Review Question - QID 3365

The patient has experienced a greater than expected blood loss during the procedure and has developed hemodynamic instability as a result. Given that the patient is a Jehovah's Witness, the use of a cell salvage (Cell Saver) is most preferred method for treating the patient's acute blood loss anemia.

Signficant intraoperative blood loss is a risk associated with major orthopedic procedures such as joint arthroplasty, and spine, tumor, and trauma surgeries. 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 intraoperative cell saver allows for the recycling of the patient's own blood that is obtained with suction, and this can then be used later to transfuse the patient. However, this should be discussed with the patient pre-operatively, as some Jehovah's witnesses may be amenable to allogenic blood transfusion or conversely be opposed to cell saver.

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 periopreative 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: Iron supplementation would be ineffective in this setting as it takes months for iron to have a meaningful effect on a patient's hemoglobin levels. Postoperative oral iron supplementation has been questionably effective due to the inflammatory effects of the surgical healing process and the implications of iron metabolism similar to anemia of chronic disease.
Answer 2: 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.
Answer 3: 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 4: 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.