title: Implementing a blood management protocol during the entire perioperative period allows a reduction in transfusion rate in major orthopedic surgery: a before-after study.
abstract: BACKGROUND
  Patient blood management (PBM) must be promoted in orthopedic surgery and relies on different strategies implemented during the entire perioperative period. Our aim was to assess whether the introduction of a pre-, intra-, and postoperative PBM protocol combining erythropoietin (EPO), ferric carboxymaltose (FCM), and tranexamic acid was effective in reducing perioperative transfusion and postoperative anemia.
  
  
  METHODS
  In a two-phase prospective observational study, all patients admitted for total hip or knee arthroplasty were included the day before surgery. In Phase 1, use of EPO, iron, and tranexamic acid was left to the discretion of the anesthesiologists. In Phase 2, a protocol combining these treatments was implemented in the perioperative period. Perioperative hemoglobin levels and transfusion rates were recorded.
  
  
  RESULTS
  A total of 367 patients were included (184 and 183 in Phase 1 and 2, respectively). During Phase 2, implementing a PBM protocol allowed an increase in preoperative EPO prescription in targeted patients (i.e., with Hb < 13 g/dL; 18 [38%] vs. 34 [62%], p = 0.03) and in postoperative use of intravenous iron (12 [6%] vs. 32 [18%], p = 0.001) and tranexamic acid (157 [86%] vs. 171 [94%] patients, p = 0.02). In Phase 2, the number of patients who received transfusions (24 [13%] vs. 5 [3%], p = 0.0003) and of patients with a Hb level of less than 10 g/dL at discharge (46 [25%] vs. 26 [14%], p = 0.01) were reduced.
  
  
  CONCLUSIONS
  Introduction of a PBM protocol, using EPO, FCM, and tranexamic acid, reduces the number of perioperative transfusions and of patients with a Hb level of less than 10 g/dL at discharge.
authors.affiliation: Département d'Anesthésie-Réanimation.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Rineau
authors.affiliation: Département d'Anesthésie-Réanimation.
authors.forename: Aurélie
authors.initials: A
authors.lastname: Chaudet
authors.affiliation: Département d'Anesthésie-Réanimation.
authors.forename: Claire
authors.initials: C
authors.lastname: Chassier
authors.affiliation: Département de Chirurgie Osseuse, L'UNAM Université, Université d'Angers, CHU d'Angers, Angers, France.
authors.forename: Pascal
authors.initials: P
authors.lastname: Bizot
authors.affiliation: Département d'Anesthésie-Réanimation.
authors.forename: Sigismond
authors.initials: S
authors.lastname: Lasocki
mesh_terms: D000328:Adult; D000740:Anemia / Q000517:prevention & control; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D001803:Blood Transfusion; D065187:Controlled Before-After Studies; D004921:Erythropoietin / Q000627:therapeutic use; D005260:Female; D005290:Ferric Compounds / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008320:Maltose / Q000031:analogs & derivatives / Q000627:therapeutic use; D019637:Orthopedic Procedures / Q000379:methods*; D059035:Perioperative Period / Q000379:methods*; D011184:Postoperative Period; D011446:Prospective Studies; D014148:Tranexamic Acid / Q000627:therapeutic use
chemical_list: D005290:Ferric Compounds; D004921:Erythropoietin; C522335:ferric carboxymaltose; D008320:Maltose; D014148:Tranexamic Acid