These authors used the nationwide Premier Healthcare claims database to evaluate the trends in frequency of drain usage in shoulder arthroplasty procedures over time, as well as the association between drain usage and blood transfusion usage, length of stay (LOS), and readmission or early infection within 30 days.
They examined 105,116 cases performed in Northeast, West, and Midwest between 2006-2016 including total, reverse, and partial shoulder arthroplasties, in which drains were used in 20% [20,886] and no drain was used in 80% [84,230]).
They found that the usage of drains decreased over time, from 25% in 2006 to 16% in 2016. After adjusting for relevant covariates, drain use was associated with an increased usage of blood transfusions (OR, 1.49; 95% CI, 1.35–1.65; p < 0.001). This represents an almost 50% increased odds for blood transfusions.
They noted a small increase in LOS (+6%, 95% CI, +4% to +7%; p < 0.001). Drain use was not associated with increased odds for early postoperative infection or 30-day readmission.
Comment: These authors have demonstrated a highly significant association between drain use in shoulder arthroplasty and the use of transfusion. As they point out, this association does not prove that drain use causes the need for transfusion. So one must consider some possible explanation for the results:
(1) In the absence of closed wound drainage, any postoperative blood loss will provide a hemostatic effect in the form of a tamponade. With the use of a drain, that effect is lost and a conduit for blood loss is introduced.
(2) Patients who are bleeding more at the end of the case are more likely to receive a drain
(3) Surgeons who take less care in establishing hemostasis are more likely to use drains
Bleeding after shoulder arthroplasty is an issue that has not been eliminated by the use of tranexamic acid. Factors that can contribute to postoperative bleeding are many
(1) Shoulder arthroplasty requires resection of osteophytes and soft tissue releases, which can lead to bleeding.
(2) The procedure is often performed in a beach chair position with the patient's blood pressure being kept at low physiologic levels. As a result potential bleeding sources may not be recognized. When the patient returns to the recovery room, he or she is supine and postoperative discomfort may drive the blood pressure up - both of which factors may increase bleeding.
(3) Early implementation of range of motion exercises may prevent effective clot formation.
Our practice is to strive for excellent hemostasis after asking the anesthesiologist to establish normal blood pressure, and using topical thrombin and oxidized regenerated cellulose
as necessary.
We do not use drains. We close the wound with staples, which provides a one-way valve allowing blood to escape if a substantial hematoma is forming. In patients that seem likely to bleed excessively (for example those who have recently been on anticoagulants or anti-inflammatory medications), we hold postoperative motion until the next morning. We reassure patients that some postoperative bleeding and bruising is not uncommon.
Using this protocol we have avoided the need for transfusion in over 99% of our cases and no longer obtain a blood type and screen unless the patient presents with a known bleeding problem or comes to the OR with a very low hematocrit.
=====
We have a new set of shoulder youtubes about the shoulder, check them out at this link.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
Use the "Search" box to the right to find other topics of interest to you.
You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
