Strategies to Decrease Blood Loss in Patients Who Undergo Total Knee Replacement: A Prospective Study of One Hundred and Fifty Cases
DOI:
https://doi.org/10.15438/rr.v3i4.43Abstract
We calculated the total blood loss in a non-randomized study of 150 total knee replacements which were performed under regional anaesthesia by a mini-subvastus surgical approach without the use of a tourniquet. In all knees, tranexamic acid was used perioperatively. The skin, subcutaneous tissue and joint capsule were infiltrated with saline adrenaline prior to making surgical incision. After cementing the prostheses, the surgical wound was packed alternately with hydrogen peroxide and Feracrylum-soaked packs for 3 minutes. Tourniquet and postoperative drain were not used in any of the knees. In our series, the mean perioperative blood loss was 433 mL (SD 74), the mean RBC volume loss was 234 mL (SD 40.4), and the mean reduction in hemoglobin level was 1.6 gm/dL. The mean preoperative hemoglobin was 12.01gm/dL (SD 1.4) and the mean postoperative hemoglobin was 10.4 gm/dL (SD 1.4). The mean preoperative hematocrit was 37.04 (SD 2.8) and the mean postoperative hematocrit was 31.29 (SD 2.7). One of our patients developed cerebral thromboembolism three days after the surgery. Postoperative hemoglobin of less then 8 g/dL was considered an indication for blood transfusion; however, none of our patients required blood transfusion in the present series.
Study Design: Therapeutic case series; Level of Evidence, IV.
Keywords: Tranexamic acid; Antifibrinolytic agent; Decreased blood loss; Total knee arthroplasty
References
Goodnough LT, Verbrugge D, Marcus RE. The relationship between hematocrit, blood lost, and blood transfused in total knee replacement: Implications for postoperative blood salvage and reinfusion. Am J Knee Surg 1995;8:83-87.
Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg [Am] 1999;81-A:2-10.
Bong MR, Patel V, Chang E, Issack PS, Hebert R, Di Cesare PE. Risks associated with blood transfusion after total knee arthroplasty. J Arthroplasty 2004;19:281-287.
Freedman J, Luke K, Monga N, Lincoln S, Koen R, Escobar M, Chiavetta J. A provincial program of blood conservation: The Ontario Transfusion Coordinators (ONTraC). Transfus Apher Sci 2005;33:343-349.
Hiippala ST, Strid LJ, Wennerstrand MI, Arvela JV, Niemelä HM, Mäntylä SK, Kuisma RP, Ylinen JE. Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg 1997;84(4):839-844.
Good L, Peterson E, Lisander B. Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth 2003;90:596-599.
Sehat KR, Evans RL, Newman JH. Hidden blood loss following hip and knee arthroplasty: Correct management of blood loss should take hidden loss into account. J Bone Joint Surg [Br] 2004;86-B(4):561-565.
Kalairajah Y, Simpson D, Cossey AJ, Verrall GM, Spriggins AJ. Blood loss after total knee replacement: Effects of computer-assisted surgery. J Bone Joint Surg [Br] 2005;87-B:1480-1482.
Biarnés Suñé A, Ciércoles Jiménez E, Márquez Martínez E, Medel Rebollo J, Godet Gimeno C, Roigé Solé J. [Risk factors for transfusion in primary knee arthroplasty]. Rev Esp Anestesiol Reanim 2006;53:18-24. [Article in Spanish].
Benoni G, Carlsson A, Petersson C, Fredin H. Does tranexamic acid reduce blood loss in knee arthroplasty? Am J Knee Surg 1995;8(3):88-92.
Hiippala S, Strid L, Wennerstrand M, Arvela V, Mäntylä S, Ylinen J, Niemelä H. Tranexamic acid (Cyklokapron) reduces perioperative blood loss associated with total knee arthroplasty. Br J Anaesth 1995;74(5):534-537.
Benoni G, Fredin H. Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: A prospective, randomised, double-blind study of 86 patients. J Bone Joint Surg [Br] 1996;78-B(3):434-440.
Rosencher N, Kerkkamp HE, Macheras G, Munuera LM, Menichella G, Barton DM, Cremers S, Abraham IL; OSTHEO Investigation. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: Blood management in elective knee and hip arthroplasty in Europe. Transfusion 2003;43(4):459–469.
Roysam GS, Oakley MJ. Subvastus approach for total knee arthroplasty: A prospective, randomized, and observer-blinded trial. J Arthroplasty 2001;16(4):454-457.
Boerger TO, Aglietti P, Mondanelli N, Sensi L. Mini-subvastus versus medial parapatellar approach in total knee arthroplasty. Clin Orthop Relat Res 2005;440:82-87.
Shah N, Nilesh G, Patel N. Mini-subvastus approach for total knee arthroplasty in obese patients. Indian J Orthop 2010;44(3):292-299.
Juelsgaard P, Larsen UT, Sørensen JV, Madsen F, Søballe K. Hypotensive epidural anesthesia in total knee replacement without tourniquet: Reduced blood loss and transfusion. Reg Anesth Pain Med 2001;26(2):105-110.
Padala PR, Rouholamin E, Mehta RL. The role of drains and tourniquets in primary total knee replacement: A comparative study of TKR performed with drains and tourniquet versus no drains, and adrenaline and saline infiltration. J Knee Surg 2004;17(1):24-27.
Hankin FM, Campbell SE, Goldstein SA, Matthews LS. Hydrogen peroxide as a topical hemostatic agent. Clin Orthop Relat Res 1984;186:244-248.
Hathial MD. Feracrylum: A therapeutic profile. Indian Pract 2000;53:267–269.
Bhagwat AM, Save S, Burli S, Karki SG. A study to evaluate the antimicrobial activity of Feracrylum and its comparison with povidone-iodine. Indian J Pathol Microbiol 2001;44(4):431-433.
Nadler SB, Hidalgo JU, Bloch T. Prediction of blood volume in normal human adults. Surgery 1962;51:224-232.
Bourke DL, Smith TC. Estimating allowable hemodilution. Anaesthesiology 1974; 41(6):609-612.
Lemaire R. Strategies for blood management in orthopaedic and trauma surgery. J Bone Joint Surg [Br] 2008;90-B(9):1128-1136.
Newman JH, Bowers M, Murphy J. The clinical advantages of autologous transfusion: A randomized, controlled study after knee replacement. J Bone Joint Surg [Br] 1997;79-B(4):630-632.
Pitsaer E. Transfusion of recuperated blood in total knee arthroplasty. Rev Chir Orthop Reparatrice Appar Mot 2002;88:777-789 (Article in French).
Brecher ME, Goodnaugh LT. The rise and fall of preoperative autologous blood donation. Transfusion 2002;42:1618-1622.
Henry DA, Carless PA, Moxey AJ, O’Connell D, Forgie MA, Wells PS, Fergusson D. Preoperative autologous donation for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2002;(2):CD003602.
Saleh E, McClelland DB, Hay A, Semple D, Walsh TS. Prevalence of anaemia before major joint arthroplasty and the potential impact of preoperative investigation and correction on perioperative blood transfusions. Br J Anaesth 2007;99:801-808.
Wang GJ, Hungerford DS, Savory CG, Rosenberg AG, Mont MA, Burks SG, Mayers SL, Spotnitz WD. Use of fibrin sealant to reduce bloody drainage and hemoglobin loss after total knee arthroplasty: A brief note on a randomized prospective trial. J Bone Joint Surg [Am] 2001;83-A(10):1503-1505.
Sharrock NE, Mineo R, Urquhart B, Salvati EA. The effect of two levels of hypotension on intraoperative blood loss during total hip arthroplasty performed under lumbar epidural anesthesia. Anesth Analg 1993;76(3):580-584.
Nilsson IM. Clinical pharmacology of aminocaproic and tranexamic acids. J Clin Pathol Suppl (R Coll Pathol) 1980;14:41-47.
Astedt B. Clinical pharmacology of tranexamic acid. Scand J Gastroenterol Suppl 1987;137:22–25.
Dunn CJ, Goa KL. Tranexamic acid: A review of its use in surgery and other indications. Drugs 1999;57(6):1005-1032.
Mannucci PM. Hemostatic drugs. N Engl J Med 1998;339:245–253.
Howes JP, Sharma V, Cohen AT. Tranexamic acid reduces blood loss after knee arthroplasty. J Bone Joint Surg [Br] 1996;78-B:995-996.
Jansen AJ, Andreica S, Claeys M, D’Haese J, Camu F, Jochmans K. Use of tranexamic acid for an effective blood conservation strategy after total knee arthroplasty. Br J Anaesth 1999;83(4):596-601.
Tanaka N, Sakahashi H, Sato E, Hirose K, Ishima T, Ishii S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg [Br] 2001;83-B(5):702-705.
Veien M, Sørensen JV, Madsen F, Juelsgaard P. Tranexamic acid given intraoperatively reduces blood loss after total knee replacement: A randomized, controlled study. Acta Anaesthesiol Scand 2002;46(10):1206-1211.
Hynes M, Calder P, Scott G. The use of tranexamic acid to reduce blood loss during total knee arthroplasty. Knee 2003;10(4):375-377.
Cid J, Lozano M. Tranexamic acid reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: Results of a meta-analysis of randomized controlled trials. Transfusion 2005;45(8):1302–1307.
Camarasa MA, Ollé G, Serra-Prat M, Martín A, Sánchez M, Ricós P, Pérez A, Opisso L. Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: A randomized clinical trial. Br J Anaesth 2006;96(5):576-582.
Orpen NM, Little C, Walker G, Crawfurd EJ. Tranexamic acid reduces early post-operative blood loss after total knee arthroplasty: A prospective randomised controlled trial of 29 patients. Knee 2006;13(2):106-110.
Molloy DO, Archbold HA, Ogonda L, McConway J, Wilson RK, Beverland DE. Comparison of topical fibrin spray and tranexamic acid on blood loss after total knee replacement: A prospective, randomised controlled trial. J Bone Joint Surg [Br] 2007;89-B(3):306–309.
Alvarez JC, Santiveri FX, Ramos I, Vela E, Puig L, Escolano F. Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion 2008;48(3):519–525.
Lozano M, Basora M, Peidro L, Merino I, Segur JM, Pereira A, Salazar F, Cid J, Lozano L, Mazzara R, Macule F. Effectiveness and safety of tranexamic acid administration during total knee arthroplasty. Vox Sang 2008;95(1):39–44.
Kagoma YK, Crowther MA, Douketis J, Bhandari M, Eikelboom J, Lim W. Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: A systematic review of randomized trials. Thromb Res 2009;123:687-696.
Kakar PN, Gupta N, Govil P, Shah V. Efficacy and safety of tranexamic acid in control of bleeding following TKR: A randomized clinical trial. Indian J Anaesth 2009; 53(6):667-671.
Charoencholvanich K, Siriwattanasakul P. Tranexamic acid reduces blood loss and blood transfusion after TKA: A prospective randomized controlled trial. Clin Orthop Relat Res 2011;469(10):2874-2880.
Dhillon MS, Bali K, Prabhakar S. Tranexamic acid for control of blood loss in bilateral total knee replacement in a single stage. Indian J Orthop 2011;45(2):148-152.
MacGillivray RG, Tarabichi SB, Hawari MF, Raoof NT. Tranexamic acid to reduce blood loss after bilateral total knee arthroplasty: A prospective, randomized double blind study. J Arthroplasty 2011;26(1):24-28.
Sepah YJ, Umer M, Ahmad T, Nasim F, Umer Chaudhry M, Umar M. Use of Tranexamic acid is a cost effective method in preventing blood loss during and after total knee replacement. J Orthop Surg Res 2011;May 21;6(1):22.
Yamasaki S, Masuhara K, Fuji T. Tranexamic acid reduces postoperative blood loss in cementless total hip arthroplasty. J Bone Joint Surg [Am] 2005;87-A(4):766-770.
Fahmy NR, Patel DG. Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet. J Bone Joint Surg [Am] 1981;63-A(3):461-465.
Ho KM, Ismail H. Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: A meta-analysis. Anaesth Intensive Care 2003;31(5):529-537.
Zufferey P, Merquiol F, Laporte S, Decousus H, Mismetti P, Auboyer C, Samama CM, Molliex S. Do antifibrinolytics reduce allogeneic blood transfusion in orthopedic surgery? Anesthesiology 2006;105:1034-1046.
Benoni G, Lethagen S, Fredin H. The effect of tranexamic acid on local and plasma fibrinolysis during total knee arthroplasty. Thromb Res 1997;85(3):195-206.
Lindoff C, Rybo G, Astedt B. Treatment with tranexamic acid during pregnancy, and the risk of thrombo-embolic complications. Thromb Haemost 1993;70(2):238-240.
Ekbäck G, Axelsson K, Ryttberg L, Edlund B, Kjellberg J, Weckström J, Carlsson O, Schött U. Tranexamic acid reduces blood loss in total hip replacement surgery. Anesth Analg 2000;91(5):1124-1130.
Benoni G, Fredin H, Knebel R, Nilsson P. Blood conservation with tranexamic acid in total hip arthroplasty: A randomized, double-blind study in 40 primary operations. Acta Orthop Scand 2001;72(5):442-448.
Aglietti P, Baldini A, Vena LM, Abbate R, Fedi S, Falciani M. Effect of tourniquet use on activation of coagulation in total knee replacement. Clin Orthop Relat Res 2000;371:169-177.
Tetro AM, Rudan JF. The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Can J Surg 2001;44(1):33-38.
Klenerman L. The tourniquet in operations on the knee: A review. J R Soc Med 1982;75(1):31-32.
Mengal B, Aebi J, Rodriguez A, Lemaire R. A prospective randomized study of wound drainage versus non-drainage in primary total hip or knee arthroplasty [Article in French]. Rev Chir Orthop Reparatrice Appar Mot 2001;87(1):29-39.
Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev 2007 Jul 18;(3):CD001825.
Salido JA, Marín LA, Gómez LA, Zorrilla P, Martínez C. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: Analysis of predictive factors. J Bone Joint Surg [Am] 2002;84-A(2):216-220.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2014 Nilen Shah, MBBS, D. Orth., MS Orth. (Bombay, India), MCh Orth. (Liverpool, U.K.), Anand Gupta, DNB Orth., Dipak Patel, MD (USA), MSc Orth. (London, U.K.), MS Orth., D. Orth., FCPS Orth. (Bombay, India)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright and License Agreement:
Authors who publish with the Reconstructive Review agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work. Reconstructive Review follows the Creative Commons Attribution-NonCommercial CC BY-NC. This license allows anyone to download works, build upon the material, and share them with others for non-commercial purposes as long as they credit the senior author, Reconstructive Review, and the Joint Implant Surgery & Research Foundation (JISRF). An example credit would be: "Courtesy of (senior author's name), Reconstructive Review, JISRF, Chagrin Falls, Ohio". While works can be downloaded and shared they cannot be used commercially.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
