TRANSFUSION NEED IN ORTHOGNATHIC surgery- A REVIEW
Table 19. Summary of transfusion rate according to procedure and predonation policy.
Procedure
BSSO single jaw Le Fort I single jaw simple Le Fort I single jaw complex Bimaxillary surgery simple Bimaxillary surgery complex
Predonation n / N
* The % transfusion rate results from the statistical model used. ** Reported transfusions after BSSO-surgery reflect cases with excessive accidental peroperative bleeding. Where n is the number of patient and N is the total number of patient.
differences( 12.5 % vs 25.7 % in the probit-normal statistical model). The reasons are wide confidence intervals and small sample sizes. The intra-study correlation in the simple bimaxillary procedure group without predonation was 0.32( p = 0.0047). The intra-study correlation in the complex bimaxillary procedure group without predonation was 0.30( p = 0.0941). The clinical interpretation of the statistical result is that we failed to prove a significantly different transfusion behaviour beween simple and complex bimaxillary procedures. It should not be interpreted as having been proven that there is no difference in transfusion rate.
4. Discussion and Conclusions Transfusion for BSSO surgery is rather independent of the duration of surgery and will be necessary only in the event of a vascular injury. Several techniques are implemented to reduce the blood loss and subsequent blood transfusion in orthognathic surgery. This review showed a‘ very low level of evidence’ that the deliberate hypotensive anesthesia is indeed correlated with less blood loss, but it remains one of the most commonly used techniques during maxillary surgery. 57-59 More than any other factor this review showed that transfusion policy, rather than strict criteria, initiates the decision to transfuse. This trend is endorsed in the paper by Faverani et al. 41 who suggest that the indication of blood replacement should be based not only on laboratory parameters( primarily, reduced Hb and Hct levels) but also on clinical signs indicative of a true need for transfusion, such as tachycardia, tremor, diaphoresis, and malaise. If a liberal reinfusion strategy of autologous blood is avoided, single Le Fort I surgery without additional
Transfusion rate( n / N) Transfusion rate(%)*
- 35 / 118 3 / 54 342 / 969 22 / 219
No predonation n / N- 19 / 408 8 / 105 187 / 1264 20 / 120
Predonation % ** 26,3 5,6 39 15,3
No predonation % ** 4,5 7,6 12,5 25,7 statistical model
case-reports probit-normal logistic regression probit-normal probit-normal
or complex procedures has historically been accompanied by a blood transfusion need of about 4.5 %, and in the case of additional procedures, about 7.6 % or less depending on the criteria for transfusion. There seems to be no influence of additional procedures, whether it concerns segmentation or grafting, on the transfusion need in single Le Fort I surgery, as long as strict transfusion criteria are followed. Bimaxillary surgery is less dependent on the depth of hypotension and rather on additional measures to lessen blood loss during surgery. Contemporary approaches allow bimaxillary surgery without complex or additional procedures in ASA I patients with a transfusion need as low as 1 – 2 %. Depending on the criteria for transfusion and the availability of predonated blood, this transfusion rate can reach levels as high as 33 – 35 %. Complex bimaxillary surgery— which is becoming more frequent in contemporary orthognathic surgery in the field of enhanced facial sculpturing, multisegmental Le Fort I osteotomies, and large bimaxillary movements with harvesting of iliac crest bone grafts in medically more compromised patients with OSAS— will approach an overall blood transfusion rate of about 20.6 % and surpass the 10 % limit that German centers use to offer a predonation policy to their patients.
Author Contributions CP designed the study and wrote the manuscript; JOA and IL reviewed the manuscript. Acknowledgments The authors declare no conflict of interest related to this study. There are no conflicts of interest and no financial interests to be disclosed.
Review Articles
References
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