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Table 4 Postoperative blood management

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

Content Conventional studies, guide lines, and recommendations Fast-track setting
Postoperative anemia See Table 2.
Compression Inelastic compression bandage after TKA seems not to reduce blood loss, but offers a slight improvement in reducing postoperative pain and early functional outcomes [167, 168]. According to other studies, there is no difference in compression method [169,170,171]. Intermittent pneumatic compression to reduce bleeding in (fast-track) high risk patients is considered later, together with thromboprophylaxis.
Cryotherapy Systematic review on 13 RCTs proved cryotherapy to be effective in reducing blood loss after TKA selected patients, while its benefits remained controversial after THA [172]. Previous systematic review and meta-analysis over 11 TKA studies show only slight short-lasting benefit of cryotherapy in routine procedures [173]. Cryotherapy has been advocated as a safe and effective strategy to improve fast-track TKA postoperative results, acting on pain, edema, and blood loss. Continuous cold flow device in the acute postoperative setting did not show superiority in comparison with traditional icing regimen. Thus, due to the costs, it should be reserved to selected cases [174].
Limb position Different knee flexion positions (e.g., hip elevation by 60° combined with 60° knee flexion) have been reported to have promising results with respect to reducing perioperative blood loss [175,176,177]. Postoperative knee flexion is therefore an easy, inexpensive, and effective method in blood loss reduction [18]. There seems to be no reason to opt for a limb position according to the pathway. Searching the literature for #limb(-)position, #blood and #fast(-)track gave 2 results, none of which consistent with orthopedics.
Postoperative cell savage PCS effectiveness and cost-effectiveness seem to be maximized in patients with pre-operative Hb 12–15 g/dL, while in patients with pre-operative Hb less than 12 g/dL it should be combined with other techniques [178]. The use of TXA has almost eliminated the need for other blood conservation strategies [73, 74], included postoperative blood salvation, and is therefore a valuable innovation to be applied under a fast-track pathway [75]. Postoperative cell salvage is still useful to those patients who cannot be administered TXA.
Drainage clamping and removal The introduction of drainage clamping in bilateral total joint arthroplasty proved effective and cost-effective in pioneer studies on TKA and THA [179, 180]. More recent studies on TKA proved its effectiveness to be debatable [181,182,183], and when effective, proved debatable intervals of administration [184,185,186]. Today, 3-h interval clamping proved effective in reducing TKA postoperative Hb drop with no increase in thromboembolic episodes and wound complications [187], and proved to be even more effective in combination with TXA, even if there is still need of a major focus on duration and intervals [188, 189]. With regard to THA, 4-h drainage clamping proved potential for routine implementation, for it reduced blood loss and the following need of transfusion with no significant difference on other clinical outcomes [190]. According to a RCT on 224 THA patients, intra-articular soaking of high concentration of TXA with 2-h clamping drainage can reduce the total blood loss and transfusion rates in primary THA without significant increase in postoperative thrombotic complications [191]. A prospective cohort study evaluated the safety and feasibility of early removal of drainage tube in primary fast-track TKA. Wound drainage was removed within 6–12 h after surgery. The procedure could drain the haematocele and reduce the risk of infection, without increasing the sense of pain, inflammatory reaction, limb swelling, and total blood loss. Removal of drainage tube was therefore safe and feasible within 6–12 h after surgery [192]. According to clinical expertise, drains can be avoided in selected cases, when local conditions free of obvious bleeding following re-established pressure ensure the absence of the risk of hematoma.