Does the intraoperative tranexamic acid decrease operative blood loss during posterior spinal fusion for treatment of adolescent idiopathic scoliosis?

Effect of tranexamic acid in spine surgeries: a systematic review and network meta-analysis

Background

Severe blood loss during spine surgery increases the need for blood transfusion. Transfusion carries the risks of infection, complications, and postoperative morbidity; therefore, minimizing these risks is crucial for all surgical patients.

Methods

A comprehensive literature search was conducted in PubMed, Cochrane, and EMBASE to find studies examining the effect of tranexamic acid (TXA) on spine surgeries in patients who received blood transfusion. We used the mean difference (MD) and 95% credible intervals (CrI) to analyze continuous outcomes, such as intraoperative blood loss, postoperative blood loss, hemoglobin drop, and length of hospital stay. To evaluate categorical outcomes, such as blood transfusion rate and complication rate, the odds ratios (OR) and 95% CrI were determined.

Results

A total of 38 randomized controlled trials were included, evaluating six outcomes across 10 treatment groups. Low-dose intravenous (IV) TXA combined with temperature intervention (15 mg/kg) significantly reduced intraoperative blood loss compared with placebo [MD: -112.0; 95% CrI: -211.0 to -14.9, surface under the cumulative ranking curve (SUCRA): 78.37%]. The administration of more than two doses of TXA significantly reduced intraoperative blood loss (MD: -101.0, 95% CrI: -161.0 to -44.1, SUCRA: 77.65%) and postoperative blood loss (MD: -177.0, 95% CrI: -275.0 to -92.4, SUCRA: 85.66%) compared with placebo. Both treatments significantly impacted the hemoglobin drop and blood transfusion rate.

Conclusions

Low-dose IV TXA with temperature intervention and the combined use of TXA significantly improved blood loss, hemoglobin drop, and blood transfusion rate during spine surgeries. Further studies involving larger populations are warranted and should be carefully designed to determine the potential risk of complications.

Systematic Review Registration

www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024531557, identifier: CRD42024531557.

Effectiveness and Safety of High-Dose Tranexamic Acid in Adolescent Idiopathic Scoliosis Surgery: A Meta-Analysis and Systematic Review

OBJECTIVE

This systematic review and meta-analysis of randomized controlled trials and retrospective controlled studies aims to evaluate the efficacy and safety of high-dose tranexamic acid (TXA) in spinal correction surgery for adolescent idiopathic scoliosis patients.

METHODS

In March 2024, a comprehensive search was conducted in PubMed, Web of Science, Embase, and Cochrane databases to identify randomized controlled trials and retrospective controlled studies comparing the effects of high-dose TXA on blood loss and transfusion requirements during spinal correction surgery.

RESULTS

This meta-analysis included 10 studies encompassing a total of 741 patients. The pooled results indicated that the use of high-dose TXA significantly reduced intraoperative blood loss [weighted mean difference (WMD) = -519.83, 95% CI (-724.74, -314.92), P < 0.00001], transfusion rate [RR = 0.28, 95% CI (0.17, 0.45), P < 0.00001], total blood loss [WMD = -891.09, 95% CI (-1623.92, -158.26), P = 0.02], and postoperative blood loss [WMD = -105.91, 95% CI (-141.29, -70.52), P < 0.00001]. There was no significant difference in operative time [WMD = -18.96, 95% CI (-40.20, 2.28), P = 0.08] and blood loss per segment [WMD = -50.51, 95% CI (-102.19, 1.17), P = 0.06]. Both groups had a comparable incidence of thromboembolic events.

CONCLUSIONS

Our meta-analysis suggests that the use of high-dose TXA reduces intraoperative blood loss, transfusion rate, total blood loss, and postoperative blood loss in spinal correction surgery for adolescent idiopathic scoliosis patients. However, there were no significant differences in operative time and blood loss per segment.

Risk factors for allogeneic red blood cell transfusion in adult spinal deformity surgery

STUDY DESIGN

Retrospective study.

PURPOSE

To investigate the risk factors for allogeneic red blood cell (RBC) transfusion in adult spinal deformity (ASD) surgery.

OVERVIEW OF LITERATURE

Studies have not thoroughly explored the roles of intraoperative hypothermia, autologous blood donation, and hemostatic agent administration, which would provide a better understanding of the risk for perioperative RBC transfusion in ASD surgery.

METHODS

The medical records of 151 patients with ASD who underwent correction surgery between 2012 and 2021 were retrospectively reviewed. Estimated blood loss and perioperative allogeneic transfusion were examined. Patients were categorized into two groups based on whether they received perioperative allogeneic blood transfusion. Logistic regression analysis was employed to investigate the effect of age, sex, blood type, body mass index, American Society of Anesthesiologists' physical status, preoperative hemoglobin level, autologous blood donation, global spine alignment parameters, preoperative use of anticoagulants or antiplatelet medicine and nonsteroidal anti-inflammatory drugs, number of instrumented fusion levels, total operative duration, three-column osteotomy, lateral interbody fusion, pelvic fixation, intraoperative hypothermia, use of gelatin-thrombin based hemostatic agents, and intraoperative tranexamic acid (TXA) with simultaneous exposure by two attending surgeons.

RESULTS

The estimated blood loss was 994.2±754.5 mL, and 71 patients (47.0%) received allogeneic blood transfusion. In the logistic regression analysis, the absence of intraoperative TXA use and simultaneous exposure (odds ratio [OR], 26.3; 95% confidence interval [CI], 7.6-90.9; p<0.001), lack of autologous blood donation (OR, 21.2; 95% CI, 4.4-100.0; p<0.001), and prolonged operative duration (OR, 1.6; 95% CI, 1.3-1.9; p<0.001) were significant independent factors for perioperative allogeneic blood transfusion in ASD surgery.

CONCLUSIONS

Autologous blood storage, intraoperative TXA administration, and simultaneous exposure should be considered to minimize perioperative allogeneic blood transfusion in ASD surgery, particularly in patients with anticipated lengthy surgeries.

Efficacy and utility of antifibrinolytics in pediatric spine surgery: a systematic review and network meta-analysis

Antifibrinolytics have gained increasing attention in minimizing blood loss and mitigating the risks associated with massive transfusions, including infection and coagulopathy in pediatric patients undergoing spine surgery. Nevertheless, the selection of optimal agent is still a matter of debate. We aim to review the utility of these agents and compare the efficacy of antifibrinolytics in pediatric and adolescent spine surgeries. A comprehensive search was performed in Scopus, Web of Science, and MEDLINE databases for relevant works. Studies providing quantitative data on predefined outcomes were included. Primary outcome was perioperative bleeding between the groups. Secondary outcomes included transfusion volume, rate of complications, and operation time. Twenty-eight studies were included in the meta-analysis incorporating 2553 patients. The use of Tranexamic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 88%), Aprotinin (RoM: 0.54, 95%CI: [0.46-0.64], p < 0.001, I2 = 0%), and Epsilon-aminocaproic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 60%) led to a 29%, 46%, and 29% reduction in perioperative blood loss, respectively. Network meta-analysis revealed higher probability of efficacy with Tranexamic acid compared to Epsilon-aminocaproic acid (P score: 0.924 vs. 0.571). The rate of complications was not statistically different between each two antifibrinolytic agent or antifibrinolytics compared to placebo or standard of care. Our network meta-analysis suggests a superior efficacy of all antifibrinolytics compared to standard of care/placebo in reducing blood loss and transfusion rate. Further adequately-powered randomized clinical trials are recommended to reach definite conclusion on comparative performance of these agents and to also provide robust objective assessments and standardized outcome data and safety profile on antifibrinolytics in pediatric and adolescent pediatric surgeries.

Tranexamic acid can reduce blood loss in adolescent scoliosis surgery: a systematic review and meta-analysis

BACKGROUND

Tranexamic acid (TXA) has been widely used in orthopedic surgery, but its efficacy in adolescent scoliosis (AS) surgery remains unclear in the literature. The purpose of this systematic review and meta-analysis is to evaluate the safety and efficacy of TXA compared to placebo treatment during or after AS surgery, by gathering data from randomized both controlled trials (RCTs) and non-RCTs.

METHODS

English and Chinese electronic databases including PubMed, Web of Science, Embase, Cochrane, CNKI, and Wan Fang database were searched to identify the relevant literature up until August 2022. The primary outcomes were intraoperative blood loss and total blood loss. The secondary outcomes included the need for transfusion, postoperative hemoglobin (Hb) level, and change in Hb level. Stata 17 was used for data analysis and the risk of bias was assessed. We followed the PRISMA checklist to ensure the quality of this article.

RESULTS

Twelve studies (795 participants) were included in the meta-analysis for intraoperative blood loss during surgery. The results suggest that TXA can reduce the intraoperative blood loss of the patients (MD = -306.40ml, 95%CI = -404.04ml to -208.77ml, p < 0.001). Six studies (2027 patients) were included in the meta-analysis for total blood loss. The pooled result shows that the total blood loss of the TXA group was significantly lower than that of the control group (MD = -779.24ml, 95% CI = -1157.10ml to -410.39ml, p < 0.001). Five studies (419 patients) were included in the meta-analysis for postoperative Hb level and shows a non-significant outcome (MD = 5.09 g/l, 95%CI = 2.92 g/l to 7.25 g/l, p = 0.611). Three studies (268 patients) were included in the meta-analysis for the postoperative Hb level. There is a non-significant decrease in the TXA group (MD = -0.23 g/l, 95%CI = -0.48 g/l to 0.01 g/l, p = 0.319). Eight studies (670 patients) reported data on the need for transfusion after surgery. The overall relative risks (RR) showed a significant difference between the TXA and control group, with a lower risk of transfusion in the TXA group (RR = 0.547, 95%CI = 0.308 to 0.972, p = 0.04).

CONCLUSIONS

The meta-analysis of the data reveals that TXA usage is associated with a significant reduction in intraoperative and total blood loss, a lower risk of transfusion, and a non-significant change in postoperative Hb levels in AS surgery However, it should be noted that the surgical operation situations varied across different studies. Therefore, further research is required to investigate the effects of TXA on specific subgroups of gender, operation time, and blood transfusion indicators. Overall, our study provides valuable evidence for the clinical management of AS surgery and may inform the development of practice guidelines and protocols for the use of TXA in this setting.

Randomized, controlled trial of two tranexamic acid dosing protocols in adult spinal deformity surgery

BACKGROUND

Tranexamic acid (TXA) is an anti-fibrinolytic effective in reducing blood loss in orthopedic surgery. The appropriate dosing protocol for adult spinal deformity (ASD) surgery is not known. The purpose of this study was to evaluate two TXA protocols [low dose (L): 10 mg/kg bolus, 1 mg/kg/hr infusion; high dose (H): 50 mg/kg, 5 mg/kg/hr] in complex ASD surgery.

METHODS

Inclusion criteria were ASD reconstructions with minimum 10 fusion levels or planned 3-column osteotomy (3CO). Standard demographic and surgical data were collected. Intraoperative estimated blood loss (EBL) was calculated by suction canisters minus irrigation plus estimated blood lost in sponges, estimated to the nearest 50 mL. Serious adverse events (SAE) were defined a priori as: venothromboembolic event (VTE), cardiac arrhythmia, myocardial infarction, renal dysfunction, and seizure. All SAE were recorded. Simple t tests compared EBL between groups. Mean EBL by total blood volume (TBV), transfusion volume, complications related to TXA were secondary outcomes.

RESULTS

Sixty-two patients were enrolled and 52 patients completed the study; 25 were randomized to H and 27 to L. Demographic and surgical variables were not different between the two groups. EBL was not different between groups (H: 1596 ± 933 cc, L: 2046 ± 1105 cc, p = 0.12, 95% CI: - 1022 to 122 cc). EBL as a percentage of TBV was lower for the high-dose group (H: 29.5 ± 14.8%, L: 42.5 ± 26.2%, p = 0.03). Intraoperative transfusion volume (H: 961 ± 505 cc, L: 1105 ± 808 cc, p = 0.5) and post-operative transfusion volume (H: 513 ± 305 cc, L: 524 ± 245 cc, p = 0.9) were not different. SAE related to TXA were not different (p = 0.7) and occurred in 2 (8%) H and 3 (11%) L. There was one seizure (H), 2 VTE, and 2 arrhythmias.

CONCLUSION

No differences in EBL, transfusion volume, nor SAE were observed between H and L dose TXA protocols. High dose was associated with decreased TBV loss (13%). Further prospective study, with pharmacologic analysis, is required to determine appropriate TXA dosage in ASD surgeries.

LEVEL OF EVIDENCE

Therapeutic Level II.

TRIAL REGISTRATION

The study was registered at Clinicaltrials.gov (NCT02053363) February 3, 2014.

Evaluation of the safety of tranexamic acid use in pediatric patients undergoing spinal fusion surgery: a retrospective comparative cohort study

Background

Pediatric spinal fusion may be associated with significant intraoperative blood loss, leading to complications from transfusion, hypoperfusion and coagulopathy. One emerging strategy to mediate these risks is by utilization of the anti-fibrinolytic agent tranexamic acid (TXA). However, concerns regarding potential adverse reactions, specifically postoperative seizures and thrombotic events, still exist. To assess these risks, we examined the perioperative morbidity of TXA use in a large national database.

Methods

Retrospective data from pediatric patients (age 18 years or younger), discharged between January 2013 to December 2015, who underwent primary or revision posterior spinal fusions, was collected from the Premier Perspective database (Premier, Charlotte, NC). Patients were stratified by TXA use and records were assessed for complications of new onset seizures, strokes, pulmonary embolisms (PE) or deep vein thromboses (DVT) occurring during the perioperative period.

Results

In this cohort of 2,633 pediatric patients undergoing posterior spinal fusions, most often to treat adolescent idiopathic scoliosis, 15% received TXA. Overall, adverse events were rare in this patient population. The incidence of seizure, stoke, PE, or DVT in the control group was 0.54% (95% CI, 0.31% to 0.94%) and not significantly different from the TXA group. There was no significant difference in the incidence of DVTs, and no incidences of stroke in either group. There were no new-onset seizures or PEs in patients who received TXA.

Conclusions

The use of TXA was not associated with an increased risk of adverse events including seizure, stroke, PE, and DVT. Our findings support the safety of TXA use in pediatric patients undergoing spinal fusion surgery.

Surgeon specialty effect on early outcomes of elective posterior spinal fusion for adolescent idiopathic scoliosis: a propensity-matched analysis of 965 patients

BACKGROUND AND OBJECTIVE

Comparative effectiveness research plays a vital role in health care delivery. Specialty training is one of these variables; surgeons who are trained in different specialties may have different outcomes performing the same procedure. The objective of this study was to investigate the impact of spine surgeon specialty (neurosurgery vs orthopedic surgery) on early perioperative outcome measures of elective posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

This is a retrospective, 1:4 propensity score-matched cohort study. 5520 AIS patients were reviewed from ACS-NSQIP pediatric database. Propensity score matching was utilized.

RESULTS

Patients operated on by orthopedic surgeons were more likely to have shorter operation time (263 min vs 285 min), shorter total hospital stay (95 h vs 118 h), lower rate of return to operating room within the same admission (1.2% vs 3.8%), lower discharge rates after postoperative day 4 (23.8% vs 30.9%), and lower unplanned readmission rate (1.6% vs 4.1%), (p < 0.05). On the other hand, patients operated on by neurosurgeons had lower perioperative blood transfusion rate (62.1% vs 69.8%), (p < 0.05). Other outcome measures and mortality rates were not significantly different between the two cohorts.

CONCLUSIONS

This retrospective study found significant differences in early perioperative outcomes of patients undergoing PSF for AIS by neurosurgeons and orthopedic surgeons. Further studies are recommended to corroborate this finding which may trigger changes in the educational curriculum for neurosurgery residents.

Acute normovolemic hemodilution in combination with tranexamic acid is an effective strategy for blood management in lumbar spinal fusion surgery

Background

The retrospective study was designed to compare the effectiveness and safety of acute normovolemic hemodilution (ANH), tranexamic Acid (TXA), and a combination of ANH and TXA in lumbar spinal fusion surgery.

Methods

Data of 120 patients underwent multi-level posterior spinal fusion for treating degenerative lumbar disease between June 2013 and December 2017 was collected, retrospectively. Four treatment strategies were enrolled, including ANH, TXA, a combination of ANH and TXA, and without any patient blood management. Intraoperative blood loss, hemoglobin and PCV at the end of surgery and at the postoperative first day, and postoperative drain collection, and intraoperative and postoperative transfusion and rate of transfusion were also collected.

Results

Intraoperative blood loss and postoperative drain collection of the TXA group, ANH combined with TXA group were statistically lower than those in the control group and ANH group (P < 0.05). Intraoperative and postoperative transfusion amount and rate of intra-operative allogenic transfusion of the ANH group, TXA group, and ANH combined with TXA group were statistically lower than those of the control group (P < 0.05). Hemoglobin and PCV at postoperative the first day in the ANH group, TXA group, and ANH combined with TXA group were significant higher than those in the control group (P < 0.05). The combination of TXA and ANH group achieved the lowest intraoperative blood loss, postoperative drain collection and allogenic transfusion rate.

Conclusion

A combination of TXA and ANH might be an effective strategy for reducing the rate of transfusion and blood loss in patients underwent lumbar spinal fusion surgery.

Sagittal age-adjusted score (SAAS) for adult spinal deformity (ASD) more effectively predicts surgical outcomes and proximal junctional kyphosis than previous classifications

BACKGROUND

Several methodologies have been proposed to determine ideal ASD sagittal spinopelvic alignment (SRS-Schwab classification) global alignment and proportion (GAP) score, patient age-adjusted alignment). A recent study revealed the ability and limitations of these methodologies to predict PJK. The aim of the study was to develop a new approach, inspired by SRS classification, GAP score, and age-alignment to improve the evaluation of the sagittal plane.

METHOD

A multi-center ASD database was retrospectively evaluated for surgically treated ASD patients with complete fusion of the lumbar spine, and minimum 2 year follow-up. The Sagittal age-adjusted score (SAAS) methodology was created by assigning numerical values to the difference between each patient's postoperative sagittal alignment and ideal alignment defined by previously reported age generational norms for PI-LL, PT, and TPA. Postoperative HRQOL and PJK severity between each SAAS categories were evaluated.

RESULTS

409 of 667 (61.3%) patients meeting inclusion criteria were evaluated. At 2 year SAAS score showed that 27.0% of the patients were under-corrected, 51.7% over-corrected, and 21.3% matched their age-adjusted target. SAAS score increased as PJK worsened (from SAAS = 0.2 for no-PJK, to 4.0 for PJF, p < 0.001). Post-operatively, HRQOL differences between SAAS groups included ODI, SRS pain, and SRS total.

CONCLUSION

Inspired by SRS classification, the concept of the GAP score, and age-adjusted alignment targets, the results demonstrated significant association with PJK and patient reported outcomes. With a lower rate of failure and better HRQOL, the SAAS seems to represent a "sweet spot" to optimize HRQOL while mitigating the risk of mechanical complications.

Hidden blood loss in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgery: a retrospective study of 765 cases at a single centre

Background

In scoliosis corrective surgery, total blood loss is composed of visible blood loss, including intraoperative haemorrhage and drainage, and hidden blood loss in which blood extravasates into the tissues and accumulates in the surgical field. The purpose of this study was to investigate hidden blood loss (HBL) and its potential risk factors in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgery and elucidate the influence of HBL on the necessity for postoperative blood transfusion.

Methods

We retrospectively studied adolescent idiopathic scoliosis patients undergoing posterior spine fusion for adolescent idiopathic scoliosis from January 2014 to December 2018 at our hospital. The patients’ demographics, blood loss-related parameters, surgeries and blood loss data were extracted. The association between patient characteristics and HBL was analyzed by Pearson or Spearman correlation analyses. Multivariate linear regression analysis was used to determine independent risk factors associated with HBL. Binary logistic regression analysis was used to analyze the influence of HBL on the necessity for postoperative blood transfusion.

Results

A total of 765 patients, of whom 128 were male and 637 were female (age range 10–18 years), were included in this study. The mean volume of HBL was 693.5 ± 473.4 ml, accounting for 53.9 % of the total blood loss. The multivariate linear regression analysis revealed that preoperative Hct (p = 0.003) and allogeneic blood transfusion (p < 0.001) were independent risk factors for HBL, while tranexamic acid (p = 0.003) was negatively correlated with HBL. Binary logistic regression analysis showed that HBL > 850 ml (P < 0.001, OR: 8.845, 95 % CI: 5.806–13.290) was an independent risk factor for the necessity for postoperative blood transfusion.

Conclusions

Substantial HBL occurred in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgeries. Allogeneic blood transfusion and preoperative Hct were independent risk factors for HBL, while tranexamic acid was negatively related to HBL. HBL and its influencing factors should be considered when planning perioperative transfusion management. Patients with HBL greater than 850 ml should be closely monitored in cases of postoperative anaemia.

Level of evidence

Level III.

The efficacy of Tranexamic Acid Administration in Patients Undergoing Tonsillectomy: An Updated Meta-Analysis

OBJECTIVE

There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy.

METHODS

We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk.

RESULTS

Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, P = .016) and the rate of post-tonsillectomy hemorrhage (RR = 0.42, 95% CI: 0.28 to 0.65, P < .0001), with no significant difference in reduction of further intervention risk (RR = 0.78, 95% CI: 0.45 to 1.35, P = .373).

CONCLUSIONS

Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.

A New Low Dose of Tranexamic Acid for Decreasing the Rate of Blood Loss in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

BACKGROUND

Previous studies have demonstrated that the use of tranexamic acid (TXA) reduces blood loss and transfusion requirements in children undergoing scoliosis surgery. Although TXA is safe and effective, significant adverse events have been reported. Using the lowest effective dose of TXA is advisable. We evaluated a new low dosing regimen for TXA based on an improved pharmacokinetic model and therapeutic plasma concentration. The purpose of this study is to evaluate the effectiveness of this new low dosing regimen in reducing blood loss and transfusion requirements in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion when compared with a control group who did not receive TXA.

METHODS

We retrospectively reviewed 90 consecutive patients with idiopathic scoliosis undergoing posterior spinal fusion at our institution from 2017 to 2020. Forty patients received TXA at the new dosing regimen (10 mg/kg load, 5 mg/kg/h infusion) and 50 patients were in the non-TXA control group. The same 2 orthopaedic surgeons, working as a team, performed all surgical procedures. We assessed the use of TXA as an independent risk factor for estimated blood loss and transfusion requirement after adjusting for age, surgical duration, body mass index, major coronal curve, and sex.

RESULTS

A comparison of the intraoperative cumulative blood loss in the 2 groups showed a significantly lower blood loss in the TXA group. (583.5±272.0 vs. 479.5±288.7 mL, P=0.03) This difference persisted when blood loss was calculated as percent of total blood volume and per vertebral level. Transfusion requirements were lower in the TXA group (4/50 patients vs. 0/40 patients, P=0.13). No patient in the TXA group required a blood transfusion during their hospitalization.

CONCLUSION

This study is the first to provide evidence that a new low dosing regimen of TXA can significantly reduce blood loss and transfusion requirements for idiopathic scoliosis patients and supports the need for a prospective, randomized clinical trial to confirm these findings.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Efficacy of antifibrinolytics in reducing blood loss during hip reconstruction surgery in cerebral palsy children. A systematic review and meta-analysis

BACKGROUND

Cerebral palsy (CP) children undergoing hip reconstruction are more prone to blood loss during surgery due to poor nutritional status, antiepileptic medication intake, depletion of clotting factors, and the extent of surgery involved. We conducted this present review to analyze whether antifibrinolytics during hip surgery in CP children would reduce surgical blood loss and transfusion requirements.

METHODS

Three databases (PubMed, EMBASE, and Cochrane library) were searched independently for publications mentioning the use of antifibrinolytics during hip reconstruction surgery in CP children. The primary outcome was to compare the surgical blood loss with and without antifibrinolytics use. Secondary outcomes were transfusion requirements, drop in hemoglobin level, length of hospital stay, and complication rates.

RESULTS

All five studies (reporting 478 patients) published on this topic were found eligible based on inclusion criteria and were included for final analysis. Primary outcome: In three of the included studies, antifibrinolytics use resulted in a significant reduction in total blood loss with a mean difference (MD) of -151.05 mL (95% CI -272.30 to -29.80, p = 0.01). In the other two studies although statistically not significant, antifibrinolytics use reduces estimated blood loss (MD: 3.27, 95% CI -21.44 to 14.91, p = 0.72). Secondary outcomes: We observed that in the antifibrinolytics group, there was a reduction in total blood transfusion requirements (OD: 0.70, 95% CI 0.35 to 1.37, p = 0.29), and a drop in haemoglobin level (MD: 0.16, 95% CI -0.62 to 0.30, p = 0.49) but statistically not significant. No adverse effects related directly to antifibrinolytics were noticed in all five studies.

CONCLUSION

Only two out of five included studies favored the use of antifibrinolytics in CP children undergoing hip reconstruction. The evidence synthesized on this meta-analysis is also not sufficient enough to support its routine use in this cohort of children for hip reconstruction surgery. High-quality studies with adequate sample size to determine the effective and safe dosage, timing, and cost involved of different antifibrinolytics are the need of the hour.

LEVEL OF EVIDENCE

Ⅲ.

Operative time in adolescent idiopathic scoliosis surgery: a need for a standard definition

Our objective is to report and define 'operative time' in adolescent idiopathic scoliosis (AIS) posterior spinal fusion surgeries. Documenting key times during surgery are important to compare operative risks, assess learning curves, and evaluate team efficiency in AIS surgery. 'Operative time' in literature has not been standardized. Systematic review was performed by two reviewers. Keywords included operative time, duration of surgery, and scoliosis. One thousand nine hundred six studies were identified, 1092 duplicates were removed and 670 abstracts were excluded. Of the 144 articles, 67 met inclusion and exclusion criteria. Studies were evaluated for number of patients, operative time, and definition of operative time. Meta-analysis was not performed due to confounders. Of the 67 studies (6678 patients), only 14 (1565 patients) defined operative time, and all specified as incision to closure. From these 14 studies, the median operative time was 248 minutes (range 174-448 minutes). In the 53 studies (5113 patients) without a definition, one study reported time in a non-comparable format, therefore, data were analyzed for 52 studies (5078 patients) with a median operative time of 252 minutes (wider range 139-523 minutes). A clear standardized definition of operative or surgical time in spine surgery does not exist. We believe that operative time should be clearly described for each published study for accurate documentation and be defined from incision time to spine dressing completion time in order to standardize study results. Level of evidence: IV.

Topical tranexemic acid reduces intra-operative blood loss and transfusion requirements in spinal deformity correction in patients with adolescent idiopathic scoliosis

PURPOSE

To evaluate the effectiveness of the use of topical tranexamic acid (tTXA) in spinal deformity correction in AIS patients METHODS: Sixty consecutive operative AIS patients were reviewed from a single institution and divided into two groups with similar demographics. Standardized peri-operative blood salvage techniques were utilized in all 60 patients. In the latter 30 patients, tTXA soaked sponges (1 g mixed in 500 ml Normal Saline) was utilised for wound packing during the entire surgical procedure compared to dry sponges as used in the former 30 patients. Both the groups were compared for the magnitude of deformity corrected, EBL per level fused, total EBL, blood transfused, drain output and peri-operative events.

RESULTS

Sixty AIS patients (mean age 14.4 yrs, 43 females, mean BMI 21.5, mean levels 10.7) were included. Both groups achieved similar change in Coronal Cobb correction. The EBVL (Estimated blood volume loss) % lost in the topical TXA group was 38% less than the control group (11.2 vs. 18.3%, p = 0.006). Similarly, the EBL/level was significantly lower in the topical TXA group (41 ± 30 ml vs. 57 ± 26 ml, p = 0.03). Three of 30 patients in the control group required at least 1 unit of blood transfusion, whereas only 1 patient in the topical TXA group required transfusion (10 vs. 3.3%, p = 0.001). No differences were noted in post-operative drain output, change in hemoglobin levels, and peri-operative complication rates.

CONCLUSION

When used as an adjunct to the conventional blood salvage techniques in spinal deformity correction procedures, the use of tTXA resulted in reduced operative blood loss, and blood transfusion requirements.

Intraoperative red blood cell salvage in posterior spinal fusions for idiopathic scoliosis: identifying potential criteria for selective use

STUDY DESIGN

Retrospective.

OBJECTIVES

Evaluate the role and effectiveness of ICS in primary posterior spinal fusion (PSF) for idiopathic scoliosis (IS). Intraoperative cell salvage (ICS) minimizes blood loss and need for allogeneic transfusions. However, it adds substantial charges ($800-1200 US) and may be of less clinical benefit in some PSF for IS.

MATERIALS AND METHODS

This was a single-hospital, retrospective analysis of 178 consecutive IS cases (10-18 years of age) who underwent primary PSF by a single pediatric spine surgeon.

RESULTS

Overall, 41% of cases received a mean 167 cc of ICS blood, after a mean EBL of 528 mL (range 200-1800 mL). No blood was returned in 59% of cases, with a mean EBL of 293 mL (range 75-700 mL). Only 6.5% of the entire cohort received > / = 250 cc via ICS, after a mean EBL of 773 mL. A positive correlation exists between EBL and vertebral levels fused, preoperative major Cobb angle, and length of anesthesia (p < 0.001). ICS may be more efficacious at an inflection point of 12 vertebral fusion levels, preoperative major Cobb angles > / = 55°, anesthesia exposure > / = 6 h, and with use of posterior column osteotomies (PCOs) (p < 0.05). In addition, lack of tranexamic acid use lead to greater EBL (p < 0.0001) and ICS volumes (p = 0.008).

CONCLUSION

The use of ICS in IS patients undergoing PSF resulted in the return of > / = 250 cc of ICS blood (similar volume to one allogeneic unit) in only 6.5% of cases. Charges for ICS set-up and processing of one bowl of ICS is much higher than for one allogeneic unit ($1200 vs. $462 US), hence transfusing lower volumes of autologous ICS blood is not cost-effective for all PSF for IS.

LEVEL OF EVIDENCE

IV; Therapeutic studies.

Role of tranexamic acid in blood loss control and blood transfusion management of patients undergoing multilevel spine surgery: A meta-analysis

BACKGROUND

This study aimed to explore the role of tranexamic acid (TXA) in blood loss control and blood transfusion management of patients undergoing multilevel spine surgery.

METHODS

In this meta-analysis, a comprehensive search of literatures was performed from PubMed, Embase, Cochrane Library, and Web of Science from inception to June 23rd, 2020. Weighed mean difference (WMD) was used as the effect size for measurement data, and risk ratio for enumeration data. Publication bias was assessed by Begg test.

RESULTS

Totally 23 studies (11 randomized controlled trials and 12 cohort studies) involving 1621 participants were enrolled in this meta-analysis. The results showed that the administration of TXA can significantly decrease the intraoperative [WMD: -215.655, 95%CI: (-307.462, -123.847), P < .001], postoperative [WMD: -69.213, 95%CI: (-104.443, -33.983), P = .001] and total [WMD: -284.388, 95%CI: (-437.66, -131.116), P < .001] volumes of blood loss of patients undergoing multilevel spine surgery. It can also significantly reduce the intraoperative [WMD: -333.775, 95%CI: (-540.45, -127.099), P = .002] and postoperative [WMD: -114.661, 95%CI: (-219.58, -9.742), P = .032] volumes of transfusion. In addition, TXA was found to significantly increase the preoperative [WMD: 0.213, 95%CI: (0.037, 0.389), P = .018] and postoperative [WMD: 0.433, 95%CI: (0.244, 0.622), P < .001] hemoglobin levels as well as the preoperative platelet count [WMD: 14.069, 95%CI: (0.122, 28.015), P = .048].

CONCLUSION

The administration of TXA can effectively reduce blood loss and transfusion, and improve hemoglobin levels and preoperative platelet count in patients undergoing multilevel spine surgery.

Safe and effective performance of pediatric spinal deformity surgery in patients unwilling to accept blood transfusion: a clinical study and review of literature

BACKGROUND

Pediatric deformity surgery traditionally involves major blood loss. Patients refusing blood transfusion add extra clinical and medicolegal challenges; specifically the Jehovah's witnesses population. The objective of this study is to review the safety and effectiveness of blood conservation techniques in patients undergoing pediatric spine deformity surgery who refuse blood transfusion.

METHODS

After obtaining institutional review board approval, we retrospectively reviewed 20 consecutive patients who underwent spinal deformity surgery and refused blood transfusion at a single institution between 2014 and 2018. We collected pertinent preoperative, intraoperative and most recent clinical and radiological data with latest follow-up (minimum two-year follow-up).

RESULTS

Twenty patients (13 females) with a mean age of 14.1 years were identified. The type of scoliotic deformities were adolescent idiopathic (14), juvenile idiopathic (1), neuromuscular (3) and congenital (2). The major coronal Cobb angle was corrected from 55.4° to 11.2° (80% correction, p <  0.001) at the latest follow-up. A mean of 11.4 levels were fused and 5.6 levels of Pontes osteotomies were performed. One patient underwent L1 hemivertebra resection and three patients had fusion to pelvis. Estimated blood loss, percent estimated blood volume loss, and cell saver returned averaged 307.9 mL, 8.5%, and 80 mL, respectively. Average operative time was 214 min. The average drop in hemoglobin after surgery was 2.9 g/dL. The length of hospital stay averaged 5.1 days. There were no intraoperative complications. Three postoperative complications were identified, none related to their refusal of transfusion. One patient had in-hospital respiratory complication, one patient developed a late infection, and one patient developed asymptomatic radiographic distal junctional kyphosis.

CONCLUSIONS

Blood conservation techniques allow for safe and effective spine deformity surgery in pediatric patients refusing blood transfusion without major anesthetic or medical complications, when performed by an experienced multidisciplinary team.

LEVEL OF EVIDENCE

Level IV.

Different Dose Regimens of Intravenous Tranexamic Acid in Adolescent Spinal Deformity Surgery: A Systematic Review and Meta-Analysis

Objective

To evaluate the efficacy and safety of different dose regimens of intravenous (IV) tranexamic acid (TXA) in adolescent spinal deformity surgery.

Methods

Two researchers independently searched multiple databases, including PubMed, Embase, Cochrane Library, and Web of Science to find studies that met the inclusion criteria. A meta-analysis was performed based on the guidelines of the Cochrane Reviewer's Handbook.

Results

Six randomized controlled trials (RCTs) and eleven non-RCTs were identified, including 1148 patients. According to different dose regimens of IV TXA, the included studies were divided into the high-dose group and the low-dose group. Compared with placebo, both groups had less total blood loss (TBL) (high dose: WMD = -1737.55, 95% CI: (-2247.16, -1227.94), P < 0.001, I ² = 0%; low dose: WMD = -528.67, 95% CI: (-666.06, -391.28), P < 0.001, I ² = 0%), intraoperative blood loss (IBL) (high dose: WMD = -301.48, 95% CI: (-524.3, -78.66), P = 0.008, I ² = 60.3%; low dose: WMD = -751.14, 95% CI: (-967.21, -535.08), P < 0.001, I ² = 0%), and blood transfusion rates (high dose: RR = 0.19, 95% CI: (0.1, 0.37), P < 0.001, I ² = 0%; low dose: RR = 0.4, 95% CI: (0.18, 0.91), P = 0.029, I ² = 57%). High-dose IV TXA use was associated with more vertebral fusion segments (WMD = 0.53, 95% CI: (0.23, 0.82), P < 0.001, I ² = 31.2%). Low-dose IV TXA use was associated with shorter operative time (WMD = -18.43, 95% CI: (-26.68, -10.17), P < 0.001, I ² = 0%).

Conclusion

High-dose and low-dose IV TXA were effective in reducing TBL, IBL, and blood transfusion rates without increasing complications in adolescent patients undergoing spinal deformity surgery. Low-dose IV TXA was effective in reducing the operative time. Both the high-dose and low-dose groups had similar preoperative and postoperative Hb levels compared to the control group.

[Progress on the application of tranexamic acid in adolescent spine corrective surgery]

OBJECTIVE

To review the advances in the application of tranexamic acid (TXA) in adolescent spinal corrective surgery.

METHODS

The mechanism of action and pharmacokinetic, effectiveness, dosage, safety as well as methods of administration were comprehensively summarized by consulting domestic and overseas related literature about the application of TXA in adolescent spinal corrective surgery in recent years.

RESULTS

TXA efficaciously reduce intraoperative blood loss, transfusion rate and volume, postoperative drainage volume in adolescent spinal corrective surgery. At present, the most common method of administration in adolescent spinal corrective surgery is that a loading dose is given intravenously before skin incision or induction of anesthesia, followed by a maintenance dose until the end of the surgery. The range of loading dose and maintenance dose is 10-100 mg/kg and 1-10 mg/(kg·h), respectively. No drug related adverse event has been reported in this range.

CONCLUSION

The effectiveness and safety of TXA in adolescent spinal surgery have been basically confirmed. However, further studies are needed to determine the optimal dosage, method of administration as well as whether it could reduce blood loss after surgery.

Comparison of Blood-Conserving and Allogenic Transfusion-Sparing Effects of Antifibrinolytics in Scoliosis Correction Surgery

Background:

Intraoperative antifibrinolytic drug administration is a safe and effective method of reducing blood loss and allogenic transfusions in patients undergoing spine deformity correction.

Aim:

This study aimed to compare the effectiveness of two antifibrinolytic drugs tranexamic acid (TXA) and epsilon amino caproic acid (EACA) in reducing peri-operative blood loss and transfusion requirements against a placebo control in patients with idiopathic scoliosis undergoing correction surgery.

Setting and Design:

This is a prospective, randomized, double-blinded, controlled comparative study.

Methodology:

Patients in TXA group received 50 mg.kg⁻¹ bolus and 10 mg.kg⁻¹.h⁻¹ infusion as against 100 mg.kg⁻¹ and 10 mg.kg⁻¹.h⁻¹ infusion in EACA group. The placebo group had saline bolus and infusion. Parameters observed included baseline demographic and deformity data, duration of surgery, total peri-operative blood loss, and allogenic packed red cell transfusion requirements.

Statistical Analysis:

Mean and standard deviation were used to represent the quantitative continuous data, and percentage was used to represent categorical data. The Student's t-test and ANOVA were used to compare means between groups. Bonferroni's multiple comparison test was used to find out the association between categorical variables.

Results:

A total of 36 patients were enrolled with 12 patients in each group. Peri-operative blood loss was 50.1% lower in patients receiving TXA and 17.7% lower in patients receiving EACA compared with the placebo group. The volume of total packed red cell transfusion was 66.7% lower in patients receiving TXA and 45.6% lower in patients receiving EACA compared with placebo.

Conclusion:

TXA was more effective in reducing total peri-operative blood loss and allogenic transfusion requirement in idiopathic scoliosis correction surgery compared to EACA.

Impact of Pediatric Subspecialty Training on Perioperative Complications in Adolescent Idiopathic Scoliosis Surgery

This was a retrospective study of data prospectively collected from 2012 to 2016 from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. The objective was to evaluate the effect of pediatric fellowship training on 30-day perioperative morbidity and mortality following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Several pathways exist in North America by which physicians acquire the clinical and technical skills to manage AIS surgically. Previous work has noted that surgeons with pediatric fellowship training tend to perform the bulk of pediatric spine surgeries. However, no study has been performed that examines if pediatric fellowship training (PFT) has an impact on early postoperative outcomes. A total of 14,194 AIS surgical patients were identified from the ACS NSQIP database. A cohort receiving isolated PSF was abstracted from this group and separated into 3 groups according to surgeon training: (1) ped+ (with PFT, n=4455); (2) ped-(without PFT, n=325); and (3) ped+match (patients selected from ped+ matched to ped- for age, sex, and fusion levels, n=325). The groups were compared for 30-day perioperative morbidity and mortality. No significant differences were noted for the 3 groups in terms of wound infections, length of hospital stay, readmissions, and unplanned returns to the operating room. Ped+match and ped- groups had no difference in neurologic injury rates. However, the ped+ and ped+match groups had significantly lower rates of blood transfusion and average volume of blood lost compared with the ped- group. Surgeons with pediatric fellowship training have a significantly lower average blood loss volume and blood transfusion rate in PSF for AIS than surgeons without such training. Understanding that different training pathways for surgeons may directly impact operative outcomes invites further examination of surgical education in North America to improve training consistency. [Orthopedics. 2020;43(5):e454-e459.].

The Use of Tranexamic Acid (TXA) in Neuromuscular Hip Reconstruction: Can We Alter the Need for Blood Transfusion?

BACKGROUND

Children with neuromuscular complex chronic conditions (NMCCC) frequently undergo hip reconstruction surgery requiring blood transfusion. The purpose of this study is to examine the efficacy of tranexamic acid (TXA) to reduce blood loss and transfusion requirement in NMCCC children undergoing hip reconstruction surgery.

METHODS

Children with NMCCC undergoing hip reconstruction surgery between 2013 and 2018 were identified. Two cohorts were identified: those who received TXA and those who did not. Patient and surgical characteristics between cohorts were used for propensity matching. Patients were matched on the basis of comorbid factors, bilateral involvement, pelvic osteotomy, open reduction, and surgeon. Comparative outcomes between cohorts were analyzed for intraoperative and postoperative blood loss and transfusion requirements and length of hospital stay (LOS).

RESULTS

A total of 166 patients underwent hip surgery at an average of 9.6 years (SD, 4.0). Propensity matching utilized 72% of the cohort including 47 TXA and 72 non-TXA subjects. There were no differences in patient or surgical characteristics across matched groups. Fifteen (15/47, 32%) TXA subjects required a postoperative blood transfusion compared with the 47% (34/72) of non-TXA subjects who required a transfusion and intraoperative transfusion rates were similar between the 2 groups. There was no significant difference in complication rate (TXA, 79%; non-TXA, 86%), reported estimated blood loss (median=200 mLfor both) or LOS (median=6 d for both). Hematocrit levels were slightly higher in TXA subjects intraoperatively (P=0.047), at the end of surgery (P=0.04), and for the overall lowest perioperative level (P=0.04). The overall percent loss of estimated blood volume was less for those who were given TXA compared with those who were not (P=0.001).

CONCLUSIONS

The use of TXA during hip reconstruction surgery in NMCCC children significantly reduced the percent loss of estimated blood volume and postoperative transfusion rate. Further prospective multicenter studies are needed to verify the positive effects and safety of TXA in the setting of hip reconstruction surgery in NMCCC children.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Do Antifibrinolytic Agents Reduce the Risk of Blood Transfusion in Children Undergoing Spinal Fusion?: A Propensity Score-matched Comparison Using a National Database

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To evaluate the effectiveness and safety of antifibrinolytic (AF) agents in reducing perioperative blood transfusion in pediatric patients undergoing spinal fusion.

SUMMARY OF BACKGROUND DATA

The potential for AF to decrease bleeding and reduce exposure to allogenic transfusions has led to widespread off-label use in a number of major pediatric surgical procedures. Recent reviews call for improving the body of evidence for their effectiveness and safety in pediatric spinal fusion.

METHODS

Children undergoing spinal fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) 2016 and 2017 databases. Univariate analyses of patient and perioperative characteristics informed the creation of a propensity score model predicting treatment with AF, followed by 1:1 matching to allow comparison of allogenic red blood cell transfusion rates and secondary outcomes between treated and untreated patients.

RESULTS

Of 6626 total patients, 5434 (81%) received AF and 1533 (23%) received a blood transfusion. Analysis of data for 1192 propensity score-matched pairs revealed that treatment with AF was associated with a statistically nonsignificant 16% reduction in perioperative transfusion (OR 0.84, 95% confidence interval 0.68-1.05, P = 0.119) and a statistically significant 43% reduction in postoperative transfusion (OR 0.57, 95% confidence interval 0.39-0.81, P = 0.002). No differences in the incidences of postoperative seizure or thrombosis were observed, with overall rates of 7.5 and 22.5 events per 10,000 patients, respectively.

CONCLUSION

AF agents appear to reduce postoperative allogenic transfusion in children undergoing spinal fusion surgery. Adverse drug effects such as thromboembolic complications and seizure were extremely rare and warrant continued monitoring, though this is the largest study to date providing evidence for the safety profile of these drugs.

LEVEL OF EVIDENCE

3.

Transfusion support: Considerations in pediatric populations

Over 400,000 units of blood and blood products are transfused to pediatric patients annually, yet only sparse high-quality data exist to guide the preparation and administration of blood products in this population. The direct application of data from studies in adult patients should be undertaken with caution, as there are dissimilarities in the pathology and physiology between adult and pediatric patients. We provide an overview of available evidence in the field of pediatric transfusion medicine, summarizing indications for blood product transfusion, thresholds for transfusion and indications for blood product modifications.

Tranexamic acid in Neurosurgery: a controversy indication-review

Tranexamic acid (TXA) is one of the measures indicated to reduce bleeding and the need for volume replacement. However, data on risks and benefits are controversial. This study analyzes the effectivity and risks of using tranexamic acid in neurosurgery. We selected articles, published from 1976 to 2019, on the PubMed, EMBASE, Science Direct, and The Cochrane Database using the descriptors: "tranexamic acid," "neurosurgery," "traumatic brain injury," "subdural hemorrhage," "brain aneurysm," and "subarachnoid hemorrhage." TXA can reduce blood loss and the need for blood transfusion in trauma and spinal surgery. Despite the benefits of TXA, moderate-to-high doses are potentially associated with neurological complications (seizures, transient ischemic attack, delirium) in adults and children. In a ruptured intracranial aneurysm, the use of TXA can considerably reduce the risk of rebleeding, but there is weak evidence regarding its influence on mortality reduction. The TXA use in brain surgery does not present benefit. However, this conclusion is limited because there are few studies. TXA in neurosurgeries is a promising method for the maintenance of hemostasis in affected patients, mainly in traumatic brain injury and spinal surgery; nevertheless, there is lack of evidence in brain and vascular surgeries. Many questions remain unanswered, such as how to determine the dosage that triggers the onset of associated complications, or how to adjust the dose for chronic kidney disease patients.

Postoperative anaemia might be a risk factor for postoperative delirium and prolonged hospital stay: A secondary analysis of a prospective cohort study

BACKGROUND

Postoperative anaemia is a frequent surgical complication and in contrast to preoperative anaemia has not been validated in relation to mortality, morbidity and its associated health economic effect. Postoperative anaemia can predispose postoperative delirium through impairment of cerebral oxygenation. The aim of this secondary analysis is to investigate the association of postoperative anaemia in accordance with the sex specific World Health Organization definition of anaemia to postoperative delirium and its impact on the duration of hospital stay.

METHODS

A secondary analysis of the prospective multicentric observational CESARO-study was conducted. 800 adult patients undergoing elective surgery were enrolled from various operative disciplines across seven hospitals ranging from university hospitals, district general hospitals to specialist clinics of minimally invasive surgery in Germany. Patients were classified as anaemic according to the World Health Organization parameters, setting the haemoglobin level cut off below 12g/dl for females and below 13g/dl for males. Focus of the investigation were patients with acute anaemia. Patients with present preoperative anaemia or missing haemoglobin measurement were excluded from the sample set. Delirium screening was established postoperatively for at least 24 hours and up to three days, applying the validated Nursing Delirium Screening Scale.

RESULTS

The initial sample set contained 800 patients of which 183 were suitable for analysis in the study. Ninety out of 183 (49.2%) suffered from postoperative anaemia. Ten out of 93 (10.9%) patients without postoperative anaemia developed a postoperative delirium. In the group with postoperative anaemia, 28 (38.4%) out of 90 patients suffered from postoperative delirium (odds ratio 3.949, 95% confidence interval, (1.358-11.480)) after adjustment for NYHA-stadium, severity of surgery, cutting/suture time, duration of anaesthesia, transfusion of packed red cells and sedation status with Richmond Agitation Scale after surgery. Additionally, patients who suffered from postoperative anaemia showed a significantly longer duration of hospitalisation (7.75 vs. 12.42 days, odds ratio = 1.186, 95% confidence interval, 1.083-1.299, after adjustments).

CONCLUSION

The study results reveal that postoperative anaemia is not only a frequent postsurgical complication with an incidence probability of almost 50%, but could also be associated with a postoperative delirium and a prolonged hospitalisation.

Safety and Effectiveness of Antifibrinolytics in Posterior Scoliosis Surgery for Adolescent Idiopathic Scoliosis: An Analysis of the NSQIP-Pediatric Database

STUDY DESIGN

This was a retrospective study of prospectively collected data.

OBJECTIVE

To utilize a large national database with prospectively collected data [National Surgical Quality Improvement Program Pediatric (NSQIP-Pediatric)] to study the safety and effectiveness of antifibrinolytic use during multilevel posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

There is currently a lack of consensus and evidence regarding the safety and effectiveness of antifibrinolytic use for pediatric patients undergoing corrective surgery for AIS.

MATERIALS AND METHODS

Patients who underwent multilevel PSF for AIS in the 2016 NSQIP-Pediatric database were identified. Preoperative and procedural characteristics were compared between patients who received antifibrinolytics versus those who did not. Multivariate regressions were used to compare perioperative transfusion rates and postoperative outcomes, such as rate of return to the operating room, 30-day readmission, and intensive care unit and hospital length of stay between the 2 treatment groups.

RESULTS

This study included 975 patients who received antifibrinolytics and 223 patients who did not. Patients who received these agents tended to have more levels fused, osteotomies performed, and longer operative times. After controlling for these variances, there were no statistical differences in rate and volume of transfusion, rate of return to the operating room, 30-day readmission, 30-day postoperative complications, or intensive care unit or hospital length of stay between the 2 treatment groups.

CONCLUSIONS

This study did not demonstrate transfusion reduction in the group that received antifibrinolytics. This finding may be, in part, secondary to nonoptimized or nonstandardized protocols for antifibrinolytic use in pediatric deformity surgery or the inability to adequately control for selection bias, as those with greater surgical invasiveness may be more likely to receive antifibrinolytics. Nonetheless, using antifibrinolytics in this population appears safe and not associated with increased perioperative complications.

LEVEL OF EVIDENCE

Level III.

Safety and efficacy of tranexamic acid in spinal canal tumors: a retrospective cohort study

Objective: The use of tranexamic acid (TXA) has become popular in spinal surgery, the purpose of this study is to investigate the effectiveness and safety of intraoperative TXA used to reduce surgical bleeding and transfusion requirements in spinal canal tumor resection.Methods: The data for patients with spinal canal tumors treated in our hospital from June 2014 to June 2017 were collected. The patients (≥18 years of age) were divided into a TXA group (group A, n = 30) and a non-TXA group (group B, n = 30). The TXA dose regimen in group A comprised a loading dose of 10 mg/kg 30 minutes before the operation, followed by a maintenance dose of 1 mg/kg per hour during the operation. Group B was not given TXA. The operation time, intraoperative blood loss, postoperative drainage, postoperative complications, coagulation function such as plasma thrombin time(PT), prothrombin time(TT), activated thromboplastin time(APTT), fibrinogen (Fib) were statistically analyzed.Results: The intraoperative blood loss and postoperative drainage volume were significant lower in group A than in group B (p<.05). There were no significant differences in the operation time, plasma thrombin time, prothrombin time, activated thromboplastin time, or fibrinogen between the two groups before and after the operation (p>.05), and no thrombotic complications occurred.Conclusion: TXA used during spinal tumor surgery can reduce the amount of intraoperative blood loss and postoperative drainage without increasing the risk of deep vein thrombosis and related complications.

Tranexamic Acid in Thoracic and Lumbar Fusions and Perioperative Blood Loss

STUDY DESIGN

This study was a retrospective cohort design.

OBJECTIVE

The objective of this study was to examine the impact of tranexamic acid (TXA) on total perioperative wound output following thoracic and lumbar spinal fusions.

SUMMARY OF BACKGROUND DATA

TXA has been extensively studied with regard to intraoperative blood loss and transfusion rates. Few studies have looked specifically at the effect of TXA on postoperative drain output.

MATERIALS AND METHODS

We examined blood loss patterns in 617 consecutive adult patients undergoing lumbar and/or thoracic fusions at a single institution from January 2009 to 2016. These patients were divided into TXA and non-TXA, as well as high-dose and low-dose TXA, groups and analyzed using a propensity score to account for differences between cohorts.

RESULTS

The TXA and non-TXA groups were demographically similar. The mean number of levels fused was higher in the TXA group (4.8 vs. 3.1 levels, P<0.01). There was a significant reduction in both intraoperative blood loss (77.7 mL per level, P=0.020) and postoperative drain output (83.3 mL per level, P=0.002) in the TXA group when examined on a per level fused basis, but no significant difference without controlling for a number of levels. Postoperative blood loss tended to be higher in the TXA group for surgeries involving >5 levels fused. There was a significantly less blood loss in the high-dose TKA group both intraoperatively (296.4 mL per level fused, P<0.001) and postoperatively (133.4 mL per level fused, P<0.001).

CONCLUSIONS

TXA significantly reduced both intraoperative and postoperative blood loss in lumbar and thoracic fusions when examined on a per level basis. However, with surgeries involving fusions >5 levels, TXA may increase postoperative drain output, with those losses offset by reduced intraoperative blood loss. High-dose TXA further reduced both intraoperative and postoperative blood loss as compared with low-dose TXA.

Reducing Allogenic Blood Transfusion in Pediatric Scoliosis Surgery:: Reporting 15 Years of a Multidisciplinary, Evidence-Based Quality Improvement Project

STUDY DESIGN

Retrospective review of prospectively collected spinal surgery and transfusion databases.

OBJECTIVES

To evaluate the efficacy of a care pathway developed at our institution since 2003 with a focus on reducing the need for blood transfusions in children undergoing scoliosis correction surgery. The care pathway includes nurse-led clinics facilitating preoperative hemoglobin optimization, intraoperative cell salvage, the use of tranexamic acid, and a transfusion criteria awareness program.

METHODS

Retrospective review of our institution's prospectively recorded spinal surgery and transfusion databases including all cases of scoliosis surgery in patients 18 years and younger between 2001 and 2015.

RESULTS

A total of 1039 procedures were included in the analysis. Overall, 24.4% of patients received a transfusion. The proportion of patients transfused was 89.2% in 2001-2003, 39.6% in 2004-2006, 16.5% in 2007-2009, 15.6% in 2010-2012, and 20.1% in 2013-2015. The volume of blood products transfused in those undergoing transfusion was 9.1 units in 2001-2003, 4.8 units in 2004-2006, 5.0 units in 2007-2009, 2.3 units in 2010-2012, and 2.1 units in 2013-2015. A multivariate logistic regression demonstrated adjusted odds ratios for the probability of receiving any transfusion of 5.45 (95% confidence interval 3.62-8.11) for patients with neuromuscular diagnoses and 11.17 (5.02-24.86) for those undergoing combined anterior and posterior surgical approach.

CONCLUSIONS

We have demonstrated over a 15-year period that the introduction of a multifaceted, multidisciplinary pathway can dramatically and sustainably reduce the need for blood transfusions and their attendant risks in pediatric scoliosis surgery. This data lends weight to the adoption of such a care pathway in pediatric scoliosis surgery.

Acute Normovolemic Hemodilution in Spinal Deformity Surgery

Objective  To prospectively compare the clinical and laboratorial aspects of patients undergoing spine deformity surgery, using the acute normovolemic hemodilution technique with tranexamic acid, versus a control group with tranexamic acid alone, and to evaluate the influence of hemodilution in intraoperative bleeding and the need for homologous transfusion.

Materials and Methods  Comparative prospective study with patients aged between 12 and 65 years undergoing spine deformity surgery with the acute normovolemic hemodilution technique associated with tranexamic acid versus a control group to which only tranexamic acid (15 mg/kg) was administered. Laboratorial exams were performed and analyzed in three different moments.

Results  A total of 30 patients were included in the present study: 17 in the hemodilution group, and 13 in the control group. The mean duration of the surgery in the hemodilution group was longer. The number of levels submitted to surgery ranged from 7 to 16 in the hemodilution group, and from 4 to 13 in the control group. Osteotomy, predominantly of the posterior kind, was performed in 20 patients. There was more intraoperative bleeding in the control group. All patients were stable during the procedures. Only 6 participants needed homologous blood transfusion, mostly from the control group ( p  > 0.05).

Conclusion  There was no significant difference between the two groups regarding the need for blood transfusion and intraoperative bleeding. The severity of the deformity was the main determinant for homologous blood transfusion.

Comparison of the Coagulation Profile of Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion With and Without Tranexamic Acid

STUDY DESIGN

Prospective, observational cohort study.

OBJECTIVE

To improve the understanding of coagulation and bleeding mechanisms during spinal deformity surgery.

SUMMARY OF BACKGROUND DATA

Fibrinolysis is the mechanism of bleeding for adolescent idiopathic scoliosis undergoing posterior spinal fusion. Antifibrinolytics have become popular; however, literature to support their use remains mixed. The mechanism of action has not been demonstrated.

METHODS

The coagulation profile of 88 adolescent idiopathic scoliosis patients undergoing posterior spinal fusion was analyzed. Standard coagulation laboratory investigations and thromboelastograms were drawn hourly through the case. Fifty-eight patients received no antifibrinolytic, whereas 30 patients received tranexamic acid by standardized protocol. The coagulation parameters, estimated blood loss, and transfusion requirements were compared in the two groups.

RESULTS

The two cohorts had no differences in demographic or surgical characteristics. Mean age was 13.6 years, 83% were female, a mean of 11.1 levels were fused, and the mean duration of surgery was 209 minutes. The tranexamic acid cohort did not demonstrate a decrease in blood loss. The transfusion rate, however, dropped from 47% in the non-tranexamic acid cohort to 23% in the tranexamic acid cohort (p = .03). Standard coagulation parameters did not differ between the groups. Fibrinolysis was diminished in the tranexamic acid cohort as measured by a Fibrinolysis score (mean maximum value 2.0 without tranexamic acid vs. 0.7 with tranexamic acid, p < .0001) and the lysis percent at 30 minutes by thromboelastogram (elevated to 3.9% without tranexamic acid vs. 1.2% with tranexamic acid at the 3-hour mark, p = .05).

CONCLUSIONS

This study provides confirmation of antifibrinolytic activity during posterior spinal fusion for adolescent idiopathic scoliosis. The presented data of fibrinolysis are proposed as standard measurements for future work on controlling blood loss during scoliosis surgery.

LEVEL OF EVIDENCE

Level 2, prospective comparative study.

The Perioperative Efficacy and Safety of Tranexamic Acid in Adolescent Idiopathic Scoliosis

OBJECTIVE

To evaluate the efficacy and safety of tranexamic acid (TXA) in patients with adolescent idiopathic scoliosis undergoing corrective surgery.

METHODS

A literature search of PubMed, Embase, and Cochrane Library was performed to identify studies published from inception to February 2019. After study selection and data extraction, statistical analysis was performed. Odds ratios and weighted mean differences (WMDs) with 95% confidence intervals (CIs) for all available clinical outcomes were analyzed using fixed-effects or random-effects models.

RESULTS

Twelve studies comprising 2500 patients were included. Intravenous TXA use was associated with significantly fewer patients received blood transfusions (odds ratio, 0.12; 95% CI, 0.06 to 0.22; P < 0.001), less intraoperative estimated blood loss (WMD, -470.07; 95% CI, -645.23 to -294.90; P < 0.001), less intraoperative estimated blood loss per segment (WMD, -27.40; 95% CI, -32.80 to -22.00; P < 0.001), less cell salvage blood transfusion (WMD, -106.02; 95% CI, -170.84 to -41.20; P = 0.001), and shorter surgical time (WMD, -26.18; 95% CI, -46.91 to -5.46; P = 0.010). No significant difference was found in postoperative hemoglobin (WMD, 0.39; 95% CI, -0.07 to 0.86; P = 0.100) and hemoglobin change (WMD, -0.92; 95% CI, -2.90 to 1.07; P = 0.360) between TXA and control groups. No renal, thromboembolic, or other major complications associated with TXA were noted in included studies.

CONCLUSIONS

TXA was effective in reducing surgical time, intraoperative estimated blood loss, and blood transfusion without increasing complications in patients undergoing corrective surgery for adolescent idiopathic scoliosis. TXA had no influence on postoperative hemoglobin and hemoglobin change.

The use of tranexamic acid in spine surgery

Patients undergoing surgical procedures of the spine with associated large volume blood loss often require perioperative blood conservation strategies. Synthetic antifibrinolytic medications such as tranexamic acid (TXA) may reduce blood transfusion requirements and postoperative complications following spinal procedures. Studies investigating the role of TXA in spine surgery have presented promising results and have proven its safety and efficacy. However, further investigation is needed to determine the optimal dosing regimen of TXA. In this article, we provide an overview of the basic science and pharmacology of TXA. A comprehensive summary of the findings from clinical trials and a review of the literature that demonstrate the risks and benefits of TXA in spine surgery are also presented.

Blood loss and perioperative transfusions related to surgery for spinal tumors. Relevance of tranexamic acid

INTRODUCTION

Tranexamic acid (TXA) has been shown to reduce bleeding. Patients with spinal tumors are fragile and acute anemia may be harmful. Tumor excision surgery is reputed to be hemorrhagic and treatment may increase thromboembolic complications. The aim of this study was to compare blood loss with or without perioperative TXA injection. The transfusion-related and postoperative complications were documents.

METHOD

This retrospective analysis of prospectively collected data involved 83 patients with spinal tumors who underwent decompressive surgery associated with bone fixation. Tranexamic acid was used arbitrarily in 36 of them, while the other 47 did not receive TXA. The overall, intraoperative and postoperative blood loss was recorded. Blood loss was reported relative to the number of fixed levels and the number of levels decompressed by laminectomy. Transfusions were quantified in number of red blood cell packets and erythrocyte volume. Postoperative complications were documented.

RESULTS

Epidemiological and morphological data were similar between groups. There were no significant differences between the two groups in the overall, intraoperative, and postoperative blood loss. A significant reduction in postoperative bleeding was found in the TXA group when the volume was related to the number of decompressed levels. A significant reduction (P<0.05) in the volume of transfused blood was identified in the treated group. No predictor of blood loss was identified, and no additional complications occurred.

CONCLUSION

The efficacy of TXA appears to be moderate during spinal tumor surgery since it does not lead to a reduction in perioperative bleeding. However, a significant reduction in transfusion volume was found without an increase in complications.

The Use of Tranexamic Acid to Reduce Surgical Blood Loss: A Review Basic Science, Subspecialty Studies, and The Evolution of Use in Spine Deformity Surgery

Significant blood loss is often seen in orthopedic surgeries, especially complex spinal procedures that constitute long surgical times, large incisions, and rich blood supplies. Tranexamic acid (TXA), a synthetic analog of the amino acid lysine, has proven to be a cost-effective method in decreasing transfusion rates and avoiding complications associated with low blood volume. Recent data on TXA's use in spine surgery suggest that TXA remains both efficacious and safe, although the ideal dosing and timing of administration is still a point of disagreement. The purpose of this study is to review the literature for the use of TXA in spine surgery to better understand its safety profile and ideal dosage. This narrative review on TXA was conducted on prospective orthopedic studies that used TXA in spine deformity surgery. TXA in adult and pediatric spine surgery has decreased intraoperative and postoperative blood loss, decreasing the need for blood transfusions. The most common dose in the literature is a 10 mg/kg loading dose, followed by 1 mg/kg per hour. Although the proper dosing of TXA for spine surgery remains debatable, studies have proven that TXA is effective at reducing blood loss without increasing the risk of thrombotic events.

The efficacy and safety of tranexamic acid in reducing perioperative blood loss in patients with multilevel thoracic spinal stenosis: A retrospective observational study

STUDY DESIGN

A retrospective study.

OBJECTIVE

To investigate the effectiveness and safety of intravenous tranexamic acid for reducing perioperative blood loss in patients with multilevel thoracic spinal stenosis (TSS).

METHODS

This is a retrospective observational study of 42 patients with multilevel TSS admitted from December 2016 to October 2017 to the spine department of Honghui Hospital who underwent posterolateral bone graft fusion with posterior laminectomy and decompression fixation. The patients were divided into 2 groups. All the surgeries were completed by the same surgeon. Group A received an intravenous infusion of 15 mg/kg 15 min prior to surgery. Continuous infuse on of tranexamic acid (TXA) at a dose of 1 mg/kg/h was provided throughout the operation until the skin was closed. Group B received no TXA as a blank control group. Group A comprised 10 males and 10 females with an average age of 53.41 ± 7.93 years; group B comprised 11 males and 11 females with an average age of 55.10 ± 8.43 years. The need for blood transfusion, volume of blood transfusion, blood coagulation function, extubation time, postoperative hospital stay and incidence of postoperative deep venous thrombosis (DVT) were recorded during and after the operation for the 2 groups.

RESULTS

There was no significant difference between the 2 groups in general characteristics, such as age, sex and body mass index (BMI) (P > .05). There was no significant difference between the 2 groups in the levels are instrumented and the laminectomy levels in each group. The average postoperative blood loss, need for blood transfusion, time to postoperative extubation and length of postoperative hospital stay in group A were lower than those in group B, and there was a significant difference between the 2 groups (P < .05). The preoperative and postoperative coagulation, and postoperative DVT did not occur 48 h after operation.

CONCLUSION

In the treatment of multilevel thoracic spinal canal stenosis using trabeculectomy with posterior laminectomy and posterolateral bone graft fusion, TXA can reduce the amount of blood transfused and the need for blood transfusion and can shorten the extubation time and the length of postoperative hospital stay without increasing the incidence of postoperative coagulation dysfunction or postoperative DVT.

LEVEL OF EVIDENCE

4.

Can tranexamic acid conserve blood and save operative time in spinal surgeries? A meta-analysis

BACKGROUND CONTEXT

It is widely accepted that tranexamic acid (TXA) effectively reduces blood losses and transfusions in major surgeries. However, limited studies investigated the role of TXA in conserving blood and saving operative time in spine surgeries.

PURPOSE

This meta-analysis was conducted to gather scientific evidence for TXA efficacy on conserving blood and saving operative time in spine surgeries.

STUDY DESIGN

A meta-analysis was performed.

PATIENT SAMPLE

Eighteen RCTs and 18 non-RCT studies involving 2,572 patients were included in the final analyses, comparing the effectiveness of intravenous TXA with a placebo/no treatment group.

OUTCOME MEASURES

Outcomes of interest included intraoperative, postoperative, and perioperative blood losses, allogeneic blood transfusion rates, cell salvage transfusion amounts, operative time, and the number of postoperative thrombosis events.

METHODS

An exhaustive literature search was conducted in the MEDLINE and EMBASE databases from January 2000 through March 2017. Meta-analysis was performed using Review Manager (RevMan) version 5.0. For continuous outcomes, the means and standard deviations were pooled to a mean difference and 95% confidence interval (CI). Odds ratios (OR) and 95% CI were calculated for dichotomous outcomes. The quantity of heterogeneity was assessed using I² statistics. When there was no statistical evidence of substantial heterogeneity (I²≤50%), a fixed-effect model was adopted; otherwise, a random-effect model was chosen. Subgroup analysis was performed when more than three studies were included on one issue, based on low or high the dose of TXA. Beijing Talent Fund (2016) was received to support this work.

RESULTS

Significantly reduced intraoperative (weighted mean difference [WMD]=-280.09.00, p<.00001), postoperative (WMD=-120.15, p<.00001), perioperative (WMD=-310.86, p<.00001) blood losses, cell salvage transfusion amount (WMD=-471.79, p=.01), perioperative transfusion rate (odds ratio [OR], 0.33 [0.17, 0.65], p=.001), and operative time (WMD=-4.69, p=.003) were observed in TXA group. Furthermore, subgroup analysis revealed that high-dose TXA could reduce both intraoperative-perioperative allogeneic transfusion rates and operative time, whereas low dose of the drug does not convey such effects.

CONCLUSIONS

With the most comprehensive literature inclusion up to the present, this meta-analysis suggests that intravenous TXA use constitutes an important measure for conserving blood and saving operative time in spinal surgeries. High-dose TXA significantly reduces intraoperative-perioperative allogeneic transfusion rates and operative time, whereas low-dose TXA does not convey such efficacies. Larger prospective trials are still required to define the optimal regimen and to confirm the safety of TXA use in such surgeries.

The Efficacy of Tranexamic Acid on Blood Loss from Lumbar Spinal Fusion Surgery: A Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

The efficacy of tranexamic acid to control blood loss from lumbar spinal fusion surgery remains controversial. We conducted a systematic review and meta-analysis to explore the influence of tranexamic acid on blood loss from lumbar spinal fusion surgery.

METHODS

We searched PubMed, Embase, Web of Science, EBSCO, and the Cochrane Library databases through March 2018 for randomized controlled trials assessing the effect of tranexamic acid on blood loss from lumbar spinal fusion surgery. A meta-analysis was performed using the random-effect model.

RESULTS

Six randomized controlled trials involving 394 patients were included in the meta-analysis. Overall, compared with control group for lumbar spinal fusion surgery, tranexamic acid significantly reduced intraoperative blood loss (standard mean difference [Std. MD] -0.32; 95% confidence interval [CI] -0.58 to -0.06; P = 0.02), and drain (Std. MD -1.12; 95% CI -1.59 to -0.64; P < 0.00001) but had no remarkable influence on hemoglobin (Std. MD -0.10; 95% CI -0.56 to 0.37; P = 0.68) and hematocrit (Std. MD -0.34; 95% CI -1.08 to 0.40; P = 0.37) 1 day after surgery and transfusion (risk ratio 0.44; 95% CI 0.16-1.19; P = 0.11). Duration of hospitalization was found to be shortened by tranexamic acid (Std. MD -1.00; 95% CI -1.68 to -0.32; P = 0.004).

CONCLUSIONS

Tranexamic acid has an important ability to decrease intraoperative blood loss and hospitalization for lumbar spinal fusion surgery.

Minimal Dose of Tranexamic Acid Is Effective in Reducing Blood Loss in Complex Spine Surgeries: A Randomized Double-Blind Placebo Controlled Study

Study Design

A randomized double-blind placebo controlled study.

Purpose

In the present study, we aimed to assess the efficacy of tranexamic acid (TXA) in reducing blood loss after laminectomy and posterolateral fusion of the spine.

Overview of Literature

Blood loss is the most significant complication involved with surgery, especially in spinal surgery. Multilevel laminectomy and laminectomy with instrumentation (pedicle screws and rods) are complex spine surgeries and are considered as medium-risk procedures for bleeding. Recent reports have demonstrated that the use of antifibrinolytic drugs during surgery may reduce the risk of postoperative bleeding and one of the most frequently used antifibrinolytics is TXA.

Methods

In this randomized clinical trial, 50 patients eligible for laminectomy (for ≥2 level) with postero-lateral fusion with a pedicular screw (laminectomy and posterior spinal fusion) were randomly assigned to receive preoperative single doses of intravenous TXA (15 mg/kg) or 0.9% normal saline.

Results

Of the 50 patients, 30 (60%) were female and 20 (40%) were male. Between-group difference with respect to the total volume of blood loss during surgery was statistically significant.

Conclusions

The findings of this study suggest that TXA can reduce both intraoperative and immediate postoperative blood loss, decrease the need for packed cell transfusion, and reduce the duration of hospitalization after complex spinal surgeries. No adverse events related to the use of TXA were encountered in this study.

Management of complex spine surgery

PURPOSE OF REVIEW

The main objective of this article is to present the updated data regarding the perioperative management of patients undergoing major spine surgery in an era where the surgical techniques are changing and there is a high demand for these surgeries in older and high-risk patients.

RECENT FINDINGS

Preoperative assessment and stabilization is now more structured protocol and it is based on a multidisciplinary approach to the patient. The Enhanced Recovery After Surgery (ERAS) programs and the Perioperative Surgical Home on major spine surgery are not yet fully evidence based but it seems that the use of a perioperative optimization of patients and use of a drugs' bundle is more effective than using single drugs or interventions on the postoperative pain reduction and faster recovery from surgery. Fluid and pain-control protocols combined with an accurate blood management represent the key to success.

SUMMARY

A tailored approach to patients undergoing major spine surgeries seems to be effective improving the outcome and quality of life of patients. Future studies should aim to understand which elements of the ERAS can be improved to allow the patient to have a long-term good outcome. VIDEO ABSTRACT.

Effectiveness and Safety of Batroxobin, Tranexamic Acid and a Combination in Reduction of Blood Loss in Lumbar Spinal Fusion Surgery

STUDY DESIGN

A prospective randomized double blind placebo controlled trail.

OBJECTIVE

To evaluate and compare the efficacy and safety of batroxobin (botropase), tranexamic acid (TXA), and their combination in reduction of perioperative blood loss in lumbar spine single level fusion surgeries.

SUMMARY OF BACKGROUND DATA

Spinal surgeries are associated with significant blood loss leading to perioperative anemia and increased need for allogenic transfusion. TXA competitively inhibits plasmin and batroxobin converts fibrinogen to fibrin and theoretically their combination is synergistic. Though TXA is widely studied in controlling blood loss, there is little information on use of batroxobin and their combination. Thus, we aimed to study effect and safety of individual drugs and their combination in controlling blood loss in spinal surgery.

METHODS

Hundred patients were randomized into four groups. Group B received batroxobin, group T received TXA, group BT received batroxobin and TXA and group P received placebo. Outcomes assessed are intraoperative and postoperative blood loss, hematocrit, allogenic blood transfusion, and deep vein thrombosis (DVT), postoperatively.

RESULT

Mean intraoperative blood loss in Group B, T, BT, and P were 268.32 ± 62.92 mL, 340.72 ± 182.75 mL, 256.96 ± 82.64 mL, and 448.44 ± 205.86 mL, respectively. Postoperative surgical site drain collection in Group B, T, BT, and P were 218.00 ± 100.54 mL, 260.40 ± 100.85 mL, 191.00 ± 87.84 mL, and 320.00 ± 125.83 mL, respectively. Intraoperative blood loss of Group P was statistically higher than Groups B and BT (P < 0.001). Mean postoperative surgical site drain collection was statistically significant (P < 0.001). No statistically significant differences in fluid administration (P = 0.751), blood transfusion (P = 1.000), preoperative and postoperative hemoglobin (P = 0.090, P = 0.134, respectively), and deep vein thrombosis (P = 1.000).

CONCLUSION

Batroxobin and combination of batroxobin with tranexamic acid significantly reduced perioperative blood loss when compared with placebo.

LEVEL OF EVIDENCE

2.

Red Blood Cell Transfusion Need for Elective Primary Posterior Lumbar Fusion in A High-Volume Center for Spine Surgery

(1) Background: This study evaluated the perioperative red blood cell (RBC) transfusion need and determined predictors for transfusion in patients undergoing elective primary lumbar posterior spine fusion in a high-volume center for spine surgery. (2) Methods: Data from all patients undergoing spine surgery between 1 January 2014 and 31 December 2016 were reviewed. Patients’ demographics and comorbidities, perioperative laboratory results, and operative time were analyzed in relation to RBC transfusion. Multivariate logistic regression analysis was performed to identify the predictors of transfusion. (3) Results: A total of 874 elective surgeries for primary spine fusion were performed over the three years. Only 54 cases (6%) required RBC transfusion. Compared to the non-transfused patients, transfused patients were mainly female (p = 0.0008), significantly older, with a higher ASA grade (p = 0.0002), and with lower pre-surgery hemoglobin (HB) level and hematocrit (p < 0.0001). In the multivariate logistic regression, a lower pre-surgery HB (OR (95% CI) 2.84 (2.11–3.82)), a higher ASA class (1.77 (1.03–3.05)) and a longer operative time (1.02 (1.01–1.02)) were independently associated with RBC transfusion. (4) Conclusions: In the instance of elective surgery for primary posterior lumbar fusion in a high-volume center for spine surgery, the need for RBC transfusion is low. Factors anticipating transfusion should be taken into consideration in the patient’s pre-surgery preparation.

High-dose Versus Low-dose Tranexamic Acid to Reduce Transfusion Requirements in Pediatric Scoliosis Surgery

BACKGROUND

Our objective was to quantify blood loss and transfusion requirements for high-dose and low-dose tranexamic acid (TXA) dosing regimens in pediatric patients undergoing spinal fusion for correction of idiopathic scoliosis. Previous investigators have established the efficacy of TXA in pediatric scoliosis surgery; however, the dosing regimens vary widely and the optimal dose has not been established.

METHODS

We retrospectively analyzed electronic medical records for 116 patients who underwent spinal fusion surgery for idiopathic scoliosis by a single surgeon and were treated with TXA. In total, 72 patients received a 10 mg/kg loading dose with a 1 mg/kg/h maintenance dose (low-dose) and 44 patients received 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose (high-dose). Estimated blood loss and transfusion requirements were compared between dosing groups.

RESULTS

Patient characteristics were nearly identical between the 2 groups. Compared with the low-dose TXA group, the high-dose TXA group had decreased estimated blood loss (695 vs. 968 mL, P=0.01), and a decrease in both intraoperative (0.3 vs. 0.9 units, P=0.01) and whole hospitalization (0.4 vs. 1.0 units, P=0.04) red blood cell transfusion requirements. The higher-dose TXA was associated with decreased intraoperative (P=0.01), and whole hospital transfusion (P=0.01) requirements, even after risk-adjustment for potential confounding variables.

CONCLUSIONS

High-dose TXA is more effective than low-dose TXA in reducing blood loss and transfusion requirements in pediatric idiopathic scoliosis patients undergoing surgery.

LEVEL OF EVIDENCE

Level-III, retrospective cohort study.

Factors Associated With Clinical Outcomes After Lumbar Interbody Fusion With a Porous Nitinol Implant

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study is to assess the association of demographic and perioperative factors with clinical outcomes of lumbar interbody fusion with a porous nitinol (TiNi) implant for degenerative disc disease.

METHODS

Forty-one patients with degenerative lumbar disease were prospectively followed for a mean of 4.8 years. All patients were instrumented with porous TiNi interbody fusion devices. The Oswestry Disability Index (ODI) and return to work were used to assess clinical outcomes. Factors including age, body mass index, smoking status, insurance status, number of comorbidities, duration of surgery, estimated blood loss, number of levels fused, time since surgery, and preoperative ODI score were assessed. A multiple linear regression analysis was performed to look for demographic and perioperative factors associated with clinical outcome.

RESULTS

All patients except one (98%) showed complete fusion on radiography at 1 year. Estimated blood loss and duration of surgery were significantly associated with higher postoperative ODI scores (P = .002 and P = .019, respectively). Smoking status, salary insurance status, age, body mass index, number of comorbidities, number of levels fused, time since surgery, and preoperative ODI score were not significantly associated with outcome.

CONCLUSIONS

Porous nitinol permitted fusion rates similar to those reported in the literature for alternative fusion cages. Poor functional outcome of patients was strongly associated with intraoperative blood loss and duration of surgery. We believe that estimated blood loss should be carefully evaluated in studies of postoperative outcome, as it may affect midterm outcomes.

LEVEL OF EVIDENCE

Level 3.