Evaluation of blood loss and need for transfusion during orthognathic surgery in the era of limited blood transfusion

Orthognathic surgery can be defined as the art and science of diagnosis and treatment by combining orthodontics and oral surgery to correct dentosseous, musculoskeletal and soft tissue deformities of jaws [1]. Since there is rich blood supply to head and neck region, considerable bleeding should be anticipated both from incised soft tissue and bone during orthognathic surgery. The use of hypotensive anaesthesia has reduced the transfusion rate dramatically and in contrast to earlier recommendations haemoglobin values between 7 g/dL and 8 g/dL seem to be acceptable in healthy patients [2]. Intravenous and topical tranexamic acid has been reported to reduce blood loss during surgery [3]. Despite rigorous testing of every unit of blood risk of transmission of several pathogens still remains [4]. Postoperative infection is another complication of allogenic transfusion. A haemoglobin concentration of 6.5–7.0 g/dL was regarded as the threshold for transfusion. Blood loss in bimaxillary orthognathic operations is usually between 400 and 600 mL, transfusion should not be considered in a healthy patient.More accurate estimation of the predicted surgical duration and blood loss volume could enable surgeons and anaesthetists to improve management during the operation. This study is hence aimed to correlate clinical variable with blood loss and need of transfusion during orthognathic surgical procedures. It also evaluates the average blood loss during maxillary and mandibular procedures when done alone or in combination.

Orthognathic surgery involves surgical handling of the facial skeleton to correct various dentofacial anomalies. The most frequently performed procedure in maxilla is Lefort 1 osteotomy and in the mandible is bilateral sagittal split osteotomy [5].

Posnick [6] et al suggested that transfusion is definitely indicated if the haemoglobin level is at or below 7g/dl and rarely considered if the haemoglobin level is more than 10g/dl.

Intraoperative haemorrhage was estimated by a volumetric method and gravimetric method. It was difficult to quantify the amount of blood on drapes, gowns, instruments and throat pack. There was also a chance of swallowing a small amount of blood. In addition to irrigating fluids and blood, the suction bottle also contained constituents such as saliva and bone powder. However, these things were applied commonly to all the cases and bias of blood loss can thus be avoided.

The total study population showed a mean blood loss of 437.27± 414.6mL. Pineiro-Aguilar et al in their systematic review found out a mean blood loss of 436.11 mL in orthognathic study.[7]A mean blood loss of 400 mL was reported by Oslen et al in their bimaxillary osteotomies [8] and Keith M, in his retrospective study observed a mean blood loss of 481.8 mL [9]. In a study conducted by H.S.Chen et al, the mean blood loss was 105.9 ± 66.83 mL during bilateral ramus osteotomy.[10]

The mean blood loss was 617.7 ± 575.2 ml in males and 326.2 ± 223.1ml in females. Similar to our study there was significantly more blood loss among males than in females in studies conducted Olsen et al [8].

While comparing the surgical procedures blood loss was higher in the bimaxillary group (583 ± 491.7) in our study.

The mean operative time in this study was 165 ± 69.9 minutes. Considering the surgical procedures, it was more in the bimaxillary group with 185.2 ± 77.9 minutes. A mean surgical duration of 255.5 ±

42.56 minutes was observed in a study conducted by H.S Chen et al [10]. Michael S Jaskolka mentioned that the amount of blood loss differed significantly with respect to various orthognathic surgical procedures and duration of surgery and suggested these as predictors of short-term quality of life after orthognathic surgery [12]. He also observed that bimaxillary procedures required one-week longer recovery period when compared to single jaw procedure. Thastum et al [13] reported that operating time and treatment modality had a significant impact on relative blood loss.

The pre-surgical blood ingredients showed higher values in males compared to females in this study which was similar to results observed in a study by Olsen et al [8].The mean reduction in blood parameters like haemoglobin, haematocrit and RBC was found to be significant.The average reduction of haemoglobin, haematocrit and RBC were 2.5g/dl, 7.8 % and 0.89x106/μL respectively (Table 2).

H.S Chen et al reported a mean reduction in blood constituents as follows; haemoglobin reduction of 1.9g/dl, haematocrit reduction of 5.7% and RBC count reduction of 0.7 [10]. A mean drop of haemoglobin concentration of 25% and PCV drop of 26% was observed post-operatively W.B Kretschmer et al.[3] Kretschmer et al in another study mentioned a 3.4g/dl drop of haemoglobin and 25% drop in haematocrit value compared to pre-operative value.

This study showed a positive correlation of blood loss with operative time and with the reduction in haemoglobin as well as RBC levels. A study by Keith M [9] to correlate different orthognathic surgeries with operating time and blood loss suggested that operating time explains 25% of the variance in blood loss. Winfried Kretschmer et al in their study reported a significant positive correlation between operating time and a decrease in haemoglobin and haematocrit values [3]. Rumasak, Apipan and Kaewpradup in 2011 and Tseng et AL [14] also had a similar positive correlation between operating time and blood loss [15].

In the present study, major vessels responsible for severe bleeding were descending palatine in Le Fort 1 osteotomy and inferior alveolar artery while performing BSSO osteotomies.

Strategies taken to reduce bleeding for surgery in our institution were the use of hypotensive anaesthesia, infiltrating the site of interest using local anaesthesia containing vasoconstrictor, careful incisions, and subperiosteal dissection. Lin et al [16] in their systematic review and meta-analysis reported that hypotensive anaesthesia resulted in a sparing of about 169mL of blood while performing orthognathic surgeries and has shown to improve the quality of the surgical field. Several studies have mentioned the use of hypotensive anaesthesia to reduce blood loss in orthognathic surgery [17]. Numerous studies have demonstrated the effectiveness of tranexamic acid to reduce bleeding in orthognathic surgery [18].

Literature review observed that use of the piezoelectric unit, erythropoietin plus iron supplements, Yunnen Baiyo capsules are effective in reducing blood loss during orthognathic surgery.[19]Bleeding can also be reduced by infiltrating the area with a vasoconstrictor such as epinephrine prior to incision. It is usually given in combination with a local anaesthetic. A decrease in blood flow will be apparent in 5 minutes after administration.

Arimoto et al conducted a study and found out that ultrasonography was effective compared to magnetic resonance imaging to determine the location of the internal maxillary artery prior to intraoral vertical ramus osteotomy [18].

Only six patients (14.3%) out of forty-two patients required allogenic blood transfusion according to anaesthetist’s protocol in this study however, none of them had any adverse reactions and postoperative period was uneventful. Five patients who required blood transfusion underwent bimaxillary surgery. Blood transfusion was also required in a female patient who underwent anterior maxillary osteotomy. Patient’s haemoglobin level dropped from 11.45 to 9.8g/dL following a 220ml blood loss during surgery. Pre-operative blood transfusion was given for one among the six patients. The patient had a pre-operative haemoglobin value of 8.8g/dl and was transfused with two units of allogenic blood pre- operatively as per anaesthetist’s instruction.

Only 1.8% of patients received a blood transfusion in a study conducted by Posnick, Choi and Chavda [19]. Politis et al observed an incidence of 0.27% life- threatening haemorrhages in Lefort 1 surgery. Posnick et al in 2010 reported that 6% of patients received an allogenic blood transfusion during bimaxillary orthognathic surgeries. M.Garg et al recommended that no routine coagulation screen or group and save with antibody screen is required for ASA 1 patients for orthognathic surgery. A study by Choi et al observed that no transfusion was required for 82 patients undergoing bimaxillary surgery.

Acknowledgement

I thank all the staff of Oral and Maxillofacial Surgery, Madha Dental College and Hospital for their cooperation and kind support throughout my research period.

Within the limitation of our study, it was concluded that even though there is a significant reduction of blood ingredients in patients undergoing orthognathic surgery, only 14% of patients underwent allogenic blood transfusion.The study also confirms a positive relationship between intraoperative blood loss and operating time.

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