Blood management and transfusion strategies in 600 patients undergoing total joint arthroplasty: an analysis of pre-operative autologous blood donation

Effects of Pre-Donated Autologous Blood Transfusion on Peri-Operative Hemoglobin Concentration and Mid-Term Health Outcomes in Primary Total Knee Arthroplasty

The effects of auto-BT in primary TKA on the perioperative hemoglobin (Hb) concentration and mid-term health outcomes are unknown. This study was performed to analyze the detailed changes in the perioperative Hb concentration before and after the operation (days 0–14 postoperatively), cardiovascular events, and mortality rate within 1 and 5 years postoperatively. One hundred patients undergoing primary TKA with auto-BT using 800 mL of preoperatively collected blood at the authors’ institution were included. The mean Hb concentration before and after autologous blood collection was 12.7 ± 1.1 and 11.7 ± 1.2 g/dL, respectively. After primary TKA with auto-BT, the mean Hb concentration on day 0, 1, 3, 7, and 14 was 10.2 ± 1.2, 9.9 ± 1.2, 10.4 ± 1.3, 10.5 ± 1.3, and 11.0 ± 1.3 g/dL, respectively. Only one (1%) patient required additional allogenic blood transfusion. No patients developed cardiovascular events, and the 1- and 5-year postoperative mortality rate was 1.0% and 2.0%, respectively. Primary TKA with auto-BT showed relatively small perioperative changes in the Hb concentration, a low incidence of cardiovascular events, and a low mortality rate within 1 and 5 years postoperatively. These findings suggest that auto-BT, in which blood is preoperatively collected, is beneficial for patient safety and health, even if its cost-effectiveness may be debatable.

Perioperative Blood Management Strategies for Total Knee Arthroplasty

Total knee arthroplasty (TKA) often causes a significant amount of blood loss with an accompanying decline in hemoglobin and may increase the frequency of allogeneic blood transfusion rates. Unfortunately, allogeneic blood transfusions have associated risks including postoperative confusion, infection, cardiac arrhythmia, fluid overload, increased length of hospital stay, and increased mortality. Other than reducing the need for blood transfusions, reducing perioperative blood loss in TKA may also minimize intra-articular hemorrhage, limb swelling, and postoperative pain, and increase the range of motion during the early postoperative period. These benefits improve rehabilitation success and increase patients' postoperative satisfaction. Preoperative anemia, coupled with intraoperative and postoperative blood loss, is a major factor associated with higher rates of blood transfusion in TKA. Thus, treatment of preoperative anemia and prevention of perioperative blood loss are the primary strategies for perioperative blood management in TKA. This review, combined with current evidence, analyzes various methods of blood conservation, including preoperative, intraoperative, and postoperative methods, in terms of their effectiveness, safety, and cost. Because many factors can be controlled to reduce blood loss and transfusion rates in TKA, a highly efficient, safe, and cost-effective blood management strategy can be constructed to eliminate the need for transfusions associated with TKA.

Total hip arthroplasty in patients with haemophilia - What are the risks of bleeding in the immediate peri-operative period?

BACKGROUND

Undergoing a major surgical intervention such as total hip arthroplasty (THA) with an underlying clotting disorder like haemophilia poses its own unique challenges. Despite the advances in factor replacement and medical management, the potential for excessive and uncontrolled haemorrhage still exists. The aim of this study was to quantify blood loss, peri-operative transfusion requirements and risk of haematoma formation in a cohort of patients with haemophilia undergoing THA.

METHODS

All patients with haemophilia types A or B who had undergone THA in the previous 10 years were identified from the Hospital In-Patient Enquiry system and theatre logs. A comprehensive review of operative records, laboratory parameters and peri-operative haematological management was conducted.

RESULTS

Eleven male patients (12 THA) were identified. The mean age was 56 years (range 28-76). The mean intra-operative blood loss was 502 ml (100-1250 ml) compared to an established normal blood loss of 400 ml. The mean drop in haemoglobin was 3.25 g/dl in 48 h. Only one patient required a post-operative transfusion of two units of red cell concentrate. There were no complications of haematoma formation.

CONCLUSION

The results in our institution compare favourably with the established blood loss reported in the literature and by assessment with International Guidelines. Average blood loss in patients with haemophilia was higher than the established normal, but there was no increased transfusion requirement.

Effect of both preoperative andpostoperative cryoceutical treatment on hemostasis and postoperative pain following total knee arthroplasty

AIM

We aimed to evaluate the hemostatic effects and the clinical outcomes of preoperative and postoperative cryoceutical treatment (C-tx) following total knee arthroplasty.

PATIENTS AND METHOD

42 patients received C-tx both preoperatively, and postoperatively. In the control group, 45 patients did not receive any C-tx. Amount of bloody drainage and verbal rating pain scores were noted.

RESULTS

We found significant difference in both the preoperative and postoperative hemoglobin levels and blood drainage (P<0.001). However, there was no significant difference in the average verbally rated pain scores (P>0.05).

CONCLUSION

C-tx performed preoperatively and postoperatively for total knee arthroplasty is effective in decreasing perioperative and postoperative hemorrhage. However, it had no superior effect on the control of postoperative pain.

Postoperative Autologous Reinfusion in Total Knee Replacement

Surgeries for total knee replacement (TKR) are increasing and in this context there is a need to develop new protocols for management and use of blood transfusion therapy. Autologous blood reduces the need for allogeneic blood transfusion and the aim of the present study was to verify the safety and the clinical efficacy. An observational retrospective study has been conducted on 124 patients, undergoing cemented total knee prosthesis replacement. Observed population was stratified into two groups: the first group received reinfusion of autologous blood collected in the postoperative surgery and the second group did not receive autologous blood reinfusion. Analysis of data shows that patients undergoing autologous blood reinfusion received less homologous blood bags (10.6% versus 30%; p = 0.08) and reduced days of hospitalization (7.88 ± 0.7 days versus 8.96 ± 2.47 days for the control group; p = 0.03). Microbiological tests were negative in all postoperatively salvaged and reinfused units. Our results emphasize the effectiveness of this procedure and have the characteristics of simplicity, low cost (€97.53 versus €103.79; p < 0.01), and easy reproducibility. Use of autologous drainage system postoperatively is a procedure that allows reducing transfusion of homologous blood bags in patients undergoing TKR.

Simultaneous bilateral total hip arthroplasties do not lead to higher complication or allogeneic transfusion rates compared to unilateral procedures

PURPOSE

About 20 % of patients undergoing a primary total hip arthroplasty could undergo a second contralateral procedure within five years. The possibility to perform simultaneous bilateral hip replacements instead of two-stage surgery could reduce hospitalisation time and patient management costs, but concerns exist because of risks related to massive blood loss and possible increase in complication rates. The purpose of this study is to assess the veracity of these concerns.

METHODS

Parameters like blood loss, transfused blood units, total hospital length of stay (surgical and rehabilitation) and presence of in-hospital complications were collected from surgery reports of two different groups of patients. The first group comprised patients undergoing simultaneous bilateral total hip arthroplasty (n = 63), while the second group consisted of patients undergoing unilateral surgery (n = 97). Occurrence of complications within six post-operative months was assessed by phone interview.

RESULTS

No differences were observed in complication, revision and mortality rates between the study groups. On the contrary, blood loss was significantly higher in the bilateral group, but the application of appropriate transfusion protocols reduced the use of allogeneic blood transfusion to the levels recorded for unilateral patients. Moreover, the difference in length of hospital stay (about two days) between the two groups was not clinically relevant.

CONCLUSIONS

Our data show that simultaneous bilateral procedures do not lead to higher complication or allogeneic transfusion rates in comparison to unilateral hip replacement, and that, in cases of bilateral disease, they could significantly reduce the total length of hospital stay and, therefore, patient management costs.