Blood conservation techniques in orthopaedic surgery.

In summary, reduction of blood loss and coincidental decrease in the number of blood transfusions is now of paramount importance in orthopaedic surgery. Methods to reduce blood loss include preoperative planning, hypotensive anesthesia, and meticulous surgical technique. If transfusion is necessary, autologous replacement is always preferable. Overall, the goals in blood conservation in surgery are first to decrease the amount of blood lost, and second to be sensible in replacement of this loss.

Blood products: optimal use, conservation, and safety.

A review of our experience in total joint arthroplasty revealed that the cell saver was not cost-effective in the case of routine primary hip or knee replacement. Its use should be restricted to cases of revision hip and knee surgery in which infection has been ruled out. Preoperative aspiration remains the most reliable method for accomplishing this. However, if the aspiration is negative and the intra-articular fluid obtained at the time of surgery is suspicious for infection, either in appearance or on Gram stain or cell count, it is best to abandon use of the cell saver. Predonation should be routine for all hip replacement cases unless there are specific contraindications. In general, there is good acceptance of this program by patients, although a few have specifically indicated they would prefer to run the risk of homologous transfusion. Two units available for primary replacement are more than ample. In cases of revisions, a first revision justifies a minimum of 3 units. For complex revision cases involving patients with three or more previous procedures on the hip, or those requiring significant bone resection or large segment grafting, the maximum possible number of units should be obtained. Autologous blood reinfusion should be done for essentially the same indications as homologous transfusion even though risks are sharply reduced. The local source for autologous collection will then follow its own specific protocol for the disposition of remaining units. In every case, the surgical technique should be careful and directed toward limiting intraoperative blood loss.

Left ventricular function in hospitalized geriatric patients.

Left ventricular ejection fraction was measured by gated wall motion in 62 patients, 75 years old or older, admitted to a Geriatric Acute Assessment Ward. From this group, 42 patients not taking digitalis or other cardioactive medication were selected for analysis. Thirty of them had clinically identifiable heart disease, whereas 12 did not. Resting left ventricular ejection fractions in the 12 patients without clinically identifiable heart disease averaged 0.60 +/- 0.09. None had an ejection fraction below 0.50. In the 30 patients with clinically identifiable heart disease, mean ejection fraction was 0.49 +/- 0.15 (range 0.17-0.84), P less than 0.01. In the patients with heart disease, reduction of ejection fraction was correlated with either cardiac enlargement or congestive heart failure. Neither age nor electrocardiographic abnormalities added to the strength of this correlation. Fifty-eight per cent of patients with congestive heart failure had ejection fractions greater than or equal to 0.40, suggesting that congestive heart failure in this age group is frequently related to diastolic left ventricular dysfunction unaccompanied by major systolic dysfunction. The prognosis of patients with congestive heart failure and ejection fractions above 0.35 was significantly better than of patients with congestive heart failure and ejection fractions below 0.35. From these data and other data available in the literature, it is proposed that the lower limit for ejection fraction be 0.50 for patients 75 years old or older. Congestive heart failure in patients 75 years old or older appears to be associated with relatively higher ejection fractions or even with ejection fractions within the normal range. In these patients, digitalis may not be indicated, and short term-prognosis is relatively favorable.