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Forum Name: Hematology Topics

Question: Transfusion of 8 pints, where is the blood going?


 Mommamia - Mon Jul 19, 2010 9:05 pm

Hello,
My grandmother (81 years old) had bilateral knee replacement 5 days ago. The surgeon said she is doing great, everything went perfectly. 2 days later she became very nauseated they emptied her stomach, then took her for a C.A.T scan, on the way she went white and limp. They treated her for low electrolytes, and had to do a blood transfusion. They gave her 8 pints of blood in a 24 hour time frame because her hemoglobin levels were not stable. After her 8th pint of blood her hemoglobin got up to 11. The next morning it dropped to 7.7 then back up to 9.5 by 11am. The doctors have run multiple tests, but nothing is showing up. Her white blood count is normal, she has no evident bleed outs, her spleen is slightly swollen, and lab results show no sign of red blood cells attaching themselves. She is doing great other than blood pressure and hemoglobin levels not staying consistent. My question is; where is the blood going? Why can we not keep her hemoglobin levels consistent? How much longer can we give her infusions before it becomes unsafe?

Thank you for any advice/answers,
Very Worried
 Dr.M.Aroon kamath - Sun Aug 08, 2010 10:48 pm

User avatar Hi,
There seems to be general consensus that Total knee arthroplasty (TKA) is an efficacious and cost-effective means of alleviating pain and restoring function in individuals with end-stage arthritis of the knee. Published studies in the literature have consistently lent support to validate this view. But, there is a lot of ongoing debate about the benefits and potential risks of simultaneous bilateral TKA procedures.

The surgical options available for these patients include
- a staged (“staggered”) procedure, with a certain time interval between 2 procedures, and
- Simultaneous knee arthroplasty (one-stage bilateral knee replacement).


The simultaneous arthroplasty procedures may be,
- conducted by a single team of surgeons, one side followed by another, or
- two separate teams, one for knee, operating simultaneously.


Quoted advantages of simultaneous bilateral TKA include,
- only one exposure to the anesthetic,
- limiting a major surgical procedure to a single event and
- feasibility of symmetrical rehabilitation of both knees, thus shorter rehabilitation and early recovery, and
- reduction in the length of the hospital stay and thereby the ultimate costs.

Quoted disadvantages include,
- prolonged sugery and exposure to the anesthetic,
- comparatively more intra-operative bleeding and transfusion needs.

These overall risks appear to be higher in patients >80 years of age as they frequently have more co-morbidities.

Several factors are being investigated as potential contributing factors for the excessive bleeding that may occur during or following simultaneous bilateral TKA procedures.
- technique(cemented vs uncemented),
- age (young vs older),
- co-morbidities,
- pre-operative hemoglobin levels(lower the level- as in rheumatoid arthritis, increases risk),
- overall tourniquet time (higher the time, risk seems to increase),
- continuous vs intermittent release of tourniquet during the procedure,
- release of tourniquet before vs after skin closure,
- suction drain vs no-drain (some studies have noted a considerable increase in blood loss by suction drainage in the patients who had an uncemented prosthesis),
- hypotensive anesthesia vs normotensive anesthesia (hypotensive anesthesia
has been shown to reduce blood loss by about 43% in major joint replacement surgeries) and
- hypothermia (higher risk in prolonged procedures and in the elderly individuals)


Often, the patients final hemoglobin depends upon,
- the pre-operative hemoglobin,
- the amount of blood transfused and
- the amount of crystalloids infused (dilutional effect).

In the case of your grandmother, it is not possible to say with conviction what caused the low hemoglobins despite transfusions, but it is more likely to be multi-factorial. Hypothermia needs to be ruled out, corrected if present and prevented.
Good luck!

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