Mod10: Orthopedic Surgery - Regional Anesthesia

Question 1

_{Orthopedic Surgery}

Advantages of Regional Anesthesia:

Answer 1

Enhanced rehabilitation

Earlier d/c home

^{(Decreased time to hospital discharge)}

Improved postop analgesia

Decreased incidence N/V

^{(Less incidence of N/V – not necessarily with SAB)}

Less respiratory & cardiac depression

Improved perfusion

^{(Improved perfusion and blood flow via sympathetic blockade)}

Reduced blood loss

Decreased risk thromboembolism

Decreased postop cognitive dysfunction

^{(Potential for less postop delirium and cognitive dysfunction if sedation avoided altogether but usually provided in combination with at least a little sedation, sometimes in combo with GA)}

Question 2

_{Orthopedic Surgery}

Neuraxial (spinal & epidural) techniques can possibly contribute to a reduced incidence of thromboembolic events (DVT & PE) by leading to…

Answer 2

Enhanced LE blood flow

^{(as the result of sympathectomy (vasodilation))}

↓ PLT reactivity

Systemic anti-inflammatory effects of LA

Factor VIII and von Willebrand factor

^{(An attenuated postoperative increase in factor VIII (plays an important role in coagulation) and von Willebrand factor – (vWF plays important role in adhesion of PLTs – so this goes up after surgery - neuraxial techniques lessen the extent of this increase))}

Antithrombin III

^{(An attenuated postoperative decrease in antithrombin III (antithrombin serves to inhibit coagulation by neutralizing thrombin – so a decrease in this will lead to enhanced coagulation – so neuraxial technique lead to less of a decrease in the activity of antithrombin III after surgery))}

Stress hormone

^{(Changes in stress hormone release)}

Question 3

_{Orthopedic Surgery}

Limitations of Regional anesthesia:

Answer 3

Motor block limits rehabilitation & early ambulation

Risk for falls and other injuries

Hypotension

Question 4

_{Orthopedic Surgery - Regional anesthesia}

Conversion to GA:

Answer 4

Always be prepared to convert to GA

Blocks can fail partially or completely, or duration of surgery can outlast block, or other complications can occur that require conversion to a GA

Always have airway equipment ready and machine checked and ready

Question 5

_{Orthopedic Surgery - Regional anesthesia}

Selecting a technique depends on:

Answer 5

Duration of surgery

Duration of postop analgesia needed

Degree of sensory/motor block necessary to allow for rehabilitation and ambulation

Question 6

_{Orthopedic Surgery - Regional anesthesia}

Contraindications:

Answer 6

Patient refusal

Infection at injection site

Systemic coagulopathy

-

Question 7

_{Orthopedic Surgery - Regional anesthesia}

Why are patients on antiplatelet agents, thrombolytics, fondaparinux, DTIs, therapeutic regimens of LMWH Not candidates for receiving (neuraxial blocks) spinal or epidural?

Answer 7

Risk for spinal or epidural hematoma

Question 8

_{Orthopedic Surgery - Regional anesthesia}

Neuraxial block placement or removal of neuraxial catheter are Not contraindicated with subQ heparin when dose is

Answer 8

< 10,000 units daily

Question 9

_{Orthopedic Surgery - Regional anesthesia}

With LMWH, guidelines on neuraxial administration is dependent on the regimen

Once-daily dosing =>

Answer 9

Neuraxial anesthesia can be administered, and

Neuraxial catheters can be removed 10-12 hours after previous dose, and then

There will have to be delay of four hours until next dose can be administered

_{Also suggested that these guidelines be utilized when considering placement of a deep Peripheral Nerve Block and plexus blocks and catheters}

Question 10

_{Orthopedic Surgery - Regional anesthesia}

With LMWH, guidelines on neuraxial administration is dependent on the regimen

Twice-daily dosing =>

Answer 10

Neuraxial catheters cannot be left in and…

Need to be removed two hours before first dose of LMWH

_{Also suggested that these guidelines be utilized when considering placement of a deep Peripheral Nerve Block and plexus blocks and catheters}

Question 11

_{Orthopedic Surgery - Regional anesthesia}

Patients on coumadin/warfarin are not candidates for neuraxial block unless INR is ….

Catheters shouldn’t be removed unless the INR is…

Answer 11

Normal

1.5 or less

_{Also suggested that these guidelines be utilized when considering placement of a deep Peripheral Nerve Block and plexus blocks and catheters}

Question 12

_{Orthopedic Surgery - Regional anesthesia}

Brachial Plexus Blocks

^{list them:}

Answer 12

Interscalene

Supraclavicular

Infraclavicular

Axillary

Question 13

_{Orthopedic Surgery - Regional anesthesia - Brachial Plexus Blocks}

Interscalene block

^{may be used for which procedure?}

Answer 13

Surgery on shoulder, arm, elbow

Fibers that innervate the ulnar side of forearm and hand (C8-T1) may be spared

thus not recommended for surgery on the hand

Question 14

_{Orthopedic Surgery - Regional anesthesia - Brachial Plexus Blocks}

Supraclavicular block

^{Indications - Risk - Precaution:}

Answer 14

Surgery on arm, hand, forearm, elbow

shoulder surgery also possible

Pneumothorax is most common serious complication of supraclavicular block (about 1% incidence)

Block of phrenic nerve occurs frequently (50% of procedures) but usually causes no clinically significant symptoms

=> BUT for this reason, bilateral supraclavicular blocks not recommended d/t fear of bilateral pneumo’s and bilateral phrenic nerve paralysis

Patients with COPD may not be ideal candidates for this block

Question 15

_{Orthopedic Surgery - Regional anesthesia - Brachial Plexus Blocks}

Infraclavicular block

^{Indication and disadvantages:}

Answer 15

Surgery for arm - elbow - forearm - hand

_{Disadvantages:}

Risk of vascular puncture and patient discomfort associated with traversing the pectoralis major and minor muscles

Question 16

_{Orthopedic Surgery - Regional anesthesia - Brachial Plexus Blocks}

Axillary block

^{Indication - Potential compliactions - Anesthesia considerations}

Answer 16

_{<u>Surgery for:</u>}

Hand - Forearm - elbow

_{<u>Potential complications: </u>}

Intravascular injection - Nerve injury from needle trauma - Intraneural injection - Hematoma

_{<u>Anesthesia of hand can be achieved by:</u>}

injecting LA solution at level of FA to block median, ulnar and radial nerves

useful for hand surgery when TQ NOT used

also to supplement brachial plexus block w/ incomplete sensory distribution

each of these blocks use 3-5 mL of LA

Question 17

_{Orthopedic Surgery - Regional anesthesia}

Forearm Blocks:

Answer 17

Median nerve block

^{provides most of the sensory innervation to palm of hand}

Ulnar nerve block

^{provides sensory innervation to dorsal and palmar sides of ulnar aspect of hand}

Radial nerve block

^{Superficial radial nerve is the distal sensory branch of radial nerve that follows radial artery along its course through the forearm}

^{Most patients have radial dominance of sensation on the dorsal aspect of the hand; supplies innervation to dorsum of thumb and dorsum of hand}

^{For many surgeries, an epidural or SAB is easier to perform than attempting to provide same extent of anesthesia with multiple PNBs…but certain co-morbidities (CAD, bacteremia, anticoagulation) may make a PNB the best choice for anesthetizing a lower extremity}

Question 18

_{Orthopedic Surgery - Regional anesthesia}

Lower Extremity Blocks

Answer 18

Femoral nerve

Saphenous nerve

Sciatic nerve

Popliteal

Ankle

Question 19

_{Orthopedic Surgery - Regional anesthesia - Lower Extremity Blocks}

Femoral nerve block:

Answer 19

Anterior aspect of thigh and knee - Medial aspect of leg

Typically combined with other blocks (such as sciatic nerve block) to provide complete anesthesia below the knee

Can do continuous FNB

Alone or in combo with other PNBs – very useful for postoperative analgesia

Question 20

_{Orthopedic Surgery - Regional anesthesia - Lower Extremity Blocks}

Saphenous nerve block:

Answer 20

Saphenous vein stripping or harvesting

In combination with sciatic nerve block for medial foot/ankle surgery

Question 21

_{Orthopedic Surgery - Regional anesthesia - Lower Extremity Blocks}

Sciatic nerve block:

Answer 21

Provides nearly complete anesthesia of foot and lower part of leg

Often combined with FNB to provide more extensive anesthesia for LE

Foot and ankle surgery - BKA - Analgesia following knee surgery involving the posterior compartment

Question 22

_{Orthopedic Surgery - Regional anesthesia - Lower Extremity Blocks}

Popliteal nerve block:

Answer 22

Provides sciatic nerve anesthesia near the point where the sciatic nerve divides into the common peroneal and tibial nerve components

Most commonly used for foot and ankle surgery, usually in combination with femoral and saphenous nerve blocks

=> for surgery on medial aspect of leg or if TQ used

Question 23

_{Orthopedic Surgery - Regional anesthesia - Lower Extremity Blocks}

Ankle block:

Answer 23

For distal foot and toe surgery

Involves anesthetizing five** separate **nerves

Two deep nerves (tibial and deep peroneal), and

Three superficial nerves (superficial peroneal, sural, and saphenous nerves)

All nerses, except the saphenous, are terminal branches of the sciatic nerve

The saphenous nerve is a sensory branch of the femoral nerve

Knowledge of the anatomy of the ankle is essential

Question 24

_{Orthopedic Surgery - Intravenous Regional anesthesia (IVRA)}

Bier block:

Answer 24

Named after August Bier

Simple method of anesthetizing the arm or leg

Involves IV injection of large volumes of dilute LA solutions into an extremity after occlusion of the circulation by a tourniquet

For surgeries lasting two hours or less

Severe tourniquet pain and max allowable TQ time limit the duration of the block

Duration of postop analgesia also limited – not usually used when postoperative pain is expected to be significant

Question 25

_{Orthopedic Surgery} **General or Regional Anesthesia** will depend on?

Answer 25

Proposed surgery - Anticipated length - Position required Patient acceptance - Co-morbidities Anticoagulation status

Question 26

_{Orthopedic Surgery} **Blood Loss** significant in:

Answer 26

Spinal ^{(Scoliosis - Instrumentation)} Pelvic fracture repairs Long bone fracture repairs Total hip arthroplasty Trauma

Question 27

_{Orthopedic Surgery - Blood Loss} **Blood loss** from **Hip Fractures** depends on:

Answer 27

**Location of fracture** Subtrochanteric, intertrochanteric \> base of femoral neck \> transcervical (midportion of femoral neck), subcapital (femoral head/neck junction) Certain fractures have **greater blood loss**, greater **mortality** A preop Hct that is normal or borderline-low may be deceiving because hemoconcentration can mask occult blood loss

Question 28

_{Orthopedic Surgery - Blood Loss - Hip fractures} Occult blood losses can be significant and this depends on a number of things, including:

Answer 28

The location of the fracture ## Footnote A preop Hct that is normal or borderline-low may be deceiving because hemoconcentration can mask occult blood loss

Question 29

_{Orthopedic Surgery - Blood Loss - Hip fractures} Hip fx patients are often dehydrated from a lack of adequate PO intake and this leads to:

Answer 29

hemoconcentration A preop Hct that is normal or borderline-low may be deceiving because hemoconcentration can mask occult blood loss

Question 30

_{Orthopedic Surgery - Blood Loss - Hip fractures} Preoperative Hct:

Answer 30

A preop Hct that is normal or borderline-low may be deceiving because hemoconcentration can mask occult blood loss Always ***type and cross*** for hip fx, especially femoral neck, intertrochanteric and subtrochanteric. 500-1000mL. Have **blood available** (in the OR fridge, preferably) before cut skin **Hip replacement**, especially Revision hip replacement surgery, also associated with significant surgical blood loss.

Question 31

_{Orthopedic Surgery - Blood Loss - Hip fractures} Reducing Blood Loss - How?

Answer 31

Induced hypotensive technique ^{Bloodless field greatly facilitates arthroscopic surgery (knee, shoulder)} Antifibrinolytics ^{Antifibrinolytics are used to prevent and treat surgical blood loss}

Question 32

_{Orthopedic Surgery - Blood Loss - Hip fractures - Reducing Blood Loss} **Induced hypotensive technique** ^{can be achieved with:}

Answer 32

Volatile agents - NTG - NTP Beta-blockers - Diltiazem

Question 33

_{Orthopedic Surgery - Blood Loss - Hip fractures - Reducing Blood Loss} **Risks** of Induced hypotensive technique:

Answer 33

Spinal cord ischemia Optic nerve ischemia Ischemia to any organ * Risks vs. benefits!!!!* * Communicate with surgeon!!!*

Question 34

_{Orthopedic Surgery - Blood Loss - Hip fractures - Reducing Blood Loss} **Antifibrinolytics** ^{Two types:}

Answer 34

**Lysine analogs** ^{Tranexamic acid (TXA) Epsilon-aminocaproic acid (AMICAR)} **Serine protease inhibitor** ^Aprotinin

Question 35

_{Orthopedic Surgery - Hip fractures - Reducing Blood Loss - Antifibrinolytics} **Lysine analogs – TXA and amicar** ^{Mechanism of action and more:}

Answer 35

Competitively inhibit the binding site of plasminogen =\> this prevents the cleavage to plasmin and the subsequent fibrinolysis Excreted by the kidneys and may be given IV or topically Both seem to be equivalent in their efficacy, although there is more evidence to support TXA use Research shows moderate decreases in peroperative blood loss in cardiac surgery, liver transplants, ortho operations and spinal fusions These are **less expensive** than aprotinin Only adverse effects are **mild N/V** with *rapid infusion rates* No reports of increased risk of thromobolytic complications or renal failure…but some surgeons will withhold administration for patients with a cardiac history or history of thromboembolic events

Question 36

_{Orthopedic Surgery - Hip fractures - Reducing Blood Loss - Antifibrinolytics} **Serine protease inhibitor** - **Aprotinin** ^{considerations:}

Answer 36

Was reported to be more efficacious at reducing blood loss, minimizing transfusions, and preventing reoperations, especially in cardiac surgery Removed from the market after studies demonstrated an increased risk in renal failure, MI, and death However, aprotinin is now available in Canada and may be available again in the U.S. at some point

Question 37

_{Orthopedic Surgery - Risks of Blood Product Administration} Which test screens blood donations for transfusion transmitted infections?

Answer 37

**Nucleic Acid Testing** ## Footnote Since it was introduction to the developing world in the 1990s and early 2000s, the residual risk of infection from blood product administration has decreased dramatically Transfusion-transmitted viral infections continue to receive the most focus because of their associated morbidity and mortality Difficult to almost impossible to accurately quantify the true risk of transfusion transmittable infections

Question 38

_{Orthopedic Surgery - Risks of Blood Product Administration} Potential viruses that can be transmitted include:

Answer 38

HIV - HCV - HBV Human T-cell lymphocytic virus **CMV** ^{(CMV is the most common transfusion-transmitted disease with an incidence of about 1-3%)}

Question 39

_{Orthopedic Surgery - Risks of Blood Product Administration} Contamination of blood components by which organism holds the largest risk of transfusion-related infection?

Answer 39

**Bacterial contamination** ## Footnote Can progress to sepsis, which continues to be significant cause of morbidity and mortality related to transfusions

Question 40

_{Orthopedic Surgery - Risks of Blood Product Administration} Common pathogens that lead to bacterial contamination come from:

Answer 40

Flora of the skin Staphylococcus - Corynebacterium Bacillus & Streptococcus ^{secondary to gam0 negative species such as e. coli and Enterobacter cloacae (kah or kee)}

Question 41

_{Orthopedic Surgery - Risks of Blood Product Administration} Whihc blood product carries the highest risk of bacterial contamination?

Answer 41

Platelets

Question 42

_{Orthopedic Surgery - Risks of Blood Product Administration} Noninfectious Risks of Blood Product Administration ^{Two types:}

Answer 42

Immune-mediated Transfusion reactions Nonimmune-mediated transfusion reactions

Question 43

_{Orthopedic Surgery - Noninfectious Risks of Blood Product Administration} Immune-mediated Transfusion reactions:

Answer 43

Febrile non-hemolytic Allergic Transfusion-related immunomodulation Alloimmunization TRALI TA-GVHD Posttransfusion purpura

Question 44

_{Orthopedic Surgery - Noninfectious Risks of Blood Product Administration} Nonimmune-mediated transfusion reactions:

Answer 44

Transfusion-associated CV overload Metabolic derangements Iron overload Microaggregate administration

Question 45

_{Orthopedic Surgery - Nonimmune-mediated blood product transfusion reactions} ## Footnote **Microaggregate administration:**

Answer 45

During storage**, microaggregates** of cellular debris, PLTs, fibrin composition, and RBCs and WBCs ***collect*** in the blood Standard **blood filters** avoid the infusion of these aggregates Traditionally thought that you couldn’t safely administer **blood with LR** because of the calcium in LR It was thought that **calcium** could chelate the **citrate** anticoagulant preservative used in stored blood and this could lead to ***blood clots*** Several studies have **_negated_** this As mixing blood with LR in ratios of more than 2:1 (RBC to LR) dose not demonstrate any clinical or experimental evidence of clot formation

Question 46

_{Orthopedic Surgery - Risks of Blood Product Administration} How do we reduce the riskk for allogenic blood components?

Answer 46

Blood Conservation Strategies such as: Autologous Blood Transfusion (ABT)

Question 47

_{Orthopedic Surgery - Blood Conservation Strategies} **Autologous Blood Transfusion (ABT)** ^{Three separate processes:}

Answer 47

Preoperative autologous blood donation (PAD) Acute normovolemic hemodilution (ANH) Perioperative blood cell salvage (cell saver)

Question 48

_{Orthopedic Surgery - Autologous Blood Transfusion (ABT)} Preoperative autologous blood donation (PAD):

Answer 48

Patients donated their own blood during the weeks before a planned surgical procedure This eliminates the risk of viral infection and alloimmunization BUT still involves blood collection and storage =\> carries risk of clinical errors in this process, CV overload, bacterial infection, and transfusion-related immunomodulation _Indications_: Difficulty finding compatible blood products because of multiple antibodies or rare blood types, for patients refusing allogenic transfusions, and scoliosis surgery in adolescents Each donation usually collects ***450 mL*** – shouldn’t exceed **6 mL/kg** Can be repeated ***weekly*** until 72 hours before surgery Patients rarely able to donate more than 4 units because of limited storage time and because hgb must remain over **11 g/dL** before donation If patients do have multiple antibodies and significant blood loss is anticipated, donated units can be frozen Keep in mind that just because the patient donated the blood doesn’t mean they have to receive it. ***Blood shouldn’t be administered to avoid waste***

Question 49

_{Ortho Sxy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)} Process of extracting blood from a patient shortly after induction of anesthesia and before surgical incision:

Answer 49

Acute Normovolemic Hemodilution (ANH)

Question 50

_{Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)} Acute Normovolemic Hemodilution (ANH)

Answer 50

Entails the removal of blood from a patient shortly after induction of anesthesia and before surgical incision Euvolemia maintained using crystalloid and/or colloid replacement The amount of blood removed varies between one and three units and about 450 to 500 mL constitutes one unit Larger volumes may be withdrawn safely in certain circumstances The aim of this blood conservation technique is to lower the patient's hemoglobin concentration during surgery This in theory minimizes the effect of surgical blood loss Hemodiluted blood has less hemoglobin than it would in the absence of intraoperative hemodilution The previously withdrawn whole blood is given back to the patient during or shortly after the surgical procedure. ANH can be used as the sole blood conservation technique, or it can be combined with preoperative autologous donation Whether ANH is effective in decreasing allogeneic blood transfusion is debatable, and outcome benefits have not been clearly demonstrated **ANH is not recommended for routine use**

Question 51

_{Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)} Acute Normovolemic Hemodilution (ANH) ^{Patient Selection:}

Answer 51

Considered for patients with normal initial hemoglobin (Hgb) levels who are expected to lose more than two units of blood (900 to 1000 mL) during surgery This recommendation based on fact that most patients can safely tolerate intraoperative blood losses up to 2 units of PRBCs without need for transfusion So the cost and labor required to implement intraoperative hemodilution isn’t justified in circumstances when blood loss isn’t expected to be more than this It is safest when used in healthy, young adults, but can be used in other populationsGood option for Jehovah's Witnesses, many of whom will consent to ANH if the blood is maintained in a closed circuit continuous flow system.

Question 52

_{Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)} **Acute Normovolemic Hemodilution (ANH)** ^{Contraindications:}

Answer 52

Preop anemia Significant cardiopulmonary comorbidity such as uncontrolled HTN, AS, or recent MI of CVA In patients with a normal or high initial Hgb levels who are undergoing cardiac surgery, **decreased blood viscosity** associated with the induced anemia may have **cardioprotective** effects

Question 53

_{Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)} **Acute Normovolemic Hemodilution (ANH)** ^{What volume of blood can be drawn?}

Answer 53

UpToDate not to withdraw more than 900 – 1000 mL To be specific to the patient, blood is withdrawn based on target Hct Target Hct will be based on individual patient history and baseline physiologic state but usually ranges from 25-30% Use the allowable blood loss formula to calculate the volume to be removed **Max Allowable Blood Loss (ABL) calculation** Volume to be removed = [EBV X (HCTi – HCTf)]/HCTi ^{HCTi = initial Hct; HCTf = final or target HCT} This is an important formula for clinical rotations! This will let you know when you need to start thinking about giving blood Average blood volumes are based on age and gender (for adult **male** this is between ***70 and 75 mL/kg***; for average adult **female** between ***65 and 70 mL/kg***; different for infants and neonates) **Averages HCTs**: Men **42-52%** - Women ***37-47%***

Question 54

_{Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)} Perioperative Blood Salvage (cell saver)

Answer 54

Requires use of **double-lumen suction catheter** - one port for ***aspiration*** from the surgical field and the other for addition of an ***anticoagulant*** solution (usually heparin or citrate) Suctioned blood then collected in a reservoir, filtered to remove large debris, and **centrifuges** --\> this results in red cell concentrates Final step is **washing** and this clears the concentrates of residual contaminants such as plasma, PLTs, free hgb, cellular fragments, WBCs, and the remaining heparin or citrate The **red cells** are resuspended in saline and then ready for reinfusion This is usually **given bac**k to the patient **immediately** but can be stored at _4 degrees C for up to six hours_ On average the **Hct r**anges between **60 and 70%** but can be as low as 50% and as high as 80% Has proven **benefits** for r_educing allogenic blood transfusion_ in major surgery, particularly ortho, spine fusion and off-pump cardiac surgery

Question 55

_{Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)} **Perioperative Blood Salvage (cell saver)** ^{Complications:}

Answer 55

**Rare** and mostly associated with ***how*** the blood is ***suctioned*** from the patient or ***contamination*** from the surgical field

Question 56

_{Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)} **Perioperative Blood Salvage (cell saver)** ^{Risks include:}

Answer 56

Nonimmunogenic hemolysis, fever, and contamination with various substances such as topical anticoagulants, urine, amniotic fluid, or bacteria

Question 57

_{Orthopedic Surgery - Blood Conservation Strategies} ## Footnote **Erythropoietin (EPO)**

Answer 57

EPO is hormone produced primarily by the kidneys Primary regulator of erythropoiesis (RBC production) **Release** is stimulated endogenously when ***Hct drops below 30%*** Also stimulated by ***physiologic hypoxia***

Question 58

_{Orthopedic Surgery - Blood Conservation Strategies} **Erythropoietin (EPO)** ^{Indicated for:}

Answer 58

Indicated for refractory anemia, such as in renal failure patients Also used for optimizing hgb levels in patients with preop anemia and in those patients participating in preoperative autologous donation Cost effectiveness and the appropriate dosing regimens of using recombinant EPO is not clear So routine use of EPO in the perioperative setting is not recommended at this time

Question 59

_{Orthopedic Surgery - Blood Conservation Strategies} **Jehovah’s Witnesses** ^Beliefs:

Answer 59

Jehovah’s witnesses are a part of an international well-established religious society Believe in the literal translation of the Bible, including biblical instructions related to blood Followers believe that once blood has left the body it shouldn’t be returned to anyone If they were to receive blood that has left the body, this is grounds for excommunication and no hope for eternal life

Question 60

_{Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses} **Most understand and accept risks**

Answer 60

Most understand and will accept the potential for death with the refusal of receiving blood products

Question 61

_{Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses} ## Footnote **Preoperative optimization:**

Answer 61

Best management is perioperative optimization to maximize alternative blood conservation therapies

Question 62

_{Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses} ## Footnote **Clear discussion:**

Answer 62

Need to have a frank and clear discussion with patient about specific concerns

Question 63

_{Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses} ## Footnote **Extracorporeal circulation:**

Answer 63

Some will consent to receiving blood components, factors concentrates derived from blood (albumin) or extracorporeal circulation which may include CP bypass, ANH, and cell saver, as long as there is **no break or disconnect** of the circulation system with the patient’s body

Question 64

_{Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses} ## Footnote **Prohemostatic medications**

Answer 64

In preparation for surgery, these patients might use prohemostatic medications such antifibrinolytics, vit K, recombinant factor VIIa, and desmopressin

Question 65

_{Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses} ## Footnote **Preoperative hgb:**

Answer 65

Should have optimal preop Hgb by administering EPO, iron and supplemental B12 and folate