Working towards transfusion-free total knee replacement surgery through patient blood management program

Abstract

Introduction: Total knee arthroplasty (TKA) is often resulted in high allogenic blood transfusions rate (ABT >30%). ABT are not without risks. ABT in TKA was showed to result in prolonged hospitalisation and increased patient morbidity and mortality. Furthermore, blood is a scarce resource, and therefore it should be used only if necessary. Patient Blood Management (PBM) is a timely application of evidence based concepts designed to maintain hemoglobin concentration, optimise hemostasis and minimise blood loss. With the aim of improving clinical outcome, PBM after TKA was adopted in our institution. Objective: To review the effectiveness before and after the implementation of PBM in our institution. Methodology: Strategies in PBM, included modern anaesthetic and surgical techniques, and the use of anti-fibrinolytic in decreasing blood loss, restrictive transfusion and single-unit blood transfusion policies, identification and optimisation of preoperative anaemia were gradually implemented in our institution from 2014 to 2017. It was a case controlled study. The control group consisted of patients with TKA done in our institution in 2013 (before the implementation of PBM), whereas the case group consisted of patients with TKA done in our institution in 2017 (after the full implementation of PBM). Patient’s demographics, preoperative haemoglobin level and the average annual ABT rate were compared between both groups. One of the concerns in PBM was the increase in medical complications after operation in anaemic patients, namely cerebrovascular accident and ischaemic heart disease. Therefore, the incidences of these complications and length of stay were compared. All the data were collected from CDARS or local joint registry database. The result was taken as significant if p<0.05. Results: 301 patients and 263 patients had primary TKA done in our institution in 2013 and 2017 respectively. The case and control groups were comparable in patients demographics and preoperative haemoglobin level (p>0.05). The average ABT rate has statistically significant decrease after the implementation of PBM (32.9% in 2013 Vs 4.1% in 2017, p<0.05). There were no patients complicated with the medical complications in both groups. PBM is effective in reducing ABT rate in our institution. There was no associated increase in medical complications. To reduce unnecessary ABT and its potential complications, PBM needs to be considered in current surgical practice.