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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.
269
270
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.
10. 9.
E
z o I--
6.
I--
4.
5-
Z
Z O O
Materials and Methods
a.
::I.
2"
1
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.
References 1. Bortnem KD, Wetmore RW, Blackbum GW et al: Analysis of therapeutic efficacy, cost, and safety of gentamicin lavage solution in orthopaedic surgery prophylaxis. Orthop Rev 19:797, 1990 2. Cone J, Day I.A, Johnson GK et al: Blood products: optimal use, conservation, and safety, p. 431. AAOS Instructional Course Lectures, 1990 3. Cordell AR, Lavender SW: An appraisal of blood salvage techniques in vascular and cardiac operations. Ann Thorac Surg 31:421, 1981 4. Duncan SE, KlebanoffG, Rogers W: A clinical experience with intraoperative autotransfusion. Ann Surg 180:296, 1974 5. Ericsson CD, Duke Jr JH, Pickering LK, Qadri SMH: Systemic absorption of bacitracin after peritoneal larage. Am J Surg 137:65, 1979 6. Faris PM, Ritter MA, Keating EM: A system for reinfusion of aspirated whole blood after total hip and knee arthroplasty. Presented at the 56th Annual Meeting of the American Academy of Orthopaedic Surgeons, Las Vegas, NV, 1989 7. Gelman ML, Frazier CH, Chandler liP: Acute renal failure after total hip replacement. J Bone Joint Surg 61A:657, 1979 8. Groh GI, Buchert PK, Allen WC: A comparison of transfusion requirements after total knee replacements using the Solcotrans autotransfusion device. Presented at the 57th Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, LA, 1990 9. Hamilton JE, Duncan E: Penetrating gunshot and stab wounds of the abdomen. Surgery 13:107, 1943 10. ttauser JM, Dawson RB: Autotransfusion: an evaluation of its value in reducing homologous blood use in trauma. Ann Clin Res 27:A583, 1979
9
Lux et al.
271
11. ttays MB, Mayfield JF: Total blood loss in major joint arthroplasty: a comparison of cemented and noncemented hip and knee operations. J Arthroplasty 3(suppl):547, 1988 12. Johnson RG, Rosengarten KR, Preston RA et al: The efficacy of postoperative autotransfusion in patients undergoing cardiac operations. Ann Thorac Surg 36: 173, 1983 13. Keeling MM, Gray LA, Brink MA et al: Intraoperative autotransfusion: experience in 725 consecutive cases. Ann Surg 197:536, 1983 14. Klebanoff G, Phillips J, Evans W: Use of disposable autotransfusion unit under varying conditions of contamination. Am J Surg 120:351, 1970 15. Martin JW, Whiteside LA, Milliano MT, Reedy M: Postoperative blood retrieval and transfusion in cementless total knee arthroplasty. J Arthroplasty 7:205, 1992 16. Martin JW, Whiteside LA, Reedy ME: Blood retrieval, TKR. Presented at the New Developments in Total Joint Reconstruction International .Symposium, St. Louis, MO, 1989 17. Mat t0x KL: Autotransfusion in tile emergency department. J Am Coil Emerg Physns 4:218, 1975 18. Mylo d GM, France MP, Muser DE, Parsons JR: Perioperative blood loss associated with total knee arthroplasty. J Bone Joint Surg 72A: I010, 1990 I-9. Nelson CL, Nelson RL, Cone J: Blood conservation techniques in orthopedic surgery, p. 425. AAOS Instructional Course Lectures, 1990 20. Reul GJ, Soils T, Greenberg SD et al: Experience with autotransfusion in the surgical management of trauma. Surgery 76:546, 1974 21. Schaff HV, Hauer JM, Bell WR et al: Autotransfusion of shed mediastinai blood after cardiac surgery: a prospective study. J Thorac Cardiovasc Surg 75:632, 1978 22. Schaff tIV, ltauer J, Gardner TJet al: Routine use of autotransfusion following cardiac surgery: experience in 700 patients. Ann Thorac Surg 27:493, 1979 23. Semkiw LB, Schurman DJ, Goodman SB, Woolson ST: Postoperative blood salvage using tile cell saver after total knee arthroplasty. J Bone Joint Surg 71A: 823, 1989 24. Sorensen TS, Andersen MR, Glenthoj J, Petersen O: Pharamcokinetics of topical gentamicin in total hip arthroplasty. Acta Orthop Scand 55:156, 1984 25. Symbas PN, Levin JM, Ferrier FL, Sybers RG: A study of autotransfusion from hemothorax. South Med J 62: 672, 1969 26. Thomson JD, Callaghan J J, Savory CG et al: Prior deposition of autologous blood in elective orthopaedic surgery. J Bone Joint Surg 69A:320, 1987 27. Weinstein AJ, McHenry MC, Gavan TL: Systemic absorption of neomycin irrigating solution. JAMA 238: 152, 1977 28. Woolson ST, Marsh JS, Tanner JB: Transfusion of previously deposited autologous blood for patients undergoing.hip replacement surgery. J Bone Joint Surg 69A:325, 1987 t'
.
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.
269
270
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.
10. 9.
E
z o I--
6.
I--
4.
5-
Z
Z O O
Materials and Methods
a.
::I.
2"
1
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.
References 1. Bortnem KD, Wetmore RW, Blackbum GW et al: Analysis of therapeutic efficacy, cost, and safety of gentamicin lavage solution in orthopaedic surgery prophylaxis. Orthop Rev 19:797, 1990 2. Cone J, Day I.A, Johnson GK et al: Blood products: optimal use, conservation, and safety, p. 431. AAOS Instructional Course Lectures, 1990 3. Cordell AR, Lavender SW: An appraisal of blood salvage techniques in vascular and cardiac operations. Ann Thorac Surg 31:421, 1981 4. Duncan SE, KlebanoffG, Rogers W: A clinical experience with intraoperative autotransfusion. Ann Surg 180:296, 1974 5. Ericsson CD, Duke Jr JH, Pickering LK, Qadri SMH: Systemic absorption of bacitracin after peritoneal larage. Am J Surg 137:65, 1979 6. Faris PM, Ritter MA, Keating EM: A system for reinfusion of aspirated whole blood after total hip and knee arthroplasty. Presented at the 56th Annual Meeting of the American Academy of Orthopaedic Surgeons, Las Vegas, NV, 1989 7. Gelman ML, Frazier CH, Chandler liP: Acute renal failure after total hip replacement. J Bone Joint Surg 61A:657, 1979 8. Groh GI, Buchert PK, Allen WC: A comparison of transfusion requirements after total knee replacements using the Solcotrans autotransfusion device. Presented at the 57th Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, LA, 1990 9. Hamilton JE, Duncan E: Penetrating gunshot and stab wounds of the abdomen. Surgery 13:107, 1943 10. ttauser JM, Dawson RB: Autotransfusion: an evaluation of its value in reducing homologous blood use in trauma. Ann Clin Res 27:A583, 1979
9
Lux et al.
271
11. ttays MB, Mayfield JF: Total blood loss in major joint arthroplasty: a comparison of cemented and noncemented hip and knee operations. J Arthroplasty 3(suppl):547, 1988 12. Johnson RG, Rosengarten KR, Preston RA et al: The efficacy of postoperative autotransfusion in patients undergoing cardiac operations. Ann Thorac Surg 36: 173, 1983 13. Keeling MM, Gray LA, Brink MA et al: Intraoperative autotransfusion: experience in 725 consecutive cases. Ann Surg 197:536, 1983 14. Klebanoff G, Phillips J, Evans W: Use of disposable autotransfusion unit under varying conditions of contamination. Am J Surg 120:351, 1970 15. Martin JW, Whiteside LA, Milliano MT, Reedy M: Postoperative blood retrieval and transfusion in cementless total knee arthroplasty. J Arthroplasty 7:205, 1992 16. Martin JW, Whiteside LA, Reedy ME: Blood retrieval, TKR. Presented at the New Developments in Total Joint Reconstruction International .Symposium, St. Louis, MO, 1989 17. Mat t0x KL: Autotransfusion in tile emergency department. J Am Coil Emerg Physns 4:218, 1975 18. Mylo d GM, France MP, Muser DE, Parsons JR: Perioperative blood loss associated with total knee arthroplasty. J Bone Joint Surg 72A: I010, 1990 I-9. Nelson CL, Nelson RL, Cone J: Blood conservation techniques in orthopedic surgery, p. 425. AAOS Instructional Course Lectures, 1990 20. Reul GJ, Soils T, Greenberg SD et al: Experience with autotransfusion in the surgical management of trauma. Surgery 76:546, 1974 21. Schaff HV, Hauer JM, Bell WR et al: Autotransfusion of shed mediastinai blood after cardiac surgery: a prospective study. J Thorac Cardiovasc Surg 75:632, 1978 22. Schaff tIV, ltauer J, Gardner TJet al: Routine use of autotransfusion following cardiac surgery: experience in 700 patients. Ann Thorac Surg 27:493, 1979 23. Semkiw LB, Schurman DJ, Goodman SB, Woolson ST: Postoperative blood salvage using tile cell saver after total knee arthroplasty. J Bone Joint Surg 71A: 823, 1989 24. Sorensen TS, Andersen MR, Glenthoj J, Petersen O: Pharamcokinetics of topical gentamicin in total hip arthroplasty. Acta Orthop Scand 55:156, 1984 25. Symbas PN, Levin JM, Ferrier FL, Sybers RG: A study of autotransfusion from hemothorax. South Med J 62: 672, 1969 26. Thomson JD, Callaghan J J, Savory CG et al: Prior deposition of autologous blood in elective orthopaedic surgery. J Bone Joint Surg 69A:320, 1987 27. Weinstein AJ, McHenry MC, Gavan TL: Systemic absorption of neomycin irrigating solution. JAMA 238: 152, 1977 28. Woolson ST, Marsh JS, Tanner JB: Transfusion of previously deposited autologous blood for patients undergoing.hip replacement surgery. J Bone Joint Surg 69A:325, 1987 t'
.