Review Question - QID 217285

Your Jehovah's Witness patient has experienced significant blood loss. The most accepted treatment is continuous, closed-loop cell salvage (Cell Saver) which sustains an uninterrupted circuit of blood.

Significant intraoperative blood loss is a risk associated with major orthopedic procedures such as joint arthroplasty, spine, tumor, and trauma cases. The most effective method of mitigating this risk is by maintaining good hemostasis during the procedure. Tranexamic acid (TXA), cell saver, and allogeneic blood transfusion are adjunctive modalities to limit and address excessive intraoperative blood loss. Patients who are Jehovah's Witnesses are generally not amenable to allogeneic blood transfusions but can often be transfused with their own blood. The use of an intraoperative continuous, close-looped cell saver allows for the recycling of the patient's own blood that is obtained with suction.

Moonen et al. reviewed perioperative blood management in elective orthopedic surgery procedures. The authors stated that the gold standard for preventing intraoperative blood loss was by maintaining adequate hemostasis and dissecting through anatomically correct tissue planes. They proposed the use of pre-operative erythropoietin and iron supplementation, pre-operative autologous blood donation, platelet-rich plasmapheresis, hypotensive epidural anesthesia, and intra-operative cell saving as adjunctive blood loss management modalities. The authors concluded that allogenic blood transfusion should be based on physiologic variables, risks of disease transmission, and patient preference.

Imai et al. performed a retrospective study of intraoperative and postoperative blood loss in patients undergoing primary total hip arthroplasty that were treated with either a control or TXA at various time points in the perioperative period. They found that patients who received TXA either 10 minutes prior to surgery or 6 hours after the original dose had a significant decrease in perioperative blood loss. Postoperative blood loss was significantly decreased in all patients that received TXA. The authors concluded that TXA is an effective adjunct for minimizing blood loss during arthroplasty procedures.

Incorrect Answers:
Answer 1: Allogeneic blood transfusion is an unacceptable choice given that Jehovah's Witnesses are known for being averse to receiving allogeneic blood transfusions. This choice would go against this patient's beliefs and autonomy.
Answer 2: Though the use of cell salvage is often acceptable, it must specifically be used in a closed-loop fashion. Traditional cell salvage technique processes in batches, and this is considered to break the continuity of blood; thus, they consider it to be unacceptable.
Answer 3: Tranexamic acid has been shown in several studies to reduce intraoperative and postoperative blood loss during arthroplasty procedures. However, this patient has already experienced profound blood loss with resulting hemodynamic instability, which would make this option ineffective for addressing the patient's blood replacement needs.
Answer 5: Preoperative erythropoietin therapy has been used to increase baseline hemoglobin levels in patients that are already anemic. However, in the acute setting, it is unlikely to be effective.