liu.seSearch for publications in DiVA
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Perioperative blood saving techniques with coagulative evaluation in orthopedic surgery
Linköping University, Department of Medicine and Care, Anaesthesiology. Linköping University, Faculty of Health Sciences.
2000 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Allogeneic blood transfusion, although often needed in major surgery with large per-and postoperative bleeding, is fraught with dangers such as clerical mishandling, immunosuppression and blood-borne infections. It is therefore important to find ways to avoid allogeneic blood transfusion by means of less bleeding, better tolerance of the bleeding or alternatives to allogeneic blood.

Aim of the study: To evaluate different methods of blood saving in total hip replacement (THR) surgery, their efficacy, and the possible risks, especially hyper- and hypocoagulation.

Patients and methods: A total of 179 patients and eight volunteers were included in five studies. All patients were operated by primary TI-IR. Blood loss, allogeneic transfusions, coagulation parameters (platelets, bleeding time, fibrinogen, APTT, PT, soluble fibrin, TAT), fibrinolysis parameters (D-dimer, tPA, PAT, PAP), functional coagulation analysis (Sonoclot, TEG) and frequency of deep vein thrombosis (ultrasonography) were investigated according to the different study regimes. Thitiy patients undergoing predonation of autologous blood (PAD) with or without autotransfusion were compared with a control group of 15 patients without blood saving treatment. Fatty patients undergoing immediate prcopcrative platelet rich plasma (PRP) harvest and autotransfusion were compared with 40 patients undergoing PAD and autotransfusion. The spontaneous and induced activation of the platelets in the blood of20 patients undergoing THR with or without additive PRP harvest were also studied with flow cytometry. The efficacy of tranexamic acid (TA) as a blood saving method was examined in a study including 40 patients. As Sonoclot coagulation analysis was the single most important coagulation analysis during the studies, a methodological examination including eight volunteers was done for the instrument.

Results and discussion: If no blood saving method is used there is a very strong possibility of allogeneic blood transfusion (100% of the patients studied needed blood). Autotransfusion is not sutlicient as a single transfusion reducing method (53% patients studied still needed blood). PAD+ autotransfusion gives sufficient reduction in allogeneic blood transfusion (5-27% of patients in tlte different studies needed blood) but needs prcopcrativc planning, and PAD is not accepted by Jehovah's Witnesses. PRP reduces allogeneic blood transfusion as effectively as predonation of two units of blood (15% of studied patients needed blood) and can replace PAD in unplanned operations and for Jehovah's Witnesses. The majority of platelets are in a resting state during THR and PRP harvest. PRP harvest did not affect the degree of platelet activation, but there were great individual differences between patients (spontaneous activated platelets, i.e. presenting P-Selektin during the operation, between 1 %-23%). Most of the platelets in the c-PRP were not activated at the time ofretransfusion but were easily activated upon stimulation with the physiological activator ADP. TA therapy started prcoperatively is easily performed and reduces bleeding by 35%, probably by significantly reducing induced fibrinolysis perioperatively. During primary THR surgety there was an early postoperative hypocoagulation during the first postoperative day, with a hypercoagulation later postoperativcly, and an observed maximal value about 7 to 10 days postopcrativcly that was still evident three weeks postopcratively. Per- and early postoperatively there was also a marked fibrinolysis that was normalized on day 1 postoperatively. Six of the 120 patients examined with ultrasonography had DVTs, all after the first week postoperatively. There were no differences in the frequency of detected DVTs, irrespective oftrcahnent with PAD, PRP or TA. Sonoclot coagulation analysis was found to be a valuable tool in detecting hypercoagulability but was restricted by a high variability. This variability can be lowered by a dual machine setting, repetitive analysis and directly analyzed arterial samples.

Conclusion: The combination ofperioperative autotransfusion and PAD is effective in preventing allogeneic blood transfusions during primary THR. PRP harvest is as effective as PAD and is useful for patients who cannot donate blood. A minor propotiion of the patient's platelets are activated during the surgery irrespective of whether or not there is PRP harvest. TA therapy started preoperatively reduces fibrinolysis during the day of surgery and reduces per-and postoperative bleeding by 35%. Primmy THR surgery gives rise to an initial hypocoagulation followed by a hypercoagulation with an observed maximal value about 7 to 10 days postoperatively which is still evident three weeks postoperatively. However, the observed frequency of thrombosis was low (5%) in the 120 patients examined with utrasonography. Sonoclot analysis is an efficient tool for following this hypercoagulation. The high variability of the method can be reduced with a dual machine setting, repetitive analysis and directly analyzed arterial samples.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2000. , 58 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 653
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-27473Local ID: 12127ISBN: 91-7219-754-4 (print)OAI: oai:DiVA.org:liu-27473DiVA: diva2:248025
Public defence
2000-12-08, Wilandersalen, Regionssjukhuset, Örebro, 09:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-08-16Bibliographically approved
List of papers
1. Perioperative autotransfusion and functional coagulation analysis in total hip replacement
Open this publication in new window or tab >>Perioperative autotransfusion and functional coagulation analysis in total hip replacement
1995 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 39, no 3, 390-395 p.Article in journal (Refereed) Published
Abstract [en]

Functional coagulation analyses like Sonoclot and thromboelastography have not been evaluated during perioperative autotransfusion. We have prospectively studied three different transfusion regimes in 45 patients undergoing total hip arthroplasty. Blood losses were replaced either with heterologous erythrocyte concentrate (group I), intra- and postoperative autotransfusion of blood salvaged with cellsaver technique (group II) or predonated autologous erythrocyte concentrates together with salvaged blood (group III). Routine and functional coagulation analyses with a Sonoclot were performed preoperatively, 6 hours postoperatively (6 h), day 1–5 and 10. An early postoperative hypo- and late postoperadve hypercoagulative phase could be detected with Sonoclot signs of platelet function and fibrin deposition in all groups. Sonoclot coagulation analyses better correlated to both blood loss and dextran dosage than APTT and platelet count in the routine coagulation analyses. Functional coagulation analysis has a potential use in individualizing plasmasubstitution and thromboprophylaxis regimes during autotransfusion in THR.

Keyword
Anesthetics, local-bupivacaine, anesthetic techniques, spinal anesthesia, autotransfusion, coagulation analysis: low molecular weight heparin, dextran
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-79954 (URN)10.1111/j.1399-6576.1995.tb04083.x (DOI)
Available from: 2012-08-16 Created: 2012-08-16 Last updated: 2017-12-07Bibliographically approved
2. Sonoclot coagulation analysis: A study of test variability
Open this publication in new window or tab >>Sonoclot coagulation analysis: A study of test variability
1999 (English)In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 13, no 4, 393-397 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To test the reproducibility of Sonoclot coagulation analysis (SCA; Sienco Inc, Morrison, CO). The authors wished to determine if the mix/release of the preloaded celite activator in standard Sono-cuvettes could be responsible for the high variation coefficients for SCA parameters with citrated whole blood and if citrated whole blood is optimal for SCA.

Design: A prospective trial.

Setting: A large academic teaching medical center.

Participants: Eight healthy volunteers.

Interventions: Repeated blood sampling was performed through indwelling radial artery catheters. Seven different Sonoclot analyzers were used to test seven different types of analysis procedures in the volunteers, involving activators of different types and amounts and in different forms, and the use of citrated or native whole blood.

Measurments and Main Results: Two-way and one-way ANOVA, variance, variance analysis, and Tukey's test were used to evaluate differences in SCA methods and volunteer influence. A high variance, with SDs up to 200% of the median values of the SCA parameters with recalcified citrated blood and the standard Sono-cuvette, was confirmed. SCA with native blood and/or the use of other types of preloaded activators, ie, kaolin, significantly (p < 0.05) reduced this variance. Repeated SCAs further reduced the variance to 10% to 35% of the variance for a single analysis (standard cuvette and native blood).

Conclusion: Improvement of the activator in the Sonocuvette, use of native whole blood, and repeated Sonoclot analyses reduced the previously reported high variability of this instrument.

Keyword
Sonoclot coagulation analysis, thromboelastography, celite, kaolin, activated coagulation time, platelet function, variance
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-79955 (URN)10.1016/S1053-0770(99)90209-4 (DOI)
Available from: 2012-08-16 Created: 2012-08-16 Last updated: 2017-12-07Bibliographically approved
3. Preoperative platelet-rich plasmapheresis and hemodilution with an autotransfusion device in total hip replacement surgery
Open this publication in new window or tab >>Preoperative platelet-rich plasmapheresis and hemodilution with an autotransfusion device in total hip replacement surgery
Show others...
2000 (English)In: Journal of clinical apheresis, ISSN 0733-2459, E-ISSN 1098-1101, Vol. 15, no 4, 256-261 p.Article in journal (Refereed) Published
Abstract [en]

The effectiveness of both preoperative autologous donation (PAD) and intraoperative autotransfusion (IAT) with an autotransfusion device has recently been questioned. Preoperative apheresis, with separation of concentrated platelet rich-plasma (c-PRP) and erythrocyte concentrate (ERC), represents an aggressive use of the autotransfusion device. Can such a procedure replace PAD in total hip replacement surgery (THR)? Eighty patients undergoing THR were investigated in a prospective and randomized study. Forty patients underwent PAD, and 2 units of ERC + plasma were retrieved within 4 weeks preoperatively. Another 40 patients underwent an immediately preoperative apheresis with a concomitant hemodilution with 4% albumin, retrieving c-PRP (30% of the platelet pool) and 2 units of ERC. Both groups used IAT up to 2 hours postoperatively, with 3% dextran-60 as a plasma substitute according to our standard of care. There were no differences in blood loss, B-hemoglobin or allogeneic transfusions between the groups: 85% of the patients did not receive allogeneic blood. Both apheresis and reinfusion of c-PRP had minor impact on the coagulation parameters. Platelet count increased slightly but significantly (P < 0.05) from 154 to 179 × 109/L after the c-PRP at wound closure. Preoperative apheresis with an autotransfusion device, separating platelet-rich plasma and erythrocyte concentrate, is a useful alternative for patients who are unable to utilize the PAD technique for either religious or practical reasons.

Keyword
platelet-rich plasmapheresis, total hip replacement, autotransfusion, ultrasonography, Sonoclot, hemodilution
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-79959 (URN)10.1002/1098-1101(2000)15:4<256::AID-JCA7>3.0.CO;2-G (DOI)
Available from: 2012-08-16 Created: 2012-08-16 Last updated: 2017-12-07Bibliographically approved
4. Tranexamic Acid Reduces Blood Loss in Total Hip Replacement Surgery
Open this publication in new window or tab >>Tranexamic Acid Reduces Blood Loss in Total Hip Replacement Surgery
Show others...
2000 (English)In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 91, no 5, 1124-1130 p.Article in journal (Refereed) Published
Abstract [en]

Intraoperatively administered, tranexamic acid (TA) does not reduce bleeding in total hip replacement (THR). Therefore, its prophylactic use was attempted in the present study because this has been shown to be more effective in cardiac surgery. We investigated 40 patients undergoing THR in a prospective, randomized, double-blinded study. Twenty patients received TA given in two bolus doses of 10 mg/kg each, the first just before surgical incision and the second 3 h later. In addition, a continuous infusion of TA, 1.0 mg · kg−1 · h−1 for 10 h, was given after the first bolus dose. The remaining 20 patients formed a control group. Both groups used preoperative autologous blood donation and intraoperative autotransfusion. Intraoperative bleeding was significantly less (P = 0.001) in the TA group compared with the control group (630 ± 220 mL vs 850 ± 260 mL). Postoperative drainage bleeding was correspondingly less (P = 0.001) (520 ± 280 vs 920 ± 410 mL). Up to 10 h postoperatively, plasma D-dimer concentration was halved in the TA group compared with the control group. One patient in each group had an ultrasound-verified late deep vein thrombosis. In conclusion, we found TA, administrated before surgical incision, to be efficient in reducing bleeding during THR.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-79960 (URN)
Available from: 2012-08-16 Created: 2012-08-16 Last updated: 2017-12-07Bibliographically approved
5. The Effects of Platelet Rish Plasmapheresis in Total Hip Replacement Surgery on Platelet Activation Studied by Flow Cytometry
Open this publication in new window or tab >>The Effects of Platelet Rish Plasmapheresis in Total Hip Replacement Surgery on Platelet Activation Studied by Flow Cytometry
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Autologous platelet rich plasma (PRP) harvest with autotransfusion devices has been used for ten years in cardiac surgery and recently in orthopedics. Its influence on the outcome of surgery is still controversial, in part because of methodological difficulties in studying platelet function during surgery.

Methods: Twenty patients undergoing primary total hip replacement (THR) were studied. Ten patients underwent an immediately preoperative platelet apheresis forming concentrated platelet rich plasma (c-PRP). Ten patients not undergoing apheresis were allocated to a control group. Platelet activation was evaluated as the population expressing P-Selektin on the surface of platelets in the c-PRP and in blood samples collected pre-, per- and postoperatively. The method used was flow cytometry.

Results and Conclusions: There is a minor population of activated platelets circulating in the patient's blood with a highly significant difference between patients (p=0.005) with a range of 1-23 % in peroperative activation. PRP harvest did not significantly alter platelet activity. The platelet apheresis procedure did not inhibit platelet function in the c-PRP as judged by a high proportion of platelets that could be activated in ADP stimulation experiments (mean value±SD 86%±7.5%).

The total number of platelets that could be activated in the c-PRP estimated as % ADP activated platelets x % sampled platelets in the c-PRP (total platelet yield), was non significantly correlated (r=-0.59, p<0.l) with postoperative bleeding, indicating a possible hemostatic effect of these platelets.

Keyword
Autotransfusion, PRP harvest, platelet, flow cytometry, P-Selektin, ADP, bleeding
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-79961 (URN)
Available from: 2012-08-16 Created: 2012-08-16 Last updated: 2012-08-16Bibliographically approved

Open Access in DiVA

No full text

By organisation
AnaesthesiologyFaculty of Health Sciences
Medical and Health Sciences

Search outside of DiVA

GoogleGoogle Scholar

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 198 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf