Mod10: Orthopedic Surgery - Regional Anesthesia Flashcards

1
Q

Orthopedic Surgery

Advantages of Regional Anesthesia:

A

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)

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2
Q

Orthopedic Surgery

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

A

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)

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3
Q

Orthopedic Surgery

Limitations of Regional anesthesia:

A

Motor block limits rehabilitation & early ambulation

Risk for falls and other injuries

Hypotension

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4
Q

Orthopedic Surgery - Regional anesthesia

Conversion to GA:

A

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

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5
Q

Orthopedic Surgery - Regional anesthesia

Selecting a technique depends on:

A

Duration of surgery

Duration of postop analgesia needed

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

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6
Q

Orthopedic Surgery - Regional anesthesia

Contraindications:

A

Patient refusal

Infection at injection site

Systemic coagulopathy

-

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7
Q

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?

A

Risk for spinal or epidural hematoma

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8
Q

Orthopedic Surgery - Regional anesthesia

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

A

< 10,000 units daily

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9
Q

Orthopedic Surgery - Regional anesthesia

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

Once-daily dosing =>

A

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

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10
Q

Orthopedic Surgery - Regional anesthesia

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

Twice-daily dosing =>

A

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

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11
Q

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…

A

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

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12
Q

Orthopedic Surgery - Regional anesthesia

Brachial Plexus Blocks

list them:

A

Interscalene

Supraclavicular

Infraclavicular

Axillary

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13
Q

Orthopedic Surgery - Regional anesthesia - Brachial Plexus Blocks

Interscalene block

may be used for which procedure?

A

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

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14
Q

Orthopedic Surgery - Regional anesthesia - Brachial Plexus Blocks

Supraclavicular block

Indications - Risk - Precaution:

A

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

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15
Q

Orthopedic Surgery - Regional anesthesia - Brachial Plexus Blocks

Infraclavicular block

Indication and disadvantages:

A

Surgery for arm - elbow - forearm - hand

Disadvantages:

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

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16
Q

Orthopedic Surgery - Regional anesthesia - Brachial Plexus Blocks

Axillary block

Indication - Potential compliactions - Anesthesia considerations

A

<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

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17
Q

Orthopedic Surgery - Regional anesthesia

Forearm Blocks:

A

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

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18
Q

Orthopedic Surgery - Regional anesthesia

Lower Extremity Blocks

A

Femoral nerve

Saphenous nerve

Sciatic nerve

Popliteal

Ankle

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19
Q

Orthopedic Surgery - Regional anesthesia - Lower Extremity Blocks

Femoral nerve block:

A

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

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20
Q

Orthopedic Surgery - Regional anesthesia - Lower Extremity Blocks

Saphenous nerve block:

A

Saphenous vein stripping or harvesting

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

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21
Q

Orthopedic Surgery - Regional anesthesia - Lower Extremity Blocks

Sciatic nerve block:

A

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

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22
Q

Orthopedic Surgery - Regional anesthesia - Lower Extremity Blocks

Popliteal nerve block:

A

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

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23
Q

Orthopedic Surgery - Regional anesthesia - Lower Extremity Blocks

Ankle block:

A

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

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24
Q

Orthopedic Surgery - Intravenous Regional anesthesia (IVRA)

Bier block:

A

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

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25
Q

Orthopedic Surgery

General or Regional Anesthesia will depend on?

A

Proposed surgery - Anticipated length - Position required

Patient acceptance - Co-morbidities

Anticoagulation status

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26
Q

Orthopedic Surgery

Blood Loss significant in:

A

Spinal

(Scoliosis - Instrumentation)

Pelvic fracture repairs

Long bone fracture repairs

Total hip arthroplasty

Trauma

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27
Q

Orthopedic Surgery - Blood Loss

Blood loss from Hip Fractures depends on:

A

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

28
Q

Orthopedic Surgery - Blood Loss - Hip fractures

Occult blood losses can be significant and this depends on a number of things, including:

A

The location of the fracture

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

29
Q

Orthopedic Surgery - Blood Loss - Hip fractures

Hip fx patients are often dehydrated from a lack of adequate PO intake and this leads to:

A

hemoconcentration

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

30
Q

Orthopedic Surgery - Blood Loss - Hip fractures

Preoperative Hct:

A

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.

31
Q

Orthopedic Surgery - Blood Loss - Hip fractures

Reducing Blood Loss - How?

A

Induced hypotensive technique

Bloodless field greatly facilitates arthroscopic surgery (knee, shoulder)

Antifibrinolytics

Antifibrinolytics are used to prevent and treat surgical blood loss

32
Q

Orthopedic Surgery - Blood Loss - Hip fractures - Reducing Blood Loss

Induced hypotensive technique

can be achieved with:

A

Volatile agents - NTG - NTP

Beta-blockers - Diltiazem

33
Q

Orthopedic Surgery - Blood Loss - Hip fractures - Reducing Blood Loss

Risks of Induced hypotensive technique:

A

Spinal cord ischemia

Optic nerve ischemia

Ischemia to any organ

  • Risks vs. benefits!!!!*
  • Communicate with surgeon!!!*
34
Q

Orthopedic Surgery - Blood Loss - Hip fractures - Reducing Blood Loss

Antifibrinolytics

Two types:

A

Lysine analogs

Tranexamic acid (TXA)

Epsilon-aminocaproic acid (AMICAR)

Serine protease inhibitor

Aprotinin

35
Q

Orthopedic Surgery - Hip fractures - Reducing Blood Loss - Antifibrinolytics

Lysine analogs – TXA and amicar

Mechanism of action and more:

A

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

36
Q

Orthopedic Surgery - Hip fractures - Reducing Blood Loss - Antifibrinolytics

Serine protease inhibitor - Aprotinin

considerations:

A

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

37
Q

Orthopedic Surgery - Risks of Blood Product Administration

Which test screens blood donations for transfusion transmitted infections?

A

Nucleic Acid Testing

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

38
Q

Orthopedic Surgery - Risks of Blood Product Administration

Potential viruses that can be transmitted include:

A

HIV - HCV - HBV

Human T-cell lymphocytic virus

CMV

(CMV is the most common transfusion-transmitted disease with an incidence of about 1-3%)

39
Q

Orthopedic Surgery - Risks of Blood Product Administration

Contamination of blood components by which organism holds the largest risk of transfusion-related infection?

A

Bacterial contamination

Can progress to sepsis, which continues to be significant cause of morbidity and mortality related to transfusions

40
Q

Orthopedic Surgery - Risks of Blood Product Administration

Common pathogens that lead to bacterial contamination come from:

A

Flora of the skin

Staphylococcus - Corynebacterium

Bacillus & Streptococcus

secondary to gam0 negative species such as <strong>e. coli</strong> and <strong>Enterobacter cloacae</strong> (kah or kee)

41
Q

Orthopedic Surgery - Risks of Blood Product Administration

Whihc blood product carries the highest risk of bacterial contamination?

A

Platelets

42
Q

Orthopedic Surgery - Risks of Blood Product Administration

Noninfectious Risks of Blood Product Administration

Two types:

A

Immune-mediated Transfusion reactions

Nonimmune-mediated transfusion reactions

43
Q

Orthopedic Surgery - Noninfectious Risks of Blood Product Administration

Immune-mediated Transfusion reactions:

A

Febrile non-hemolytic

Allergic

Transfusion-related immunomodulation

Alloimmunization

TRALI

TA-GVHD

Posttransfusion purpura

44
Q

Orthopedic Surgery - Noninfectious Risks of Blood Product Administration

Nonimmune-mediated transfusion reactions:

A

Transfusion-associated CV overload

Metabolic derangements

Iron overload

Microaggregate administration

45
Q

Orthopedic Surgery - Nonimmune-mediated blood product transfusion reactions

Microaggregate administration:

A

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

46
Q

Orthopedic Surgery - Risks of Blood Product Administration

How do we reduce the riskk for allogenic blood components?

A

Blood Conservation Strategies

such as:

Autologous Blood Transfusion (ABT)

47
Q

Orthopedic Surgery - Blood Conservation Strategies

Autologous Blood Transfusion (ABT)

Three separate processes:

A

Preoperative autologous blood donation (PAD)

Acute normovolemic hemodilution (ANH)

Perioperative blood cell salvage (cell saver)

48
Q

Orthopedic Surgery - Autologous Blood Transfusion (ABT)

Preoperative autologous blood donation (PAD):

A

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

49
Q

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:

A

Acute Normovolemic Hemodilution (ANH)

50
Q

Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)

Acute Normovolemic Hemodilution (ANH)

A

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

51
Q

Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)

Acute Normovolemic Hemodilution (ANH)

Patient Selection:

A

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.

52
Q

Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)

Acute Normovolemic Hemodilution (ANH)

Contraindications:

A

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

53
Q

Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)

Acute Normovolemic Hemodilution (ANH)

What volume of blood can be drawn?

A

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%

54
Q

Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)

Perioperative Blood Salvage (cell saver)

A

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 back to the patient immediately but can be stored at 4 degrees C for up to six hours

On average the Hct ranges 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

55
Q

Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)

Perioperative Blood Salvage (cell saver)

Complications:

A

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

56
Q

Ortho Sgy - Blood Conservation Strategies - Autologous Blood Transfusion (ABT)

Perioperative Blood Salvage (cell saver)

Risks include:

A

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

57
Q

Orthopedic Surgery - Blood Conservation Strategies

Erythropoietin (EPO)

A

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

58
Q

Orthopedic Surgery - Blood Conservation Strategies

Erythropoietin (EPO)

Indicated for:

A

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

59
Q

Orthopedic Surgery - Blood Conservation Strategies

Jehovah’s Witnesses

Beliefs:

A

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

60
Q

Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses

Most understand and accept risks

A

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

61
Q

Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses

Preoperative optimization:

A

Best management is perioperative optimization to maximize alternative blood conservation therapies

62
Q

Orthopedic Surgery - Blood Conservation Strategies -<strong> Jehovah’s Witnesses</strong>

Clear discussion:

A

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

63
Q

Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses

Extracorporeal circulation:

A

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

64
Q

Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses

Prohemostatic medications

A

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

65
Q

Orthopedic Surgery - Blood Conservation Strategies - Jehovah’s Witnesses

Preoperative hgb:

A

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