Blood Management And Advanced Techniques In Tka Syllabus
Blood Management And Advanced Techniques In Tka Syllabus blood_management_and_advanced_techniques_in_tka_syllabus blood_management_and_advanced_techniques_in_tka_syllabus 2 2013 pdf 258413772373414384
2013-03-17
: Pdf Blood Management And Advanced Techniques In Tka Syllabus blood_management_and_advanced_techniques_in_tka_syllabus 3 2013 pdf
Open the PDF directly: View PDF 
.
Page Count: 26
| Download | |
| Open PDF In Browser | View PDF |
1/14/2013 The Effect of a Comprehensive Blood Management Protocol on Decreasing Transfusion Rates Following Primary Total Joint Arthroplasty Charles A. Hope, II, MD1, Robert W. Eberle2 , Constance B. Squibb, RN, BSN, MPA2 (1) Optim Orthopedics, Savannah, GA (2) Medtronic Advanced Energy, LLC, Portsmouth, NH Presented at the AABB Annual Meeting and CTTXPO 2012 October 6-9, 2012, Boston, MA 1 | MDT Confidential Disclosures • Stryker – Consultant and Speaker on Hip and Knee Arthroplasty surgical techniques and instrumentation. • Medtronic Advanced Energy – Consultant and Speaker Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 2 | MDT Confidential INTRODUCTION • Primary total joint arthroplasty (TJA) is generally an elective procedure and is associated with significant blood loss. • Considerable variations exists in transfusion practices and in strategies for the management of blood loss from primary TJA which include; – Pre-donation of autologous blood – Salvage and re-infusion of intraoperative and postoperative shed blood – The pre-operative use of erythropoietin for the stimulation of red blood cell production and volume. Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 3 | MDT Confidential 1 1/14/2013 4 | MDT Confidential 5 | MDT Confidential Landscape is Changing … • Medicare no longer paying for the first three units of blood product • Headlines are stating, “Hospitals are Overspending on Blood Transfusions” October 9, 2012 Health Leaders Media • One report estimates that $65 M could be saved if readmission after hip and knee replacement were avoided 6 | MDT Confidential 2 1/14/2013 PURPOSE • The purpose of our study was to evaluate the influence of a comprehensive surgical and clinical blood management protocol on the post-operative transfusion rate in patients undergoing primary TJA. Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 7 | MDT Confidential MATERIALS AND METHODS • Study – Prospective, continuous series – 505 primary TJA procedures – Intra- and peri-operative blood management protocol • Control – Retrospective continuous series – 1,092 control primary TJA procedures – Performed prior to blood management protocol implementation • Single surgeon – Similar MIS/Tissue Sparing surgical techniques and TJR implants Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 8 | MDT Confidential MATERIALS AND METHODS Pre-Operative Blood Management Protocol Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 9 | MDT Confidential 3 1/14/2013 MATERIALS AND METHODS Initial Screening Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 10 | MDT Confidential MATERIALS AND METHODS Hgb < 13 g/dl and inadequate Iron Levels Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 11 | MDT Confidential MATERIALS AND METHODS Hgb < 13 g/dl and adequate Iron Levels Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 12 | MDT Confidential 4 1/14/2013 MATERIALS AND METHODS Hgb> 13 g/dl and adequate iron levels and can tolerate oral iron Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 13 | MDT Confidential MATERIALS AND METHODS Intra-Operative • For the study group, the intra-operative blood management protocol utilized the Aquamantys® (AQM) bipolar sealing technology to achieve and maintain wound hemostasis. Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 14 | MDT Confidential MATERIALS AND METHODS Intra-Operative The Aquamantys® System with Transcollation technology combines radiofrequency (RF) energy and saline for haemostatic sealing and coagulation of soft tissue and bone at the surgical site. RF energy and saline are applied to tissue Blood Management Protocol Hope, et al. Heat induced shrinkage occurs Vessels <1mm may be occluded, reducing bleeding AABB Annual Meeting October 6-9, 2012, Boston, MA 15 | MDT Confidential 5 1/14/2013 RESULTS • There was no significant difference in demographics between study groups. • Of the 505 treatment TJA cases, there were 4 (< 1.0%) cases in which post-operative allogenic blood transfusion was necessary. • In the control group (n=1,092), there were 57 (5.3%) cases requiring allogeneic blood transfusions. • This proportional difference was statistically significant (p < 0.0001). Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 16 | MDT Confidential SURGEON RESPONSE • In subsequent patients − Post-operative reinfusion drains were eliminated for Total Knee Arthroplasty. − The use of cell saver and reinfusion drains were eliminated in Total Hip Arthroplasty. Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 17 | MDT Confidential CONCLUSIONS • Our findings show a significant decrease in allogeneic transfusion rates following primary TJA when a total intra- and peri-operative blood management protocol was implemented featuring pre-operative anemia control and active intraoperative hemostasis control. Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 18 | MDT Confidential 6 1/14/2013 CONCLUSIONS Clinical Value Continuum of Combined Protocols Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 19 | MDT Confidential CONCLUSIONS Covance report; 2008 MedPAR database based on ICD-9-CM Codes for 100% of Medicare beneficiaries. Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 20 | MDT Confidential CONCLUSIONS • The proposed blood management protocol was easy to implement and effective within the scope of our single surgeon study. • Further study of this blood management protocol beyond a single surgeon’s experience is warranted. Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 21 | MDT Confidential 7 1/14/2013 THANK YOU! Blood Management Protocol Hope, et al. AABB Annual Meeting October 6-9, 2012, Boston, MA 22 | MDT Confidential 8 1/15/2013 Tourniquetless TKA VUMEDI January 15, 2013 H. Del Schutte, Jr., M.D. Medical Univ. of South Carolina Disclosure • Consultant / speaker • Medtronic • Stryker • Depuy Tourniquet Use 1 1/15/2013 Tourniquet Surgery Tourniquetless tka • Arterial calcification 2 1/15/2013 Tourniquet use • Arterial damage Tourniquet use • Arterial damage Tourniquetless tka • Obesity 3 1/15/2013 Tourniquetless tka • Infection – antibiotic concentration, tissue oxygen perfusion • Blood loss • Vascular Effects – Arterial damage • Return to OR – DVT • Multi-organ effects – Pulmonary, hepatic, splenic • Cognitive function • Pain • Muscle function / Rehab Tourniquet use • Antibiotic concentration • SCIP guidelines – Vancomycin - 1hour – Ancef - 20 min Blood loss •Tka vs Hand surgery •Transfusion rate •Wound healing •Infection •Rehab •Hematoma Rate Picture courtesy Fred Cushner •Anticoagulants •Pain •Decreased rom •Infection 4 1/15/2013 Tranfusion in TKA •6 % - 42% incidence •$200/unit - $1000 total cost •LOS .5 to 1 day longer •Per surgery costs in pts with transfusions – •$3000 knees •$2000 hips Picture courtesy Fred Cushner •Medical risks - infection •Decreased supply •Increased demand Tourniquet use • Blood loss – Blood loss after tka – effect of tourniquet release and cpm - Lotke et al JBJS 1991 • Group 1 full tourniquet and splint • Group 2 full tourniquet and cpm • Group 3 tourniquet released and splint –1400cc blood loss • Group 4 tourniquet released and cpm –1800 cc blood loss Hematoma formation 5 1/15/2013 Minimizing Blood loss •Tissue Adhesives •Tranxemic Acid •Tourniquet use •Transcollation®* Picture courtesy Fred Cushner *A combination of radiofrequency (RF) and saline that provides hemostatic sealing of soft tissue and bone. Epinephrine Injection in TKA • Injected along anticipated arthrotomy site • Injected into fat pad Bipolar sealer technology in TKA 6 1/15/2013 Transcollation Technology in TKAs Transfusions reduced by 64% ** Blood loss reduced by 30% * * Marulanda GA, et al. Surg Technol Int. 2005;14:281-6. ** Weeden S. EFORT; 2007 Comparison of Blood loss in Total Knee Arthroplasty with and without Tourniquet use: a retrospective study of 372 patients Schutte Jr HD, Martin SM, Patrick M, Barfield W, Kavolous J.,. Calculated blood loss • 172 TKAs with tourniquet 1,499.8 • 113 without tourniquet 1,538.5 • 87 w/o tourniquet and with Transcollation 1,368.5 7 1/15/2013 Transfusion rate • 172 TKAs with tourniquet 29% • 113 without tourniquet 17% • 87 w/o tourniquet and with Transcollation 13% Drains - $50-250 Tourniquetless TKA – OR time Patient group 172 TKAs with tourniquet 113 without tourniquet 87 w/o tourniquet and with Transcollation OR TIME 62.7 61.5 55.9 8 1/15/2013 Tourniquetless TKA – COST Cost reductions in our series based on: • No tourniquet • No drain • 6 minutes OR time Tourniquet use • Arterial damage Tourniquet use • Arterial damage –Often missed at surgery –.1% primary tka –.2% revision tka • 50% lawsuit 9 1/15/2013 Tourniquet use • Arterial damage • Return to OR –Missed arterial injury –Hematomas Tourniquet use – DVT? • • • • • PTE was detected in 6 patients (7.0%) 2 of 5 (40.0%) patients bilateral TKAs w T 3 of 42 (7.1%)bilateral TKAs w/o T 1 of 14 (7.1%) unilateral TKA w T PTE did not occur in patients who underwent unilateral TKA without tourniquet. • median D-Dimer significantly higher in patients with tourniquet, both in unilateral TKA ( p=0.003) and in bilateral TKAs (p=0.004). Nishiguchia,et al 2005 Tourniquet use • Pulmonary function • Multi-organ function 10 1/15/2013 Tourniquet release Tourniquet use • Pulmonary function – “Tourniquet application within a safe limit may cause pulmonary gas exchange impairment several hours after tourniquet deflation” Tourniquet use • Multi-organ function 11 1/15/2013 Tourniquet use • Cardiac function J Int Med Res. 2010 Jul-Aug;38(4):1519-29. Effect of high-dose vitamin C on oxygen free radical production and myocardial enzyme after tourniquet ischaemia-reperfusion injury during bilateral total knee replacement. Lee JY, Kim CJ, Chung MY. Tourniquet use • Cognitive function Tourniquet use • Cognitive function Cognitive dysfunction after tka Rodriguez et al, Jl. of Arthroplasty 2005 HITS (cerebral emboli) 22 of 37 pts. Cognitive dysfunction 41% at 1 week 18% at 3 mos. higher complication rate 12 1/15/2013 Tourniquet use • Pain Tourniquet use • Pain • Vandenbussche et al, International Orthopedics – Prospective randomized study with and without tourniquet Sig. decreased pain at 6 hours – Increased flexion at 5 days • Abdel-Salam, JBJS 77-B – 80 pts. – sig. degcreased pain without tourniquet • Barwell, JBJS 79-B – 88 pts. Sig. decreased pain with early release • Worland, Jl of Arthroplasty 1997 – 28 bilat knees, sig. decreased pain without tourniquet Tourniquet use • Muscle function 13 1/15/2013 Tourniquet use • Patellofemoral tracking – Husted, Jl. of Arthroplasty 2005 • Tourniquet deflation improved patellar tracking – Lombardi, JBJS-B 87-B • Decreased need for lat. release if tourniquet released Tourniquet use • Muscle function Arthroscopy. 2001 Jul;17(6):603-7. The effect on leg strength of tourniquet use during anterior cruciate ligament reconstruction: A prospective randomized study. Nicholas SJ, Tyler TF, McHugh MP, Gleim GW. CONCLUSIONS: Tourniquet use of less than 114 minutes during ACL reconstruction had no effect on the strength of the lower extremity after surgery. Tourniquet Use • Range of Motion • Ledin, Aspenberg, and Good. Acta Orthopaedica 2012; 83 (5): 499–503 499 – Randomized RSA study with 50 patients – Found less postoperative pain and greater range of motion (11° more) in the non-tourniquet group (p = 0.001 at 2 years). 14 1/15/2013 Range of Motion Range of Motion Tourniquet Use • Cement Interdigitation • Ledin, Aspenberg, and Good. Acta Orthopaedica 2012; 83 (5): 499–503 499 – No statistically significant effect on prosthesis migration • Vertullo CJ. Presented at the Australian Knee Society Annual Scientific Meeting 2009, Palm Cove; AOA Annual Science Meeting 2010, Adelaide; ISAKOS Meeting 2011, Rio De Janeiro. – Prospective, randomized trial of 40 patients, quantified cement penetration in tourniquet and tourniquetless arms. – Mean cement penetration and standard deviation (SD) were nearly identical in each group (2.98 mm with SD of 0.82 in the tourniquet group versus 3.10 with SD of 0.84 in the tourniquetless group). 15 1/15/2013 Tourniquetless TKA - Rehab • Our series of 372 patients Patient group ROM at 8wks 172 TKAs w/ tourniquet 113 w/o tourniquet 87 w/o tourniquet and with Transcollation 105.4 109.5 114.6 CMS - Applicable Conditions • The FY 2012 final rule addressed the following applicable readmissions: 1. Acute myocardial infarction 2. Heart failure 3. Pneumonia Readmission for orthopaedic procedures is NOT currently covered; this may change… 47 Federal Register Volume 76, Number 87 (Thursday, M ay 5, 2011) Unplanned Readmissions after TKA - Poster #20 AAHKS 2012 Consideration 30 Day Readmission Rate Metric 5.65% Readmission associated with: Increased LOS p < .001 Revision surgery p < .001 Most common readmitting diagnoses: Post-op infection .5% of pts Unspecified prosthetic complication .31% of pts Hematoma .28% of pts PE .22% of pts Financial Impact: 48 Avg profit – w/ reimbursement $5,219 Re-admitted pts – w/ reimbursement $2,583 less profitable (p=.001) Net avg loss – w/o reimbursement $5,326 per episode of care Derman et al. Risk Factors, Causes, and the Financial Implications of Unplanned Readmissions after TKA. Poster #20, AAHKS 2012. 16 1/15/2013 Relationship between timing of TQ release and readmission Rama et al, J Bone Joint Surg, 2007 Early-TQ Release Late-TQ Release P Value All regional complications Parameter 7.9% 14.8% .006 Complications that required another operation* .3% 3.1% .04 *Wound dehiscence, hematomas, and infections that required drainage and / or debridement and knee stiffness that required manipulation with pt under anesthesia. 10x rate of reoperations due to post op complications in late versus early TQ release group! Rama K, Apsingi S, Poovali S, Jetti A. Timing of tourniquet release in knee arthroplasty. J Bone Joint Surg am, 2007; 89:699-705. Tourniquetless TKA • Infection – antibiotic concentration, tissue oxygen perfusion • Blood loss • Vascular Effects – Arterial damage • Return to OR – DVT • Multi-organ effects – Pulmonary, hepatic, splenic • Cognitive function • Pain • Muscle function / Rehab Tourniquetless TKA • Intraoperative (real time) control of blood loss • Decreased metabolic challenges • Improved postoperative function 17 1/15/2013 Thank you 18
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.4 Linearized : No Page Count : 26 Creator : PDFMerge! (http://www.pdfmerge.com) Producer : iText® 5.3.5 ©2000-2012 1T3XT BVBA (ONLINE PDF SERVICES; licensed version) Modify Date : 2013:01:15 18:05:24-05:00 Create Date : 2013:01:15 18:05:24-05:00EXIF Metadata provided by EXIF.tools