Preoperative use of recombinant human erythropoietin in pediatric orthopedics: a decision model for long-term outcomes

Predictive factors of intraoperative cell salvage during pediatric scoliosis surgery. Cell saver during scoliosis surgery in children

INTRODUCTION

Blood-saving strategy during spinal surgery in children often includes recombinant erythropoietin (rEPO) and antifibrinolytic therapapy (AFT). The aim of this study was to investigate the efficacy of intraoperative blood salvage in decreasing homologous blood transfusion.

MATERIAL AND METHODS

Using the prospective data from patients operated during a one year period for scoliosis correction, we calculate the predictable hematocrit at day postoperative 1 without the use of blood salvage and compare it to the target hematocrit transfusion according to patient's status. Predictors analyzed were: age, weight, surgical indication, Cobb's angle, ASA status, preoperative hemoglobin, number of level fused, sacral fusion and thoracoplasty. Statistical analyses were performed using a classification tree analysis.

RESULTS

This study included 147 patients. Blood salvage was estimated avoiding homologous blood transfusion in 17 patients. Predictors of the efficacy of blood salvage were: neuromuscular indications, number of level fused and BMI. Blood salvage was found totally ineffective in: patients with no neuromuscular diseases with either: surgeries interesting<13 levels fused or surgeries interesting>13 levels with a preoperative BMI ≥ 21. In all other cases, blood salvage can decrease homologous transfusion. The model exhibited 97% of accurate for the prediction if the inefficacy of blood salvage. The AUCROC of the model was 0.93 [95% confidence interval 0.9 to 0.99] and the overall validation was 60.1% of explained variability.

CONCLUSION

The present study indicates that blood salvage is ineffective under certain circumstances. More studies are mandatory to confirm these results.

Bloodless medicine: current strategies and emerging treatment paradigms

BACKGROUND

Advances in our understanding of the risks associated with allogeneic blood transfusions (ABTs) and the growing number of patients who wish to avoid ABTs have led to the emergence of new treatment paradigms for "bloodless" medicine and surgery.

STUDY DESIGN AND METHODS

Here, we review prior studies and summarize current strategies for bloodless care used at our institution. We advocate three basic principles: 1) diagnosing and aggressively treating anemia, 2) minimizing blood loss from laboratory testing and invasive procedures, and 3) identifying and managing bleeding diatheses. Anemia is treated with erythropoiesis-stimulating agents as well as iron, folate, and B12 when indicated. Low-volume phlebotomy tubes are used for laboratory testing. Autologous blood salvage is used for childbirth and surgical patients who have the potential for substantial bleeding.

RESULTS

Although there have been few retrospective studies and no prospective studies to guide management, prior studies suggest that outcomes for surgical patients managed without ABTs are comparable to those of historic controls.

CONCLUSIONS

Given the emerging evidence that patients who avoid ABTs do as well if not better than patients who accept ABTs, further efforts are needed to determine whether all patients could benefit from bloodless strategies. Bloodless approaches in selected patients could reduce risks, improve outcomes, and decrease costs for all patients.

Cost-utility analyses in spine care: a qualitative and systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

A systematic review was performed to identify US-based cost-utility analyses (CUA) studies in spine care and to critically evaluate the quality of the available literature.

SUMMARY OF BACKGROUND DATA

There has been a recent trend in the United States toward increased publication of economic analyses in spine care. The cost-effectiveness of spine interventions and the quality of published literature is not well understood.

METHODS

A MEDLINE search was conducted to identify cost analyses in spine care. Articles were excluded on the basis of the following criteria: nonspine care, nonoperative, non-US based, nonclinical, and not CUA. Of the 424 screened articles, 20 met inclusion criteria. Quality of studies was assessed using the Quality of Health Economic Studies instrument.

RESULTS

Evidence for the cost-effectiveness of operative spinal intervention is varied. The majority of available studies report favorable cost-effectiveness ratios, however, a few studies suggest that certain operative interventions are not cost-effective. Average Quality of Health Economic Studies score of all included studies was 75.1 (60-93). The quality of evidence is variable and there are a number of weaknesses in the available literature, most significant of which is that few studies adopt a long-term time horizon or have sufficient follow-up (N = 3/20). High Quality of Health Economic Studies scoring studies were more likely to have sensitivity analysis (P = 0.016), societal cost perspective (P = 0.014), and a funding disclosure (P = 0.03).

CONCLUSION

There is a small but rapidly growing body of US-based CUA in spine care. The quality of CUA evidence is variable but there are significant opportunities to strengthen future CUA studies in spine. This study highlights the need for more attention to CUA research and the quality of these studies in spine care.

Bloodless medicine: what to do when you can't transfuse

A better understanding of risks associated with allogeneic blood transfusions (ABTs), along with a growing population of patients who do not accept transfusions, have led to the emergence of new treatment paradigms with “bloodless medicine.” In this chapter, we review prior studies describing management and outcomes in patients who refuse transfusion (referred to as “bloodless patients” herein) and summarize the approaches used at our institution. Bloodless management for surgical patients includes treatment of preoperative anemia, use of autologous blood salvage, and minimizing blood loss with procedures. Other adjuncts for both medical and surgical patients include minimizing blood loss from laboratory testing using pediatric phlebotomy tubes and conservative testing. Anemia can be treated with erythropoiesis-stimulating agents, as well as iron, folate, and B12 when indicated. Although there are limited retrospective studies and no prospective studies to guide management, prior reports suggest that outcomes for surgical patients managed without ABTs are comparable to historic controls. A recent risk-adjusted, propensity-matched, case-control study of outcomes of all hospitalized patients who refused ABT at a large academic health center showed that bloodless management was not an independent predictor of adverse outcomes. Surprisingly, there was a lower overall mortality in the bloodless group and discharge hemoglobin levels were similar for both bloodless and control groups. Further research is now needed to optimize therapy and identify novel interventions to manage bloodless patients. Lessons learned from bloodless patients are likely to benefit all patients given recent evidence suggesting that patients who avoid ABTs do as well, if not better, than those who accept transfusions.

Cost-effective studies in spine surgeries: a narrative review

BACKGROUND CONTEXT

Although the pathologic processes that affect the spine remain largely unchanged, our techniques to correct them continue to evolve with the development of novel medical and surgical interventions. Although the primary purpose of new technologies is to improve patients' quality of life, the economic impact of such therapies must be considered.

PURPOSE

To review the available peer-reviewed literature on spine surgery that addresses the cost-effectiveness of various treatments and technologies.

STUDY DESIGN

A narrative literature review.

METHODS

Articles published between January 1, 2000 and December 31, 2012 were selected from two Pubmed searches using keywords cost-effectiveness AND spine (216 articles) and cost analysis AND spine (358 articles). Relevant articles on cost analyses and cost-effectiveness were selected by the authors and reviewed.

RESULTS

Cervical and lumbar surgeries (anterior cervical discectomy and fusion, standard open lumbar discectomy, and standard posterior lumbar laminectomy) are reasonably cost effective at 2 years after the procedure (<100,000 US dollars per quality-adjusted life years gained) and become more cost effective with time because of sustained clinical improvements with relatively low additional incurred costs. The usage of transfusion avoidance technology is not cost effective because of the low risk of complications associated with allogenic transfusions. Although intraoperative neuromonitoring and imaging modalities are both cost saving and cost-effective, their cost-effectiveness is largely dependent on the baseline rate of neurologic complications and implant misplacement, respectively. More rigorous studies are needed to evaluate the cost-effectiveness of recombinant bone morphogenetic protein.

CONCLUSIONS

An ideal new technology should be able to achieve maximal improvement in patient health at a cost that society is willing to pay. The cost-effectiveness of technologies and treatments in spine care is dependent on their durability and the rate and severity of the baseline clinical problem that the treatment was designed to address.

Adolescent idiopathic scoliosis (AIS) - an indication for surgery? A systematic review of the literature

PURPOSE

Historically, the treatment options for AIS, the most common form of scoliosis are: Exercises, in-patient rehabilitation, braces and surgery. While there is evidence in the form of prospective controlled studies that Scoliosis Intensive Rehabilitation (SIR) and braces can alter the natural history of the condition, there is no review on prospective controlled trials for surgical treatment. The aim of this review was to perform a systematic search of the Pub Med literature to reveal the evidence on scoliosis surgery.

METHODS

A systematic review has been performed using the Pub Med database. Literature has been searched for the outcome parameter; 'rate of progression' and only prospective controlled studies that have considered the treatment versus the natural history have been included.

RESULTS

No controlled study, not in the short, mid or long term, searched within the review, has been found to reveal evidence to support the hypothesis that the effects of surgery as a treatment option for AIS is superior to natural history.

CONCLUSIONS

No evidence has been found in terms of prospective controlled studies to support surgical intervention from the medical point of view. In the light of the unknown long-term effects of surgery and in concluding on the lack of evidence already found that surgery might change the signs and symptoms of scoliosis, a randomized controlled trial (RCT) is long overdue. Until such a time that such evidence exists, there can be no medical indication for surgery. The indications for surgery are limited for cosmetic reasons in severe cases and only if the patient and the family agree with this.