Blood loss management
1. Introduction
Periprosthetic fractures around the knee often occur in elderly patients. Frailty and sarcopenia add to other comorbidities to make these patients acutely susceptible to blood loss anemia. Therefore, careful consideration of initial, ongoing, and perioperative blood loss must be taken, especially with femoral fractures.
Many of these patients are on anticoagulation, which predisposes them to increased blood loss at the time of injury. Medical co-management for reversal of anticoagulation should be considered. Fracture stabilization usually helps to prevent ongoing blood loss. Therefore, these patients benefit from timely surgery. Medical workup, blood transfusion, and reversal of anticoagulation should be done expeditiously to avoid delaying fracture repair.
2. Time of hospital admission
Coagulation parameters including PT/PTT and INR along with a CBC should be obtained on presentation and again after a few hours to evaluate for ongoing blood loss. Administration of reversal agents such as vitamin K, protamine, and prothrombin complex concentrate, factor Xa inhibitor antidote should be considered as clinically appropriate.
3. Perioperative
The use of spinal anesthetic if medically appropriate can help to decrease blood loss. Elevating the extremity above the torso with pads and /or Trendelenburg positioning decreases venous pressure and blood loss as well. Besides, utilization of cell saver blood harvest and antifibrinolytics (tranexamic acid or aminocaproic acid, both systemic and topical), combined with careful dissection and hemostasis is required.
Administration of fresh frozen plasma should be considered if coagulation appears incompetent.
4. Postoperative
Temporary extremity elevation and compression followed by early mobilization is beneficial and can be helped with the treatment of symptomatic postoperative anemia. A minimum hemoglobin level of 8 g/dl is desirable, and this should be 10 g/dl in patients with ischemic heart disease.
Chemical thromboprophylaxis is usually used, even in patients who have experienced perioperative blood loss.
