Management of perioperative care (including blood loss)
1. Introduction
Periprosthetic fractures around the shoulder often occur in elderly patients. Frailty and sarcopenia add to other comorbidities to make these patients acutely susceptible to blood loss anemia. Initial, ongoing, and perioperative blood loss must therefore be carefully considered.
Many of these patients are on anticoagulation, which predisposes them to increased blood loss at the time of injury. Surgical and medical co-management should therefore be considered for reversal of anticoagulation.
Fracture stabilization usually helps to prevent ongoing blood loss, and these patients therefore 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, prothrombin complex concentrate, and factor Xa inhibitor antidote should be considered as clinically appropriate.
Unnecessarily delaying surgery in frail patients has a negative impact on mortality and outcomes.
3. Perioperative
Careful dissection and hemostasis are mandatory. Utilization of antifibrinolytics (tranexamic acid or aminocaproic acid, both systemic and topical) may be beneficial if not contraindicated.
Administration of fresh frozen plasma should be considered if coagulation appears incompetent.
Early detection, prevention, and management of delirium, decubitus, and malnutrition needs to be guaranteed for all frail patients. Orthogeriatric co-management should be implemented.
4. Postoperative
Early mobilization of the extremity and the patient 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 administered, even for patients who have experienced perioperative blood loss.
