**4. Postoperative strategies**

### **4.1 Postoperative autotransfusion**

There are certain orthopedic surgical procedures (such as knee arthroplasty), in which postoperative bleeding through postsurgical drainages is very significant due to the

Blood Transfusion in Knee Arthroplasty 117

Transfusion requirements are a matter that concerns doctors not only for disease transmission risk but also for transmission complications and the high-cost of the procedure (Garcia-Erce et al., 2002). There has been a recent trend towards developing a protocol in order to decrease transfusion requirements (Garcia-Erce et al., 2002; Kourtzis et al., 2004). Several options have come up, pharmaceutical as well as transfusion options alternatively to

According to different studies who have studied predictive factors in trauma surgeries, preoperative hemoglobin level and levels of red cell mass are predictors of transfusion needs. The higher the levels of hemoglobin and red cell mass, the less need to transfuse

Occult blood has an outstanding paper regarding blood management in the patient being operated of arthroplastic surgery. Occult blood can reach 50% of the missed blood

During surgery there are several options to consider in order of preventing bleeding, such as: use or not have drainages, aspiration pressure and time of aspiration of drainages and

The use of drainages in orthopedic surgery is a matter of tradition. Its use prevents postoperative hematomas and diminishes postoperative pain, but its use is still controversial (Corpe et al., 2000). Despite several evidence-based medical studies, British

Drains have been related to the transfusion necessity and infection rate, among others. But some studies, such as Seyfert's et al (Seyfert et al., 2002), prove that placing drainages with

On the other hand, there are studies whose results highlight that not using drainages does not avoid transfusions nor does it reduce blood loss. Padala et al. find questionable the use of drainages in primary knee surgery as it increases transfusions (Padala et al., 2004). Some studies hold on to the fact that it is not necessary their use in primary knee arthroplasty (Adalberth et al., 1998; Corpe et al., 2000; Jenny et al., 2001), nor hip or knee (Crevoisier et al., 1998; Niskanen et al., 2000), nor primary hip (Acus, III et al., 1992; Beer et al., 1991; Hadden & McFarlane, 1990; Kumar et al., 2006). Della Valle et al found out in their study

orthopedists were not following their recommendations in 2003 (Canty et al., 2003).

suction does not increase transfusion requirements or postoperative course.

**5. Surgical aspects and its relationship with bleeding** 

allogeneic transfusion, summed up in table 2.

(Garcia-Erce et al., 2002; Lozano et al., 2008).

the use of ischemia during prosthetic surgery.

**SURGICAL VARIABLES** 

4. Number of drainages 5. Aspiration pressure

Table 2. Different surgical options to reduce bleeding

**5.2 Drainages and non-infectious complications** 

7. Tourniquet 8. Surgical technique

1. Drainages and non-infectious complications 2. Relation between drainage and infection 3. Use of postoperative blood retrieval

6. Start / Opening-up / End of drainage

perioperatively (Sehat et al., 2000).

**5.1 Introduction** 

completion of most of the surgery with lower extremity ischemia, so that bleeding occurs primarily in the early hours of the postoperative period. For this reason, in this type of surgeries, blood retrieval during postoperative time has been the main instruction and the one that has achieved major performance. Several devices for postoperative blood retrieval have been designed, in order to aspirate, store and retransfuse lost blood through postsurgical drainages.

Reinfused blood is often filtered rather than washed. It would be restricted to orthopedic programmed surgeries where estimated postoperative bleeding is between 750 and 1000 mL, and at least the equivalent to one packed red blood cells can be retrieved. Autotransfused blood must be collected and reinfused within a 4-6 hour-period. Stored blood in surgical drainage holds a better oxygen release to tissues than that from blood bank, although having a lower hematocrit. Furthermore, it owns better rheological characteristics and fewer ionic disturbances than blood bank. Hematocrit is low because it is total blood, which means that with this blood reinfusion we will not be able to raise hematocrit, but we will succeed in not diminishing its value.

Comparison analysis from obtained data in several studies shows that, regarding blood bank, blood from postsurgical drainage in orthopedic surgery, even with lower hematocrit and hemoglobin (8-10 g/dL), has higher concentrations of erythrocytic ATP and 2,3-BPG, less ionic disturbances and possibly, less immunosuppressive action. This blood includes too activated coagulation factors and fibrinogen degradation products, which could be the cause of coagulopathies. However, no significant increase in bleeding has been found, neither coagulation disorders clinically expressive There are no differences in perioperative inflammatory mediators levels between patients receiving unwashed retrieved blood from those who do not get it (Munoz et al., 2005b). Fat particles content, which is the main cause of fat embolism and respiratory distress syndrome, is controlled using a filter between collection and reinfusion container, and dismissing the last 80-100 cc. These methods allow removal of 90% of fat particles in the retrieved blood. The remaining 10% is eliminated by leukodepletion filter. These filters have shown to be effective in dismissing bacteria and tumor cells. In accordance with the abovementioned, unwashed blood must be limited to a maximum 1000 ml reinfusion. This collecting system brings advantages such as minimum contamination risk as it is a closed circuit and greater hemodynamic stability during postoperative period due to the disposal of blood volume, which is reinfunded if necessary. Moreover, it is cheap and can be used in Jehovah's Witnesses, as it is a closed circuit in which blood does not lose total contact with the patient's body.

Contraindications for using postsurgical drains' blood are: renal failure, altered hepatic function, coagulation disorders, infusion of hemostatic agents or inadequate solutions (topic antibiotics, antiseptics, oxygenated water) and neoplastic or septic disease. Retrieval of postoperative blood reduces both patients' percentage that would receive allogeneic blood transfusion and volume of transfusion (Carless et al., 2004).

#### **4.2 Iron supplements**

The use of intravenous iron during postoperative of orthopedic-surgical patients, is an effective treatment to increase hemoglobin levels, as shown in five clinical trials randomized controlled; unlike oral iron supply.
