SLIDE 1 Blood Management, VTE PPx, and TXA: To Clot or Not to Clot?
Lawrence V. Gulotta, MD
Director of Research, Sports Medicine and Shoulder Service Co-Medical Director, Leon Root Motion Analysis Laboratory Attending Surgeon, Sports Medicine and Shoulder Service Hospital for Special Surgery New York, NY
SLIDE 2
Disclosures
Zimmer-Biomet, Inc – Speaking and Consulting
SLIDE 3
SLIDE 4
SLIDE 5
You Should Do Something
SLIDE 6
Shoulder Arthroplasty
SLIDE 7
Shoulder Arthroplasty
Willis et al. JSES 2009 100 consecutive patients Surveillance 4 Extremity U/S at POD#2 and 12 weeks 13% had DVT 2% had non-fatal PE 1% fatal PE Similar to THA
Mechanical Boots and ECASA Initiated
SLIDE 8
Shoulder Arthroplasty
Follow-Up Study Bedi et al. AAOS 2010 178 patients Surveillance U/S done at 6 and 12 weeks. 2.2% had DVT at 6 weeks 0.6% had DVT at 12 week 0% PE
SLIDE 9
Shoulder Arthroplasty
Mayo Registry 2885 Patients 5 PE’s (0.17%) 0 Fatal
SLIDE 10 Shoulder Arthroplasty
Navarro et al. CORR 2013 Retrospective database review 2574 eligible patients, All types of arthroplasty All Patients:
– 0.51% DVT – 0.54% PE
Trend towards more frequent in trauma patients
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Shoulder Arthroplasty
Jameson et al. JSES 2011 UK Database – 4,061 cases DVT: 0% PE: 0.2% Mortality: 0.22%
SLIDE 12
Rarely Clinically Relevant (though not zero) Should You Go Looking? VTE is There if You Look for It
SLIDE 13 Surveillance Dopplers?
Schwarcz et al. Ann Vasc
441 THA and TKA’s U/S within 1 Week 5 Positive (1.3%) 3 Had PE – two of which had a negative surveillance Doppler. No Role for Surveillance U/S
SLIDE 14
What Makes a Patient High Risk?
SLIDE 15
Virchow’s Triad
SLIDE 16 High Risk Patients
- High Risk = 2 or More Factors
SLIDE 17 Options for DVT PPx
SLIDE 18 Recommendations at HSS
Shoulder Arthroplasty
Moderate Risk Procedure –Low Risk Patient
- Plexipulse
- ECASA 325mg BID 6
weeks
–High Risk Patient (h/o VTE, 2 or more risk factors)
- Coumadin/Lovenox
- Xeralto becoming more
common
SLIDE 19
Blood Management
“ Do I need to donate blood? ”
SLIDE 20
Blood Management
National Heart, Lung and Blood Institute (NHLBI) –Pre-op donation if risk is >10% of transfusion
SLIDE 21 Blood Transfusions – Millett et al. JBJS 2006 –25% of 124 TSA’s needed transfusion –Strongest Predictor: pre-op Hb < 110 g/L –78% of Autologous units wasted
- 90% of patients with pre-op
Hb > 130 g/L
Do Not Recommend Pre-Op Donation
SLIDE 22
Blood Transfusions – 366 Shoulder Arthroplasties – 7.4% Transfusion Rate Risk Factors –Low Pre-op Hgb –High blood loss –Humeral cement fixation
SLIDE 23 Blood Transfusions
– Mayo, JSES 2014
Arthroplasties
Risk Factors –Age –> 5 hrs OR time –Humeral revision –Low Pre-Op Hgb –Diabetes –CAD
SLIDE 24 Tranexamic Acid
“Standard of Care” for THA, TKA
SLIDE 25
Tranexamic Acid
SLIDE 26 Tranexamic Acid
– Cleveland – 110 Patients
- Randomized
- Placebo with Saline
- 2g Topical TXA
Drain Output
– 170mL vs 108mL
Hgb Loss Post-Op
– 2.6 g/dL vs 1.7 g/dL
No transfusion either group
TXA has drastically reduced transfusions in Hip and Knee Arthroplasty, and data shows it to do the same for S houlder. Does not appear to increase the risk of VTE Though not used in “ high risk” VTE patients
SLIDE 27 Recommendations at HSS
Strongest factor that predicts post-op transfusion is pre-op Hgb Ironically, also contraindication for pre-op blood donation Do not routinely recommend autologous donation If pre-op Hbg < 11 g/dL, refer back to PMD/Heme for pre-op
- ptimization.
- Iron, nutrition, possible Epo
TXA now routinely used IV Given with pre-op Abx Drastically reduced transfusions.
SLIDE 28
Thank You
