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Patient blood management minimizes post-TKA transfusions

Natalia Reoutova
02 Jun 2020
A single-centre retrospective study of Hong Kong patients shows a profound reduction in mean transfusion rates after primary total knee arthroplasty (TKA) following the implementation of a patient blood management (PBM) programme.

PBM is an evidence-based multimodal approach to maintain blood mass via haemoglobin maintenance, haemostasis optimization, and blood loss minimization. Key components of PBM, including modern surgical, anaesthetic and perioperative techniques, were gradually introduced for patients undergoing TKA at Queen Mary Hospital (QMH) in Hong Kong between 2014 and 2018. [Hong Kong Med J 2020, doi: 10.12809/hkmj198289]

According to data retrospectively collected from 262 patients who underwent primary unilateral TKA in 2013 and from 215 patients who had the procedure in 2018 at the same university-based centre, the mean transfusion rate significantly decreased from 31.3 percent in 2013 to 1.9 percent after PBM implementation (p<0.001). No significant change was observed in the mean units of blood used per transfusion episode.

“Patients with acquired or congenital coagulopathy, as well as those currently taking anticoagulants, were included in our study. Notably, these patients were at greater risk of perioperative blood loss and transfusion,” highlighted the researchers.

Following full PBM implementation in 2018, the mean length of hospitalization significantly decreased to 8.77 days from 14.49 days in 2013 (p<0.001). “However, there was no difference in the rate of unexpected readmission through the Emergency Department [2013, 3.8 percent; 2018, 3.7 percent; p=0.96], the proportion of patients who exhibited early prosthetic joint infection within 90 days after index surgery [2013, 0.4 percent; 2018, 0 percent; p=0.36], or the proportion of patients with 90-day mortality [2013, 0 percent; 2018, 0.5 percent; p=0.27],” reported the researchers.

“Blood transfusion is a life-saving therapy, but it is a limited resource. In recent years, there have been recurrent blood shortages in Hong Kong, and the Hong Kong Red Cross has issued an urgent appeal for blood donors on several occasions,” wrote the researchers. “[Therefore,] healthcare professionals should be judicious in prescribing transfusions and should consider methods to minimize their number.”

When PBM was first initiated at QMH in 2014, the strategies introduced included single-unit transfusion policy and restrictive transfusion policy with transfusion triggered at haemoglobin level ≤8 g/dL in healthy individuals. In 2015, the traditional practice of routine placement of a surgical drain during TKA (associated with a higher transfusion rate) was stopped, and the use of topical tranexamic acid was implemented to reduce perioperative blood loss. In 2016, preoperative anaemia screening and correction were initiated, including iron supplementation where needed. By the time of full PBM implementation in 2018, patients were receiving combined intravenous and topical tranexamic acid, as well as active warming to avoid intraoperative hypothermia, and were subject to a more stringent restrictive transfusion policy triggered at haemoglobin level ≤7 g/dL.

“The mean annual transfusion rate after primary TKA exhibited a stepwise reduction as PBM strategies were implemented during the period from 2014 to 2018,” wrote the researchers. “Although we focused on patients undergoing TKA, the principles of PBM could be useful for other medical or surgical specialties.”
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Most Read Articles
05 Jul 2020
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