Methods of reducing allogeneic blood demand in orthopedic surgery

Abstract

Despite advances in this field, allogeneic blood transfusion still carries a lot of risk; the availability of heterologous blood is also constantly decreasing. We describe the most popular methods for reducing the allogeneic blood requirement. Basic information is presented about the physiological mechanisms of compensation for intraoperative blood loss, which can be compromised by respiratory and cardiovascular disease or infections. Preoperative anemia (manifested by low hemoglobin levels) is statistically the most significant factor that increases the need for allogeneic blood transfusion. This paper evaluates the importance of oral and intravenous iron supplementation in the perioperative period, and the use of erythropoietin to boost Hb levels. Minimizing intraoperative blood loss also decreases the need for transfusion, and may be accomplished via meticulous hemostasis, an appropriate surgical approach, atraumatic surgical technique, reduced surgery time, and rational tourniquet use. Controlled intraoperative hypotension is a method of proven efficacy. Synthetic antifibrinolytic agents are also used to reduce perioperative blood loss; however, few clinical trials have focused on the use of such drugs in orthopedics. The use of postoperative drainage is still debatable. The allogeneic blood requirement can also be reduced by autologous blood transfusion. Autologous transfusion can be accomplished by preoperative autotransfusion, preoperative hemodilution, and intra- or postoperative blood salvage. It is currently the safest method of compensating for perioperative blood loss, avoiding all the described risks of heterologous blood transfusion.

Effects of intravenous iron monotherapy for patients with iron deficient anemia undergoing total knee arthroplasty

“…Preoperative anemia is considered a common factor leading to postoperative blood transfusions, and iron deficiency (ID) is the most common cause of anemia, with a prevalence rate of 41% [6]. Several blood management strategies, such as erythropoietin administration and intravenous (IV) or oral iron supplementation, have been used to achieve optimal preoperative Hb levels and reduce the requirement of postoperative transfusion [7,8]. Studies have indicated that iron supplementation is a safe and efficient method for increasing preoperative Hb levels prior to major orthopedic surgeries [9][10][11].…”

Is deliberate hypotension a safe technique for orthopedic surgery?: a systematic review and meta-analysis of parallel randomized controlled trials

“…Thus, blood transfusion, in particular the transfusion of red blood cells, is a common practice in orthopedic surgery [2]. In view of potential adverse effects of blood transfusion [3] and an increasing shortage of blood resources, many efforts have been made on the alternatives to transfusion or blood conservation measures to minimize allogeneic blood transfusion, such as acute hypervolemic or normovolemic hemodilution, perioperative blood salvage, use of epoetin alfa to stimulate erythropoiesis, hemostatic agents, deliberate hypotension, and others [4, 5].…”

“…The ideal technique should be easy to perform, have a short onset time, an effect that disappears quickly when drug administration is discontinued, a rapid elimination without toxic metabolites, negligible effects on vital organs, and a predictable and dose-dependent effect. It has been shown that the use of deliberate hypotension can shorten the operative time, reduce the risk of tissue edema caused by ligation or electrocautery, and improve myocardial performance by reducing cardiac preload and afterload [4, 6]. A recent retrospective cohort study indicates that deliberate hypotension has a potential ability to minimize length of hospital stay for patients undergoing orthognathic surgery [7].…”