Reinfusion of whole blood following addition of tobramycin powder to the wound during total knee arthroplasty

The Journal of Arthroplasty Vol. 8 No. 3 1993

Reinfusion of Whole B l o o d Following A d d i t i o n of Tobramycin P o w d e r t o the W o u n d During Total Knee Arthroplasty P a u l S. L u x , M D , J e f f r e y w .

Martin,

MD, and Leo A. Whiteside,

MD

Abstract: This study prospectively examined nine human volunteers who underwent unilateral cementless total knee arthroplasty and had 600 mg of tobramycin powder added to their wound just prior to fascial closure. Serum levels of tobramycin were measured at 30 minutes, 4 hours, 8 hours, and 12 hours after surgery. Tobramycin levels in the reinfused whole blood were measured with each reinfusion. Patients were reinfused up to 12 hours after surgery and then thereservoir was left to suction drainage. All patients had significant levels Of semrfitObramycin 30 minutes after surgery. The average serum level was 5.5 gg/ml (~'ange, 3.0-10.6 ~tg/ml). This level was achieved prior to any reinfusion and represented systemic absorption of tobramycin from the bleeding surfaces of the muscle and bone. All patients received at least one reinfusion of 400 ml of whole blood in the first 8 hours after surgery. Two thirds of the patients received a second reinfusion within the same time frame. Serum tobramycin levels measured postreinfusion indicated that the risk of attaining potential toxic levels of aminoglycoside was not dependent on reinfusion, but on absorption from the wound. The dose of tobramycin in the drain was measured and found to be excessive and potentially toxic (range, 27-312 mg; average, 132 mg). Despite this fact, reinfusion was not as likely to produce toxic serum levels as Was local uptake of the antibiotic. Although no patient in this series had any complaints relating to the high dose of tobramycin (deafness or renal failure), caution should be exercised when using antibiotics in a reinfusion system. Because most of the antibiotic delivered into the wound is absorbed immediately, the need for irrigating the wound with plain saline prior to reinfusion is not necessary. K e y words: tobramycin, total knee arthroplasty, reinfusion, whole blood.

Autotransfusion has b e c o m e a p o p u l a r and safe m e t h o d for returning w h o l e blood to a patient after a variety of e m e r g e n c y and elective surgical procedures. 3 " 4 " 6 " 8 - 1 ~ 1 7 6 This popularity arose

b e e n reported for u n c e m e n t e d total knee arthroplasty (TKA) and 1,700 ml for revision procedures.tl'18-26"28 Some c o n t e m p o r a r y blood retrieval systems do not require washing of the blood prior to retransfusion (Solcotrans [Solco Basle, Inc., Rockland, MD] and Constavac [Stryker Surgical, Kalamazoo, MI]). 6,s, ~5.~6 This potentially exposes the patient to contamination from the surgical w o u n d w h e n the blood is returned to the circulation. ~4 Previous studies h a v e m e a s u r e d serum levels of antibiotics after w o u n d irrigation during total hip arthroplasty arid other surgical procedures. ~'5"7"24"27 All concluded that a significant level of antibiotics

out of growing concerns for the use of h o m o l o g o u s blood which m a y be c o n t a m i n a t e d with the h u m a n immunodeficiency virus (HIV) or hepatitis v i r u s . 2A9 Furthermore, m e a n blood loss of 1,400 ml has

From the DePaul Biomedmnical Research Laboratory, Missottri Bone and Joint Center, St. Louis, Missouri. Reprint requests: Paul S. Lux, MD, DePaul Biomechanical Re-

search Laboratory, Missouri Bone and Joint Center, 3165 McKelvey Road, Suite 240, St. Louis, MO 63044.

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The Journal of Arthroplasty Vol. 8 No. 3 June 1993

were absorbed from the wound. Also, reports of renal failure and ototoxicity, common to the systemic administration of these drugs, could be found following wound irrigation.7 This study was undertaken to determine tile safety of adding tobramycin powder to a wound during cementless TKA and subsequently having the drainage blood reinfused.

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Materials and Methods

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Nine human volunteers who underwent unilateral cementless TKA (Ortholoc III, Dow Corning Wright, Arlington, TN) had 600 mg of tobramycin (Nebcin, Eli Lilly and Co., Indianapolis, IN) powder added to their wound just prior to fascial closure. All wounds were drained with the Constavac CBC, and reinfusion wasattempted on all patients up to 12 hours after surgery. All patients had an epidural anesthetic and were started on a continuous passive motion machine in the recovery room. Serum levels oftobramycin were measured at 30 minutes, 4 hours, 8 hours, and 12 hours after surgery. Levels of tobramycin i n t h e reinfused blood were also measured at the time Of reinfusion (4-8 hours after surgery) and the volume of reinfused blood was recorded.

Results The nine patients enrolled in the study had serum levels of tobramycin sampled at 30 minutes, 4 hours, 8 hours, and 12 hours. The results are shown in Table 1. The range of serum tobramycin levels at one half hour was 4.1-10.6 p.g/ml (average, 5.5 ~g/ml). At 4 hours the range of serum tobramycin levels was 3.4-11.I lzg/ml (average, 6.6 i.tg/ml). By 8 hours the levels ranged from 2.2 i.tg/ml to 7.0 ixg/ml (average, 4.6 IJ.g/ml). At 12 hours the range of tobramycin serum levels was 0.9 to 5.3 i,tg/ml (average, 2.5 ~g/ nil). This data is summarized in Figure 1, which also shows standard deviations.

Table 1. Serum Tobramycin Levels (p.g/ml)

Case

1/2 hour

4 hour

8 hour

12 hour

1 2 3 4 5 6 7 8 9

6.6 3.6 5.1 10.6 5.8 4.1 4.7 3.0 5.9

5.3 3.4 4.3 6.3 6.6 11.1 6.7 5.7 9.9

2.2 5.2 3.3 3.6 4.2 7.0 3.6 6.9 5.1

0.9 2.9 1.9 1.8 2.4 5.3 1.8 3.2 2.6

Amount Reinfused

(mg) 49 127 108 27 119 197 136 312 116

0 TIME(HOURS)

Fig. 1. Concentration of tobramycin in the serum following the addition of 600 mg of tobramycin powder to the wound at the completion of total knee arthroplasty.

Tile results of the dosage of tobramycin in the reinfused blood were calculated using the level of tobramycin in the drained blood and multiplying by the Volume reinfused: tobramycin (p.g/ml) x volume (in ml) = m g tobramycin. These results are summarized in Table 1. The amount of tobramycin ranged from 49 mg to 312 mg in the blood that was reinfused 4 - 8 hours after surgery. No patients had any complications directly or indi, rectly related to the administration of tobramycin powder to their surgical wounds. There were no cases of elevated creatinine, which was measured before surgery and on the first and third postoperative days. There were no subjective instances of ototoxicity found by questioning the patients while in the hospital or during their l-month follow-up visit.

Conclusions Tobramycin was chosen for this study because it is an antibiotic that is easily measured in the serum. Ahhough not ahvays used for antibiotic irrigation, it represents a marker for other compounds such as bacitracin or polymixin, which are very difficult to quantify in tile systemic circulation. This study was undertaken to determine the safety of adding tobramycin powder to a surgical wound and then having the whole blood reinfused. The data suggest that the majority of the antibiotic was absorbed directly from tile bleeding surfaces of tile bone, muscle, and synovial lining of the knee joint. This was evident in that tile peak level of tobramycin was seen at 4 hours after surgery, which was prior to any reinfusion. The level of tobramycin in the reinfused whole

Reinfusion of Whole Blood Following TKA

blood was significant, h o w e v e r it did not elevate the serum level substantially w h e n reinfused. This m a y be a result of the slow administration of the whole blood ( 1 . 5 - 2 hours) and the body's ability to eliminale the drug. The half-life of tobramycin in patients with normal renal fimction is 2 hours. An equilibrium between infusion of tobramycin and excretion by the kidney existed from 4 to 12 hours after surgery. Had the blood that contained tobramycin not been reinfused, the level of the drug would have dropped quickly after 4 hours. In conclusion, it is safe to add antibiotic p o w d e r to a w o u n d following cementiess total joint arthroplasty in a patient with normal renal function. Caution is advised h o w e v e r w h e n the drainage blood is reinfused as the bolus of the drug can be significant and potentially cause toxic side effects. Because most of the antibiotic delivered into the w o u n d is absorbed immediately, 'the need for irrigating the w o u n d with plain saline prior to reinfusion is not necessary.

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