Blood Management Newsletter December 2010
INTRODUCTION
This newsletter will focus on the importance of a multi-disciplinary approach to a Blood Management program and how orthopedic surgery fits into the vital role of a successful program. Dr. George W. Zimmerman has been a champion of our Blood Management program from the very start. He performs around 500 total hip and knee arthroplasties a year and is one of the leaders in the field of orthopedic sports medicine. Through an evidence-based approach and strategic studies and evaluations, we have adopted many changes in his practice to achieve superior patient outcomes. Through teamwork and collaboration, we have cut his blood product usage by 70%. I am very proud to have him on our team and thankful for his knowledge which he shares with others. The article below will give an insight of a Blood Management from an orthopedic surgeon’s point of view. (Ty Walker, CCP, PBMT – Director of Blood Management, Perfusion.com, Inc.)
FEATURED ARTICLE
I have been asked to provide an orthopedic surgeon’s point of view and perspective on blood management for this newsletter issue. I am a hip and knee surgeon with a large total joint arthroplastic practice in a community-based hospital and serve as a director of the The American Osteopathic Academy of Orthopedics (AOAO). Over the last 12-18 months, 
I have become very interested in developing and implementing a comprehensive blood conservation program to decrease surgical blood loss and reduce blood transfusions after total joint surgery. Patients undergoing total hip and knee surgery often sustain a significant blood loss related to surgery, secondary to multiple reasons. The postoperative anemia may have numerous deleterious effects on the patients to include delayed rehabilitation, higher complication rates, limited pain control, and poor postoperative outcomes. The ability to limit postoperative bleeding may reduce this problems and ultimately result in better patient satisfaction and a more positive surgical result. With this in mind, we have taken into account preoperative, intraoperative, and postoperative measures to develop a multimodal blood conservation strategy to decrease complications, increase patient safety, and improve our postsurgical results.
During the preoperative period, we have a comprehensive medical workup completed on each patient. This evaluation includes preoperative blood work to identify the patient’s medical status, nutritional status, and preoperative hemoglobin. We are delighted to find hemoglobins greater than or equal to 13 and more concerned with those less than 10. In the case of preoperative anemia with hemoglobins less than 10, we refer to a hematologist for further evaluation and workup. Hemoglobins between 10 and 12 are considered for epoetin alfa (procrit) injections. We believe that identification of a patient at risk for postoperative anemia is an ideal way to prevent the problem before it occurs. We are presently looking at a means of performing “in office” hemoglobin testing. This would allow us preoperatively more time to treat the patient with a lower hemoglobin.
As far as autologous blood donation, we have found this to be inconvenient and costly. Most authorities agree that preoperative autologous blood donation is ineffective and no longer considered “a standard of care”.
Recent developments in total joint arthroplasty have led most surgeons to minimal dissection surgery with smaller incisions, limited soft tissue injury, and less blood loss. Meticulous intraoperative hemostasis is the key to prevention of postoperative bleeding. Our total knee surgeries are performed with a tourniquet. The device is deflated before wound closure and the wound is examined for any free-bleeding vessels that would be coagulated. We provide an injection of lidocaine with epinephrine and Toradol to the soft tissue and arthrotomy site of both hips and knees intraoperatively to aid with pain control and postoperative bleeding. Tranexamic acid has been used in cardiac surgery with encouraging results for quite some time, with limited complications and no increased risk of DVT. We have begun administering 20 mg per kg 1 time intravenous bolus dose before surgery to our “high-risk for postoperative anemia” patients, but now consider providing this pharmacologic agent to all patients undergoing total joint surgery. We believe that if it is good for our high-risk patients, then why not use it on the majority of our patients. The only true contraindication to this agent would be those who have a history of DVT or PE.
Solid evidence to support the multiple uses of platelet rich plasma (“PRP”) remains hard to come by; however, some studies have shown promising results for PRP. We have performed a trial with our own patients that has produced positive results. We were able to show a significantly less use of narcotics, a higher functional range of motion, and had better postoperative hemoglobins and a significant decrease in the need for blood transfusions. We believe the use of autologous platelet gels and fibrin sealants has enhanced the efficacy of our total joint arthroplasty surgeries.
For total hip arthroplasty, we have gone to cell salvage intraoperatively and postoperatively. The literature remains unclear on the true efficacy of these salvage systems; however, we believe there is enough evidence to support their use. We feel that the perioperative blood salvage measures represents another valuable modality to maximize the patient’s hemoglobin. Postoperatively, we use 1 more modality to reduce our blood loss for total knee angioplasty and that is cryotherapy. We feel that cryotherapy can decrease blood loss, improve pain control, reduce narcotic use, decrease the postoperative edema, and allow a better range of motion. Cryotherapy has been shown to improve patient outcomes and postoperative results. All in all, I feel the most significant alteration in our practice that has decreased the use of blood products, is an alteration in our perioperative transfusion trigger. We have employed strict evidence-based transfusion criteria and have gone from the “10/30 rule” to a more aggressive hemoglobin of 7 and hematocrit of 20 before transfusion. With our alterations in practice and our blood conservation means preoperatively, intraoperatively, and postoperatively, we have significantly decreased the blood product usage at our institution. We believe with our practice changes, we have increased patient safety, decreased our complication rate, and have significantly and positively improved our postoperative results.
As always, we welcome and appreciate any comments, questions, suggestions and dialogue at Perfusion.com regarding this and other topics of interest.
Thank you for your time and attention.
George W. Zimmerman, D.O.
