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Joint replacement surgeons have many options for blood management
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Because surgeons create blood loss anemia when performing total knee arthroplasty, they need to take responsibility for minimizing the consequences, according to an investigator at the 11th Annual Current Concepts in Joint Replacement (CCJR) Spring Meeting in Las Vegas.
Bernard N. Stulberg, MD, a professor of orthopedic surgery at Cleveland Clinic, Center for Adult Reconstruction, said the effects of acute blood loss anemia include fatigue, confusion, reduced vigor, delayed wound healing, delayed rehabilitation and depressed cardiac function, as well “as perhaps modulation that comes with transfusion.”
The good news, though, is that “most patients with proper preoperative assessment can go through total knee replacement (TKR) without the need for blood transfusion,” Stulberg told Orthopedics Today.
Stratifying risks
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Stulberg noted that quality joint environments develop programmatic strategies to improve outcomes and decrease cost, which tend to be patient specific. “You stratify patients by risk of requiring transfusion, to allow time to take steps to minimize need for transfusion, if the patient is at risk,” Stulberg said. “It is pretty clear in the literature now that minimizing transfusion, while optimizing postoperative hemoglobin, will improve surgical outcomes.”
The main predictor of transfusion risk is preoperative hemoglobin. Hemoglobin less than 13 g/dL “predicts the greatest risk,” Stulberg said. Because the patient loses blood after surgery, it is important that the patient “settle out at a range that is not going to need a transfusion” by about postoperative day 3.
All phases of operative intervention need to be considered when developing an individual strategy to minimize blood loss for TKR and perhaps total hip replacement: preoperative status, intraoperative techniques and postoperative management.
“You need to check the hemoglobin level at least 4 weeks in advance, so you can do something if need be,” Stulberg said at the CCJR meeting. For example, a small woman with a small blood volume and a hemoglobin level of 13 g/dL, “has a 50% chance of requiring a transfusion.”
Once the patient at risk is identified, Procrit (epoetin alfa injection) can be given. “This allows you to kind of kick the response in and develop red blood cells, so that the patient becomes his own blood bank and avoids transfusion,” said Stulberg, who advocates avoiding autologous blood donation because it is wasteful, time-consuming, costly and “not as effective as other strategies.”
Unused autologous blood
Data from the late 1990s indicate that 55% of blood taken for primary TKR “was not even used. It was thrown away,” Stulberg said. “Even if you use it, you still have breakthrough, and significant breakthrough in 10% to 13% of the preoperative hemoglobin group — as high as 11% to 18% for primary revision.”
Intraoperative interventions include being vigilant in soft tissue and tissue handling, cement vs. uncemented devices, and electrocautery or bipolar tissue sealant.
“You should also use general anesthesia,” Stulberg said. Thrombin sealants and the use of local injection approaches can also minimize bleeding.
Transexamic acid “may prove beneficial and is receiving renewed interest,” Stulberg said. One Canadian study found transexamic acid decreased the transfusion rate from 13% to 2%.
Postoperatively, “you need to avoid drains and use safer approaches to venous thromboembolism, as well as being more aggressive with IV iron and lowering transfusion triggers,” Stulberg concluded. – by Bob Kronemeyer
Reference:
- Stulberg BN. Blood conservation in TKA: Hedging your bets. Paper 38. Presented at the 11th Annual Current Concepts in Joint Replacement Spring Meeting. May 23-26. Las Vegas.
- Bernard N. Stulberg, MD, Cleveland Clinic, ORI, 1730 W. 25th St., Cleveland, OH 44113; 216-363-3300; e-mail: stulbeb@ccf.org.
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