Should postoperative haemoglobin and potassium levels be checked routinely following blood-conserving primary total joint arthroplasty?

Abstract

Aims Despite declining frequency of blood transfusion and electrolyte supplementation following total joint arthroplasty, postoperative blood analyses are still routinely ordered for these patients. This study aimed to determine the rate of blood transfusion and electrolyte restoration in arthroplasty patients treated with a perioperative blood conservation protocol and to identify risk factors that would predict the need for transfusion and electrolyte supplementation. Patients and Methods Patients undergoing primary total joint arthroplasty of the hip or knee between July 2016 and February 2017 at a single institution were included in the study. Standard preoperative and postoperative laboratory data were collected and reviewed retrospectively. A uniform blood conservation programme was implemented for all patients. Need for blood transfusion or potassium supplementation was determined through a coordinated decision by the care team. Rates of transfusion and supplementation were observed, and patient risk factors were noted. Results The overall rate of blood transfusion was 1.06% in the study population of 1132 total joint arthroplasties performed in 1023 patients. Of the 12 patients requiring transfusion, 11 were female, ten occurred in patients undergoing total hip arthroplasty, and all 12 patients had a preoperative haemoglobin level less than 130 g/l. Operative duration and surgical blood loss were significantly greater in those patients requiring blood transfusion. Nearly all patients requiring transfusion had a history of, or risk factors for, cardiovascular disease. Potassium supplementation was required in 15.5% of the study cohort; 72% of these patients receiving potassium presented with a potassium level less than 4 mmol/l during preoperative testing, while the remaining 28% had a past medical history of either significant anaemia, cardiopulmonary, cardiovascular, or renal diseases that had required substantial medical management. Conclusion A consistent blood-conserving perioperative strategy effectively minimized need for blood transfusion in total joint arthroplasty patients below previously reported rates in the literature. We suggest that postoperative full blood counts and basic metabolic panels should not routinely be ordered in these patients unless their preoperative haemoglobin and potassium is below 130 g/dl or 4 mmol/l respectively, and they have medical comorbidities.

Are Routine Postoperative Laboratory Tests Really Necessary After High Tibial Osteotomy Surgery?

“…Lin et al [10] reported that the incidence of abnormal electrolytes was low and the predictive value was small, and 0.92% of the patients undergo ing lumbar spinal surgery were diagnosed with hypokalaemia required postoperative clinical treatment. Likewise, Greco et al [14] demonstrated an incidence as great as 15.5% for patients who were provided electrolyte supplementation after total joint arthroplasty, and con rmed that preoperative potassium level associated with required postoperative clinical treatment with a threshold identi ed at a preoperative potassium level of 4mmol/L. In line with previous studies, we found that 3.55% of patients required potassium supplementation after HTO surgery.…”

Cost of investigations during the acute hospital stay following total hip or knee arthroplasty, by complication status

“…Given the high volume, optimising investigation approaches may provide substantial cost savings even when the percentage of overall cost reduction is small. Recent studies have identi ed examples of ine cient routine investigations, including radiographs and blood tests, during post-arthroplasty care in tertiary centres in USA and in China (5)(6)(7)(8)(9)(10)(11). However, only one similar study has been conducted in Australia, investigating the utility of week-one radiographs postarthroplasty (4).…”

Cost of investigations during the acute hospital stay following total hip or knee arthroplasty, by complication status

“…Given the high volume, optimising investigation approaches may provide substantial cost savings even when the percentage of overall cost reduction is small. Recent studies have identi ed examples of ine cient routine investigations, including radiographs and blood tests, during post-arthroplasty care in tertiary centres in USA and in China (5)(6)(7)(8)(9)(10)(11). In Australia, only one similar study has been conducted; it found that routine post-operative radiographs did not alter inpatient management of any patients, despite 23% having atypical radiographic ndings in that cohort (4).…”

“…Post-operative investigations, which are used by clinicians to detect complications, can impose substantial burden both nancially on the health system and physically on the patient (3). Recent studies have questioned investigation practices following total hip or total knee arthroplasty, and they have identi ed existing cost-ine ciency at individual institutions (4)(5)(6)(7)(8)(9)(10)(11). However, a general lack of knowledge on current practices greatly limits the applicability of such ndings.…”