Nursing, University of Kentucky, CON Building, 751 Rose Street, Lexington, KY 40536-0232, USA
| | - Allison R Jones
- Department of Acute, Chronic & Continuing Care, School of Nursing, University of Alabama at Birmingham, NB 543, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Michelle R Brown
- Clinical Laboratory Science, University of Alabama at Birmingham, SHPB 474, 1705 University Boulevard, Birmingham, AL 35294, USA
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Kansagra A, Andrzejewski C, Krushell R, Lehman A, Greenbaum J, Visintainer P, McGirr J, Mahoney K, Cloutier D, Ehresman A, Stefan MS. Blood Management Strategies to Reduce Transfusions After Elective Lower-Extremity Joint Arthroplasty Surgeries: One Tertiary Care Hospital’s Early Experience With an Alternative Payment Model—a Total Joint “Bundle”. Am J Med Qual 2017; 32:668-674. [DOI: 10.1177/1062860616687035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood loss associated with lower-extremity total joint arthroplasty (TJA) often results in anemia and the need for red blood cell transfusions (RBCTs). This article reports on a quality improvement initiative aimed at improving blood management strategies in patients undergoing TJA. A multifaceted intervention (preoperative anemia assessment, use of tranexamic acid, discouragement of autologous preoperative blood collection, restrictive RBCT protocols) was implemented. The results were stratified into 3 intervention periods: 1, pre; 2, peri; and 3, post. Fractional logistic regression was used to describe differences between various intervention periods. During the study period, 2511 patients underwent TJA. Compared with the preintervention period, there was 81.8% decrease in total units of RBCT during the postintervention period. Using activity-based costing (~$1000/unit), the annualized saving in RBC expenditure was $480 000. A multidisciplinary approach can be successful and sustainable in reducing RBCT and its associated costs for patients undergoing TJA.
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Affiliation(s)
- Ankit Kansagra
- Baystate Medical Center, Springfield, MA
- Tufts University School of Medicine, Boston, MA
| | - Chester Andrzejewski
- Baystate Medical Center, Springfield, MA
- Tufts University School of Medicine, Boston, MA
| | | | | | | | | | | | | | | | | | - Mihaela S. Stefan
- Baystate Medical Center, Springfield, MA
- Tufts University School of Medicine, Boston, MA
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