Patient blood management in Hip and Knee surgery: A methodological approach – Part 2  Blood losses strategy and anemia tolerance

Abstract

A patient’s surgical journey always begins when a surgeon recommends recourse to surgery. The surgeon will focus on the joint to be replaced and the anesthesiologist (and other specialists if needed) will deal with other aspects of the patient’s  care. Our analysis deals with “blood risk” issues, but also touches upon all aspects associated with this kind of surgery. The preoperative management of the blood resource will be based on the outcome of the activities performed by anesthesiologist and surgeon, as well as of any other specialists who might be consulted for a specific case. In orthopedic patients who are candidates to undergo surgery entailing perioperative bleeding, the occurrence of anemia has been observed to range between 24% and 35%. Based on these data, the test to measure iron levels allows to observe the quantity of iron in the blood, mighting to perform  a MSBOS (Maximum Surgery Blood Order Scheduling).

An important concept to present is the low Ht physiology! It has been observed that avoiding hypovolemia is essential and that the main determinants of whole blood fluidity are the red blood cell concentration (hematocrit), plasma viscosity, cellular interactions and shear rate. Finally an intense monitoring decreases the tendency towards need for allogeneic transfusion.

Based on these criteria and on our experience in Orthopaedic surgery, in a clinical application of the low Ht Physiology, in a good knowledge concerning blood losses recovery, antithrombotic prophylaxis, antifibrynolitic activity and, least but non last, normotermia and pain control, we suggest a multimodal approach on this problem and some useful solutions.

 Key words: Hip /Knee surgery- Blood- Anemia- Low Hematocrit - Anesthesia