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Blood Loss in Total Knee Arthroplasty (control & management)

Mehran Soleymanha , MD. ( Asso . Prof. GUMS , Knee surgery fellowship, SBUMS - Akhtar Hospital). Blood Loss in Total Knee Arthroplasty (control & management). Oct . 26 . 2016 - Tehran-Iran. Perioperative bleeding in total knee arthroplasty ……………….. 450 to 1100 mL

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Blood Loss in Total Knee Arthroplasty (control & management)

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  1. Mehran Soleymanha , MD. (Asso. Prof. GUMS , Knee surgery fellowship, SBUMS - Akhtar Hospital) Blood Loss in Total Knee Arthroplasty(control & management) Oct . 26 . 2016 - Tehran-Iran

  2. Perioperative bleeding in total knee arthroplasty ……………….. 450 to 1100 mL Preoperative anemia …………………………………………….. 20 – 25 % Post – operative anemia …………………………………………… 60 – 80 % RBC transfusion rate ………………………………………………… 16 – 22 % Implementing a blood management protocol during the entire perioperative period allows a reduction in transfusion rate in major orthopedic surgery: a before-after study. Rineau E, et al. Transfiousen (2016) 56:673-81.

  3. Potential complication of RBC transfusion Transmission of infectious Circulatory overload Thrombophlebitis / Embolism Hyperkalemia Clotting abnormalities Hemolytic reactions Nonhemolytic febrile reactions Prolongs hospital stay surgical site infection Mortality Blood management after total joint arthroplasty in the United States: 19-year trend analysis. Rasouli, MR, et al. Transfiousen (2016)56:1112-20.

  4. Potential complication of post- op anemia Increase incidence of infection Increase length of hospital stay Increase mortality Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Spahn DR. Anesthesiology (2010)113:482-95.

  5. patient blood management program Aim= Reducing preoperative blood loss & post – op anemia • optimization of hematopoiesis • Reduction of blood loss • Restrictive transfusion triggers Protocol A Patient Blood Management Program in Prosthetic Joint Arthroplasty Decreases Blood Use and Improves Outcomes. Loftus T, et al. J Arthroplasty (2016) 31:11-4.

  6. outpatient preoperative evaluation Anemia ( Hgb < 12 in female & Hgb < 13 in male ) Hemophilia Platelet count < 100,000 History of coagulation diseases history of bleeding disorders Drug history (anticoagulants – NSAIDs – antiplatelet )

  7. Pre-operative Blood Management autologous blood donation ( costly – unnecessary storage ) Erythropoietin ( expensive ) Hemodilution ( require personnel and storage facility) Hypotensive anesthesia Strategies for reducing peri-operative blood loss in total knee arthroplasty. Su EP, et al. Bone Joint J (2016) 98:98-100.

  8. Intra-operative Blood Management Tourniquet use Tranexamic acid Local infiltration anesthesia with Epinephrine Tissue homeostasis ( bipolar sealants / fibrin sealants) Reduced Blood Loss and Transfusion Rates: Additional Benefits of Local Infiltration Anaesthesia in Knee Arthroplasty Patients. Bhutta et al. J Arthroplasty (2015) 11:2034-7.

  9. Post-operative Blood Management suction drain Cell salvage Compression and cryotherapy Pain control Rehabilitation – post op flexion position The Use of a Closed-Suction Drain in Revision Knee Arthroplasty May Not Be Necessary : A Prospective Randomized Study. Abolghasemian, et al. J Arthroplasty. 2016 1544-1548.

  10. What does the level -1 evidence say?

  11. use of tourniquet • Effective in reducing intra operative blood loss • Reducing excessive post – op inflammation Tourniquet use in total knee arthroplasty: a meta-analysis. Tai TW, et al. Knee Surg Sport Traumatol Arthros (2011)19:1121-30. • Limb occlusion pressure Lower tourniquet cuff pressure reduces postoperative wound complications after total knee arthroplasty: a randomized controlled study of 164 patients. Olivecrona C, er al. J Bone Joint Surg (2012) 94:2216-21.

  12. how tourniquet use 1. Inflated before incision and deflated following skin closure 2. inflated before the incision and deflated following cement hardening * 3. Inflated before cement application and deflated following cement hardening A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty. Kvederas G, et al. Knee Surg Sport Traumatol Arthros (2013) 21:2790-9.

  13. Tranexamic acid • Just prevents clot breakdown • 2 hours half-life • 90% urine excretion in 24 hours Intravenous versus topical tranexamic acid administration in primary total knee arthroplasty: a meta-analysis. Shin YS, et al. Knee Surg Sports Traumatol Arthrosc (2016)

  14. Closed suction drainage No clear benefit or drawback to the use of closed drainage after primary total knee arthroplasty No clear benefit or drawback to the use of closed drainage after primary total knee arthroplasty: a systematic review and meta-analysis. Hai-bo Si, et al. BMC Musculoskelet Disord (2016) 17:183.

  15. Postoperative leg position Post- op flexion position of the leg in TKA was effective and safe, decreasing total blood loss & blood transfusion requirement Postoperative leg position following total knee arthroplasty influences blood loss and range of motion: a meta-analysis of randomized controlled trials. Fu X, et al. Current Med Res Opin (2016)32:771-8.

  16. Take home massage

  17. Pre-operative Hemoglobin optimization • Occult cancer • Nutritional deficiency • Chronic anemia • Chronic systemic disease Anemia (Hgb < 12 in women) (Hgb < 13 in men) • Referral to anemia clinic • Obtain iron studies • initial Treatment as appropriate • ( Iron , vit B12 , Erythropoietin ) Minimizing Blood Transfusion in Total Hip and Knee Arthroplasty Through a Multimodal Approach. Holt, et al . J Arthroplasty (2016) 31:378-382.

  18. Minimization of perioperative blood loss • Tourniquet inflated before the incision and deflated followed cement hardening • active peripheral thrombosis • history of DVT – PE • strong family history PE or cardiac vascular disease IV TXA Contradiction ? Yes No 20 mg/kg 10 mg/kg , 20 min before inflation of tourniquet 10 mg/kg , 15 min before deflation of tourniquet 2-3 g TXA (30 - 100 cc) 5 min before deflating tourniquet Minimizing Blood Transfusion in Total Hip and Knee Arthroplasty Through a Multimodal Approach. Holt, et al . J Arthroplasty (2016) 31:378-382.

  19. Utilization of appropriate transfusion triggers Post- op day 1 Hgb level 7 < Hgb < 8 Hgb < 7 Hgb > 8 History of: Acute coronary syndrome Congestive heart failure Hemodynamically unstable Systolic blood pressure < 100 Heart rate > 100 Erythropoietin 4000 unit. SC + Ferrous sulfate transfusion transfusion Minimizing Blood Transfusion in Total Hip and Knee Arthroplasty Through a Multimodal Approach. Holt, et al . J Arthroplasty (2016) 31:378-382.

  20. TANKS

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