Intraoperative bleeding — a complication that occurs in more than 18 percent of elective knee and hip replacements — has serious ramifications for both patient outcomes and costs, according to Sean McMillan, DO, chief of orthopedics and director of orthopedic sports medicine at Burlington, N.J.-based Lourdes Medical Center.
During a May 9 webinar sponsored by BD and hosted by Becker's ASC Review, Dr. McMillan explained how a plant-based product helped him save time, reduce the risk of complications and minimize intraoperative bleeding in orthopedic surgeries.
The burden of intraoperative bleeding
Uncontrolled bleeding can increase procedure times by up to 37 minutes per case, Dr. McMillan said. For surgeons performing multiple joint procedures each day, the time wasted quickly adds up. It also erodes patient trust. If a patient expects to be walking — or home — soon after a procedure, intraoperative bleeding might throw a wrench in those plans.
Then, there's the cost factor: every time blood is transfused, it adds $700 to $800 to a case's expense and can increase a patient's length of stay up to six days. Ultimately, uncontrolled bleeding can leave procedures costing thousands of dollars more than anticipated.
"These are all things to consider when you're thinking about your bundled payment or just patient satisfaction and overall outcomes," Dr. McMillan said.
The search for a solution
To minimize the risks associated with intraoperative bleeding, Dr. McMillan and other members of Lourdes Medical Center's products committee evaluated solutions on three measures: ease-of-use, cost-effectiveness and positive outcomes. Arista™, a ready-to-use, plant-based microfibrillar collagen hemostat product, checked all those boxes.
Surgeons should understand precisely what issue they're targeting when selecting a hemostatic agent, Dr. McMillan said. Advanced hemostatic agents such as Arista provide broad coverage for issues like diffuse bleeding, whereas other agents are better suited for local applications like residual oozing. Lourdes conducted trials of several agents, including Arista, Surgiflo® and thrombin, before deciding to use Arista with or without tranexamic acid.
Arista works by dehydrating the blood and turning it into polysaccharide spheres, or what Dr. McMillan describes as "little chiclets." Those spheres form a gelatinous bond with each other, creating a glucose barrier to prevent further blood loss. Within 24 to 48 hours, the body dissolves the powder.
The benefits of Arista™
The body recognizes the polysaccharide spheres as native and breaks them down quickly. The rapid dissolution prevents adhesion formation, thereby reducing the risk of infections and boosting the value proposition for orthopedic surgeons.
"The fact that it goes away in one to two days is huge because I don't want to leave anything behind in the body," Dr. McMillan said. "That's something that myself, my joint partners and colleagues spoke about when trialing these different agents. That was a big deal to us because we want to make sure our patients get up, get moving quickly and have a low risk of infection."
Arista can be used regardless of whether a patient has renal insufficiency and it is not dependent upon a patient's coagulopathic state. Arista is also cell-saver compatible, comes ready-to-use right out of the package and has a five-year shelf life, alleviating expiration and restocking concerns associated with other hemostatic products.
Helping to save costs, Arista is available in three quantities — 1 gram, 3 grams and 5 grams. That purchasing flexibility and the scientific studies documenting the product's efficacy made Arista highly appealing to Lourde's product team, according to Dr. McMillan. Researchers have found that, compared to a gelatin sponge, Arista is quicker to hemostasis and shortens surgical times, resulting in faster operating room turnover and better patient outcomes.
How to achieve optimal results through planning
Dr. McMillan offered two cautions for surgical teams introducing Arista into their practices. The first is to prevent it from potentially interfacing with bone cement. This is recommended to avoid any risk of iatrogenic implant loosening. Dr. McMillan's second piece of advice is to use Arista intentionally, as carelessly dumping the powder when not planned or prepared may not yield optimal expected results. He recommends targeting locations on known bleeding, such as the posterior capsule of a knee or around the glenoid and capsule in a shoulder.
Lourdes Medical Center of Burlington has been collecting data as to the benefits of Arista for almost two years, with promising results in the first 250 elective cases, according to Dr. McMillan. The orthopedics chief plans to continue using the powder as an integral part of his practice's efforts to reduce intraoperative bleeding, keep costs down and improve patient satisfaction.
"Clinically speaking, we have data that shows that this has been effective for us," Dr. McMillan said. "It's safe, it goes away quickly, and it doesn't cause adhesions. And the body recognizes it as native, so I'm not worried about some sort of reaction to the body. The cost-effectiveness speaks for itself. … It's easy to use; there's no mixing, no thrombin addition, no defrosting, so it really makes for a happy environment for my staff, as well as my partners and I."
To view the webinar, click here. To access the webinar slides, click here.