The document discusses strategies to reduce blood loss and transfusion requirements during total hip and knee replacement surgeries. It notes that average blood loss is 1.5 liters for THR and TKR but hidden blood loss accounts for 26-50% more. Revision surgeries have even higher blood loss. Options discussed to reduce transfusions include preoperative autologous blood donation, blood conservation measures, use of erythropoietin to increase hematocrit levels preoperatively, and hemostatic agents. Risks of transfusions include errors, infections, increased costs and length of stay.

1. Dr. Jatinder S. Luthra

2.  None

3.  Average 1 – 1.5 litres
 Appreciated and replaced

4. Average blood loss after THR 1.5L
Hidden loss 470ml ( 26%)
 Average blood loss after TKR 1.5L
Hidden loss 765 ml ( 50 %)

5.  Revision Hip surgeries
– 2.5L – 3.0 L
 Cementless TKR –
Higher blood loss
 B/l TKR

6.  Allogenic Blood transfusion
 Preoperative Autologous blood Donation
 Blood conservation measures

7.  Primary THR – 2.0 ( +/- 1.8)
 Revision THR – 2.9 ( +/- 2.3)
Bae et al Arthroplasty 1999
 Primary TKR – 1-2 units
 Revision TKR – 3-4 units

8.  Pre op Hb - < 10g - 90 %

9.  Weight
 Age
 Aspirin
 Female
 Comorbidities
 B/L TKR

10. Risks of Blood Transfusion
 Clerical error
 Bacterial
contamination
 Increased length of
stay
 Immunomodulation
 Cost

11.  1-2 units – primary joint replacement
 4-6 units – revision joint replacement
 Hb > 11gm
 5-7 days interval ( last unit 3 days before
surgery)

13.  Scheduling difficulties
 Limited shelf life
 Clerical errors
 Bacterial contamination

16.  Perioperative blood salvage
 Haemodilution
 Intraop Pharmacologic agents
 Increased Haematopoiesis

17.  Preop blood donation
Post op Blood transfusion
 Blood lost intraop lower haematocrit

18. TOPICAL AGENTS SYSTEMIC ANTIFIBRINOLYTIC
 Thrombin  Desmopressin
 Fibrin glue  Aprotinin
 Collagen  Tranexamic acid
 Epinephrine sponges  E-aminocaproic acid
 Bone wax

20. ERYTHROPOIETIN

21.  Glycoprotein hormone
 Secreted by Kidneys
(Peritubular cells)
 Acts on RBC
progenitors

22. Alex Schwazer
 Increases oxygen Italian Race walker
delivery
 Endurance sports
Cycling
Boxing
Athletics
Rowing

23. LANCE ARMSTRONG

26. 50%
40%
30%
20% Blood transfusion
10%
0%
Placebo 20000EPO 40000 EPO

27. Blood Transfusion
60%
40%
20% Blood Transfusion
0%
Placebo EPO

29. 40%
30%
20% Blood transfusion
10%
0%
EPO PAD EPO +PAD

30. 30%
25%
20%
15%
Blood Transfusion
10%
5%
0%
EPO PAD

31.  Dose – 40,000 IU ( 600IU/Kg)
 Augmented with iron supplementation
 In most studies drug is indicated for preop
anemia in range of 11g to 13g

32.  Increased risk of Thromboembolic Events

38.  Level A evidence to recommend use of Erythropoietin
before major orthopaedic procedure
 FDA approved drug before major orthopaedic surgeries
 NICE guideline recommend EPO only for anemia
associated with Ca and renal disease
 Most studies the Pre op Hb level was 11g to 13g
 Extremely useful in patients with rare antibodies in
blood, Jehovah witness !
 Post Op anemia is not corrected by Erythropoietin !!!

39. THANK YOU

40.  Exacerbation of hypertension ?
 Best effect in patients with Hb 10 – 13
 Below Hb 10 Erythropoitin is already secreted
unless renal failure