MAJOR ORTHOPEDIC PROCEDURES
Major operations require special preparation on the part of the
anesthesiologist, increased attention to the details of intraoperative monitoring
and fluid management, and active participation whenever possible in postoperative
pain management.
Management of Blood Loss
Major orthopedic procedures are associated with significant blood
loss[38]
(see Chapter
47
and Chapter 48
).
Public awareness of the dangers of transfusion has increased dramatically as a result
of the acquired immunodeficiency syndrome epidemic and recognition of other risks
of transfusion, such as hepatitis, malaria, and bovine spongiform encephalitis in
Great Britain.[39]
[40]
[41]
A plan to minimize homologous transfusion
for
all patients undergoing joint replacement, tumor resections, or major spinal surgery
should be established. This may begin with predonation of autologous blood,[42]
preoperative erythropoietin[43]
(e.g., in Jehovah's
Witnesses[44]
or patients with preoperative anemia),
intraoperative hemodilution,[45]
[46]
induced hypotension,[47]
conduction anesthesia,
use of a cell saver,[48]
[49]
preservation of normothermia,[50]
or by tolerating
lower hematocrit values postoperatively (i.e., lowering the so-called transfusion
trigger[51]
) and the use of antifibrinolytic agents.
[52]
[53]
In practice,
combination of several of these modalities is most effective in reducing homologous
transfusion. At The Hospital for Special Surgery, most patients predonate autologous
blood and receive hypotensive anesthesia, and the transfusion trigger has been lowered
to the mid-20s. Cell savers, which are expensive and have certain risks,[54]
are used selectively in the operating room for major spinal surgery for scoliosis.
Antifibrinolytic drugs and postoperative cell salvage are probably best used when
expected blood loss exceeds 2 L but is unwarranted in more minor procedures because
of the risks of aprotinin.[52]
[54]
[55]
[56]
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