**5.1 Introduction**

116 Recent Advances in Arthroplasty

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

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

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

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

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

hematocrit, but we will succeed in not diminishing its value.

transfusion and volume of transfusion (Carless et al., 2004).

postsurgical drainages.

with the patient's body.

**4.2 Iron supplements** 

controlled; unlike oral iron supply.

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 allogeneic transfusion, summed up in table 2.

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

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 perioperatively (Sehat et al., 2000).

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 ischemia during prosthetic surgery.

### **SURGICAL VARIABLES**


Table 2. Different surgical options to reduce bleeding
