Options to reduce the need of stored blood in Total Joint Arthroplasty (TJA)

Abstract

Aims and Objectives: Stored blood units are limited and will become even scarcer in the future, as the high-birthrate age group is getting older and the number of blood donors is decreasing. Stored blood also involves risks: transmission of diseases, immunological shock, side effects. Which are the options to reduce the perioperative need of stored blood? Materials and Methods: Based on published studies, the pre-, peri- and postoperative actions and their practical application in order to prevent anemia, bleeding and the need of stored blood were compiled and evaluated. Own experiences are presented. In-house statistics were evaluated and show obvious effects. Results: The following actions should be taken into account: -Preoperative anemia has to be avoided as the risk of complications and mortality is increased. It is to be detected by blood samples and the reason for it needs to be treated. Iron deficiency is quite often the cause. The oral substitution of iron needs several weeks/months. It can also be given intravenous 2-3 weeks preoperatively.-The preoperative setting and discontinuation of anticoagulants and platelet aggregation inhibitors should be reflected.-The operation should be performed at normal temperature of the patient to allow normal function of enzyme systems and platelets.-Careful haemostasis is self-evident.-A tourniquet prevents bleeding during surgery of the knee, but reactive hyperemia may be unfavorable.-The use of a cell saver is worthwhile in blood-rich surgeries. With a drainage blood can also be collected postoperatively.-Tranexamic acid prevents fibrinolysis thus reducing bleeding. It is given preoperatively, if necessary again after 2-4 hours. Although the application is off-label in TJA, it has become established, particularly as there is good experience in other surgeries since many years.-Intra- and postoperative coagulation management is of importance.-Rational use of blood units should be standard (see guidelines).-The frequency and amount of blood samples should be restricted (1 mg of iron is lost per 2 ml of blood).In-house statistics show a clear reduction in the consumption of stored blood units after the introduction of the cell saver and the tranexamic acid. In Total hip arthroplasty the need decreased from 10 to 2.6% and in Total knee arthroplasty from 5 to 1.4%. Conclusion: With the help of an interdisciplinary collaboration of all professional groups, which should already start with the family doctor and before admission to the hospital, the demand for stored blood can be decreased and the perioperative risk for the patient will be reduced.