Abstract
Purpose
Surgical patients experience inadvertent hypothermia as a result of anaesthesia-induced thermoregulatory impairment. Previous studies have found that hypothermia is associated with increased blood loss and transfusion requirements. This study examined the incidence of hypothermia in patients undergoing total hip arthroplasty (THA), whether hypothermia is associated with increased blood loss, and whether any such association is modified by tranexamic acid (TXA) administration.
Methods
An observational prospective study was performed in 941 consecutive patients undergoing elective THA, with and without intra-operative administration of TXA. The presence of hypothermia on post-anaesthesia care unit admission was determined, and the post-operative bleeding index calculated. Transfusions and complications were documented.
Results
The incidence of peri-operative inadvertent hypothermia was 84.2 %. TXA was administered to 751 (79.8 %) patients. The bleeding index was 2.6 (95 % confidence interval [CI] 2.6–2.7) in patients treated with TXA and 3.1 (95 % CI 2.8–3.4) in patients who did not receive TXA (p = 0.012). Mild hypothermia did not have a significant impact on the bleeding index (difference, −0.4; 95 % CI, −1.1 to +0.2; p = 0.190), nor on the effectiveness of TXA (difference, 0.4; 95 % CI, −0.3 to +1.1; p = 0.250).
Conclusion
The incidence of hypothermia in our THA population was high, despite peri-operative air warming. However, mild hypothermia was not significantly associated with increased blood loss and did not reduce the effectiveness of TXA.
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References
Rajagopalan S, Mascha E, Na J, Sessler DI (2008) The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology 108(1):71–77
Kurz A (2008) Thermal care in the perioperative period. Best Pract Res Clin Anaesthesiol 22(1):39–62
Frank SM, Fleisher LA, Breslow MJ, Higgins MS, Olson KF, Kelly S, Beattie C (1997) Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 277(14):1127–1134
Hooper VD, Chard R, Clifford T et al (2010) ASPAN’s evidence-based clinical practice guideline for the promotion of perioperative normothermia: second edition. J Perianesth Nurs 25(6):346–365
Kurz A, Sessler DI, Lenhardt R (1996) Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 334(19):1209–1215
Melling AC, Ali B, Scott EM, Leaper DJ (2001) Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 358(9285):876–880
Leijtens B, Koeter M, Kremers K, Koeter S (2013) High incidence of postoperative hypothermia in total knee and total hip arthroplasty: a prospective observational study. J Arthroplasty 28(6):895–898
Casati A, Fanelli G, Ricci A et al (1999) Shortening the discharging time after total hip replacement under combined spinal/epidural anesthesia by actively warming the patient during surgery. Minerva Anestesiol 65(7–8):507–514
Johansson T, Lisander B, Ivarsson I (1999) Mild hypothermia does not increase blood loss during total hip arthroplasty. Acta Anaesthesiol Scand 43(10):1005–1010
Dan M, Martos SM, Beller E, Jones P, Randle R, Liu D (2015) Blood loss in primary total knee arthroplasty—body temperature is not a significant risk factor--a prospective, consecutive, observational cohort study. J Orthop Surg Res 10:97
Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A (1996) Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet 347(8997):289–292
Henry DA, Carless PA, Moxey AJ et al (2007) Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 4:CD001886
Hourlier H, Fennema P (2014) Single tranexamic acid dose to reduce perioperative morbidity in primary total hip replacement: a randomised clinical trial. Hip Int 24(1):63–68
Hourlier H, Fennema P, Line B (2008) A novel blood-saving plan for less-invasive primary total hip replacement. Orthopedics 31 (12 Suppl 2)
Hourlier H (2006) A modified direct lateral minimally invasive approach to the hip. Surgical techniques and early results. J Bone Joint Surg (Br) 88-B(SUPP I):61
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D (1999) A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 130(6):461–470
Turpie AG, Bauer KA, Eriksson BI, Lassen MR, Committee PSS (2002) Postoperative fondaparinux versus postoperative enoxaparin for prevention of venous thromboembolism after elective hip-replacement surgery: a randomised double-blind trial. Lancet 359(9319):1721–1726
Rosenbaum PR, Rubin DB (1983) The central role of the propensity score in observational studies for causal effects. Biometrika 70:41–55
Rubin DB (1997) Estimating causal effects from large data sets using propensity scores. Ann Intern Med 127(8 Pt 2):757–763
PSMATCH2 (2014) Stata module to perform full Mahalanobis and propensity score matching, common support graphing, and covariate imbalance testing, version 4.0. http://ideas.repec.org/c/boc/bocode/s432001.html
Kurz A (2008) Physiology of thermoregulation. Best Pract Res Clin Anaesthesiol 22(4):627–644
Kiekkas P, Poulopoulou M, Papahatzi A, Souleles P (2005) Effects of hypothermia and shivering on standard PACU monitoring of patients. AANA J 73(1):47–53
Matsukawa T, Sessler DI, Sessler AM, Schroeder M, Ozaki M, Kurz A, Cheng C (1995) Heat flow and distribution during induction of general anesthesia. Anesthesiology 82(3):662–673
Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL (2014) Miller’s Anesthesia, 2-Volume Set, 8th Edition. 8th edn. Saunders, London
Sessler DI (2008) Temperature monitoring and perioperative thermoregulation. Anesthesiology 109(2):318–338
NICE quality standards [QS49] (2013). National Institute for Health and Care Excellence
Morais S, Ortega-Andreu M, Rodriguez-Merchan EC, Padilla-Eguiluz NG, Perez-Chrzanowska H, Figueredo-Zalve R, Gomez-Barrena E (2014) Blood transfusion after primary total knee arthroplasty can be significantly minimised through a multimodal blood-loss prevention approach. Int Orthop 38(2):347–354
Alvarez JC, Santiveri FX, Ramos I, Vela E, Puig L, Escolano F (2008) Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion 48(3):519–525
Yamasaki S, Masuhara K, Fuji T (2004) Tranexamic acid reduces blood loss after cementless total hip arthroplasty-prospective randomized study in 40 cases. Int Orthop 28(2):69–73
Iwai T, Tsuji S, Tomita T, Sugamoto K, Hideki Y, Hamada M (2013) Repeat-dose intravenous tranexamic acid further decreases blood loss in total knee arthroplasty. Int Orthop 37(3):441–445
Hourlier H, Reina N, Fennema P (2015) Single dose intravenous tranexamic acid as effective as continuous infusion in primary total knee arthroplasty: a randomised clinical trial. Arch Orthop Trauma Surg 135(4):465–471
Iwai T, Tsuji S (2013) Reply to letter to the editor: inadequate methodology renders results on the use of tranexamic acid inconclusive. Int Orthop 37(8):1647
Forget P, Grosu I, Thienpont E (2013) Inadequate methodology renders results on the use of tranexamic acid inconclusive. Int Orthop 37(7):1417–1418
Poeran J, Rasul R, Suzuki S et al (2014) Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ 349:g4829
Acknowledgments
The authors would like to thank Liam Davenport (AMR Advanced Medical Research) for his editorial support.
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Reina, N., Fennema, P. & Hourlier, H. The impact of mild peri-operative hypothermia on the effectiveness of tranexamic acid in total hip arthroplasty. International Orthopaedics (SICOT) 41, 55–60 (2017). https://doi.org/10.1007/s00264-016-3170-y
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DOI: https://doi.org/10.1007/s00264-016-3170-y