Perioperative blood management for total hip/knee arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YUAN Mingcheng , DING Zichuan , LING Tingxian ,  ZHOU Zongke

Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

ZHOU Zongke, Email: zhouzongke@scu.edu.cn

Keywords：

Total hip arthroplasty; total knee arthroplasty; blood management; blood loss; transfusion

DOI：

10.7507/1002-1892.202002162

Video：

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Objective To review the perioperative blood management (PBM) of total knee arthroplasty (TKA) and total hip arthroplasty (THA).Methods Recent researches on PBM for TKA and THA were comprehensively read and summarized. Then the advantages and disadvantages of various measures together with the clinical experience of West China Hospital of Sichuan University were evaluated from three aspects, including optimizing hematopoiesis, reducing blood loss and blood transfusion, which could provide a basis for clinical selection.Results There are many PBM methods in TKA and THA, among which the optimization of hematopoiesis mainly includes the application of perioperative iron and erythropoietin. Measures to reduce bleeding include the use of tourniquet, intraoperative controlled hypotension, and perioperative antifibrinolytic agents. Autologous blood transfusion includes preoperative autologous blood donation, hemodilution and cell salvage. Allogeneic blood transfusion is the ultimate treatment for anemia. The application of erythropoietin combined with iron therapy for blood mobilization before surgery together with intraoperative controlled hypotension for bleeding control and the multiple use of tranexamic acid can achieve satisfactory clinical results.Conclusion In the perioperative period of TKA and THA, single or multiple use of different blood management measures should be considered carefully according to the physical and economic conditions of patients individually, so as to reduce the blood loss and allogeneic blood transfusion optimally, and finally accelerate the recovery of patients.

Citation： YUAN Mingcheng, DING Zichuan, LING Tingxian, ZHOU Zongke. Perioperative blood management for total hip/knee arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(12): 1612-1618. doi: 10.7507/1002-1892.202002162 Copy

1.	周宗科, 翁习生, 孙天胜, 等. 中国骨科手术加速康复——围术期血液管理专家共识. 中华骨与关节外科杂志, 2017, 10(1): 1-7.
2.	Stulberg BN, Zadzilka JD. Blood management issues using blood management strategies. J Arthroplasty, 2007, 22(4 Suppl 1): 95-98.
3.	American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology, 2015, 122(2): 241-275.
4.	Kim JL, Park JH, Han SB, et al. Allogeneic blood transfusion is a significant risk factor for surgical-site infection following total hip and knee arthroplasty: a meta-analysis. J Arthroplasty, 2017, 32(1): 320-325.
5.	Mathew KK, Vakharia RM, Salem HS, et al. Is iron deficiency anemia a risk factor for poorer outcomes in primary total knee arthroplasty? J Arthroplasty, 2020, 35(5): 1252-1256.
6.	Litton E, Xiao J, Ho KM. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ, 2013, 347: f4822.
7.	Yang Y, Li H, Li B, et al. Efficacy and safety of iron supplementation for the elderly patients undergoing hip or knee surgery: a meta-analysis of randomized controlled trials. J Surg Res, 2011, 171(2): e201-207.
8.	Park HS, Kim TY, Kim HJ, et al. The effect of intraoperative ferric carboxymaltose in joint arthroplasty patients: a randomized trial. J Clin Med, 2019, 8(10): 1674.
9.	Lachance K, Savoie M, Bernard M, et al. Oral ferrous sulfate does not increase preoperative hemoglobin in patients scheduled for hip or knee arthroplasty. Ann Pharmacother, 2011, 45(6): 764-770.
10.	Alsaleh K, Alotaibi GS, Almodaimegh HS, et al. The use of preoperative erythropoiesis-stimulating agents (ESAs) in patients who underwent knee or hip arthroplasty: a meta-analysis of randomized clinical trials. J Arthroplasty, 2013, 28(9): 1463-1472.
11.	Voorn VM, van der Hout A, So-Osman C, et al. Erythropoietin to reduce allogeneic red blood cell transfusion in patients undergoing total hip or knee arthroplasty. Vox Sang, 2016, 111(3): 219-225.
12.	Li Y, Yin P, Lv H, et al. A meta-analysis and systematic review evaluating the use of erythropoietin in total hip and knee arthroplasty. Ther Clin Risk Manag, 2018, 14: 1191-1204.
13.	Goodnough LT, Skikne B, Brugnara C. Erythropoietin, iron, and erythropoiesis. Blood, 2000, 96(3): 823-833.
14.	Bernabeu-Wittel M, Romero M, Ollero-Baturone M, et al. Ferric carboxymaltose with or without erythropoietin in anemic patients with hip fracture: a randomized clinical trial. Transfusion, 2016, 56(9): 2199-2211.
15.	张磊, 郑连杰, 杨梁, 等. 重组人促红细胞生成素短期快速应用对同期双侧全膝关节置换术围手术期输血的影响. 大连医科大学学报, 2017, 39(6): 570-574, 579.
16.	关健, 曹晓瑞, 王刚, 等. 促红细胞生成素联合铁剂应用于同期双侧人工全膝关节置换术围术期的有效性与安全性. 医学综述, 2017, 23(12): 2465-2469, 2473.
17.	王百盛, 李如珍, 韩文锋, 等. 联合应用重组人促红细胞生成素与蔗糖铁治疗初次全髋关节置换围术期贫血的疗效分析. 创伤外科杂志, 2019, 21(3): 192-196, 200.
18.	Feagan BG, Wong CJ, Kirkley A, et al. Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial. Ann Intern Med, 2000, 133(11): 845-854.
19.	Laffosse JM, Minville V, Chiron P, et al. Preoperative use of epoietin beta in total hip replacement: a prospective study. Arch Orthop Trauma Surg, 2010, 130(1): 41-45.
20.	So-Osman C, Nelissen RG, Koopman-van Gemert AW, et al. Patient blood management in elective total hip-and knee-replacement surgery (Part 1): a randomized controlled trial on erythropoietin and blood salvage as transfusion alternatives using a restrictive transfusion policy in erythropoietin-eligible patients. Anesthesiology, 2014, 120(4): 839-851.
21.	Tomeczkowski J, Stern S, Müller A, et al. Potential cost saving of Epoetin alfa in elective hip or knee surgery due to reduction in blood transfusions and their side effects: a discrete-event simulation model. PLoS One, 2013, 8(9): e72949.
22.	Dong J, Min S, He KH, et al. Effects of the nontourniquet combined with controlled hypotension technique on pain and long-term prognosis in elderly patients after total knee arthroplasty: a randomized controlled study. J Anesth, 2019, 33(5): 587-593.
23.	Bombardieri AM, Sharrock NE, Ma Y, et al. An observational study of cerebral blood flow velocity during hypotensive epidural anesthesia. Anesth Analg, 2016, 122(1): 226-233.
24.	Weinstein SM, YaDeau JT, Memtsoudis SG. Lack of association between levels and length of intraoperative controlled hypotension and acute kidney injury in total hip arthroplasty patients receiving neuraxial anesthesia. Reg Anesth Pain Med, 2018, 43(7): 725-731.
25.	Schnettler T, Papillon N, Rees H. Use of a tourniquet in total knee arthroplasty causes a paradoxical increase in total blood loss. J Bone Joint Surg (Am), 2017, 99(16): 1331-1336.
26.	Zan PF, Yang Y, Fu D, et al. Releasing of tourniquet before wound closure or not in total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty, 2015, 30(1): 31-37.
27.	谢小伟, 岳辰, 黄泽宇, 等. 全膝关节置换术应用与不应用止血带的随机对照研究. 中国矫形外科杂志, 2017, 25(17): 1572-1576.
28.	Zhang W, Liu A, Hu D, et al. Effects of the timing of tourniquet release in cemented total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res, 2014, 9: 125.
29.	Huang Z, Xie X, Li L, et al. Intravenous and topical tranexamic acid alone are superior to tourniquet use for primary total knee arthroplasty: A prospective, randomized controlled trial. J Bone Joint Surg (Am), 2017, 99(24): 2053-2061.
30.	张子琦, 梁佳林, 左小莉, 等. 气压止血带对人工全膝关节置换术围术期失血量的影响. 中国修复重建外科杂志, 2019, 33(6): 681-684.
31.	Goel R, Rondon AJ, Sydnor K, et al. Tourniquet use does not affect functional outcomes or pain after total knee arthroplasty: a prospective, double-blinded, randomized controlled trial. J Bone Joint Surg (Am), 2019, 101(20): 1821-1828.
32.	McCarthy Deering E, Hu SY, Abdulkarim A. Does tourniquet use in TKA increase postoperative pain? A systematic review and meta-analysis. Clin Orthop Relat Res, 2019, 477(3): 547-558.
33.	Hasanain MS, Apostu D, Alrefaee A, et al. Comparing the effect of tourniquet vs tourniquet-less in simultaneous bilateral total knee arthroplasties. J Arthroplasty, 2018, 33(7): 2119-2124.
34.	Luo ZY, Wang HY, Wang D, et al. Oral vs intravenous vs topical tranexamic acid in primary hip arthroplasty: a prospective, randomized, double-blind, controlled study. J Arthroplasty, 2018, 33(3): 786-793.
35.	Wang D, Wang HY, Luo ZY, et al. Finding the optimal regimen for oral tranexamic acid administration in primary total hip arthroplasty: a randomized controlled trial. J Bone Joint Surg (Am), 2019, 101(5): 438-445.
36.	Huang Z, Ma J, Shen B, et al. Combination of intravenous and topical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial. J Arthroplasty, 2014, 29(12): 2342-2346.
37.	Xie J, Ma J, Yao H, et al. Multiple boluses of intravenous tranexamic acid to reduce hidden blood loss after primary total knee arthroplasty without tourniquet: a randomized clinical trial. J Arthroplasty, 2016, 31(11): 2458-2464.
38.	Zeng WN, Liu JL, Wang FY, et al. Low-dose epinephrine plus tranexamic acid reduces early postoperative blood loss and inflammatory response: a randomized controlled trial. J Bone Joint Surg (Am), 2018, 100(4): 295-304.
39.	Jules-Elysee KM, Tseng A, Sculco TP, et al. Comparison of topical and intravenous tranexamic acid for total knee replacement: a randomized double-blinded controlled study of effects on tranexamic acid levels and thrombogenic and inflammatory marker levels. J Bone Joint Surg (Am), 2019, 101(23): 2120-2128.
40.	Abdel MP, Chalmers BP, Taunton MJ, et al. Intravenous versus topical tranexamic acid in total knee arthroplasty: both effective in a randomized clinical trial of 640 patients. J Bone Joint Surg (Am), 2018, 100(12): 1023-1029.
41.	崔丹荔, 雷一霆, 许宏, 等. 人工全髋关节置换术中首次大剂量联合术后五次静脉应用氨甲环酸的前瞻性临床研究. 中国修复重建外科杂志, 2019, 33(8): 935-939.
42.	Zhou J, Chen Z, Jin J, et al. A study of preoperative autologous blood donation timing. Indian J Hematol Blood Transfus, 2018, 34(1): 138-142.
43.	Jin J, Zhou J, Zhang QL, et al. Application of component apheresis in pre-deposited autotransfusion. Ann Clin Lab Sci, 2018, 48(5): 634-638.
44.	van Bodegom-Vos L, Voorn VM, So-Osman C, et al. Cell salvage in hip and knee arthroplasty: a meta-analysis of randomized controlled trials. J Bone Joint Surg (Am), 2015, 97(12): 1012-1021.
45.	Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev, 2016, 10: CD002042.

1. 周宗科, 翁习生, 孙天胜, 等. 中国骨科手术加速康复——围术期血液管理专家共识. 中华骨与关节外科杂志, 2017, 10(1): 1-7.
2. Stulberg BN, Zadzilka JD. Blood management issues using blood management strategies. J Arthroplasty, 2007, 22(4 Suppl 1): 95-98.
3. American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology, 2015, 122(2): 241-275.
4. Kim JL, Park JH, Han SB, et al. Allogeneic blood transfusion is a significant risk factor for surgical-site infection following total hip and knee arthroplasty: a meta-analysis. J Arthroplasty, 2017, 32(1): 320-325.
5. Mathew KK, Vakharia RM, Salem HS, et al. Is iron deficiency anemia a risk factor for poorer outcomes in primary total knee arthroplasty? J Arthroplasty, 2020, 35(5): 1252-1256.
6. Litton E, Xiao J, Ho KM. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ, 2013, 347: f4822.
7. Yang Y, Li H, Li B, et al. Efficacy and safety of iron supplementation for the elderly patients undergoing hip or knee surgery: a meta-analysis of randomized controlled trials. J Surg Res, 2011, 171(2): e201-207.
8. Park HS, Kim TY, Kim HJ, et al. The effect of intraoperative ferric carboxymaltose in joint arthroplasty patients: a randomized trial. J Clin Med, 2019, 8(10): 1674.
9. Lachance K, Savoie M, Bernard M, et al. Oral ferrous sulfate does not increase preoperative hemoglobin in patients scheduled for hip or knee arthroplasty. Ann Pharmacother, 2011, 45(6): 764-770.
10. Alsaleh K, Alotaibi GS, Almodaimegh HS, et al. The use of preoperative erythropoiesis-stimulating agents (ESAs) in patients who underwent knee or hip arthroplasty: a meta-analysis of randomized clinical trials. J Arthroplasty, 2013, 28(9): 1463-1472.
11. Voorn VM, van der Hout A, So-Osman C, et al. Erythropoietin to reduce allogeneic red blood cell transfusion in patients undergoing total hip or knee arthroplasty. Vox Sang, 2016, 111(3): 219-225.
12. Li Y, Yin P, Lv H, et al. A meta-analysis and systematic review evaluating the use of erythropoietin in total hip and knee arthroplasty. Ther Clin Risk Manag, 2018, 14: 1191-1204.
13. Goodnough LT, Skikne B, Brugnara C. Erythropoietin, iron, and erythropoiesis. Blood, 2000, 96(3): 823-833.
14. Bernabeu-Wittel M, Romero M, Ollero-Baturone M, et al. Ferric carboxymaltose with or without erythropoietin in anemic patients with hip fracture: a randomized clinical trial. Transfusion, 2016, 56(9): 2199-2211.
15. 张磊, 郑连杰, 杨梁, 等. 重组人促红细胞生成素短期快速应用对同期双侧全膝关节置换术围手术期输血的影响. 大连医科大学学报, 2017, 39(6): 570-574, 579.
16. 关健, 曹晓瑞, 王刚, 等. 促红细胞生成素联合铁剂应用于同期双侧人工全膝关节置换术围术期的有效性与安全性. 医学综述, 2017, 23(12): 2465-2469, 2473.
17. 王百盛, 李如珍, 韩文锋, 等. 联合应用重组人促红细胞生成素与蔗糖铁治疗初次全髋关节置换围术期贫血的疗效分析. 创伤外科杂志, 2019, 21(3): 192-196, 200.
18. Feagan BG, Wong CJ, Kirkley A, et al. Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial. Ann Intern Med, 2000, 133(11): 845-854.
19. Laffosse JM, Minville V, Chiron P, et al. Preoperative use of epoietin beta in total hip replacement: a prospective study. Arch Orthop Trauma Surg, 2010, 130(1): 41-45.
20. So-Osman C, Nelissen RG, Koopman-van Gemert AW, et al. Patient blood management in elective total hip-and knee-replacement surgery (Part 1): a randomized controlled trial on erythropoietin and blood salvage as transfusion alternatives using a restrictive transfusion policy in erythropoietin-eligible patients. Anesthesiology, 2014, 120(4): 839-851.
21. Tomeczkowski J, Stern S, Müller A, et al. Potential cost saving of Epoetin alfa in elective hip or knee surgery due to reduction in blood transfusions and their side effects: a discrete-event simulation model. PLoS One, 2013, 8(9): e72949.
22. Dong J, Min S, He KH, et al. Effects of the nontourniquet combined with controlled hypotension technique on pain and long-term prognosis in elderly patients after total knee arthroplasty: a randomized controlled study. J Anesth, 2019, 33(5): 587-593.
23. Bombardieri AM, Sharrock NE, Ma Y, et al. An observational study of cerebral blood flow velocity during hypotensive epidural anesthesia. Anesth Analg, 2016, 122(1): 226-233.
24. Weinstein SM, YaDeau JT, Memtsoudis SG. Lack of association between levels and length of intraoperative controlled hypotension and acute kidney injury in total hip arthroplasty patients receiving neuraxial anesthesia. Reg Anesth Pain Med, 2018, 43(7): 725-731.
25. Schnettler T, Papillon N, Rees H. Use of a tourniquet in total knee arthroplasty causes a paradoxical increase in total blood loss. J Bone Joint Surg (Am), 2017, 99(16): 1331-1336.
26. Zan PF, Yang Y, Fu D, et al. Releasing of tourniquet before wound closure or not in total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty, 2015, 30(1): 31-37.
27. 谢小伟, 岳辰, 黄泽宇, 等. 全膝关节置换术应用与不应用止血带的随机对照研究. 中国矫形外科杂志, 2017, 25(17): 1572-1576.
28. Zhang W, Liu A, Hu D, et al. Effects of the timing of tourniquet release in cemented total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res, 2014, 9: 125.
29. Huang Z, Xie X, Li L, et al. Intravenous and topical tranexamic acid alone are superior to tourniquet use for primary total knee arthroplasty: A prospective, randomized controlled trial. J Bone Joint Surg (Am), 2017, 99(24): 2053-2061.
30. 张子琦, 梁佳林, 左小莉, 等. 气压止血带对人工全膝关节置换术围术期失血量的影响. 中国修复重建外科杂志, 2019, 33(6): 681-684.
31. Goel R, Rondon AJ, Sydnor K, et al. Tourniquet use does not affect functional outcomes or pain after total knee arthroplasty: a prospective, double-blinded, randomized controlled trial. J Bone Joint Surg (Am), 2019, 101(20): 1821-1828.
32. McCarthy Deering E, Hu SY, Abdulkarim A. Does tourniquet use in TKA increase postoperative pain? A systematic review and meta-analysis. Clin Orthop Relat Res, 2019, 477(3): 547-558.
33. Hasanain MS, Apostu D, Alrefaee A, et al. Comparing the effect of tourniquet vs tourniquet-less in simultaneous bilateral total knee arthroplasties. J Arthroplasty, 2018, 33(7): 2119-2124.
34. Luo ZY, Wang HY, Wang D, et al. Oral vs intravenous vs topical tranexamic acid in primary hip arthroplasty: a prospective, randomized, double-blind, controlled study. J Arthroplasty, 2018, 33(3): 786-793.
35. Wang D, Wang HY, Luo ZY, et al. Finding the optimal regimen for oral tranexamic acid administration in primary total hip arthroplasty: a randomized controlled trial. J Bone Joint Surg (Am), 2019, 101(5): 438-445.
36. Huang Z, Ma J, Shen B, et al. Combination of intravenous and topical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial. J Arthroplasty, 2014, 29(12): 2342-2346.
37. Xie J, Ma J, Yao H, et al. Multiple boluses of intravenous tranexamic acid to reduce hidden blood loss after primary total knee arthroplasty without tourniquet: a randomized clinical trial. J Arthroplasty, 2016, 31(11): 2458-2464.
38. Zeng WN, Liu JL, Wang FY, et al. Low-dose epinephrine plus tranexamic acid reduces early postoperative blood loss and inflammatory response: a randomized controlled trial. J Bone Joint Surg (Am), 2018, 100(4): 295-304.
39. Jules-Elysee KM, Tseng A, Sculco TP, et al. Comparison of topical and intravenous tranexamic acid for total knee replacement: a randomized double-blinded controlled study of effects on tranexamic acid levels and thrombogenic and inflammatory marker levels. J Bone Joint Surg (Am), 2019, 101(23): 2120-2128.
40. Abdel MP, Chalmers BP, Taunton MJ, et al. Intravenous versus topical tranexamic acid in total knee arthroplasty: both effective in a randomized clinical trial of 640 patients. J Bone Joint Surg (Am), 2018, 100(12): 1023-1029.
41. 崔丹荔, 雷一霆, 许宏, 等. 人工全髋关节置换术中首次大剂量联合术后五次静脉应用氨甲环酸的前瞻性临床研究. 中国修复重建外科杂志, 2019, 33(8): 935-939.
42. Zhou J, Chen Z, Jin J, et al. A study of preoperative autologous blood donation timing. Indian J Hematol Blood Transfus, 2018, 34(1): 138-142.
43. Jin J, Zhou J, Zhang QL, et al. Application of component apheresis in pre-deposited autotransfusion. Ann Clin Lab Sci, 2018, 48(5): 634-638.
44. van Bodegom-Vos L, Voorn VM, So-Osman C, et al. Cell salvage in hip and knee arthroplasty: a meta-analysis of randomized controlled trials. J Bone Joint Surg (Am), 2015, 97(12): 1012-1021.
45. Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev, 2016, 10: CD002042.

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