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HEMOGLOBIN VALUE REDUCTION AND NECESSITY OF TRANSFUSION IN BIMAXILLARY ORTHOGNATHIC SURGERY www.indiandentalacademy.com

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• j oral maxillofacial surgery 2005 vol 63:623628 • Emeka nkenke, Peter kessler, Jorg wiltfang,and volker weisbach.

• university of Erlangen-nuremberg, Erlangen, Germany.. www.indiandentalacademy.com

AIM OF THE STUDY • To assess the reduction of the Hb value and the rate of transfusions in the patients undergoing bimaxillary orthognathic surgery.

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PURPOSE OF THE STUDY • To assess the reduction of the Hb value and the frequency of blood transfusions during bimaxillary orthognathic surgery and to discuss the clinical consequences.

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• Bimaxillary orthognathic surgery may be complicated by excessive blood loss.

• Homologous transfusion may be associated with risks like transfussion reactions and acquisition of infectious diseases.

• Autologous blood transfusion has been said to be effective alternative for the orthognathic surgery patients.

• Based on these data the need for autologous blood donation in light of a reduced risk of infections by homologous blood transfusion is discussed in this study. www.indiandentalacademy.com

PATIENTS & METHODS • 56 patients are included • 31 females and 25 males • Mean age 28.6 +/- 13.0 years range from 14 to 66 years.

• The patients were invited to join the autologous blood donation.

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• In particular, Hb value of ≥ 11.5g/100ml for women and ≥ 12.0 g/100ml for men • Absence of risk factors for bacteremia are requested • Infectious diseases were excluded by testing for markers of HIV, Syphilis, and hepatitis B & C • Frequency of donation not greater than 1 unit / week , beginning 6 to 7 weeks before the surgery is chosen.

• There was no age limit for blood donations.

• At each donation 450ml of blood were collected via phlebotomy. www.indiandentalacademy.com

• Patients received 280mg of ferroous sulphate 2 times a day beginning several days before phlebotomy and continuing for up to 2 months after surgery ,when the initial serum ferritin concentration was below 50µ/l.

• The autologous blood units were cross-matched on the day before the operation.

• The patients were starved 6 hrs before surgery.

• All patients received routine antibiotics, steroids , and thrombiosis prophylaxis perioperatively.

• Standardized G.A technique with a continuous fluid administration of 10ml/kg body weight/h was applied. www.indiandentalacademy.com

• A single segment Le fort 1 osteotomy and a modified bilateral segittal split ramus osteotomy were carried out and stabilization was performed by rigid fixition • Duration of the surgery is documented.

• The venous Hb concentration was assessed preoperatively, intraoperatively after the down fracture of the maxilla, and on the second day after the surgery.

• A threshold for transfusion a Hb value of 7.5g/100ml was chosen.

• Post operatively , symptoms of anemia were documented. www.indiandentalacademy.com (lethargy,orthostatic

RESULTS • 52 pts were operated on because of maxillary deficiency and mandibular excess.

• 2 of these pts suffered from an additional cleft lip and palate malformations.

• In 4 pts the indication for bimaxillary surgery was an obstructive sleep apnea • After the autologous blood donation program was explained and recommended to the patients 35 subjects participated in autologous blood transfusion.

• 6 of them were excluded after examination because of HIV infection , leucocytosis ,risk of bacteremia, . www.indiandentalacademy.com

• Pre operatively, the Hb levels of the donors and non-donors did not show significant differences.

• In 12 pts of donor group, 1 unit of blood was collected , while in 17 pts a predeposit of 2 units was carried out .

• After regeneration interval of 6 weeks, the Hb values of the pts who predeposited blood were still significantly reduced compared with the Hb levels before donation. www.indiandentalacademy.com

• Operation times did not differ significantly for the 2 pts groups.

• The Hb levels decreased significantly compared with the preoperative values for donor and nondonars.

• Intraoperatively, none of the pts who did not predeposit blood reached the critical Hb value of 7.5g/100ml.

• In the donor group, the Hb value decreased below this level in 3 pts.

• The preoperative Hb values after a regeneration time of 6 weeks of these pts were below the average value of the donor group.

• They showed levels of 12.8, 12.5 and 10.6g/100ml respectively. www.indiandentalacademy.com

• At day 2 after surgery, Hb levels did not differ significantly for donors and non-donors.

• Again the values reduced significantly compared with the intraoperative data.

• The Hb levels decreased on average by 2.6 ±1.4g/100ml in the non-donors and by 2.6 ± 1.1g/100ml in the donors, respectively.

• None of the pts showed clinical signs of anemia 2 days after surgery. www.indiandentalacademy.com

DISCUSSION • The conservation of blood is recognized to be a priority in all forms of surgery, especially in elective procedures because of risks of blood transfusions.

• Clinical guidelines have discouraged homologous transfusion because of the possible acquirement of various infections.

• Autologus transfusion has also got the disadvantages like development of hypovolemia and anemia etc.

• When autologous blood has been donated to avoid homologous transfusion, the guidelines for the use of autologous blood do not differ from those of homologous blood.

• And if there is no decrease in Hb level below 7.5g/dl the predepositedwww.indiandentalacademy.com blood is not returned to their donors.

• The results from this study show that none of the patients who did not predeposit blood had to be transfused.

• The analysis of the transfusion rate of the patients who had donated autologous blood show that 3 to 31 pts (9.6%)received blood . This rate is considerably less.

• Out of 56 pts only 3 pts in this study had to be transfused.

• The improved way of testing homologous blood decrease the risk of transfusion of infections .

• Therefore , instead of autologous blood homologous blood should be accepted in the scarce cases of transfusion in bimaxillary orthognathic surgery. www.indiandentalacademy.com

CONCLUSION • The individual statistics of the study show that there was only a limited reduction of the intraoperative and postoperative Hb levels as a consequence of bimaxillary orthognathic surgery • Increased safety of homologous blood and the minimal transfusion rates support abandonment of routine predepositing of autologous blood and the acceptance of homologous blood in the rare case of transfusion in bimaxillary surgery. www.indiandentalacademy.com

BLOOD LOSS AND TRANSFUSION REQUIREMENTS IN ORTHOGNATHIC SURGERY www.indiandentalacademy.com

BLOOD LOSS AND TRANSFUSION REQUIREMENTS IN ORTHOGNATHIC SURGERY • JOMS 1996 VOL 54:21-24

• Nabil samman et al Dept of OMFS, university of HongKong.

AIM OF THE STUDY: to quantify the blood loss and tranfusion requirements based on a series of 360 consecutive patients undergoing orthognathic surgery. www.indiandentalacademy.com

• PURPOSE : this study quantified the blood loss and transfusion requirements in orthognathic surgery. • PATIENTS AND METHODS: 360 healthy orthognathic surgery patients were included in this retrospective study. female:male -1.8:1, age -8 to 49 yrs (mean24).

EBV,EBL and transfused blood were calculated. www.indiandentalacademy.com

SURGICAL METHOD • All patients underwent a variety of maxillary and mandibular osteotomies according to a strict surgical protocol for each procedure.

• 69 pts had single jaw surgery, • 291 pts underwent bimaxillar4y osteotomies.

• In most of the pts, more than one procedures was performed and , in 73 cases, a free bone graft was obtained from the ilium and transplanted to the osteotomy site.

• The decision to transfuse intraoperatively was left to the anesthesiologist, • And postoperative transfusion was a surgical decision. www.indiandentalacademy.com

ESTIMATED BLOOD VOLUME AND BLOOD LOSS ESTIMATION • EBV was calculated for each pts using the body wight formula(75ml/kg for men, 66ml/kg for women) • EBL wasv calculated by weighing sponges, measuring suctioned blood, irrigation sol durig surgery.

• In addition the data about preoperative body weight; Hb value; hematocrit; duration of the surgery ; post opp blood loss and transfusion were caliculated. www.indiandentalacademy.com

RESULTS

• 84 pts (23.3%) required blood transfusion. most pts required 1or 2 units of transfusion and only 12 pts required more than 2units.

• Of the 69 pts who underwent single jaw surgery, 6 (8.7%) were transfused. And these 6 pts were all cleft palate cases undergoing either Lefort 2 osteotomy via bicoronal flap (3cases), and grafting of residual alveolar cleft.

• Of 291 pts who underwent bimaxillary surgery, 78(26.7%) were transfused, 45 pts received 1 unit of blood, 22 received 2 units, 11 received over 2 units, www.indiandentalacademy.com • Only 5 pts suffered hemorrhagic complications but only 2 of them are transfused with more than

DISCUSSION

• Based on the data in this series of 360 cases, w concur with the view that single jaw osteotomies, wether maxillary or mandibular, including segmentalized Lefort 1 and combined body and ramus procedures, can be considered as unlikely to require blood transfusion.

• But in Bimaxillary osteotomies, approximately 27% require a transfusion of 1 to 2 units of blood.

• The proximity of the transfusion requirements of bimaxillary osteotomies to 30% probability threshold suggests that at least in some circumstances, if not routinely, cross-matching or predepositing 2 units of blood would be essential.

• Furthermore, an unpredictable group of 4% will require a larger www.indiandentalacademy.com transfusion.

CONCLUSIONS • Transfusion is not necessary for single jaw surgery unless a bicoronal flap or iliac bone harvest are required. Although only 27% of bimaxillary osteotomy pts required transfusion of 1 to 2 units, this group was not predictable based on the type of procedure involved, and a further sub group required a larger transfusion. www.indiandentalacademy.com

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