Fibrinogen, fibrin and its degradation products in drained blood after major orthopaedic surgery

Transfusion of intra-operative autologous whole blood: influence on complement activation and interleukin formation

BACKGROUND AND OBJECTIVES

Transfusion of autologous whole blood is one available method to reduce the need for allogenic blood transfusion. The objective of this study was to investigate the safety of transfusion of intra-operative autologous whole blood by monitoring plasma concentration of laboratory variables and adverse events after transfusion with the Sangvia(®) system.

MATERIALS AND METHODS

The clinical trial was designed as an open, prospective, multi-centre study, and a total of 20 patients undergoing primary hip arthroplasty were included. Systemic blood samples were taken and analysed preoperatively, at transfusion start and end and at 3, 6, 24 and 48 h after the transfusion.

RESULTS

Elevated values of complement activation and pro-inflammatory cytokines were seen in the intra-operatively collected blood but the impact on systemic levels were limited with low peak levels, systemic elevations before transfusion and normalization during the study period. Elevated levels of free haemoglobin and potassium were also detected in the intra-operatively collected blood, but systemic values were within reference values after the transfusion. No clinically relevant adverse event occurred during the study.

CONCLUSION

Inflammatory mediators and plasma haemoglobin were increased in intra-operatively salvaged and filtered blood compared to circulatory levels. Intra-operative retransfusion of autologous whole blood caused a transient systemic increase that normalized in the early postoperative period. There were no significant adverse events reported in the study. These data suggest that the Sangvia(®) system can be used for intra-operative collection and retransfusion of salvaged blood.

Ward round--Late presentation of acute compartment syndrome in the thigh

Acute compartment syndrome of the thigh is rare but has been described as a result of femur fracture and also thigh contusion in sports injury. Emergency fasciotomy has routinely been the recommended treatment. We describe a patient with a closed femur fracture, initially without any syndrome whilst on traction, and required surgical intervention. He was found to have a large haematoma associated with significant muscle damage in the posterior compartment. This case is unusual in that symptoms started 12 days after injury possibly after manipulation of the leg whilst on traction. Diagnosis is mainly clinical with an earliest alarming sign being disproportional increasing pain on passive stretch of the group of muscles. A high index of suspicion and prompt intervention are required to diagnose and treat compartment syndrome and prevent irreversible damage.

Efficacy and economics of postoperative blood salvage in patients undergoing elective total hip replacement

INTRODUCTION

Patients undergoing total hip replacement (THR) regularly receive allogenic blood transfusions. The infusion of allogenic blood exposes the recipient to significant risks including the transmission of infection, anaphylactic and haemolytic reactions. The purpose of this study was to determine the effect of introducing a system to retransfuse salvaged drainage blood in patients undergoing primary THR.

PATIENTS AND METHODS

We reviewed records of 109 consecutive patients who underwent THR following the introduction of the ABTrans autologous retransfusion system at our institution in January 2000. For comparison, we reviewed the medical records of 109 patients who underwent the same procedure immediately before the introduction of the retransfusion system.

RESULTS

Overall, 9% of patients treated with blood salvage and 30% treated without blood salvage required allogenic blood transfusions. Patients treated with the salvage system had significantly smaller haemoglobin drops in the peri-operative period (difference 0.56 g/dl; P = 0.001). The overall cost of using the retransfusion system was similar to that of routine vacuum drainage when the savings of reduced allogenic blood transfusion were taken into account.

CONCLUSIONS

The retransfusion of postoperative drainage blood is a simple, effective and safe way of providing autologous blood for patients undergoing primary THR.

Fibrinogen levels following Amicar in surgery for idiopathic scoliosis

STUDY DESIGN

Prospective evaluation of fibrinogen levels before surgery and after surgery in patients with idiopathic scoliosis undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) who received Amicar to decrease perioperative blood loss.

OBJECTIVES

To assess a possible association between postoperative fibrinogen levels and Amicar administration.

SUMMARY OF BACKGROUND DATA

Our previous randomized, double-blind (Amicar and control) study demonstrated a rise in fibrinogen levels on the first postoperative day in the Amicar group, but not in the control group. Fibrinogen levels were not measured on the remaining postoperative days. We subsequently measured fibrinogen levels on all postoperative days in 21 consecutive patients with idiopathic scoliosis and found a dramatic increase throughout the postoperative hospitalization. This study is a continuation of our analysis of postoperative fibrinogen levels.

METHODS

We analyzed fibrinogen levels before surgery and on all postoperative days (4 or 5 days) until discharge in 51 consecutive patients, including our 21 previously reported patients, who received Amicar and underwent a PSF and SSI. We also analyzed the same factors with respect to perioperative blood loss as in our previous Amicar studies.

RESULTS

There were 41 females and 10 males with a mean age at surgery of 14.2 +/- 1.8 years. Their mean hospitalization was 4.6 +/- 0.8 days. Their mean estimated intraoperative blood loss was 766 +/- 308 mL and postoperative suction drainage 532 +/- 186 mL for a total perioperative blood loss of 1297 +/- 311 mL. The perioperative transfusion requirements were 0.5 +/- 0.6 U per patient. The preoperative fibrinogen was 255.5 +/- 58.3 mg/dL, and it rose steadily throughout the postoperative period to 680.9 +/- 111.9 mg/dL on the fifth postoperative day. There were no complications related to the use of Amicar.

CONCLUSIONS

Fibrinogen levels rise steadily throughout the postoperative period. The significance of this increase is unknown. Was it due to the use of Amicar or just the effects of surgery itself? Further investigations will be necessary.

Acute compartment syndrome of the thigh in a football athlete: a case report and the role of the vacuum-assisted wound closure dressing

We present a case of compartment syndrome of the thigh due to blunt injury in a Division I American football player managed with fasciotomy and vacuum-assisted wound closure. This case report discusses the vacuum-assisted wound closure dressing as an alternative to more traditional closure techniques such as suture retention devices and split-thickness skin grafting. We feel that any surgeon involved in performing fasciotomies should be familiar with this increasingly used closure device and its potential complications.

The role of amicar in decreasing perioperative blood loss in idiopathic scoliosis

STUDY DESIGN

Four separate studies on the role of Amicar in decreasing perioperative blood loss in idiopathic scoliosis.

OBJECTIVES

To assess the efficacy and possible mechanisms of action for Amicar.

SUMMARY OF BACKGROUND DATA

Preliminary prospective, randomized double-blind and analysis of same-day anterior spinal fusion (ASF), fibrinogen, and posterior spinal fusion (PSF) studies have demonstrated Amicar to be effective in idiopathic scoliosis surgery. Increased fibrinogen secretion is a possible explanation.

METHODS

Amicar is administered at 100 mg/kg over 15 minutes not to exceed 5 g at anesthesia induction. Maintenance is 10 mg/kg per hour until wound closure.

RESULTS

Preliminary study: Amicar (N = 28) was effective compared with a control group (N = 31). Perioperative blood loss and transfusion following PSF were 1,604 +/- 517 mL and 1.1 +/- 1.0 U in the Amicar group compared with 2,312 +/- 994 mL and 2.1 +/- 1.1 U in the control group (P < 0.003). Prospective, randomized double-blind study confirmed this efficacy, although primarily in postoperative suction drainage: 1,391 +/- 212 mL and 1.1 +/- 1.0 U compared with 1,716 +/- 513 mL and 2.1 +/- 1.3 U (P < 0.002). A fibrinogen study (N = 21) demonstrated steady and excessive increase following PSF: before surgery it was 266 +/- 63 mg/dL and on the fifth postoperative day 699 +/- 94 mg/dL. In same-day anterior and posterior spinal surgery, Amicar was again effective, but primarily in decreasing chest tube drainage and during PSF. Group 1 (N = 15, no Amicar) 3,807 +/- 105 mL and 3.1 +/- 1.5 U; Group 2 (N = 27, Amicar for PSF only) 2,080 +/- 659 mL and 1.9 +/- 0.9 U; and Group 3 (N = 16, both ASF and PSF) 2,183 +/- 851 mL and 1.0 +/- 0.8 U.

CONCLUSIONS

Amicar appears highly effective in decreasing perioperative blood loss. This results in less autologous blood donation, blood transfusion, costs, and complications. Its mechanism of action is uncertain but may be related to increased fibrinogen secretion.

Composition of the blood sampled from surgical drainage after joint arthroplasty: quality of return

BACKGROUND

The quality of blood obtained with a device for postoperative blood drainage and autotransfusion (Bellovac-ABT, Astra Tech AB) was investigated in 50 patients who underwent total hip replacement (THR) or total knee replacement (TKR) surgeries.

STUDY DESIGN AND METHODS

The Bellovac-ABT drainage set was inserted and blood collection began after skin closure (THR) or 15 minutes after tourniquet deflation (TKR). A collecting bag stayed in place for less than 6 hours. The product was then returned after sedimentation and discard of supernatant, without anticoagulants.

RESULTS

Blood returned with the Bellovac-ABT had optimal hemoglobin levels and red blood cell (RBC) counts; the low platelet count reduced the risk of disseminated intravascular coagulation. Inertia of materials maintained acceptable values of C-reactive protein, whereas cytokines and complement split products rose rapidly. Higher concentrations of adenosine triphosphate and 2,3-diphosphoglycerate than in circulating blood suggested a normal RBC metabolism. No adverse reactions were observed in any participants.

CONCLUSION

Because of its simplicity and safety, the Bellovac-ABT autologous blood transfusion system is recommended in THR or TKR without joint infection or malignancy.

Clinical spectrum of acute compartment syndrome of the thigh and its relation to associated injuries

The reason for the described clinical variability of acute compartment syndrome of the thigh, with high morbidity and mortality in some patients and an uncomplicated clinical course in others, is not known. To better define the clinical spectrum and factors determining the clinical course of this rare clinical entity, we did a retrospective multicenter study of 28 patients with 29 thigh compartment syndromes. The leading cause of acute thigh compartment syndrome was blunt trauma from motor vehicle accidents (46%) or contusion (39%). Pain with passive motion was present in all patients who were conscious, followed by paresthesia (60%), and paralysis (42%). The anterior compartment was involved most frequently with mean compartment pressure of 58 +/- 3 mm Hg. Myonecrosis, sepsis, and need for skin grafting were observed more frequently in patients with ipsilateral femur fracture. Only 7% of patients with isolated thigh compartment syndromes had short-term complications compared with 57% of patients with ipsilateral femur fractures. The incidence of complications correlated with the time to fasciotomy. Mortality was limited to patients with high injury severity scores. The clinical spectrum of thigh compartment syndrome is comparable with that of other compartment syndromes and its clinical course is determined by its associated injuries.

Delayed presentation of acute compartment syndrome after contusion of the thigh

Acute compartment syndrome has been described as a result of thigh contusion in several contact sports, and emergent fasciotomy has routinely been recommended. However, recent data suggest that thigh contusions in athletes presenting with isolated elevation of compartment pressures in the absence of neurovascular deficits may be treated expectantly. We describe a case of anterior thigh contusion, which initially presented with isolated compartmental hypertension without neurovascular symptoms. Under nonoperative treatment the patient developed delayed acute compartment syndrome from persistent muscular hemorrhage ten days after the initial trauma, requiring operative treatment. This case demonstrates that expanding hematoma formation may result in delayed increase of intramuscular pressures and compromise of myoneural perfusion in patients with severe thigh contusions. Early evacuation of the hematoma may help to prevent late development of compartment syndrome and reduce the risk for long-term complications.

Fibrinolytic activity and postoperative salvaged untreated blood for autologous transfusion in major orthopaedic surgery

OBJECTIVE

To evaluate the fibrinolytic activity in a closed surgical wound, in postoperatively drained blood, and during autologous transfusion.

DESIGN

Prospective study.

SETTING

National hospital, Norway.

PATIENTS

9 patients operated on for thoracic scoliosis.

MAIN OUTCOME MEASURE

Concentrations of plasmin/antiplasmin (PAP), alpha2-antiplasmin, and D-dimers in drained, arterial, and mixed venous blood before, during, and after infusion of 10 ml/kg body weight of postoperatively drained, untreated blood.

RESULTS

In drained blood the concentration of alpha2-antiplasmin was 31% of the preoperative arterial control value. Together with the increased concentrations of PAP to 18076 microg/L and D-dimers to 126 mg/L, this indicates extensive fibrinolytic activity in the closed wound. The postoperative autologous transfusion of drained, untreated blood increased the concentration of PAP from 507 to 2453 microg/L and of D-dimer from 0.7 mg/L to 15.3 mg/L in systemic blood.

CONCLUSION

The systemic concentration of fibrin(ogen) degradation products, indicated by D-dimers, after recirculation of drained, untreated blood might impair coagulation. The extensive activation of plasmin might exhaust available alpha2-antiplasmin in the wound and result in postoperative rebleeding.