Blood Loss in Total Knee Arthroplasty control management

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

• Perioperative bleeding in total knee arthroplasty ………………. . 450 to 1100 m. L • 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. 2

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. 3

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. 4

patient blood management program Aim = Reducing preoperative blood loss & post – op anemia • optimization of hematopoiesis Protocol • Reduction of blood loss • Restrictive transfusion triggers 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. 5

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 ) 6

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. 7

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. 8

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. 9

What does the level -1 evidence say? 10

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 (2011)19: 1121 -30. Sport Traumatol Arthros • 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. 11

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. 12

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) 13

Closed suction drainage 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. 14

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. 15

Take home massage 16

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 B 12 , Erythropoietin ) Minimizing Blood Transfusion in Total Hip and Knee Arthroplasty Through a Multimodal Approach. Holt, et al. J Arthroplasty (2016) 31: 378 -382. 17

Minimization of perioperative blood loss Tourniquet inflated before the incision and deflated followed cement hardening IV TXA Contradiction ? No 20 mg/kg 10 mg/kg , 20 min before inflation of tourniquet 10 mg/kg , 15 min before deflation of tourniquet • • • active peripheral thrombosis history of DVT – PE strong family history PE or cardiac vascular disease Yes 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. 18

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

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