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Rapid Responses: Rapid Responses published:
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Not just the Swiss
- Charles E Baker (20 April 2004)
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UK hospitals can improve the efficiency of red cell use
- Benedict A Rogers, David Johnstone (25 April 2004)
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National Audit
- Rob J Alcock (12 May 2004)
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Tranexemic acid after Total Hip Replacment Surgery
- M ahmad (13 December 2007)
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Tranexamic Acid
- Mahmood Ahmad (14 December 2007)
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Charles E Baker, Consultant Anaesthetist University Hospital of North Staffordshire, Stoke-on-Trent, ST4 6QG
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Editor- Muller et al are to be congratulated on their attempts to reduce red cell usage within their unit. I would like to share the experiences from my Trust. In 1999 I conducted a three month audit of allogeneic blood usage in orthopaedic surgery and found a transfusion rate of 51% for total knee replacements (n = 65) and 54% for primary hip replacements (n = 61). I introduced post operative transfusion guidelines, point of care testing for haemoglobin levels and cell salvage equipment. We currently use cell salvage routinely for total knee replacements, but not for primary hip replacements. In Muller et al’s study it is used for both procedures.1 Our most recent audit figures for April – September 2003 for total knee replacements show an overall allogeneic transfusion rate of 11% (n = 129). This is further reduced to just 7% in non anaemic patients (haemoglobin >120g/l). The allogeneic transfusion rate for primary hip replacements is 30% (n = 50). My next aim is to reduce the number of patients presenting for elective surgery with anaemia. Through doing this I hope to further reduce the transfusion rate in primary hip and knee surgery. I would also add that Muller et al’s article used the term autologous transfusion imprecisely. Autologous transfusion is a general term that encompasses several techniques: Pre donation Acute normovolaemic haemodilution (ANH) Minimal ANH is the removal of 1 or 2 units of blood immediately prior to surgery. This has little benefit in reducing blood requirements. It does provide whole blood with intact platelet and clotting function and as such may be useful especially following Cardiopulmonary Bypass. Extreme ANH should be the term reserved for removing blood and infusing fluids such that the resultant haemoglobin is approximately 70 g/l. At this level there is evidence to show that it reduces allogeneic blood requirements.2 Intra operative cell salvage (ICS) - shed blood is anticoagulated, centrifuged and washed in saline to remove cellular and non cellular debris. It is filtered and reinfused to the patient. It has active 2,3 DPG but in common with stored blood has no platelet or coagulation factors. Post operative cell salvage (PCS) Washed - as for ICS but may not require anticoagulation. Unwashed - these are reinfusion devices where blood is usually just filtered and returned to the patient. Muller et al use the term autologous transfusion to describe pre
donation. Pre donation is not actively encouraged by the National Blood
Service (NBS) at present. It has the following disadvantages:
In summary, at my Trust we have also strived to reduce inappropriate red cell usage and have achieved comparable figures. Autologous transfusion is a general term, the specific technique utilised should always be mentioned. References: 1 Muller U, Exadaktylos A, Roeder C, Pisan M, Eggli S, Juni P. Effect of a flow chart on use of blood transfusions in primary total hip and knee replacement: prospective before and after study. BMJ 2004;328:934-938. 2 Levack D, Gillon J. Intraoperative conservation of red cell mass: Controlled hypotension or haemodilution - not necessarily mutually exclusive? Br. J. Anaesth.1999;82:161-163. 3 SHOT annual report 2001/2002 Competing interests: None declared |
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Benedict A Rogers, Surgical Trainee Stoke Mandeville Hospital, Bucks HP21 8AL, David Johnstone
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Editor – Muller et al(1) demonstrated the effective use of a flow chart to reduce red cell usage. In Stoke Mandeville Hospital we recently concluded a yearlong study improving the efficiency of red cell usage in total knee and total hip surgery. Over an initial six-month period (01/02/03-31/07/03) 68 Total Hip Replacements (THRs) were carried out, 167 units were crossmatched (75 patients) and 60 used (22 patients), a crossmatch:transfusion (C:T) ratio of 3.21. In accordance with guidelines produced by the British Society for Haematology(2) (BSH), the following changes were implemented: i) group & save serum only for elective THR and TKR ii) all patients should have a full blood count (FBC) on day 2 post op iii) a Hb < 8 g/dl should be considered the indication for transfusion in patients over 65yrs. The subsequent six-month period (01/08/03-31/01/04) showed a significant improvement in the use of red cell for the 64 THRs carried out. 60 units were crossmatched in total (a 40% reduction), with 37 units being used (a 29% reduction), thus reducing the C:T ratio to 1.62 Similar reductions though of lesser magnitude were seen in total knee replacement surgery, where patients already had serum group & saved preoperatively. The BSH guidelines(2) state that ‘compatible blood should not be available for surgery where the usage is <50%’, as is the case in elective THR. We therefore conducted a telephone survey of 44 UK orthopaedic units, showing for THR surgery that 20 units (44%) routinely crossmatch blood preoperatively, whilst only 5 units had any standardized protocol for the day on which the post op FBC should be taken. Whilst the Muller et al paper used a flow chart to improve the efficiency of red cell usage, our study suggests similar improvements could be achieved in the UK by the implementation national guidelines. References 1.Muller et al. Effect of a flow chart on the use of blood transfusions in primary total hip and knee replacement: prospective before and after study. BMJ 2004;328:934-938 2.Guidelines for the clinical use of red cell transfusions. British Journal of Haematology. 2001, 113, 24-31 Competing interests: None declared |
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Rob J Alcock, Consultant Anaesthetist RJAH Orthopaedic & District Hospital NHS Trust, Oswestry, SY107AG
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Sir I read with great interest the study published by Muller et al, (1.), and was envious of their success in achieving a dramatic change in practice. The main concern I have with this article is in grouping hip and knee replacements together. As I, and I believe a great many practitioners within the UK, would consider them to present very separate transfusion challenges. A national audit of transfusion practice in hip and knee replacement is currently being undertaken within the UK. The results of this will be very interesting, and no doubt reveal a wide variation in transfusion practice between centres. However I suspect that it willalso show that knee replacements receive very little homologous blood transfusion. This is in part due to a lower total blood loss and also to the success of post -operative unwashed autologous red cell transfusion drains. The use of homologous transfusion following hip replacement is likely to remain significant. I suspect that UK anaesthetists are slow to adopt the transfusion triggers that are used in this study and widely advocated be bodies such as the Scottish Inter-Collegiate Guideline Network, because of concerns about the presence of silent coronary artery disease and the possibility of ischaemia caused by low Haemoglobin. Morbidity due to this is difficult to quantify. I do not think this has been satisfactorily addressed in previous studies. There is, however, plenty of scope for UK practitioners to follow the example of our Swiss Colleagues and at least rationalise the use of bank blood. Yours Faithfully Rob Alcock References (1.) Urs Müller, Aristomenis Exadaktylos, Christoph Roeder, Markus Pisan, Stefan Eggli, and Peter Jüni Effect of a flow chart on use of blood transfusions in primary total hip and knee replacement: prospective before and after study BMJ 2004; 328: 934-938 Competing interests: None declared |
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M ahmad, SHO Thromboprophylaxis Trials Epsom General Hospital
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A study recently published in Belgium compared a single preoperative bolus dose of tranexamic acid (15 mg/kg) on blood loss post-surgery. On 40 patients who were either randomized to get 15 mg/kg Tranexemic acid before surgery or an equal volume of Normal Saline it was found that Tranexemic acid that post-operative blood loss was on average 352 ml in the non- Tranexemic acid group vs 524 ml in the Tranexemic acid group.(p=0.013)[1] Another double blind trial in Sweden in 100 Total Hip arthoplasty patients showed on average 0.97 liters of blood loss in the Tranexamic acid group and 1.3 liters in the placebo group. (p<0.001).[2] In the Royal London hospital an observational study with a cohort of 64 patients published in 2005 showed that in 64 patients 32 of which recieved Tranexemic acid 20 mg/kg on induction. They were then matched to another set of 32 for age, sex, procedure, disease and pre-operative Hb level. In the group recieving Tranexamic acid the mean fall in Hb was 2.8 g/dl and the group not recieving Tranexamic acid the mean fall was 3.8 g/dl.(p<0.05) [3] A randomized double blind control trial in Finland on 40 Hip Arthoplasty patients showed that patients with tranexamic acid (10 mg/kg given as a bolus followed by an infusion of 1 mg/kg/hour for 10 hours) had only 334 ml post-operative blood loss as compared to a 622 ml blood loss in patients recieving a placebo. (p=0.001)[4] [1]P. Acta Chir Belg. 2007 Jul-Aug;107(4):397-401 Reduction of blood loss with tranexamic acid in primary total hip replacement surgery.Claeys MA, Vermeersch N, Haentjens [2]B.Acta Orthop. 2005 Jun;76(3):314-9 Tranexamic acid in total hip arthroplasty saves blood and money: a randomized, double-blind study in 100 patients.Johansson T, Pettersson LG, Lisander [3]Ann R Coll Surg Engl. 2005 Mar;87(2):99-101. Links The use of tranexamic acid to reduce blood loss during total hip arthroplasty: an observational study.Hynes MC, Calder P, Rosenfeld P, Scott G. [4] Acta Orthop Scand. 2003 Dec;74(6):665-9. Links Tranexamic acid reduces blood loss and blood transfusions in primary total hip arthroplasty: a prospective randomized double-blind study in 40 patients.Husted H, Blønd L, Sonne-Holm S, Holm G, Jacobsen TW, Gebuhr P. Competing interests: None declared |
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Mahmood Ahmad, SHO Thromboprophylaxis Research Epsom General Hospital,
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An intresting trial in Osaka on 21 patients who underwent staged bilateral hip arthoplasty at an interval of nearly 16 months. On one side 1000 mg was administered 15 minutes before incision and subsequently in the operation on the other side no Tranexemic acid was given. Reduction in blood post-operatively was significantly lower after the operation than in the control groups.(p<0.001)[1] In another study in the same hospital in Osaka on 40 patients who had cementless total hip arthroplasty. In 20 patients 1000 mg of Tranexamic acid was given and the other 20 were operated without Tranexamic Acid. Significant reduction was observed in blood loss in the first 2 hrs in Tranexamic acid patients.(p<0.001)[2] In a trial in Cheltenham General Hospital 50 patients who either recieved 10mg/kg of Tranexamic acid or a Placebo. It showed no significant difference in post-operative bleeding between the two groups.[3] 40 patients in Montreal either recieved a 10 mg/kg bolus pre-surgery and 1 mg/kg/hr till wound closure. In the tranexamic acid group on average 1308 +/- 462 mL was lost while in the non-Tranexamic acid group 1469 +/- 405 mL was lost post-operatively.[4] [1]J Bone Joint Surg Am. 2005 Apr;87(4):766-70. Tranexamic acid reduces postoperative blood loss in cementless total hip arthroplasty.Yamasaki S, Masuhara K, Fuji T. [2]Int Orthop. 2004 Apr;28(2):69-73. Tranexamic acid reduces blood loss after cementless total hip arthroplasty-prospective randomized study in 40 cases.Yamasaki S, Masuhara K, Fuji T. [3]J Arthroplasty. 2004 Jun;19(4):488-92. Bone bleeding during total hip arthroplasty after administration of tranexamic acid.Garneti N, Field J. [4] Can J Anaesth. 2004 Jan;51(1):31-7. Tranexamic acid reduces the need for allogenic red blood cell transfusions in patients undergoing total hip replacement.Lemay E, Guay J, Côté C, Roy A Competing interests: None declared |
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