The role of autologous blood transfusion in adolescents undergoing spinal surgery

Tranexamic acid use is associated with reduced intraoperative blood loss during spine surgery for Marfan syndrome

PURPOSE

The utility of tranexamic acid (TXA) in patients with Marfan syndrome (MFS) is uncertain given associated aberrations within the vasculature and clotting cascade. Therefore, this study aimed to assess the association of TXA use with intraoperative blood loss and allogeneic blood transfusions in patients with MFS who underwent spinal arthrodesis.

METHODS

We queried our institutional database for MFS patients who underwent spinal arthrodesis for scoliosis between 2000 and 2020 by one surgeon. We excluded procedures spanning < 4 vertebral levels, those using anterior or combined anterior/posterior approaches, and those involving growing rods, postoperative infection, or spondylolisthesis. Fifty-two patients met our criteria, of whom 22 were treated with TXA and 30 were not. Mean differences in blood loss, transfusion volume, and proportions receiving transfusion were compared between TXA and the control groups using Student t, chi-squared, or Fisher exact tests. Alpha = 0.05.

RESULTS

MFS patients treated with TXA experienced less mean (± standard deviation) intraoperative blood loss (1023 ± 534 mL) compared to the control group (1436 ± 1022 mL) (p = 0.01). The TXA group had estimated blood volume loss of 27% ± 16% compared to 36% ± 21% for controls (p = 0.05). No differences were found in allogeneic transfusion rate (p = 0.66) or transfusion volume (p = 0.15).

CONCLUSIONS

We found an association between TXA use and reduced blood loss during surgical treatment of MFS-associated scoliosis, suggesting that the connective tissue deficiency in MFS does not interfere with TXA's mechanism of action.

LEVEL OF EVIDENCE

III.

Development of Consensus Based Best Practice Guidelines for Perioperative Management of Blood Loss in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Delphi process with multiple iterative rounds using a nominal group technique.

OBJECTIVE

The aim of this study was to use expert opinion to achieve consensus on various methods for minimizing blood loss in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

BACKGROUND DATA

Perioperative blood loss management represents a critical component of safely performing PSF in children with AIS. Little consensus exists on ways to mitigate excessive blood loss after PSF.

METHODS

An expert panel composed of 21 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible.

RESULTS

Consensus was reached to support 21 best practice guideline measures for perioperative management of blood loss in patients undergoing PSF for AIS. Areas included preoperative assessment and preparation, intraoperative strategies to decrease blood loss, and postoperative transfusion indications.

CONCLUSION

We present a consensus-based best practice guideline consisting of 21 recommendations for strategies to minimize and manage blood loss during PSF. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.

Effect of intraoperative autologous transfusion techniques on perioperative hemoglobin level in idiopathic scoliosis patients undergoing posterior spinal fusion: A prospective randomized trial

BACKGROUND

Massive blood loss during posterior spinal fusion for adolescent idiopathic scoliosis remains a significant risk for patients. There is no consensus on the benefit of acute normovolemic hemodilution (ANH) or intraoperative cell salvage (ICS) in scoliosis surgery.

METHODS

Patients were randomized to one of two groups. Group A received ANH and ICS during operation, while group B received only ICS. Patients' age, sex, height, weight, body blood volume, number of fusion level, Cobb angle, number of screws, duration of surgery, and skin incision length were recorded. Hemoglobin and hematocrit levels were obtained preoperatively and postoperatively (0 h and 24 h).

RESULTS

There were 22 patients in each group. There was no significant difference in total blood loss. The perioperative decrease in hemoglobin levels between preoperation and postoperation 24 h (group A 2.79 ± 1.15 and group B 2.76 ± 1.00) showed no significant difference ( p = 0.93). Group A observed a larger decrease in hemoglobin levels at postoperative 0 h relative to preoperative level (2.57 ± 0.82 g/dl), followed by a smaller decrease within the next 24 h (0.22 ± 1.33 g/dl). Group B showed a continued drop in hemoglobin levels of similar magnitude at postoperation 0 h (1.60 ± 0.67 g/dl) and within the next 24 h (1.16 ± 0.78 g/dl). One patient from group B received 1 unit of allogenic blood transfusion ( p = 0.33).

CONCLUSIONS

The addition of ANH to ICS in posterior spinal fusion surgery for AIS resulted in a similar decrease in hemoglobin levels between preoperative values and at 24 h postoperatively.

Management of Scoliosis in Patients With Loeys-Dietz Syndrome

BACKGROUND

Loeys-Dietz syndrome (LDS) is a genetic connective tissue disorder. We sought to determine the incidence of scoliosis in patients with LDS, characterize the spectrum of spinal deformity, determine the results of bracing and surgery, and define surgical complications.

METHODS

Patients were selected from our institution's database of 183 patients with LDS. Imaging measurements were performed for 141 patients whose records permitted spinal evaluation. Deformity changes and complications after intervention were recorded for patients who underwent bracing or surgery, and associations were tested using Student t tests (significance, P<0.05).

RESULTS

Eighty-eight of 141 (62%) patients with LDS had scoliosis, with main thoracic and thoracolumbar curves being most common. Fifteen patients were braced (mean age, 9±3 y) for a mean of 2.3 years. They had a mean postbracing curve progression of 12±21 degrees (5±9 deg./y). There were no significant differences in age, sex, curve type, or prebracing curve magnitude between successfully braced (n=4) and unsuccessfully braced (n=11) patients (P>0.05). Nine patients, (mean age, 12±3 y), underwent 24 surgical procedures (16 growing rod procedures, 8 fusions). Mean curve corrections were 61% for growing rods and 73% for fusions. Associated blood loss for these procedures was 400 mL and 1293 mL, respectively, and normalized blood loss for fusion was 2.34 mL/kg/level. Fifteen of 24 surgical procedures involved complications (63%), including cerebrospinal fluid leaks (n=7) and blood loss >20% of estimated total blood volume (n=11).

CONCLUSIONS

Scoliosis was present in 62% of our sample of LDS patients. Bracing did not halt curves in 11 of 15 patients, whose curves progressed >5 degrees or to >50 degrees by completion of bracing. At latest follow-up, 47% of the braced patients had undergone surgery after prior bracing attempts. The high blood loss associated with these operations is believed to be related to vascular fragility in patients with LDS.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

Blood transfusion in the surgical treatment of adolescent idiopathic scoliosis-a single-center experience of patient blood management in 210 cases

BACKGROUND

The surgical treatment of adolescent idiopathic scoliosis can be associated with substantial blood loss, requiring allogeneic red blood cell (RBC) transfusion. This study describes the use of RBC and the effect of a standardized perioperative patient blood management program.

STUDY DESIGN AND METHODS

Patients treated with posterior instrumented fusion were consecutively enrolled over a 6-year period. Patient blood management strategies were implemented in 2011, including prophylactic tranexamic acid, intraoperative permissive hypotension, restrictive fluid therapy (including avoidance of synthetic colloids), restrictive RBC trigger according to institutional standardized protocol, the use of cell savage, and goal-directed therapy according to thrombelastography.

RESULTS

In total, 210 patients were included. 64 patients (31%) received RBC transfusions. A decline in the intraoperative rate of RBC transfusion was observed, from 77% in 2011 to 13% in 2016 (p < 0.001). Patients in the transfusion group had a significantly larger major curve, lower preoperative hemoglobin, higher estimated blood loss, and an increased use of crystalloid volume resuscitation. Multiple logistic regression showed that significant predictors for RBC transfusion were preoperative hemoglobin level (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.27-0.57), estimated blood loss (OR, 1.26; 95% CI, 1.15-1.42), and year of surgery (indicating the effect of patient blood management) (OR per year, 0.76; 95% CI, 0.58-0.99).

CONCLUSION

A perioperative patient blood management program substantially reduced the need for RBC transfusion. A preoperative evaluation of anemia is essential to further minimize transfusion rates.

Does a dual attending surgeon strategy confer additional benefit for posterior selective thoracic fusion in Lenke 1 and 2 adolescent idiopathic scoliosis (AIS)? A prospective propensity matching score analysis

BACKGROUND CONTEXT

With an increased cost of adolescent idiopathic scoliosis (AIS) surgery over the past 10 years, improvement of patient safety and optimization of the surgical management of AIS has become an important need. A dual attending surgeon strategy resulted in reduction of blood loss and complication rate.

PURPOSE

This study aimed to investigate the perioperative outcome of posterior selective thoracic fusion in Lenke 1 and 2 AIS patients comparing a single versus a dual attending surgeon strategy.

STUDY DESIGN

A prospective cohort study was carried out.

PATIENT SAMPLE

The study sample comprised 60 patients OUTCOME MEASURE: Operative duration, blood loss, postoperative hemoglobin, need for transfusion, morphine usage, and duration of hospital stay were the outcome measures.

METHODS

A total of 116 patients who underwent posterior selective thoracic fusion from two centers were prospectively recruited. The patients were grouped into Group 1 (single surgeon) and Group 2 (two surgeons). One-to-one matching analysis using "propensity score-matched cohort patient sampling method" was done for age, gender, height, weight, preoperative Cobb angle, number of fusion level, and Lenke classification. The outcome measures included operative duration, blood loss, postoperative hemoglobin, need for transfusion, morphine usage, and duration of hospital stay. This study was self-funded with no conflict of interest.

RESULTS

From 86 patients who were operated by the two surgeons (Group 2), 30 patients were matched with 30 patients who were operated by a single surgeon (Group 1). Group 2 (164.0±25.7 min) has a significantly shorter operation duration (p=.000) compared with Group 1 (257.3±51.4 min). The total blood loss was significantly more (p=.009) in Group 1 (1254.7±521.5 mL) compared with Group 2 (893.7±518.4 mL). There were seven patients (23.3%) in Group 1 who received allogenic blood transfusion (p<.05). The morphine usage and average hospital stay were significantly lower in Group 2, 22.4±10.7 mg and 3.4±0.7 days, respectively (p<.05). In Group 1, there was one patient who developed a superficial wound infection. No other major complications were noted.

CONCLUSIONS

A dual attending surgeon strategy was superior to a single surgeon strategy in posterior selective thoracic fusion in Lenke 1 and 2 AIS patients and will lead to a faster operation, reduced intraoperative blood loss, reduced risk of allogenic transfusion, reduced morphine requirement, and shorter hospital stay.

Assessment of Intraoperative Blood Loss at Different Surgical Stages During Posterior Spinal Fusion Surgery in the Treatment of Adolescent Idiopathic Scoliosis

STUDY DESIGN

Prospective clinical study.

OBJECTIVE

To analyze the amount of blood loss at different stages of Posterior Instrumented Spinal Fusion (PSF) surgery in adolescent idiopathic scoliosis (AIS) patients.

SUMMARY OF BACKGROUND DATA

Knowing the pattern of blood loss at different surgical stages may enable the surgical team to formulate a management strategy to reduce intraoperative blood loss.

METHODS

One hundred AIS patients who underwent PSF from January 2013 to December 2014 were recruited. The operation was divided into six stages; stage 1-exposure, stage 2-screw insertion, stage 3-release, stage 4-correction, stage 5-corticotomies and bone grafting, and stage 6-closure. The duration and blood loss at each stage was documented. The following values were calculated: total blood loss, blood loss per estimated blood volume, blood loss per minute, blood loss per vertebral level fused, and blood loss per minute per vertebral level fused.

RESULTS

There were 89 females and 11 males. The mean age was 17.0 ± 5.8 years old. Majority (50.0%) were Lenke 1 curve type. The mean preoperative major Cobb angle was 64.9 ± 15.0°. The mean number of levels fused was 9.5 ± 2.3 levels. The mean operating time was 188.5 ± 53.4 minutes with a mean total blood loss 951.0 ± 454.0 mLs. The highest mean blood loss occurred at stage 2 (301.0 ± 196.7 mL), followed by stage 4 (226.8 ± 171.2 mL) and stage 5 (161.5 ± 146.6 mL). The highest mean blood loss per minute was at stage 5 (17.1 ± 18.3 mL/min), followed by stage 3 (12.0 ± 10.8 mL/min). The highest mean blood loss per vertebral levels fused was at stage 2 (31.0 ± 17.7 mL/level), followed by stage 4 (23.9 ± 18.1 mL/level) and stage 5 (16.6 ± 13.3 mL/level).

CONCLUSION

All stages were significant contributors to the total blood loss except exposure (stage 1) and closure (stage 6). Blood loss per minute and blood loss per minute per level was highest during corticotomies (stage 5), followed by release (stage 3). However, the largest amount of total blood loss occurred during screw insertion (stage 2).

LEVEL OF EVIDENCE

2.

The pattern of blood loss in adolescent idiopathic scoliosis

BACKGROUND CONTEXT

Previous studies have shown that modern intraoperative blood-saving techniques dramatically reduce the allogeneic transfusion requirements in surgery for adolescent idiopathic scoliosis (AIS). No studies have looked at the pattern of postoperative hemoglobin (Hb) in AIS patients undergoing corrective spinal surgery and correlated this with the timing of allogeneic transfusion.

PURPOSE

To describe the pattern of perioperative blood loss in instrumented surgery for AIS. We look at the recommendations regarding an ideal preoperative Hb, the need for preoperative cross-matching, and the timing of postoperative Hb analysis.

STUDY DESIGN

This was a retrospective case series. Surgeries were performed by one of four substantive pediatric spinal surgeons within a single regional center over a 3-year period.

PATIENT SAMPLE

A consecutive series of 86 patients who underwent posterior instrumented fusion for AIS were included: 10 males and 76 females. Mean age was 14 years (range 10-17 years). All patients had posterior instrumented fusion using various blood-saving techniques (eg, cell-saver). All patients were cross-matched preoperatively, and our transfusion trigger value (TTV) was 7 g/dL.

OUTCOME MEASURES

Hemoglobin level was the outcome measure. Hemoglobin readings were obtained preoperatively, within 2 hours of surgery, and daily up to 5 days after surgery. This physiologic measure was assessed using routine blood sampling techniques and standardized laboratory processing.

METHODS

Patient predictor variables (demographic and surgical) were assessed for association with Hb levels in a hierarchical model, with repeated Hb readings at the lower level being clustered within an individual patient at the upper level of the structure. The variation of Hb levels within individuals was compared with mean levels in different individuals via the variance partition coefficient of the model structure.

RESULTS

No patients required intraoperative allogeneic transfusion. Only four patients (4.65%) received allogeneic transfusion, all within 2 days of surgery. A clinically important drop in Hb occurred within the first 2 postoperative days, rising thereafter. The average postoperative drop in Hb was 4.1 g/dL. Young males had lower postoperative Hb values. Neither the preoperative curve magnitude (Cobb angle of major curve) nor the number of vertebrae/levels fused significantly affected the blood loss.

CONCLUSIONS

We recommend setting a minimum preoperative Hb value that is 5 g/dL higher than your TTV. Because no patients required an intraoperative transfusion when using modern blood-saving techniques, preoperative cross-matching is unnecessary and potentially wasteful of blood reserves. Hemoglobin analysis beyond the second postoperative day is unnecessary unless clinically indicated.

Blood salvage produces higher total blood product costs in single-level lumbar spine surgery

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine the incremental cost-effectiveness of cell saver for single-level posterior lumbar decompression and fusion (PLDF).

SUMMARY OF BACKGROUND DATA

Intraoperative cell salvage is used during surgery to reduce the need for perioperative allogeneic blood transfusion. Although the use of cell saver may be beneficial in certain circumstances, its utility has not been clearly established for the common procedure of an adult single-level PLDF.

METHODS

Randomly selected adult patients treated with a single-level PLDF between July 2010 and June 2011 at a single institution were identified. Patients who had a combined anterior and posterior approach were excluded. The final study sample for analysis consisted of 180 patients. Hospital records were reviewed to determine whether: (1) cell saver was available during surgery, (2) recovered autologous blood was infused, and (3) the patient received intra- or postoperative allogeneic transfusions. Estimated blood loss, levels fused, volume(s) transfused, and all related complications were recorded. Costs included the cost of allogeneic blood transfusion, setting up the cell saver recovery system, and infusing autologous blood from cell saver, whereas effectiveness measures were allogeneic blood transfusions averted and quality adjusted life years.

RESULTS

The incremental cost-effectiveness ratio was $55,538 per allogeneic transfusion averted, with a decrease in the transfusion rate from 40.0% to 38.7% associated with the cell saver approach. This translated into an incremental cost-effectiveness ratio of $5,555,380 per quality adjusted life years gained, which is well above the threshold for an intervention to be considered cost-effective ($100,000 per quality adjusted life years gained).

CONCLUSION

The use of cell saver during a single-level PLDF does not significantly reduce the need for allogeneic blood transfusion and is not cost-effective. The high cost of cell saver in combination with the low complication rate of allogeneic blood transfusion, suggest that cell saver should not be used for single-level PLDF. Further studies are needed to evaluate the necessity for cell saver among other types of spinal surgery.

Predictive factors for the use of autologous cell saver transfusion in lumbar spinal surgery

STUDY DESIGN

Retrospective review.

OBJECTIVE

To identify risk factors for cell saver transfusion in lumbar spinal surgery and determine if cell saver transfusions affected intraoperative or postoperative transfusion rates.

SUMMARY OF BACKGROUND DATA

Cell saver has been used to minimize allogeneic blood transfusion in lumbar spinal surgery. Conflicting reports exist, which call into question the efficacy of cell saver use.

METHODS

We reviewed medical records of randomly selected patients who underwent posterolateral fusion with or without transforaminal interbody fusion from July 2010 to June 2011. Transfusion rates and transfusion-related complications were determined. Binary logistic regression was performed to identify risk factors for use of autologous cell saver transfusion.

RESULTS

There were 178 females and 107 males, with a mean age of 57.2 years. Of the 285 cases, 39 had no cell saver available, 147 had cell saver available but no autologous blood was recovered or transfused and 99 had an autologous cell saver transfusion. Patients who had cell saver transfusion had a higher rate of intraoperative allogeneic blood transfusion (52%) compared with those who did not (22%). There was no significant difference in the rate of postoperative transfusions or transfusion-related reactions between patients who did and did not have cell saver transfusion. Patient's age, smoking status, American Society of Anesthesiologists grade, use of anticoagulants preoperatively, primary or revision surgery, iliac crest bone graft harvest, anesthesiologist, or surgeon had no significant effect on cell saver infusion. Body mass index (odds ratio [OR] = 1.06), number of posterolateral fusion levels fused (OR = 2.50), and number of transforaminal interbody fusions performed (OR = 2.41) were independent risk factors for the use of autologous cell saver transfusion.

CONCLUSION

Body mass index, multi-level fusion and transforaminal interbody fusion result in increased use of autologous cell saver transfusion in lumbar spinal surgery. Use of autologous cell saver transfusion did not reduce the requirement for intraoperative or postoperative allogeneic blood transfusion.

LEVEL OF EVIDENCE

2.

Efficacy and cost-effectiveness of cell saving blood autotransfusion in adult lumbar fusion

The objective of this study was to explore the use of cell saver blood autotransfusion in spinal surgery and to evaluate the efficacy and cost-effectiveness of cell saver blood autotransfusion during lumbar spine fusion in adults. Specific indications for the use of cell saver in adult lumbar fusion surgery have not yet been clearly determined. A total of 50 consecutive candidates for posterolateral fusion with internal fixation were prospectively randomized into either receiving perioperatively cell saving autotransfusion (Group A: 25 patients) or not (Group B: 25 patients). The use of cell saving technique did not exclude the use of allogenic blood transfusion. Surgical indications were spinal stenosis, spondylolisthesis, adolescent idiopathic scoliosis, degenerative scoliosis and fractures. Medical and financial data were recorded. A cost-analysis was performed. Patients in Group A received 880 +/- 216 mL from cell saver and 175 +/- 202 mL allogenic blood. The patients in Group B received 908 +/- 244 mL allogenic blood. Blood volumes data collected were expressed in mean +/- SD values. The cost of blood transfusion in Group A was 995 +/-euro447 per patient and 1220 +/- 269 in Group B (P < 0.05). In elective lumbar fusion blood requirements can be satisfied with the use of autotransfusion. The use of cell saver appears to be useful and cost-effective during most elective lumbar fusions.

Allogeneic transfusion after predonation of blood for elective spine surgery

The literature suggests preoperative autologous blood donation in total joint arthroplasty is associated with increased overall transfusion rates compared with nondonation and is not cost-effective for all patients. We asked whether the amount of intraoperative blood loss and blood replacement differs between autologous donors and nondonors in elective spine surgery and whether the rates of allogeneic blood transfusions differ between the two groups; we then determined the cost of wasted predonated units. We retrospectively reviewed 676 patients who underwent elective lumbar spine surgery and compared relevant data to that in a matched cohort of 51 patients who predonated blood and 51 patients who received only cell-saver blood and underwent instrumented spinal fusion. Patients who predonated blood had similar blood loss as patients who did not predonate, but they had more blood replacement (1391 cc compared with 410 cc). Patients who predonated blood also had a lower preoperative hemoglobin level and wasted a half unit of blood on average. There was no major difference in allogeneic blood transfusion rates between the two groups. Our data suggest for short, instrumented lumbar fusion surgeries in patients with a normal coagulation profile, preoperative blood donation is not beneficial.

LEVEL OF EVIDENCE

Level II, therapeutic study.

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

BACKGROUND CONTEXT

Spine surgery for scoliosis is associated with significant blood loss and may require blood transfusion. The risks inherent in blood transfusion have inspired interventions, including human recombinant erythropoietin (rHuEPO), which has emerged as a safe and effective adjunct in minimizing exposure to allogenic blood in children undergoing scoliosis surgery. However, there is little information in the literature on their economic impact on the health-care system.

PURPOSE

The purpose of this study was to evaluate the cost-effectiveness of rHuEPO in adolescent idiopathic scoliosis.

STUDY DESIGN/SETTING

We designed a decision analytic model capturing costs and potential long-term outcomes of transfusion-related complications to compare the cost-effectiveness of preoperative rHuEPO with a control group and a common alternative, preoperative autologous donation (PAD).

PATIENT SAMPLE

This is a decision analytic model. Decision modeling relies on a summation of the probability of different clinical studies; no patients were specifically studied.

OUTCOME MEASURES

The standard cost-effectiveness ratio (C/E) of $50,000 per quality-adjusted life year (QALY) was used as the threshold value for determining the cost-effectiveness of these two preoperative intervention strategies.

METHODS

From the model we calculated the probability that a patient would experience transfusion-related complications based on the mean number of allogenic units transferred as a result of scoliosis surgery. The standard C/E of $50,000 per QALY was used as the threshold value for determining the cost-effectiveness. Some aspects of the model were derived from retrospective data from the literature. Sensitivity analyses were also conducted to discover which variables, when changed within the accepted range, caused the final result of the model to change significantly.

RESULTS

Results indicated a cost per year-of-life-saved exceeding $1 million for the PAD arm and over $1.5 million for the rHuEPO arm. The low rates of transfusion in adolescent idiopathic scoliosis surgery and the relative safety of the blood supply create a scenario where even inexpensive interventions are not cost-effective. However, rHuEPO would become cost-effective if decreased transfusion rates or higher postoperative hematocrit resulted in decreased length of stay.

CONCLUSION

The use of rHuEPO preoperatively and the use of PAD are not cost-effective although both techniques remain clinically effective tools.

Pre-operative predeposit autologous donation in children presenting for elective surgery: a review

Predeposit Autologous blood donation (PAD) in children decreases the life-time complications associated with allogeneic blood. These complications include transmission of known or unknown pathogens and alloimmunization against future blood transfusions, organ transplants and pregnancies. In view of the potential long term benefits of PAD should it be considered a component of paediatric blood conservation programs. This paper reviews the literature to explore the risk of benefit analysis of adopting PAD in paediatric practice.

Wasting of preoperatively donated autologous blood in the surgical treatment of adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective, case-control.

OBJECTIVE

Evaluate the utility of preoperative autologous blood donation (PABD) for surgical treatment of adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Recent data have highlighted overuse of PABD in elective surgery; however, PABD is a major blood conservation strategy for AIS surgery.

METHODS

Medical records of 123 patients treated for AIS between June 1995 and November 2004 were reviewed. Patients were divided into PABD (n = 104) and nondonors (NPABD; n = 19).

RESULTS

No differences existed between PABD and NPABD for age, major curve size, or operative procedures. Average PABD preoperative hematocrit was lower than NPABD (37.8 vs. 40.2; P < 0.005). PABD patients were 9 times more likely to be transfused than NPABD, and 3 times more likely to be transfused for each unit donated. There was a 25% transfusion risk reduction for each percent preoperative hematocrit increase. Minimum one autologous unit was not transfused in 32 patients (31%). Twenty-nine PABD patients (28%) were transfused for hematocrit >30. Fifty-three PABD patients (51%) wasted at least one unit or were transfused for hematocrit >30.

CONCLUSIONS

The majority of PABD patients (51%) wasted minimum one autologous unit or were transfused at a high hematocrit (>30). More precise PABD guidelines are needed to limit unnecessary transfusion and wasted resources.

Surgical treatment for scoliosis in Marfan syndrome

STUDY DESIGN

Review of results of patients with Marfan syndrome treated with instrumented posterior fusion alone for scoliosis.

OBJECTIVE

To analyze the results of surgical treatment for scoliosis in Marfan syndrome.

SUMMARY OF BACKGROUND DATA

Few studies have been reported in the literature on surgical treatment for scoliosis in Marfan syndrome, analyzing long-term results of posterior instrumented fusion.

METHODS

Twenty-three patients with Marfan syndrome with a mean age of 17 years (range, 11-31 years) were treated surgically from 1982 to 1995 for scoliosis, using a posterior instrumented fusion alone (Harrington rod with sublaminar wires in the first 16 cases, and a more recent hybrid instrumentation in the remaining 7 cases). All of the patients received a long posterior instrumented fusion, including 12.3 levels on average (range, 9-17), extending the fusion area to vertebrae that were neutral and stable in both coronal and sagittal planes before surgery. Patients were analyzed as two different groups (Group 1 and Group 2) according to the different posterior instrumentations employed: Group 1 included 16 patients treated by the Harrington distraction rod technique with sublaminar wires, while Group 2 included 7 patients treated using more recent hybrid instrumentations. Presentation features, complications, and results were analyzed.

RESULTS

At a minimum follow-up of 7 years (maximum, 18 years), all 23 patients were reviewed. The mean age was 26.8 years (range, 20-38 years). The average preoperative scoliosis value of 69.91 degrees was initially corrected to 38.17 degrees, averaged 40.89 degrees 1 year after surgery, and was finally equal to 44.09 degrees at the last follow-up. Differences in terms of scoliosis correction achieved with different instrumentations (Groups 1 and 2) did not reach statistical significance. In Group 2 patients, the percentage of postoperative correction was slightly lower (44.23%) than that of Group 1 (46.55%) but remained more stable at the last follow-up (40.97% vs. 36.38% of Group 1). There were 11 complications in 10 of the 23 patients (43.4%); two complications occurred in 1 patient. Intraoperatively, dural tears occurred in 2 cases (8.6%). Pseudarthrosis with instrumentation failure in 2 cases (8.6%) required revision surgery. Five (21.7%) distal hook dislodgements with moderate loss of scoliosis correction, 1 (4.3%) mild loss of correction without instrumentation failure, and 1 asymptomatic cervicothoracic junctional kyphosis. did not require surgery. All complications occurred among the 16 Group 1 patients, treated using the Harrington rod instrumentation with sublaminar wires.

CONCLUSIONS

These results seemed to demonstrate that a satisfactory stabilization of scoliosis can be achieved by posterior instrumentation alone in patients with Marfan syndrome. Instrumented posterior fusion should be extended to include vertebrae that are neutral and stable in both coronal and sagittal planes before surgery, in order to ensure stabilization of the deformity and reduce the risks of decompensation of the spine.

Blood Conservation in Pediatric Anesthesia

This review focuses on perioperative blood conservation techniques and the role of transfusion triggers and algorithms, preoperative autologous donation, acute normovolemic hemodilution, intraoperative blood salvage, deliberate hypotension, and preoperative recombinant human erythropoietin in avoiding allogeneic blood transfusion in pediatric patients.

Transfusion of post-operative shed blood: laboratory characteristics and clinical utility

Increased awareness of the potential hazards of allogenic blood transfusion, such as incompatibility reactions, metabolic and immunologic disorders, or transmission of viral diseases, has led to an emphasis on allogeneic blood alternatives. For orthopaedic surgery, several autologous transfusion modalities have emerged as alternatives to allogeneic blood transfusion, avoiding its immunomodulatory effects. Among them, transfusion or return of post-operative salvaged shed blood has become popular in major orthopaedic procedures. However, although the effectiveness of this blood-saving method is well documented, several authors have questioned its safety and recommended the use of washed blood. Therefore, this review analyses the haematologic characteristics of unwashed filtered shed blood, including metabolic status and survival of red blood cells, the components of the haemostatic system, the content of fat particles, bacterial and tumour cells and the possibility of their removal, the content of inflammatory mediators, and the effects on the patient's immune system. From data reviewed in this paper, it can be concluded that post-operative salvage of blood seems to be an excellent source of functional and viable red cells without many of the transfusion-related risks and with some immuno-stimulatory effects. In addition, from our experience, post-operative re-infusion of unwashed shed blood after major spine procedures has proved to reduce post-operative homologous transfusion requirements and to complement pre-operative autologous blood donation, without any clinically relevant complication.

Predeposit autologous donation in spinal surgery: a multicentre study

BACKGROUND

Allogeneic blood transfusions (ABT) are often necessary in elective spine surgery because of perioperative blood loss. Preoperative autologous blood donation (PABD) has emerged as the principal means to avoid or reduce the need for ABT. Consequently, a multicentre study was conducted to determine the yield and efficacy of PABD in spine surgery and the possible role of recombinant human erythropoietin (EPO) in facilitating PABD.

METHODS

We retrospectively reviewed the hospital charts and blood bank records from all consecutive spine surgery patients who were referred for PABD. Data were obtained from two A-category hospital blood banks and one general hospital. Although we collected data from 1994, the analytic study period was from the last quarter of 1995 to December 2003. Fifty-four (7%) out of 763 patients referred for PABD were rejected, and medical records were available for 680 patients who were grouped into spinal fusion (556; 82%) and scoliosis surgery (124;18%). EPO was administered to 120 patients (17.6%). From 1999 to 2003, PABD steadily increased from 60 to 209 patients per year.

RESULTS

Overall, 92% of the patients were able to complete PABD, 71% were transfused, and almost 80% avoided ABT. PABD was more effective in fusions (86%) than in scoliosis (47%). Blood wastage was 38%, ranging from 18% for scoliosis to 42% for fusions. EPO allowed the results in the anaemic patients to be improved.

CONCLUSIONS

Therefore, despite the limitations of this retrospective study, we feel that PABD is an excellent alternative to ABT in spine surgery. However, the effectiveness of PABD may be enhanced if associated with other blood-saving techniques.

Blood loss in pediatric spine surgery

This article reviews the extent of blood loss in spine surgery for scoliosis corrections in the pediatric age group. An extensive literature review presents blood loss values in surgery for adolescent idiopathic scoliosis, cerebral palsy, Duchenne muscular dystrophy, spinal muscular atrophy, and myelomeningocoele. The underlying disorder plays a major role in determining the extent of blood loss. Blood loss is considerably higher in those patients with a neuromuscular scoliosis compared with adolescent idiopathic scoliosis. Within the neuromuscular group those with Duchenne muscular dystrophy demonstrate the highest mean levels of blood loss. Blood loss is also shown to be progressively greater with increasing numbers of vertebral levels incorporated into the fusion, with posterior fusions compared to anterior fusions, and in those patients having both anterior and posterior fusions.

The Cell Saver in adult lumbar fusion surgery: a cost-benefit outcomes study

STUDY DESIGN

Review of efficacy of Cell Saver in a nonrandomized group of patients undergoing lumbar fusion.

OBJECTIVES

Determine the necessity and cost-effectiveness of the use of Cell Saver for adult lumbar spine fusions.

SUMMARY OF BACKGROUND DATA

Specific indications for the use of Cell Saver in adult lumbar fusion surgery have not been clearly determined. In addition to effectiveness in blood replacement, the economic benefits of the Cell Saver have not been evaluated.

METHODS

A total of 102 consecutive cases of posterolateral fusion with internal fixation were reviewed retrospectively. There were 56 patients in the Cell Saver group and 46 patients in the control group. Recorded hospital medical and financial data were analyzed for each patient.

RESULTS

There was a 38% recovery rate of blood using the Cell Saver. This resulted in a decreased need for postoperative transfusion in the study group (1 U to 36% of patients) relative to the control group (1 U to 50% of patients). Significant predictors for surgery time were the number of levels fused (P < 0.0001), patient's weight (P = 0.0030), and use of Cell Saver (P = 0.0472). Significant indicators of blood loss were the number of levels fused (P < 0.0001) and surgical time (P = 0.0304). The average cost for blood-related charges in the Cell Saver group was 512 dollars versus 270 dollars per patient in the control group. CONCLUSIONS.: While the Cell Saver group did require fewer postoperative transfusions, the difference was not as much as expected. In elective fusions for degenerative conditions of the lumbar spine, blood requirements can usually be satisfied with predonation of autologous blood. With contemporary practices of predonation, the use of the Cell Saver appears to be neither necessary nor cost-effective during most elective lumbar fusions.

Predictors of red cell transfusion in children and adolescents undergoing spinal fusion surgery

STUDY DESIGN

A retrospective review was performed.

OBJECTIVE

To determine clinical predictors of allogeneic and autologous red cell transfusion in children and adolescents undergoing spinal fusion surgery.

SUMMARY OF BACKGROUND DATA

Blood loss during spinal fusion surgery often results in the need for transfusion therapy. Preoperative identification of patients at increased risk for red cell transfusion would allow more specific use of interventions designed to control excessive bleeding.

METHODS

The medical records of all patients undergoing posterior spinal fusion surgery at a single institution between July 1, 1999 and June 30, 2001 were reviewed. Logistic and stepwise multiple regression analyses were used to identify predictors of allogeneic and autologous red cell transfusion during the operative and postoperative periods.

RESULTS

Posterior spinal fusion surgery was performed in 107 patients (males, 42%) with a median age of 13.7 years (range, 1-20 years). The median intraoperative blood loss was 22 mL/kg (range, 4.4-72 mL/kg). Blood transfusion involved 63 patients (59%) who received 17 mL/kg (range, 3-65 mL/kg) of allogeneic packed red blood cells and 14 patients (13%) who received 7 mL/kg (range, 4-19 mL/kg) of autologous red cells donated before surgery. Underlying neuromuscular disease, lower body weight, and a higher number of vertebrae fused independently predicted a greater number of allogeneic red cells transfused (R2 = 0.53). The amount of autologous blood donated before surgery predicted the number of autologous red cells transfused (R2 = 0.56).

CONCLUSIONS

Allogeneic red cell transfusion often is required for small patients with underlying neuromuscular disease who undergo extensive spinal fusion surgery. These patients may be less able to donate autologous blood before surgery. Newer therapies to reduce blood loss and transfusion requirement are needed most for this population.

Spine deformity correction in Marfan syndrome

STUDY DESIGN

Retrospective review of records and radiographs with postoperative questionnaire of patients with Marfan syndrome receiving surgical correction for spinal deformity.

OBJECTIVE

To characterize and analyze the challenges of surgical correction for spinal deformity in Marfan syndrome and to present recommendations that may reduce morbidity and increase success for these procedures.

SUMMARY OF BACKGROUND DATA

Spinal deformities are common in Marfan syndrome and usually refractory to conservative management. The few, smaller studies of surgical intervention reported on earlier surgical techniques but suggested increased complication rates.

METHODS

Records and radiographs of 39 patients with confirmed Marfan syndrome who underwent surgical management at either of two institutions for primary scoliosis (n = 26), kyphosis (n = 7), or deformity secondary to previous surgery elsewhere (n = 6) were reviewed. Presentation features, complications, and therapeutic results were analyzed. Low back outcome scores were generated from a questionnaire given to patients after surgery.

RESULTS

Increased blood loss and rates of infection (10%), dural tear (8%), instrumentation fixation failure (21%), pseudarthrosis (10%), and coronal (8%) and sagittal (21%) curve decompensation were noted. Infection was often associated with dural tear and decompensation with extreme correction. One patient died of valvular insufficiency 11 weeks after surgery.

CONCLUSION

The cardiopulmonary condition of patients with Marfan syndrome should be evaluated and planned for before surgery. Preoperative computed tomograph to assess bony adequacy for fixation and magnetic resonance imaging to evaluate dural ectasia are indicated. Attention paid to the sagittal profile, extension of fusion to vertebrae neutral and stable in both planes, minimization of soft tissue dissection, and avoidance of extreme correction may prevent curve decompensation.

Perioperative autologous blood donation in children

Autologous blood donation in children has become a standard of care. Children have to live with the life-time complications associated with allogeneic blood including the transmission of known and unknown pathogens, and the impact of alloimmunization on future blood transfusions, organ transplants and pregnancies. Donor reaction, allogeneic exposure and utilization rates in pediatric preoperative autologous donation (PAD) programs are as good if not better than reported in adult literature. Children are very resilient when undergoing extreme isovolemic hemodilution (IHD). PAD, IHD and intraoperative blood recovery appear to be useful components of a pediatric blood conservation program. Prospective, randomized studies addressing the specific needs of children are required to properly define their perioperative role.

Hematuria associated with low-volume cell saver in pediatric orthopaedics

A low-volume autotransfusion device, Haemocell System 350, was used for four consecutive pediatric orthopaedic patients. Although the initial patient evidenced no hematuria, transient hematuria was noted in three consecutive patients. Follow-up blood urea nitrogen, electrolytes, and creatinine levels were all within normal limits. After discontinuation of the device, no further hematuria has occurred in subsequent patients. Although intraoperative low-volume cell savers may have a role in pediatric orthopaedic surgery associated with low total blood volume loss, we observed three cases of postoperative hematuria by using this device in cases with large total blood volume loss [>28% estimated blood volume (EBV)]. Although all of these cases were transitory, we recommend caution in the use of low-volume intraoperative blood-salvage devices in pediatrics at this time.

Combination of blood-saving methods decreases homologous blood requirements in scoliosis surgery

A study was conducted in patients undergoing surgery for idiopathic scoliosis, to determine whether combining blood-saving methods would decrease the need for homologous blood. Five groups were compared in a prospective, randomized fashion. In control patients (n = 13), blood loss was replaced by colloids. Preoperative haemodilution (PHD group) was used in ten patients. In the intraoperative autotransfusion (IAT) group (n = 11), washed red cells were returned to the patient. In the PHD+IAT group, both methods were combined (n = 13). In the fifth group, in addition, arterial hypotension was maintained with sodium nitroprusside (the PHD+IAT+HA group, n = 10). The haemoglobin value was kept above 79 g/l. Total blood loss did not differ between groups. The use of homologous blood in the PHD+IAT and PHD+IAT+HA groups was significantly less than in controls. It is concluded that blood-saving measures can be combined with an augmentative effect.