Blood Loss And Transfusion Patterns During Open Intramedullary Nailing Of Diaphyseal Femoral Fractures In Kenyatta National Hospital

Abstract

Background: Diaphyseal femoral fractures are some of the commonest injuries treated in Kenyatta National Hospital. The sharp increase in these patients is due to rise of motorizing mode of transport, making it a public health concern in our country. The intramedullary nailing system for fixation of these fractures commonly available in KNH is the one utilizing distal locking jig making it an open method. Lack of equipment like image intensifier, traction table and long duration of stay before surgery favors open intramedullary nailing. Determining the level of expected blood loss, predicts the need for blood transfusion during surgery. Factors that affect blood loss during open intramedullary nailing can greatly influence pattern of blood loss and transfusion needs. There is paucity of data on the quantity of blood loss and transfusion pattern in open intramedullary nailing of femoral fractures. Objectives: To determine blood loss and transfusion pattern in patients undergoing open reduction and intramedullary nailing of diaphyseal femoral fractures. Study design: Prospective observational cross-sectional study Setting: KNH orthopaedic wards and theatres Methodology: Consecutive sampling was used to enroll eligible patients with a closed diaphyseal femoral fractures undergoing open interlocking nailing procedure one day before operation. The patients were identified after decision to operate was made and one day before the day of surgery. Written consent was sought from the patient. Patients’ biodata was acquired and recorded. The pattern of the fracture was observed and recorded. Time between admission and surgery was also noted. The blood sample was obtained and taken to the laboratory for hemoglobin level test before surgery, intraoperative parameters such as mode of anesthesia, diathermy use, average intra-operative blood pressure, duration of surgery, length of incision and units of blood transfused were noted. Repeat HB level test was done 72 hours after surgery. The collected data was analyzed using SPSS v.20 and Microsoft excels, and presented in the form of percentages, means and their 95% confidence intervals. x Timeline: The study was carried out between February 2017 and June 2018 Results: The study involved seventy subjects comprising of males (84%) and females (16%). Average (mean) age of the subjects was 32 years. The mean blood loss estimated was 3.3g/dl which is equivalent to 1485ml. Of the total patients 94% had blood cross-match requested but only 35% received blood transfusion. For those who received transfusion, only one unit was given per patient. The main reason for transfusion was anesthetist assessment of intraoperative bleeding at 69.2%. The factors than mainly influenced blood loss was the complexity of fracture and duration between injury and surgery. All the patients were operated under spinal anaethesia and median length of operation was 120 minutes. Diathermy was used in 75% of the cases and most surgeries were done by registrars at 84%. The ratio of blood cross-matched to that which was transfused was 4.5:1. Conclusion and recommendation: Fractures operated early have significant low blood loss. Lack of blood for transfusion should not be a limiting factor for operating patients with a HB above 13.5g/dl. There is unnecessary cross-matching for patient undergoing open ILN.