erythropoitin and total joint replacement

Erythropoietin and Total Joint replacement

Dr. Jatinder S. Luthra

Conflict of Interest

None

Blood loss after Joint replacement

Average 1 – 1.5 litres

Appreciated and replaced

Blood loss after Joint replacement

Average blood loss after THR 1.5L Hidden loss 470ml ( 26%) Average blood loss after TKR 1.5LHidden loss 765 ml ( 50 %)

Blood loss after Joint replacement Revision Hip

surgeries – 2.5L – 3.0 L

Cementless TKR – Higher blood loss

B/l TKR

Allogenic Blood transfusion

Preoperative Autologous blood Donation

Blood conservation measures

Allogenic Blood transfusion

Primary THR – 2.0 ( +/- 1.8) Revision THR – 2.9 ( +/- 2.3) Bae et al Arthroplasty 1999

Primary TKR – 1-2 units Revision TKR – 3-4 units

Allogenic Blood transfusion

Pre op Hb - < 10g - 90 %

Allogenic Blood transfusion

Weight Age Aspirin Female Comorbidities B/L TKR

Allogenic Blood transfusion

Clerical error Bacterial

contamination Increased length of

stay Immunomodulatio

n Cost

Risks of Blood Transfusion

Preoperative Autologous Blood Donation

1-2 units – primary joint replacement 4-6 units – revision joint replacement

Hb > 11gm

5-7 days interval ( last unit 3 days before surgery)

Preoperative Autologous Blood Donation

Preoperative Autologous Blood Donation

Scheduling difficulties Limited shelf life Clerical errors Bacterial contamination

Preoperative Autologous Blood Donation

Preoperative Autologous Blood Donation

Blood Conservation measures

Perioperative blood salvage

Haemodilution

Intraop Pharmacologic agents

Increased Haematopoiesis

Blood Conservation measures -Haemodilution

Preop blood donation Post op Blood transfusion

Blood lost intraop lower haematocrit

Blood Conservation measures-Intraop. Pharmacologic agents

TOPICAL AGENTS

Thrombin Fibrin glue Collagen Epinephrine sponges Bone wax

SYSTEMIC ANTIFIBRINOLYTIC

Desmopressin Aprotinin Tranexamic acid E-aminocaproic acid

Blood Conservation measures -Increased haematopoiesis

ERYTHROPOIETIN

Erythropoietin - Haemopoiesis

Glycoprotein hormone

Secreted by Kidneys

(Peritubular cells)

Acts on RBC progenitors

Erythropoietin -substance of abuse

Increases oxygen delivery

Endurance sports Cycling Boxing Athletics Rowing

Alex Schwazer

Italian Race walker

Erythropoietin -substance of abuse

LANCE ARMSTRONG

Erythropoietin and Total joint replacement

Erythropoietin and Total joint replacement

Erythropoietin reduces blood transfusion in THR – A randomized control trial

Placebo 20000EPO 40000 EPO0%

10%

20%

30%

40%

50%

Column2

Erythropoietin reduces blood transfusion in Joint replacement surgery

Placebo

EPO 0%

20%

40%

60%

Blood Transfusion

Blood Trans-fusion

Erythropoietin and Total joint replacement

EPO Vs PAD

EPO PAD EPO +PAD0%5%

10%15%20%25%30%35%

Column1

EPO Vs PAD

EPO PAD0%

5%

10%

15%

20%

25%

30%

Column2

Erythropoietin and Total joint replacement

Dose – 40,000 IU ( 600IU/Kg)

Augmented with iron supplementation

In most studies drug is indicated for preop anemia in range of 11g to 13g

Complications of Erythropoietin

Increased risk of Thromboembolic Events

Complications of Erythropoietin

Complications of Erythropoietin

Complications of Erythropoietin

Erythropoietin and Total joint replacement – EVIDENCE STATEMENT

Evidence Based Ortho

Summary Level A evidence to recommend use of Erythropoietin

before major orthopaedic procedure

FDA approved drug before major orthopaedic surgeries

NICE guideline recommend EPO only for anemia associated with Ca and renal disease

Most studies the Pre op Hb level was 11g to 13g

Extremely useful in patients with rare antibodies in blood, Jehovah witness !

Post Op anemia is not corrected by Erythropoietin !!!

THANK YOU

Exacerbation of hypertension ?

Best effect in patients with Hb 10 – 13

Below Hb 10 Erythropoitin is already secreted unless renal failure