Preoperative Management Aimed at optimizing patient hemoglobin levels to allow for better patient stress tolerance at the time of surgery vitamin supplementation iron login to view 7 more bullets folate and vitamin B12 supplementation login to view 1 more bullet anemia-associated vitamin supplementation login to view 2 more bullets erythropoietin (EPO) recombinant protein of natural glycoprotein produced by renal pericapillary cells login to view 1 more bullet studies have demonstrated greater efficacy than preoperative autologus blood donation and reinfusion systems high cost associated with use login to view 1 more bullet recommended for high risk patients (e.g. low preoperative hemoglobin, surgeries with significant blood loss anticipated, etc.) three dosing regimens have been proposed: login to view 3 more bullets preoperative autologous blood donation preoperative procurement of 1 to 2 units of autologous blood performed at least 3 weeks from the planned surgery to allow for recovery of hemoglobin levels may be of benefit in patients with normal Hb (>14 g/dL) ubdergoing procedures with high expected blood loss login to view 1 more bullet current literature does not seem to support efficacy and cost effectiveness in the management of postoperative anemia login to view 1 more bullet preoperative embolization standard treatment for oncology cases with highly vascular tumors login to view 1 more bullet performed within 24 hours of the procedure Preoperative labs CBC evaluate hemoglobin levels determine mean corpuscular volume login to view 2 more bullets folate B12 Intraoperative Management Acute normovolemic hemodilution autologus blood harvested right before or at the time of surgery removed volume is replaced with colloid extracted blood is transfused in the perioperative period requires less planning than preoperative autologus blood transfusion not commonly performed due to increased time in OR and associated labor Tourniquet allows for a dry surgical field and better theoretical cement interdigitation during arthroplasty cases minimum inflation pressure of 100 -150 mm Hg of systolic pressure may use of esmarch bandage to exsanguinate limb prior to inflating tourniquet login to view 1 more bullet may also elevate limb for gravity exsanguination prior to inflating tourniquet avoid use longer than 2 hours tourniquets should be cautiously used in patients with severe peripheral vascular disease risk of arterial complications associated with: login to view 4 more bullets preoperative vascular surgery consultation in high risk patients Tranexamic acid (TXA) lysine derivative that competitively blocks plasmin binding sites on fibrin results in a decrease in fibrinolysis and stabilized clot formation multiple studies have demonstrated a significant reduction in operative blood loss and transfusion rates with perioperative administration no increased risk of DVT and PE does not alter PT and PTT times multiple dosing regimens and routes of administration utilized IV, oral, and topical all appear equally efficacious contraindications active intravascular clotting severe drug allergy (anaphylaxis) subarachnoid hemorrhage side effects seizures login to view 1 more bullet Aminocaproic acid lysine derivative that competitively inhibits plasmin results in decreased fibrinolysis studies have demonstrated decreased blood loss with aminocaproic acid in arthroplasty lower cost than TXA does not decrease seizure threshold Topical hemostatic agents collagen agents stimulate the instrinsic pathway of coagulation cascade to promote hemostasis microfibrillar collagen login to view 2 more bullets fibrin sealant consists of two seperate mixtures login to view 2 more bullets combining the mixtures creates a fibrin seal where it is sprayed platelet-rich plasma centrifugation of patient's blood to isolate plasma with high contents of platelets, growth factors, and clotting factors proposed benefit of improved hemostasis, wound healing and recovery platelet-poor plasma isolated from centrifugation process combined with thrombin and calcium to provide an autologous fibrin sealant gelfoam sponges manufactured from animal-skin gelatin and processed into sponge-form isolated use exerts mostly mechanical hemostasis against low-pressure bleeders can be soaked with thrombin, which can act as a scaffold for the coagulation cascade excess gelfoam should be removed as it may interfere with bone healing topical hemostatic agents do not appear to be cost-effective in total joint arthroplasty cases beneficial in spine surgery to promote hemostasis without inflicting harm to adjacent neural structures topical TXA typically administered near the end of the procedure to control postoperative bleeding decreases fibrinolysis and stabilizes clot formation may be an alternative route of adminstration in patients with higher risk of complications login to view 1 more bullet gelatin-thrombin matrix commonly used in spine surgery to control epidural bleeding login to view 1 more bullet consists of porcine or bovine gelatine matrix combined with human derived thrombin acts at the end stage of the coagulation cascade leading to fibrin formation Reinfusion systems (cell saver) recycles intraoperative blood loss for later transfusion can be transfused intraoperatively during longer procedure collected blood is filtered, washed, and transfused within 6 to 8 hours from the procedure serves as an alternative to allogenic blood transfusion theoretical benefits of minimizing wound complications and hematoma formation complications coagulopathy login to view 3 more bullets contamination cost Postoperative Management Allogenic blood transfusion preoperative hemoglobin strongest risk factor for postoperative blood transfusion other risk factors female gender increased age larger patient size longer procedures lateral releases in total knee arthroplasty 1 unit of packed red blood cells generally increases hemoglobin by 1 g/dL no absolute criteria for transfusion transfusion should especially be considered at hemoglobin <8 g/dL routine transfusion should be avoided for hemoglobin > 8 g/dL login to view 5 more bullets Allogenic platelet transfusion blood product most likely to be contaminated stored at room temperature infections in 10 cases per million units transfused gram positive organisms most common thrombocytopenia platelet count below 5,000/mm^3 login to view 1 more bullet platelet count below 50,000/mm^3 login to view 1 more bullet platelet count below 100,000/mm^3 login to view 1 more bullet platelet count above 100,000/mm^3 login to view 1 more bullet Postoperative iron supplementation daily oral iron supplementation for mild acute blood loss anemia related to surgery Special Consideration Jehovah's Witness (JW) hold beliefs that blood transfusions are forbidden by the Bible some patients may still consent to a blood transfusion some patients may consider the use of cell saver as an alternative to allogenic blood transfusion use of colloids and coagulation factors are not forbidden and a matter of personal choice bovine-derived hemostatic agents are generally approved by JW products derived from human plasma are a personal decision of JW login to view 1 more bullet