CONTROVERSIAS EN CIRUGÍA ORAL Y MAXILOFACIAL II

 

Autologous blood transfusion in orthognathic surgery: not necessary

Autotransfusión sanguínea en cirugía ortognática: no necesario

 

 

F. Hernández Alfaro, R. del Rosario Regalado, D. Mair

Clínica Teknon, Barcelona, España

Dirección para correspondencia

 

 

 

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ABSTRACT

Surgery for maxillofacial deformities has seen important developments over the last decades and the number of patients undergoing these types of treatment has increased considerably. One of the most debated issues in the recent literature concerns the need for preoperative autologous blood donation. A revision of the relevant publications of recent years reveals opposite views.

Key words: Autotransfusión; Blood; Orthognathic Surgery.

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RESUMEN

La cirugía de las deformidades maxilofaciales ha evolucionado de manera importante en las últimas décadas y el número de pacientes que reciben este tipo de tratamiento ha aumentado de forma considerable. Uno de los temas más debatidos en la literatura reciente se refiere a la necesidad de autodonación sanguinea preoperatoria. hacemos una revisión de las publicaciones relevantes en años recientes, que demuestran puntos de vista opuestos.

Palabras clave: Autotransfusión; Sangre; Cirugía ortognática.

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Surgery for maxillofacial deformities has seen important developmentsover the last decades and the number of patients undergoing these types of treatment has increased considerably. One of the most debated issues in the recent literature concerns the need for preoperative autologous blood donation. A revision of the relevant publications over recent years reveals opposite views.

In a prospective study of 1000 patients who underwent orthognathic surgery, Kramer observed an incidence of severe hemorrhaging that was 1.1%.¹ All bleeding occurred during bimaxillary surgery and it was caused by the laceration of the branches of maxillary vessels, mostly produced by irregular fractures of the pterygoid or during the descent of the maxilla. The author does not mention the average operative time, but he recommends the routine donation of autologous blood in order to avoid relevant episodes of anemia intra- or post-operatively, and for preventing the need for homologous blood donation.

After a revision of 178 orthognathic surgical procedures, Martini suggests the need for preoperative autologous blood donation, and he also noted a direct relationship between mean blood loss during surgery and operative time.² The mean time for single-jaw surgery of the mandible was 193± 83 mins, in single-jaw surgery for the maxilla this was 196± 59 mins, and for double-jaw surgery mean time was 324± 81 mins. Between 1998 and 2001 the percentage of autologous transfusions in operated patients was 35%, but as from 1999 transfusions were no longer used in single-jaw surgery. The author proposed a donation of autologous blood of three to four units for bimaxillary surgery, and in certain cases entailing greater risk in single-jaw surgery, for medial and legal reasons.

In a study of 56 double-jaw operations, Nkenke compared a group of patients who had predeposited autologous blood 6 weeks before surgery with a control non-donor group.³ The mean value of preoperative hemoglobin was lower in the predeposited blood group (13.5/14.1 mg/100 ml) as was intraoperative hemoglobin (11,9/12,8 mg/100 ml). Hemoglobin values lower than 7,5mg/100ml were considered to indicate the need for transfusion and, as a result, three patients (9.6%) of the predeposit group were transfused. None of the patients in the non-donor group required a transfusion. There were no significant differences in the mean surgical times of the two groups (208/219 min) nor in the evaluation of postoperative hemoglobin (11.0/11.5 mg/100 ml). The author does not advise predepositing autologous blood given the increased safety of homologous blood and the low percentage of patients that required transfusions during the study.

Ueki assessed 62 patients who were treated surgically for mandibular prognathia and the blood parameters were evaluated.⁴ He established 4 different groups: one containing the mandibular bilateral sagittal split osteotomies (BSSO), another with the intraoral vertical ramus osteotomies (IVRO), a third with Le Fort I osteotomies combined with BSSO, and a fourth group that contained Le Fort I osteotomies combined with IVRO. Mean blood loss varied between 125.5 ml in the IVRO group and 343.6 ml in Le Fort I osteotomy with BSSO group. None of the patients required a blood transfusion. The mean time of the surgery was 84.1 mins in the group treated with IVRO and 205.0 mins in the group treated with the combined Le Fort I and BSSO. A statistically significant correlation was found between the duration of the surgery and the volume of blood lost. The author concludes that there is little risk of marked bleeding in routine orthognathic surgery, and that blood transfusions should be considered only for high-risk patients.

Nath evaluated the need for autologous blood donation in 913 patients, of whom 260 had been treated by means of orthognathic surgery.⁵ The author does not provide data on the type of surgery carried out. 126 of these 260 patients had undergone preoperative autologous blood donation. He found that 29 patients (11.15%) who underwent orthognathic surgery required transfusions: 26 transfused patients (10.0% of the total, 20.63% of the autologous blood donors) had previously undergone autologous blood donation, and 3 patients (1.15% of the total, 2.23% of the non-donor patients) received homologous transfusions. The author considered the need for transfusion is overestimated given the relatively small risk of bleeding.

In his revision of 115 patients, Dhariwal found of the patients who had undergone bimaxillary surgery, 9 patients (8%) were transfused with homologous blood.⁶ The mean operative time was 270 mins, but it should be taken into account that 20 patients had additional procedures. No correlation was found between blood loss, surgical time and the type of procedure used. The author is of the belief that in 5 (55.55%) out of the 9 transfused patients, the transfusion was inappropriate, and that this was carried out because the anesthetist was inexperienced, and due to the fact that homologous blood was available. In 4 (44.44%) of the remaining patients, the blood was supplied as a result of bleeding of specific vessels during the surgery and possible postoperative bleeding. The author is of the opinion that, for the patient, what is most indicated is the use of a combination of strategies for minimizing bleeding, and for transfusions to be carried out only when absolutely necessary. He considered that in elective orthognathic surgery autotransfusions should be avoided.

Khan carried out a retrospective study of 25 patients who underwent bimaxillary osteotomies. He found that in just one case (4%) was there need for a transfusion of homologous blood.⁷ He concluded that, when faced with an estimated transfusion requirement of less than 5%, testing and banking blood should not be indicated. Only in selected cases would this be necessary, if hemoglobin and blood volume levels are low.

Gong compared a retrospective study of 83 patients who had undergone bimaxillary surgery, separating them into two groups.⁸ One group contained 43 patients, 34 of whom had previously autodonated blood, and the second group contained 40 patients who had not autodonated blood previously and who were subjected to a protocol to minimize blood loss by means of: a thorough evaluation of the surgical case, hypotensive anesthetic techniques, expert surgeon, local anesthesia with a vasoconstrictor, cocainization of the nasal mucosa, maintaining the patient in an anti-Trendelenburg position, use of electrocoagulation, clean incisions directly through the periosteum, plugging open surgical fields with gauze. The volume of blood lost during surgery was 899 ml in the first group and 403 ml in the second group. 37% of patients in the first group received a transfusion and none in the second group. The author considers that transfusion or self-donation should only be a consideration in selected cases with preexisting pathology.

In a prospective study of 29 patients undergoing orthognathic surgery, Yu evaluated intraoperative blood loss in relation to surgical time.⁹ 8 patients (27.58) treated only with single-jaw surgery (the author does not make any distinction between the maxilla and the mandible) had a mean blood loss of 266.3 ml and a mean operative time of 169.9 mins. 21 patients (72.41%) who underwent double-jaw surgery had a mean blood loss of 751.4 ml with a mean operative time of 296.4 mins. The author found a statistically significant correlation between operative time and blood loss.

In a retrospective study of 438 patients who underwent orthognathic surgery, Umstadt analyzed the need for blood transfusions.¹⁰ 1.55% of patients undergoing maxillary osteotomies and 3.03% of patients undergoing bimaxillary osteotomies required a transfusion of homologous blood. None of the patients undergoing just a mandibular osteotomy required a transfusion. A postoperative value of hemoglobin that was lower than 7.5 mg/100 ml was considered indicative of the need for a blood transfusion. The author affirms that autologous blood donation before surgery is not necessary because the percentage probability for transfusion that was found was lower than the 10% indicated by German regulations.

If the need arises, autologous blood transfusion has the advantage of eliminating the risk of transmitting a virus and of immunological reactions such as hemolysis, fever or allergic reaction.¹¹ Also, the risk of postoperative infection is reduced. The cost of the programs for administering autologous blood together with the high percentage of underuse of these units, anemia and hypovolemia after the donation, represent the disadvantages of this technique.

In spite of this, the need for transfusions in orthognathic surgery should be questioned in view of the low incidence of marked bleeding in a large proportion of the literature revised. Deciding on an autotransfusion should take into account the level and expected duration of the anemia, surgical time and the probability of considerable loss of blood.¹²

Complete coagulation during the operation in order to prevent bleeding is impossible given the extensive vascularization of the maxillofacial region. Various techniques can be used for controlling bleeding. Of note is the use of hypotensive anesthetic techniques that maintain a mean arterial blood pressure of 55 to 60 mmHg. Well-controlled hypotension reduces blood loss by 40 to 50%.¹³ In these cases, close cooperation between surgeons and anesthetists who are familiar with the more painful moments of the operation and also those with hypertension, is fundamental. The administration of adrenalin and suitable analgesic agents at the start of the operation by the surgeon, and during the osteotomies by the anesthetist, prevent these moments of intraoperative stress for the patient. The dosage of anesthetic drugs for maintaining controlled hypotension during orthognathic surgery can be monitored as a result of the latest technology such as the bispectral index (BIS).¹⁴ The BIS permits very strong analgesic medication and deep sedation. Hypotension is controlled and neuronal suffering is avoided. Less bleeding signifies a cleaner surgical field with better vision. Intraoperative complications and surgical time are reduced and there are fewer needs for transfusions.

Kurian elaborated a valid protocol for reducing blood loss, by maintaining the patient in a semi-sitting position of 20-30 degrees during the surgery, with arterial blood pressure medium low, using tranexamic acid IV during the perioperative period, and elective ligation of the palatine vessels in order to prevent immediate postoperative bleeding complications. ¹⁵ Intraoperative cauterization and ligation of these vessels does not interfere in the revascularization of the palate or in the ossification of fractures.¹⁶ With this protocol venous return is diminished, cardiac output is reduced and a mean arterial blood pressure is achieved.

Other new technologies reduce surgical time and as a result bleeding time. Good preparation and case studies using surgery on models, 3D virtual surgery and soft tissue simulation, prepares the surgeon for what he will encounter in the operating room, while reducing the need for improvising surgical acts during the procedure.¹⁷

Also, the reduction of surgical time in orthognathic surgery allows this to be carried out practically on an outpatient basis.¹⁸ An expert surgeon with instrument nurses and assistants that have been well-trained with regard to intraoperative movements, also reduces surgical time considerably, while setbacks such as the sectioning of blood vessels and the tearing of soft tissue, etc. are avoided.

With regard to our experience, between March 1994 and March 2006 we carried out 857 orthognathic surgery procedures. Of these, 513 were double-jaw and 344 singlejaw. In this series, surgery-assisted maxillary expansion was not included, nor mentoplasties or isolated procedures. In none of these cases was carrying out blood transfusions necessary.

Between May 2005 and May 2006, we evaluated in a prospective fashion 163 consecutive patients who underwent orthognathic surgery (103 double-jaw, 60 single-jaw). We recorded the hematic loss values in cc and operative time of each intervention. In single-jaw surgery, mean intraoperative hematic loss was 93cc (with a range of 45-179). Mean operative time for these procedures was 47 mins (with a range of 32-74). With regard to double-jaw surgery, mean hematic loss was 167 cc (with a range of 145-260). Mean surgical time was 83 mins (with a range of 59-128).

In the current protocols for different specialties, the preoperative donation of autologous blood and its posterior transfusion is recommended for invasive elective surgery with an increased risk of considerable blood loss.¹⁹ When orthognathic surgery is a routine intervention, and practiced as elective surgery in young, healthy patients, and when techniques and protocols are applied that reduce surgical time and bleeding, autotransfusions are not necessary in our opinion. We believe that transfusions make sense for saving lives or for preventing deterioration, but not in a prophylactic manner for inducing faster postoperative recovery.²⁰ The possibility of self-donation should be considered only for those patients with a clinical history that is indicative of considerable blood loss during surgery or after prolonged surgical time.

 

 

Dirección para correspondencia:
Dr. F. Hernández Alfaro
Clínica Teknon
C/ Marquesa de Vilallonga 12, despacho 50
08015 Barcelona, España

Recibido:20.07.06
Aceptado: 06.10.06

 

 

References

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