Preoperative haematinics and transfusion protocol reduce the need for transfusion after total knee replacement.

Department of Orthopaedic and Trauma Surgery, University Hospital Miguel Servet, Zaragoza, Spain.
International Journal of Surgery (London, England) (Impact Factor: 1.44). 04/2007; 5(2):89-94. DOI: 10.1016/j.ijsu.2006.02.003
Source: PubMed

ABSTRACT Unilateral total knee replacement (TKR) can result in a substantial blood loss and 30-50% of these patients receive allogeneic blood transfusion (ABT), this transfusion rate may be even higher among anaemic patients.
We assessed the requirements for ABT in 156 consecutive patients undergoing surgery for primary TKR, who received iron ferrous sulphate (256 mg/day; 80 mg of Fe(2+)), vitamin C (1000 mg/day) and folic acid (5mg/day) during the 30-45 days preceding surgery, and who were transfused if Hb <80 g/L and/or clinical signs/symptoms of acute anaemia/hypoxemia (Group 2). A previous series of 156 TKR patients serves as a control group (Group 1).
Compared to those in Group 1, patients in Group 2 presented a lower transfusion rate (5.8% vs. 32%, for Group 2 and Group 1, respectively; p<0.01), and a lower transfusion index (1.78+/-0.44 vs. 2.22+/-0.65 units per transfused patient, respectively; p<0.05). After patient's stratification according to a preoperative Hb above or below 130 g/L, the differences in transfusion rate remained significant, although 19% of patients from Group 2 still needed ABT if their preoperative Hb <130 g/L.
This protocol seems to be effective for avoiding ABT in non-anaemic TKR patients, whereas for anaemic patients another blood saving strategy, such us preoperative erythropoietin administration or postoperative blood salvage, should be added to further increase its effectiveness.

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    ABSTRACT: Pre-operative anaemia is present in 20-40% of patients scheduled for major elective orthopaedic procedures 1-3 . Pre-operative anaemia has been linked to post-operative infections, poorer physical functioning and recovery, decreased quality of life, and increased length of hospital stay and mortality 1-6 . It is not, however, clear whether anaemia is a modifiable risk factor of poorer outcomes and not simply a marker of other conditions that confer increased risk 3 . Peri-operative blood loss during these surgical procedures leads to a significant post-operative decline in haemoglobin level. This in turn induces post-operative anaemia and/or worsens pre-existing anaemia 7,8 . As a result, a significant proportion of patients receive allogeneic blood tor treat acute post-operative anaemia. The transfusion of allogeneic blood has, however, been linked to increased post-operative morbidity and mortality and longer hospital stays 9-13 . Therefore, an orthodox approach to the Patient Blood Management (PBM) paradigm recommended that patients scheduled for major orthopaedic procedures should have a full blood cell counts, iron status and some inflammatory marker tested, preferably 30 days before the scheduled surgical procedure, to allow the implementation of appropriate treatment, if available 14-17 . Although the most common sources of anaemia among patients undergoing orthopaedic surgery are related to iron deficiency and chronic diseases, given their co-morbidity profile 18 , vitamin B 12 and folic acid should also be measured and deficiencies replenished accordingly 14,15 . Some studies have shown that, for patients presenting with iron deficiency and iron-deficiency anaemia, administration of ferrous salts (100-200 mg/day for 4-6 weeks) improves haemoglobin levels, reduces transfusion rates and, in some cases, shortens the time spent in hospital 19,20 . If there is poor absorption or poor tolerance of oral iron or an accelerated response to treatment is required, pre-operative intravenous iron supplementation, starting 3-4 weeks prior to the scheduled procedure, increases haemoglobin levels and/or corrects anaemia and reduces allogeneic blood transfusion requirements 21-24 . As for patients presenting with moderate anaemia (haemoglobin between 10 and 13 g/dL), but without iron deficiency and/or clinical or laboratory signs of inflammation, pre-operative administration of recombinant human erythropoietin (rHuEPO) has been proven to increase haemoglobin levels and reduce the rate of allogeneic blood transfusion 24 . The minimum effective dose of rHuEPO for this indication is presently unknown, but it has been shown that most patients attain the target haemoglobin level with one or two doses 22,23,26 . In this issue of Blood Transfusion, Theusinger et al. 27 report the results of a pragmatic approach to PBM in major orthopaedic surgery, which was successfully implemented at the Balgrist University Hospital in Zurich (2009-2011; n=6,721). We honestly believe that they must be congratulated for this initiative. One fundamental pillar of their PBM programme was the detection of pre-operative anaemia, by contacting the patient's general practitioner when the patient presented to the anaesthesiologist, at least 4 weeks prior to surgery. This highlights the overwhelming importance of enhancing communication/collaboration between primary health care workers and specialised medical staff, by unifying and sharing all patients' electronic records, and by reducing the high rate of patients not presenting to the anaesthesiologist or presenting too late (70% of patients). Among the reported patients (n=1,985), 9% were found to be anaemic and were initially treated with one dose of intravenous iron (1,000 mg), rHuEPO (40,000 IU) and vitamin B 12 (1 mg), plus 5 mg folic acid orally per day for 4 weeks (n=178). After 14 days, only 15% (n=26) of these patients were still anaemic and received a second dose of intravenous iron, rHuEPO and vitamin B 12 . All treated patients had normal haemoglobin levels on the day of surgery. The PBM programme also included meticulous surgical technique, optimal surgical blood-saving techniques (cell salvage and/or topical haemostatic agents), and standardised transfusion triggers. Interestingly, this PBM programme did not involve the use of tranexamic acid, as this may promote a hypercoagulable state in some patients (for example, Please note that reference 25 is not present in the text
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    ABSTRACT: IntroductionFew literatures have studied the blood management in patients treated with staged bilateral primary total knee arthroplasty (TKA) in a single hospitalization period. Therefore, this study aims to evaluate the effectiveness and safety of the newly introduced multimodal blood management (MBM) in these patients.Materials and methodsWe retrospectively compared the perioperative parameters in 70 cases undergoing staged bilateral primary TKA in a single hospitalization period from 2012¿2013 in a single center with two different groups of patients, allocating cases to the group with the newly introduced MBM (Group A, n =33) and controls to the group without the newly introduced MBM (Group B, n =37). The newly introduced MBM protocols include preoperative hemoglobin (Hb) evaluation, high protein diet, tourniquet release after skin closure, preoperative oral iron treatment and femoral canal obturation, and one dose of tranexamic acid (TXA) IV with another one if necessary. While in the control group, only routine blood-saving techniques were used.ResultsGroup A had a transfusion rate of 9% (3/33), whereas 32.4% of patients (12/37) in Group B received allogenic blood transfusion. Significant benefits were also found in Group A in terms of postoperative Hb and hematocrit (Hct), reduction of postoperative pain, swelling, postoperative pain, length of stays, and hospital costs. No deep vein thrombosis (DVT) events were found in all these patients.Conclusions The newly introduced MBM in staged bilateral TKA in a single hospitalization period can reduce blood loss effectively as well as pain and knee joint swelling instead of leading to increased complications and result in significant cost savings.
    Journal of Orthopaedic Surgery and Research 11/2014; 9(1):116. DOI:10.1186/s13018-014-0116-1 · 1.58 Impact Factor


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