Knowing that infection is one of the most devastating complications for patients undergoing hip or knee replacement, Harpal Khanuja, Johns Hopkins associate professor of orthopaedic surgery, makes it his mission to address the issue through a multimodal approach to blood management. 

Blood transfusions can increase the risk of adverse outcomes, delay rehabilitation and extend a patient’s hospital stay, so limiting blood loss is crucial. “Transfusions have inherent risks,” says Khanuja. “There is the potential for complications, including infection and associated comorbidities.”

The multimodal blood management approach instituted at Johns Hopkins involves treating patients who are hypotensive postoperatively with fluids first, then blood products as needed, using antifibrinolytic agents such as tranexamic acid, and lowering the restrictive threshold for transfusions from <10 g/dL to <7 g/dL hemoglobin in hemodynamically stable patients. In a study of patients with hip fractures, Khanuja found the new restrictive threshold of <7 g/dL was associated with the same or better outcomes compared with a threshold of <8 g/dL. Overall, the transfusion rate for joint replacements at Johns Hopkins dropped from 20% to 2%. This approach lowered infection rates and had the additional benefits of decreasing hospital costs and conserving blood.

With such progress, Khanuja says transfusion is no longer the primary concern in blood management. The new focus is on the extent of anemia after surgery and how anemia affects patient recovery. “Now most joint replacements are outpatient procedures in a hospital setting. We are trying to get patients up the same day and get them moving, so anemia is the better indicator of patient outcomes,” says Khanuja. “We need to think of anemia in terms of how a patient feels postoperatively. How much energy do they have? How much better can we make them feel?”

Patient health optimization is a key component to addressing the effects of anemia. “Our department policy is to have all anemia examined if levels are not within a healthy range before surgery,” says Khanuja. Typically, the primary physician would clear a patient for surgery who is slightly anemic because this low level is considered “the patient’s normal.” Khanuja encourages orthopaedic surgeons to question that assumption. “If a patient is slightly anemic, I’m wondering if they have an underlying condition that could be exacerbated with surgery,” says Khanuja. “They could have a small bleeding ulcer made worse by the anti-inflammatories or blood thinners prescribed postoperatively. There are many reasons to address the anemia.” 

The same vigilance for anemia risks is applied to other risk factors as well, through diabetes control, weight loss, smoking cessation and nutritional screening. “We want to give patients the best outcome,” says Khanuja. “That is something that is important to us, and that we will always be on top of at Hopkins.”

Published in Framework Fall 2019 and OrthopaedicSurgery Winter 2020.