Preoperative screening and intervention for mild anemia with low iron stores in elective hip and knee arthroplasty

Abstract

BACKGROUND Preoperative anemia in patients undergoing elective hip and knee arthroplasty is associated with increased postoperative morbidity and mortality, red blood cell (RBC) transfusion, and length of stay (LOS). The aim of this study was to assess the effect of optimizing hemoglobin (Hb) levels before elective primary hip and knee arthroplasty. STUDY DESIGN AND METHODS This is a prospective comparative cohort study of patients who underwent elective hip and knee arthroplasty before (control) and after (intervention) the launch of a Hb optimization program. Patients with anemia followed an agreed upon algorithm dependent on their medical history and blood variables taken on listing for surgery. The primary outcome for this study was the requirement for allogenic RBC transfusion. Secondary outcomes included hospital LOS, admission to critical care, readmission, medical complications, incidence of thromboembolic events, mortality, and costs. RESULTS A total of 1814 control patients operated between February 2012 and February 2013 were compared to 1622 intervention patients operated between February 2013 and May 2014. In the intervention group transfusion was significantly reduced (108 [6%] vs. 63 [4.1%], p = 0.005) as well as readmission (81 [4.5%] vs. 48 [2.3%], p= 0.020) and critical care admission (23 [1.3%] vs. 9 [0.5%], p = 0.030). LOS was significantly reduced from 3.9 days to 3.6 days (p = 0.017). The saving for the cohort was £263,000 ($342,000). CONCLUSIONS Algorithm‐led preoperative anemia screening and management in elective arthroplasty was associated with reduced RBC transfusion, readmission, critical care admission, LOS, and costs.

Preoperative anemia increases the risk of red blood cell transfusion and prolonged hospital length of stay in children undergoing spine arthrodesis surgery

“…Preoperative identification and treatment of patients with anemia is considered one of the pillars of Patient Blood Management . Preoperative anemia has been identified as a preventable risk factor for perioperative transfusion, and preoperative hemoglobin optimization through iron supplementation has been shown to significantly reduce the intraoperative nadir for hemoglobin and reduce the need for perioperative transfusion in adults . Recent pediatric studies suggest a strong relationship between preoperative anemia, transfusion, and outcomes in both neonates and older children undergoing non‐cardiac surgery.…”

Scaling Up Quality Improvement for Surgical Teams (QIST) - avoiding surgical site infection and anaemia at the time of surgery: protocol for a cluster randomised controlled trial

“…Successful implementation of preoperative anaemia optimisation for elective hip and knee replacement patients has been achieved and positive results reported from at least one NHS Trusts in England. (28) This work showed that a relatively straightforward clinical pathway including the use of oral and/or IV iron resulted in significant reductions in the number of patients transfused (6 v 4.1% p = 0.005), length of hospital stay (3.9 v 3.6 days p = 0.017), critical care admissions (1.27 v 0.55% p = 0.03) and hospital readmissions (4.5% v 3.0% p = 0.02). This was found to be cost effective, resulting in savings of £162.46 per patient screened, or £406,000 for a Trust performing 2500 primary THR or TKRs per annum.…”

Blood management in total knee arthroplasty: state-of-the-art review

“…Increased Hb concentrations also prevent transfusion-related complications 19. Health economic analysis reveals significant savings from preoperative anaemia screening and management 2. The benefits of treating anaemia may not purely reflect increased Hb concentrations, as iron is important for cellular processes such as oxygen transport and cellular immunity 20…”

“…A study of arthroplasty surgeons in the USA revealed transfusion rates ranging from 3.8% to 63.8% for primary TKA,87 rising to 84% for bilateral TKA 88. Studies in the UK reported transfusion rates of 2.7% for primary TKA2 and 29.1% for revision TKA 4…”

“…The number of primary and revision knee arthroplasty procedures continues to increase,1 and blood management strategies form a key intervention to improve outcomes and reduce costs 2. The primary goal is to reduce the severity of postoperative anaemia through preoperative optimisation and minimising intraoperative and postoperative blood loss through patient-specific approaches.…”