Blood Loss in Cemented THA is not Reduced with Postoperative Versus Preoperative Start of Thromboprophylaxis

Abstract

Background Thrombin formation commences perioperatively in orthopaedic surgery and therefore some surgeons prefer preoperative initiation of pharmacologic thromboprophylaxis. However, because of the potential for increased surgical bleeding, the postoperative initiation of thromboprophylaxis has been advocated to reduce blood loss, need for transfusion, and bleeding complications. Trials on timing of thromboprophylaxis have been designed primarily to detect thrombotic events, and it has been difficult to interpret the magnitude of blood loss and bleeding events owing to lack of information for bleeding volume and underpowered bleeding end points. Questions/purposes We therefore asked whether there are differences in blood loss, transfusion requirements, and other postoperative clinical complications with preoperative versus postoperative start of thromboprophylaxis with dalteparin. Methods In a double-blind, randomized controlled trial, 80 patients undergoing primary cemented THA were allocated to dalteparin injections starting 12 hours before or 6 hours after surgery. Blood loss was measured by weighing sponges and drapes, volume in suction drains during surgery, and wound drains until removal 24 hours postoperatively. Hemoglobin and hematocrit were recorded at predefined times during and after surgery. Results We found no differences in blood loss (1081 mL ± 424 mL versus 1023 mL ± 238 mL), bleeding-related events (10% versus 17%), or number of patients who had transfusions (12 versus five) with preoperative and postoperative thromboprophylaxis, respectively. Other complications were few in both groups. Conclusions Our data suggest blood loss is similar with preoperative and postoperative initiation of dalteparin thromboprophylaxis, but indicate a trend toward fewer transfusion requirements which might favor postoperative start of thromboprophylaxis.

Biomarkers of Coagulation and Fibrinolysis during Cemented Total Hip Arthroplasty with Pre- versus Postoperative Start of Thromboprophylaxis

“…This variation in pro- and anticoagulant activities over time is in accordance with other studies [2]. It also confirmed the primary endpoint, that is, the bleeding parameters in our clinical trial that showed the same bleeding whether 5000 IU dalteparin was injected 12 hours before or 6 hours after surgery [16]. The results are also in accordance with a recent study by Llau [17] and colleges who injected 40 mg enoxaparin at the same timepoints after total knee arthroplasties (TKA).…”

“…Previously, we have reported the same amount of bleeding with the two regimens [16]. LMWHs have repeatedly been shown to be effective against postoperative thrombosis after THA, and our findings therefore support the view that dose and the interval between surgery and the first administration of prophylaxis are important [9, 33].…”

Similar Clinical Outcomes with Preoperative and Postoperative Start of Thromboprophylaxis in THA: A Register-based Study

“…In this study, we relied on the ICD-10-coded clinical events reported by all Norwegian hospitals. Estimations of ''Major bleeding,'' a term frequently used in hip arthroplasty trials, have been reported from 0.1% to 3.1% [7], and vary even more with other bleeding definitions [4,5,13]. Although the criteria to report on this term vary substantially and affect trial results, by using the ICD-10 codification, we found a bleeding rate of 2.7%, which is within this range, and with no difference between the two cohorts.…”

Hidden blood loss and its influential factors after total hip arthroplasty

“…It is also a procedure that frequently leads to massive blood loss. Previous studies showed that the total blood loss was in the range of 1,023–1,785 mL [ 2 - 5 ] and 30%–69% of patients needed blood transfusion after THA [ 6 , 7 ]. Keating and Meding reported that transfusion is an independent risk factor for post-operative complications, such as immune disorder and infection [ 8 ].…”