Identification of the haemoglobin level associated with a lower risk of complications after total hip and knee arthroplasty.

BACKGROUND: Preoperative anaemia is associated with poor outcomes in surgical patients, but the preoperative haemoglobin cut-off that determines lower morbidity in total knee arthroplasty (TKA) and total hip arthroplasty (THA) is not well established. METHODS: Planned secondary analysis of data collected during a multicentre cohort study of patients undergoing THA and TKA in 131 Spanish hospitals during a single 2-month recruitment period. Anaemia was defined as haemoglobin <12 g dl-1 for females and < 13 g dl-1 for males. The primary outcome was the number of patients with 30-day in-hospital postoperative complications according to European Perioperative Clinical Outcome definitions and specific surgical TKA and THA complications. Secondary outcomes included the number of patients with 30-day moderate-to-severe complications, red blood cell transfusion, mortality, and length of hospital stay. Binary logistic regression models were constructed to assess association between preoperative Hb concentrations and postoperative complications, and variables significantly associated with the outcome were included in the multivariate model. The study sample was divided into 11 groups based on preoperative Hb values in an effort to identify the threshold at which increased postoperative complications occurred. RESULTS: A total of 6099 patients were included in the analysis (3818 THA and 2281 TKA), of whom 8.8% were anaemic. Patients with preoperative anaemia were more likely to suffer overall complications (111/539, 20.6% vs. 563/5560, 10.1%, p < .001) and moderate-to-severe complications (67/539, 12.4% vs. 284/5560, 5.1%, p < .001). Multivariable analysis showed preoperative haemoglobin ≥14 g dl-1 was associated with fewer postoperative complications. CONCLUSION: Preoperative haemoglobin ≥14 g dl-1 is associated with a lower risk of postoperative complications in patients undergoing primary TKA and THA.

Blood transfusion after primary total knee arthroplasty can be significantly minimised through a multimodal blood-loss prevention approach.

PURPOSE: Our aim was to clarify the effective decrease in blood transfusion after primary total knee arthroplasty (TKA) from a multimodal blood-loss prevention approach (MBLPA) and the related risk factors of blood transfusion. METHODS: We retrospectively compared the rate of postoperative blood transfusion in 418 cases of primary TKA during 2010 from a single institution with two different groups of patients, allocating cases to the group with MBLPA (group 1, study group, N = 71) and controls to the group without MBLPA (group 2, standard group, N = 347). MBLPA procedure included pre-operative haemoglobin (Hb) optimisation; femoral canal obturation; limited incision and release; peri- and intra-articular use of saline with adrenalin, morpheic chloride, tobramycin, betamethasone and ropivacaine; tourniquet release after skin closure; 24 hour drain under atmospheric pressure; and two doses of tranexamic acid (TXA) i.v.. In the control group, surgeons followed the standard procedure without blood-saving techniques. Case-control comparison and blood transfusion risk factors were analysed. RESULTS: Group 1 had a zero transfusion rate (0/71), whereas 27.4% of patients (95/347) in group 2 received allogenic blood transfusion. Significant transfusion risk factors were pre-operative Hb <12 g/dl), American Society of Anesthesiologists (ASA) status III and nonobese body mass index (BMI); Age and gender were not significant risk factors. CONCLUSIONS: MBLPA in primary TKA was highly effective, with a zero transfusion rate. Risk factors for transfusion were determined, and eliminating them contributed to the avoidance of allogeneic blood transfusion in our study series.

Defining the Most Effective Patient Blood Management Combined with Tranexamic Acid Regime in Primary Uncemented Total Hip Replacement Surgery.

The application of patient blood management (PBM) combined with tranexamic acid administration (TXA) results in decreased total blood loss volume (TVB) and transfusions in total hip replacements (THRs). Dosages, timing, and routes of administration of TXA are still under debate as all these aspects, as well as interpatient variations, may affect the efficacy of the protocol. This study aims to examine the effectiveness of timing and route of administration of TXA in combination with PBM by reducing the TBV following THR surgery. Consecutive primary uncemented THRs operated by a single surgical and anaesthetic team had the data prospectively collected and then retrospectively studied. Five treatment groups were formed, reflecting the progressive evolution of our protocol. Group 1 included patients managed with PBM alone (preoperative erythrocyte mass optimisation to at least 14 g/dL haemoglobin (Hb), hypotensive spinal anaesthesia and restrictive red blood cell transfusion criteria). Group 2 included patients with PBM and topical 3 g TXA diluted in normal saline to a total volume of 50 mL. Group 3 were patients with PBM and an IV dose of 20 mg/kg TXA at induction, followed by 20 mg/kg TXA as a continuous infusion for the duration of the operation. Group 4 consisted of patients managed as per Group 3 plus another 20 mg/kg TXA at three-hour post-procedure. Group 5 (combined): PBM and IV TXA as per Group 4 and topical TXA as per Group 2. A generalised linear model with the treatment group as an independent variable was modelled, using TBV as the dependent variable. The transfusion rate for all groups was 0%. TBV at 24 h, oscillated from 613.5 ± 337.63 mL in Group 1 to 376.29 ± 135.0 mL in Group 5. TBV at 48 h oscillated from 738.3 ± 367.3 mL (PBM group) to 434 ± 155.2 mL (PBM + combined group). The multivariate regression model confirmed a significant decrease of TBV in all groups with TXA compared with the PBM-only group. Overweight and preoperative Hb were confirmed to significantly influence TBV. The optimal regime to achieve the least TBV and a transfusion rate of 0% requires PBM and one loading 20 mg/kg dose of TXA, followed by continuous infusion of 20 mg/kg for the duration of the operation in uncemented THRs. Additional doses of TXA did not add a clear benefit.

Preoperative Correction of Anemia to Allow a 3000 ml Blood Loss Without Transfusion in a Jehovah's Witness Presenting for Explantation of an Infected Hip Joint Prosthesis: A Case Report.

A 70-year-old Jehovah's Witness was treated with iron carboxymaltose intravenously, recombinant human erythropoietin alpha subcutaneously, and vitamin B12 and folate orally for 9 weeks to raise hemoglobin (Hb) from 10.8 to 17.0 g/dL before explantation of an infected hip joint prosthesis. The target Hb was calculated from the following formula: Hbtarget = Hbfinal/(1 - ABL/EBV), where Hbtarget= Hb to achieve before surgery, Hbfinal = lowest Hb patient could tolerate taking into consideration his comorbidities (7 g/dL), ABL = volume of blood the surgeon estimated the patient would lose intra- and postoperatively (3000 mL), and EBV = estimated blood volume (75 mL/kg for an adult man). Spinal anesthesia was provided with a single shot hyperbaric bupivacaine and fentanyl. Acute hypervolemic hemodilution was achieved with lactated Ringer's solution and hydroxyethyl starch. To further minimize blood loss, controlled hypotension to a mean blood pressure of 55 mm Hg was achieved with a propofol infusion and tranexamic acid was administered. Surgical blood loss was estimated to be 2500 mL. Hb at the end of surgery was 13.3 g/dL; on postoperative day 5, 11.7 g/L. No blood products were utilized.

Continuous hemofiltration in hyperthermic septic shock patients.

BACKGROUND: Severe hyperthermia commonly accompanies septic shock. High body temperature in absence of infection activates the inflammatory response and is associated with a high mortality. Three years ago, our hypothesis that sustained fever is harmful in septic shock led us to the development of a protocol aiming at decreasing hyperthermia (>/=39.5 degrees C) by means of hemofiltration when the patients did not respond to antipyretics. We present a report of temperature and hemodynamic changes and the outcome of 19 consecutive hyperthermic septic shock patients with multiorgan system failure and compare them with a historical similar group of patients in whom hyperthermia was not treated with hemofiltration. METHODS: Depending on renal function, patients were treated with continuous low-flow hemofiltration (n = 8) or hemodiafiltration, (n = 11). Core temperature was registered every hour. A hemodynamic index (HI) was defined (mean arterial pressure to noradrenaline dose) and used during the first 24 hours to describe the patients' hemodynamic profile by means of its percent variation starting 6 hours before instituting the hemofiltration. RESULTS: The patients' temperature decreased linearly from 39.8 degrees C +/- 0.5 degrees C before hemofiltration to 37 degrees C +/- 1.2 degrees C after 24 hours of treatment (p < 0.001). The HI decreased significantly from -6 hours to the onset of hemofiltration (p = 0.002) and increased significantly after 24 hours (p = 0.008). Twenty-eight-day mortality was 32% (6 of 19) when compared with 100% (11 of 11) in the historical group (p < 0.001). CONCLUSIONS: Continuous low-flow hemofiltration decreased body temperature and vasopressor requirements in hyperthermic septic shock patients. The mortality was unexpectedly low.

Tranexamic Acid in a Multimodal Blood Loss Prevention Protocol to Decrease Blood Loss in Revision Total Knee Arthroplasty: A Cohort Study.

PURPOSE: To clarify if blood loss and transfusion requirements can be decreased in revision knee surgery through a multimodal blood loss approach with tranexamic acid (TXA). PATIENTS AND METHODS: A retrospective study was designed in 87 knees (79 patients) that received a knee revision between 2007 and 2013. To avoid heterogeneity in the surgical technique, only revisions with one single implant system were included. A treatment series of 44 knees that received TXA and other techniques in a multimodal blood loss protocol was compared to a control series of 43 knees that received neither TXA nor the rest of the multimodal blood loss protocol. No differences in the complexity of surgeries or case severity were detected. RESULTS: A significant decrease was observed from 58% transfusion rate in the control group to 5% in the treated group. The postoperative haemoglobin drop was also significantly different. Although the use of a blood loss prevention approach including TXA was the most relevant factor in the transfusion risk (OR=15), longer surgical time also associated an increased risk of transfusion (OR=1.15). CONCLUSION: This study supports the use of a two-dose intravenous TXA under a multimodal blood loss prevention approach in revision knee replacement with significant reduction in the transfusion rate, postoperative blood loss and haemoglobin drop.

Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial.

BACKGROUND: Abundant literature regarding the use of intravenous tranexamic acid (TXA) in primary total knee replacement is available. Randomized controlled trials have confirmed the efficacy of topical TXA compared with placebo, but the comparison between topical and intravenous TXA is unclear. The present study was designed to verify noninferior efficacy and safety of topical intra-articular TXA compared with intravenous TXA in primary total knee replacement with cemented implants. METHODS: A Phase-III, single-center, double-blind, randomized, controlled clinical trial was performed to compare topical intra-articular TXA (3 g of TXA in 100 mL of physiological saline solution) with two intravenous doses of TXA (15 mg/kg in 100 mL of physiological saline solution, one dose before tourniquet release and another three hours after surgery) in a multimodal protocol for blood loss prevention. The primary outcome was the blood transfusion rate, and the secondary outcomes included visible blood loss (as measured in the drain) at twenty-four hours postoperatively and invisible blood loss (as estimated from the Nadler formula) at forty-eight hours postoperatively. The sample size of seventy-eight patients was calculated to give a statistical power of 99% for demonstrating noninferiority. Thirty-nine patients each were allocated to receive topical intra-articular TXA (the experimental group) and intravenous TXA (the control group); there were no significant differences in demographics or preoperative laboratory values between the groups. Noninferiority was estimated by comparing the confidence intervals with a delta of 10%. Student t and Mann-Whitney tests were used to assess the significance of any differences. RESULTS: The transfusion rate was zero in both groups; thus, noninferiority was demonstrated for the primary efficacy end point, suggesting equivalence. Noninferiority was also demonstrated for the secondary efficacy end points. Drain blood loss at twenty-four hours was 315.6 mL (95% confidence interval [CI], 248.5 to 382.7 mL) in the experimental group and 308.1 mL (95% CI, 247.6 to 368.5 mL) in the control group (p = 0.948, Mann-Whitney). Also, estimated blood loss at forty-eight hours was 1259.0 mL (95% CI, 1115.6 to 1402.3 mL) in the experimental group and 1317.9 mL (95% CI, 1175.4 to 1460.4 mL) in the control group (p = 0.837, Mann-Whitney). No significant safety differences were seen between groups. CONCLUSIONS: Topical administration of TXA according to the described protocol demonstrated noninferiority compared with intravenous TXA, with no safety concerns. This randomized controlled trial supports the topical intra-articular administration of TXA in primary total knee replacement with cemented implants. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Transfusion Requirements in Microsurgical Reconstruction in Maxillofacial Surgery: Ethical and Legal Problems of Patients Who Are Jehovah's Witnesses.

Objective To study transfusion requirements in patients with cancer undergoing head and neck reconstructive surgery and to discuss surgical and anesthetic strategies to reduce blood loss when the patient is a Jehovah's Witness. Material and Methods A descriptive study to expose the percentage of blood transfusions performed in patients with cancer undergoing microsurgical reconstructions in the department of oral and maxillofacial surgery of the referred hospital in the past 9 years. Results Two hundred thirty-seven microsurgical reconstructions were performed in head and neck tumors between January 2001 and December 2009. Statistical analysis shows a significant decrease (p = 0.035) in the number of patients needing transfusions patients in recent years. Conclusions The treatment of patients who are Jehovah's Witnesses is an ethical and moral dilemma for the clinician and in particular for surgeons.

Blood loss control with two doses of tranexamic Acid in a multimodal protocol for total knee arthroplasty.

Average blood loss after total knee arthroplasty (TKA) usually ranges from 1500 to 1900 cc, including both the postoperative drain and hidden blood loss. This represents about 46% of TKA patients requiring postoperative blood transfusion. Not only the risks of disease transmission but also those of ABO incompatibility, infection due to immunosupression, increased procedure costs, and increased length of hospital stay, are potential problems that foster blood saving strategies. In this study, 71 unilateral TKAs using a multimodal protocol to decrease blood loss were compared to 61 historical cases. Patients in both groups underwent cemented TKA with the same system, surgical technique, and multimodal protocol (MIS approach, plug in the femoral canal, tourniquet removal after wound closure and compressive bandage, analgesic periarticular infiltration with vasoconstrictor, postoperative drain at atmospheric pressure, opened 2 hours after the end of the surgical procedure and removed after 24 hours). The study series incorporated intravenous tranexamic acid (TXA) infusion in 2 doses of 10-15 mg/kg, 15 minutes before tourniquet release and 3 hours later. Results showed no transfusion requirements in the TXA series (0%), with 23/61 (37.7%) transfusions in the control, with an average cost decrease of 240 euros per patient. Visible bleeding in 24h significantly decreased from 553.36 cc (range 50-1500) to 169.72 cc (range 10-480) in the TXA series. As a conclusion, implementing a TXA-based multimodal protocol produced significant decrease in the transfusion rate, visible blood loss, and cost per patient, thus proving effectiveness and efficiency in the surgical management of TKA.

Comparing Entropy and the Bispectral index with the Ramsay score in sedated ICU patients.

OBJECTIVE: ENTROPY is a new anesthetic depth monitor based on the analysis of the EEG signal. Our aim has been to evaluate sedation of intubated surgical critically ill patients by means of the Ramsay sedation score, the Bispectral index and ENTROPY, and to analyse the correlation between these variables. METHODS: Sedation was evaluated every 15 min for a 1 h period in 50 non-paralysed postoperative critically ill, intubated patients, enrolled over a 6 month period. A 5 min steady-state period was allowed before each assessment. Both the Bispectral index and the Entropy parameters Response Entropy (RE) and State Entropy (SE), were collected before assessing the Ramsay scale. RESULTS: Mean values for SE, RE and BIS were 53 +/- 27, 60 +/- 30, and 62 +/- 24 respectively. The median value for the Ramsay was 6 (range 1-6). Significant correlation was found between the four variables (SE-BIS: r = 0.79, p < 0.001; RE-BIS: r = 0.80, p < 0.001; SE-Ramsay: rho = -0.71, p < 0.001, RE-Ramsay: rho = -0.72, p < 0.001; BIS-Ramsay: rho = -0.78, p < 0.001; RE-SE: r = 0.98, p < 0.001). An overlap of BIS and Entropy values for every Ramsay score value between 4-6 was found. CONCLUSIONS: ENTROPY, BIS and Ramsay score values correlate significantly in sedated postoperative ICU patients. ENTROPY does not appear superior to BIS for the assessment of sedation in this context.