Blood Management

• Surgical morbidity and mortality are inversely correlated with preoperative Hb levels.
• In patients undergoing hip replacement or spine surgery, the postoperative infection rate with allogeneic blood transfusion appears to be 7- to 10-fold higher than with autologous blood or no transfusion. (Blumberg N, Semin Hematol 1997;34:34).

Pre-op Surgical Considerations

• Preoperative anemia:  hematologic workup, correction of vitamin B12 or iron deficiencies, and evaluation for other sources of ongoing blood loss, such as the gastrointestinal tract. 
• Keating, M.E. and Meding, J.B., 2002. Perioperative blood management practices in elective orthopaedic surgery. Journal of the American Academy of Orthopaedic Surgeons, 10(6), pp.393-400.
• NSAIDs should be stopped 4weeks prior to any elective surgery.
• Average Hb drop: single TKA=3.85 ± 1.4 g/dL; bilateral TKA=5.42 ± 1.8 g/dL; single THA=4.07 ± 1.74 g/dL (Keating EM, JAAOS 2002;10:393)
• Regional hypotensive anesthesia reduces intraoperative blood loss by 43%. (Nelson CL, JBJS 1986;68A:350).
• Consider Epoetin Alpha based on pre-operative hemoglobin levels after hematolgic workup.

• (Cushner FD, Orthopedics 1999;22(1sup):S145), (Peirson JL, JBJS 2004;86A:1512).
• Consider IV tranexamic acid, one doe at the beginning of the case and one dose at the time of closure.

Anemia

• Definition: Hemoglobin <12g/dL (HCT<36%) in women and less than 14g/dL (HCT<41%) in men. (Washington Manual)
• Clinical manifestations: fatigue, headache, dyspnea, lightheadedness, headache, angina, pallor, visual impairment, syncope, tachycardia.
• Adequate tissue oxygenation can usually be attained with a Hb of 7-8g/dL in a normovolemic patient. (Washington Manual)

Suggested Transfusion Guidelines (Fakhry SM, Sabiston's Textbook of Surgery 15th ed, 1997 page 121)

• Hgb <8 with two or more of the following:
  • estimated or anticipated blood loss of >15% of total blood volume
  • Diastolic pressure <60mmHg
  • Systolic blood pressure drop >30mmHg from baseline
  • Tachycardia >100 beats per minute
  • Oliguria/anuria
  • Mental status changes
• Hgb <10gm/100ml in pt with known risk of coronary artery disease or pulmonary insufficiency
• Symptomatic anemia with any of the following:
  • Tachycardia >100 beats per minute
  • Mental status changes
  • Evidence of myocardial ischemia including angina
  • Shortness of breath or dizziness with exertion
  • Orthostatic hypotension
• Unfounded/Questionalble indications:
  • Hgb of 7-10 in an otherwise stable, asymptomatic patient
  • Pre-donated autologous blood without medical indication

Allogenic Transfusion Risks

 Allogenic Transfusion

• Transfusion threshold Hemoglobin of 7 g/dL to 8 g/dL is indicated in most patients.  (Carson JL, Cochrane Database Syst Rev 2012;4:CD002042)
• Prophylactic transfusion considers for high risk patients with Hgb <10 g/dL. Risk factors for ischemia:  CAD/MI, heart failure, chronic pulmonary disease, chronic renal disease.   
• Consider for symptomatic anemia, (tachycardia, hypotension, or orthostatic hypotension not responsive to fluid boluses), 
• All patients receiving allogenic transfusions should be premedicated with acetaminophen and diphenhydramine 25-50mg PO/IV.
• Transfusion requires an 18-gauge catheter. Each unit is given over 4hours.
• One unit of RBC's increases the Hgb in the average adult by 1g/dL.
• Consider giving Lasix 20mg IV between units in elderly, CHF patients.
• Indications for transfusion as well as informed consent should be documented in the medial record.

Preoperative Autologous Blood Donation

• risks=preoperative anemia, ischemic event, clerical error in transfusion
• Hgb decreases an average of 1g/dL for each unit donated or 3-4% of pre-donation Hgb level
• Must be done 3-5 weeks prior to the procedure and must have a pre-donation Hgb level of >11g/dL and weight >110lbs. Blood is usable for @40 days unless frozen.
• All patients undergoind autologous donation should be treated with iron (Ferrous Sulfate 325mg PO TID) before and after donation. Patients should also be given stool softeners (Colace 100mg PO BID or Surfak 240mg PO QD) because iron is associated with constipation.
• Contraindications: indwelling catheter, recent MI, aortic stenosis, unstable angina

Epoetin Alpha (erythropoietin)

• Stimulates erythropoiesis
• Indicated for patients with Hgb of 10 to 13g/dL who do not want to give autologous blood.
• Erthropoietin 600 IU SQ on days 21, 14, and 7 before surgery.
• Risks: thromboembolic events when raising Hgb above 12g/dL (in spine surgery, malignancies, CRF patients).

Tranexamic acid

• TXA
• antifibrinolytic medication which stabilizes clot and prevents its degradation
• 20mg/kg as a single dose before hip incision or tourniquet deflation in TKAs
• 1 gm IV 20 min preop
• Consider subfascial tranexamic acid injection to reduce peri-operative transfusion requirements by 43%.  (Drakos  A, JOT 2016, 30:409)
• J Am Acad Orthop Surg, Vol 18, No 3, March 2010, 132-138.
• Yamasaki S, Masuhara K, Fuji T: Tranexamic acid reduces postoperative blood loss in cementless total hip arthroplasty. J Bone Joint Surg Am 2005; 87:766-770. [Abstract/Free Full Text]
• Husted H, Blond L, Sonne-Holm S, Holm G, Jacobsen T, Gebhur P: Tranexamic acid reduces blood loss and blood transfusions in primary total hip arthroplasty: A prospective randomized double-blind study in 40 patients. Acta Orthop Scand 2003; 74:665-669. [Web of Science][Medline]
• Johansson T, Pettersson LG, Lisander B: Tranexamic acid in total hip arthroplasty saves blood and money: A randomized, double-blind study in 100 patients. Acta Orthop 2005; 76:314-
• Ralley CORR 2010:468, No. 7, July 2010:1905-1911

Fibrin Glue

• not effective in reducing blood loss or transfusion requirement in TKA ( Aguilera X, JBJS 2013;95:2001)

Review References

• Lemos MJ, JBJS 1996;78:1260
• Keating, M.E. and Meding, J.B., 2002. Perioperative blood management practices in elective orthopaedic surgery. Journal of the American Academy of Orthopaedic Surgeons, 10(6), pp.393-400.
• Stramer SL. Current risks of transfusion-transmitted agents: a review. Arch Pathol Lab Med. 2007 May;131(5):702-7. 
• Zou S, Stramer SL, Notari EP, Kuhns MC, Krysztof D, Musavi F, Fang CT, Dodd RY. Current incidence and residual risk of hepatitis B infection among blood donors in the United States. Transfusion. 2009 Aug;49(8):1609-20.