Management of Jehovah's Witness patients for scoliosis surgery: the use of platelet and plasmapheresis

Serum Levels of VWF, t-PA, TNF-α, and ICAM-1 in Patients Receiving Hemocoagulase Combined with Platelet-Rich Plasma during Total Hip Replacement

Objectives

This study aimed to investigate the effect of hemocoagulase combined with platelet-rich plasma (PRP) in total hip replacement (THR) on reducing bleeding and improving knee joint function in the patients with osteoarthritis.

Methods

From February 2018 to February 2020, 80 osteoarthritis patients undergoing THR were included in the study, of which 40 cases were treated with PRP and hemocoagulase (test group) in the joint capsule in THR and the other 40 cases received saline and thrombin in the joint capsule after THR (control group). Postoperative drainage and corresponding functional exercise were performed for the two groups 12 hours after operation. The outcome measures including operation time, soft-tissue release, blood routine, drainage volume, perioperative blood loss, postoperative incision inflammation, deep vein thrombosis (DVT), and range of motion (ROM) of the joint were recorded.

Results

The hemoglobin and hematocrit values of the test group on the second postoperative day were significantly higher than those of the control group (P < 0.05). The postoperative drainage volume and perioperative blood loss were significantly lower than those of the control group (P < 0.05). The test group was better than the control group in the ROM of the joint at 7 and 15 days after the operation (P < 0.05). A lower value of prothrombin time and activated partial thromboplastin time was revealed in the test group compared with the control group (P < 0.05). No significant difference in the operation time, intraoperative soft-tissue release, postoperative incision inflammation, incidence of DVT, incidence of deep infection, and ROM at day 90 after THR was found in the two groups (P > 0.05).

Conclusions

The application of hemocoagulase combined with PRP in THR can reduce perioperative blood loss, increase wound healing speed and quality, and improve coagulation and immune function. It is a safe and effective method for the patients with knee osteoarthritis who underwent THR.

Perioperative blood conservation strategies for pediatric scoliosis surgery

PURPOSE

Many pediatric patients with severe scoliosis requiring surgery have baseline anemia. Pediatric scoliosis fusion surgery is associated with perioperative blood loss requiring transfusion. As such, many patients in this surgical population could benefit from a perioperative blood conservation program.

METHODS

Here we present a narrative review of perioperative blood conservation strategies for pediatric scoliosis surgery involving nurses, transfusion medicine physicians, anesthesiologists, surgeons, dieticians, perfusionists and neurophysiologists spanning the pre-, intra- and postoperative phases of care.

RESULTS

The review highlights how perioperative blood conservation strategies, have the potential to minimize exposures to exogenous blood products. Further, we describe a relevant example of blood conservation related to the care of a Jehovah's Witness patient undergoing staged scoliosis repair. Lastly, we outline areas which would benefit from clinical studies to further elucidate perioperative blood conservation interventions and their outcomes relevant to pediatric scoliosis surgery patients.

CONCLUSION

Interdisciplinary communication and meticulous blood conservation strategies are proving to be a means of reducing if not eliminating the need for allogeneic blood products for surgical correction of pediatric scoliosis.

The effects of platelet apheresis on blood saving and coagulation in bilateral total hip replacement: A prospective study on 60 patients

BACKGROUND

Preoperative platelet rich plasma (PRP) harvest has been used in cardiopulmonary surgery for more than 10 years. There is no previous study dealing with PRP in bilateral total hip replacement. This study was to investigate the effects of PRP on blood saving and blood coagulation function in patients with bilateral total hip replacement.

PATIENTS AND METHODS

A prospective, randomized, clinical trial was conducted. Sixty patients were enrolled, including 30 patients undergoing PRP in the PRP group and 30 controls. The surgery time, total transfusion volume, blood loss, allogenic blood transfusion, autologous blood transfusion, urine volume, drainage volume, some blood parameters (including Fibrinogen, D-dimer, Prothrombin time, international normalizedratio, activated partial thromboplastin time, Platelet, Haemoglobin B), thrombelastogram (TEG) and blood-gas parameters were studied in the perioperative stage. The measurement data were analyzed statistically.

RESULTS

There was no statistical difference between the two groups in baseline characteristics, surgery time, total transfusion volume, blood loss, autologous blood transfusion, etc. Allogenic blood transfusion in the PRP group was less than the control group with statistical difference (p = 0.024). Fibrinogen in the PRP group was higher than the control group (p = 0.008). Among the TEG indicators, activated clotting time and coagulation time K in the PRP group were less than the control group. Clotting rate and maximum amplitude in the PRP group were higher. The blood-gas parameters presented no statistical difference.

CONCLUSION

The results suggested that PRP probably played a positive role in blood coagulation function as well as blood saving in patients with bilateral total hip replacement.

Blood conservation strategies in orthopedic surgeries: A review

In orthopedics management of surgical blood loss is an important aspect which has evolved along with modern surgeries. Replacement of lost blood by transfusion alone is not the answer as was considered earlier. Complications like infection and immune reaction due to blood transfusion are a major concern. Today numerous techniques are available in place of allogenic blood transfusion which can be employed safely and effectively. In this article we have reviewed these techniques, their merits and demerits.

Blood conservation techniques in spinal deformity surgery: a retrospective review of patients refusing blood transfusion

STUDY DESIGN

A retrospective review.

OBJECTIVE

To review the effectiveness of blood conservation techniques in the spinal fusion of patients that refuse blood transfusion; specifically the Jehovah's witnesses population.

SUMMARY OF BACKGROUND

Spinal surgery can be challenging in patients refusing blood transfusion. There is paucity in the literature examining blood conservation techniques in spinal surgery.

METHODS

The radiographic and medical records of 19 Jehovah's witnesses patients who underwent spinal deformity surgery at a single institution between 2000 and 2003 were reviewed. Patients were assessed for excessive blood loss (EBL), deformity correction, operative time, perioperative complications, and hospital stay. At latest follow-up (mean, 40 months; range, 8-76) the patients were examined for radiographic fusion, progression and complications.

RESULTS

Spinal fusion was attempted in 19 patients, with a mean age of 17 years (range, 10-36 years). All 19 patients were identified through the "Bloodless Surgery Program." Hypotensive anesthesia, hemodilution, and cell saver was employed for all 19 cases. Erythropoietin with supplemental iron was used in 15 patients. Aprotinin was used in 3 patients. EBL and blood returned by cell saver averaged 855 and 341 mL, respectively. Operative times average 315 minutes. The average drop in hemoglobin from after surgery was 3.1 g/dL. There were 2 intraoperative complications: (i) transient loss of somatosensory evoked potential/motor evoked potential signals; and (ii) one surgery abandoned due to EBL. The average spinal deformity correction was 58%. There were 3 postoperative complications, none related to their refusal of a transfusion. 17 patients were available for radiographic and clinic follow-up of at least 24 months. All displayed radiographic fusion without progression.

CONCLUSION

These blood conservation techniques allow satisfactory completion of deformity surgery on those patients not willing to be transfused and without major anesthetic or medical complications.

The effects of platelet apheresis in total hip replacement surgery on platelet activation

BACKGROUND

Autologous platelet rich plasma (PRP) harvest with autotransfusion devices has been used for 10 years in cardiac surgery and recently in orthopedics as a blood saving method. The quality of the harvested platelets has not been adequately examined, in part because of methodological difficulties in studying platelet function during surgery.

METHODS

Twenty patients undergoing primary total hip replacement (THR) were studied. Ten patients underwent an immediate preoperative platelet apheresis to obtain concentrated platelet rich plasma (c-PRP). The other 10 patients not undergoing apheresis were allocated to a control group. Platelet activation was evaluated as the population expressing P-selectin on the surface of platelets in the c-PRP and in blood samples collected pre-, per- and postoperatively. The method used was flow cytometry.

RESULTS AND CONCLUSIONS

A minor population of activated platelets was found to be circulating in the patients' blood, with a highly significant difference between patients (P = 0.005), and with a range of 1-23% in peroperative activation. PRP harvest did not significantly alter platelet activity. The platelet apheresis procedure did not inhibit platelet function in the c-PRP, as judged by a high proportion of platelets that could be activated in ADP stimulation experiments (mean value +/- SD 86% +/- 7.5%).

Preoperative platelet-rich plasmapheresis and hemodilution with an autotransfusion device in total hip replacement surgery

The effectiveness of both preoperative autologous donation (PAD) and intraoperative autotransfusion (IAT) with an autotransfusion device has recently been questioned. Preoperative apheresis, with separation of concentrated platelet rich-plasma (c-PRP) and erythrocyte concentrate (ERC), represents an aggressive use of the autotransfusion device. Can such a procedure replace PAD in total hip replacement surgery (THR)? Eighty patients undergoing THR were investigated in a prospective and randomized study. Forty patients underwent PAD, and 2 units of ERC + plasma were retrieved within 4 weeks preoperatively. Another 40 patients underwent an immediately preoperative apheresis with a concomitant hemodilution with 4% albumin, retrieving c-PRP (30% of the platelet pool) and 2 units of ERC. Both groups used IAT up to 2 hours postoperatively, with 3% dextran-60 as a plasma substitute according to our standard of care. There were no differences in blood loss, B-hemoglobin or allogeneic transfusions between the groups: 85% of the patients did not receive allogeneic blood. Both apheresis and reinfusion of c-PRP had minor impact on the coagulation parameters. Platelet count increased slightly but significantly (P<0.05) from 154 to 179 x 10(9)/L after the c-PRP at wound closure. Preoperative apheresis with an autotransfusion device, separating platelet-rich plasma and erythrocyte concentrate, is a useful alternative for patients who are unable to utilize the PAD technique for either religious or practical reasons.