erythropoitin and total joint replacement
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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
