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The Effect of Hypotensive Anesthesia on Hemoglobin Levels during Total Knee Arthroplasty. J Clin Med 2020; 10:jcm10010057. [PMID: 33375273 PMCID: PMC7795316 DOI: 10.3390/jcm10010057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/19/2020] [Accepted: 12/22/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction: Hypotensive epidural anesthesia (HEA) is used in total joint arthroplasty as a safe and effective blood-saving modality. In order to maintain the blood pressure and heart rate patients, receive 1000 to 1500 mL of lactated Ringer’s solution during surgery. While HEA reduces the intraoperative blood loss, the effect of intravenous fluid loading on hemoglobin levels is not fully understood. The current study investigates the effect of HEA on perioperative hemoglobin levels. Materials and Methods: The study included 35 patients operated on by a single surgeon undergoing primary total knee arthroplasty under HEA. Intraoperatively, at least 300 mL of intravenous fluid were given every 15 min over the first 60 min after HEA. Blood samples were drawn before entering the operating room, after HEA, as well as after inflation of the tourniquet, every 15 min thereafter, as well as in the recovery room and on postoperative days one and two. In addition, fluid in- and outtake was recorded. Results: Patients received a mean 1275 mL during the 60 min of tourniquet time. The mean arterial pressure (MAP) 5 min after HEA dropped to 60 mmHg and reached a constant level of around 58 mmHg 15 min after HEA. The average hemoglobin level dropped from 13.9 g/dL prior to HEA, to 12.5 g/dL immediately after HEA (p < 0.001). Intraoperatively the hemoglobin level dropped further and reached 11.8 g/dL at 60 min in the absence of blood loss. Conclusions: Hypotensive epidural anesthesia and the resulting fluid substitution resulted in an average hemoglobin drop of 2.1 g/dL within the first 60 min. This needs to be taken into account when evaluating the need for blood transfusions after primary joint replacement surgery under HEA.
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Shin HJ, Min BH, Na HS. FIBTEM as a predictor of intra- and postoperative blood loss in revision total hip arthroplasty: A prospective observational study. Medicine (Baltimore) 2018; 97:e10929. [PMID: 29851830 PMCID: PMC6392916 DOI: 10.1097/md.0000000000010929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Revision total hip arthroplasty (THA) may cause intra- and postoperative massive bleeding. This prospective observational study evaluated if the maximum clot firmness of FIBTEM (MCFFIB) could act as a predictor of perioperative massive bleeding in revision THA.Fifty-eight adult patients undergoing revision THA were included. Pre- and postoperative MCFFIB, hematological and hemostatic laboratory data, as well as the amount of intra- and postoperative blood loss (IBL and PBL) were obtained.The change rate (MCFFIB-C) between the pre- and postoperative MCFFIB had a significant correlation with IBL (ρ = 0.431, P = .001). Moreover, PBL had a significant correlation with MCFFIB-C (ρ = 0.292, P = .026). The MCFFIB-C cut-off value of ≥ 29% showed the highest sensitivity and specificity for predicting IBL ≥ 1000 mL or PBL ≥500 mL. The incidence of red blood cell transfusion in the postoperative period was higher in patients showing MCFFIB-C ≥ 29% (34% vs 8%, P = .015).The change rate between pre- and postoperative MCFFIB values was correlated well with the amount of IBL or PBL. Moreover, particular change rate of MCFFIB could predict massive bleeding in revision THA.
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Guo P, He Z, Wang Y, Gao F, Sun W, Guo W, Li Z, Cheng L. Efficacy and safety of oral tranexamic acid in total knee arthroplasty: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e0587. [PMID: 29718858 PMCID: PMC6393150 DOI: 10.1097/md.0000000000010587] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug widely used as a blood-sparing technique in total knee arthroplasty (TKA), and it is usually administrated by intravenous or intraarticular injection. Recently, the oral form of TXA has been applied in TKA patients. However, there is no final consensus regarding the effectiveness and safety of oral TXA. The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the efficacy and safety of oral TXA versus control for blood loss after TKA. METHODS We searched PubMed, Embase, Medline, Web of Science, and Cochrane Library databases for relevant studies through August 2017. The mean difference (MD) of total blood loss, hemoglobin (Hb) drop, hematocrit (Hct), drain output, and risk difference (RD) of transfusion rate and thromboembolic complications in the TXA and control groups were pooled throughout the study. The outcomes were pooled by Stata 12.0. RESULTS A total of 5 RCTs (608 patients) were included in this study. All the included studies were randomized and the quality of included studies was relatively high. The pooled results indicated that the oral TXA group had significantly less Hb drop (standardized mean difference [SMD], -0.936; 95% confidence intervals [CI], -1.118,-0.754), Hct drop (SMD, -0.693; 95% CI, -1.113, -0.274), and drain output (SMD, -0.793; 95% CI, -0.959, -0.628) than the control group. No statistically significant differences were found in transfusion rate and the incidence of thromboembolic complications between the 2 groups. Total blood loss could not be evaluated for the insufficient date. CONCLUSIONS Our meta-analysis suggested that the administration of oral TXA provided significantly better results with respect to Hb drop, Hct drop, and drain output without increasing the transfusion rate and the risk of thromboembolic complications after TKA. Nevertheless, our current study with some limitations such as the small sample size only provided limited quality of evidence, confirmation from further meta-analysis with large-scale, well-designed RCTs is required.
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Affiliation(s)
- Peipei Guo
- The Graduate School of Peking Union Medical College, Beijing
| | - Zike He
- Department of Orthopedics, Henan Province Hospital of TCM, Zhengzhou City, Henan
| | - Yanhua Wang
- Department of Trauma and Orthopedics, Peking University People's Hospital, Beijing
| | - Fuqiang Gao
- Center for Osteonecrosis and Joint-preserving and Reconstruction, Department of Orthopedic Surgery, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, China-Japan Friendship Hospital, Peking Union Medical College, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Wei Sun
- Center for Osteonecrosis and Joint-preserving and Reconstruction, Department of Orthopedic Surgery, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, China-Japan Friendship Hospital, Peking Union Medical College, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Wanshou Guo
- Center for Osteonecrosis and Joint-preserving and Reconstruction, Department of Orthopedic Surgery, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, China-Japan Friendship Hospital, Peking Union Medical College, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Zirong Li
- Center for Osteonecrosis and Joint-preserving and Reconstruction, Department of Orthopedic Surgery, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, China-Japan Friendship Hospital, Peking Union Medical College, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Liming Cheng
- Center for Osteonecrosis and Joint-preserving and Reconstruction, Department of Orthopedic Surgery, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, China-Japan Friendship Hospital, Peking Union Medical College, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
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Athanasiadis T, Beule AG, Wormald PJ. Effects of Topical Antifibrinolytics in Endoscopic Sinus Surgery: A Pilot Randomized Controlled Trial. ACTA ACUST UNITED AC 2018; 21:737-42. [DOI: 10.2500/ajr.2007.21.3097] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Bleeding in endoscopic sinus surgery (ESS) may increase the risk of intraoperative complications and is associated with poorer outcomes Antifibrinolytic agents have been shown to reduce bleeding if administered systemically. The aim of this study was to determine the effect of topical epsilon-aminocaproic acid (EACA) and tranexamic acid (TA) on bleeding in the surgical field during ESS. Methods A prospective blind randomized controlled trial was performed. Thirty patients undergoing ESS were randomized to receive either 2.5 g of EACA, 100 mg of TA, or 1 g of TA while the contralateral side received saline. The solution was applied as a spray at the conclusion of operating on each side. Bleeding was documented using standardized videoendoscopy and grading scales. Results EACA did not show a significant effect on intraoperative bleeding. TA at 100 mg showed a clinically significant improvement in the surgical field at 2, 4, and 6 minutes after application. The mean for 2 minutes was TA, 1.6 ± 1.08, and control, 2.2 ± 1.3; at 4 minutes was TA, 1.25 ± 1.2, and control, 1.7 ± 1.2,; and at 6 minutes was TA, 0.75 ± 1.2, and control, 1.3 ± 1.4 (p < 0.05). TA at 1 g also approached significance at all time points. Combined results from the two TA groups showed a significant improvement in the surgical field at 2, 4, 6, and 8 minutes after application. TA was regarded by the blinded surgeon as more effective than saline in 80% of cases. No adverse effects were encountered after topical application of either drug. Conclusion Topical application of TA is effective in achieving hemostasis and improving the surgical field. In contrast to EACA, TA is a valuable tool in ESS that merits additional evaluation.
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Affiliation(s)
- Theodore Athanasiadis
- Department of Otorhinolaryngology, Head and Neck Surgery, The Queen Elizabeth Hospital, University of Adelaide, Australia
| | - Achim G. Beule
- Department of Otorhinolaryngology, Head and Neck Surgery, The Queen Elizabeth Hospital, University of Adelaide, Australia
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Greifswald, Greifswald, Germany
| | - Peter J. Wormald
- Department of Otorhinolaryngology, Head and Neck Surgery, The Queen Elizabeth Hospital, University of Adelaide, Australia
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Ma J, Sun J, Guo W, Li Z, Wang B, Wang W. The effect of platelet-rich plasma on reducing blood loss after total knee arthroplasty: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e7262. [PMID: 28658120 PMCID: PMC5500042 DOI: 10.1097/md.0000000000007262] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Efficacy and safety of platelet-rich plasma (PRP) compared with control for preventing postoperative bleeding after total knee arthroplasty (TKA) is controversial. We performed a meta-analysis of randomized controlled trials (RCTs) to determine whether PRP might reduce blood loss and improve function following TKA. METHODS PubMed, Medline, Embase, Web of Science, and the Cochrane Library were searched to identify RCTs comparing PRP with control for patients undergoing unilateral TKA. The mean difference (MD) of total blood loss, hemoglobin (Hb) level, Hb drop, drain volume, range of motion (ROM), Western Ontario and McMaster Osteoarthritis Index (WOMAC) scores, length of hospital stay (LOS), and odds ratios of transfusion rate and postoperative complications in the PRP and control groups were pooled throughout the study. Relevant data were meta-analyzed using RevMan v5.3. RESULTS Six RCTs involving 529 patients were included (208 PRP vs. 321 controls). The application of PRP in TKA had a significantly less calculated total blood loss (MD = -98.11; 95% confidence interval [CI]: -153.63 to -42.59, P = .0005) and lower Hb drop (MD = -0.34; 95% CI: -0.59 to -0.09, P = .008) than the control in the early postoperative period while decreasing the LOS (MD = -2.12; 95% CI: -3.47 to -0.76, P = .002). No significant differences were seen in drain volume, Hb level, transfusion rate, ROM, WOMAC scores, and complications between the 2 groups (P > .05). CONCLUSIONS Our meta-analysis suggests that PRP appears to be effective in reducing postoperative blood loss and lowering Hb drop without increasing the risks of postoperative complications after TKA. However, owing to the variation of included studies, no firm conclusions can be drawn.
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Affiliation(s)
- Jinhui Ma
- Department of Bone and Joint Surgery, Center for Osteonecrosis and Joint Preserving & Reconstruction, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Jiale Sun
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Shijingshan District, Beijing, 100144 China
| | - Wanshou Guo
- Department of Bone and Joint Surgery, Center for Osteonecrosis and Joint Preserving & Reconstruction, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Zirong Li
- Department of Bone and Joint Surgery, Center for Osteonecrosis and Joint Preserving & Reconstruction, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Bailiang Wang
- Department of Bone and Joint Surgery, Center for Osteonecrosis and Joint Preserving & Reconstruction, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Weiguo Wang
- Department of Bone and Joint Surgery, Center for Osteonecrosis and Joint Preserving & Reconstruction, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
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Gao F, Ma J, Sun W, Guo W, Li Z, Wang W. Topical fibrin sealant versus intravenous tranexamic acid for reducing blood loss following total knee arthroplasty: A systematic review and meta-analysis. Int J Surg 2016; 32:31-7. [DOI: 10.1016/j.ijsu.2016.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/13/2016] [Accepted: 06/11/2016] [Indexed: 10/21/2022]
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Panteli M, Pountos I, Giannoudis PV. Pharmacological adjuncts to stop bleeding: options and effectiveness. Eur J Trauma Emerg Surg 2015; 42:303-10. [PMID: 26660675 PMCID: PMC4886148 DOI: 10.1007/s00068-015-0613-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 11/29/2022]
Abstract
Severe trauma and massive haemorrhage represent the leading cause of death and disability in patients under the age of 45 years in the developed world. Even though much advancement has been made in our understanding of the pathophysiology and management of trauma, outcomes from massive haemorrhage remain poor. This can be partially explained by the development of coagulopathy, acidosis and hypothermia, a pathological process collectively known as the “lethal triad” of trauma. A number of pharmacological adjuncts have been utilised to stop bleeding, with a wide variation in the safety and efficacy profiles. Antifibrinolytic agents in particular, act by inhibiting the conversion of plasminogen to plasmin, therefore decreasing the degree of fibrinolysis. Tranexamic acid, the most commonly used antifibrinolytic agent, has been successfully incorporated into most trauma management protocols effectively reducing mortality and morbidity following trauma. In this review, we discuss the current literature with regard to the management of haemorrhage following trauma, with a special reference to the use of pharmacological adjuncts. Novel insights, concepts and treatment modalities are also discussed.
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Affiliation(s)
- M Panteli
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.
| | - I Pountos
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK
| | - P V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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Ghoz A, Al-Khateeb H, Rajkumar S, Tavares S, Andrade A. Use of a Thrombin Fibrin Sealant in Reducing Blood Loss in Revision Hip Arthroplasty. Open Orthop J 2015; 9:511-4. [PMID: 27468998 PMCID: PMC4645936 DOI: 10.2174/1874325001509010511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/31/2015] [Accepted: 05/03/2015] [Indexed: 11/25/2022] Open
Abstract
We present a retrospective evaluation assessing the use of a novel fibrin sealant, Quixil® (OMRIX Biopharmaceuticals S.A.) in reducing blood transfusions following revision total hip replacement surgery. Forty four patients underwent revision total hip replacement surgery using Quixil®, while 45 patients underwent revision total hip replacement surgery without the use of Quixil®. The duration of surgery and patient demographics were similar in both groups. Average blood loss was 1,010ml in the Quixil® group versus 1,021ml in the non-Quixil group. The use of cell saver and intra-operative blood transfusion were similar in both groups. The mean pre-operative Haemoglobin was 13.0 g/dl in the Quixil® group versus 12.4 g/dl in the non-Quixil group. The mean post-operative haemoglobin was 10.2 g/dl and 9.1 g/dl in the Quixil® and non-Quixil groups respectively. There was no difference in the blood transfused post-operatively between the two groups. Total units of blood transfused in Quixil®versus non-Quixil group were 60 verus 86. Total units of intra-operative blood transfused in Quixil®versus non-Quixil group were 16 versus 23. The use of fibrin tissue adhesive in revision total hip arthroplasty seems to be an effective and reliable means to reduce blood-transfusion requirements and prevent post-operative decreases in hemoglobin.
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Affiliation(s)
- Ali Ghoz
- Hinchingbrooke Hospital, Hinchingbrooke Park, Hinchingbrooke, Huntingdon, Cambridgeshire PE29 6NT, UK
| | - Hesham Al-Khateeb
- Department of Trauma and Orthopaedics, King Hamad University Hospital, Bahrain
| | | | - Shawn Tavares
- Royal Berkshire Hospital, Craven Rd, Reading RG1 5AN, UK
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Wang H, Shan L, Zeng H, Sun M, Hua Y, Cai Z. Is fibrin sealant effective and safe in total knee arthroplasty? A meta-analysis of randomized trials. J Orthop Surg Res 2014; 9:36. [PMID: 24884626 PMCID: PMC4024649 DOI: 10.1186/1749-799x-9-36] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/28/2014] [Indexed: 11/10/2022] Open
Abstract
The objective of this study was to evaluate the efficacy and safety of fibrin sealant in patients following total knee arthroplasty (TKA). A comprehensive literature search of the electronic databases PubMed, MEDLINE, Web of Science, and Cochrane Library for published randomized controlled trials (RCTs) was undertaken. The evidence base was critically appraised using a tool from the Cochrane Bone, Joint and Muscle Trauma Group. Eight RCTs involving 641 patients were included. The use of fibrin sealant significantly reduced postoperative drainage (weighted mean difference (WMD) -346, 95% confidence interval (CI) -496.29 to -197.54, P < 0.00001) and blood transfusions (risk ratio (RR) 0.47, 95% CI 0.35 to 0.63, P < 0.00001) and led to a significant improvement in the range of motion (WMD 16.59, 95% CI 6.92 to 26.25, P = 0.0008). However, using fibrin sealant did not significantly reduced total blood loss (WMD -305.25, 95% CI -679.44 to 68.95, P = 0.11). Regarding complications, there were no significant differences in any adverse events, fever, infection, or hematoma among the study groups. In conclusion, the present meta-analysis indicates that the use of fibrin sealant was effective and safe as a hemostatic therapy for patients with TKA.
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Affiliation(s)
| | | | | | | | - Yingqi Hua
- Department of Orthopedics, Tenth People's Hospital of Tongji University, 301 Yanchang Road, Shanghai 200072, China.
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11
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Monsef JB, Della Valle AG, Mayman DJ, Marx RG, Ranawat AS, Boettner F. The impact of blood management on length of stay after primary total knee arthroplasty. Open Orthop J 2014; 8:108-13. [PMID: 24894715 PMCID: PMC4040929 DOI: 10.2174/1874325001408010108] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 03/20/2014] [Accepted: 03/29/2014] [Indexed: 11/22/2022] Open
Abstract
The current study investigates the impact of patient factors, surgical factors, and blood management on postoperative length of stay (LOS) in 516 patients who underwent primary total knee arthroplasty. Age, gender, type of anticoagulation, but not body mass index (BMI) were found to be highly significant predictors of an increased LOS. Allogeneic transfusion and the number of allogeneic units significantly increased LOS, whereas donation and/or transfusion of autologous blood did not. Hemoglobin levels preoperatively until 48 hours postoperatively were negatively correlated with LOS. After adjusting for confounding factors through Poisson regression, age (p = 0.001) and allogeneic blood transfusion (p = 0.002) were the most significant determinants of LOS. Avoiding allogeneic blood plays an essential role in reducing the overall length of stay after primary total knee arthroplasty.
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Affiliation(s)
- Jad B Monsef
- Adult Reconstruction & Joint Replacement Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alejandro G Della Valle
- Adult Reconstruction & Joint Replacement Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - David J Mayman
- Adult Reconstruction & Joint Replacement Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Robert G Marx
- Adult Reconstruction & Joint Replacement Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Amar S Ranawat
- Adult Reconstruction & Joint Replacement Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Friedrich Boettner
- Adult Reconstruction & Joint Replacement Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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12
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Xu Q, Yang Y, Shi P, Zhou J, Dai W, Yao Z, Zhang C. Repeated doses of intravenous tranexamic acid are effective and safe at reducing perioperative blood loss in total knee arthroplasty. Biosci Trends 2014; 8:169-75. [DOI: 10.5582/bst.2014.01063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Topical tranexamic acid in total knee replacement: a systematic review and meta-analysis. Knee 2013; 20:300-9. [PMID: 23815893 DOI: 10.1016/j.knee.2013.05.014] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 05/25/2013] [Accepted: 05/29/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND To examine the safety and efficacy of topical use of tranexamic acid (TA) in total knee arthroplasty (TKA). METHODS An electronic literature search of PubMed Medline; Ovid Medline; Embase; and the Cochrane Library was performed, identifying studies published in any language from 1966 to February 2013. The studies enrolled adults undergoing a primary TKA, where topical TA was used. Inverse variance statistical method and either a fixed or random effect model, depending on the absence or presence of statistical heterogeneity were used; subgroup analysis was performed when possible. RESULTS We identified a total of seven eligible reports for analysis. Our meta-analysis indicated that when compared with the control group, topical application of TA limited significantly postoperative drain output (mean difference: -268.36ml), total blood loss (mean difference=-220.08ml), Hb drop (mean difference=-0.94g/dL) and lowered the risk of transfusion requirements (risk ratio=0.47, 95CI=0.26-0.84), without increased risk of thromboembolic events. Sub-group analysis indicated that a higher dose of topical TA (>2g) significantly reduced transfusion requirements. CONCLUSIONS Although the present meta-analysis proved a statistically significant reduction of postoperative blood loss and transfusion requirements with topical use of TA in TKA, the clinical importance of the respective estimates of effect size should be interpreted with caution. LEVEL OF EVIDENCE I, II.
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Lee YC, Park SJ, Kim JS, Cho CH. Effect of tranexamic acid on reducing postoperative blood loss in combined hypotensive epidural anesthesia and general anesthesia for total hip replacement. J Clin Anesth 2013; 25:393-398. [DOI: 10.1016/j.jclinane.2013.02.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 02/12/2013] [Accepted: 02/13/2013] [Indexed: 11/24/2022]
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Albirmawy OA, Saafan ME, Shehata EM, Basuni AS, Eldaba AA. Topical application of tranexamic acid after adenoidectomy: a double-blind, prospective, randomized, controlled study. Int J Pediatr Otorhinolaryngol 2013; 77:1139-42. [PMID: 23669000 DOI: 10.1016/j.ijporl.2013.04.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 04/09/2013] [Accepted: 04/12/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Is to evaluate the efficacy of tranexamic acid when applied locally in children after primary isolated adenoidectomy with respect to intra-operative blood loss and post-operative bleeding. STUDY DESIGN Prospective, double-blind, randomized, controlled trial. SETTING Otolaryngology department, Tanta University and Tiba Hospitals, Egypt. PATIENTS AND METHODS Over three years, 400 children underwent primary isolated adenoidectomy followed by topical application of tranexamic acid (tranexamic acid group, 200 children) or saline (Placebo group, 200 children) with at least two weeks' follow up. Intra-operative blood loss and post-operative hemorrhage were monitored. RESULTS Both groups were almost equivalent in age and gender. The frequency of primary post-adenoidectomy hemorrhage as well as the rate of postnasal packing and blood transfusion required to manage severe bleeding were higher in placebo group. The volume of blood loss during surgery showed significant reduction in tranexamic acid group. CONCLUSION Topical application of tranexamic acid after adenoidectomy led to a significant reduction in blood loss during surgery and decreasing in the rate of post-operative bleeding as well as the need for postnasal packing and blood transfusion.
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Jeon SH, Kim JH, Lee JM, Seo ES. Efficacy of extramedullary femoral component alignment guide system for blood saving after total knee arthroplasty. Knee Surg Relat Res 2012; 24:99-103. [PMID: 22708110 PMCID: PMC3374006 DOI: 10.5792/ksrr.2012.24.2.99] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 12/04/2011] [Accepted: 02/23/2012] [Indexed: 10/29/2022] Open
Abstract
PURPOSE To compare the extramedullary femoral alignment guide system with the conventional intramedullary alignment guide system for bleeding and transfusion rate after total knee arthroplasty (TKA). MATERIALS AND METHODS Forty-nine female TKA patients were randomized into two groups: intramedullary (IM) group vs. extramedullary (EM) group. Drained volume of blood, hemoglobin concentration, hemoglobin drop, and transfusion rate were compared between the two groups. Wound problems, bleeding-related problems and thromboembolic complications were collected. RESULTS The mean drained volume via vacuum drainage was less in the EM group than that in the IM group (482.9 mL vs. 266.8 mL, p=0.001). Hemoglobin at 5 days after surgery was higher in the EM group (9.3 g/dL vs. 9.9 g/dL, p=0.002) than that in the IM group. The drop in hemoglobin after 5 days was smaller in the EM group (3.5 g/dL vs. 2.9 g/dL, p=0.003) than that in the IM group. The EM group had a lower prevalence of allogeneic transfusion (45.0% vs. 20.5%, p=0.026) than that in the IM group. No significant complications developed in either group. CONCLUSIONS The results suggest that the extramedullary femoral alignment guide technique is an advantageous method that can reduce the drained volume of blood and the allogeneic transfusion rate.
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Affiliation(s)
- Suk Ha Jeon
- Department of Orthopedic Surgery, National Medical Center, Seoul, Korea
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion management of patients in the peri-operative period. II. The intra-operative period. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:189-217. [PMID: 21527082 PMCID: PMC3096863 DOI: 10.2450/2011.0075-10] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Alternative procedures for reducing allogeneic blood transfusion in elective orthopedic surgery. HSS J 2010; 6:190-8. [PMID: 21886535 PMCID: PMC2926355 DOI: 10.1007/s11420-009-9151-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 12/01/2009] [Indexed: 02/07/2023]
Abstract
Perioperative blood loss is a major problem in elective orthopedic surgery. Allogeneic transfusion is the standard treatment for perioperative blood loss resulting in low postoperative hemoglobin, but it has a number of well-recognized risks, complications, and costs. Alternatives to allogeneic blood transfusion include preoperative autologous donation and intraoperative salvage with postoperative autotransfusion. Orthopedic surgeons are often unaware of the different pre- and intraoperative possibilities of reducing blood loss and leave the management of coagulation and use of blood products completely to the anesthesiologists. The goal of this review is to compare alternatives to allogeneic blood transfusion from an orthopedic and anesthesia point of view focusing on estimated costs and acceptance by both parties.
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Kazemi SM, Mosaffa F, Eajazi A, Kaffashi M, Daftari Besheli L, Bigdeli MR, Zanganeh RF. The effect of tranexamic acid on reducing blood loss in cementless total hip arthroplasty under epidural anesthesia. Orthopedics 2010; 33:17. [PMID: 20055345 DOI: 10.3928/01477447-20091124-30] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Total hip arthroplasty (THA) is associated with high intraoperative and postoperative blood loss. Antifibrinolytic drugs have been used to minimize the potential risks of bleeding and blood transfusion. Studies on the effect of tranexamic acid on decreasing blood loss in THA have revealed interesting results, but most have focused on cemented THA. Yet its benefits in THA, especially in cementless THA, have not been proved. We conducted a prospective double-blind randomized controlled study on 64 patients who were candidates for cementless THA under epidural anesthesia between 2006 and 2008. Patients were randomly assigned into study and control groups. Patients in both groups were well matched regarding preoperative characteristics. Five minutes preoperatively 32 patients of the study and control groups received 15 mg/kg tranexamic acid or normal saline intravenously respectively. Our findings showed a significantly smaller decrease in 6- and 24-hour postoperative hemoglobin levels, less intraoperative and postoperative bleeding, and less need for allogenic blood transfusion in the tranexamic acid group. Our results also revealed a higher mean of 6- and 24-hour hematocrit level and shorter hospital stay in the tranexamic acid group compared to the control group, which were not statistically meaningful. In our study no thromboembolic event was seen; except 1 patient in the control group. Our study showed that administering tranexamic acid before the start of cementless THA under epidural anesthesia can reduce intraoperative and postoperative bleeding as well as need for blood transfusion.
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Schumer RA, Chae JS, Markert RJ, Sprott D, Crosby LA. Predicting transfusion in shoulder arthroplasty. J Shoulder Elbow Surg 2010; 19:91-6. [PMID: 19664937 DOI: 10.1016/j.jse.2009.05.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Revised: 05/07/2009] [Accepted: 05/07/2009] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study was conducted to evaluate the incidence of transfusion in shoulder arthroplasty, determine clinical factors associated with increased risk for transfusion, and develop an algorithm to assist the surgeon in preoperative planning with regards to blood management. MATERIAL AND METHODS The study had 2 phases: (1) development of a clinical prediction rule for transfusion using 280 procedures and (2) a validation study of the algorithm applied to 109 new patients. Phase 1 consisted of a retrospective record review of 280 consecutive shoulder arthroplasties to determine risk factors for transfusion. Phase 1 also identified a preoperative hemoglobin level of less than 12.5 g/dL as predictive of the need for blood transfusion. This cutoff was prospectively applied to 109 patients undergoing shoulder arthroplasty in phase 2. RESULTS The transfusion rate for phase 1 was 19.6%. Preoperative hemoglobin level (P < .001), age (P= .003), and the number of comorbid conditions (P = .005) were statistically significant risk factors. Patients with a preoperative hemoglobin level of less than 12.5 g/dL have a 4-fold increased risk of requiring a blood transfusion. In phase 2, the cutoff of less than 12.5 g/dL yielded a sensitivity of 88%, specificity of 78%, and positive and negative likelihood ratios of 4.0 and 0.15, respectively. CONCLUSION Preoperative hemoglobin level, age, and number of comorbid conditions are all predictive of transfusion in shoulder arthroplasty. Tailoring blood ordering based on a preoperative hemoglobin level of 12.5 g/dL is safe and effective. LEVEL OF EVIDENCE Prognostic study, level 2.
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Affiliation(s)
- Ross A Schumer
- Department of Orthopaedic Surgery, Sports Medicine and Rehabilitation, Wright State Universty-Boonshoft School of Medicine, Dayton, OH, USA
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Rosenberg AG. Reducing blood loss in total joint surgery with a saline-coupled bipolar sealing technology. J Arthroplasty 2007; 22:82-5. [PMID: 17570284 DOI: 10.1016/j.arth.2007.02.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 02/28/2007] [Indexed: 02/01/2023] Open
Abstract
Despite the availability of a number of techniques to reduce blood loss in patients undergoing total joint arthroplasty, many patients remain at risk of receiving blood transfusions postoperatively. We have used a new technology that couples bipolar radiofrequency energy with saline to reduce blood loss in patients undergoing total joint surgery. The use of this technology has been shown to effectively minimize the risk of transfusion and reduce intraoperative and postoperative bleeding-related complications.
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Affiliation(s)
- Aaron G Rosenberg
- Department of Orthopaedic Surgery, Rush Medical College, Rush-Presbyterian-St Luke's Medical Center, Chicago, Illinois 60612, USA
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Moonen AFCM, Neal TD, Pilot P. Peri-operative blood management in elective orthopaedic surgery. A critical review of the literature. Injury 2006; 37 Suppl 5:S11-6. [PMID: 17338906 DOI: 10.1016/s0020-1383(07)70006-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Blood loss during orthopaedic procedures can be extensive and the need for allogeneic blood is a common requirement. However, blood transfusion conceals a number of well-recognised risks and complications and blood products have become more expensive because of their specific preparation procedure. Surgical technique, awareness of the problem and restriction of transfusion triggers are important factors affecting the management of blood loss. Several studies have additionally shown the efficacy of epoetin injections in increasing the pre-operative haemoglobin level. On the other hand, the true benefit of pre-operative autologous donation, acute normovolemic haemodilution and COX-2 selective NSAIDs remains under dispute. Regarding the role of platelet rich plasmapheresis, fibrin sealing and anti-fibinolytic drugs more data are needed. Hypotensive epidural anaesthesia seems to be an advantageous method in minimising peri-operative blood loss. However, this is not a widely performed technique in orthopaedic surgery. In addition, post-operative blood cell saving systems after total knee or hip arthroplasty have been reported to significantly minimise allogeneic blood transfusions when compared to control groups. It can be concluded that many interventions diminish more or less allogeneic blood transfusion in elective orthopaedic surgery. Nevertheless more prospective studies are needed and appropriate algorithms should be applied in peri-operative blood loss management. This review presents an overview of the available interventions which aim to diminish the use of allogeneic blood in elective orthopaedic surgery.
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Affiliation(s)
- A F C M Moonen
- Department of Orthopaedic Surgery, Atrium MC, Heerlen, The Netherlands.
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Abstract
Perioperative blood management continues to be a challenge in major orthopaedic surgical procedures. Techniques used have varied through the years, and ongoing attempts to minimize patients' exposure to allogeneic blood continue to be explored. To date, the majority of blood management options focus on either blood replacement with safe effective blood products or the preoperative stimulation of red blood cell production in the surgical patient with erythropoietin. This article describes a new device that uses thermal energy to inhibit blood loss from soft tissue and bone during orthopaedic surgery. Early clinical trials indicate that the bipolar device may reduce blood loss and decrease exposure to blood transfusions.
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Affiliation(s)
- Kathleen A Geier
- Bone and Joint Medical Associates of Northern California, Oakland, CA, USA
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