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

2. Preoperative anemia …………………………………………….. 20 – 25 %
Perioperative bleeding in total knee arthroplasty ……………… to 1100 mL
Preoperative anemia …………………………………………… – 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:

3. 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:

4. 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:

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

6. 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 )

7. 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:

8. 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:

9. 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

10. What does the level -1 evidence say?

11. 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 Sport Traumatol Arthros (2011)19:
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:

12. 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:

13. 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)

14. Closed suction drainage
No clear benefit or drawback to the use of closed drainage after primary total knee arthroplasty
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.

15. 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.

16. Take home massage

17. 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 B12 , Erythropoietin )
Minimizing Blood Transfusion in Total Hip and Knee Arthroplasty Through a Multimodal Approach. Holt, et al . J Arthroplasty (2016) 31:

18. Minimization of perioperative blood loss
Tourniquet inflated before the incision and deflated followed cement hardening
active peripheral thrombosis
history of DVT – PE
strong family history PE or cardiac vascular disease
IV TXA Contradiction ? No
Yes
20 mg/kg
10 mg/kg , 20 min before inflation of tourniquet
10 mg/kg , 15 min before deflation of tourniquet
2-3 g TXA ( 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:

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

20. TANKS