Blood management in orthopedic surgery

Can Intra-Operative Cell Salvage Reduce the Rate of Allogeneic Transfusion in Pediatric Spinal Deformity Surgery?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The objective of this study was to characterize the association between cell-salvage and allogeneic transfusion rate in pediatric patients undergoing posterior arthrodesis for scoliosis.

METHODS

NSQIP Pediatric database years 2016-2022 was used. Patients under the age of 18 who received posterior arthrodesis with 7 or more surgical levels for spinal deformity correction were included. Rates of cell-salvage and allogeneic transfusion were determined. We assessed the impact of cell-salvage on the rate of allogeneic transfusion using chi-square test and multivariable logistic regression.

RESULTS

There were 34,241 patients in this study. The rate of allogeneic transfusion was 21.6% (n = 7407). The allogeneic transfusion rates for idiopathic, neuromuscular, and congenital/syndromic scoliosis were 12.3%, 50.8%, and 25.9%, respectively. Cell-salvage was used in 71.1% of patients (n = 24,344). In the multivariable regression analysis, longer operative time (P < .001), non-idiopathic scoliosis (P < .001), hematocrit less than 35 (P < .001), and ≥13 surgical levels (P < .001) were associated with higher odds of allogeneic transfusion. Use of cell-salvage (P < .001), increasing age (P < .001), and increasing patient weight (P < .001) were associated with significantly lower odds of allogeneic transfusion. In a subanalysis, use of cell-salvage was associated with reduced rate of allogeneic transfusion in patients with idiopathic scoliosis. Cell-salvage was not associated with reduced rates of allogeneic transfusion in neuromuscular and congenital/syndromic scoliosis.

CONCLUSION

This is the largest study investigating the impact of cell-salvage on rate of allogeneic transfusion in pediatric spinal deformity surgery. Use of cell-salvage is associated with reduced allogeneic transfusion rates in idiopathic scoliosis surgery.

High-volume, Multilevel Local Anesthetics-Epinephrine Infiltration in Kyphoscoliosis Surgery: Blood Conservation

INTRODUCTION

Scoliosis surgery is usually associated with severe bleeding. Various systemic strategies for blood conservation were applied, while the local techniques get less attention. The preemptive use of sufficient volume for proper tissue infiltration at two levels was applied. The local epinephrine may control bleeding without reliance upon deliberate hypotension, permitting a higher tissue perfusion.

MATERIALS AND METHODS

This prospective study included 46 patients scheduled for posterior spinal fusion for scoliosis correction. Patients were randomized into two groups. group I received a cocktail of high volume (100 ml/each 10 cm of wound length) of local anesthetics and epinephrine tumescent infiltration at the subcutaneous (SC) followed by intramuscular level bilaterally. Group C received saline infiltration in the same technique. Statistically, data were analyzed according to its distribution using the t-test, Mann-Whitney, and Chi-square tests as appropriate.

RESULTS

There was a significant reduction in blood loss (38%), reduced blood and fluid transfusion (36% and 23%), and reduced operative time (23%), with higher surgeon satisfaction. The surgical field visibility (Fromme's scale) was much better during SC and muscular dissection in Group I, while it was fair during the bony work. The satisfactory field in spite of higher mean blood pressure in Group I greatly omitted the reliance upon deliberate hypotension.

CONCLUSION

The high-volume multilevel infiltration of epinephrine cocktail can provide a significant blood and operative time conservation in kyphoscoliosis surgery.

The Role of Hemapheresis in Autotransfusion

Hemapheresis is a commonly used technique for single donor procedures of cell and/or plasma collection. In our blood center a new protocol was carried out to study the application of Hemonetics MCS3p to autotransfusion. PES and TAE protocols were applied: 40 patients for ‘each branch and 40 as controls completed the protocol. In the TAE protocol, 2 units of red cell concentrate were collected at day 0, in the PES protocol 300 ml of plasma were added, while in the control group 400 ml of whole blood were collected. Complete blood cell count, clotting parameters, and the EPO level were tested. The two protocols (TAE and PES) prove effective and safe: no significant change was shown for the clotting time and factors, other hematological and plasma values were controlled:; the endogenous EPO doubles its value 24-h after the procedure and the difference compared to controls is highly significant.

The effect of postoperative pain on postoperative blood loss after sequential bilateral total knee arthroplasty

Background

Bilateral total knee arthroplasty is generally accompanied by a significant amount of blood loss. We investigated the relationship between the intensity of pain and the amount of blood loss in the early postoperative period after bilateral total knee arthroplasty.

Methods

A prospective study was conducted on 91 patients who underwent elective sequential bilateral total knee arthroplasty for osteoarthritis. All patients received combined spinal and epidural anesthesia. Patients were divided into three groups based on their scores on the verbal numerical rating scale (VNRS) for pain at 6 hours postoperatively. The VNRS was classified as follows; mild pain (n = 34, VNRS score 0-4), moderate pain (n = 24, VNRS score 5-6), and severe pain (n = 33, VNRS score 7-10). We compared the mean arterial pressures and the amount of blood loss during the first 24 postoperative hours in the three groups. Factors influencing postoperative blood loss were analyzed.

Results

Postoperative mean arterial pressures and blood loss were not different among the groups. Of the factors examined, the amount of postoperative blood loss was only dependent on the amount of intraoperative blood loss (P = 0.001).

Conclusions

Early postoperative pain has no effect on postoperative blood pressure and the amount of blood loss after bilateral total knee arthroplasty. For postoperative blood loss, intraoperative blood loss is the main determinant.

Identification and treatment of anaemia in patients awaiting hip replacement

INTRODUCTION

The correction of anaemia prior to total hip arthroplasty reduces surgical risk, hospital stay and cost. This study considers the benefits of implementing a protocol of identifying and treating pre-operative anaemia whilst the patient is on the waiting list for surgery.

PATIENTS AND METHODS

From a prospective series of 322 patients undergoing elective total hip arthroplasty (THA), patients identified as anaemic (haemoglobin (Hb) < 12 g/dl) when initially placed upon the waiting list were appropriately investigated and treated. Pre- and postoperative Hb levels, need for transfusion, and length of hospital stay were collated for the entire patient cohort.

RESULTS

Of the cohort, 8.8% of patients were anaemic when initially placed upon the waiting list for THA and had a higher transfusion rate (23% versus 3%; P < 0.05) and longer hospital stay (7.5 days versus 6.6 days; P < 0.05). Over 40% of these patients responded to investigation and treatment whilst on the waiting list, showing a significant improvement in Hb level (10.1 g/dl to 12.7 g/dl) and improved transfusion rate.

CONCLUSIONS

Quantifying the haemoglobin level of patients when initially placed on the waiting list helps highlight those at risk of requiring a postoperative blood transfusion. Further, the early identification of anaemia allows for the utilisation of the waiting-list time to investigate and treat these patients. For patients who respond to treatment, there is a significant reduction in the need for blood transfusion with its inherent hazards.

Severe blood loss during spinal reconstructive procedures: The potential usefulness of topical hemostatic agents

Complex spinal reconstructive procedures are invariably associated with excessive intraoperative blood loss that significantly increases the risk of severe perioperative complications. In some cases, excessive hemorrhage is equivalent to estimated total blood volume. Unfortunately, widely exposed bony surfaces are not amenable to standard hemostatic maneuvers utilized during soft tissue surgery. This article evaluates the clinical effectiveness of several approaches to blood management in this setting, and hypothesizes that underappreciated topical hemostatic agents may provide benefit by reducing the need for autologous predonation, banked donor blood or antifibrinolytic agents. Topical agents combining collagen, thrombin and fibrin have demonstrated initial promise by inducing platelet aggregation and initiating the clotting cascade when applied directly to bleeding bony sites. Clinical studies are clearly warranted.

Preoperative erythropoietin in spine surgery

Spine surgery may be associated with profuse intraoperative bleeding that often requires blood transfusions. In recent years several techniques have been developed to avoid allogenic transfusions and their potential complications to surgical patients. In this study we review and analyse the role of preoperative recombinant human erythropoietin (rHuEPO) administration in spine surgery as a blood conservation strategy. Between 1998 and 2002, a total of 250 patients scheduled for spine surgery were included in our blood-sparing program: 114 patients (group 1), operated on before rHuEPO approval (2000), underwent preoperative autologous blood donation (ABD) alone, and 136 patients operated on after rHuEPO approval (groups 2 and 3) received rHuEPO while undergoing ABD. Adding rHuEPO to ABD resulted in higher haemoglobin and haematocrit values the day of surgery, more ABD units retrieved per patient and, consequently, reduced allogenic transfusion requirements. The effectiveness of rHuEPO as the only preoperative blood conservation technique was evaluated in ten patients with a predicted blood loss of less than 30% of their total volume, scheduled for lumbar surgery. Data from these patients were matched with those from a similar group of patients who had undergone ABD. Patients receiving rHuEPO alone had higher haemoglobin levels the day of surgery than did patients in the ABD program. Neither group required allogenic transfusions.

CONCLUSIONS

preoperative rHuEPO is useful for reducing allogenic blood requirements in elective spine surgery. In patients with an expected blood loss of around 50% of blood volume, rHuEPO improves ABD, minimising preoperative anaemia and increasing the number of ABD units collected. In patients with expected blood loss below 30% of total volume, rHuEPO administration may replace ABD.

Seguridad y eficacia del hierro intravenoso en la anemia aguda por fractura trocantérea de cadera en el anciano

BACKGROUND AND OBJECTIVE

An important percentage of patients with hip fracture need allogeneic transfusion to resolve their perioperative anemia. Our goal was to determine the safety profile and usefulness of parenteral iron in order to avoid allogeneic transfusions in trochanteric hip fracture (THF).

PATIENTS AND METHOD

A pseudo-experimental study was performed comparing a historic THF group (n = 104) with another group (n = 23) treated with parenteral iron (Venofer) (doses of 100 mg). Patients who had primary blood diseases or were receiving anticoagulation therapy were excluded. Age, gender, elapsed time, type of THF (international AO classification), surgical procedure, transfusion procedure and quantity, hemoglobin and hematocrit at days 0 and +2 (if a surgical procedure was not performed) and postoperatively were examined. We also analyzed the morbidity (post-surgical infection) and hospital stay and mortality rate at the first month.

RESULTS

We have not observed any adverse reactions upon iron administration. The iron group was transfused less times (39.1% vs. 56.7%) and had lower morbidity (infection) (20.3% vs. 35.4%) (p = 0.04), lower mortality (13% vs. 16.3%), less blood consumption (0.87 vs. 1.31 units) and less stay (13.7 vs. 14.3 days).

CONCLUSIONS

Parenteral administration of iron could be a safe and effective way to avoid or reduce allogeneic blood transfusions in THF patients. The reduction in the transfusional rate in the iron treated group is also accompanied by a reduction in the morbidity, infection rate, mortality rate and hospital stay.

Perioperative blood and blood product management for spinal deformity surgery

BACKGROUND CONTEXT

Spinal deformity surgery, like many other orthopedic procedures, involves significant operative blood loss. In order to avoid the necessity of bank blood transfusions, many blood management strategies have been devised.

PURPOSE

The goal of this review is to analyze the utility of current blood management strategies.

STUDY DESIGN/SETTING

Review paper.

METHODS

Using Medline reviews, pertinent data on blood management agents and strategies were assembled.

RESULTS

Techniques can be organized into preoperative, intraoperative and postoperative categories. Preoperative techniques include autologous blood donation and red cell augmentation. In addition to some established surgical and anesthesia techniques, recent pharmacologic agents have become available to include thrombotic agents and antifibrinolytics, which surgeons may add to their intraoperative armamentarium. A brief mention of postoperative blood salvage drains is also included.

CONCLUSIONS

The judicious use of the agents and techniques can significantly reduce the need for blood transfusions in the setting of spinal deformity surgery.

Neurosurgical procedures in Jehovah's Witnesses: an increased risk?

OBJECTIVE

Because of the growing numbers of members worldwide in the sect of Jehovah's Witnesses, the refusal of blood and blood products due to religious reasons is increasingly encountered in clinical practice. As an alternative to blood transfusion, Jehovah's Witnesses accept blood-free volume substitution, and they sometimes accept the intraoperative reinfusion of autologous blood via a so-called cell saver. The aim of this study was to examine whether the refusal of blood transfusion affects the surgical indications for neurosurgery and whether morbidity and mortality rates are higher after neurosurgical interventions in Jehovah's Witnesses.

METHODS

The pre-, intra-, and postoperative hemoglobin and hematocrit values as well as coagulation parameters of a group of Jehovah's Witnesses (n = 103) were compared with those of a valid control group.

RESULTS

The total intraoperative blood loss during spinal and intracranial surgery in Jehovah's Witnesses was often less than in controls, which suggests a less traumatic surgical procedure. Hemodynamically relevant blood loss occurred in two spinal and four intracranial interventions. The patients were managed without receiving blood transfusions or blood products, although increased time in the intensive care unit and increased convalescence days were necessary. Mean surgical times were 17.5 minutes longer for spinal interventions and 36.7 minutes longer for intracranial interventions than for patients in the control group. This may be attributed to a more careful and thus slower surgical technique and to longer and more extensive hemostasis. The length of hospitalization was 15% longer for Jehovah's Witnesses than for controls.

CONCLUSION

The morbidity and mortality rates for Jehovah's Witnesses undergoing neurosurgery were not higher than those of the control group. Thus, it can be concluded that Jehovah's Witnesses did not have a higher risk when microsurgical techniques and extensive anesthetic monitoring were applied during neurosurgery. Because the surgical success rate for Jehovah's Witnesses corresponded to that of the control group, the increase in costs because of longer treatment times is compensated in the long run by avoiding a lengthier illness, sometimes with more expensive conservative therapy.

Preoperative autologous blood donation by elderly patients undergoing orthopaedic surgery

BACKGROUND AND OBJECTIVES

To assess the feasibility of a programme of predeposit in elderly patients undergoing elective orthopaedic surgery.

PATIENTS AND METHODS

We retrospectively studied 789 elderly patient candidates (> 65 years of age) for orthopaedic surgery (total hip and knee replacement and spinal surgery), who were undergoing a programme of preoperative autologous blood donation (PABD) in our city hospital between January 1990 and December 1998.

RESULTS

Six hundred and eighty-eight patients (87.2%) were transfused with autologous blood; 128 (16.2%) also received allogeneic blood. Hip arthroplasty revision was characterized by the greatest blood consumption. The predeposit programme was discontinued in 96 patients (12.2%) because of the following complications: the onset of anaemia (11.0%); vasovagal reactions (0.5%); lack of venous access (0.4%); or cardiac complications (0.2%). No episodes of reaction to autologous transfusion were recorded.

CONCLUSIONS

Our study confirms the feasibility of PABD in elderly patients undergoing elective orthopaedic surgery.

Comparison of acute normovolemic hemodilution and preoperative autologous blood donation in clinical practice

STUDY OBJECTIVE

To compare, by model simulation, acute normovolemic hemodilution (ANH) and preoperative autologous blood donation (PABD) to predict their efficacy in current clinical practice. To discuss their similarities and offer guidelines based on expected operative blood loss.

DESIGN

Model simulation using data obtained from total hip arthroplasty procedures.

SETTING

University medical center.

PATIENTS

91 patients who participated in PABD undergoing single, primary, total hip replacement surgeries from January to December 1997.

INTERVENTIONS

A nonanemic (Hb baseline 14 g/dL), average-sized patient (estimated blood volume 5,000 mL) who donated two units by either PABD or ANH was assumed for model simulation. The Hb-final, as a function of 250-mL blood loss increments after retransfusion of two autologous units, was calculated for each technique and compared to a control (nondonor) to predict the effectiveness of PABD and ANH in conserving red cell mass. Data from hip arthroplasties over a 12-month period were used to determine the parameters for the model. Results were subjected to regression analysis and tested for parallelism of slopes, with p < 0.05 accepted to indicate a statistical difference.

MAIN RESULTS

The difference in Hb-final between PABD and ANH was not statistically different over a wide range of blood loss. When compared to control, there was no difference in Hb-final measurements in the estimated blood loss (EBL) range of less than 1,000 mL. ANH and PABD provide some benefit when EBL is greater than 1,500 mL in nonanemic, average-sized patients. As blood loss increases, the benefit of autologous collection becomes more clinically evident.

CONCLUSION

PABD exemplifies a "chronic" form of ANH in current clinical practice and offers little advantage over ANH as a blood conservation technique for high-blood-loss operations. When surgical blood loss is predictably mild to moderate (range 250 to 1,000 mL), neither blood conservation technique is necessary.

Primary and revision total hip replacement in patients who are Jehovah's Witnesses

The Jehovah's Witnesses do not accept allogeneic blood transfusion or certain types of autologous blood transfusion and, therefore, present the orthopaedic surgeon with a challenge in the management of perioperative blood loss. Accepting a patient who is a Jehovah's Witness as a surgical candidate requires the surgeon to be prepared medically to use known techniques to limit red blood cell loss or increase red blood cell mass, to resort to extraordinary means when necessary, and to be prepared philosophically to deal with catastrophic blood loss in a patient who may refuse even potentially life-saving transfusion. Issues pertinent to the management of intraoperative blood loss in the patient who is a Jehovah's Witness require careful delineation and specific treatment guidelines. The authors herein review their past and current experiences in the perioperative blood management of this patient population in an attempt to address this need.

An open-label, randomized study to compare the safety and efficacy of perioperative epoetin alfa with preoperative autologous blood donation in total joint arthroplasty

A multicenter, randomized, open-label, parallel-group study was conducted to compare the safety and efficacy of perioperative recombinant human erythropoietin (Epoetin alfa) with the safety and efficacy of preoperative autologous donation (PAD) in total joint arthroplasty. A total of 490 patients scheduled for total joint (i.e., hip or knee) surgery and having hemoglobin (Hb) levels > or = 11 to < or = 13 g/dL were randomized to receive weekly doses of subcutaneous Epoetin alfa on preoperative Days -21, -14, and -7, and on the day of surgery, or to participate in a PAD program. The mean baseline Hb level in both groups was 12.3+/-0.6 g/dL, increasing to 13.8 g/dL in the Epoetin alfa-treated group and decreasing to 11.1 g/dL in the PAD group before or on the day of surgery. In the PAD group, 156/219 (71.2%) patients were transfused with autologous blood, and 42/219 (19.2%) patients were transfused with allogeneic blood. A smaller proportion, 27/209 (12.9%) patients, in the Epoetin alfa-treated group were transfused with allogeneic blood (P = .078 compared with the PAD group). Moreover, patients in the PAD group received a total of 325 units of blood (79 allogeneic units and 246 autologous units) compared with patients in the Epoetin alfa group who received a total of 54 units of blood. The mean postoperative Hb level was 11.0 g/dL in the Epoetin alfa-treated group and 9.2 g/dL in the PAD group. Compared with the PAD arm, mean Hb levels measured preoperatively, postoperatively on Day 1, and at discharge visits were significantly greater in the Epoetin alfa-treated arm (P < .0001 ).

Blood conservation in hip trauma

Patients with hip or pelvic fractures experience significant blood loss as a result of the fracture and from the surgery that subsequently is performed. The emergent and unplanned nature of fracture surgery precludes the use of preoperative blood donation and the optimization of chronic medical problems. Blood transfusion frequently is required to maintain adequate tissue O2 delivery in these injured patients. However, the administration of allogeneic blood causes other problems, including a well documented increase in the risk of infectious complications. Perioperative measures to minimize blood loss such as hypotensive anesthesia and red blood cell salvage are important, but often are inadequate to prevent the need for blood transfusion. Recently, erythropoietin therapy has been shown to stimulate hematopoiesis in patients with hip fractures. The authors discuss their experience with blood loss management in these patients with hip injuries, including aggressive Fe replacement therapy and the use of recombinant human erythropoietin.

An algorithm to optimize perioperative blood management in surgery

Innovation in surgical blood management has been fueled by patients' perceptions of the risks associated with allogeneic blood transfusions and by surgeons' attitudes toward the use of allogeneic blood. The challenge is to determine the best blood management strategy to implement in the individual patient, particularly in patients with anemia who are at high risk of allogeneic blood transfusion. An algorithm to estimate safe blood loss based on individual patient parameters has been developed. The algorithm uses patient weight, gender, and preoperative hematocrit level to derive the volume of blood loss that can be tolerated while maintaining a target postoperative hematocrit level. Because the margin of safe blood loss can be anticipated, the most appropriate blood conservation option(s) can be implemented and perioperative blood management can be optimized.

Transfusion-free surgery is a treatment plan for all patients

Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal.

New transfusion strategies

The "new transfusion strategies" are designed to minimize exposure to allogeneic transfusion while maximizing the use of autologous red cells. While not always possible in all clinical situations, this approach appears to be the current transfusion strategy paradigm. Physician and patient concerns about the risk of transfusion therapy are driving these strategies. When combined with management of the elements of cardiopulmonary physiology responsible for cardiac output and tissue perfusion, the autologous techniques of hemodilution, cell salvage, and predeposit are reasonable strategies for achieving the desired goals of allogeneic transfusion avoidance. Of the 11 policies and interventions proposed by the Blood Management Conference6 several need to be iterated as underpinnings for these strategies. They include: 1. assessing transfusion needs on a patient case basis; 2. transfusions are to be given and effect-benefit assessed before proceeding with additional transfusion; 3. limited exposure to allogeneic blood if possible; 4. minimize perioperative blood loss ranging from surgical technique to decreasing laboratory assessments; and 5. maximize oxygen delivery physiology as a first step in improving basic oxygen delivery.