Blood transfusions in bimaxillary orthognathic surgery: Are ...


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Blood transfusions in bimaxillary orthognathic surgery: Are ...

  1. 1. 314Siew-Ging Gong, BDS, MS, MA, PhD Blood transfusions in bimaxillaryAssistant Professor and Research ScientistCo-Director, Dentofacial Program orthognathic surgery: Are they necessary?Department of Orthodontics and Pediatric DentistrySchool of DentistryUniversity of MichiganAnn Arbor, MichiganVejayan Krishnan, BDS, MS Excessive blood loss is one of the major complications of orthognathicDivision Head surgery. Numerous strategies, including hypotensive anesthetic tech-Oral and Maxillofacial Surgery niques and blood transfusion, have been developed to deal with theHenry Ford HospitalDetroit, Michigan blood loss. Blood for transfusions can be obtained from banked blood or from autologous donation. In this study, the authors looked at 2David Waack, DDS groups of patients who had bimaxillary orthognathic surgery. OnePrivate PracticeWaterford, Michigan group included patients who had autodonated blood (group 1) and who were operated on between 1991 and 1993, and the other patientsReprint requests: did not autodonate and were operated on between 1998 and 2000Dr Siew-Ging GongDepartment of Orthodontics and (group 2). It was found that fewer than 50% of patients in group 1 Pediatric Dentistry were transfused, and none of the group 2 patients were. A protocol toSchool of Dentistry lessen blood loss that should obviate the need for blood transfusion isUniversity of MichiganAnn Arbor, MI 48109 proposed. It is concluded that blood transfusion should no longer be aFax: +734-763-8100 consideration during routine bimaxillary orthognathic surgery. (Int JE-mail: Adult Orthod Orthognath Surg 2002;17:314–317) One of the major complications of or- drome, syphilis, and cytomegalovirus.9,10 thognathic surgery is the potential for ex- Some of the disadvantages of banked cessive blood loss. The literature has several blood are overcome with the use of prede- reports of life-threatening hemorrhage fol- posited autologous transfusions. This has lowing orthognathic surgery. 1–4 Various been shown to be successful in the man- strategies have been adopted to minimize agement of the orthognathic patient.11,12 blood loss during routine orthognathic This practice has become the standard of surgery.3–5 The most notable of these is the care for many surgeons around the world utilization of induced hypotensive anes- who perform orthognathic surgery. thetic techniques to reduce the mean arter- The purpose of the present study was ial pressure to between 55 and 60 mmHg.6–8 twofold: (1) to determine the transfusion This has been achieved through the use of practice in a group of or thognathic inhalational anesthetics in combination surgery patients who had autodonated with other drugs such as beta blockers, ni- their blood prior to surgery, and (2) to de- troglycerin, and sodium nitroprusside. termine the need for transfusion in a Another method for dealing with blood group of orthognathic surgery patients loss following orthognathic surgery is the who had not autodonated their blood. transfusion of blood obtained as an autol- ogous transfusion or from banked blood. Materials and methods The use of banked blood has potential complications, such as errors in typing and This was a retrospective study con- cross-matching, administration, and trans- ducted at 2 different time periods. Patients Int J Adult Orthod Orthognath Surg mission of diseases including hepatitis, were classified into 2 groups based on Vol. 17, No. 4, 2002 malaria, acquired immunodeficiency syn- these time periods. Inclusion criteria were COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
  2. 2. Int J Adult Orthod Orthognath Surg Vol. 17, No. 4, 2002 315 14 12 12 10 10 No. of patients 8 No. of patients 8 6 6 4 4 2 2 0 0 200 400 600 800 10001200 1400 1600 1800 200 300 400 500 600 700 800 Blood loss (mL) Blood loss (mL)Fig 1 Volume (mL) of blood loss of patients in group 1 (n = 43; mean Fig 2 Volume (mL) of blood loss of patients in group 2 (n = 40; mean898.5 mL, SD 418.67 mL). 402.5 mL, SD 139.57 mL). that all patients had bimaxillary orthog- donated 1 unit of blood, and 13 had do- nathic surgery and were healthy (ASA I) in- nated 2 units. Sixteen patients were trans- dividuals. Patients who had any medical fused; this represents 47% of those who conditions that would predispose them to had autodonated their blood and 37% of excessive bleeding were excluded from the total number of patients in group 1. this study. Group 1 consisted of patients Thirteen patients received 1 unit of blood operated on between January 1991 and and 3 received 2 units. December 1993, most of whom (34/43) The amount of blood loss in the group 2 had autodonated their blood prior to patients is shown in Fig 2. The mean blood surgery, and group 2 patients were oper- loss in this group was 403 mL, with a range ated on between January 1998 and De- from 200 to 800 mL. None of the patients cember 2000 and had not autodonated in this group autodonated their blood, and their blood prior to surgery. none was transfused. Data was obtained by review of medical records and charts. Factors evaluated in- Discussion cluded: (1) estimated blood loss (EBL), (2) number of autodonated units of blood, The evolution of contemporary orthog- and (3) blood/blood product replacement. nathic surgery began with the work of Trauner and Obwegeser in 1957.13 Since Results then, major advances have been made in the performance of these operations. There were a total of 83 patients en- These include modifications of the tech- rolled in this study: 43 in group 1 and 40 in niques of performing the procedures14–16 group 2. The average age of the patients as well as the use of newer technology.17,18 was 20 years (range of 15 to 49 years). All Attempts were also made to improve peri- patients had Le Fort I maxillary surgery and operative care of the orthognathic surgery bilateral sagittal split ramus osteotomies in patient. A significant effort was made to the mandible. Rigid fixation was used on manage the excessive blood loss that oc- all patients. curred during these procedures. Blood loss The amount of blood loss in group 1 pa- of between 500 and 2,000 mL for bimaxil- tients is represented in Fig 1. The mean lar y surger y has previously been re- blood loss in group 1 was 899 mL, with a ported.6,19 Blood replacement comprised range of 200 to 1,800 mL. Thirty-four pa- banked blood or autologous transfusions. tients in this group had autodonated their Due to the shortcomings of transfusing blood. Twenty-one patients had auto- banked blood, Hegtvedt et al12 studied the COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
  3. 3. 316 Gong et aluse of autologous transfusions in the or- 4. Administration of local anesthesia withthognathic surgery patient. They demon- vasoconstrictor at incision sites prior tostrated that it was a very useful alternative surgery and allowing adequate time forto banked blood. In the present study, we vasoconstriction to occur. At the start ofhave shown that fewer than 50% of the surgery, the local anesthesia can be ad-group 1 and none of the group 2 patients ministered on the jaw to be worked onwere transfused. first, prior to the surgeons’ leaving the The reason for not transfusing all the room to scrub. By the time the sur-patients in group 1 was the amount of geons are ready to start the operation,blood loss and the cardiovascular response sufficient vasoconstriction will have oc-to the blood loss. If the blood loss was less curred.than 500 mL, then transfusions were not 5. Cocainization of the nasal mucosa priortypically considered. More significant, how- to maxillary surgery. This minimizes theever, was the cardiovascular response to blood loss when the mucosa is re-the blood loss. The adult human body is flected. Nu-gauze (Johnson & Johnson)able to tolerate a blood loss of between is used for this application and can be10% and 30% of blood volume without left in until the surgery is completed.significant cardiovascular compromise.20 6. Placement of the patient in a reverseThis means blood losses of between 600 Trendelenburg position.and 1,800 mL can be tolerated by the 7. Use of an electrocautery unit to makehuman body (assuming total blood vol- incisions. This can reduce blood loss atume of 6 liters). In most hospitals, transfu- the incisions. Care must be taken not tosion practice is guided by the cardiovascu- use excessive heat on the tissue to pre-lar response to blood loss, with the vent necrosis and excessive scarring.anticipated responses to significant blood 8. Incisions that are made cleanly throughloss being tachycardia and hypotension. the periosteum before tissue reflection In group 2, none of the patients were is undertaken. This will prevent exces-transfused. The blood loss in this group sive oozing from macerated mucosa.was significantly lower than group 1. This 9. Packing of open surgical sites with gauzewas achieved by adherence to a protocol to minimize constant oozing of minimize the blood loss.The protocol in-cludes some of the maneuvers described Adherence to a protocol such as theby Hegtvedt 21 to reduce surgical blood one we have used will significantly reduceloss. Our protocol includes the following. operating room time and blood loss. This has been clearly demonstrated in group 2,1. A thorough workup of the patient to where 40 patients undergoing bimaxillary minimize errors in judgment when the orthognathic surgery did not autodonate surgery is performed. Accurate and any blood prior to surgery and did not re- precise model surgery is essential to quire any transfusions postoperatively. It is meet this end. This can also help our conclusion that autodonation is no shorten the operation. longer required prior to performing bimax-2. Hypotensive anesthetic techniques, illary surgery. The blood loss can be mini- when patients can tolerate this maneu- mized by the protocol we have described, ver. Aside from reducing blood loss, this eliminating the need for any blood transfu- can also facilitate visibility during the sions postoperatively. Autodonation or operation by providing a fairly blood- blood transfusion should only be a consid- less operating field.3 eration when significant blood loss is an-3. Skilled surgeons to perform the opera- ticipated due to the patient’s medical his- tion. Aside from shortening the operat- tory or when autogenous bone grafting is ing time, this can also prevent surgical performed simultaneously. During routine mishaps like cutting blood vessels. In a bimaxillary orthognathic surgery on a residency program, only the most se- healthy adult, blood transfusions should nior residents, and only those with a no longer be a consideration. clear understanding of the procedures, should be operating. COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
  4. 4. Int J Adult Orthod Orthognath Surg Vol. 17, No. 4, 2002 317 References 11. Marciani RD, Dickson LG. Autologous transfusion in orthognathic surgery. J Oral Maxillofac Surg 1985;43:201–204. 1. Newhouse RF, Schow SR, Kraut RA, Price JC. Life- 12. Hegtvedt AK, Collins ML, White RP, Turvey TA. Min- threatening hemorrhage from a Le Fort I os- imizing the risk of transfusion in orthognathic teotomy. J Oral Maxillofac Surg 1982;40:117–119. surgery: Use of predeposited autologous blood. 2. Hemmig SB, Johnson RS, Ferraro N. Management Int J Adult Orthod Orthognath Surg 1987;2(4): of a ruptured pseudoaneurysm of a sphenopala- 185–192. tine artery following a Le Fort I osteotomy. J Oral 13. Trauner R, Obwegeser H. The surgical correction Maxillofac Surg 1987;45:533–536. of mandibular prognathism and retrognathia 3. Lanigan DT, Hey JH, West RA. Major vascular com- with consideration of genioplasty. Oral Surg Oral plications of orthognathic surgery: Hemorrhage Med Oral Pathol 1957;10:677–689. associated with Le Fort I osteotomies. J Oral Max- 14. Dal Pont G. Retromolar osteotomy for the correc- illofac Surg 1990;48:561–573. tion of prognathism. J Oral Surg 1961;19:42–47. 4. Lanigan DT, Hey JH, West RA. Major vascular com- 15. Hunsuck EE. A modified intra-oral sagittal split- plications of or thognathic surger y : False ting technique for correction of mandibular aneurysms and arteriovenous fistulas following prognathism. J Oral Surg 1968;26:250–253. orthognathic surgery. J Oral Maxillofac Surg 16. Bell WH, Schendel SA. Biologic basis for modifica- 1991;49:571–577. tion of the sagittal ramus split operation. J Oral 5. Lustbader DP, Schwartz MH, Zito J, Stern M. The Surg 1977;35:362–369. use of percutaneous transcatheter embolization 17. Paulus GW, Steinhauser EW. A comparative study to control postoperative bleeding following Le of wire osteosynthesis versus bone screws in the Fort I osteotomy: Report of three cases. J Oral treatment of mandibular prognathism. Oral Surg Maxillofac Surg 1991;49:426–431. Oral Med Oral Pathol 1982;52:2–6. 6. Schaberg SJ, Kelly JF, Terry BC, Posner MA, Ander- 18. Jeter TS, Van Sickels JE, Dolwick MF. Modified son EF. Blood loss and hypotensive anesthesia in techniques for internal fixation of sagittal ramus orofacial corrective surgery. J Oral Surg 1976; osteotomies. J Oral Maxillofac Surg 1984;42: 34:147–156. 270–272. 7. Lessard MR, Trepanier CA, Banbault JP, et al. 19. Kelly JF, Terry BC. Blood volume changes in the Isoflurane-induced hypotension in orthognathic surgical treatment of oro-facial deformities: A surgery. Anesth Analg 1989;69:379–383. preliminary report. J Oral Surg 1973;31:90–94. 8. Fromme GA, MacKenzie RA, Gould AB Jr, Lund BA, 20. Moore FD. The effects of hemorrhage on body Offord KP. Controlled hypotension for orthog- composition. N Engl J Med 1965;273:567–577. nathic surgery. Anesth Analg 1986;65:683–686. 21. Hegtvedt AK. Intraoperative and postoperative 9. Myhre BA. Fatalities from blood transfusion. patient care. Oral Maxillofac Surg Clin North Am JAMA 1980;244(12):1333–1335. 1990;2(4):857–868. 10. Faust RJ, Warner MA. Transfusion risks. Int Anesth Clin 1990;28(4):184–189. COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.