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Blood Management in Total Joint Arthroplasty

Blood Management in Total Joint Arthroplasty. James Prosser, DO Garden City Hospital. Introduction. Perioperative blood management techniques for orthopaedic surgery are critical to avoiding the risks and consequences associated with allogenic blood transfusion. Risks and Consequences.

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Blood Management in Total Joint Arthroplasty

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  1. Blood Management in Total Joint Arthroplasty James Prosser, DO Garden City Hospital

  2. Introduction • Perioperative blood management techniques for orthopaedic surgery are critical to avoiding the risks and consequences associated with allogenic blood transfusion

  3. Risks and Consequences • Blood-borne infections- Hep, HIV, HTLV, and CMV • Isoimmunization • Anaphylactic reaction • Hemolytic reaction

  4. Risk of Transmission • HIV- 1 in 500,000 • Hep C- 1 in 100,000 • Hep B- 1 in 50,000

  5. Other Allogenic Complications • Increased length of stay • Increased post-operative infection

  6. Surgeon’s Goal • Reduce the need for allogenic transfusions of patients undergoing total joint arthroplasty

  7. Methods to Reduce Allogenic Transfusions • Pre-operative • Intra-operative • Post-operative

  8. Pre-operative Methods • Pre-operative planning -reduce time • Pre-operative Autologous Donation(PAD)

  9. PAD • Red Cross Program most widely used • Between 12-70 years of age • Weigh atleast 110 pounds/ 1 unit • Hematocrit>34% • Last donation 1 week prior to surgery • Supplemental iron • Ferrous sulfate-320 mg TID • 1 week before donations to time of surgery

  10. Drawbacks to PAD • Patient’s time and effort • Cost • Autologous donation>allogenic donation • Phlebotomy induced anemia • Average drop of 1g/dL(2 units donated)

  11. Intra-operative Methods • Anesthesia • Hypotensive vs. Normotensive • Epidural vs. General • Time • decrease • Cell Saver • Cost- equipment and operator • Atleast 2 units of blood loss • Debris and infection

  12. Post-operative Methods • Consta Vac drain • Initial 6 hours following surgery • Carried out by a ward nurse • <100 mL, reinfusion did not occur • Cheap • May prevent amount PAD

  13. Breakthrough Transfusions • The need for allogenic blood in PAD patients

  14. Transfusion Trigger • Defined as the standard protocol by which to transfuse • No common denominator • Historically • Hemoglobin – 10g/dL • Hematocrit – 30% • Physiologically • Vitals • Urine output • Individual(age, gender, medical history)

  15. Study #1 • Sculco, T. and Gallina, J.: Blood Management Experience: Relationship Between Autologous Blood Donation and Transfusion in Orthopaedic Surgery. Orthopedics, 22(Supplement): S129-S134, January 1999. From The Hospital of Special Surgery, New York, NY.

  16. Study #1 (continued…) • Retrospective case study review of 1405 patients who underwent elective uni-lateral/bi-lateral THA or TKA between 1994 and 1996 • All patients received; • Daily oral iron supplementation • Epidural hypotensive anesthesia • Post-op drains w/out transfusion

  17. Study #1 (continued…) • Results • 83% participated in PAD • 80% PAD patients transfused • 50% non-PAD patients transfused • Hb<11, 90% transfused(1.5 units) • Hb>13, 50% transfused(.75 units) • 10% breakthrough transfusion • 40% PAD blood discarded

  18. Study #1(continued…) • Conclusion • Unilateral, primary procedure with a pre-operative Hb>13, donate 1 unit • Revision, bi-lateral, pre-operative HB<13, donate 2 units

  19. Study #2 Bierbaum, B.; Callaghan, J.; Galante, J.; Rubash, H.; Tooms, R.; and Welch, R.: An analysis of blood management in patients having a total hip or knee arthroplasty. J. Bone and Joint Surg., 81-A: 2-10, January 1999. From; New England Baptist, Mass General, University of Iowa, Rush Presbyterian, and Campbell Clinic.

  20. Study #2(continued…) • 330 orthopods participate in study • Logistic regression analysis of 9482 patients evaluated from September of 1996 to June 1997

  21. Study #2(continued…) • Results • 61% PAD patients • Hb>14, 8% allogenic • Hb<9, 62% allogenic • 9% breakthrough transfusion • 45% PAD blood discarded • 1g/dL decrease in PAD patients

  22. Study #2(continued…) • Complications • Infection • No transfusion-3% • PAD-4% • Allogenic-7% • Length of stay • No transfusion-5.4 days • PAD-5.6 days • Allogenic-6.6 days

  23. Study #2(continued…) • Conclusion • The variables that most consistently predicted the transfusion of allogenic blood were a low baseline Hb and a lack of PAD • The present study supports the strategy of reducing the number of units of PAD by patients with a higher Hb

  24. Study #3 • Grosvenor, D.; Goyal, V.; Goodman, S.: Efficacy of Postoperative Blood Salvage Following Total Hip Arthroplasty in Patients with and without Deposited Autologous Units. J. Bone and Joint Surg., 82-A: 951-954, July 2000. From Stanford University Medical Center.

  25. Study #3(continued…) • Retrospective case study of 156 patients undergoing unilateral, elective THA from October of 1997 to October of 1998 • 82 patients underwent post-operative blood salvage(PBS)- Group A • 74 patients without PBS- Group B

  26. Study #3(continued…) • Results • 10% Group A received allogenic transfusion • 23% Group B received allogenic transfusions • EBL<300mL • Group A- 1% allogenic transfusion • Group B- 12% allogenic transfusion • EBL 300-600mL • Group A- 2% allogenic transfusion • Group B- 21% allogenic transfusion

  27. Study #3(continued…) • Results • No PBS- 50% allogenic transfusion • No PAD- 60% allogenic transfusion • Neither- 100% allogenic transfusion

  28. Study #3(continued…) • Conclusion • PAD resulted in the most substantial reductions in allogenic transfusions • PBS demonstrated a substantially lower risk of allogenic transfusion among PAD patients • May add an element of patient satisfaction to THA

  29. Effect of Tourniquet on Blood Management • Aglietti, P.: Effect of Tourniquet Use on Activation of Coagulation in Total Knee Replacement. Clinical Orthopaedics and Related Research, 371: 169-177, 2000. From the University of Florence, Italy.

  30. Parameters of Study • 20 patients undergoing TKA randomly assigned to two groups; one with a tourniquet and one without • No difference in age, gender, BMI, diagnosis, duration of surgery, and IV fluids

  31. Results • Tourniquet group • Intra EBL- 350mL • Post EBL- 290mL • Total- 640mL • No tourniquet group • Intra EBL- 482mL • Post EBL- 145mL • Total- 627mL

  32. The Future of Blood Management

  33. The Future of Blood Management • Martinowitz, Beer-Sheva; Chanan-Tauber, Tel Hashomer; and Horoszowski, Rehovot.: The Use of Fibrin Tissue Adhesive to Reduce Blood Loss and the need for Blood Transfusion after Total Knee Arthroplasty. J. Bone and Joint Surg., 81-A: 1580-1586, November 1999. From Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva.

  34. Adhesive • Fibrin tissue adhesive • Fibrinogen and thrombin • Mimic last step of coagulation cascade • Thrombin activates fibrinogen • Factor xiii activated • Cross link between fibrin molecules • Poor studies

  35. Study • Multicenter, prospective, randomized, standard treatment controlled study with 58 patients with OA of the knee schedules to have unilateral, cemented TKA • 29 patients receive FTA • 29 patients without FTA

  36. Procedure • Once prosthesis inserted with cement and before wound closure, 10-20mL applied by topically spraying with the use of a double syringe spray device • Cover entire joint surface

  37. Results • Post-operative blood loss • FTA- 360mL • Non- 878mL • Decrease in Hb • FTA- 25g/L • Non- 37g/L • Total calculated blood loss • FTA- 1063mL • Non- 1768mL • Transfusion requirements • FTA- 17% • Non- 55%

  38. Conclusion • FTA reduced apparent blood loss, drop in Hb, total blood loss, and transfusion requirements

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