REVIEWS
Rafał Nowak
1, A, D, E, Ewa Zawiślak
1, B, D–F, Maciej Kielan
2, B, E, F, Marta Greczner
2, B, FThe Necessity of Autologous Blood Transfusion
in Patients Undergoing Orthognathic
Surgery Procedures – Review of Literature
Potrzeba autologicznej transfuzji krwi u pacjentów poddanych
planowym zabiegom chirurgii ortognatycznej – przegląd piśmiennictwa
1 Department of Maxillofacial Surgery, Wroclaw Medical University, Poland 2 Doctoral studies, Wroclaw Medical University, Poland
A – concept; B – data collection; C – statistics; D – data interpretation; E – writing/editing the text; F – compiling the bibliography
Abstract
Views about blood management in orthognathic surgery have changed in the last decade. The possibility of per-forming surgery with hypotensive anaesthesia, using tissue injections of local anesthesia with vasoconstrictor improvement of surgical techniques and using piezosurgery have considerably reduced blood loss during opera-tions. Patients who undergo orthognatic operation are in most cases healthy young persons, without systemic diseases and American Society of Anestesiologist (ASA) grade 1. The aim of this study is to review the literature of the last twenty years, on the autologous blood donation requirements before bimaxillary osteotomies. The bibliog-raphy included an analysis from the Elsevier database (Dent. Med. Probl. 2013, 50, 2, 223–227).
Key words: bimaxillary osteotomy, orthognathic surgery, autologous blood donation.
Streszczenie
Poglądy na temat potrzeb autologicznej transfuzji krwi u pacjentów poddanych elektywnym zabiegom chirurgii ortognatycznej, a szczególnie operacjom dwuszczękowym zmieniły się w ostatnim dziesięcioleciu. Możliwość prze-prowadzenia zabiegu operacyjnego w hipotensji, ostrzykiwanie tkanek miękkich środkiem znieczulającym z dodat-kiem środków naczyniozwężających, doskonalenie technik operacyjnych oraz wykorzystanie piezochirurgii w zna-czącym stopniu zmniejszają śródoperacyjną utratę krwi. Pacjenci operowani z powodu wad gnatycznych to zwykle ludzie młodzi, bez obciążeń chorobami ogólnymi, klasyfikowani przez anestezjologów do pierwszej grupy (ASA I) ryzyka operacyjnego podczas znieczulenia ogólnego według Amerykańskiego Towarzystwa Anestezjologicznego. Celem pracy jest przegląd współczesnego piśmiennictwa na temat potrzeb zabezpieczania pacjenta przed zabiegiem osteotomii dwuszczękowej w krew autologiczną. Analizą objęto piśmiennictwo pozyskane z bazy bibliotecznej Elsevier. Hasłami indeksowymi były: chirurgia ortognatyczna, autotransfuzja, osteotomia dwuszczękowa (Dent.
Med. Probl. 2013, 50, 2, 223–227).
Słowa kluczowe: osteotomia dwuszczękowa, chirurgia ortognatyczna, autotransfuzja krwi.
Dent. Med. Probl. 2013, 50, 2, 223–227
ISSN 1644-387X © Copyright by Wroclaw Medical University and Polish Dental Society
The history of blood transfusions begins in the 17th century. In 1628, a British physiologist Wil-liam Harvey published the first information about the human circulatory system. In 1665 Lower con-ducted the first ever transfusion between animals. Two years later, Jean-Baptiste Denis reported an experiment he had conducted himself, where the
blood of a sheep was transfused to a deranged man in order to “cure” him.
The first allogeneic blood transfusion took place in 1818 and was conducted by a British ob-stetrician, James Blundell. Until the beginning of the 20th century the majority of experiments with blood transfusion led to deaths of patients,
which forced many European governments to pro-hibit blood transfusions. Great breakthrough in the field of post-transfusion complications came in 1901, when Karl Landsteiner discovered a sys-tem of ABO erythrocyte antigens. The following years brought the works of Reuben and Ottenberg on the universal donors and recipients of blood. World War I and World War II delivered a great deal of new experience in the fields of blood trans-fusions, organization of blood banks and various means for storage and preservation of blood de-rivatives. The discovery of protein Rh erythrocyte antigen in 1939 paved the way for the contempo-rary era of transfusiology [1, 2].
Autotransfusion (autologous transfusion) is the process of transfusing blood, where the donor and the recipient are the same person. This de-creases the risk of infections as well as immuniza-tion and transfusion complicaimmuniza-tions, yet it does not exclude them totally, similarly to the human er-ror during blood collection, preparation, storage, transport and transfusion. Autotransfusion proce-dures include:
– preoperative autologous blood donation – PAD, – intra- and postoperative autotransfusion – IAT, – intraoperative hemodilution,
– intraoperative transfusion of extravasated blood (from the surgical site) or postoperative transfusion (from drain).
Blood sampling, which serves as a safety pre-caution during elective surgeries e.g. orthogna-thic surgery, may be burdened with various com-plications both local and general. Local compli-cations include damage of blood vessels, nerves, creation of haematoma and its infection as well as local inflammations. General complications in-clude faintness, inflammations and thrombosis of large vessels as well as cardiovascular compli-cations. Human errors as well as administrative errors connected with blood collecting and stor-ing, transportation from the blood bank as well as with the transfusion itself cannot be exclud-ed. Despite the fact that every patient is tested for viral diseases, the presence of antibodies and the fact that his or her blood group in the ABO sys-tem and the D antigen in the Rh syssys-tem are deter-mined, human error may never be excluded in that kind of research, similarly to the mistake in label-ling blood containers and their improper storage or transport [3, 4].
The aim of this paper is to present the posi-tions of various authors regarding the require-ments and indications of donating autologous blood to patients before the planned bimaxillary osteotomy, based on the contemporary literature. The review focused on the literature available in the Elsevier database with such key words as:
or-thognathic surgery, bimaxillary osteotomy and autologous blood donation. Eventually, 24 publi-cations were chosen for the review.
Most common defects of the cranio-facial skel-eton are: wrong bone structure or position, bone under- and overdevelopment as well as asymmetri-cal bone growth. This leads to disorders of the sto-matognathic system and can adversely influence the facial morphology and aesthetics. Patients seeking help are usually generally healthy, young adults, for whom the orthognathic operation is not only a way of improving the physiology of their masticatory system, but also the opportunity to free themselves from the complex of being “dif-ferent” related to abnormal facial morphology and appearance.
Various kinds of osteotomies within the cra-niofacial skeleton are standard in the contempo-rary field of orthognathic surgery. They pertain to the mandible or maxilla. Bimaxillary operations with additional procedures such as rhinoplastics or zygoma ostotomy and chin corrections are al-so commonplace. The dynamic development of this discipline began in the 1960s. The first com-plex treatments used to last several hours and were burdened with high risk of general and local com-plications. At present, the most commonly per-formed osteotomies pertain to maxilla or mandi-ble. The combinations of these procedures are bi-maxillary operations.
Due to the extent of surgeries as well as the time necessary to perform them, one of the main risk factors during orthognathic procedures is blood loss. In such case a transfusion may be required. In the case of maxillary osteotomy, the most com-mon sources of bleeding are sphenopalatine ar-tery, descending palatine arar-tery, plexus pterygoi-deus and smaller branches of the maxillary artery, which may be damaged during the separation of maxilla from pterygoid process of the sphenoid bone, during maxillary down fracture as well as during considerable impaction in the back section and maxillary advancement. During mandible os-teotomy damaging inferior alveolar artery and fa-cial artery is possible. Its probability drops with the proper subperiosteal preparation and protec-tion of the soft tissue with use of special tools. Therefore, in many clinics dealing with orthogna-thic surgery, donating autologous blood of the pa-tient before an orthognathic procedure used to be standard procedure for years.
The need for autologous blood transfusion after bimaxillary osteotomy has been greatly re-duced in the last decade to the point, where this kind of procedure is no longer recommended as standard [5–10]. Blood loss during surgery can be greatly reduced thanks to the development of
sur-gical and anaesthesiolosur-gical techniques, piezosur-gery, decrease in surgery time as well as the possi-bility of operating in the state of hypotension [11, 12]. Orthognathic procedures conducted on pa-tients in hypotension have become a standard, as they enable to reduce the intraoperative blood loss to as much as 40% [13–17]. What is more, periop-erative and intraopperiop-erative pharmacotherapy (fen-tanyl, erythropoietin, tranexamic acid) allow for “economizing” on the patient’s blood. Patients who undergo bimaxillary osteotomy are usual-ly young, healthy people, with without systemic illnesses, qualified for the first perioperative risk group (ASA-I) during general anaesthesia accord-ing to ASA (American Society of Anaesthesiolo-gists) [9, 18, 19]. According to Pińeiro-Aguilar et al., who conducted a systematic review of the lit-erature regarding the problem in question, the av-erage blood loss during an orthognathic proce-dure is 436.11 ml [10]. It is a commonly accepted fact that in an adult the loss of 20% of circulating blood could be safely substituted with crystalloid or colloid solutions, without any damage to the pa-tient’s health.
The decision about transfusion is made by a surgeon or anaesthesiologist based on the gen-erally accepted standards and algorithms of con-duct in treating patients with blood and blood de-rived products. At present the indications regard-ing blood transfusion are considered individually for every patient. The level of haemoglobin (Hb) itself cannot be an indication for transfusion. The critical level of haemoglobin for healthy people is not known, but probably it is 5 g/dl. The patients’ death rate increases at Hb < 6 g/dl and it is the crit-ical value, which from the medcrit-ical point of view is an indication for transfusion. At Hb > 7 g/dl, what should be taken into account are the physiological indicators showing hypoxia (tachycardia, hypo-tension, lower saturation of mixed venous blood), general diseases (cardiological, neoplastic) as well as the age of the patient (> 65 years) [20–23]. Ac-cording to the National Health Service (Great Brit-ain), blood transfusion should be used in the cases of saving lives and for prevention of deterioration of health and not for accelerating recovery, which unfortunately is the case in some clinics [22].
The conclusion of the research conducted by Rummasak et al. [24] is the donation of autologous blood to selected patients in specific clinical cas-es. The risk group involves patients with low body mass, especially women, with additional surgical procedures planned. A notion worth consider-ing is donatconsider-ing autologous blood to patients with rare blood type or in the case of difficulties with accessing blood of the given type verified in the blood bank.
Dhariwal et al. [14] recorded only 3% of cases (4 patients), where blood transfusion was neces-sary in the total group of 115 patients, who under-went bimaxillary osteotomy in 1996–2000. None of the cases was urgent and all patients were do-nated blood from the blood bank. These authors also draw attention to the high costs of blood col-lecting, storing and transport as well as of labora-tory screening of patients undergoing autotrans-fusion. They stress the possibility of complications after autotransfusion in the form of embolic mi-crocoagulopathy, anaemia, hypovolemia, bacteri-al infection of the blood as well as post-transfu-sion complications. In their conclupost-transfu-sions they reach a point, where they do not recommend cross-matching of blood, but only securing blood of the respective type in the blood bank on condition that it is available up to 30 minutes after cross-match-ing. In their opinion, the greatest efforts should be made towards minimizing the blood loss during operation and transfusions should only be used in cases, where they are indispensable.
According to Fenner et al. [25], typically there are no indications for transfusion in patients after bimaxillary osteotomy and consequently for pre-operative autodonation. In the retrospective study of 105 patients operated on in the Clinic of Oral and Maxillofacial Surgery in Erlagen (Germany), in the period between 2003 and 2007 no transfu-sion of autologous blood was done after the proce-dure of bimaxillary osteotomy. The lowest postop-erative value of haemoglobin was 6.8 g/dL, which at full hemodynamic stability was not an indica-tion for transfusion. Similarly to Dhariwal et al., these authors claim that there is no need for earli-er blood cross-matching before the opearli-eration and that blood/Rh typing and verifying accessibility of blood in the blood bank is sufficient.
A similar attitude is presented by Kretschmer et al. [9]. Among 225 patients, who were operated on in the Clinic of Oral and Maxillofacial Surgery in Stuttgart (Marienhospital, Germany) in 2006– 2009 due to cranio-facial defects using bimaxi-lary procedures additionally with maxilbimaxi-lary seg-mentalization, only 9 patients required postopera-tive transfusion of homologous blood. In 64 cases the procedure of bimaxillary osteotomy involved an additional procedure (e.g. genioplasty, rhino-plasty) and in 45 cases involved harvesting bone graft from iliac crest. The indication for trans-fusion was the level of haemoglobin lower than 70 g/L or the decrease in PCV (packed cell volume) by 0.20 in relation to its level before the procedure. The treatment protocol did not include donating autologous blood as a safety precaution before the procedure. All procedures were conducted in con-trolled hypotension, at 120–80 mm Hg systolic
blood pressure and 80–55 mm Hg diastolic blood pressure and all patients were qualified for group I according to ASA (generally healthy). Accord-ing to the authors, sheer controlled hypotension leads to a decrease in intraoperative blood loss by around 40%, while additional surgical procedures such as harvesting bone graft from iliac crest or additional cranio-facial osteotomies did not cause any statistically significant increase in blood loss.
Moenning claims that out of 188 generally healthy patients, who underwent bimaxillary os-teotomy in 1987–1990, only four patients required blood transfusion (2.1%). Similarly to Dhariwal et al. and Kretschmer et al., he did not indicate any statistically significant difference in blood loss in patients, who had undergone additional surgical proccedures. The author suggests that the decision about donating autologous blood before a bimaxil-lary procedure should be made by the patient him-self, after a doctor had provided an honest presenta-tion of the risks and benefits of autotransfusion [5].
Garg et al. point out the necessity of perform-ing laboratory tests coverperform-ing the coagulation sys-tem, ABO/Rh blood group and antibodies before the procedure. The aim of such actions is to track patients with coagulation disorders or with rare blood group. In such cases the author considers donation of autologous blood as safety precaution, yet this is not a rule [19].
It should not be forgotten that blood donation before the procedure leads to anaemisation of the organism. What is more, the fact that blood ex-pires sets a strict time limit as to when the
opera-tion can be conducted. In random cases of chang-ing the appointed time of the procedure, blood may expire and become useless.
The final aspect, which should be considered, pertains to blood economy. The procedure of col-lecting 1 unit of blood, its storing and conduct-ing necessary tests, is the cost several hundreds of PLN. This does not include the costs of transport and potential utilization. Consequently, unreason-able and useless blood collection for donation dur-ing orthognathic procedures may lead to unneces-sary costs, which otherwise could be saved for oth-er investments.
Conclusions
The necessity of blood transfusion in orthog-nathic surgery has been greatly reduced in the re-cent years. Many authors dealing with the dis-cussed problem agree that there is no need for au-tologous transfusion. There are no indications for autologous donation before elective orthognathic procedures, as there are no indications for postop-erative transfusions. The necessity of blood trans-fusions in orthognathic surgeries in the form it was known years ago has become an exception.
The necessity of donating autologous blood could be considered in selected clinical cases, economy is not without meaning. Autologous do-nation requires a number of costly laboratory tests and may be burdened with complications as in the case of any donor or recipient.
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Address for correspondence:
Rafał Nowak
Department of Maxillofacial Surgery Wroclaw Medical University Borowska 213
50-556 Wrocław Poland
Tel: +48 71 784 36 90
E-mail: rafal.nowak@chirurgiatwarzy.pl Conflict of interest: None declared Received: 29.04.2013
Revised: 26.06.2013 Accepted: 28.06.2013
Praca wpłynęła do Redakcji: 29.04.2013 r. Po recenzji: 26.06.2013 r.
