Is hip replacement surgery high risk for bleeding?

From the Guidelines

Hip replacement surgery is considered a high-risk procedure for venous thromboembolism, but the risk of bleeding is moderate. According to the acc/aha 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery 1, hip replacement surgery falls into the highest risk category for thromboembolism, with a risk of deep vein thrombosis ranging from 40-80%. However, the risk of bleeding during hip replacement surgery is typically managed through various techniques, including careful surgical approach, use of tranexamic acid, controlled hypotension during surgery, and sometimes cell salvage techniques to collect and reinfuse the patient's own blood.

Some key points to consider in managing bleeding risk during hip replacement surgery include:

• Patients taking blood thinners like warfarin, clopidogrel, or direct oral anticoagulants are typically advised to stop these medications before surgery according to specific timelines (warfarin 5 days prior, clopidogrel 7 days, DOACs 48-72 hours) 1.
• The bleeding risk is higher in patients with bleeding disorders, liver disease, or those unable to stop anticoagulation therapy.
• Most surgeons use drains after surgery to monitor and manage post-operative bleeding, and patients receive prophylactic anticoagulants after surgery to prevent blood clots while balancing the risk of bleeding.
• A consistent bleed risk classification scheme, as proposed by the scientific and standardization committee communication 1, would enable easier interpretation of clinical trial results and inform guideline recommendations on the topic.

In terms of specific bleeding risk, hip replacement surgery is not typically considered a high-bleed-risk procedure, but rather a moderate-bleed-risk procedure, with a background 30-day major bleed event rate of around 1-2% 1. However, this risk can vary based on individual factors, and surgeons must carefully manage this risk through various techniques to minimize complications.

From the Research

Hip Replacement Surgery and Bleeding Risk

• Hip replacement surgery is associated with a high risk of bleeding, with significant blood loss occurring during and after the operation 2, 3, 4, 5, 6.
• The use of antifibrinolytic agents, such as tranexamic acid, has been shown to reduce blood loss and transfusion rates in patients undergoing total hip arthroplasty 2, 3, 4, 6.
• Studies have demonstrated that tranexamic acid can be effective in reducing bleeding and transfusion rates when administered intravenously or topically during hip replacement surgery 2, 3, 4, 6.

Factors Associated with Bleeding Risk

• Preoperative hemoglobin and hematocrit levels, BMI, operating time, and the use of blood transfusion have been identified as factors associated with major bleeding in patients undergoing total hip arthroplasty 5.
• Patients with lower preoperative hemoglobin levels (<13 g/dL) are at higher risk of major bleeding and may benefit from the use of tranexamic acid 3, 5.

Benefits of Tranexamic Acid

• Tranexamic acid has been shown to reduce blood loss, transfusion rates, and hospital stay in patients undergoing total hip arthroplasty 2, 3, 4, 6.
• The use of tranexamic acid can also result in cost savings for the healthcare system and reduce the risk of adverse events associated with blood transfusion 4, 6.