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

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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.

Introduction

The demand for total joint arthroplasty (TJA) is going to increase between 174 and 673% by 2030 [1, 2]. In the USA, orthopedic procedures account for up to 10% of all packed-red cell transfusions in a year, 39% of which are used in TJA [3]. Blood loss can be extensive, and allogenic blood transfusion (ABT) is commonly performed. ABTs are associated with risks and complications [3,4,5,6,7]: to try and prevent them, it is necessary to invest in increasingly expensive safety procedures [8]. Moreover, the potential side effects of ABTs also impact social costs [9], accounting for the high economic cost of ABTs.

Innovations able to maintain patient safety while reducing the amount of ABTs therefore add value to orthopedic surgery procedures, where value is defined as outcomes achieved per money spent [10]. Opportunities for improvement arise especially in elective procedures, where room for planning is available. Indeed, experience of blood management in 2511 elective procedures reduced the amount of ABTs without increasing the number of recoveries and readmissions, generating an annual saving of $ 480,000 [11].

Blood management is a pillar of innovative health care models such as bundled payments [12] and fast-track pathways [13,14,15], as perioperative coordinated care is associated to a better and quicker recovery [15]. Accurate blood management can contribute to home discharge of 85-year-old patients 3 days after surgery[16], as well as to safely perform procedures in outpatient settings [17].

Although many strategies and algorithms have been proposed to reduce ABTs, there is no consensus about the most successful combination, given the different opinions over the same procedure, and the need to adapt the procedures to the characteristics of individual patients [18,19,20].

The purpose of this investigation is to identify information to support blood management strategies in fast-track TJA pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research.

Reviews on blood management in orthopedics surgery [3], elective orthopedic surgery [8], total hip and knee arthroplasty [18, 21], and lower limb joint arthroplasty in a bundled payment [11] have been published. However, no review, to our knowledge, focuses on blood management in fast-track orthopedic pathways, except for general European Guidelines on perioperative venous thromboembolism prophylaxis [22].

Such a review should be helpful in two ways: first, by elaborating a synthesis on what has been published on the topic; second, by pointing out which parts of the perioperative process offer room for improvement.

Materials and methods

We proceeded in four steps.

First, we identified conventional blood management strategies in elective orthopedic procedures, to achieve a general road map to support the research on fast-track innovations. Six articles addressed the perioperative approach to the topic [3, 8, 9, 18, 21, 23]. To provide a clear roadmap and adhering to previous recommendations [24,25,26], the strategies were divided in preoperative, intraoperative, and postoperative [27].

Second, we searched PubMed, Embase, Ebsco host, and Cochrane reviews for blood management strategies related to fast-track total joint arthroplasty, using the following keywords: fast(-)track surgery, orthop(a)edics, total joint arthroplasty, blood, blood management. After removing duplicates and studies not related to TJA procedures, 16 articles were eligible. These were read in full text to ensure their consistency with a fast-track TJA pathway.

Third, we designed tables to match every step of the perioperative process with information from the fast-track literature. In each table, information reported in the central column is therefore coming from conventional procedures. When it was not possible to fill the relevant column of the tables with information on fast-track joint arthroplasty arising from the second step, we performed a further search on the topic using PubMed, Embase, Ebsco host and Cochrane reviews databases, bibliographies, and articles suggested by colleagues. These results—which are useful both for clinical and further research—are highlighted in the table with a *.

Fourth, we submitted the information reported in the right column to the opinion of clinicians who operate using fast-track surgery protocols for TJA at our hospital, to (i) check whether the information was sound, (ii) offer them opportunities for improvement, and (iii) identify practices which they already used, as such practices may be not reported in the published literature.

We acknowledge that steps three and four prevent the research from being entirely reproducible, which represents the main limitation of our study, but we believe this disadvantage to be offset by the advantage of providing information which can be missed with conventional research. We therefore opted for a narrative rather than a systematic review. Accordingly, we have adopted four of the six Cochrane recommendations for a systematic review27 (Table 1).

Table 1 Cochrane guidelines for systematic review

All searches were completed by January 21st, 2019.

Results

Preoperative blood management

Preoperatively, patients are thoroughly assessed, to decide whether to include them in an accelerated pathway, to plan clinical contingencies, and to educate the patients to take active part in the process. All are key steps in a successful fast-track design (Table 2).

Table 2 Preoperative blood management

Intraoperative blood management

Intraoperative management plays the most important role in safety, blood loss minimization, and early recovery (Table 3) [18].

Table 3 Intraoperative blood management

Several studies have also investigated the role of intraoperative intermittent pneumatic compression devices (IPCDs) in preventing postoperative venous thromboembolism (VTE), but we report them in the following section because of their association with postoperative pharmacological prophylaxis.

Postoperative blood management

Fifty percent of the total blood loss in TKA occurs postoperatively [165], especially within the first 4 h (Table 4) [166].

Table 4 Postoperative blood management

Postoperative thromboprophylaxis is the step of perioperative management which received the greatest focus in fast-track surgery [129]. For practical reasons, we report findings about it in separate tables.

A prospective clinical study of 632 primary TJA patients evaluated the best combination between mechanical treatment (compression) and pharmacological chemoprophylaxis (aspirin and/or low molecular weight heparin) to prevent postoperative thromboembolic events (Table 5) [193].

Table 5 Mechanical and chemical thromboprophylaxis in 632 primary TJA patients

The evaluation was performed answering four questions.

According to these results, the authors advocate routine use of mobile mechanical compression devices, which are able to prevent those VTEs and complications associated with chemical anticoagulants. This is consistent (i) with recommendations of the American Academy of Orthopedic Surgeons and the American College of Chest Physicians [194, 195], (ii) with a retrospective study of 3379 patients which confirmed mechanical treatment with IPCD to be a fast, easy, cheap, and safe support to postoperative multimodal approach [196], and (iii) with clinical pillars for TJA in a bundled payment paradigm [12].

With regard to accelerated pathways, the European Guidelines on VTE prevention were formulated cross-referencing the risk of the patient with the risk of the procedure, adopting Caprini score as an assessment criterion [22, 197] (*).

We summarize them in the following table (Table 6).

Table 6 VTE prevention in fast-track and day-surgery orthopedic procedures

The benefits of early mobilization and the combination between mechanical measures and aspirin are confirmed by other studies, both in fast-track [198] (*) and in conventional pathways [199].

The same guidelines underline the option, in selected procedures, to limit thromboprophylaxis treatment only to the period of hospitalization, and suggest to extend the treatment to up to 4 weeks in high-risk patients and procedures.

The first recommendation is based on a weak level of evidence (2C), but is supported by a large prospective study on 17,582 fast-track TJA procedures according to which 90-day incidence of VTE after in-hospital treatment was only 0.40% [53] (*). On the contrary, the second recommendation is based on a moderate level of evidence (2B), and supports the hypothesis of the prospective study: extended treatment for LOS more than 5 days and high-risk patients is strongly recommended.

Other studies suggest warfarin-based chemoprophylaxis for 6 weeks after THA [200], as well as fish oil as a cost-effective supplement to aspirin after TKA [201], prompting for prospective studies to confirm these suggestions.

Discussion and limitations

The purpose of this investigation was to identify information to support blood management strategies in fast-track TJA pathways. The investigation confirmed the lack of comprehensive reviews on the topic, which we divided according to recommendations in preoperative, intraoperative, and postoperative.

The need for blood transfusions remains the most significant predictor of a longer stay (more than 3 days) also within accelerated pathways, occurring between 12% and 22% of THA and TKA. However, it seems not to compromise a high patient satisfaction, a fundamental assessment of quality in fast-track procedures. Waiting for blood transfusions is indeed one of the main reasons for a delay in discharge.

Identifying the reasons behind it makes it possible to assess the best clinical and logistical solution for the patient, starting preoperatively. The need for transfusion is associated with age, comorbidities, ASA score, and anemia (with iron deficiency as the most common and reversible cause). In general, a classic transfusion trigger had been established when postoperative hematocrit level at the first day is 25% less than preoperative, while more recent studies found preoperative iron supplement to be a cost-effective solution for non-anemic THA patients. However, fast-track procedures are becoming more and more inclusive, provided that a multidisciplinary management of risk factors is implemented. TKA patients aged ≥ 65 show a weak but significant association between postoperative Hb and 6-min walk test early after surgery, but not with other functional criteria nor quality of life. Postoperative anemia, blood transfusions, and lack of mobilization are the main medical causes of delayed discharge (27.3 more than 4 days) for THA patients aged ≥ 85, while preoperative anemia is the main medical cause of readmission of the same population within 90 days after the intervention, together with suspected (but disproved) thromboembolic events. Finally, stroke is a recognised event which can occur after both TKA and THA procedures: it is therefore fundamental to check for preoperative anticoagulants to avoid cardiovascular perioperative complications in elderly patients. If these precautions prove successful, fast-track pathways realize the possibility of including older patients in major joint replacement programs [202].

Intraoperatively, tranexamic acid is probably the simplest, safe and cost-effective innovation also in case of fast-track procedures, for it almost eliminated the need for other blood conservation strategies. Its benefits increase when combined (i) with local infiltration analgesia, both in hip and knee replacement, as it produces a significant reduction in postoperative Hb levels, pain and length of stay, together with better rehabilitation outcomes; (ii) with low-dose epinephrine in THA, producing a reduction of 180 mL blood loss within 24 h after surgery. The benefits of minimally invasive surgery on blood loss are still debated, and more studies are needed to evaluate its impact on patient satisfaction in fast-track TJA. With regard to TKA, the use of a tourniquet reduces bleeding during surgery, but produces no benefit on knee extension, postoperative Hb levels, pain, and nausea; studies are evaluating its use in combination with multimodal anaesthetic and analgesic regimens. General anesthesia is equivalent to spinal anesthesia with regard to blood loss, but the former dominates the second on several other outcomes, including early mobilization, amount of opioid consumption, and pain scores 6 h after surgery.

Postoperative thromboprophylaxis is the step which has received greater focus. The European Guidelines on VTE prevention suggest different combinations according to patient characteristics and procedures, underlining the benefits of early mobilization together with mobile mechanical compression and pharmacological treatment. Traditional icing provides a high cost-effective benefit on several postoperative outcomes, such as pain, edema, and blood loss, reserving more complicate cryotherapy devices only to selected patients. Finally, removal of drains is safe and feasible within 6–12 h after TKA, although clinical experts question their usefulness.

Several strategies and treatments such as hypotensive epidural anesthesia, topical fibrin sealants, platelet-rich plasma, sealing femoral tunnel, and limb position shows no variation between conventional or fast-track procedures.

A methodological limitation of the study is its partial reproducibility, as the fast-track information achieved from the first electronic search is integrated with information from further searches, previous knowledge, article references, or clinical tips. This is also why the study may not be exhaustive. However, this methodological limitation likely compensates for the lack of information and systematic approach on several topics in this field.

Conclusion

Many blood management strategies have been put forward to support safe and cheaper orthopedic elective TJA procedures. This article provides a roadmap to more uniform blood management in fast-track orthopedic pathways, pointing out current evidence as well as suggestions for further research.

The difference between conventional and fast-track pathways does not lie in the issues of blood management, which are related to surgical procedures, materials and patients, but in the way in which these contents are integrated with each other, since elective orthopedic procedures offer significant room for planning.

The more fast-track clinical studies are able to add evidence, the greater the benefits for patients, providers, and funders. The next step, therefore, is to put theory into practice [203].

Availability of data and materials

Not applicable.

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GB, FN, and PP contributed to the design of the work. FP contributed to the acquisition and analysis. PS contributed to the interpretation of data. NM and GP developed the idea, supervised the writing of and revision of the manuscript. All authors read and approved the final manuscript.

Correspondence to Nicola Maffulli.

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Keywords

  • Blood management
  • Fast-track surgery
  • Orthopedics
  • Joint replacement
  • Health care value
  • Ethics