BLOOD DONATION BEFORE TOTAL JOINT SURGERY
Total hip and knee surgery entails making cuts in bone tissue. Cuts through bone tissue bleed plentiful because the very small blood vessels in bone tissues have very thin walls that cannot contract themselves and cannot be ligated.
Although this bleeding is more like oozing from cut bone surfaces, it continues for some time after the operation and the total amount of blood lost may be considerable, about one liter blood in more complicated primary operation, and more than two liters blood in revision operations.
Erythrocytes
The blood, or rather the erythrocytes (red blood corpuscles) in it, transport the oxygen from lung to the tissues. The substance contained in erythrocytes that transports the oxygen is called hemoglobin.There is an optimal level (concentration) of hemoglobin (Hb) in the blood of healthy individuals, ranging from about 120 to 160 g / Liter blood in women and from 135 to 170 g/ Liter blood in men (Lemos 1996).If the concentration of hemoglobin in the blood falls under a certain level, (usually set at 80 g /L) the transportation of oxygen to the tissues is endangered. The patient must then get a transfusion of blood, which pours more erythrocytes in the circulation and restores the levels of hemoglobin in the circulating blood.
Studies demonstrated that up to 40% of patients with primary ( (primary= the first total joint operation)) total hip and 30% of patients with primary total knee operation received blood transfusion.
For rules about when you will need a blood transfusion
The need for blood transfusion during and after total joint surgery depends mainly on two factors:
- the concentration of hemoglobin in your blood before the total joint surgery ,
- the amount of the blood loss during the operation, the more bleeding the higher the risk of transfusion
Concentration of hemoglobin
The higher the level of hemoglobin concentration in your blood before the surgery the lower the risk of blood transfusion during and after the primary uncomplicated total hip / knee joint surgery. (Salido 2002)
Look at this Table to assess the risk of having blood transfusion during an uncomplicated primary total hip operation
RISK OF HAVING TRANSFUSION Hemoglobin level (g / L) Risk to have transfusion percent having transfusion <110 very high 100 % 110 - 130 high 70 % 130 -150 medium 35 % > 150 low 13 %
Patients with simultaneous bilateral total hip / knee replacement, patients with revision operations of their total hip / knee prostheses, and patients with certain medical conditions (high body weight, high blood pressure, obstructive pulmonary disease, etc,) have increased risks for blood transfusion in spite of normal hemoglobin levels.
Reduction of bleeding
There are several ways how to reduce bleeding from the operative wound, beyond the usual careful treating of all bleeding vessels .
a) For some of the complicated total joint operations, the anesthesiologist may lower your blood pressure (put you in the so called controlled hypotension) during surgery. The blood will not squirt so forcibly out of cut surfaces and the total blood loss will diminish.
b)The surgeon may use drugs that reduce bleeding from the vessels during the operation. These drugs are used mainly in cardiac surgery. These drugs, however, intervene in the physiological ("normal ") process of blood clotting and orthopedic surgeons fear that the side effect of these drugs may be an increased rate of deep vein thrombosis, heart infarcts, an possibly circulation damage in the extremities. (Kovesi 2003)
c) the surgeon may spray a fibrin sealant onto the operation wound before the closure to seal the small bleeding vessels (Wang 2003)
All these methods may have side-effects. Discuss them always with your surgeon.
Autologous blood is
your own blood
If the surgeon believes that you may need blood during or after the total joint surgery you should in the first hand consider the donation of your own blood prior to your surgery.Your blood will be stored and it will be transfused back to you during and / or after your surgery. This is called autologous transfusion. You can donate your blood at one or two occasions within 35 to 14 days prior to your total hip / knee replacement.
Discuss the need for autologous blood donation always with your surgeon already early on before your surgery.
Autologous blood donation diminishes the risk of postoperative deep vein thrombosis.
There are, however, some diseases that prohibit autologous blood donation such as anemia, cardiac disease, but not a cancer. Some medications make preoperative blood donation impossible. Also, advanced age (>75 years) and low hemoglobin concentrations (usually < 110 g /Lt) prohibit the autologous blood donation.
The autologous blood is stored in liquid state and it can be used during 42 days from the date of collection. The blood can be also stored in frozen state in special circumstances for about one year. Freezing must be done at the time for blood collection. Freezing the blood is costly and is used in very special circumstances only.
Your body will usually replace the donated blood in time for your surgery, but usually not entirely . You may help your body by taking Iron supplements together with Folic acid, and C vitamin. Ask you doctor for details about the doses. Remember also that Iron supplements may cause bowel problems.The medicine that might help your body more effectively to replace the predonated blood, erythropoietin, has not been approved for this use yet in many countries.
The present rule (2001) usually says: If you can predonate your blood, then NO erythropoietin. If you are not able to predonate your blood, then YES to erythropoietin.
For more information on the risks with autologous blood transfusion
What happens with your blood if your surgery will be postponed?
Your blood already being stored in liquid form cannot be frozen later if your surgery is postponed for any reason.
Your blood bank may use so called "piggy-back" technique to save your banked blood that is about to expire. The blood unit about to expire will be first transfused back to you. After some time (usually only about 30 minutes) the Blood Bank will collect a new unit of fresh blood from you. This new unit may be stored for another 42 days.
Allogenic or blood bank blood
If you are not able to donate, for whatever reason, blood for yourself, you may receive blood collected from other persons. This is called allogenic blood transfusion (older term is homologous transfusion) and the blood you will receive is allogenic blood (alien blood).Discuss the need and the risks of alien blood transfusion always with your surgeon early on before your surgery.
(In some centers it is recommended that you solicit family members or friends to donate blood on your behalf. This is called Directed Blood donation. This is also an allogenic (alien) blood.Not sure that they may do it if they do not have identical blood groups with you. Persons who may give blood for you must meet also several other conditions, ask the Blood Bank at your hospital for advice. Remember also that it takes a minimum of 2 days to test and process the donated blood before it can be transfused.)
If you cannot find a designated donator who may donate blood for you, you will receive blood from the hospital Blood Bank if necessary.
Blood transfusion and risk of infection(AIDS, viral hepatitis)
Patients are often concerned about receiving allogenic (Blood bank) blood because of the risk of transmitting HIV virus and viral hepatitis.
The Blood Banks follow, however, universal guidelines in screening all blood and blood products to ensure maximum safety. The risk of transmission of viral diseases by blood transmission is nowadays very low.
The patients may, however, still have adverse reactions during and after the transfusion of the allogenic Blood Bank blood such asfever, rash, and a quick pulse (tachycardia).
Some studies also demonstrated that use of Blood Bank blood has been associated with higher rates of postoperative infections.
Thus, there is no question that your own blood is the safest.
For more information on the risks with allogenic (alien) blood transfusion
Blood salvage techniques.
A new technique to reduce the need for blood transfusion is the use of blood salvage techniques.The surgeon's assistant sucks continually the oozing blood from the operation wound. Also after the operation, the oozing blood is removed from the wound through sterile suction tubes.
This shed blood may be collected, salvaged, and eventually reinfused.
Actually, about 88 % of the red blood cells (erythrocytes) survive well this management and do the job to transport oxygen.
There are two techniques for collection and preparing of the shed blood.
The first type device collects whole blood. The whole blood is filtered, admixed with anticoagulants (to prevent congealing) and reinfused into the patient.
The second type device collects the blood, wash it, separates only red blood cells and eventually reinfuses packed red blood cells into the patient.
Both types of cell salvage devices are used in operations with blood loss > 800 ml blood. The second type device needs a trained technician for use
Can you avoid blood transfusion after your total joint surgery?
There are two ways, that reduce the risk of blood transfusion during your total joint operation:
1) increase your preoperative level of blood hemoglobin
2) decrease perioperative bleeding
1) Because the need for transfusion depends on the level of hemoglobin in your blood before the operation, there is a chance that you may obviate the blood transfusion if your hemoglobin level before the operation will be sufficiently high. (See the Table above)
The doctors may rise the level of blood hemoglobin before the surgery with a genetically engineered hormone called erythropoietin (Procrit TM) so much that the patient will not need blood transfusion during the total joint surgery.
Normally this hormone is produced in kidneys. The kidneys have the ability to "gauge" the level of oxygen transported in the blood (in the blood red cells), and when this level falls under a certain level, the kidneys will manufacture more erythropoietin. The hormone then stimulates the bone marrow to produce more red cells so that more oxygen may be transported to tissues.Studies demonstrated that administration of Procrit during four weeks before surgery diminished the need for transfusion after total hip and knee surgery in patients with low hemoglobin levels (110-130 g/Lt) before the surgery. (The sportsmen use sometimes such forbidden doping techniques to improve their performance).
Current rules restrict the use of erythropoietin in orthopedic patients only to patients who cannot participate in the preoperative autologous blood donation program and to operations where the blood loss is expected to be >900 ml blood.
Also patients with hemoglobin levels >130g/Liter blood cannot benefit from preoperative treatment with erythropoietin.
Discuss always this option with your surgeon for the possible benefits and risks of this procedure.
Several studies documented that erythropoietin permits safe predonation of autologous blood, and permits also predonation of more blood than can be predeposited without it.
2) The surgeon may use special drugs and special techniques to reduce bleeding.
The currently used drugs for reduction of perioperative bleeding may have, however, certain side-effects. These drugs are:
aprotinin (Trasylol TM) which is very effective in reducing bleeding during major revision operations of failed total joints (Jeserschek 2003)
tranexamic acid (Cyclokapron TM) which is effective in reducing bleeding during total joint surgery (Kovesi 2003)
The surgeon may also spray fibrin sealant on the blood oozing tissues to reduce bleeding in total knee surgery. (Wang 2001)
Total joint operation and Jehovah’s WitnessesSome patients don't accept any form of blood transfusion for religious reasons.
Studies demonstrated that even complicated revision operations of total joints were carried out without the use of blood transfusion in these patients. These patients were treated preoperatively with erythropoietin.
Also all measures to diminish perioperative bleeding should be used with exceptional care in these patients.
Your surgeon will decide if the use of Procrit instead of blood transfusion will be acceptable in your case.
The main disadvantage of not replacing the lost blood ( besides the cases where the blood loss endangers directly the life of the patient) is that it takes longer time to get back to full strength. In patients with low hemoglobin levels after the surgery it usually takes more than three months of treatment with iron and vitamin supplements to return to normal blood levels of hemoglobin.
References:
Salido JA: J Bone Joint Surg-Am, 2002; 84-A: 216- 20
Lemos MJ , Healy WL: J Bone Joint Surg-Am, 1996; 78-A: 1260- 1270
Jeserschek R et al.: J Bone Joint Surg-Br, 85-B: 174-7
Kovesi T , Royston D.: Vox Sang 2003; 84: 2-10
Wang GJ et al.: J Bone Joint Surg-Am, 2001; 83-A: 1503- 5
Before you take any action, please read the DISCLAIMER