Does IV adrenaline reduce peri-operative bleeding?

Jans et al. A randomised trial of the effect of low dose epinephrine infusion in addition to tranexamic acid on blood loss during total hip arthroplasty. British Journal of Anaesthesia. (2016) 116 (3):357-362.doi: 10.1093/bja/aev408

Background

  • Adrenaline thought to play a role in pro-coagulation, through increased platelet numbers, aggregation and fibrinogen level

Hypothesis

  • Epinephrine administration (iv) could reduced the perioperative blood loss in patients undergoing elective fast track THA

Method

  • Randomized, double blind, parallel group, placebo controlled. Randomisation via block randomisation
  • 2 Danish surgical centres between 2012-2013; ELECTIVE FAST TRACK THA patients only
  • Strict inclusion and exclusion criteria based around co-morbidites likely to be exacerbated by adrenaline infusion (see paper for full list)
  • Spinal anaesthetic (Bupivicaine 0.5%) – All received same dose. Standardized positioning, monitoring and no use of drains in any patients
  • All subjects received 1g tranexamic acid
  • Standardized fluid therapy -0.9% saline 12ml/kg/hr in first hour, then 6ml/kg/hr until end of surgery (last stitch). Blood loss replaced 1:1 with hydroxyethyl starch
  • Post op – pts allowed to E+D, iv fluids at discretion of physician (not standardised)

Outcome measures

  • Primary – intraoperative blood loss -Surgical nurse measuring suction drain contents and weighing swabs
  • Secondary – Blood loss at 24 hours post op -Calculated using Gross formula and Nadler equation

Results

  • 100 patient in each arm (adequately powered to detect 40% less blood loss to pilot study). All patients accounted for. Similar groups in terms of age, genders and ASA status.
  • No significant change in blood loss intra op (P = 0.23). Statistically significant reduction in 24 hour blood loss of 184ml (p=0.04).
  • No patients given blood transfusion

Pros:

  • First study of its kind
  • Clear – hypothesis, randomisation and blinding process
  • Adequate power; Similar groups
  • Maximal attempts to treat to groups equally intra op (bar sedation)
  • All patients who entered trial accounted for
  • Overall good attempt to minimise any bias

Cons:

  • Given no patients received blood transfusion, perhaps time effort and money would be better spent looking at high risk groups of patients where blood conservation is more needed.
  • No link to underlying mechanism of coagulation attempted
  • Long term complications not followed up
  • Confounders leading to lower Hbs post op such as SIRS/sepsis not looked for.
  • Limited information on patient co-morbidities provided

summary by Dr Evan Wild

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