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Institutionally Adopted Perioperative Blood Management Program Significantly Decreased the Transfusion Rate of Patients Having Primary Total Hip Replacement Surgery

Institutionally Adopted Perioperative Blood Management Program Significantly Decreased the... Hindawi Advances in Orthopedics Volume 2021, Article ID 2235600, 6 pages https://doi.org/10.1155/2021/2235600 Research Article Institutionally Adopted Perioperative Blood Management Program Significantly Decreased the Transfusion Rate of Patients Having Primary Total Hip Replacement Surgery 1 1 2 2 1 Hargita Do¨mo¨to¨r, Ada´m L. Varga, Ro´bert Sződy, Ferenc To´th, and Ga´bor Nardai Department of Anesthesiology and Intensive Care, P´eterfy Hospital and National Institute of Trauma, Budapest, Hungary Department of Traumatology, Pe´terfy Hospital and National Institute of Trauma, 1081, Fiumei u´t 17, Budapest, Hungary Correspondence should be addressed to Ga´bor Nardai; nardai@hotmail.com Received 10 August 2021; Accepted 18 September 2021; Published 30 September 2021 Academic Editor: Panagiotis Korovessis Copyright © 2021 Hargita Do¨mo¨to¨r et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Perioperative transfusion in patients undergoing orthopedic surgery increases the number of postoperative complications. *us, we have introduced an institution-tailored perioperative blood management program (PBM) to decrease the amount of blood transfused in patients going through primary total hip replacement (THR) surgery. We have conducted a before-after obser- vational cohort study in two predetermined observational periods. Demographic and clinical data, ASA scores, laboratory parameters, features of surgical procedure, and anesthesia were registered. Parameters of perioperative fluid administration, transfusion rate, and postoperative complications were also assessed. One hundred patients in the first and 108 patients in the second observational period were enrolled. Eventhough the ratio of posttraumatic THR procedures increased (9% vs. 17%), the PBM protocol has been utilized effectively and a significant decrease in perioperative blood transfusion rate has been observed (61% vs. 21%). *e abolishment of routine preoperative LMWH prophylaxis (90% vs. 16%), intraoperative use of tranexamic acid (10% vs. 84%), and the encouraged exploitation of our postoperative observational facility (5% vs. 39%) were abided by our colleagues. Patients still requiring transfusion had lower preoperative hemoglobin levels (129 vs. 147 g/l), scored higher in ASA (ASA III: 46% vs. 19%), and more often presented postoperative hypotension (40% vs. 7%), oliguria (23% vs. 5%), and infections (9% vs. 2%). We conclude that the individualized perioperative blood management protocol was successfully implemented and yielded a lower transfusion rate and better outcomes. Our study suggests that a partial, institution-tailored PBM program may be suitable and beneficial in countries where the modalities of perioperative blood management are limited. validated the creation of a program aiming to reduce blood 1. Introduction use in perioperative care. *e program incorporated the Total hip replacement surgery is one of the most common elements of the internationally approved perioperative blood management (PBM) concept: preoperative anemia orthopedic procedures with a considerable risk of bleeding. We have high-quality evidence that excessive transfusion, screening and management, reduction of perioperative besides depleting the national blood reserve, increases the blood loss, postoperative anemia tolerance, and individ- number of postoperative complications, hospital length-of- ualized transfusion therapy [3]. However, whether partial stay [1], and costs [2]; thus, every healthcare provider has a implementation of the program results in transfusion responsibility to take measures to reduce blood transfusion benefit is yet to be clarified. A local clinical advisory board rates. In our institution, a preliminary audit has shown that was set up to determine which of the possible measures among patients undergoing THR, the transfusion rate is could both be feasible and have merit in our institution’s above 50% (local audit 2012, data not shown). *is result setting. 2 Advances in Orthopedics of more than 1000 ml [3]; whereas, in our institution, the 2. Methods average intraoperative blood loss during THR is 300–800 ml 2.1.DevelopmentoftheInstitution-TailoredProtocol(Table1). (local audit 2012, data not shown); thus, we deemed the cost- Clinical advisory board (senior anesthesiologist—leader, benefit ratio unfavourable. consultant orthopedic surgeons, and critical care *e summary of the measures implemented compared to specialists) assembled the interventions integrated into the general PBM elements is given in Table 1. local PBM program, and the following elements were in- troduced by institutional guidelines and staff education: (a) careful preoperative screening program for anemia 2.2. Data Collection. A periinterventional, single-center, (Hgb< 120 g/l). *e preoperative anesthesia visits for pa- before-after study with prospective data collection was ap- tients undergoing THR have been scheduled at least 3 proved by local clinical directory board. Patients: adult weeks prior to surgery whenever possible. Anemic patients patients having primary THR surgery in a three-month were referred for anemia management, and surgeries were period of 2013 and 2016. Data were collected from electronic delayed if necessary. (b) Individualized vs. routine ad- charts of the hospital informatics system, blood bank, and ministration of preoperative LMWH, based on the patient’s paper-based charts of anesthesia, surgery, and postoperative risk of thromboembolism. (c) Routine administration of care until discharge. TXA dose has been predetermined as 15 mg/kg intravenous bolus tranexamic acid on incision 15 mg/kg single bolus infusion at the incision. Oliguria and has been incorporated in our THR protocol as it is shown anuria (urine output< 0,5 ml/kg/h) have been recorded in th th th that tranexamic acid can significantly reduce intraoperative the 6 , 12 , and 24 hours postoperatively. Perioperative blood loss, and if the presence of contraindications is hypotension was defined as systolic blood pressure under carefully evaluated, complications are rare [4]. (d) Leaving 100 Hg mm measured intraoperatively and in the first 24 wound drains after major joint replacement surgery is a hours postoperatively. Comparisons were made between the controversial topic among orthopedic surgeons. Due to the 2013 and 2016 groups regarding demographics, clinical data, complexity and controversy of the topic, the omission of type of anesthesia, basic features, and indication of surgical wound drain use has not been made mandatory, but only procedure. We have also examined the utilization ratio of encouraged and ultimately entrusted to the surgeon’s PBM measures, the corresponding change in transfusion judgment. (e) Viscoelastometry-based point-of-care, goal- rate, complications, and hospital length-of-stay. Long term directed hemostasis treatment using rotational throm- follow-up (3 months) of infection-related complications boelastometry (ROTEM) has been introduced in the (surgical and systemic) has only been performed in the after management of major/massive surgical bleeding. (f) *e period (2016) using the data of the electronic hospital chart. practice of restrictive transfusion is one that requires both extensive training of personnel and the development of facilities that allow continuous monitoring of the patients 2.3. Statistical Analysis. Data are given as mean with 95% confidence interval or as a percentage of the total and the in the early postoperative period. We have extended the postoperative high-dependency unit with the capacity to amount of blood transfused as a ratio with the number of patients that received transfusion in the denominator. *e observe patients undergoing major joint replacement with moderate-to-high cardiovascular or bleeding risk for the significance of differences between groups was analyzed by Mann–Whitney, chi-square, and Fischer tests as applicable. critical first 24 hours led by an anesthetist. (g) We have also conducted institution-wide education among doctors and A p value< 0.05 was considered statistically significant. nurses working in surgical wards on the principles and practice of restrictive transfusion policy. Single unit 3. Results transfusion and clinical reassessment applicable has also become a recommended, although not obligatory, policy. 3.1. Comparison of the Population of 2013 and 2016. *ese measures ensure patient safety while allowing Demographic and clinical data of the population are given in practitioners to determine the patient’s individual physi- Table 2. ologic tolerance of anemia, thus providing a wider range of *ere were no significant differences between demo- tolerable hemoglobin levels. (h) To ratify this novel policy, graphic data, preexisting clinical features, modality of an- we have established an administrative control on trans- esthesia, length, and technique of surgery between 2013 and fusion that requires practitioners to specify the indication 2016 as given in Table 2. Eventhough it did not achieve (hemodynamic instability, chest pain, dyspnea, and active statistical significance, the increase of posttraumatic sur- bleeding) of transfusion on the request form if the patient’s geries (vs. osteoarthritis) is notable. hemoglobin level is above 80 g/l. *ere has been a significant increase in the utilization of Perioperative erythropoietin treatment as a modality of all institutionally approved PBM measures (Table 3). *e use anemia management has not been implemented due to its of tranexamic acid has become part of the routine unless unavailability in Hungary. contraindications are present. Admission ratio to postop- *e routine use of cell salvage devices has not been erative high-dependency units increased significantly, incorporated in our policy either. Eventhough they are granting greater safety to patients with higher anesthetic proven to be efficient in reducing the transfusion ratio, this risk. A restrictive hemoglobin trigger has been kept unless an concerns mostly procedures with the anticipated blood loss indication of keeping a higher hemoglobin level was present. Advances in Orthopedics 3 Table 1: Elements of the general PBM program as integrated into our institutional protocol. Preoperative screening Yes Surgery, if Hgb> 120 g/l Anemia screening/correction Anemia correction, iron supplements Yes Anemia correction, EPO treatment No Off label in Hungary Less invasive surgical technique No Not changed during study period Tranexamic acid administration Yes Liberal use Autologous blood donation No Not supported by national blood service Minimizing blood loss Hemostasis optimization, preoperative Yes Preoperative LMWH only if high risk Hemostasis optimization, intra/postoperative Yes Viscoelastometry-guided protocol Cell salvage techniques No Not beneficial Normothermia Yes Increasing anemia tolerance Advanced postoperative care Yes Postop HDU introduced Rational hemotherapy Restrictive transfusion threshold Yes Transfusion, if Hgb< 80 g/l Table 2: Demographic and clinical data of the population. Data are shown as mean (CI 95%) and percentage of the total. 2013 (n � 100) 2016 (n � 108) Age (years) 68 (65–70) 68 (66–69) ns Female (%) 70 64 ns ASA III. (%) 22 21 ns BMI (kg/m ) 28.1 (27.8–28.9) 28 (27.7–29.0) ns Preoperative Hgb level (g/l) 138 (135–141) 126 (123–129) ns Antiplatelet therapy (%) 16 10 ns Indication: hip fracture (%) 9 16,6 ns Neuraxial anesthesia (%) 80 84 ns Length of surgery (min) 90 (84.9–95.1) 100 (95–105) ns Cemented THR (%) 73 74 ns Table 3: Implementation ratio of the elements of the local PBM program. 2013 (n � 100) 2016 (n � 108) Preoperative LMWH (%) 90 16 P< 0.05 Tranexamic acid (i.v.) (%) 10 84 P< 0.05 Wound drainage (%) 100 89 P< 0.05 Postoperative HDU admission (%) 5 39 P< 0.05 Transfusion trigger< 80 g/l (%) 5 86 P< 0.05 A significant difference has been observed in the higher rate. Infection rates were significantly higher among transfusion ratio of the before and after groups (61% vs. patients who needed to receive a blood transfusion (Table 5). 21%), eventhough there was no significant disparity in fluid 4. Discussion administration, postoperative hemoglobin levels, and hos- pital length-of-stay. In the after group, patients suffered Based on the results above, we can declare that our insti- from postoperative hypotension significantly less frequently tution-tailored perioperative blood management protocol (12% vs. 35%), but there was no significant difference in the was successfully implemented and had a significant impact incidence of oligoanuria. *e amount of blood received by on postoperative transfusion rates and complications. *is patients transfused has shown minimal change (Table 4). supports the assumption that it is not required to execute every element of the PBM program to beneficially influence 3.2. Assessment of Clinical Features and Transfusion perioperative transfusion needs. Requirements in 2016. Clinical data and complications be- Improving hemostasis in the entire perioperative period tween transfused and not transfused patients in 2016 are and upgrading postoperative care are the most important given in Table 5. pillars of success in our opinion. Research data are conflicted Between the transfused and not transfused groups, there regarding preoperative or postoperative administration of was no significant difference in age, surgical, and anesthetic prophylactic LMWH concerning perioperative blood loss. technique. Patients that received transfusion had a signifi- Robust studies found no difference in the effectiveness re- cantly higher anesthetic risk (ASA III, 20% vs. 50%), and garding prevention of thromboembolic events between their preoperative hemoglobin levels were significantly those whose LMWH prophylaxis were initialized preoper- lower. *ey received tranexamic acid significantly less often atively and those who were started postoperatively if no (64% vs. 91%) and presented hypotension (7% vs. 40%) and indication other than the surgery itself was present [5]. oliguria (5% vs. 23%) in the first 24 hours at a significantly Recent studies focusing on the effect of timing of LMWH 4 Advances in Orthopedics Table 4: Fluid management, transfusion rate, and complications. Data are shown as mean (CI 95%) and percentage of the total. 2013 (n � 100) 2016 (n � 108) Crystalloids administered, intraoperative (ml) 3421 (3280–3560) 2872 (2720–3030) ns Crystalloids administered, postoperative (ml) 1319 (1160–1480) 2113 (1940–2280) ns Min. Hgb. level in postoperative 24 hours (g/l) 101 (98.5–104) 104 (101–107) ns Transfusion ratio (%) 61 21 P< 0.05 Units transfused RBC/number of transfused patients 3 2,8 ns Postoperative hypotension/24 hours (%) 35 12 P< 0.05 Postoperative oligoanuria/24 hours (%) 5 8 ns Hospital length-of-stay (days) 12 11 ns Table 5: Clinical data and complications between transfused and not transfused patients in 2016. Data are shown as mean (CI 95%) and percentage of the total. Transfusion (n � 85) Transfusion+ (n � 22) Age (years) 68 73 ns ASA III (%) 20 50 P< 0.05 Length of surgery (min) 98 (93–103) 104 (84–119) ns Cemented THR (%) 72 84 ns Indication: hip fracture (%) 14 27 ns Preoperative Hgb level (g/l) 143 (140–146) 126 (129–133) P< 0.05 Tranexamic acid i.v. (%) 91 64 P< 0.05 Neuraxial anesthesia (%) 86 77 ns Postoperative hypotension/24 hours (%) 7 40 P< 0.05 Postoperative oligoanuria/24 hours (%) 5 23 P< 0.05 Infection rate (%)/<3 months 2 9 P< 0.001 Surgical and systemic infections. prophylaxis on bleeding risk were not conclusive [6, 7]. In postoperative first 24 hours in a high-dependency unit where patients with the indication of hip fracture, immobilization their fluid balance was carefully evaluated, thus again in- creasing the reported incidence. Taking this into consider- as a major risk factor is present; thus, this portion of patients received preoperative prophylactic LMWH. ation together with the substantial drop in the incidence of Between 2013 and 2016, the listed contraindications of hypotension and the relatively unchanged amount of ad- tranexamic acid administration had become more permis- ministered intravenous fluids, we postulate that the data sive due to novel clinical data on its safety, thus further from 2013 underestimates the incidence of oliguria. augmenting its liberal use. Surgical technique was unchanged between 2013 and In 2013, viscoelastometry has not been available in our 2016, and all our institution’s surgeons used the anterolateral institution. A ROTEM device was introduced in 2014, and surgical approach (Watson-Jones). One has to consider that from that point, it has become part of the everyday routine as the improvement of the manual skills of our surgical staff part of the hemostatic diagnostics and management of and more vigilant surgical hemostasis may have a role in the trauma and surgical patients. *e insights and experience reduction of our transfusion rates. Whether this is signifi- cant is beyond the scope of our study. Postoperative wound gained using viscoelastometry are in themselves great tools in hemostatic management, and whenever the need arises, drainage insertion is a conflicting issue. *e amount of data viscoelastometric measurements are readily available en- is vast, and the results are conflicting regarding both long- suring patient safety as it is proven invaluable across all and short-term complications [10], the effects on wound surgical fields frequently encountering massive blood loss healing and infection rate. Concerning the topic of post- and consequential multiple forms of coagulopathy [8, 9]. As operative transfusion rates and hospital length-of-stay, ev- part of our PBM program using ROTEM-guided hemostatic idence suggests that leaving a wound drain can be management has become institutionally recommended with detrimental [11]. Based on this evidence, we concluded to the indication of substantial intraoperative bleeding. encourage but not recommend to omit wound drainage. *e introduction of this new practice was detectable in results. We have observed a major decrease in the incidence of postoperative hypotension. We consider this a consequence *e study shows that yet there are no ultimate predictors regarding the need for perioperative transfusion, there are of better hemostatic practice and not the more appropriate hemodynamic management. *e fact that the amount of several shared characteristics among patients deemed nec- crystalloid infusions used remained unchanged and vaso- essary to be given blood, and the early recognition and pressor use was also similar (data not shown) supports this evaluation of these characteristics play a crucial part in assumption. *ere was no detectable difference in the in- adequate fluid and blood management. Among these, the cidence of oliguria in the first 24 hours. *ere has also been a most self-explanatory is lower preoperative hemoglobin drastic increase in the number of patients spending the levels. Eventhough, before elective surgery, anemia is usually Advances in Orthopedics 5 successfully managed, it is obvious that patients at the lower perioperative transfusion ratio, thus both reducing the risk end of the normal range concerning the hemoglobin level are of transfusion-associated complications and lifting the at higher risk for postoperative symptomatic anemia. Of burden from our National Blood Reserve. We have also course, it also can be taken into consideration that THR conducted a successful training program resulting in a more surgery is usually performed at a relatively advanced age and professional approach to precision medicine. As a result, at that the age group with a lower preoperative hemoglobin short-term postoperative complications were significantly level may frequently be associated with underlying disease or decreased. Our results encourage other hospitals to attempt frailty. implementing their own institution-tailored PBM protocols It is shown that patients that needed blood transfusion even if application in full is not feasible. perioperatively received tranexamic acid at a lower ratio. *is could have been a consequence of a lapse in the Data Availability implementation of this modality, and some of the most common diseases such as anamnestic thromboembolic *e data used to support the findings are available from the events and/or medical anticoagulation are among the corresponding author upon request. contraindications of the administration of tranexamic acid. It is a long-standing and widely accepted fact that Conflicts of Interest postoperative hypotension and oliguria are good, easily assessable markers of hypovolemia and can be predictors of *e authors declare that there are no conflicts of interest. adverse outcome [12]. It is important to note the fact that hypotension and oliguria are not always the result of References hypovolemia and/or anemia but can also be caused by the many conditions associated with surgical and other iatro- [1] V. A. Ferraris, D. L. Davenport, S. P. Saha, P. C. Austin, and genic insults that result in the impairment of cardiac output J. B. Zwischenberger, “Surgical outcomes and transfusion of such as decompensation due to fluid overload, vasoplegia, minimal amounts of blood in the operating room,” Archives of and acute kidney injury. Understandably, patients with the Surgery, vol. 147, no. 1, pp. 49–55, 2012. worse clinical conditions are more susceptible to such ef- [2] A. Kleineruschkamp, ¨ P. Meybohm, N. Straub, fects. *e fact is that in the transfusion group, the incidence K. Zacharowski, and S. Choorapoikayil, “A model-based cost- of these in the first 24 hours postoperatively is congruent effectiveness analysis of Patient Blood Management,” Blood Transfus, vol. 17, pp. 16–26, 2019. with our earlier observation that these patients were overall [3] N. Desai, N. Schofield, and T. Richards, “Perioperative patient in a worse clinical condition. blood management to improve outcomes,” Anesthesia & It is shown that the transfusion group had an elevated Analgesia, vol. 127, no. 5, pp. 1211–1220, 2018. postoperative infection rate. *at is in accordance with the [4] M. Goldstein, C. Feldmann, H. Wulf, and T. Wiesmann, aforementioned difference in the overall clinical condition of “Tranexamic acid prophylaxis in hip and knee joint re- these patients as well. *ere are compelling data including placement,” Deutsches Aerzteblatt Online, vol. 114, pp. 824– many surgical fields that perioperative transfusion is a risk 830, 2017. factor of postoperative infection [1, 13–15]. It is up to debate [5] N. Strebel, M. Prins, G. Agnelli, and H. R. Buller, ¨ “Preop- whether there is causality established by the immunosup- erative or postoperative start of prophylaxis for venous pressive effects of transfusion [16] or it is merely a statistical thromboembolism with low-molecular-weight heparin in elective hip surgery?” Archives of Internal Medicine, vol. 162, correlation deriving from the same premise that those re- no. 13, pp. 1451–1456, 2002. quiring transfusion are either in a worse preoperative clinical [6] P. O. Borgen, O. E. Dahl, and O. Reikeras, “Preoperative condition and/or underwent greater surgical stress. versus postoperative initiation of dalteparin thrombopro- We acknowledge the limitations of this study; this is a phylaxis in THA,” HIP International, vol. 20, no. 3, single-center study, and as such, it cannot give information pp. 301–307, 2010. regarding the applicability of the process in different in- [7] P. O. Borgen, O. E. Dahl, and O. Reikeras, ˚ “Blood loss in stitutes. Pillars and parts of the PBM program would be cemented THA is not reduced with postoperative versus differentially important in other systems. As a before-after preoperative start of thromboprophylaxis,” Clinical Ortho- study that incorporated multiple interventions, we cannot paedics and Related Research, vol. 470, no. 9, pp. 2591–2598, determine the ratio of the overall efficiency that could be attributed to a single measure. Regarding the overall effi- [8] K. Gorlinger, ¨ A. Perez-Ferrer, ´ D. Dirkmann et al., “*e role of evidence-based algorithms for rotational thromboelas- ciency, as mentioned above, we cannot determine to which tometry-guided bleeding management,” Korean Journal of extent the success can be attributed to the PBM measures Anesthesiology, vol. 72, no. 4, pp. 297–322, 2019. and to what extent are the changing surgical techniques and [9] L. Spiezia, F. Vasques, A. Behr et al., “Perioperative coagu- skills responsible. lation assessment of patients undergoing major elective or- thopedic surgery,” Internal and Emergency Medicine, vol. 11, 5. Conclusion no. 6, pp. 793–801, 2016. [10] M. Nanni, F. Perna, C. Calamelli et al., “Wound drainages in We conclude that our institution-tailored PBM program was total hip arthroplasty: to use or not to use? Review of the successful and the consequential results have deemed it a literature on current practice,” Musculoskeletal Surgery, worthy endeavor. We have greatly decreased our vol. 97, no. 2, pp. 101–107, 2013. 6 Advances in Orthopedics [11] H. Xu, J. Xie, Y. Lei, Q. Huang, Z. Huang, and F. Pei, “Closed suction drainage following routine primary total joint arthroplasty is associated with a higher transfusion rate and longer postoperative length of stay: a retrospective cohort study,” Journal of Orthopaedic Surgery and Research, vol. 14, no. 1, p. 163, 2019. [12] J. Lesko and J. R. Johnston, “Oliguria,” AACN Clinical Issues: Advanced Practice in Acute and Critical Care, vol. 8, no. 3, pp. 459–468, 1997. [13] K. A. Horvath, M. A. Acker, H. Chang et al., “Blood trans- fusion and infection after cardiac surgery,” 8e Annals of 8oracic Surgery, vol. 95, no. 6, pp. 2194–2201, 2013. [14] C. Rhee, L. Lethbridge, G. Richardson, and M. Dunbar, “Risk factors for infection, revision, death, blood transfusion and longer hospital stay 3 months and 1 year after primary total hip or knee arthroplasty,” Canadian Journal of Surgery, vol. 61, no. 3, pp. 165–176, 2018. [15] Y.-K. He, H.-Z. Li, and H.-D. Lu, “Is blood transfusion as- sociated with an increased risk of infection among spine surgery patients?: A meta-analysis,” Medicine (Baltimore), vol. 98, no. 28, Article ID e16287, 2019. [16] M. A. Blajchman, “Immunomodulation and blood transfu- sion,” American Journal of 8erapeutics, vol. 9, no. 5, pp. 389–395, 2002. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Advances in Orthopedics Hindawi Publishing Corporation

Institutionally Adopted Perioperative Blood Management Program Significantly Decreased the Transfusion Rate of Patients Having Primary Total Hip Replacement Surgery

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Hindawi Advances in Orthopedics Volume 2021, Article ID 2235600, 6 pages https://doi.org/10.1155/2021/2235600 Research Article Institutionally Adopted Perioperative Blood Management Program Significantly Decreased the Transfusion Rate of Patients Having Primary Total Hip Replacement Surgery 1 1 2 2 1 Hargita Do¨mo¨to¨r, Ada´m L. Varga, Ro´bert Sződy, Ferenc To´th, and Ga´bor Nardai Department of Anesthesiology and Intensive Care, P´eterfy Hospital and National Institute of Trauma, Budapest, Hungary Department of Traumatology, Pe´terfy Hospital and National Institute of Trauma, 1081, Fiumei u´t 17, Budapest, Hungary Correspondence should be addressed to Ga´bor Nardai; nardai@hotmail.com Received 10 August 2021; Accepted 18 September 2021; Published 30 September 2021 Academic Editor: Panagiotis Korovessis Copyright © 2021 Hargita Do¨mo¨to¨r et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Perioperative transfusion in patients undergoing orthopedic surgery increases the number of postoperative complications. *us, we have introduced an institution-tailored perioperative blood management program (PBM) to decrease the amount of blood transfused in patients going through primary total hip replacement (THR) surgery. We have conducted a before-after obser- vational cohort study in two predetermined observational periods. Demographic and clinical data, ASA scores, laboratory parameters, features of surgical procedure, and anesthesia were registered. Parameters of perioperative fluid administration, transfusion rate, and postoperative complications were also assessed. One hundred patients in the first and 108 patients in the second observational period were enrolled. Eventhough the ratio of posttraumatic THR procedures increased (9% vs. 17%), the PBM protocol has been utilized effectively and a significant decrease in perioperative blood transfusion rate has been observed (61% vs. 21%). *e abolishment of routine preoperative LMWH prophylaxis (90% vs. 16%), intraoperative use of tranexamic acid (10% vs. 84%), and the encouraged exploitation of our postoperative observational facility (5% vs. 39%) were abided by our colleagues. Patients still requiring transfusion had lower preoperative hemoglobin levels (129 vs. 147 g/l), scored higher in ASA (ASA III: 46% vs. 19%), and more often presented postoperative hypotension (40% vs. 7%), oliguria (23% vs. 5%), and infections (9% vs. 2%). We conclude that the individualized perioperative blood management protocol was successfully implemented and yielded a lower transfusion rate and better outcomes. Our study suggests that a partial, institution-tailored PBM program may be suitable and beneficial in countries where the modalities of perioperative blood management are limited. validated the creation of a program aiming to reduce blood 1. Introduction use in perioperative care. *e program incorporated the Total hip replacement surgery is one of the most common elements of the internationally approved perioperative blood management (PBM) concept: preoperative anemia orthopedic procedures with a considerable risk of bleeding. We have high-quality evidence that excessive transfusion, screening and management, reduction of perioperative besides depleting the national blood reserve, increases the blood loss, postoperative anemia tolerance, and individ- number of postoperative complications, hospital length-of- ualized transfusion therapy [3]. However, whether partial stay [1], and costs [2]; thus, every healthcare provider has a implementation of the program results in transfusion responsibility to take measures to reduce blood transfusion benefit is yet to be clarified. A local clinical advisory board rates. In our institution, a preliminary audit has shown that was set up to determine which of the possible measures among patients undergoing THR, the transfusion rate is could both be feasible and have merit in our institution’s above 50% (local audit 2012, data not shown). *is result setting. 2 Advances in Orthopedics of more than 1000 ml [3]; whereas, in our institution, the 2. Methods average intraoperative blood loss during THR is 300–800 ml 2.1.DevelopmentoftheInstitution-TailoredProtocol(Table1). (local audit 2012, data not shown); thus, we deemed the cost- Clinical advisory board (senior anesthesiologist—leader, benefit ratio unfavourable. consultant orthopedic surgeons, and critical care *e summary of the measures implemented compared to specialists) assembled the interventions integrated into the general PBM elements is given in Table 1. local PBM program, and the following elements were in- troduced by institutional guidelines and staff education: (a) careful preoperative screening program for anemia 2.2. Data Collection. A periinterventional, single-center, (Hgb< 120 g/l). *e preoperative anesthesia visits for pa- before-after study with prospective data collection was ap- tients undergoing THR have been scheduled at least 3 proved by local clinical directory board. Patients: adult weeks prior to surgery whenever possible. Anemic patients patients having primary THR surgery in a three-month were referred for anemia management, and surgeries were period of 2013 and 2016. Data were collected from electronic delayed if necessary. (b) Individualized vs. routine ad- charts of the hospital informatics system, blood bank, and ministration of preoperative LMWH, based on the patient’s paper-based charts of anesthesia, surgery, and postoperative risk of thromboembolism. (c) Routine administration of care until discharge. TXA dose has been predetermined as 15 mg/kg intravenous bolus tranexamic acid on incision 15 mg/kg single bolus infusion at the incision. Oliguria and has been incorporated in our THR protocol as it is shown anuria (urine output< 0,5 ml/kg/h) have been recorded in th th th that tranexamic acid can significantly reduce intraoperative the 6 , 12 , and 24 hours postoperatively. Perioperative blood loss, and if the presence of contraindications is hypotension was defined as systolic blood pressure under carefully evaluated, complications are rare [4]. (d) Leaving 100 Hg mm measured intraoperatively and in the first 24 wound drains after major joint replacement surgery is a hours postoperatively. Comparisons were made between the controversial topic among orthopedic surgeons. Due to the 2013 and 2016 groups regarding demographics, clinical data, complexity and controversy of the topic, the omission of type of anesthesia, basic features, and indication of surgical wound drain use has not been made mandatory, but only procedure. We have also examined the utilization ratio of encouraged and ultimately entrusted to the surgeon’s PBM measures, the corresponding change in transfusion judgment. (e) Viscoelastometry-based point-of-care, goal- rate, complications, and hospital length-of-stay. Long term directed hemostasis treatment using rotational throm- follow-up (3 months) of infection-related complications boelastometry (ROTEM) has been introduced in the (surgical and systemic) has only been performed in the after management of major/massive surgical bleeding. (f) *e period (2016) using the data of the electronic hospital chart. practice of restrictive transfusion is one that requires both extensive training of personnel and the development of facilities that allow continuous monitoring of the patients 2.3. Statistical Analysis. Data are given as mean with 95% confidence interval or as a percentage of the total and the in the early postoperative period. We have extended the postoperative high-dependency unit with the capacity to amount of blood transfused as a ratio with the number of patients that received transfusion in the denominator. *e observe patients undergoing major joint replacement with moderate-to-high cardiovascular or bleeding risk for the significance of differences between groups was analyzed by Mann–Whitney, chi-square, and Fischer tests as applicable. critical first 24 hours led by an anesthetist. (g) We have also conducted institution-wide education among doctors and A p value< 0.05 was considered statistically significant. nurses working in surgical wards on the principles and practice of restrictive transfusion policy. Single unit 3. Results transfusion and clinical reassessment applicable has also become a recommended, although not obligatory, policy. 3.1. Comparison of the Population of 2013 and 2016. *ese measures ensure patient safety while allowing Demographic and clinical data of the population are given in practitioners to determine the patient’s individual physi- Table 2. ologic tolerance of anemia, thus providing a wider range of *ere were no significant differences between demo- tolerable hemoglobin levels. (h) To ratify this novel policy, graphic data, preexisting clinical features, modality of an- we have established an administrative control on trans- esthesia, length, and technique of surgery between 2013 and fusion that requires practitioners to specify the indication 2016 as given in Table 2. Eventhough it did not achieve (hemodynamic instability, chest pain, dyspnea, and active statistical significance, the increase of posttraumatic sur- bleeding) of transfusion on the request form if the patient’s geries (vs. osteoarthritis) is notable. hemoglobin level is above 80 g/l. *ere has been a significant increase in the utilization of Perioperative erythropoietin treatment as a modality of all institutionally approved PBM measures (Table 3). *e use anemia management has not been implemented due to its of tranexamic acid has become part of the routine unless unavailability in Hungary. contraindications are present. Admission ratio to postop- *e routine use of cell salvage devices has not been erative high-dependency units increased significantly, incorporated in our policy either. Eventhough they are granting greater safety to patients with higher anesthetic proven to be efficient in reducing the transfusion ratio, this risk. A restrictive hemoglobin trigger has been kept unless an concerns mostly procedures with the anticipated blood loss indication of keeping a higher hemoglobin level was present. Advances in Orthopedics 3 Table 1: Elements of the general PBM program as integrated into our institutional protocol. Preoperative screening Yes Surgery, if Hgb> 120 g/l Anemia screening/correction Anemia correction, iron supplements Yes Anemia correction, EPO treatment No Off label in Hungary Less invasive surgical technique No Not changed during study period Tranexamic acid administration Yes Liberal use Autologous blood donation No Not supported by national blood service Minimizing blood loss Hemostasis optimization, preoperative Yes Preoperative LMWH only if high risk Hemostasis optimization, intra/postoperative Yes Viscoelastometry-guided protocol Cell salvage techniques No Not beneficial Normothermia Yes Increasing anemia tolerance Advanced postoperative care Yes Postop HDU introduced Rational hemotherapy Restrictive transfusion threshold Yes Transfusion, if Hgb< 80 g/l Table 2: Demographic and clinical data of the population. Data are shown as mean (CI 95%) and percentage of the total. 2013 (n � 100) 2016 (n � 108) Age (years) 68 (65–70) 68 (66–69) ns Female (%) 70 64 ns ASA III. (%) 22 21 ns BMI (kg/m ) 28.1 (27.8–28.9) 28 (27.7–29.0) ns Preoperative Hgb level (g/l) 138 (135–141) 126 (123–129) ns Antiplatelet therapy (%) 16 10 ns Indication: hip fracture (%) 9 16,6 ns Neuraxial anesthesia (%) 80 84 ns Length of surgery (min) 90 (84.9–95.1) 100 (95–105) ns Cemented THR (%) 73 74 ns Table 3: Implementation ratio of the elements of the local PBM program. 2013 (n � 100) 2016 (n � 108) Preoperative LMWH (%) 90 16 P< 0.05 Tranexamic acid (i.v.) (%) 10 84 P< 0.05 Wound drainage (%) 100 89 P< 0.05 Postoperative HDU admission (%) 5 39 P< 0.05 Transfusion trigger< 80 g/l (%) 5 86 P< 0.05 A significant difference has been observed in the higher rate. Infection rates were significantly higher among transfusion ratio of the before and after groups (61% vs. patients who needed to receive a blood transfusion (Table 5). 21%), eventhough there was no significant disparity in fluid 4. Discussion administration, postoperative hemoglobin levels, and hos- pital length-of-stay. In the after group, patients suffered Based on the results above, we can declare that our insti- from postoperative hypotension significantly less frequently tution-tailored perioperative blood management protocol (12% vs. 35%), but there was no significant difference in the was successfully implemented and had a significant impact incidence of oligoanuria. *e amount of blood received by on postoperative transfusion rates and complications. *is patients transfused has shown minimal change (Table 4). supports the assumption that it is not required to execute every element of the PBM program to beneficially influence 3.2. Assessment of Clinical Features and Transfusion perioperative transfusion needs. Requirements in 2016. Clinical data and complications be- Improving hemostasis in the entire perioperative period tween transfused and not transfused patients in 2016 are and upgrading postoperative care are the most important given in Table 5. pillars of success in our opinion. Research data are conflicted Between the transfused and not transfused groups, there regarding preoperative or postoperative administration of was no significant difference in age, surgical, and anesthetic prophylactic LMWH concerning perioperative blood loss. technique. Patients that received transfusion had a signifi- Robust studies found no difference in the effectiveness re- cantly higher anesthetic risk (ASA III, 20% vs. 50%), and garding prevention of thromboembolic events between their preoperative hemoglobin levels were significantly those whose LMWH prophylaxis were initialized preoper- lower. *ey received tranexamic acid significantly less often atively and those who were started postoperatively if no (64% vs. 91%) and presented hypotension (7% vs. 40%) and indication other than the surgery itself was present [5]. oliguria (5% vs. 23%) in the first 24 hours at a significantly Recent studies focusing on the effect of timing of LMWH 4 Advances in Orthopedics Table 4: Fluid management, transfusion rate, and complications. Data are shown as mean (CI 95%) and percentage of the total. 2013 (n � 100) 2016 (n � 108) Crystalloids administered, intraoperative (ml) 3421 (3280–3560) 2872 (2720–3030) ns Crystalloids administered, postoperative (ml) 1319 (1160–1480) 2113 (1940–2280) ns Min. Hgb. level in postoperative 24 hours (g/l) 101 (98.5–104) 104 (101–107) ns Transfusion ratio (%) 61 21 P< 0.05 Units transfused RBC/number of transfused patients 3 2,8 ns Postoperative hypotension/24 hours (%) 35 12 P< 0.05 Postoperative oligoanuria/24 hours (%) 5 8 ns Hospital length-of-stay (days) 12 11 ns Table 5: Clinical data and complications between transfused and not transfused patients in 2016. Data are shown as mean (CI 95%) and percentage of the total. Transfusion (n � 85) Transfusion+ (n � 22) Age (years) 68 73 ns ASA III (%) 20 50 P< 0.05 Length of surgery (min) 98 (93–103) 104 (84–119) ns Cemented THR (%) 72 84 ns Indication: hip fracture (%) 14 27 ns Preoperative Hgb level (g/l) 143 (140–146) 126 (129–133) P< 0.05 Tranexamic acid i.v. (%) 91 64 P< 0.05 Neuraxial anesthesia (%) 86 77 ns Postoperative hypotension/24 hours (%) 7 40 P< 0.05 Postoperative oligoanuria/24 hours (%) 5 23 P< 0.05 Infection rate (%)/<3 months 2 9 P< 0.001 Surgical and systemic infections. prophylaxis on bleeding risk were not conclusive [6, 7]. In postoperative first 24 hours in a high-dependency unit where patients with the indication of hip fracture, immobilization their fluid balance was carefully evaluated, thus again in- creasing the reported incidence. Taking this into consider- as a major risk factor is present; thus, this portion of patients received preoperative prophylactic LMWH. ation together with the substantial drop in the incidence of Between 2013 and 2016, the listed contraindications of hypotension and the relatively unchanged amount of ad- tranexamic acid administration had become more permis- ministered intravenous fluids, we postulate that the data sive due to novel clinical data on its safety, thus further from 2013 underestimates the incidence of oliguria. augmenting its liberal use. Surgical technique was unchanged between 2013 and In 2013, viscoelastometry has not been available in our 2016, and all our institution’s surgeons used the anterolateral institution. A ROTEM device was introduced in 2014, and surgical approach (Watson-Jones). One has to consider that from that point, it has become part of the everyday routine as the improvement of the manual skills of our surgical staff part of the hemostatic diagnostics and management of and more vigilant surgical hemostasis may have a role in the trauma and surgical patients. *e insights and experience reduction of our transfusion rates. Whether this is signifi- cant is beyond the scope of our study. Postoperative wound gained using viscoelastometry are in themselves great tools in hemostatic management, and whenever the need arises, drainage insertion is a conflicting issue. *e amount of data viscoelastometric measurements are readily available en- is vast, and the results are conflicting regarding both long- suring patient safety as it is proven invaluable across all and short-term complications [10], the effects on wound surgical fields frequently encountering massive blood loss healing and infection rate. Concerning the topic of post- and consequential multiple forms of coagulopathy [8, 9]. As operative transfusion rates and hospital length-of-stay, ev- part of our PBM program using ROTEM-guided hemostatic idence suggests that leaving a wound drain can be management has become institutionally recommended with detrimental [11]. Based on this evidence, we concluded to the indication of substantial intraoperative bleeding. encourage but not recommend to omit wound drainage. *e introduction of this new practice was detectable in results. We have observed a major decrease in the incidence of postoperative hypotension. We consider this a consequence *e study shows that yet there are no ultimate predictors regarding the need for perioperative transfusion, there are of better hemostatic practice and not the more appropriate hemodynamic management. *e fact that the amount of several shared characteristics among patients deemed nec- crystalloid infusions used remained unchanged and vaso- essary to be given blood, and the early recognition and pressor use was also similar (data not shown) supports this evaluation of these characteristics play a crucial part in assumption. *ere was no detectable difference in the in- adequate fluid and blood management. Among these, the cidence of oliguria in the first 24 hours. *ere has also been a most self-explanatory is lower preoperative hemoglobin drastic increase in the number of patients spending the levels. Eventhough, before elective surgery, anemia is usually Advances in Orthopedics 5 successfully managed, it is obvious that patients at the lower perioperative transfusion ratio, thus both reducing the risk end of the normal range concerning the hemoglobin level are of transfusion-associated complications and lifting the at higher risk for postoperative symptomatic anemia. Of burden from our National Blood Reserve. We have also course, it also can be taken into consideration that THR conducted a successful training program resulting in a more surgery is usually performed at a relatively advanced age and professional approach to precision medicine. As a result, at that the age group with a lower preoperative hemoglobin short-term postoperative complications were significantly level may frequently be associated with underlying disease or decreased. Our results encourage other hospitals to attempt frailty. implementing their own institution-tailored PBM protocols It is shown that patients that needed blood transfusion even if application in full is not feasible. perioperatively received tranexamic acid at a lower ratio. *is could have been a consequence of a lapse in the Data Availability implementation of this modality, and some of the most common diseases such as anamnestic thromboembolic *e data used to support the findings are available from the events and/or medical anticoagulation are among the corresponding author upon request. contraindications of the administration of tranexamic acid. It is a long-standing and widely accepted fact that Conflicts of Interest postoperative hypotension and oliguria are good, easily assessable markers of hypovolemia and can be predictors of *e authors declare that there are no conflicts of interest. adverse outcome [12]. 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Advances in Orthopedics – Hindawi Publishing Corporation

Published: Sep 30, 2021

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