As in the majority of the hospitals, we use a blood management program. We use postsurgery blood recovery system in some situations: low presurgery Hb level, tranexamic acid contraindication..., but, if the surgeon practices an intraarticular infiltration of local anesthetic, within a fast recovery system, we won't be able to use it, . What is more important in your opinion, faster recovery or lower possibility of blood transfusion?
That is a difficult question and will depend upon the comorbidity of a given patient. In a relatively young patient without any major comorbidity, fast track is most likely the better option as most of these patients will tolerate quite well a lower hemoglobin concentration as they will compensate the decrease in oxygen delivery by increasing cardiac output. So in this group you most likely can still avoid blood transfusion. In patients with a higher risk profile I believe one should balance the advantage of fast track versus the potential disadvantage of blood transfusion. A potential option to consider is the use of a small cell salvage machine that remains with the patient for a few hours after the intervention. But this is quite an investment for the hospital.
It is indeed a difficult question.
One option is collecting retransfusion blood for 4-6 hours, and then changing to introduction of local anesthetic solutions. If you you spinal or general anesthesia the first hours are already covered by pain relief.
Kindest regards,
Robert Slappendel
Throughout my surgical life I have used all sorts of ways to close and care of a post joint wound.
The original three drains, gave their way to auto-transfusion drains and for the last 7 years to no drains.
In the case of low pre-op Hb of known cause, discussion and treatment with the haematologist can help to Hb increase. If the cause is unknown then again haematologist has to know and after consultation with him and the anesthetist cell saver machine can be used.
In the case, as my practice is now, of no drain use, there is no problem with the injections of any agents locally, as these agents will "remain locally" (more or less).
In case of Low post op Hb, iron tablets for about three weeks may help the Hb recovery.
For knee replacements and if I use a tourniquet, I use no tranexamic acid due to my fear of post op PE. If there is no tourniquet used, then I ask the anaesthetist to inject it systemically near the end of the operation.
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