CONTROVERSIAS EN CIRUGÍA ORAL Y MAXILOFACIAL I

 

Autologous blood transfusions in orthognathic surgery: a necessity

Autotransfusión sanguínea en cirugía ortognática: necesario

 

 

L. Naval¹, R. González², F. Rodríguez Campo¹, M. Muñoz¹, J. Sastre¹

1 Médico Adjunto
2 Médico Residente
Servicio de Cirugía Oral y Maxilofacial (Jefe de Servicio Dr. F.J. Díaz)
Hospital de la Princesa. Madrid, España

Dirección para correspondencia

 

 

 

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ABSTRACT

Daily medical care can be simplified by saving blood, and the quality of care improved from the point of view of morbidity and safety. The economic and social cost can be reduced for patients and for health professionals such as anesthetists, surgeons, and for the blood banks and teams directing private and public hospitals. Initially the interest in avoiding the adverse secondary effects of allogenic transfusion (ALT) (infectious disease transmission, transfusion reactions, such as Acute Respiratory Distress associated with transfusion, cost, sensitivity...) followed by the desire to save limited resources, has led to multiple work groups developing new strategies for dealing with a common problem: replacing or saving blood lost during surgical interventions and the immediate postoperative period.
Over recent years we have seen a reduction in the use of all blood types during surgery, especially allogenic, as a result of improvements in surgical and anesthesia techniques. Among these is the use of the patient’s own blood (autologous transfusion or autotransfusion) (AUT) in its different modalities.¹
We have carried out a revision of the different modalities of AUT and the experience of our Service, which has been practicing this since the end of the 80s,² is shown.

Key words: Autotransfusión; Blood; Orthognathic Surgery.

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RESUMEN

El ahorro de sangre es un asunto que puede simplificar la asistencia médica diaria y mejorar su calidad tanto desde el punto de vista de morbilidad, seguridad y coste económico y social para los pacientes, profesionales de la salud como anestesistas, cirujanos, banco de sangre y de los equipos de dirección de hospitales públicos y privados.
Inicialmente el interés por evitar los efectos adversos secundarios a la transfusión alogénica (TAL) (transmisión de enfermedades infecciosas, reacciones transfusionales, como el Distress Respiratorio Agudo asociado a transfusión, costes, sensibilizaciones…) y posteriormente el ahorro de recursos limitados hacen que múltiples grupos de trabajo desarrollen nuevas estrategias frente a un problema común: la reposición o el ahorro de la sangre perdida durante las intervenciones quirúrgicas y el postoperatorio inmediato.
Asistimos en los últimos años a un menor uso durante las cirugías de cualquier tipo de sangre, especialmente la alogénica, gracias a la mejora de las técnicas quirúrgicas y anestésicas. Entre ellas la utilización de sangre del propio paciente (autóloga o autotransfusión) (AUT) en sus distintas modalidades. ¹
Llevamos a cabo una revisión de las distintas modalidades de AUT mostrando la experiencia de nuestro Servicio en el que se lleva practicando desde finales de los años 80.²

Palabras clave: Autotransfusión; Sangre; Cirugía ortognática.

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Introduction

Various international institutions have opted over the last years for promoting autologous donation (AUT).^3,4 The aims behind this are clear - saving blood, especially that of the less common blood groups, reducing the possible adverse effects of allogenic transfusion (ALT) such as hepatitis infections, HIV, HTLV, Acute Respiratory Distress associated with transfusion, avoiding the sensitivity of patients, reducing the delays when programming surgery because of blood shortages, and avoiding conscience issues concerning certain social groups (Jehovah’s Witnesses).5 Other measures are currently contemplated without AUT: controlled hypotension, position on the operating table, useful drugs in transfusion medicine:^6-8 EPO, Recombinant Factor VIIa, aprotinin, antifibrinolytics, the arginine vasopressin derivative(DDAVP). Three different types of autologous transfusions (AUT) have in fact been described, which are:

1. Predeposit AUT blood transfusion: on some occasions combined with erythropoietin (EPO)

2. AUT with acute normovolemic hemodilution

3. AUT with intra- or postoperative blood salvage In the case of Jehovah’s Witnesses only some of them accept intraoperative blood salvage.⁴

 

Transfusion criteria

Tachycardia of >110 beats/minute, hypotension of <50 mm. Hg, need for vasopressors for maintaining the previous AP, ECG signs of ischemia , Hb < 7-8 g/dl in elderly or cardiopathic patients or < 4-5 g/dl in healthy patients.

Predeposit AUT

This is handed by the blood bank in the center. People meeting certain requirements, and with surgery programmed within approximately 4-6 weeks, can participate. A pack of the patient’s blood is extracted with a minimum interval of 72 hours between the extraction and the surgery or the following extraction. Usually the maximum number of packs that can be extracted is therefore five. The patients should be correctly instructed, and a week in advance they are given ferrous sulfate 325 g to be taken, three times a day and for month after the surgery. On some occasions folic acid can also be taken and in some cases EPO can be administered.

There are no requirements with regard to age or weight, but there are certain health criteria: absence of convulsions and stable arterial pressure (a 2:1 solution of crystalloids is received by patients with hypotension or epilepsy), absence of bacteriemia or active infection, hemoglobin of 11 g or over, or hematocrit of 33%, and suitable extraction lines. Once the packs are full of blood, they are correctly labeled and stored at 4º centigrade for at least six weeks and crossedmatched in order to avoid any possibility of error before the re-infusion. On carrying out the extraction, the normal serology tests are carried out.⁴ If these prove positive, autodonation is ruled out and the patient and his doctor are informed. Predeposit AUT can be carried out as from the 2^nd trimester of a pregnancy. Legally, predeposited blood cannot be included in the reserves of the blood bank, that is to say, although there may be unused units, these cannot be used for other patients. The cost is similar to that of allogenic blood or a little lower.

Some candidates, for example oncological patients, that have low preoperative levels of Hb. or Hct, can benefit before the autodonation from synthetic erythropoietin (EPO), although the cost of this is quite high (2.000-3.000 per patient).⁷

The use of transfusions, and in particular predeposit AUT, is decreasing in some centers and for certain pathologies^5-7 as a result of the introduction of improved anesthetic and surgical techniques, and this includes other types of autodonation.

AUT with acute normovolemic hemodilution

This is carried out by the Department of Anesthesia, at the beginning of the surgery. A few units of whole blood are drawn and kept at room temperature, which are re-infused at the end of the surgery, or within a 6-hour period depending on the criteria set by the anesthetist. Volemia must be re-established using a 3 to 1 crystalloid/colloid ratio per unit of extracted blood, and further treatment will depend on the patient’s progress.⁷ If these is good cardio-pulmonary function, a hematocrit of 25 to 35% can be tolerated. Intraoperative bleeding will therefore be very diluted, permitting cells and plasma to be replaced by means of reinfusion, and blood viscosity will in this way be reduced from the beginning.

Surgery time tends to be lengthened a little (16 ± 2 min) but time spent on waiting lists is reduced. The cost is very low (24 € per patient). Serology does not have to be carried out (HIV, HBV, HCV) nor does the blood have to be typed, and the bags must therefore remain in the operating room. Hemoglobin above 10 g is required together with normal coagulation, a platelet count above 100.000 and good cardiopulmonary health. A blood loss of one to two liters can be compensated. It has been reported in the literature that in maxillofacial surgery two units can be extracted and that this will be enough for 89% of patients, thus resorting to allogenic transfusions can be avoided.⁷ This could be complemented (evaluating the cost) with EPO.

AUT with blood recovered intra-and postoperatively

At the moment this is not a procedure that should be used in our specialty, as our type of surgery is usually subject to contaminated secretions such as saliva or nasosinusal mucous. In any event, it is an expensive procedure requiring an infrastructure, and it is only indicated for surgery entailing considerable loss of blood volume both intra- and postoperatively.

Other measures

The value of other procedures favoring hemostasia has been claimed: infiltration with an anesthetic/ vasoconstrictor preparation (limited duration), position of the patient and controlled hypotension, not recommended for patients with a possible pathology of arterial obstruction.

 

Experience of the Princesa Hospital

We have been carrying out autologous transfusion in our department since 1986, using the predeposit method for a variety of pathologies, especially in oncological and orthognathic surgery. We have since incorporated, in a less protocolized form, some improvements such as the use of controlled hypotension and acute normovolemic hemodilution. We have studied the blood bank records with regard to the blood requirements in our department. Over the last nine years, that is to say from 1996 to the present time, June 2005, a total of 435 requests for cross-matching predeposit allogenic or autologous transfusions have been processed by the blood bank: 197 for oncological or reconstructive surgery and 151 for orthognathic surgery, and 52 for a variety of pathologies.

The mean age of the orthognathic surgery group was 23.93 years (ranging from 16 to 55). The maximum number of packs collected per patient was four. Of the group with 151 patients, predeposit AUT was carried out in 138 cases (91.4%), and no units were used in 35.1% of these patients. One unit was used in 29.8%, and in another 35.1% two or more units were used (Fig. 1). Of our AUT patients, 91. 4 % received two or more units. In 13 patients (8.6%) allogenic transfusion was used for a variety of reasons: difficult peripheral lines, low levels of Hb, erroneous programming of dates, or because more that four units were needed.

 

Discussion

As in so many fields of human activity, simplifying and reducing the cost of surgical techniques is desirable. While certain products may be becoming increasingly reliable, such as blood derivatives, they do entail risks and they can be difficult to obtain, so establishing a procedure protocol is fundamental in order to meet these goals. In this sense, allogenic transfusions in programmed surgery should be avoided. Is carrying out an autotransfusion in all orthognathic surgery patients necessary? This retrospective study group has observed how 35.1% of patients had autologous blood available, but that this was not used. And in 29.8% only one unit was used. That is to say that in 64.9% of the cases, the indication for transfusing the patient’s own blood was somewhat dubious.

As our figures show, putting an end to allogenic donations could easily be achieved if a protocol for predeposit autodonation were introduced. However, from the bibliography relating to the data used we can deduce that the use of more than two units^7,8 per patient is unusual. It is clear (Fig. 2) that there is a surplus of blood, and this means that there is an unnecessary use of resources. We therefore believe that the correct procedure would be to have individualized protocols so that all surgery that is expected to be long and difficult, with various osteotomies (bimaxillary segmental surgery, and/or additional procedures such as graft harvesting...) should make use of predeposit autologous blood donation. However, in most cases the other type of autologous blood donation, acute normovolemic hemodilution, (two units) would be sufficient. It would be safer and more economical, and it could be carried out without resorting to the blood bank.

Planning and carrying out this procedure carefully is of course very important in order to avoid wasting time unnecessarily, as is using the so called "other measures": particularly controlled hypotension. The works of other authors with controlled hypotension and autologous blood transfusions coincide with these findings.⁹

 

 

Dirección para correspondencia:
Dr. L. Naval
Servicio de Cirugía Maxilofacial
Hospital Universitario La Princesa
c/ Diego de León 62 - 28006 Madrid, España
Email: lnaval@infomed.es

Recibido: 18.10.05
Aceptado: 15.11.05

 

 

References

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3. Autologous Blood Donation and Transfusión in AABB Tech. Manual 50th anniversary 12 th edition 2003;105-25.        [ Links ]

4. Transfusion medicine and alternatives to blood transfusion, NATA, nataonline.com R&J Editions Medicales 2000 edition.        [ Links ]

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8. Habler O, Schwenzer K, Zimmer K, Prager M, König U, Oppenrieder K, Pape A, Steikraus E, Reither A, Buchrot A, Zwissler B. Effects of standardized actue normovolemic hemodilution on intraoperative allogenic blood transfusion in patients undergoing major maxillofacial surgery. Int J Oral Maxfac Surg 2004;33:467-75.        [ Links ]