Blood management in fast-track orthopedic surgery: an evidence-based narrative review

Abstract

Background and purpose: Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research. Methods and materials: We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital. Results: Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction. Conclusion: The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.

Introducing enhanced recovery after surgery in a high-volume orthopaedic hospital: a health technology assessment

“…According to a randomized controlled trial, accelerated TKA resulted in significantly lower knee pain scores and improved functional outcomes 7 days after surgery [32]. An evidence-based review on blood management in Total Joint Arthroplasty (TJA) underlined how accelerated pathways provide useful room for perioperative planning and prediction, generating additional value in comparison to a conventional protocol [9]. A prospective cohort study reported improved function, quality of life, reduced pain, and better Patient-Related Outcome Measurements (PROMs) after accelerated total hip arthroplasty (THA) [40].…”

“…chronic) or conditions of risk. Despite accelerated pathways show improved accessibility to protected categories of patients [9,51,52], their safety remains controversial [53][54][55][56][57][58].…”

“…The incremented cost is mainly due to more investments in human resources at the preoperative phase, in order to provide patient assessment and education. Despite the benefits of pre-operative education for hip and knee replacement are controversial [65,66], current evidence supports the effectiveness of an adequate patient assessment over the perioperative process [9,51,67], which is corroborated by the improved outcomes perceived by the professionals involved in the ERAS pathway. This finding may support the hypothesis that accelerated pathways do not differ from conventional treatment in medical content or surgical technique, but rather from the way in which the perioperative process is planned and integrated, which is probably what makes ERAS pathway a valuable innovation [9].…”

“…Despite the benefits of pre-operative education for hip and knee replacement are controversial [65,66], current evidence supports the effectiveness of an adequate patient assessment over the perioperative process [9,51,67], which is corroborated by the improved outcomes perceived by the professionals involved in the ERAS pathway. This finding may support the hypothesis that accelerated pathways do not differ from conventional treatment in medical content or surgical technique, but rather from the way in which the perioperative process is planned and integrated, which is probably what makes ERAS pathway a valuable innovation [9]. A moderate additional investment at the preoperative phase is outweighed by a reduction in hospital LOS, which -once the safety of the procedures is maintained -reduces in turn the time spent by the patient in the healthcare environment, generates significant cost savings to the funder, and potentially reduce waiting lists in order to provide a higher number of treatments.…”

Perioperative management of geriatric patients for orthopedic surgeries

“…Orthopedic surgeries often require blood transfusion. 9 There should be proper assessment of hemoglobin before surgery as it is seen that that patients with anemia have more risk of surgical complications and death especially during orthopedic surgeries because of the large quantities of blood loss due to bone trauma and the difficulties of achieving hemostasis in this tissue. If hemoglobin level is less than 6% the risk may increase up to 30%.…”