Patients with and without rheumatoid arthritis benefit equally from preoperative epoetin-alpha treatment.

BACKGROUND: Preoperative epoetin-alpha administration is said to have a limited effect in patients with chronic inflammatory diseases such as rheumatoid arthritis (RA), due to lower iron availability. We studied the effects of preoperative epoetin-alpha treatment in orthopedic surgery patients in a daily life setting in which iron supplementation was assured, and compared the effects in RA and non-RA patients. METHODS: In an open, naturalistic, randomized controlled trial, 695 orthopedic surgery patients with preoperative hemoglobin (Hb) values of 10-13 g/dL, either with RA (113) or without RA (582), received either preoperative epoetin-alpha treatment added to standard care, or standard care alone. Hb values and transfusions were evaluated from entry into the study until 4-6 weeks after surgery. RESULTS: Both in RA and non-RA patients, perioperative Hb values were significantly higher and transfusion requirements were significantly lower in epoetin-alpha treated patients than in control patients (p < 0.001). In RA patients, the outcomes regarding Hb values were not significantly or relevantly different from non-RA patients. INTERPRETATION: Just as with orthopedic patients in general, RA patients benefit from preoperative epoetin-alpha treatment in combination with iron supplementation. We postulate that iron supplementation during epoetin-alpha therapy in RA patients is important for optimal efficacy.

Perioperative blood transfusions and delayed wound healing after hip replacement surgery: effects on duration of hospitalization.

Patients who receive allogeneic blood transfusions after orthopedic surgery have a longer duration of hospitalization, and this cannot be explained by a more frequent incidence of infections in transfused patients. To determine whether transfusion of allogeneic blood interferes with wound healing and therefore increases the duration of hospitalization, we performed an observational study in 444 consecutive patients scheduled for elective primary hip surgery. Transfusion, wound, and infection variables were collected at five time points during treatment. Of the 444 consecutive patients studied, 92 received blood transfusions during their perioperative course. Thirty-one percent of transfused patients developed wound-healing disturbances versus 18% of the nontransfused group (P < 0.05); allogeneic blood transfusion was the only significant predictor for development of minor wound-healing disturbances. Duration of hospitalization was prolonged in transfused patients (12.3 versus 9.8 days) and could be predicted by 4 significant variables: requirement for blood transfusion (adds 2.7 +/- 0.5 days), presence of wound-healing disturbances (adds 1.3 +/- 0.5 days), duration of surgery (adds 0.2 +/- 0.1 days/10 min), and patient's age (adds 0.9 +/- 0.2 days/10 yr). These data suggest that allogeneic blood transfusion is associated with an increased incidence of wound-healing disturbances and that prevention of allogeneic blood transfusion may be relevant in limiting the duration of admission after elective orthopedic surgery.

An algorithm to reduce allogenic red blood cell transfusions for major orthopedic surgery.

In a previous prospective study, we confirmed that transfusion-related immunosuppression predisposes to postoperative infections, impairs the postoperative healing of wound and thereby prolongs hospitalization. This increases the well-known risks, such as transmission of infection or transfusion reactions, and has obliged us to revise our transfusion guidelines. We used a relational database containing information about 28,861 orthopedic surgery patients was used to determine when and how to improve these guidelines for transfusions. The survey showed the circumstances surrounding a high incidence of allogenic red cell infusions: failure to follow the guidelines, the preoperative use of nonselective NSAIDs, low preoperative Hb level, failure to retrieve blood, and high cut-off values for allogenic red cell transfusion. The first step was to determine the Hb level before giving red cell infusions and ensure compliance with predefined cut-off values. Subsequent measures included: use of COX 2-selective NSAIDs alone in the perioperative period; erythropoietin and iron therapy when the Hb level fell below 13 g/dL; use of cell salvage during and after surgery; administration of aprotinin to patients expected to have a high blood loss. The type of anesthesia had no blood-sparing effect. Although these steps can not be regarded as a new approach, we show that by following a strict rules with appropriate steps and in a concerted fashion, the use of allogenic red blood cells was reduced by 80%. Moreover, the amount of blood saved had other effects--e.g., the incidence of deep wound infections was reduced by 40%. The outcome is described in an algorithm summarizing the steps in a comprehensive perioperative diagram for giving blood.

Prior ibuprofen exposure does not augment opioid drug potency or modify opioid requirements for pain inhibition in total hip surgery.

PURPOSE: In previous animal studies, a prior exposure to non-steroidal anti-inflammatory drugs (NSAID) augmented opioid drug potency. This study was designed to answer the question whether a similar effect can be attained in man. The objective was to use NSAID for preoperative pain reduction and at the same time use the NSAID exposure to reduce opioid requirements for pain inhibition in major orthopedic surgery. METHODS: In this double-blind, randomized study, 50 patients scheduled for total hip surgery were included. Patients of Group I received a placebo drug three times a day two weeks before surgery, and those allocated to Group II received ibuprofen (600 mg) three times a day. For surgical anesthesia, all patients received intrathecal bupivacaine 20 mg plus 0.1 mg morphine in a total volume of 4 mL. RESULTS: The preoperative or postoperative visual analogue scale pain scores or the amount of iv morphine showed no differences between the two groups in the first 24 hr after surgery. The median total blood loss in the ibuprofen group was 1161 mL vs 796 mL in the placebo group (P < 0.01). CONCLUSION: Pretreatment with ibuprofen before major hip surgery does not improve the pain scores or reduce morphine requirement but significantly increases blood loss. Considering the presence of relevant adverse effects, pretreatment with a non-selective NSAID is not recommended.