Anemia and Patient Blood Management in Hip and Knee Surgery

Institute of Anesthesiology, University Hospital and University of Zurich, Zurich, Switzerland.
Anesthesiology (Impact Factor: 5.88). 08/2010; 113(2):482-95. DOI: 10.1097/ALN.0b013e3181e08e97
Source: PubMed


A systematic search was conducted to determine the characteristics of perioperative anemia, its association with clinical outcomes, and the effects of patient blood management interventions on these outcomes in patients undergoing major orthopedic surgery. In patients undergoing total hip or knee arthroplasty and hip fracture surgery, preoperative anemia was highly prevalent, ranging from 24 +/- 9% to 44 +/- 9%, respectively. Postoperative anemia was even more prevalent (51% and 87 +/- 10%, respectively). Perioperative anemia was associated with a blood transfusion rate of 45 +/- 25% and 44 +/- 15%, postoperative infections, poorer physical functioning and recovery, and increased length of hospital stay and mortality. Treatment of preoperative anemia with iron, with or without erythropoietin, and perioperative cell salvage decreased the need for blood transfusion and may contribute to improved patient outcomes. High-impact prospective studies are necessary to confirm these findings and establish firm clinical guidelines.

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    • "Measuring the incidence of patients with severe anaemia can be viewed as a surrogate marker of cardiovascular complications only. Numerous data exist however in the medical literature showing the clinical impact of post-operative anaemia on patient outcomes [4] [14] [21]. Disappointingly, Figs. "
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    ABSTRACT: To understand the mechanisms related to both the onset and correction of severe anaemia after orthopaedic surgery, we analysed all the full blood counts (FBCs) for patients on one orthopaedic ward during a one-year period in an academic hospital. FBCs were screened and the medical records of those patients for whom a postoperative haemoglobin (Hb) concentration below 8g/dL was recorded at least once were reviewed. The onset of postoperative anaemia was determined by calculating the various time intervals delineated by surgery, the time at which the transfusion threshold was reached and the time at which the lowest Hb level (nadir) and transfusion (if any) occurred. A total of 6573 FBCs drawn from 1255 patients were screened. The medical records of 74 consecutive patients with at least one Hb value<8g/dL were analysed. The postoperative Hb nadir was 7.4 (± 0.6) g/dL (mean - SD). The medians (IQR 25-75) of the calculated intervals were: (surgery - nadir): 72 (48-144) h, (nadir - transfusion): 7 (5-21) h and (transfusion threshold - transfusion): 26 (11-51) h. Delayed transfusion (defined as>12hours between the time at which the transfusion threshold was reached and actual transfusion) was observed in 57% of severely anaemic patients after orthopaedic surgery. Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
    Full-text · Article · Jun 2015
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    • "Patient blood management addresses preoperative anemia and the associated risk of allogeneic transfusion, both of which are independently associated with adverse outcomes including increased postoperative mortality and morbidity. As such, blood management is one of the most modifiable factors that might significantly impact length of stay [14-18]. The current study investigates the impact of patient factors, surgical factors, and blood management on postoperative length of stay in patients who underwent primary total knee arthroplasty. "
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    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.
    Full-text · Article · May 2014 · The Open Orthopaedics Journal
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    • "Total joint replacement surgery such as total hip arthroplasty (THA) and total knee arthroplasty (TKA) is associated with intra- and postoperative blood loss leading to postoperative anemia. This can be subsequently treated with allogeneic blood transfusion [1,2]. Yet, allogeneic blood transfusions carry the risk of infections and non-infectious transfusion reactions [3]. "
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    ABSTRACT: Despite evidence that erythropoietin and intra- and postoperative blood salvage are expensive techniques considered to be non-cost-effective in primary elective total hip and knee arthroplasties in the Netherlands, Dutch medical professionals use them frequently to prevent the need for allogeneic transfusion. To actually change physicians' practice, a tailored strategy aimed at barriers that hinder physicians in abandoning the use of erythropoietin and perioperative blood salvage was systematically developed. The study aims to examine the effectiveness, feasibility and costs of this tailored de-implementation strategy compared to a control strategy. A cluster randomized controlled trial including an effect, process and economic evaluation will be conducted in a minimum of 20 Dutch hospitals. Randomisation takes place at hospital level. The hospitals in the intervention group will receive a tailored de-implementation strategy that consists of four components: interactive education, feedback in educational outreach visits, electronically sent reports on hospital performance (all aimed at orthopedic surgeons), and information letters or emails aimed at other involved professionals within the intervention hospital (transfusion committee, OR-personnel, pharmacists). The hospitals in the control group will receive a control strategy (i.e., passive dissemination of available evidence). Outcomes will be measured at patient level, using retrospective medical record review. This will be done in all hospitals at baseline and after completion of the intervention period. The primary outcome of the effect evaluation is the percentage of patients undergoing primary elective total hip or knee arthroplasty in which erythropoietin or perioperative blood salvage is applied. The actual exposure to the tailored strategy and users' experiences will be assessed in the process evaluation. In the economic evaluation, the costs of the tailored strategy and the control strategy in relation to the difference in their effectiveness will be compared. This study will show whether a systematically developed tailored strategy is more effective for de-implementation of non-cost-effective blood saving measures than the control strategy. This knowledge can be used in national and international initiatives to make healthcare more efficient. It also provides more generalized knowledge regarding de-implementation strategies.Trial registration: This trial is registered at the Dutch Trial Register NTR4044.
    Full-text · Article · Apr 2014 · Implementation Science
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