Blood Management in Total Joint Arthroplasty

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
Surgeons 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
• Hematocritgt34
• 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

• Patients time and effort
• Cost
• Autologous donationgtallogenic 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
• lt100 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
• Hblt11, 90 transfused(1.5 units)
• Hbgt13, 50 transfused(.75 units)
• 10 breakthrough transfusion
• 40 PAD blood discarded

18
Study 1(continued)

• Conclusion
• Unilateral, primary procedure with a
  pre-operative Hbgt13, donate 1 unit
• Revision, bi-lateral, pre-operative HBlt13, 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
• Hbgt14, 8 allogenic
• Hblt9, 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
• EBLlt300mL
• 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.

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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