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Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection

Javad Parvizi MD, FRCS
Thorsten Gehrke MD


Title:
Blood Conservation

Liaisons:
Mohammad R Rasouli MD

Leaders:
Luiz Sérgio Marcelino Gomes MD, PhD (International), Brian Parsley MD (US)

Delegates:
Wael Barsoum MD, Hari Bezwada MD, James Cashman MD, Julio Garcia MD, William Hamilton MD, Eric Hume MD, Rajesh Malhotra MD, Stavros Memtsoudis MD, PhD, Alvin Ong MD, Fabio Orozco MD, Douglas Padgett MD, Ricardo Reina MD, Marco Teloken MD, Emmanuel Thienpont MD, Jonathan H Waters MD

Vol 1, Num S1, September 2014

 

   

Question 1: Is blood transfusion associated with an increased risk of surgical site infection (SSI)/periprosthetic joint infection (PJI)?

Consensus: Yes. Allogeneic blood transfusions is associated with an increased risk of SSI/PJI. The role of autologous transfusion in the risk of SSI/PJI remains inconclusive.

Delegate Vote: Agree: 91%, Disagree: 5%, Abstain: 4% (Strong Consensus)


Question 2: What are the predictors of the need for allogeneic blood transfusion in patients undergoing surgery for TJA?

Consensus: A lower preoperative hemoglobin level is the strongest predictor for the potential need for allogeneic transfusion after TJA. The use of general anesthesia, higher Charlson comorbidity index, female gender, and longer duration of surgery are predictors of the potential need for allogeneic blood transfusion in patients undergoing total joint arthroplasty (TJA).

Delegate Vote: Agree: 90%, Disagree: 4%, Abstain: 6% (Strong Consensus)


Question 3A: What is the role of the type of anesthesia in minimizing blood loss and allogeneic blood transfusion during arthroplasty surgery for PJI?

Consensus: Compared to general anesthesia, neuraxial anesthesia reduces the amount of blood loss during TKA or THA.

Delegate Vote: Agree: 77%, Disagree: 11%, Abstain: 12% (Strong Consensus)


Question 3B: Is there evidence against neuraxial blockade in PJI cases (due to probable risk of spreading infection)?

Consensus: No. The decision to use neuraxial versus general anesthesia in patients with PJI lies with the anesthesia team and needs to take into account the numerous benefits of neuraxial anesthesia versus the potential for development of infectious central nervous system complications (arachnoiditis, meningitis, and abscess) with the use of anesthesia.

Delegate Vote: Agree: 83%, Disagree: 6%, Abstain: 11% (Strong Consensus)


Question 4A: What is the role for adjuvant technologies including cell salvage systems, reinfusion drains, bipolar sealers, and hemodilution for minimizing blood loss during surgery for PJI?

Consensus: There is no defined benefit for the use of cell salvage systems, reinfusion drains, biopolar sealers, and hemodilution for management of PJI.

Delegate Vote: Agree: 85%, Disagree: 8%, Abstain: 7% (Strong Consensus)


Question 4B: What is the role for adjuvant technologies including cell salvage systems, reinfusion drains, bipolar sealers, and hemodilution for minimizing blood loss during TJA?

Consensus: There is no defined benefit for the use of cell salvage systems, reinfusion drains, biopolar sealers, and hemodilution during primary, unilateral TJA.

Delegate Vote: Agree: 80%, Disagree: 11%, Abstain: 9% (Strong Consensus)


Question 5A: Does the use of a drain(s) influence the incidence of SSI/PJI?

Consensus: No. There is no evidence to demonstrate that the use of closed drains increases the risk of SSI/PJI following TJA.

Delegate Vote: Agree: 88%, Disagree: 8%, Abstain: 4% (Strong Consensus)


Question 5B: When should drain(s) be removed?

Consensus: There is no conclusive evidence for the optimal timing of drain removal.

Delegate Vote: Agree: 68%, Disagree: 22%, Abstain: 10% (Strong Consensus)


Question 6A: What is the role for tranexamic acid (TA) for minimizing blood loss during surgery for treatment of PJI?

Consensus: Administration of both intravenous and topical TA reduces the amount of blood loss and allogeneic blood transfusion in TJA.

Delegate Vote: Agree: 82%, Disagree: 5%, Abstain: 13% (Strong Consensus)


Question 6B: Does administration of topical TA have an advantage over intravenous (IV) administration?

Consensus: Topical TA does not have any obvious advantage over IV administration of the drug and both are safe. However, topical TA may be used in certain group of patients in whom IV TA is considered to be inappropriate.

Delegate Vote: Agree: 76%, Disagree: 4%, Abstain: 20% (Strong Consensus)


Question 7: What is the role for other agents such as platelet-rich plasma (PRP), fibrin glue for minimizing blood loss?

Consensus: The routine use of PRP is not recommended. There is some evidence that fibrin products may reduce blood loss.

Delegate Vote: Agree: 91%, Disagree: 1%, Abstain: 8% (Strong Consensus)


Question 8: What is the role for blood salvage (intraoperative and postoperative) during the second stage of two-stage exchange arthroplasty for treatment of PJI?

Consensus: The role of blood salvage (intraoperative and postoperative) during the second stage exchange arthroplasty is inconclusive. Blood salvage should be utilized with caution.

Delegate Vote: Agree: 80%, Disagree: 11%, Abstain: 9% (Strong Consensus)


Question 9: What is the role of administration of erythropoietin, hematinics, or other agents between the two stages of exchange arthroplasty for the treatment of PJI?

Consensus: Treatment of preoperative anemia with iron, with or without erythropoietin, will reduce the risk of transfusion in patients undergoing TJA.

Delegate Vote: Agree: 78%, Disagree: 9%, Abstain: 13% (Strong Consensus)


Question 10: Are self-contained suction suction devices a source of contamination?

Consensus: There is evidence indicating that the tip of surgical suction drains can be a source of contamination.

Delegate Vote: Agree: 70%, Disagree: 9%, Abstain: 21% (Strong Consensus)


Question 11: What is the role of preoperative autologous blood donation between the two stages of exchange arthroplasty for PJI?

Consensus: There is no role for autologous blood donation between the two stages of exchange arthroplasty for PJI.

Delegate Vote: Agree: 83%, Disagree: 7%, Abstain: 10% (Strong Consensus)