Effectiveness and safety of an optimized blood management program in total hip and knee arthroplasty

Abstract

Little has been published on blood management in total hip and knee arthroplasty (THA and TKA, respectively) patients focusing on both hematopoiesis and hemostasis. Our aim was to explore the effectiveness and safety of an optimized blood management program in THA and TKA patients in a large, single-center, retrospective study.We retrospectively reviewed consecutive primary unilateral THA and TKA patients’ data at our institution through the National Health Database. They were divided into 3 groups according to an optimized blood management program: group A—combined use of intravenous and topical tranexamic acid (TXA); group B—use of recombinant human erythropoietin (rHuEPO) and iron supplements in addition to treatments in group A; group C—use of additional multiple boluses of TXA in addition to treatments in group B. The primary outcomes were hemoglobin (Hb) drop and calculated total blood loss (TBL). Other outcome measurements such as transfusion rate, postoperative length of stay (PLOS), venous thromboembolism (VTE), and mortality were also compared.From 2014 to 2016, a total of 1907 unilateral THA (986 in group A, 745 in group B, and 176 in group C) and 1505 unilateral TKA (795 in group A, 556 in group B, and 154 in group C) procedures were conducted at our institution. The Hb drop, calculated TBL, and PLOS in group C were significantly lower than those in groups A and B for THA and TKA patients. The transfusion rate in group C was also significantly less than in groups A and B for THA patients, while it was similar in groups A and B for TKA patients. No patients in group C received a transfusion. A significant difference was not detected in the incidence of deep vein thrombosis. No episode of symptomatic pulmonary embolism or all-cause mortality occurred within 30 days postoperatively.The current retrospective study suggests that for patients receiving primary unilateral THA or TKA, multiple boluses of intravenous TXA combined with topical TXA, rHuEPO, and iron supplements can reduce the calculated TBL, Hb drop, transfusion rate, and PLOS without increasing the incidence of VTE or mortality.

Short‐term perioperative iron in major orthopedic surgery: state of the art

“…The efficacy of perioperative intravenous iron administration of (iron sucrose or iron isomaltoside) to reduce transfusion rates in knee or hip arthroplasty has been evaluated in one RCT and three observational studies (3574 patients) (Table ).…”

“…More recently, in a large retrospective study, Zhang et al . showed that intravenous (20 mg/kg) plus topical (1 g) tranexamic acid administration resulted in very low ABT in hip or knee arthroplasty. Additional perioperative administration of intravenous iron sucrose (200 mg/48 h) and EPO (10 000 IU/day) to anaemic patients, rather than oral iron (150–300 mg/day), further reduced ABT in hip arthroplasty (3·9% vs. 7·2%; RR: 0·54, 95% CI: 0·35–0·82, P = 0·0035,) but not in knee arthroplasty (2·2% vs. 2·9%; RR: 0·74.…”

“…Four out of 14 studies involving intravenous iron administration did not specifically report on the adverse drug effects (ADEs) . In the remaining 10 studies (2200 patients), only 25 ADEs were reported, mostly occurring in hip fracture patients (23).…”

Six-Dose Intravenous Tranexamic Acid Regimen Further Inhibits Postoperative Fibrinolysis and Reduces Hidden Blood Loss following Total Knee Arthroplasty

“…Oral or intravenous iron supplements (Shanghai UCB Trading Co., Ltd., Shanghai, China) and subcutaneous erythropoietin (Shenyang 3SBio Inc., Shenyang, China) were administered to patients with postoperative anemia according to the optimized blood management program. 12 The criterion of blood transfusion was set as a Hb level of <7 g/dL or 7 to 10 g/dL with symptomatic anemia according to the guidelines by the National Ministry of Health. 12…”

“…12 The criterion of blood transfusion was set as a Hb level of <7 g/dL or 7 to 10 g/dL with symptomatic anemia according to the guidelines by the National Ministry of Health. 12…”