Perioperative blood saving measures in total hip and knee arthroplasty

Abstract

This dissertation explores and discusses different aspects of blood loss and blood-saving measures in total hip and knee arthroplasty.

Background: Worldwide, approximately

1 million total hip and 1 million total knee prostheses are implanted each year. Total hip arthroplasty and total knee arthroplasty are associated with a considerable amount of total blood loss. Postoperative anemia may seriously impede functional mobility in the early postoperative phase following total hip and knee arthroplasty. Recovery

after total hip and knee arthroplasties is frequently complicated by the need for

homologous blood transfusions, with their concomitant disadvantages.

Therefore it is important:

- to increase preoperative hemoglobin levels;

- to reduce perioperative blood loss;

- to maintain higher postoperative hemoglobin levels;

- to minimize the use of homologous blood transfusions.

In this thesis, 6 randomized controlled trials (RCT’s) on 750 total hip and knee arthroplasties in total were described (1 RCT on autologous platelet gel in total knee arthroplasty and 5 RCT’s on autologous blood retransfusion in hip and knee arthroplasty). Further, a prospective study on the safety of autotransfusion in 1800 patients, a survey to the use of blood saving measures by dutch orthopedic surgeons in 2002 and 2007 and a review on blood loss in total hip and knee arthroplasty and on the effect of the various blood saving methods were described. Moreover, the autologous blood transfusion data of the various studies were pooled and reduction of homologous bloodtransfusion requirement was studied.

Main conclusions

- Total blood loss during and after primary total hip and knee prosthesiology is

considerable, totaling about 1500 mL. This results in a postoperative decline in

hemoglobin levels of 3.0 to 4.0 g/dL (≈ 1.9-2.5 mmol/L). Intraoperative blood loss in

total hip arthroplasty amounts to about 500 mL.

- There has been an increase in the use of blood-saving measures by orthopedic

surgeons in the Netherlands, but there is considerable variation in practice

between various orthopedic departments.

- Use of autologous platelet gel does not result in less blood loss in total knee

arthroplasty.

- Use of a postoperative autologous blood transfusion system after a primary total

knee arthroplasty causes less total blood loss and higher postoperative hemoglobin

values compared to no drain. Its use is advised in primary total knee

prosthesiology.

- Use of a postoperative autologous blood transfusion system after a primary total

hip arthroplasty does not result in less total blood loss or higher postoperative

hemoglobin values compared with no drainage. It can result in 50% fewer leaking

wounds upon hospital discharge.

- In primary total hip prosthesiology, the use of a new combined intra- and

postoperative autologous blood transfusion filter system results in less perioperative

blood loss and less hemoglobin decrease after the operation. Its use should be

considered in total hip arthroplasty.

- No difference was observed in adverse events during hospital stay and at three

months follow-up between the autologous blood transfusion groups and the

control groups.

- Use of an autologous blood retransfusion system in hip prosthesiology results in

45% fewer required homologous blood transfusions.

- It is recommended to use a blood-saving protocol for total hip and knee prosthesiology (see the protocol in chapter 2)