Blood loss during the perioperative period of total joint arthroplasty has been well described in the literature. Despite numerous advances, allogeneic transfusion rates are still reported as high as 50%. Often the literature focuses on one area or mechanism of blood loss prevention but this article focuses on a multimodal approach to blood loss prevention including preoperative optimization, intraoperative technique, and postoperative management. Hemoglobin drop and transfusion rates were retrospectively reviewed for 134 control patients undergoing total knee arthroplasty (TKA) in three groups. Group 1 included low risk patients (Hb >14 g/dl), Group 2 included intermediate risk patients (Hb 13-14 g/dl) utilizing reinfusion drain and preoperative autologous blood donation, and Group 3 included high risk (Hgb <13) patients treated with preoperative erythropoietin (EPO). These controls were then compared to two groups of patients undergoing minimally invasive total knee arthroplasty (MIS TKA). Group 4 included 20 consecutive patients undergoing MIS TKA with intraoperative injection of lidocaine and epinephrine along the arthrotomy site. Group 5 included 22 consecutive patients treated with similar technique plus the additional intraoperative use of a bipolar sealer device. The combined utilization of MIS TKA, epinephrine, and bipolar sealer minimized hemoglobin drop (2.74 (Std Dev 0.77) vs 3.29 (SD 1.05) g/dl, p= 0.01) and total blood transfusions (0.05 (SD 0.21) vs 0.86 (SD 0.63) units, p< 0.01) compared with the traditional TKA approach for high risk patients using reinfusion drain and preoperative autologous donation (Group 2). This series demonstrates how a busy knee practice minimizes hemoglobin drop and transfusion requirements with preoperative optimization of high risk patients utilizing EPO, minimally invasive technique, intraoperative hemostasis obtained with epinephering injection, use of a bipolar sealer, and postoperative management with a reinfusion drain

Perioperative blood conservation remains an important topic today in order to reduce complications, improve function, and facilitate recovery after a total knee replacement (TKR). Studies have shown that the degree of postoperative anemia is related to an increase in complications. A greater blood loss and need for transfusion is associated with a higher risk of infection, a slower recovery process, increased morbidity to patients, as well as an increased cost to the health care system. Typical blood loss estimates range from 800cc to over 1700cc, when accounting not only for intraoperative but postoperative blood loss. Several strategies have been developed to help mitigate the risk of perioperative blood loss and need for subsequent transfusion. Firstly, preoperative measures such as vitamin and mineral supplementation can ensure the starting hemoglobin and red cell count are maximised. Additionally, erythropoietin can be helpful in refractory cases of preoperative anemia. Preoperative autologous blood donation was used extensively in the past, but has fallen out of favor due to its inefficiency and cost. Intraoperatively, measures such as the use of a tourniquet, meticulous technique, and expeditious surgery can help reduce blood loss. The most effective method, however, has been the use of tranexamic acid (TXA). TXA, an antifibrinolytic compound, has been extremely effective at reducing perioperative blood loss without increasing the risk of thromboembolic events. TXA can be used topically or intravenously. Other methods that can reduce intraoperative blood loss include the use of fibrin sealants, applied to the soft tissues and bony surfaces around the knee. Postoperatively, the avoidance of wound drains is associated with a higher blood count and reduced transfusion risk. Alternatively, drainage reinfusion systems can be used to raise the postoperative blood count, particularly in cases of bilateral TKR

Perioperative blood conservation remains an important topic today in order to reduce complications, improve function, and facilitate recovery after a total knee replacement (TKR). Studies have shown that the degree of postoperative anemia is related to an increase in complications. A greater blood loss and need for transfusion is associated with a higher risk of infection, a slower recovery process, increased morbidity to patients, as well as an increased cost to the healthcare system. Typical blood loss estimates range from 800cc to over 1700cc, when accounting not only for intraoperative but postoperative blood loss. Several strategies have been developed to help mitigate the risk of perioperative blood loss and need for subsequent transfusion. Firstly, preoperative measures such as vitamin and mineral supplementation can ensure the starting hemoglobin and red cell count are maximised. Additionally, erythropoietin can be helpful in refractory cases of preoperative anemia. Preoperative autologous blood donation was used extensively in the past, but has fallen out of favor due to its inefficiency and cost. Intraoperatively, measures such as the use of a tourniquet, meticulous technique, and expeditious surgery can help reduce blood loss. The most effective method, however, has been the use of tranexamic acid (TXA). TXA, an antifibrinolytic compound, has been extremely effective at reducing perioperative blood loss without increasing the risk of thromboembolic events. TXA can be used topically or intravenously. Other methods that can reduce intraoperative blood loss include the use of fibrin sealants, applied to the soft tissues and bony surfaces around the knee. Postoperatively, the avoidance of wound drains is associated with a higher blood count and reduced transfusion risk. Alternatively, drainage reinfusion systems can be used to raise the postoperative blood count, particularly in cases of bilateral TKR

Traditional use of tourniquets and reinfusion drains in total knee replacement (TKR) has recently been challenged. Many studies have challenged the benefits of their use. Our aim was to compare the outcomes of three different blood management techniques in primary TKR. We conducted a prospective randomised study of 87 patients with a mean age of 71 years. All patients were randomised into three groups: Group A (29 patients without tourniquet and drain), Group B (27 patients without tourniquet or drain but cell salvage system) and Group C (31 patients with the use of tourniquet and drain). The results showed no difference between the postoperative haemoglobin drop and blood transfusion rate between the groups. At day two, range of knee movements (Group A: 80.2 degree; Group B: 79.6 degree; Group C: 77.9 degree) showed no significant difference. Two Group C patients (6.4%) had postoperative thromboembolic events (one DVT, one TIA). Knee stiffness leading to readmission (Group A: 6.8%; Group B: 7.4%; Group C: 3.2%) and superficial wound problems did not reveal any significant difference. The average operative time and hospital stay were the same in all groups and there was no wound haematoma or deep infection in any groups. There was no statistical difference between the groups for any outcome measure assessed thus the use of tourniquets and drains in total knee arthroplasty are controversial and questionable. We can conclude that all techniques are safe and it is the surgeon's choice as to which they apply routinely in their clinical practice

We prospectively audited 79 patients undergoing primary knee or hip arthroplasty (38 knees, 41 hips) and found that 66% (58% of knees, 73% of hips) had at least one unit of blood transfused postoperatively, with a mean transfusion requirement of 1.3 units per patient (1.1 for knees, 0 to 6; 1.5 for hips, 0 to 4). We then established a new protocol for postoperative blood transfusion. This requires the calculation of the maximum allowable blood loss (MABL) that each individual patient can safely lose based upon their weight and preoperative haematocrit. The total blood loss up to this volume is replaced with colloid. When a patient’s total blood loss reaches their MABL their haematocrit is measured at the bedside using the Microspin system (Bayer plc, Newbury, UK). If their haematocrit is low (< 0.30 for men, < 0.27 for women), blood is transfused. As a safety net all patients have their haemoglobin formally checked on days 1, 2, and 3 after surgery and have a transfusion if the haemoglobin levels are less than 8.5 g/dl. We conducted a further audit of 82 patients (35 knees, 47 hips) after the introduction of this protocol. Under the new protocol only 24% of patients required blood (11% of knees, 34% of hips) with a mean transfusion requirement of 0.56 units per patient (0.26 for knees, 0 to 4; 0.79 for hips, 0 to 4). The use of clinical audit and the introduction of strict guidelines for transfusion can change transfusion practice and result in improved patient care. Our transfusion protocol is a simple and effective method of keeping transfusion to a minimum and is particularly useful in departments which do not have the facility to use autologous blood or reinfusion drains for elective orthopaedic surgery

Background. One-stage bilateral total hip arthroplasty (THA) is twice as invasive as unilateral THA. Therefore, increases in bleeding, postoperative anemia, and complications are a concern. The purpose of this study was to investigate hemoglobin values and the use of autologous and allogenic blood transfusion after one-stage bilateral THA. Methods. Twenty-nine patients (7 men and 22 women; 58 hips) were treated with one-stage bilateral THA. The mean age of subjects at the time of surgery was 60.6 years. The average body mass index for patients was 21.7 kg/m. 2. The diagnoses were secondary osteoarthritis due to developmental dysplasia of the hip (n=25) and avascular necrosis (n=4). All patients had donated 800 ml of autologous blood in 2 stages preoperatively (1 to 4 weeks apart). All patients took iron supplements starting from 5 weeks preoperatively. For all patients, the procedure was performed under general anesthesia in the lateral decubitus position via a posterolateral approach. Intra-operative blood salvage was not used. Suction drains were inserted subfascially. As a general rule, pre-donated autologous blood was transfused back to the patients intra- or post-operatively. Allogenic blood transfusion was performed when clinical symptoms of anemia occurred (hypotension, low urinary output, tachycardia, etc.) rather than using a preset blood threshold (hemoglobin level <8 g/dl). To determine changes in blood pressure following surgery until the next morning, systolic and diastolic blood pressure were measured at 3-hr intervals. Results. The mean duration of surgery was 67.4 min for the procedure on the side that was operated on first, 32.7 min to change to the other side, and 68.4 min for the procedure on the other side. The mean blood loss was 576.1 ml. Hemoglobin values at baseline, at the time of autologous blood donation, and on the first day after surgery were 13.2, 12.7, and 8.7 g/dl respectively. Hemoglobin values were significantly different between the 2 weeks before surgery and the first day after surgery. Systolic and diastolic blood pressure were the lowest 3–6 hrs postoperatively (mean, 86/55). Blood reinfusion using autologous blood was performed for all patients. The allogenic blood transfusion rate was 25.0% (range, 2–8 units). In terms of complications, one patient developed an arrhythmia on postoperative day 5. This was the patient for whom autologous blood donation could not be performed due to pre-existing anemia. This patient also had right-sided sciatic nerve palsy. Discussion. With respect to one-stage bilateral THA, Gie showed that allogenic blood transfusion rate with or without autologous blood donation was 42% and 87% respectively. The allogenic blood transfusion rate was 25.0% in our study. Establishing a procedure to perform surgery in a shorter time period may further reduce the rate of allogenic blood transfusion. Although not used herein, intraoperative blood salvage may also be considered. Conclusions. In one-stage bilateral THA, autologous blood donation is effective in managing perioperative anemia and reducing the rate of allogenic blood transfusion. Perioperative blood management based on individual patients' situations are important for the safe performance of one-stage bilateral THA

Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists’ physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again.