Findings
Question 4. What is the effect of anemia and blood transfusion on function?
Case clarification
This patient is a previously vital community ambulator.
Currently, she is having difficulty ambulating due to fatigue. Early ambulation, a primary goal of hip fracture surgery, is not being accomplished.
Relevance
Elderly patients following hip surgery are at risk of com- plications of sustained recumbency such as thromboem- bolic events and infection.
Current opinion
Transfusion is performed to increase oxygen carrying capacity of blood to tissues. Many patients appear to “perk up” with increased energy, vitality, and ambulatory capac- ity following transfusion. It is unclear whether this appar- ent benefit is in fact substantial and sustained.
Finding the evidence
• Cochrane Database, with search term “perioperative anemia”
Current evidence supports a restrictive transfusion thresh- old of 7.0–8.0 g/dL for healthy patients
• Although anemia is a known risk factor for cardiac events in the presence of pre-existing cardiovascular disease, current clinical evidence does not support a more aggressive transfusion protocol in this population
• Limited evidence suggests a higher transfusion thresh- old does not improve function after orthopedic surgery
• The risks of transfusion include hemolytic and non- hemolytic reactions, infection, and immune modulation
References
1. Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev 2006;1:CD001825.
2. 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(5):687–96.
3. Henry DA, Carless PA, Moxey AJ, O’Connell D, Forgie MA, Wells PS, et al. Pre-operative autologous donation for minimis- ing perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2002;2:CD003602.
4. Billote DB, Glisson SN, Green D, Wixson RL. A prospective, randomized study of preoperative autologous donation for hip replacement surgery. J Bone Joint Surg Am. 2002;84-A(8):
1299–304.
5. Faris PM, Ritter MA, Abels RI. The effects of recombinant human erythropoietin on perioperative transfusion requirements in patients having a major orthopaedic operation. The American Erythropoietin Study Group. J Bone Joint Surg Am 1996;78(1):
62–72.
6. Hebert, P, Wells G, Blajchman M, etal. A multicenter, rand- omized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340:409–17.
7. Lotke P, Barth P, Garino J, Cook E. Predonated autologous blood transfusions after total knee arthroplasty: Immediate versus delayed administration. J Arthroplasty 199•;14:647–50.
8. Carson J, Terrin M, Barton F, et al. A pilot randomized trial comparing symptomatic vs. hemoglobin-level-driven red blood cell transfusions following hip fracture. Transfusion 1998;38:
522–9.
9. Carson J, Hill S, Carless P, et al. Transfusion triggers: A system- atic review of the literature. Transfus Med Rev 2002;16:187–99.
10. Carson J, Duff A, Poses R, et al. Effect of anaemia and cardio- vascular disease on surgical mortality and morbidity. Lancet 1996;348:1055–60.
11. Carson J, Terrin M, Magaziner J, et al. Transfusion trigger trial for functional outcomes in cardiovascular patients undergoing surgical hip fracture repair (FOCUS). Transfusion 2006;46:
2192–206.
12. Hill S, Carless PA, Henry DA, Carson JL, Hebert PPC, Henderson KM, McClelland B. Transfusion thresholds and other strategies
Finding the evidence
• PubMed clinical queries search/ systematic reviews:
“red blood cell transfusion and risks and orthopedic surgery”
Quality of the evidence
Level II• 2 randomized trials
Findings
Acute hemolytic reactions are the most immediate of the adverse events associated with red blood cell transfusion.
Reaction rates are 1 per 18,000, and mortality approxi- mately 1 per 1,000,000. Accidental transfusion of ABO- incompatible blood is the leading cause of fatal reactions.
Delayed hemolytic reactions can occur secondary to red blood cell alloantibodies in 1 per 5,000 units. Febrile non- hemolytic reactions occur in about 3% of patients, but are usually self-limited. Leukoreduction reduces the incidence of febrile reaction. TRALI (transfusion-related acute lung injury) is a severe reaction to donor leukocyte antibodies.
Estimated risk of this potentially serious reaction is 1 in 5,000 transfusions.19
Infection risk from transfused blood appears to be decreasing. Current estimates suggest the risk of HIV transmission of under 1 in 2,000,000; hepatitis B 1 in 100,000;
and hepatitis C, 1 in 1,000,000. The risk of other pathogens such as Creutzfeldt–Jakob disease is unknown.20
Perioperative blood transfusion may increase the risk of surgical-site infection or infection at remote sites such as pneumonia or urinary tract infection. Transfusion-mediated immune modulation may result in a reduced host response to pathologic organisms. In a meta-analysis of 20 studies relating transfusion and bacterial infection, the authors quote an increased risk of infection after transfusion of 3.45 (CI 1.43–15.15) and even higher in the trauma patient (RR 5.26, CI 5.03–5.43).21
Recommendation
• The risks of transfusion include hemolytic and non- hemolytic reactions, infection, and immune modulation [overall quality: high]
Summary of recommendations
• Closed suction drainage devices increase transfusion requirements after orthopedic surgery
• Antifibrinolytic drugs hold promise, but concerns sur- rounding adverse side effects limit routine use
• Autologous blood predonation and perioperative eryth- ropoietin may both reduce the need for allogeneic transfu- sion, but cost concerns remain
• Transfusion thresholds are controversial, and may vary dependent upon comorbidities such as cardiac disease.
C H A P T E R 9 Blood Transfusion
17. Carson J, Terrin M, Barton F, et al. A pilot randomized trial comparing symptomatic vs. hemoglobin-level-driven red blood cell transfusions following hip fracture. Transfusion 1998;38:
522–9.
18. Christodoulou C, Dafni U, Aravantinos G, Koutras A, Samantas E, Karina M, et al. Effects of epoetin-alpha on quality of life of cancer patients with solid tumors receiving chemotherapy. Anti Cancer Res 2009;29(2):693–702.
19. Klein HG, Spahn DR, Carson JL. Red blood cell transfusion in clinical practice. Lancet 2007;370:415–26.
20. Pineda AA, Vamvakas EC, Gorden LD, Winters JL, Moore SB.
Trends in the incidence of delayed hemolytic and delayed sero- logic transfusion reactions. Transfusion 1999;39:1097–103.
21. Hill GE, Frawley WH, Griffith KE, et al. Allogeneic blood trans- fusion increases the risk of postoperative bacterial infection: a meta-analysis. J Trauma 2003;54:908–14.
for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2000;1:CD002042.
13. Grover M, Talwalkar S, Casbard A, Boralessa H, Contreras M, et al. Silent myocardial ischaemia and haemoglobin concentra- tion: a randomized controlled trial of transfusion strategy in lower limb arthroplasty. Vox Sang 2006;90:105–12.
14. Hébert PC, Yetisir E, Martin C, Blajchman MA, Wells G, Marshall J, et al. Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group. Is a low transfusion threshold safe in critically ill patients with cardiovascular dis- eases? Crit Care Med 2001;29:227–34.
15. Foss NB, Kristensen MT, Jensen PS, Palm H, Krasheninnikoff M, Kehlet H. The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery. Transfusion 2009;49:227–234.
16. Halm EA, Wang JJ, Boockvar K, Penrod J, Silberzweig SB, Magaziner J, et al. Effects of blood transfusion on clinical and functional outcomes in patients with hip fracture. Transfusion 2003;43:1258–365.
Wound Infections
Wesley G. Lackey
1, Kyle J. Jeray
1, Atul F. Kamath
2, John G. Horneff III
2, and John L. Esterhai, Jr
2,31Greenville Hospital System University Medical Center, Greenville, SC, USA
2Hospital of the University of Pennsylvania, Philadelphia, PA, USA
3Veterans Affairs Hospital, Philadelphia, PA, USA
Case scenario
A 28-year-old man is brought to the Emergency Department after falling 8 feet (2.5 m) from a ladder. Examination and radiographs reveal a closed split-depression tibial plateau fracture. The soft tissue envelope allows primary open reduction and internal fixation of the fracture with a lateral buttress plate. At the 2 week follow-up, there is drainage from the wound with surrounding erythema.
Importance of the problem
Surgeons perform over 27 million operations yearly in the United States,1 with almost 500,000 of these procedures resulting in a surgical site infection (SSI),2 implying that infection complicates nearly 2% of all surgical wounds.
Open fractures, which occur at a rate of 250,000 per year in the US,3 have an increased rate of infection; although the risk varies depending on the severity of injury, the rate of infection can be as great as 50% in contaminated fracture wounds.4,5 These wound infections may require multiple subsequent operative procedures and prolonged antibiotic treatment courses, and result in complications such as delayed fracture union and possible amputation.
Wound infections cost an estimated $1.5 billion per year in the US, with an estimated $3,000–$30,000 spent per infec- tious event.6 According to epidemiologic hospital data, a patient who develops an SSI is five times more likely to be
readmitted to the hospital and has mortality rates twice that of a patient without an SSI.7 The National Surgical Infection Prevention Project was initiated in the US in August 2002 by Medicare and Medicaid to better character- ize the nature of SSI and to formulate better strategies to prevent and combat these infections.8 Although access to care and advances in technology and sanitation have improved health-related outcomes, infections and wound complications are still major factors relating to morbidity and mortality.
The risk of infection has also been strongly correlated with medical comorbidities9,10 and other host factors.11 The additional treatment required to treat infections, as well as wound and bone healing complications, leads to a signifi- cant increase in healthcare costs and significantly impacts the patient’s quality of life.
Despite aggressive medical and surgical management and evolving diagnostic and treatment modalities, ortho- pedic infections remain a challenging problem for both patients and clinicians. Where possible, a summary of the best available literature has been provided; due to the lack of homogeneity, well-controlled human clinical trials (level I and level II evidence) and suitable meta-analyses do not exist for most topics.
Relevant anatomy
Wound infections may occur in any anatomic location, and multiple factors contribute to their occurrence. For example,
Evidence-Based Orthopedics, First Edition. Edited by Mohit Bhandari.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.
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C H A P T E R 1 0 Wound Infections
4. What is the role of wound culture in diagnosing and treating orthopedic infections?
Therapy
5. What is the management of infected hardware?