Intraoperative use of autologous platelet-rich and platelet-poor plasma for orthopedic surgery patients

AORN Journal,  Oct, 2004  by Kathleen M. Floryan,  William J. Berghoff

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Use of autologous platelet concentrate to accelerate soft and hard tissue healing is strongly supported in medical literature. Studies report accelerated bone regeneration, reduced inflammation, decreased blood loss, reduced postoperative narcotic requirements, and improved hard and soft tissue wound healing. (1) Initially, intended for use in patients undergoing total knee arthroplasty (TKA), its use has expanded to

* bone fractures;

* laminectomy procedures;

* lateral epicondylitis (ie, tennis elbow);

* nonunion and bony defects;

* other total joint arthroplasty procedures (eg, hip, shoulder);

* plantar fasciitis;

* shoulder arthroscopy and distal clavicle resection; and

* spinal fusion.

New products and instruments frequently are introduced in the perioperative environment; however, perioperative nurses often are not well versed in the scientific rationale behind use of these novel devices before they are introduced in the OR setting. This was the experience of nursing staff members at Parkview Orthopaedic Hospital, Fort Wayne, Ind, in 2003 when intraoperative use of autologous platelet-rich plasma (PRP) and platelet-poor plasma (PPP) was introduced. The purpose of this article is to help other perioperative nurse who may be introduced to this technology. This article defines autologous PRP and PPP; describes processing and application of PRP and PPP; and reports clinical application outcomes of the use of platelet concentrate for a group of patients who underwent TKA.

BACKGROUND

Autologous PPP (ie, autologous fibrin glue) was first described in 1972. (2,3) Autologous PRP also may be called platelet concentrate, platelet gel, and autologous platelet gel. (4) Autologous platelet gel was developed in the early 1990s as a by-product of PRP sequestration in cardiac surgery. (5) Autologous platelet gel is produced from PRP and has two to four times the concentration of platelets. Normal platelet counts range between 150,000 platelets per cubic millimeter ([mm.sup.3]) and 350,000 platelets per [mm.sup.3], averaging approximately 200,000 platelets per [mm.sup.3] Platelet-rich plasma is measured as 1,000,000 platelets per [mm.sup.3]. (4)

The developing body of medical literature documents use of autologous platelet gel and PPP in cardiothoracic surgery; cosmetic and plastic surgery; ear, nose, and throat surgery; general surgery; major vascular surgery; neurosurgery; obstetrics and gynecological surgery (ie, cesarean section, hysterectomy); ophthalmology; oral surgery; orthopedic surgery; urology; and wound healing. (6) Further study is ongoing in all these fields regarding the effectiveness of autologous PRP use. It should be noted that autologous platelet gel is not approved by the US Food and Drug Administration for use as a biologic agent. Combining PRP with thrombin and calcium to create a gel is considered to be the practice of medicine. (7)

How ARE PRP AND PPP OBTAINED AND WHY ARE THEY USED?

Parkview Orthopaedic Hospital uses a platelet concentrate system to obtain PRP and PPP. Platelets are separated from 30 mL to 55 mL of whole autologous blood collected from a patient preoperatively, preferably 45 minutes to one hour before induction of anesthesia. The platelet concentrate system used at Parkview Orthopaedic Hospital includes a single-use separation kit with a syringe primed with anticoagulant citrate dextrose solution A (ACD-A). (8) Proper safety precautions for preventing needle stick injuries are used.

The sterile, nonpyrogenic ACD-A solution contains citric acid, sodium citrate, and dextrose in water and is used as an anticoagulant in autologous blood collection and reinfusion, as well as in routine or therapeutic apheresis procedures. Experience has demonstrated that a 5-mL dose of ACD-A for every 30 mL to 55 mL whole blood prevents unwanted clotting. The blood is separated via a single, 12-minute centrifuge spin, which collects approximately 6-mL PRP and 30-mL PPP per 55 mL of separated whole blood (Figures 1, 2, 3).

[FIGURES 1-3 OMITTED]

Platelets contain growth factors (ie, cytokines) which support and accelerate bone and soft tissue healing (Table 1). (9,10) These growth factors are activated when autologous platelets are combined with 5,000 units topical thrombin and 5 mL of 10% calcium chloride using a 10:1 ratio of PRP to the thrombin/calcium chloride solution. Activation refers to the initiation of the clotting cascade of fibrinogen to fibrin and the degranulation of platelets.

The properties of autologous platelet gel and its contained growth factors are well described. (7) Platelet-derived growth factor (PDGF) assists in the stimulation of cell division at the injury site, which promotes angiogenesis, reepithelialization, and the formation of granulation tissue. The PDGF also is responsible for stimulating osteoblast and collagen production. Platelet concentrates also have the potential to improve fracture healing and enhance osteogenesis. (9) Transforming growth factor-beta (TGF-b) enhances bone ingrowth and mechanical fixation of implants; this suggests that coating a prosthesis with TGF-b may help improve the functional outcome of total joint replacements. (11) The concentration of growth factors in autologous platelet gel is significantly higher than that found in whole blood from the same patient, resulting in 10 to 25 times more PDGF and TGF-b than at the baseline level. (12) The clinical application of autologous platelet gel, therefore, has the potential to improve soft and bone tissue healing and enhance osteogenesis. (9,13,14)