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Hammon DE, Chidambaran V, Templeton TW, Pestieau SR. Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Paediatr Anaesth 2023; 33:894-904. [PMID: 37528658 DOI: 10.1111/pan.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.
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Affiliation(s)
- Dudley E Hammon
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Thomas W Templeton
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sophie R Pestieau
- Department of Anesthesiology, Washington National, Washington, DC, USA
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2
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Gebretsadik H, Kahsay G, Adams E, Van Schepdael A. A comprehensive review of capillary electrophoresis-based techniques for erythropoietin isoforms analysis. J Chromatogr A 2023; 1708:464331. [PMID: 37660565 DOI: 10.1016/j.chroma.2023.464331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/05/2023]
Abstract
Different CE techniques have been used to analyze erythropoietin. These techniques have been shown to be effective in differentiating and quantifying erythropoietin isoforms, including natural and recombinant origins. This review provides a comprehensive overview of various capillary electrophoresis-based techniques used for the analysis of erythropoietin isoforms. The importance of erythropoietin in clinical practice and the necessity for the accurate analysis of its isoforms are first discussed. Various techniques that have been used for erythropoietin isoform analysis are then described. The main body of the review focuses on the different capillary electrophoresis-based methods that have been developed for erythropoietin isoform analysis, including capillary zone electrophoresis and capillary isoelectric focusing. The advantages and drawbacks of each method as well as their applications are discussed. Suggestions into the future directions of the area are also described.
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Affiliation(s)
- Hailekiros Gebretsadik
- KU Leuven - University of Leuven, Department of Pharmaceutical and Pharmacological Sciences, Pharmaceutical Analysis, Herestraat 49, O&N2, PB 923, 3000 Leuven, Belgium
| | - Getu Kahsay
- KU Leuven - University of Leuven, Department of Pharmaceutical and Pharmacological Sciences, Pharmaceutical Analysis, Herestraat 49, O&N2, PB 923, 3000 Leuven, Belgium
| | - Erwin Adams
- KU Leuven - University of Leuven, Department of Pharmaceutical and Pharmacological Sciences, Pharmaceutical Analysis, Herestraat 49, O&N2, PB 923, 3000 Leuven, Belgium
| | - Ann Van Schepdael
- KU Leuven - University of Leuven, Department of Pharmaceutical and Pharmacological Sciences, Pharmaceutical Analysis, Herestraat 49, O&N2, PB 923, 3000 Leuven, Belgium.
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Julien-Marsollier F, Penisson L, Happiette A, Ilharreborde B. Can hydroxyapatite charged collagen sponge help reduce perioperative blood loss in adolescent idiopathic scoliosis surgery? Preliminary results in 68 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:883-888. [PMID: 36653577 DOI: 10.1007/s00586-022-07512-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 11/10/2022] [Accepted: 12/17/2022] [Indexed: 01/20/2023]
Abstract
PURPOSE Patient blood management has been recently emphasized to avoid perioperative blood transfusion in AIS surgery. Hydroxyapatite charged collagen sponge (HCS) is a bone substitute material made of collagen and ceramized hydroxyapatite, with associated haemostatic properties. The goal of this study was to assess the impact of HCS in the perioperative blood loss in AIS surgery. METHODS After IRB approval, all AIS patients undergoing primary correction were prospectively included over a 15-month period. Patients receiving HCS at the end of the procedure were compared to a control group (matched for age, gender, and fusion levels) without any haemostatic agent or bone substitute. The same perioperative blood saving strategies were used in both groups. Two subfascial drains were used for 48 h in all patients. Perioperative blood loss and transfusion rates were analysed. RESULTS A total of 34 patients were included in each group. No difference in drainage volume was observed at day 1, but the reduction was statistically different at day 3 (1135 mL [800-1640] versus 930 [480-1510], p = 0.028, 0.63 ml/Kg/h [0.4-0.92] versus 0.46 [0.29-0.7], p = 0.042). Multivariate analysis found that the use of HCS was associated with a decrease in the postoperative blood loss (OR = 1.17 [1.10-1.25]). The transfusion rate was lower in the HCS group [0 (0% vs. 3(8.8%), p = 0.076)]. No infection occurred, and no complication was reported. CONCLUSION With 27% reduction in drain volume, hydroxyapatite charged collagen sponge can be considered as a blood salving strategy in AIS surgery. The role of the biomaterial in fusion rate still needs to be further assessed.
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Affiliation(s)
- Florence Julien-Marsollier
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, 48 boulevard Sérurier, 75019, Paris, France. .,Université de Paris, Paris, France.
| | - Leo Penisson
- UFR Sciences Pharmaceutiques, Université de Bordeaux, Bordeaux, France
| | - Adele Happiette
- Université de Paris, Paris, France.,Department of Orthopedic Surgery, Robert Debré Hospital, 48 boulevard Sérurier, 75019, Paris, France
| | - Brice Ilharreborde
- Université de Paris, Paris, France.,Department of Orthopedic Surgery, Robert Debré Hospital, 48 boulevard Sérurier, 75019, Paris, France
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Cao S, Lv K, Peng C, Bai G, Gao X, Wang J, Cao J, Ning R, Chu J, Liu T. Efficacy and safety of erythropoietin in isolated spinal metastasis patients with total en bloc spondylectomy surgery: a case-control study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1021-1028. [PMID: 36715756 DOI: 10.1007/s00586-023-07554-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/07/2022] [Accepted: 01/21/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The purpose of our study is to identify the effect of short-term and high-dose use of erythropoietin (EPO) in spinal isolated metastatic patients with Total en bloc spondylectomy (TES) surgery by assessing hematological parameters, transfusion volume, postoperative complications, recurrence-free survival (RFS), and overall survival (OS). METHODS From January 2015 and January 2022, 93 isolated spinal metastasis patients were selected and separated into 2 groups based on the treatment method used (EPO + TXA (Tranexamic acid) group, n = 47; and TXA group, n = 46). Indexes for evaluation included hemoglobin (Hb), hematocrit (Hct), red blood cells (RBC), RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, transfusion rate, and mean units transfused. RESULTS The average follow-up duration was 38.13 months. There was no significant difference (P > 0.05) in RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, and transfusion rate between the two groups. However, patients in EPO + TXA group have significantly higher Hb, Hct, and RBC values than those in the TXA group on postoperative days 1, 2, 3, and 5. Moreover, the mean transfusion volume in EPO + TXA group was significantly lower than those in the TXA group (P = 0.011). CONCLUSIONS Perioperative short-term and high-dose administration of EPO could improve the anemia-related hematological parameters and reduce the requirement for blood transfusion without increasing the risk of deep vein thrombosis and tumor progression in solitary spinal metastatic patients with TES surgery.
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Affiliation(s)
- Shuang Cao
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Kai Lv
- Department of Orthopedics, Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Cheng Peng
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Guangjian Bai
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Xin Gao
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Jing Wang
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Jiashi Cao
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Rende Ning
- Department of Orthopedics, Third Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China.
| | - Jianjun Chu
- Department of Orthopedics, The Second People's Hospital of Hefei, Hefei, Anhui Province, China.
| | - Tielong Liu
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China.
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Mihas A, Ramchandran S, Rivera S, Mansour A, Asghar J, Shufflebarger H, George S. Safe and effective performance of pediatric spinal deformity surgery in patients unwilling to accept blood transfusion: a clinical study and review of literature. BMC Musculoskelet Disord 2021; 22:204. [PMID: 33607982 PMCID: PMC7896412 DOI: 10.1186/s12891-021-04081-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/11/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander Mihas
- Florida International University Herbert Wertheim College of Medicine, 11200 SW 8th Street, Miami, FL, 33199, USA
| | - Subaraman Ramchandran
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA.
| | - Sebastian Rivera
- Department of Orthopedic Surgery, Jackson Memorial Hospital, University of Miami, 1611 NW 12th Avenue, Miami, FL, 33136, USA
| | - Ali Mansour
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
| | - Jahangir Asghar
- Cantor Spine Institute, 3000 Bayview Drive Suite 200, Fort Lauderdale, FL, 33306, USA
| | - Harry Shufflebarger
- Paley Orthopedic and Spine Institute at St. Mary's Medical Center, 901 45th Street, West Palm Beach, FL, 33407, USA
| | - Stephen George
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
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Role of preoperative erythropoietin in the optimization of preoperative anemia among surgical patients - A systematic review and meta-analysis. Hematol Transfus Cell Ther 2021; 44:76-84. [PMID: 33583767 PMCID: PMC8885371 DOI: 10.1016/j.htct.2020.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/02/2020] [Accepted: 12/07/2020] [Indexed: 11/23/2022] Open
Abstract
Preoperative anemia is a common finding. Preoperative allogeneic transfusion, iron therapy, vitamin supplementation and erythropoietin therapy are the current management strategies for preoperative anemia. Previous reviews regarding erythropoietin were limited to specialties, provided little evidence regarding the benefits and risks of erythropoietin in managing preoperative anemia and included non-anemic patients. The purpose of our systematic review was to determine the role of erythropoietin solely in preoperatively anemic patients and to investigate the complications of this treatment modality to produce a guideline for preoperative management of anemic patients for all surgical specialties. The PubMed/Medline, Google Scholar, and Cochrane Library were searched for randomized trials evaluating the efficacy of erythropoietin in preoperative anemia. The risk ratio (RR) and standardized mean difference (SMD) was used to pool the estimates of categorical and continuous outcomes, respectively. Allogeneic transfusion and complications and the 90-day mortality were the primary outcomes, while the postoperative change in hemoglobin, bleeding in milliliters and the number of red blood cell (RBC) packs transfused were the secondary outcomes. Results: Eight studies were included, comprising 734 and 716 patients in the erythropoietin group and non-erythropoietin group, respectively. The pooled estimate by RR for allogeneic transfusion was 0.829 (p = 0.049), while complications and the 90-day mortality were among the 1,318 (p = 0.18) patients. Conclusion: Preoperative erythropoietin provides better outcomes, considering the optimization of preoperative anemia for elective surgical procedures. The benefits of erythropoietin are significantly higher, compared to the control group, while the risks remain equivocal in both groups. We recommend preoperative erythropoietin in anemic patients.
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Pennington Z, Ehresman J, Westbroek EM, Lubelski D, Cottrill E, Sciubba DM. Interventions to minimize blood loss and transfusion risk in spine surgery: A narrative review. Clin Neurol Neurosurg 2020; 196:106004. [DOI: 10.1016/j.clineuro.2020.106004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/04/2020] [Accepted: 06/06/2020] [Indexed: 12/26/2022]
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Guan XZ, Wang LL, Pan X, Liu L, Sun XL, Zhang XJ, Wang DQ, Yu Y. Clinical Indications of Recombinant Human Erythropoietin in a Single Center: A 10-Year Retrospective Study. Front Pharmacol 2020; 11:1110. [PMID: 32848738 PMCID: PMC7397815 DOI: 10.3389/fphar.2020.01110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 07/08/2020] [Indexed: 01/06/2023] Open
Abstract
In the 1980s, recombinant human erythropoietin (rhEPO) began to be used in clinical practice. In this study, the clinical application of rhEPO from single-center in recent ten years was reviewed, and the scope of indications and clinical efficacy were evaluated. The medical records of 35829 in-patients who were treated with rhEPO in the first Medical Center of the Chinese PLA General Hospital from 2009 to 2018 were collected. According to the scope of indications approved by CFDA (China Food and Drug Administration), curative effect and off-label of rhEPO were analyzed. Of the 35829 patients, 19013 (53.1%) were male and 16816 (46.9%) were female, with an average age of (52.1 ± 18.6) years. The usage of rhEPO is increasing year by year. The overall effective rate was 53.1%. The number of patients who met the indications accounted for 67.2%, and the effective rate patients with indications and Off-label were 48.8% and 50.7%. Among the patients with irregular use of rhEPO perioperative imperfect laboratory examination patients accounted for the highest proportion (7.1%). The volume of RBC(s) (red blood cell(s)) transfusion in patients with rhEPO was significantly less than that in patients without rhEPO (p<0.05). The use of rhEPO Off-label is very common and has a certain curative effect. It can be used as evidence support for the update of the scope of indications. In addition, There are still irregular use of rhEPO and transfusion in clinic. The unreasonable use of rhEPO and transfusion should be further standardized to ensure the safety and effectiveness.
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Affiliation(s)
- Xiao-Zhen Guan
- Department of Transfusion, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lei-Li Wang
- Center for clinical laboratory Medicine, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xue Pan
- Department of Transfusion, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Li Liu
- Department of Transfusion, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiao-Lin Sun
- Department of Transfusion, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiao-Juan Zhang
- Department of Transfusion, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - De-Qing Wang
- Department of Transfusion, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yang Yu
- Department of Transfusion, The First Medical Center of Chinese PLA General Hospital, Beijing, China
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Friedman GN, Benton JA, Echt M, De la Garza Ramos R, Shin JH, Coumans JVCE, Gitkind AI, Yassari R, Leveque JC, Sethi RK, Yanamadala V. Multidisciplinary approaches to complication reduction in complex spine surgery: a systematic review. Spine J 2020; 20:1248-1260. [PMID: 32325247 DOI: 10.1016/j.spinee.2020.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/30/2020] [Accepted: 04/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND CONTEXT Complex spine surgery carries a high complication rate that can produce suboptimal outcomes for patients undergoing these extensive operations. However, multidisciplinary pathways introduced at multiple institutions have demonstrated a promising potential toward reducing the burden of complications in patients being treated for spinal deformities. To date, there has been no effort to systematically collate the multidisciplinary approaches in use at various institutions. PURPOSE The present study aims to determine effective multidisciplinary strategies for reducing the complication rate in complex spine surgery by analyzing existing institutional multidisciplinary approaches and delineating common themes across multiple practice settings. STUDY DESIGN Systematic review. METHODS We followed guidelines established under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The studies reported on data from PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Cochrane. We included articles that described either approaches to, or results from, the implementation of multidisciplinary paradigms during the preoperative, perioperative, and postoperative phases of care for patients undergoing complex spine surgery. We excluded studies that only targeted one complication unless such an approach was in coordination with more extensive multidisciplinary planning at the same institution. RESULTS A total of 406 unique articles were identified. Following an initial determination based on title and abstract, 22 articles met criteria for full-text review, and 10 met the inclusion criteria to be included in the review. Key aspects of multidisciplinary approaches to complex spine surgery included extensive preoperative workup and interdisciplinary conferencing, intraoperative communication and monitoring, and postoperative floor management and discharge planning. These strategies produced decreases in surgical duration and complication rates. CONCLUSIONS This study represents the first to systematically analyze multidisciplinary approaches to reduce complications in complex spine surgery. This review provides a roadmap toward reducing the elevated complication rate for patients undergoing complex spine surgery.
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Affiliation(s)
- Gabriel N Friedman
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Joshua A Benton
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Department of Physical Medicine and Rehabilitation, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Murray Echt
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Department of Physical Medicine and Rehabilitation, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Rafael De la Garza Ramos
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Department of Physical Medicine and Rehabilitation, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jean-Valery C E Coumans
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew I Gitkind
- Department of Physical Medicine and Rehabilitation, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Reza Yassari
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Department of Physical Medicine and Rehabilitation, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | | | - Rajiv K Sethi
- Neuroscience Institute, Virginia Mason Medical Center, Seattle, WA, USA; Department of Health Services, University of Washington, Seattle, WA, USA
| | - Vijay Yanamadala
- Center for Surgical Optimization, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Spinal Disorders Study Group, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Department of Physical Medicine and Rehabilitation, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.
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Esfahani K, Dunn LK, Naik BI. Blood Conservation for Complex Spine and Intracranial Procedures. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
Blood management strategies are integral to successful outcomes in many types of orthopaedic surgery. These strategies minimize blood loss and transfusion requirements, ultimately decreasing complications, improving outcomes, and potentially eliminating risks associated with allogeneic transfusion. Practices to achieve these goals include preoperative evaluation and optimization of hemoglobin, the use of pharmacologic agents or anesthetic methods, intraoperative techniques to improve hemostasis and cell salvage, and the use of predonated autologous blood. Guidelines can also help manage allogeneic transfusions in the perioperative period. Although the literature on blood management has focused primarily on arthroplasty and adult spine surgery, pediatric spinal fusion for scoliosis involves a large group of patients with a specific set of risk factors for transfusion and distinct perioperative considerations. A thorough understanding of blood management techniques will improve surgical planning, limit transfusion-associated risks, maintain hemostasis, and optimize outcomes in this pediatric population.
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12
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Kisilevsky AE, Stobart L, Roland K, Flexman AM. Spine tumor resection among patients who refuse blood product transfusion: a retrospective case series. J Clin Anesth 2016; 35:434-440. [PMID: 27871571 DOI: 10.1016/j.jclinane.2016.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 07/15/2016] [Accepted: 08/09/2016] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE To describe the perioperative blood conservation strategies and postoperative outcomes in patients who undergo complex spinal surgery for tumor resection and who also refuse blood product transfusion. DESIGN A retrospective case series. SETTING A single-center, tertiary care and academic teaching hospital in Canada. PATIENTS All adult patients undergoing elective major spine tumor resection and refusing blood product transfusion who were referred to our institutional Blood Utilization Program between June 1, 2004, and May 9, 2014. MEASUREMENTS Data on the use of iron, erythropoietin, preoperative autologous blood donation, acute normovolemic hemodilution, antifibrinolytic therapy, cell salvage, intraoperative hypotension, and active warming techniques were collected. Data on perioperative hemoglobin nadir, adverse outcomes, and hospital length of stay were also collected. MAIN RESULTS Four patients who refused blood transfusion (self-identified as Jehovah's Witnesses) underwent non-emergent complex spine surgery for recurrent chondrosarcoma, meningioma, metastatic adenocarcinoma, and metastatic malignant melanoma. All patients received 1 or more perioperative blood conservation strategy including preoperative iron and/or erythropoietin, intraoperative antifibrinolytic therapy, and cell salvage. No patients experienced severe perioperative anemia (average hemoglobin nadir, 124 g/L) or anemia-related postoperative complications. CONCLUSIONS Patients who decline blood product transfusion can successfully undergo major spine tumor resection. Careful patient selection and timely referral for perioperative optimization such that the risk of severe anemia is minimized are important for success.
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Affiliation(s)
- Alexandra E Kisilevsky
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Liam Stobart
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Kristine Roland
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Alana M Flexman
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.
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Dupuis C, Michelet D, Hilly J, Diallo T, Vidal C, Delivet H, Nivoche Y, Mazda K, Dahmani S. Predictive factors for homologous transfusion during paediatric scoliosis surgery. Anaesth Crit Care Pain Med 2015; 34:327-32. [DOI: 10.1016/j.accpm.2015.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 04/10/2015] [Indexed: 02/02/2023]
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14
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Guinn NR, Guercio JR, Hopkins TJ, Grimsley A, Kurian DJ, Jimenez MI, Bolognesi MP, Schroeder R, Aronson S. How do we develop and implement a preoperative anemia clinic designed to improve perioperative outcomes and reduce cost? Transfusion 2015; 56:297-303. [DOI: 10.1111/trf.13426] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 10/15/2015] [Accepted: 10/15/2015] [Indexed: 12/16/2022]
Affiliation(s)
| | - Jason R. Guercio
- North American Partners in Anesthesia; Hospital of Central Connecticut; New Britain Connecticut
| | | | | | | | | | - Michael P Bolognesi
- Department of Surgery; Duke University Medical Center; Durham North Carolina
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Efficacy of Erythropoietin-Beta Injections During Autologous Blood Donation Before Spinal Deformity Surgery in Children and Teenagers. Spine (Phila Pa 1976) 2015; 40:E1144-9. [PMID: 26502101 DOI: 10.1097/brs.0000000000001108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective observational study OBJECTIVE.: To clarify the efficacy of recombinant human erythropoietin-beta (EPO-beta) injections during autologous blood donation (ABD) before spinal deformity surgery in children and teenagers. SUMMARY OF BACKGROUND DATA ABD is preferred for spinal deformity surgery. A few studies have assessed the usefulness of preoperative ABD with EPO-beta in anemic patients. METHODS Fifty-six spinal deformity surgery patients (41 females, 15 males; median age: 15 yrs; range, 5-19 yrs) underwent preoperative ABD. ABD was performed weekly according to the patient's body weight with a subcutaneous EPO-beta injection (24,000 U). The collected blood volumes were compared among the low hemoglobin (low-Hb) (<13 g/dL), mid-Hb (13-13.9 g/dL), and high-Hb (≥14 g/dL) groups using the Kruskal-Wallis test. The effects of EPO-beta injection on the Hb levels were estimated using a linear mixed model. RESULTS The patients underwent a median of four ABD collections (range, two to six). The median collected volume per ABD was 200 mL (range, 40-400 mL). The median total blood collection was 700 mL (range, 160-1,350 mL); the corresponding values were 700 mL, 700 mL, and 800 mL in the low-Hb, mid-Hb, and high-Hb groups, respectively (P = 0.964). The median blood loss was 500 mL (range, 10-2,940 mL); 53 out of 55 patients (96%) did not require unplanned allogeneic transfusion, including 11 out of 12 (92%) cases with blood loss >1,000 mL. The additional recovery of Hb levels with one EPO-beta injection was 0.29 ± 0.14 g/dL (P = 0.039) after adjusting for confounding factors. CONCLUSION ABD with an EPO-beta injection is useful for avoiding allogeneic transfusion during spinal deformity surgery in children and teenagers, and patients in the low-Hb group achieved ABD volumes equivalent to those in the high-Hb group. Thus, an additional recovery of Hb levels of 0.29 g/dL per injection can be expected after 1 week. LEVEL OF EVIDENCE 4.
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Guan J, Karsy M, Schmidt MH, Bisson EF. Impact of Preoperative Hematocrit Level on Length of Stay after Surgery on the Lumbar Spine. Global Spine J 2015; 5:391-5. [PMID: 26430593 PMCID: PMC4577325 DOI: 10.1055/s-0035-1550090] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 02/17/2015] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective case series. Objective Recent studies suggest that baseline hematocrit (Hct) levels may affect the surgical outcomes after orthopedic procedures. The authors examined whether preoperative Hct values had a significant effect on the hospital length of stay (LoS) after lumbar spinal procedures. Methods We retrospectively reviewed patients who underwent routine lumbar spine procedures from November 2012 through September 2013. Patients were included if they had both a baseline Hct and hospital LoS recorded. Patients were divided into two groups: those with an Hct ≥ 40% (nonanemic) and those with an Hct < 40% (anemic). LoS after surgery was evaluated for each group. Results One hundred seventeen patients underwent lumbar spine procedures for lumbar stenosis (n = 34), symptomatic lumbar disk herniation (n = 39), lumbar spondylolisthesis (n = 26), lumbar adjacent segment disease (n = 8), or symptomatic recurrent lumbar disk herniation (n = 10). Mean LoS was 3.3 and 2.4 days in anemic (27 patients) and nonanemic groups (90 patients), respectively (p = 0.02). The linear regression analysis demonstrated that a decrease in Hct was associated with a longer stay. A decrease from preoperative to postoperative day 1 Hct of 3.5 points resulted in an increased LoS of 1 day (R (2) = 0.145; p = 0.002). The correlation of Hct decrease with longer LoS remained (β = 0.167, p = 0.006) after adjusting for other variables with multivariate regression analysis. Conclusions Lower preoperative Hct or a substantial decrease in Hct may contribute to longer hospitalization after lumbar spine surgery. These findings should prompt an investigation into the strategies for optimizing Hct levels in patients with preoperative anemia prior to lumbar spine procedures.
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Affiliation(s)
- Jian Guan
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, United States
| | - Michael Karsy
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, United States
| | - Meic H. Schmidt
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, United States
| | - Erica F. Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, United States,Address for correspondence Erica F. Bisson, MD Department of Neurosurgery, University of Utah175 N. Medical Drive East, Salt Lake CityUT 84132
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Colomina MJ, Basora Macaya M. [Optimization of preoperative hemoglobin levels in patients without anemia and/or patients who undergo surgery with high blood loss]. ACTA ACUST UNITED AC 2015; 62 Suppl 1:35-40. [PMID: 26320342 DOI: 10.1016/s0034-9356(15)30005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To minimize allogeneic blood transfusions (ABTs) during complex surgery and surgery with considerable blood loss risk, various blood-sparing techniques are needed (multimodal approach). All surgical patients should be assessed with sufficient time to optimize hemoglobin levels and iron reserves so that the established perioperative transfusion strategy is appropriate. Even if the patient does not have anemia, improving hemoglobin levels to reduce the risk of ABT is justified in some cases, especially those in which the patient refuses a transfusion. Treatment with iron and/or erythropoietic agents might also be justified for cases that need a significant autologous blood reserve to minimize ABT during surgery with considerable blood loss.
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Affiliation(s)
- M J Colomina
- Servicio de Anestesiología y Reanimación, Área de Traumatología, Hospital Universitario Vall d'Hebron, Barcelona, España.
| | - M Basora Macaya
- Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
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Pérez-Ferrer A, Gredilla-Díaz E, de Vicente-Sánchez J, Sánchez Pérez-Grueso F, Gilsanz-Rodríguez F. Implementation of a patient blood management program in pediatric scoliosis surgery. ACTA ACUST UNITED AC 2015; 63:69-77. [PMID: 26049212 DOI: 10.1016/j.redar.2015.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 03/07/2015] [Accepted: 04/19/2015] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To determine whether the implementation of a blood conservation program, and the adoption and progressive association of different methods, reduces transfusion requirements in pediatric patients undergoing scoliosis surgery of different origins. MATERIAL AND METHOD Quasi-experimental, nonrandomized, descriptive study, approved by the Ethics Committee for Research of our institution. 50 pediatric patients (ASA I-III) aged 5 to 18 years, undergoing scoliosis surgery of any etiology by a single posterior or double approach (anterior and posterior) were included. A historical group with no alternatives to transfusion: Group No ahorro=15 patients (retrospective data collection) was compared with another 3 prospective study groups: Group HNA (acute normovolemic hemodilution)=9 patients; Group HNA+Rec (intraoperative blood salvage)=14 patients, and Group EPO (HNA+Rec+erythropoietin±preoperative donation)=12 patients; according with the implementation schedule of the transfusion alternatives in our institution. RESULTS The rate of transfusion in different groups (No ahorro, HNA, HNA+Rec, EPO) was 100, 66, 57, and 0% of the patients, respectively, with a mean±SD of 3.40±1.59; 1.33±1.41; 1.43±1.50; 0±0 RBC units transfused per patient, respectively. Statistically significant differences (P<.001) were found in both the transfusion rate and number of RBC units. CONCLUSIONS The application of a multimodal blood transfusion alternatives program, individualized for each pediatric patient undergoing scoliosis surgery can avoid transfusion in all cases.
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Affiliation(s)
- A Pérez-Ferrer
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España.
| | - E Gredilla-Díaz
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - J de Vicente-Sánchez
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - F Sánchez Pérez-Grueso
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario La Paz, Madrid, España
| | - F Gilsanz-Rodríguez
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España
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Xu X, Wang Y, Zhang J, Du Y, Li Y, Xing N, Wei X, Li Z, Wang Z, Xue J, Yan J, Zhang W. The association of perioperative autologous blood transfusion with the early postoperative cognitive dysfunction in aged patients following lumbar surgery. Transfus Apher Sci 2015; 53:48-51. [PMID: 25907924 DOI: 10.1016/j.transci.2015.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/14/2015] [Accepted: 03/06/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Intraoperation autologous blood transfusion is an effective method that is used in surgeries with an important blood loss. Several studies suggest that massive blood transfusion is one of the independent risks for postoperative cognitive dysfunction (POCD). Whether the autologous blood is one of the risk factor for POCD or not, we retrospectively examined the incidence of POCD and the probable risk factors in patients undergoing lumbar surgery in our hospital, with the same aged non-POCD patients as controls. METHODS Eighty-one patients who underwent lumbar surgery were included. Perioperative data were examined for association with POCD on the 7 postoperative days by a Mini-Mental State Test. Multivariable logistic regression analysis was conducted to determine the probable risks associated with POCD. RESULTS POCD was found in 21 patients. Participants who developed POCD were more likely to had a lower eduction level, more likely to had more blood loss, higher incidence of preoperative anemia, and perioperative allogeneic blood transfusion of more than 3 units as independent risk factors for POCD 7 d postoperatively (P < 0.05). Otherwise, there is no significant difference of the patients received autologous blood or not (P > 0.05). CONCLUSION Autologous blood transfusion is not a risk factor for POCD in aged patients following lumbar surgery. Autologous blood is likely to be a better method of intraoperative blood transfusion during lumbar spine surgery.
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Affiliation(s)
- Xiaohan Xu
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Ying Wang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Jie Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yingying Du
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yanna Li
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Na Xing
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xin Wei
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Zhisong Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Zhongyu Wang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Jinhu Xue
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Jie Yan
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China.
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Abstract
AbstractBackgroundNeurosurgery may involve significant blood loss and frequently requires allogeneic red blood cell (RBC) transfusion. Preoperative recombinant erythropoietin (EPO) may be used to improve erythroid status and recovery, and used either alone or in combination with preoperative autologous donation (PAD) it may reduce exposure to allogeneic RBC. We wished to study the use of EPO with and without PAD and the risk of RBC transfusion in neurosurgery.MethodsUsing a retrospective case-control design, 57 patients who received EPO preoperatively were matched 2:1 for age, sex, year of surgery, and International Classification of Diseases code most responsible for surgery (three were excluded because of stringent matching criteria, leaving 54 cases and 108 comparison subjects). Thirty-two cases participated in PAD. Medical and anesthetic records as well as laboratory investigations were reviewed and extracted.ResultsAllogeneic RBC exposure was identical for EPO cases and comparison subjects (18.5%). Concomitant PAD and EPO did not reduce allogeneic RBC exposure (21.9%), and resulted in a greater number of RBC units transfused. Last recorded hemoglobin levels suggested that autologous RBCs were not more liberally used. Patients who engaged in PAD and EPO suffered from iatrogenic anemia. A significant proportion (58.6%) of the autologous RBCs was ultimately not used and discarded.ConclusionFurther research is needed to determine the efficacy of EPO in neurological surgery. PAD does not appear to reduce the risk of allogeneic RBC transfusion, despite concomitant EPO. Indeed, PAD resulted in iatrogenic anemia and increased transfusion requirements. The cost-effectiveness of blood conservation efforts in neurosurgery deserves additional research.
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Muñoz M, Gómez-Ramírez S, García-Erce JA. Implementing Patient Blood Management in major orthopaedic procedures: orthodoxy or pragmatism? BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 12:146-149. [PMID: 24931839 PMCID: PMC4039694 DOI: 10.2450/2014.0050-14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Manuel Muñoz
- Perioperative Transfusion Medicine, School of Medicine, University of Málaga, Málaga, Spain
| | - Susana Gómez-Ramírez
- Department of Internal Medicine, University Hospital Virgen de la Victoria, Málaga, Spain
| | - José A. García-Erce
- Department of Haematology and Haemotherapy, General Hospital San Jorge, Huesca, Spain
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Sambandam B, Batra S, Gupta R, Agrawal N. Blood conservation strategies in orthopedic surgeries: A review. J Clin Orthop Trauma 2013; 4:164-70. [PMID: 26403876 PMCID: PMC3880946 DOI: 10.1016/j.jcot.2013.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 11/13/2013] [Indexed: 11/28/2022] Open
Abstract
In orthopedics management of surgical blood loss is an important aspect which has evolved along with modern surgeries. Replacement of lost blood by transfusion alone is not the answer as was considered earlier. Complications like infection and immune reaction due to blood transfusion are a major concern. Today numerous techniques are available in place of allogenic blood transfusion which can be employed safely and effectively. In this article we have reviewed these techniques, their merits and demerits.
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Affiliation(s)
- Balaji Sambandam
- Senior Resident, Lok Nayak Hospital, New Delhi, India,Corresponding author.
| | - Sahil Batra
- Senior Resident, Lok Nayak Hospital, New Delhi, India
| | - Rajat Gupta
- Senior Resident, Lok Nayak Hospital, New Delhi, India
| | - Nidhi Agrawal
- Specialist Anesthesia, V.M.M.C. & Safdarjung Hospital, New Delhi, India
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Partridge J, Harari D, Gossage J, Dhesi J. Anaemia in the older surgical patient: a review of prevalence, causes, implications and management. J R Soc Med 2013; 106:269-77. [PMID: 23759887 DOI: 10.1177/0141076813479580] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
This review provides the clinician with a summary of the causes, implications and potential treatments for the management of anaemia in the older surgical patient. The prevalence of anaemia increases with age and is frequently identified in older surgical patients. Anaemia is associated with increased postoperative morbidity and mortality. Allogenic blood transfusion is commonly used to treat anaemia but involves inherent risks and may worsen outcomes. Various strategies for the correction of pre- and postoperative anaemia have evolved. These include correction of nutritional deficiencies and the use of intravenous iron and erythropoesis stimulating therapy. Clear differences exist between the elective and emergency surgical populations and the translation of research findings into these individual clinical settings requires more work. This should lead to a standardized approach to the management of this frequently encountered clinical scenario.
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Kodama J, Seki N, Fukushima C, Kusumoto T, Nakamura K, Hiramatsu Y. Postoperative decreased levels of D-dimer in patients with gynecologic cancer with enoxaparin and fondaparinux thromboprophylaxis. Mol Clin Oncol 2013; 1:737-744. [PMID: 24649238 PMCID: PMC3915345 DOI: 10.3892/mco.2013.120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 04/05/2013] [Indexed: 11/23/2022] Open
Abstract
The purpose of the present study was to evaluate the effects of enoxaparin (ENO) and fondaparinux (FPX) on postoperative plasma D-dimer levels and risk factors associated with postoperative venous thromboembolism (VTE) and pulmonary thromboembolism (PTE) in patients with gynecologic cancer. For this study, 434 patients with gynecologic cancer were recruited and a surgical treatment strategy was employed. Plasma D-dimer levels were measured prior to surgery, as well as on a schedule up to 3 weeks postoperatively and again after day 28. Patients with clinical signs and elevation of the plasma D-dimer level underwent multidetector row computed tomography. The D-dimer value was significantly lower in patients with ENO or FPX on postoperative days 3–10 compared to patients with gynecologic cancers who were not receiving ENO or FPX. The D-dimer value was significantly lower in patients with FPX compared to patients with ENO on postoperative days 5–7. The D-dimer value on postoperative day 3, the use of erythropoiesis-stimulating agents (ESAs), advancing age and non-O blood group were independent risk factors for postoperative VTE. The D-dimer value on postoperative day 3 and the use of ESAs were independent risk factors for postoperative PTE. The postoperative D-dimer value was significantly lower in patients with gynecologic cancer who were administered ENO or FPX compared to patients were not administered either ENO or FPX. The use of ESAs and high plasma D-dimer levels on postoperative day 3 were independent risk factors for postoperative VTE and PTE.
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Affiliation(s)
- Junichi Kodama
- Department of Obstetrics and Gynecology, Hiroshima City Hospital, Naka-ku, Hiroshima 730-8518
| | - Noriko Seki
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Kita-ku, Okayama 700-8558, JapanDentistry and Pharmaceutical Sciences, Kita-ku, Okayama 700-8558, Japan
| | - Chikako Fukushima
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Kita-ku, Okayama 700-8558, JapanDentistry and Pharmaceutical Sciences, Kita-ku, Okayama 700-8558, Japan
| | - Tomoyuki Kusumoto
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Kita-ku, Okayama 700-8558, JapanDentistry and Pharmaceutical Sciences, Kita-ku, Okayama 700-8558, Japan
| | - Keiichiro Nakamura
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Kita-ku, Okayama 700-8558, JapanDentistry and Pharmaceutical Sciences, Kita-ku, Okayama 700-8558, Japan
| | - Yuji Hiramatsu
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Kita-ku, Okayama 700-8558, JapanDentistry and Pharmaceutical Sciences, Kita-ku, Okayama 700-8558, Japan
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Torres-Claramunt R, Ramírez M, López-Soques M, Saló G, Molina-Ros A, Lladó A, Cáceres E. Predictors of blood transfusion in patients undergoing elective surgery for degenerative conditions of the spine. Arch Orthop Trauma Surg 2012; 132:1393-8. [PMID: 22707213 DOI: 10.1007/s00402-012-1563-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND The requirement of blood in the surgery of degenerative conditions of lumbar spine is around 10 %. Preoperative autologous blood donation is an effective method that is used in surgeries with an important blood loss. This is an expensive method because of the great number of predonated blood units not used in the postoperative period (around 70 % in our practice). OBJECTIVE To know the risk factors associated with transfusion in the postoperative period in patients who undergo surgeries of degenerative conditions of the lumbar spine. METHODS We designed a retrospective study of 142 cases of patients operated for degenerative conditions of the lumbar spine (not including simple disk hernia or adult degenerative scoliosis). RESULTS Female sex, age >60 years, preoperative ASA score 3 and preoperative hemoglobin ≤136 g/L are the risk factors related to the need of blood transfusion in the postoperative period. After application of a statistical study, female sex and preoperative ASA score 3 were the most important variables to explain transfusional risk. A woman with ASA score 3 has a 61 % foretold probability to be transfused in the postoperative period, while a man with ASA < 3, only 1.1 %. For this reason, application of this method to patients with these risk factors is more cost-effective. CONCLUSIONS Females, ASA 3, preoperative hemoglobin ≤136 g/L and age older than 60 years increase the risk to be transfused in the postoperative period for degenerative conditions of the spine.
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Affiliation(s)
- Raúl Torres-Claramunt
- Orthopaedic Departement Parc de Salut Mar, Universitat Autònoma Barcelona, Passeig Marítim 25-29, 08003 Barcelona, Spain.
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Rölfing JHD, Bendtsen M, Jensen J, Stiehler M, Foldager CB, Hellfritzsch MB, Bünger C. Erythropoietin augments bone formation in a rabbit posterolateral spinal fusion model. J Orthop Res 2012; 30:1083-8. [PMID: 22144136 DOI: 10.1002/jor.22027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 11/17/2011] [Indexed: 02/04/2023]
Abstract
We tested the hypothesis that erythropoietin (EPO) enhances bone formation after posterolateral spinal fusion (PLF) in a rabbit model. Thirty-four adult rabbits underwent posterolateral intertransverse arthrodesis at the L5-L6 level using 2.0 g autograft per side. The animals were randomly divided into two groups receiving subcutaneous daily injections of either EPO or saline for 20 days. Treatment commenced 2 days preoperatively. Hemoglobin was monitored at baseline and 2, 4, and 6 weeks after fusion surgery. After euthanasia 6 weeks postoperatively, manual palpation, radiographic, and histomorphometric examinations were performed. Bone volume of the fusion mass was estimated by CT after 6 weeks. EPO increased bone fusion volume to 3.85 ccm (3.66-4.05) compared with 3.26 ccm (2.97-3.55) in the control group (p<0.01). EPO treatment improved vascularization of the fusion mass and increased hemoglobin levels (p<0.01). Fusion rate tended to be higher in the EPO group based on manual palpation, CT, and radiographic examinations. For the first time EPO has shown to augment bone formation after autograft PLF in a rabbit model. Increased vascularization provides a partial explanation for the efficacy of EPO as a bone autograft enhancer.
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Buljan M, Nemet D, Golubic-Cepulic B, Bicanic G, Tripkovic B, Delimar D. Two different dosing regimens of human recombinant erythropoietin beta during preoperative autologous blood donation in patients having hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2011; 36:703-9. [PMID: 21964703 DOI: 10.1007/s00264-011-1367-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 09/12/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE Our aim was to evaluate the effectiveness of two different dosing regimens of human recombinant erythropoietin (rHu-EPO) for preoperative autologous blood collection in patients undergoing total hip arthroplasty (THA). METHODS Prospective randomised trials in which erythropoietin 15,000 IU was administered intravenously twice a week or 30,000 IU once a week (total 90,000 IU) combined with ferrous II sulphate (Ferro-Gradumet 2) orally and compared with Ferro-Gradumet 2 alone. RESULTS Although different dosing regimens of rHu-EPO administration during preoperative autologous blood donation have similar effects on the collection of two units of autologous blood, preoperative haemoglobin level and perioperative allogenic blood transfusion, a once weekly dose regimen of rHu-EPO was more convenient (although not statistically significantly) for patients. CONCLUSION We recommend the more practical and comfortable but yet highly effective therapeutic regimen with a single weekly intravenous administration of rHu-EPO for patients scheduled for THA.
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Affiliation(s)
- Melita Buljan
- Department of Orthopaedic Surgery, Clinical Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
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Abstract
Although the safety of the blood supply has been greatly improved, there still remain both infectious and noninfectious risks to the patient. The incidence of noninfectious transfusion reactions is greater than that of infectious complications. Furthermore, the mortality associated with noninfectious risks is significantly higher. In fact, noninfectious risks account for 87-100% of fatal complications of transfusions. It is concerning to note that the majority of pediatric reports relate to human error such as overtransfusion and lack of knowledge of special requirements in the neonatal age group. The second most frequent category is acute transfusion reactions, majority of which are allergic in nature. It is estimated that the incidence of adverse outcome is 18:100,000 red blood cells issued for children aged less than 18 years and 37:100,000 for infants. The comparable adult incidence is 13:100,000. In order to decrease the risks associated with transfusion of blood products, various blood-conservation strategies can be utilized. Modalities such as acute normovolemic hemodilution, hypervolemic hemodilution, deliberate hypotension, antifibrinolytics, intraoperative blood salvage, and autologous blood donation are discussed and the pediatric literature is reviewed. A discussion of transfusion triggers, and algorithms as well as current research into alternatives to blood transfusions concludes this review.
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Affiliation(s)
- Josée Lavoie
- Pediatric Cardiac Anesthesia, McGill University, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada.
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Kodama J, Seki N, Masahiro S, Kusumoto T, Nakamura K, Hongo A, Hiramatsu Y. D-dimer level as a risk factor for postoperative venous thromboembolism in Japanese women with gynecologic cancer. Ann Oncol 2010; 21:1651-1656. [DOI: 10.1093/annonc/mdq012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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An open-label, randomized, parallel-group study of perioperative epoetin alfa versus standard of care for blood conservation in major elective spinal surgery: safety analysis. Spine (Phila Pa 1976) 2009; 34:2479-85. [PMID: 19927096 DOI: 10.1097/brs.0b013e3181bd163f] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, open-label, randomized, parallel-group study at 80 centers. OBJECTIVE To demonstrate there is no clinically important additional risk for deep vein thrombosis with perioperative use of epoetin alfa versus standard of care in spine surgery without prophylactic anticoagulation. SUMMARY OF BACKGROUND DATA Trials of epoetin alfa in orthopedic surgery that demonstrated no additional risk of thrombovascular events included perioperative pharmacologic anticoagulation. METHODS Subjects received epoetin alfa 600 U/kg subcutaneously once weekly starting 3 weeks before spinal surgery plus standard of care for blood conservation, or standard of care alone. Perioperative anticoagulation therapy was not permitted; mechanical deep vein thrombosis prophylaxis was allowed. Doppler imaging for deep vein thrombosis was done on postoperative day 4 (or day of discharge), or for suspected deep vein thrombosis. Deep vein thrombosis was diagnosed by Doppler result or adverse event report. The criterion for no additional risk of deep vein thrombosis was a 1-sided 97.5% upper confidence limit < or =4% between groups. RESULTS Of the 680 subjects analyzed (340 in each treatment group), 16 (4.7%) in the epoetin alfa group and 7 (2.1%) in the standard of care group had a diagnosis of deep vein thrombosis either by Doppler or by adverse event report with normal Doppler. The between-group difference was 2.6% (97.5% upper confidence limit, 5.4%). Deep vein thrombosis confirmed by Doppler (4.1% vs. 2.1%), other clinically relevant thrombovascular events (1.5% vs. 0.9%), and all adverse events combined (76.5% vs. 73.2%) occurred with similar frequency in the 2 treatment groups. CONCLUSION This study documented a higher incidence of deep vein thrombosis and similar rates of other clinically relevant thrombovascular events with epoetin alfa versus standard of care for blood conservation in subjects who did not receive prophylactic anticoagulation before spinal surgery. Antithrombotic prophylaxis should be considered when erythropoietin is used in the surgical setting.
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Epstein NE. Bloodless spinal surgery: a review of the normovolemic hemodilution technique. ACTA ACUST UNITED AC 2008; 70:614-8. [DOI: 10.1016/j.surneu.2008.01.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Accepted: 01/05/2008] [Indexed: 10/22/2022]
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BASORA MISERICORDIA, COLOMINA MARÍAJ, MORAL VICTORIA, LLAU JUANV, VILA MIGUEL, DURÁN LOURDES, SILVA SONSOLES, SÁNCHEZ CALIXTOA. Descriptive study of perioperative transfusion practices in Spanish hospitals. ACTA ACUST UNITED AC 2008. [DOI: 10.1111/j.1778-428x.2008.00093.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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