Red blood cell transfusion triggers and transfusion alternatives in elective orthopedic hip and knee replacement surgery &amp;ndash; a review

So‐Osman, Cynthia

doi:10.2147/ijctm.s87182

Cited by 2 publications

(1 citation statement)

References 66 publications

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“…Although allogeneic transfusions are relatively safe, transfusion reactions, transmission of diseases and immunomodulatory effects resulting in increased susceptibility of infections may occur. 17 In the Dutch transfusion guideline, the following three thresholds were recommended for adult patients undergoing elective surgery: consider transfusion if the haemoglobin (Hb) level is <4 mmol/L (6.4 g/dL) in healthy adults (American Society of Anesthesiologists (ASA) physical status classification 1); consider transfusion if the Hb level is <5 mmol/L (8 g/dL) in ASA 1 patients >60 years and in uncomplicated ASA 2 and ASA 3 patients; consider transfusion if the Hb level is <6 mmol/L (9.6 g/dL) in ASA 4 patients, patients who are not able to increase their cardiac output to compensate for haemodilution, patients with sepsis, patients with severe pulmonary disease or patients with symptomatic cerebrovascular disease. 18 Ninety per cent of Dutch hospitals reported to use this guideline.…”

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confidence: 99%

Hospital variation in allogeneic transfusion and extended length of stay in primary elective hip and knee arthroplasty: a cross-sectional study

et al. 2017

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ObjectivesOutcomes in total hip and knee arthroplasty (THA and TKA), such as allogeneic transfusions or extended length of stay (LoS), can be used to compare the performance of hospitals. However, there is much variation in these outcomes. This study aims to rank hospitals and to assess hospital differences of two outcomes in THA and TKA: allogeneic transfusions and extended LoS, and to additionally identify factors associated with these differences.DesignCross-sectional medical record review study.SettingData were gathered in 23 Dutch hospitals.Participants1163 THA and 986 TKA patient admissions.OutcomesHospitals were ranked based on their observed/expected (O/E) ratios regarding allogeneic transfusion and extended LoS percentages (extended LoS was defined by postoperative stay >4 days). To assess the reliability of these rankings, we calculated which percentage of the existing variation was based on differences between hospitals as compared with random variation (after adjustment for variation in patient characteristics). Associations between hospital-specific factors and O/E ratios were used to explore potential sources of differences.ResultsThe variation in O/E ratios between hospitals ranged from 0 to 4.4 for allogeneic transfusion, and from 0.08 to 2.7 for extended LoS. Variation in transfusion could in 21% be explained by hospital differences in THA and 34% in TKA. For extended LoS this was 71% in THA and 78% in TKA. Better performance (low O/E ratios) in transfusion was associated with more frequent tranexamic acid (TXA) use in TKA (R=−0.43, p=0.04). Better performance in extended LoS was associated with more frequent TXA use in THA (R=−0.45, p=0.03) and TKA (R=−0.65, p<0.001) and local infiltration analgesia (LIA) in TKA (R=−0.60, p=0.002).ConclusionsRanking hospitals based on allogeneic transfusion is unreliable due to small percentages of variation explained by hospital differences. Ranking based on extended LoS is more reliable. Hospitals using TXA and LIA have relatively fewer patients with transfusions and extended LoS.

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Section: Introductionmentioning

confidence: 99%

Hospital variation in allogeneic transfusion and extended length of stay in primary elective hip and knee arthroplasty: a cross-sectional study

et al. 2017

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The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial

et al. 2017

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BackgroundPerioperative autologous blood salvage and preoperative erythropoietin are not (cost) effective to reduce allogeneic transfusion in primary hip and knee arthroplasty, but are still used. This study aimed to evaluate the effectiveness of a theoretically informed multifaceted strategy to de-implement these low-value blood management techniques.MethodsTwenty-one Dutch hospitals participated in this pragmatic cluster-randomized trial. At baseline, data were gathered for 924 patients from 10 intervention and 1040 patients from 11 control hospitals undergoing hip or knee arthroplasty. The intervention included a multifaceted de-implementation strategy which consisted of interactive education, feedback on blood management performance, and a comparison with benchmark hospitals, aimed at orthopedic surgeons and anesthesiologists. After the intervention, data were gathered for 997 patients from the intervention and 1096 patients from the control hospitals. The randomization outcome was revealed after the baseline measurement. Primary outcomes were use of blood salvage and erythropoietin. Secondary outcomes included postoperative hemoglobin, length of stay, allogeneic transfusions, and use of local infiltration analgesia (LIA) and tranexamic acid (TXA).ResultsThe use of blood salvage (OR 0.08, 95% CI 0.02 to 0.30) and erythropoietin (OR 0.30, 95% CI 0.09 to 0.97) reduced significantly over time, but did not differ between intervention and control hospitals (blood salvage OR 1.74 95% CI 0.27 to 11.39, erythropoietin OR 1.33, 95% CI 0.26 to 6.84). Postoperative hemoglobin levels were significantly higher (β 0.21, 95% CI 0.08 to 0.34) and length of stay shorter (β −0.36, 95% CI −0.64 to −0.09) in hospitals receiving the multifaceted strategy, compared with control hospitals and after adjustment for baseline. Transfusions did not differ between the intervention and control hospitals (OR 1.06, 95% CI 0.63 to 1.78). Both LIA (OR 0.0, 95% CI 0.0 to 0.0) and TXA (OR 0.3, 95% CI 0.2 to 0.5) were significantly associated with the reduction in blood salvage over time.ConclusionsBlood salvage and erythropoietin use reduced over time, but not differently between intervention and control hospitals. The reduction in blood salvage was associated with increased use of local infiltration analgesia and tranexamic acid, suggesting that de-implementation is assisted by the substitution of techniques. The reduction in blood salvage and erythropoietin did not lead to a deterioration in patient-related secondary outcomes.Trial registrationwww.trialregister.nl, NTR4044Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-017-0601-0) contains supplementary material, which is available to authorized users.

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Red blood cell transfusion triggers and transfusion alternatives in elective orthopedic hip and knee replacement surgery – a review

Cited by 2 publications

References 66 publications

Hospital variation in allogeneic transfusion and extended length of stay in primary elective hip and knee arthroplasty: a cross-sectional study

Hospital variation in allogeneic transfusion and extended length of stay in primary elective hip and knee arthroplasty: a cross-sectional study

The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial

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