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Daniels AH, Daher M, Singh M, Balmaceno-Criss M, Lafage R, Diebo BG, Hamilton DK, Smith JS, Eastlack RK, Fessler RG, Gum JL, Gupta MC, Hostin R, Kebaish KM, Klineberg EO, Lewis SJ, Line BG, Nunley PD, Mundis GM, Passias PG, Protopsaltis TS, Buell T, Scheer JK, Mullin JP, Soroceanu A, Ames CP, Lenke LG, Bess S, Shaffrey CI, Burton DC, Lafage V, Schwab FJ. The Case for Operative Efficiency in Adult Spinal Deformity Surgery: Impact of Operative Time on Complications, Length of Stay, Alignment, Fusion Rates, and Patient-Reported Outcomes. Spine (Phila Pa 1976) 2024; 49:313-320. [PMID: 37942794 DOI: 10.1097/brs.0000000000004873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To analyze the impact of operative room (OR) time in adult spinal deformity (ASD) surgery on patient outcomes. BACKGROUND It is currently unknown if OR time in ASD patients matched for deformity severity and surgical invasiveness is associated with patient outcomes. MATERIALS AND METHODS ASD patients with baseline and two-year postoperative radiographic and patient-reported outcome measures (PROM) data, undergoing a posterior-only approach for long fusion (>L1-Ilium) were included. Patients were grouped into short OR time (<40th percentile: <359 min) and long OR time (>60th percentile: >421 min). Groups were matched by age, baseline deformity severity, and surgical invasiveness. Demographics, radiographic, PROM data, fusion rate, and complications were compared between groups at baseline and two years follow-up. RESULTS In total, 270 patients were included for analysis: the mean OR time was 286 minutes in the short OR group versus 510 minutes in the long OR group ( P <0.001). Age, gender, percent of revision cases, surgical invasiveness, pelvic incidence minus lumbar lordosis, sagittal vertical axis, and pelvic tilt were comparable between groups ( P >0.05). Short OR had a slightly lower body mass index than the short OR group ( P <0.001) and decompression was more prevalent in the long OR time ( P =0.042). Patients in the long group had greater hospital length of stay ( P =0.02); blood loss ( P <0.001); proportion requiring intensive care unit ( P =0.003); higher minor complication rate ( P =0.001); with no significant differences for major complications or revision procedures ( P >0.5). Both groups had comparable radiographic fusion rates ( P =0.152) and achieved improvement in sagittal alignment measures, Oswestry disability index, and Short Form-36 ( P <0.001). CONCLUSION Shorter OR time for ASD correction is associated with a lower minor complication rate, a lower estimated blood loss, fewer intensive care unit admissions, and a shorter hospital length of stay without sacrificing alignment correction or PROMs. Maximizing operative efficiency by minimizing OR time in ASD surgery has the potential to benefit patients, surgeons, and hospital systems.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Mohammad Daher
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Manjot Singh
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Mariah Balmaceno-Criss
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell, New York, NY
| | - Bassel G Diebo
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - David K Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin S Smith
- University of Virginia Health System, Charlottesville, VA
| | | | - Richard G Fessler
- Department of Neurological Surgery, Rush University Medical School, Chicago, IL
| | | | | | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX
| | | | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA
| | - Stephen J Lewis
- Division of Orthopaedics, Toronto Western Hospital, Toronto, Canada
| | | | | | | | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | | | - Thomas Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, CA
| | | | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, Canada
| | | | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Shay Bess
- Denver International Spine Center, Denver, CO
| | | | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | | | - Frank J Schwab
- Department of Orthopedic Surgery, Northwell, New York, NY
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Chen LY, Chang Y, Wong CE, Chi KY, Lee JS, Huang CC, Lee PH. Risk Factors for 30-day Unplanned Readmission following Surgery for Lumbar Degenerative Diseases: A Systematic Review. Global Spine J 2023; 13:563-574. [PMID: 36040160 PMCID: PMC9972270 DOI: 10.1177/21925682221116823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Surgical procedures for lumbar degenerative diseases (LDD), which have emerged in the 21-century, are commonly practiced worldwide. Regarding financial burdens and health costs, readmissions within 30days following surgery are inconvenient. We performed a systematic review to integrate real-world evidence and report the current risk factors associated with 30-day readmission following surgery for LDD. METHODS The Cochrane Library, Embase, and Medline electronic databases were searched from inception to April 2022 to identify relevant studies reporting risk factors for 30-day readmission following surgery for LDD. RESULTS Thirty-six studies were included in the review. Potential risk factors were identified in the included studies that reported multivariate analysis results, including age, race, obesity, higher American Society of Anesthesiologists score, anemia, bleeding disorder, chronic pulmonary disease, heart failure, dependent status, depression, diabetes, frailty, malnutrition, chronic steroid use, surgeries with anterior approach, multilevel spinal surgeries, perioperative transfusion, presence of postoperative complications, prolonged operative time, and prolonged length of stay. CONCLUSIONS There are several potential perioperative risk factors associated with unplanned readmission following surgery for LDD. Preoperatively identifying patients that are at increased risk of readmission is critical for achieving the best possible outcomes.
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Affiliation(s)
- Liang-Yi Chen
- Section of Neurosurgery, Department
of Surgery, College of Medicine, National Cheng Kung University, National Cheng Kung University
Hospital, Tainan, Taiwan
| | - Yu Chang
- Section of Neurosurgery, Department
of Surgery, College of Medicine, National Cheng Kung University, National Cheng Kung University
Hospital, Tainan, Taiwan
| | - Chia-En Wong
- Section of Neurosurgery, Department
of Surgery, College of Medicine, National Cheng Kung University, National Cheng Kung University
Hospital, Tainan, Taiwan
| | - Kuan-Yu Chi
- Department of Education, Center for
Evidence-Based Medicine, Taipei Medical University
Hospital, Taipei, Taiwan
| | - Jung-Shun Lee
- Institute of Basic Medical
Sciences, College of Medicine, National Cheng Kung
University, Tainan, Taiwan,Department of Cell Biology and
Anatomy, College of Medicine, National Cheng Kung
University, Tainan, Taiwan
| | - Chi-Chen Huang
- Section of Neurosurgery, Department
of Surgery, College of Medicine, National Cheng Kung University, National Cheng Kung University
Hospital, Tainan, Taiwan,Chi-Chen Huang, Attending Doctor, Section
of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital,
College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Po-Hsuan Lee
- Section of Neurosurgery, Department
of Surgery, College of Medicine, National Cheng Kung University, National Cheng Kung University
Hospital, Tainan, Taiwan,Po-Hsuan Lee, Attending Doctor, Section of
Neurosurgery, Department of Surgery, National Cheng Kung University Hospital,
College of Medicine, National Cheng Kung University, No. 138, Shengli Rd, North
District, Tainan 704, Taiwan.
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Lubelski D, Alomari S, Pennington Z, Lo L, Witham T, Theodore N, Sciubba DM, Bydon A. Single-Surgeon Versus Dual-Surgeon Strategy in Spinal Tumor Surgery: A Single Institution Experience. Clin Spine Surg 2022; 35:E566-E570. [PMID: 35276721 DOI: 10.1097/bsd.0000000000001302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective of this study is to compare the outcomes of spinal tumor surgery between dual-surgeon and single-surgeon approach. SUMMARY OF BACKGROUND DATA Perioperative adverse outcomes may be improved with 2 attending surgeons in spinal deformity cases. It is unclear if this advantage may be seen in spinal oncology operations. METHODS A retrospective chart review identified 24 patients who underwent spinal tumor surgery by two attending surgeons between January 1, 2016, and April 30, 2020 at a single tertiary care institution. 1:1 matching was then performed to identify 24 patients who underwent spinal tumor operations of similar complexity by a single attending surgeon. Postoperative outcomes were collected. RESULTS Cases in the dual-surgeon group had significantly lower total operative time (601 vs. 683 minutes), reduced estimated blood loss (956 vs. 1780 ml), and were less likely to have an intraoperative blood transfusion (41.7% vs. 75.0%). The incidence of cerebrospinal fluid leak and wound infection did not significantly differ between groups, nor were there differences in total length of hospital stay, discharge disposition, 6-month emergency room visit, readmission, and reoperation rates. CONCLUSION Dual-surgeon strategy in spinal tumors surgery may lead to decreased operative time and estimated blood loss. These benefits may have clinical and cost implications, but should be weighed against the impact of resident and fellow training. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Brown NJ, Wilson B, Ong V, Gendreau JL, Yang CY, Himstead AS, Shahrestani S, Shlobin NA, Reardon T, Choi EH, Birkenbeuel J, Cohn SJ, Sahyouni R, Yang I. Use of Tranexamic Acid for Elective Resection of Intracranial Neoplasms: A Systematic Review. World Neurosurg 2022; 160:e209-e219. [PMID: 34995825 DOI: 10.1016/j.wneu.2021.12.117] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND As an established antifibrinolytic agent, tranexamic acid (TXA) has garnered widespread use during surgery to limit intraoperative blood loss. In the field of neurosurgery, TXA is often introduced in cases of traumatic brain injury or elective spine surgeries; however, its role during elective cranial surgeries is not well established. We report a systematic review of the use of TXA in elective surgical resection of intracranial neoplasms. METHODS We performed this systematic review following PRISMA guidelines to identify studies investigating the use of TXA in elective neurosurgical resection of intracranial neoplasms. Variables extracted included patient demographics, surgical indications, type of surgery performed, TXA dose and route of administration, operative duration, blood loss, transfusion rate, postoperative hemoglobin level, and complications. RESULTS After careful screening, 4 articles (consisting of 682 patients) met our inclusion/exclusion criteria. The studies included 2 prospective cohort studies, 1 retrospective cohort study, and 1 case series. A χ2 test of pooled data demonstrated that patients administered TXA had a significantly decreased need for blood transfusions during surgery (odds ratio, 0.6273; 95% confidence interval, 0.4254-0.9251; P = 0.018). Mean total blood loss was 821.9 mL in the TXA group and 1099.0 mL in the control group across the studies. There was no significant difference in postoperative hemoglobin levels, with a mean of 11.4 g/dL in both the TXA and control groups. CONCLUSIONS These results support the use of intraoperative TXA in tumor resection. However, its role in tumor resection has been less well investigated compared with its use in other areas of neurosurgery.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Bayard Wilson
- Department of Neurological Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Vera Ong
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA.
| | - Chen Yi Yang
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Shane Shahrestani
- Keck School of Medicine of USC, Los Angeles, California, USA; Medical Scientist Training Program, California Institute of Technology, Pasadena, California, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, USA
| | - Elliot H Choi
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Jack Birkenbeuel
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Sebastian J Cohn
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ronald Sahyouni
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Isaac Yang
- Department of Neurological Surgery, University of California Los Angeles, Los Angeles, California, USA
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Ardeljan AD, Polisetty TS, Palmer J, Vakharia RM, Roche MW. Comparative Analysis on the Effects of Sarcopenia following Primary Total Knee Arthroplasty: A Retrospective Matched-Control Analysis. J Knee Surg 2022; 35:128-134. [PMID: 32629511 DOI: 10.1055/s-0040-1713355] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite the high incidence of sarcopenia in the orthopaedic community, studies evaluating the influence of sarcopenia following primary total knee arthroplasty (TKA) are limited. Therefore, the purpose of this study is to determine if sarcopenic patients undergoing primary TKA have higher rates of (1) in-hospital lengths of stay (LOS); (2) medical complications; (3) implant-related complications; (4) fall risk; (5) lower extremity fracture risk; and (6) costs of care. Sarcopenia patients were matched to controls in a 1:5 ratio according to age, sex, and medical comorbidities. The query yielded 90,438 patients with (n = 15,073) and without (n = 75,365) sarcopenia undergoing primary TKA. Primary outcomes analyzed included: in-hospital LOS, 90-day medical complications, 2-year implant-related complications, fall risk, lower extremity fracture risk, and costs of care. A p-value of less than 0.05 was considered statistically significant. Patients with sarcopenia undergoing primary TKA had greater in-hospital LOS (4 vs. 3 days, p < 0.0001). Sarcopenic patients were also found to have increased incidence and odds of 90-day medical complications (2.9 vs. 1.1%; odds ratio [OR] = 2.83, p < 0.0001), falls (0.9 vs. 0.3%; OR = 3.54, p < 0.0001), lower extremity fractures (1.0 vs. 0.2%; OR = 5.54, p < 0.0001), and reoperation (0.9 vs. 0.5%; OR = 1.87, p < 0.0001). Additionally, sarcopenic patients had greater 2-year implant-related complications (4.3 vs. 2.4%; OR = 1.80, p < 0.0001), as well as day of surgery ($52,900 vs. 48,248, p < 0.0001), and 90-day ($68,303 vs. $57,671, p < 0.0001) costs compared with controls. This analysis of over 90,000 patients demonstrates that patients with sarcopenia undergoing primary TKA have greater in-hospital LOS, increased odds of 90-day medical complications, falls, lower extremity fractures, and reoperations. Additionally, sarcopenia was associated with greater 2-year implant-related complications, day of surgery costs, and 90-day costs. The study is useful as it can allow orthopaedic surgeons to properly educate these patients of the potential complications which may occur following their surgery.
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Affiliation(s)
- Andrew D Ardeljan
- Division of Health Professions, Nova Southeastern College of Osteopathic Medicine, Ft. Lauderdale, Florida.,Orthopaedic Research Department, Holy Cross Orthopaedic Research Institute, Ft. Lauderdale, Florida
| | - Teja S Polisetty
- Orthopaedic Research Department, Holy Cross Orthopaedic Research Institute, Ft. Lauderdale, Florida.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Joseph Palmer
- Department of Orthopaedic Surgery, Broward Health Medical Center, Ft. Lauderdale, Florida
| | - Rushabh M Vakharia
- Orthopaedic Research Department, Holy Cross Orthopaedic Research Institute, Ft. Lauderdale, Florida
| | - Martin W Roche
- Orthopaedic Research Department, Holy Cross Orthopaedic Research Institute, Ft. Lauderdale, Florida
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6
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Darveau SC, Pertsch NJ, Toms SA, Weil RJ. Short term outcomes associated with patients requiring blood transfusion following elective laminectomy and fusion for lumbar stenosis: A propensity-matched analysis. J Clin Neurosci 2021; 90:184-190. [PMID: 34275547 DOI: 10.1016/j.jocn.2021.05.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/25/2021] [Accepted: 05/27/2021] [Indexed: 12/01/2022]
Abstract
Perioperative blood transfusion has been associated with poor outcomes but the impacts of transfusion after fusion for lumbar stenosis have not been well-described. We assessed this effect in a large cohort of patients from 2012 to 2018 in the National Surgical Quality Improvement Program (NSQIP). We evaluated baseline characteristics including demographics, comorbidities, hematocrit, and operative characteristics. We generated propensity scores using baseline characteristics and patients were matched to approximate randomization. We assessed odds of 30-day outcomes including prolonged length-of-stay (LOS), complications, discharge to facility, readmission, reoperation, and death using logistic regression. We identified 16,329 eligible patients who underwent lumbar fusion for stenosis; 1,926 (11.8%) received a transfusion. Before matching, there were multiple differences in baseline covariates including age, gender, BMI, ASA class, medical comorbidities, hematocrit, coagulation indices, platelets, operative time, fusion technique, number of levels fused, and osteotomy. However, after matching, no significant differences remained. In the matched cohorts, transfusion was associated with increased prolonged LOS (OR 1.66, 95% CI 1.45-1.91, p < 0.001), minor complication (OR 1.60, 95% CI 1.20-2.12, p = 0.001), major complication (OR 1.51, 95% CI 1.16-1.98, p = 0.003), any complication (OR 1.54, 95% CI 1.24-1.92, p < 0.001), discharge to facility (OR 1.70, 95% CI 1.48-1.95, p < 0.001), 30-day readmission (OR 1.56, 95% CI 1.23-1.99, p < 0.001), and 30-day reoperation (OR 1.85, 95% CI 1.35-2.53, p < 0.001). Although transfusion is performed based on perceived clinical need, this study contributes to growing evidence that it is important to balance the risks of perioperative blood transfusion with its benefits.
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Affiliation(s)
- Spencer C Darveau
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States.
| | - Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States
| | - Steven A Toms
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
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George S, Ramchandran S, Mihas A, George K, Mansour A, Errico T. Topical tranexemic acid reduces intra-operative blood loss and transfusion requirements in spinal deformity correction in patients with adolescent idiopathic scoliosis. Spine Deform 2021; 9:1387-1393. [PMID: 33844193 DOI: 10.1007/s43390-021-00337-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/17/2021] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Stephen George
- Department of Orthopedic Surgery, Center for Spinal Disorders, Nicklaus Children's Hospital, Miami, FL, 33155, USA
| | - Subaraman Ramchandran
- Department of Orthopedic Surgery, Center for Spinal Disorders, Nicklaus Children's Hospital, Miami, FL, 33155, USA.
| | - Alexander Mihas
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Kevin George
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Ali Mansour
- Department of Orthopedic Surgery, Center for Spinal Disorders, Nicklaus Children's Hospital, Miami, FL, 33155, USA
| | - Thomas Errico
- Department of Orthopedic Surgery, Center for Spinal Disorders, Nicklaus Children's Hospital, Miami, FL, 33155, USA
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8
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Pennington Z, Ehresman J, Molina CA, Schilling A, Feghali J, Huq S, Medikonda R, Ahmed AK, Cottrill E, Lubelski D, Frank SM, Sciubba DM. A novel predictive model of intraoperative blood loss in patients undergoing elective lumbar surgery for degenerative pathologies. Spine J 2020; 20:1976-1985. [PMID: 32603855 DOI: 10.1016/j.spinee.2020.06.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 05/28/2020] [Accepted: 06/19/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Intraoperative blood loss (IOBL) is unavoidable during surgery; however, high IOBL is associated with increased morbidity and increased risk for requiring allogenic blood transfusion, itself associated with poorer outcomes. PURPOSE Here we sought to develop and validate a predictive calculator for IOBL that could be used by surgeons to estimate likely blood loss. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE Series of consecutive patients who underwent elective lumbar spine surgery for degenerative pathologies over a 27-month period at a single tertiary care center. OUTCOME MEASURES Primary outcome was IOBL. Secondary outcome was the occurrence of "major intraoperative bleeding," defined as IOBL exceeding 1 L. METHODS Charts of included patients were reviewed for medical comorbidities, preoperative laboratory data, surgical plan, and anesthesia records. Univariate linear regressions were performed to find significant predictors of IOBL, which were then subjected to a multivariate analysis to identify the final model. Model training was performed using 70% of the included cohort and external validation was performed using 30% of the cohort. Results of the model were deployed as a freely available online calculator. RESULTS We identified 1,281 patients who met inclusion/exclusion criteria. Mean age was 60±15 years, mean Charlson Comorbidity score was 1.1±1.6, and 51.8% were male. There were no significant differences between the training and validation cohorts with regard to any of the demographic variables or intraoperative variables; tranexamic acid use and surgical invasiveness were also similar in both cohorts. Multivariate analysis identified body mass index (βₙ=7.14; 95% confidence interval [3.15, 11.13]; p<.001), surgical invasiveness (βₙ=29.18; [24.62, 33.74]; p<.001), tranexamic acid use (βₙ=-0.093; [-0.171, -0.014]; p=.02), and surgical duration (βₙ=2.13; [1.75, 2.51]; p<.001) as significant predictors of IOBL. The model had an overall fit of r=0.693 in the validation cohort. Construction of a receiver-operating curve for predicting major IOBL showed a C-statistic of 0.895 within the validation cohort. CONCLUSION Here we identify and validate a model for predicting IOBL in patients undergoing lumbar spine surgery. The model was a moderately strong predictor of absolute IOBL and was demonstrated to predict the occurrence of major IOBL with a high degree of accuracy. We propose it may have future utility when counseling patients about surgical morbidity and the probability of requiring transfusion.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Camilo A Molina
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Andrew Schilling
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Sakibul Huq
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Ravi Medikonda
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
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9
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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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10
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Nobre LV, Garcia LV. [Role of acute hemodilution in blood transfusion rate in patients submmited to scoliosis surgery: observational retrospective study]. Rev Bras Anestesiol 2020; 70:209-214. [PMID: 32493689 DOI: 10.1016/j.bjan.2019.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 12/18/2019] [Accepted: 12/22/2019] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The study assessed the role of acute hemodilution in the blood transfusion rate in patients submitted to surgical treatment of scoliosis. METHODS Retrospective observational study performed at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (HC-FMRP?USP). Medical charts of patients submitted to elective correction of scoliosis between January 1996 and December 2016 were analyzed. Variables assessed were: age, weight, sex, presence of comorbidities, data regarding anesthesia and surgery, lab data, adverse events and blood transfusion rate. The final sample consisted of 33 procedures performed by the same anesthesiologist and same surgeon, divided into two groups: Hemodilution Group (n = 16) and Control Group (n = 17). Indication of acute normovolemic hemodilution was determined by patient refusal of blood transfusion for religious reasons. RESULTS The sample was statistically homogeneous and the groups were compared in terms of the attributes analyzed. The volume of homologous blood used by the Hemodilution Group was significantly lower than the Control Group (p = 0.0016). The percentage of patients who required transfusion was 12.5% in the Hemodilution Group, while it was 70.69% (p = 0.0013) in the Control Group. Upon hospital discharge, mean values of hemoglobin and hematocrit between groups did not present significant differences (p = 0.0679; p = 0.1027, respectively). CONCLUSIONS Acute normovolemic hemodilution, in scoliosis correction surgeries reduces blood transfusion rates, meeting patient needs without increasing adverse events or infection rates.
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Affiliation(s)
- Layana Vieira Nobre
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor pelo Programa de Pós-Graduação em Ciências da Saúde Aplicadas ao Aparelho Locomotor, Ribeirão Preto, SP, Brasil.
| | - Luis Vicente Garcia
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Ribeirão Preto, SP, Brasil
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Nobre LV, Garcia LV. Role of acute hemodilution in blood transfusion rate in patients submitted to scoliosis surgery: observational retrospective study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32493689 PMCID: PMC9373322 DOI: 10.1016/j.bjane.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background and objectives The study assessed the role of acute hemodilution in the blood transfusion rate in patients submitted to surgical treatment of scoliosis. Methods Retrospective observational study performed at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (HC-FMRP–USP). Medical charts of patients submitted to elective correction of scoliosis between January 1996 and December 2016 were analyzed. Variables assessed were: age, weight, sex, presence of comorbidities, data regarding anesthesia and surgery, lab data, adverse events and blood transfusion rate. The final sample consisted of 33 procedures performed by the same anesthesiologist and same surgeon, divided into two groups: Hemodilution Group (n = 16) and Control Group (n = 17). Indication of acute normovolemic hemodilution was determined by patient refusal of blood transfusion for religious reasons. Results The sample was statistically homogeneous and the groups were compared in terms of the attributes analyzed. The volume of homologous blood used by the Hemodilution Group was significantly lower than the Control Group (p = 0.0016). The percentage of patients who required transfusion was 12.5% in the Hemodilution Group, while it was 70.69% (p = 0.0013) in the Control Group. Upon hospital discharge, mean values of hemoglobin and hematocrit between groups did not present significant differences (p = 0.0679; p = 0.1027, respectively). Conclusions Acute normovolemic hemodilution, in scoliosis correction surgeries, reduces blood transfusion rates, meeting patient needs without increasing adverse events or infection rates.
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Ehresman J, Pennington Z, Schilling A, Medikonda R, Huq S, Merkel KR, Ahmed AK, Cottrill E, Lubelski D, Westbroek EM, Farrokh S, Frank SM, Sciubba DM. Cost-benefit analysis of tranexamic acid and blood transfusion in elective lumbar spine surgery for degenerative pathologies. J Neurosurg Spine 2020; 33:177-185. [PMID: 32197253 DOI: 10.3171/2020.1.spine191464] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 01/21/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Blood transfusions are given to approximately one-fifth of patients undergoing elective lumbar spine surgery, and previous studies have shown that transfusions are accompanied by increased complications and additional costs. One method for decreasing transfusions is administration of tranexamic acid (TXA). The authors sought to evaluate whether the cost of TXA is offset by the decrease in blood utilization in lumbar spine surgery patients. METHODS The authors retrospectively reviewed patients who underwent elective lumbar or thoracolumbar surgery for degenerative conditions at a tertiary care center between 2016 and 2018. Patients who received intraoperative TXA (TXA patients) were matched with patients who did not receive TXA (non-TXA patients) by age, sex, BMI, ASA (American Society of Anesthesiologists) physical status class, and surgical invasiveness score. Primary endpoints were intraoperative blood loss, number of packed red blood cell (PRBC) units transfused, and total hemostasis costs, defined as the sum of TXA costs and blood transfusion costs throughout the hospital stay. A subanalysis was then performed by substratifying both cohorts into short-length (1-4 levels) and long-length (5-8 levels) spinal constructs. RESULTS Of the 1353 patients who met inclusion criteria, 68 TXA patients were matched to 68 non-TXA patients. Patients in the TXA group had significantly decreased mean intraoperative blood loss (1039 vs 1437 mL, p = 0.01). There were no differences between the patient groups in the total costs of blood transfusion and TXA (p = 0.5). When the 2 patient groups were substratified by length of construct, the long-length construct group showed a significant net cost savings of $328.69 per patient in the TXA group (p = 0.027). This result was attributable to the finding that patients undergoing long-length construct surgeries who were given TXA received a lower amount of PRBC units throughout their hospital stay (2.4 vs 4.0, p = 0.007). CONCLUSIONS TXA use was associated with decreased intraoperative blood loss and significant reductions in total hemostasis costs for patients undergoing surgery on more than 4 levels. Furthermore, the use of TXA in patients who received short constructs led to no additional net costs. With the increasing emphasis put on value-based care interventions, use of TXA may represent one mechanism for decreasing total care costs, particularly in the cases of larger spine constructs.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Salia Farrokh
- 3Department of Pharmacy, Division of Critical Care and Surgery Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
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Raman T, Vasquez-Montes D, Varlotta C, Passias PG, Errico TJ. Decision Tree-based Modelling for Identification of Predictors of Blood Loss and Transfusion Requirement After Adult Spinal Deformity Surgery. Int J Spine Surg 2020; 14:87-95. [PMID: 32128308 DOI: 10.14444/7012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background Multilevel fusions and complex osteotomies to restore global alignment in adult spinal deformity (ASD) surgery can lead to increased operative time and blood loss. In this regard, we assessed factors predictive of perioperative blood product transfusion in patients undergoing long posterior spinal fusion for ASD. Methods A single-institution retrospective review was conducted on 909 patients with ASD, age > 18 years, who underwent surgery for ASD with greater than 4 levels fused. Using conditional inference tree analysis, a machine learning methodology, we sought to predict the combination of variables that best predicted increased risk for intraoperative percent blood volume lost and perioperative blood product transfusion. Results Among the 909 patients included in the study, 377 (41.5%) received red blood cell (RBC) transfusion. The conditional inference tree analysis identified greater than 13 levels fused, American Society of Anesthesiologists (ASA) score > 1, a history of hypertension, 3-column osteotomy, pelvic fixation, and operative time > 8 hours, as significant risk factors for perioperative RBC transfusion. The best predictors for the subgroup with the highest risk for intraoperative percent blood volume lost (subgroup mean: 53.1% ± 42.9%) were greater than 13 levels fused, ASA score > 1, preoperative hemoglobin < 13.6 g/dL, 3-column osteotomy, posterior column osteotomy, and pelvic fixation. Patients who underwent major blood transfusion intraoperatively had significantly longer length of stay (8.5 days) versus those who did not (6.1 days) (P < .0001). The overall 90-day complication rate in patients who underwent major blood transfusion intraoperatively was 49%, compared with 19% in those who did not (P < .0001). By multivariate regression analysis, patients with a preoperative hemoglobin > 13.0 were less likely to require major blood transfusion (odds ratio: 0.52, P = .046). Conclusions Using a supervised learning technique, this study demonstrates that greater than 13 levels fused, ASA score > 1, 3-column osteotomy, and pelvic fixation are consistent risk factors for increased intraoperative percent blood volume lost and perioperative RBC transfusion. The addition of having a preoperative hemoglobin < 13.6 g/dL or undergoing a posterior column osteotomy conferred the highest risk for intraoperative blood loss. This information can assist spinal deformity surgeons in identifying at-risk individuals and allocating healthcare resources. Level of Evidence 3.
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Affiliation(s)
- Tina Raman
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Dennis Vasquez-Montes
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Chris Varlotta
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Thomas J Errico
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
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Mikhail C, Pennington Z, Arnold PM, Brodke DS, Chapman JR, Chutkan N, Daubs MD, DeVine JG, Fehlings MG, Gelb DE, Ghobrial GM, Harrop JS, Hoelscher C, Jiang F, Knightly JJ, Kwon BK, Mroz TE, Nassr A, Riew KD, Sekhon LH, Smith JS, Traynelis VC, Wang JC, Weber MH, Wilson JR, Witiw CD, Sciubba DM, Cho SK. Minimizing Blood Loss in Spine Surgery. Global Spine J 2020; 10:71S-83S. [PMID: 31934525 PMCID: PMC6947684 DOI: 10.1177/2192568219868475] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery. METHODS A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery. RESULTS There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements. CONCLUSION As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.
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Affiliation(s)
| | | | - Paul M. Arnold
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Norman Chutkan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John G. DeVine
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Daniel E. Gelb
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Fan Jiang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Brian K. Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas E. Mroz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmad Nassr
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K. Daniel Riew
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lali H. Sekhon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA.
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Batista MFS, Costa CO, Vialle EN, Guasque JBRC, Fiorentin JZ, Souza CDS. Acute Normovolemic Hemodilution in Spinal Deformity Surgery. Rev Bras Ortop 2019; 54:516-523. [PMID: 31686710 PMCID: PMC6819157 DOI: 10.1016/j.rbo.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/21/2018] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Marianna Fergutz Santos Batista
- Serviço de Ortopedia e Traumatologia, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná (PUC-PR), Curitiba, PR, Brasil
| | - Caroline Oliveira Costa
- Serviço de Ortopedia e Traumatologia, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná (PUC-PR), Curitiba, PR, Brasil
| | - Emiliano Neves Vialle
- Serviço de Ortopedia e Traumatologia, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná (PUC-PR), Curitiba, PR, Brasil
| | - Joana Bretas Rondon Cabral Guasque
- Serviço de Ortopedia e Traumatologia, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná (PUC-PR), Curitiba, PR, Brasil
| | - Joana Zulian Fiorentin
- Serviço de Ortopedia e Traumatologia, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná (PUC-PR), Curitiba, PR, Brasil
| | - Camila de Santiago Souza
- Serviço de Ortopedia e Traumatologia, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná (PUC-PR), Curitiba, PR, Brasil
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Vakharia RM, Cohen-Levy WB, Vakharia AM, Donnally CJ, Law TY, Roche MW. Sleep Apnea Increases Ninety-Day Complications and Cost Following Primary Total Joint Arthroplasty. J Arthroplasty 2019; 34:959-964.e1. [PMID: 30814026 DOI: 10.1016/j.arth.2018.12.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sleep apnea (SA) negatively affects bone mineralization, cognition, and immunity. There is paucity in the literature regarding the impact of SA on total joint arthroplasty (TJA). The purpose of this study is to compare complications in patients with and without SA undergoing either total knee (TKA) or total hip arthroplasty (THA). METHODS A retrospective review from 2005 to 2014 was conducted using the Medicare Standard Analytical Files. Patients with and without SA on the day of the primary TJA were queried using the International Classification of Diseases, ninth revision codes. Patients were matched by age, gender, Charlson Comorbidity Index), and body mass index. Patients were followed for 2 years after their surgery. Ninety-day medical complications, complications related to implant, readmission rates, length of stay, and 1-year mortality were quantified and compared. Logistic regression was used to calculate odds ratios (OR) with their respective 95% confidence interval and P values. RESULTS After the random matching process there were 529,240 patients (female = 271,656, male = 252,106, unknown = 5478) with (TKA = 189,968, THA = 74,652) and without (TKA = 189,968, THA = 74,652) SA who underwent primary TJA between 2005 and 2014. Patients with SA had greater odds of developing medical complications following TKA (OR 3.71) or THA (OR 2.48). CONCLUSION The study illustrates an increased risk of developing postoperative complications in patients with SA following primary TJA. Surgeons should educate patients on these adverse effects and encourage the use of continuous positive airway pressure which has been shown to mitigate many postoperative complications.
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Affiliation(s)
| | - Wayne B Cohen-Levy
- Department of Orthopedic Surgery, University of Miami Hospital, Miami, FL
| | | | - Chester J Donnally
- Department of Orthopedic Surgery, University of Miami Hospital, Miami, FL
| | - Tsun Yee Law
- Holy Cross Hospital, Orthopedic Research Institute, Fort Lauderdale, FL
| | - Martin W Roche
- Holy Cross Hospital, Orthopedic Research Institute, Fort Lauderdale, FL
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Predicting lowest hemoglobin level and risk of blood transfusion in spinal fusion surgery for adolescent idiopathic scoliosis. 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 2019; 28:1342-1348. [DOI: 10.1007/s00586-019-05939-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/14/2019] [Accepted: 02/28/2019] [Indexed: 01/21/2023]
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Abstract
STUDY DESIGN Descriptive study. OBJECTIVES This study aimed to evaluate the hidden blood loss (HBL) of patients who underwent lumbar fusion surgery for degenerative spine and to analyze its risk factors. SUMMARY OF BACKGROUND DATA When planning transfusion strategies, blood loss calculation is important. However, in clinical practice, spine surgeons usually ignore the possibility that a large amount of HBL may occur after lumbar fusion surgery. MATERIALS AND METHODS We studied the patients who underwent posterior lumbar fusion (PLF) surgery for degenerative spine from 2014 to 2015 in one institution. The patient's demographics, comorbid conditions, coagulation panel value, surgical time, number of levels fused, American Society of Anesthesiologists (ASA) classification, cell saver, preoperative hematocrit level, preoperative hemoglobin level, and postoperative complications were collected retrospectively. Pearson correlation analyses were used to find an association between patient characteristics and HBL. Multivariate linear analysis was used to determine independent risk factors of HBL. RESULTS We reviewed 169 consecutive patients who underwent PLF surgery for degenerative spine in one institution. The mean amount of HBL was 588 mL, which was 39% of the total blood loss. On the basis of the model of multiple linear regression analysis, the multilevel fusion (P=0.001), surgical time (P=0.034), and fibrinogen level (P=0.027) were independent risk factors that contributed to HBL, but age of 60 years or above (P=0.110), postoperative complications (P=0.278), and cell saver were not (P=0.739). CONCLUSIONS We conclude that a large amount of HBL may occur in patients who underwent PLF surgery for degenerative spine. In addition, significant hidden loss may have a correlation with postoperative mortality. Multilevel fused, surgical time, and fibrinogen level should be paid close attention when considering strategies of fluid infusion and blood transfusion.
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Maher KM, Owusu-Akyaw K, Zhou J, Cooter M, Ross AK, Lark RK, Taicher BM. Analysis of the impact of race on blood transfusion in pediatric scoliosis surgery. Paediatr Anaesth 2018; 28:352-360. [PMID: 29520878 DOI: 10.1111/pan.13352] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Surgical correction of pediatric scoliosis is associated with significant blood loss. Minimizing estimated blood loss and blood transfusion is beneficial as transfusions have been associated with increased morbidity, including risk of surgical site infections, longer hospitalizations, and increased cost. Although there is evidence that African-American or Black adults are more likely to require intraoperative blood transfusion compared with Caucasian or White adults, the reasons for this difference are unclear. METHODS The electronic records for all patients <18 y/o undergoing primary corrective scoliosis surgery by a single pediatric orthopedic surgeon at a single academic medical center between 2013 and 2015 were collected and reviewed. Multivariate models were performed to assess the association between Black race and blood loss/transfusion in primary pediatric scoliosis surgery. RESULTS In a multivariate model, Black race was independently associated with 1.61 times higher estimated blood loss than White race (P < .01; 95% CI = 1.16-2.23). Additionally, compared to a White patient, the odds a Black patient received blood transfusion was 6.25 times higher (P = .03; 95% CI = 1.56-25.06) and among the patients who received blood transfusion, Black race was independently associated with 2.61 times greater volume of blood transfusion than White race (P < .01; 95% CI = 1.54-4.41). CONCLUSION Black race was independently associated with increased estimated blood loss, increased rate of blood transfusion, and increased amount of blood transfused during surgical correction of pediatric scoliosis. Further investigation is needed to better understand the etiology of the disparity and assess opportunities for improving outcomes.
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Affiliation(s)
- Keila M Maher
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Kwadwo Owusu-Akyaw
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jingzhu Zhou
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Allison K Ross
- Division of Pediatric Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Robert K Lark
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brad M Taicher
- Division of Pediatric Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Purvis TE, Goodwin CR, De la Garza-Ramos R, Ahmed AK, Lafage V, Neuman BJ, Passias PG, Kebaish KM, Frank SM, Sciubba DM. Effect of liberal blood transfusion on clinical outcomes and cost in spine surgery patients. Spine J 2017; 17:1255-1263. [PMID: 28458067 DOI: 10.1016/j.spinee.2017.04.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 01/12/2017] [Accepted: 04/24/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Blood transfusions in spine surgery are shown to be associated with increased patient morbidity. The association between transfusion performed using a liberal hemoglobin (Hb) trigger-defined as an intraoperative Hb level of ≥10 g/dL, a postoperative level of ≥8 g/dL, or a whole hospital nadir between 8 and 10 g/dL-and perioperative morbidity and cost in spine surgery patients is unknown and thus was investigated in this study. PURPOSE This study aimed to describe the perioperative outcomes and economic cost associated with liberal Hb trigger transfusion among spine surgery patients. STUDY DESIGN/SETTING This is a retrospective study. PATIENT SAMPLE The surgical billing database at our institution was queried for inpatients discharged between 2008 and 2015 after the following procedures: atlantoaxial fusion, anterior cervical fusion, posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, other procedures, and tumor-related surgeries. In total, 6,931 patients were included for analysis. OUTCOME MEASURES The primary outcome was composite morbidity, which was composed of (1) infection (sepsis, surgical-site infection, Clostridium difficile infection, or drug-resistant infection); (2) thrombotic event (pulmonary embolus, deep venous thrombosis, or disseminated intravascular coagulation); (3) kidney injury; (4) respiratory event; and (5) ischemic event (transient ischemic attack, myocardial infarction, or cerebrovascular accident). MATERIALS AND METHODS Data on intraoperative transfusion were obtained from an automated, prospectively collected anesthesia data management system. Data on postoperative hospital transfusion were obtained through a Web-based intelligence portal. Based on previous research, we analyzed the data using three definitions of a liberal transfusion trigger in patients who underwent red blood cell transfusion: a liberal intraoperative Hb trigger as a nadir Hb level of 10 g/dL or greater, a liberal postoperative Hb trigger as a nadir Hb level of 8 g/dL or greater, or a whole hospital nadir Hb level of 8-10 g/dL. Variables analyzed included in-hospital morbidity, mortality, length of stay, and total costs associated with a liberal transfusion strategy. RESULTS Among patients with a whole hospital stay nadir Hb between 8 and 10 g/dL, transfused patients demonstrated a longer in-hospital stay (median [interquartile range], 6 [5-9] vs. 4 [3-6] days; p<.0001) and a higher perioperative morbidity (n=145 [11.5%] vs. n=74 [6.1%], p<.0001) than those not transfused. Even after adjusting for age, gender, race, American Society of Anesthesiologists class, Charlson Comorbidity Index score, estimated blood loss, baseline Hb value, and surgery type, logistic regression analysis revealed that patients with a nadir Hb of 8-10 g/dL who were transfused had an independently higher risk of perioperative morbidity (odds ratio=2.11, 95% confidence interval, 1.44-3.09; p<.0001). Estimated additional costs associated with liberal trigger use, defined as a transfusion occurring in patients with a whole hospital stay nadir Hb of 8-10 g/dL, ranged from $202,675 to $700,151 annually. CONCLUSIONS Transfusion using a liberal trigger is associated with increased morbidity, even after controlling for possible confounders. Our results suggest that modification of transfusion practice may be a potential area for improving patient outcomes and reducing costs.
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Affiliation(s)
- Taylor E Purvis
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter G Passias
- Division of Spinal Surgery, NYU Medical Center-Hospital for Joint Diseases, New York City, NY, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Interdisciplinary Blood Management Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Aoude A, Nooh A, Fortin M, Aldebeyan S, Jarzem P, Ouellet J, Weber MH. Incidence, Predictors, and Postoperative Complications of Blood Transfusion in Thoracic and Lumbar Fusion Surgery: An Analysis of 13,695 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database. Global Spine J 2016; 6:756-764. [PMID: 27853659 PMCID: PMC5110346 DOI: 10.1055/s-0036-1580736] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 02/03/2016] [Indexed: 01/28/2023] Open
Abstract
Study Design Retrospective cohort study. Objective To identify predictive factors for blood transfusion and associated complications in lumbar and thoracic fusion surgeries. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent lumbar or thoracic fusion from 2010 to 2013. Multivariate analysis was used to determine predictive factors and postoperative complications associated with transfusion. Results Out of 13,695 patients, 13,170 had lumbar fusion and 525 had thoracic fusion. The prevalence of transfusion was 31.8% for thoracic and 17.0% for lumbar fusion. The multivariate analysis showed that age between 50 and 60, age between 61 and 70, age > 70, dyspnea, American Society of Anesthesiologists class 3, bleeding disease, multilevel surgery, extended surgical time, return to operation room, and higher preoperative blood urea nitrogen (BUN) were predictors of blood transfusion for lumbar fusion. Multilevel surgery, preoperative BUN, and extended surgical time were predictors of transfusion for thoracic fusion. Patients receiving transfusions who underwent lumbar fusion were more likely to develop wound infection, venous thromboembolism, pulmonary embolism, and myocardial infarction and had longer hospital stay. Patients receiving transfusions who underwent thoracic fusion were more likely to have extended hospital stay. Conclusion This study characterizes incidence, predictors, and postoperative complications associated with blood transfusion in thoracic and lumbar fusion. Pre- and postoperative planning for patients deemed to be at high risk of requiring blood transfusion might reduce postoperative complications in this population.
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Affiliation(s)
- Ahmed Aoude
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Quebec, Canada
| | - Anas Nooh
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Quebec, Canada,Department of Orthopedic Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Maryse Fortin
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sultan Aldebeyan
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Quebec, Canada,Department of Orthopedic Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Peter Jarzem
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean Ouellet
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael H. Weber
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Quebec, Canada,Address for correspondence Michael H. Weber, MD, PhD, FRCSC McGill University Health Centre, Montreal General Hospital siteA5-169, 1650 Cedar Avenue, Montreal, QuebecCanada H3G 1A4
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McCunniff PT, Young ES, Ahmadinia K, Kusin DJ, Ahn UM, Ahn NU. Chronic Antiplatelet Use Associated With Increased Blood Loss in Lumbar Spinal Surgery Despite Adherence to Protocols. Orthopedics 2016; 39:e695-700. [PMID: 27111080 DOI: 10.3928/01477447-20160419-04] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/10/2016] [Indexed: 02/03/2023]
Abstract
There are conflicting reports regarding postoperative bleeding risks associated with discontinuation of antiplatelet therapy at least 7 days preoperatively. Most of the studies in the spine literature are based on surveys or anecdotal evidence. The majority of surgeons discontinue therapy 7 days preoperatively, but this varies widely from 5 to 21 days. The purpose of this retrospective study was to assess whether chronic antiplatelet use is associated with increased intraoperative blood loss, need for transfusion, and perioperative complications. Of 454 patients who underwent elective lumbar spinal surgery, 85 were on antiplatelet therapy and 369 were not. All patients stopped antiplatelet therapy at least 7 days preoperatively with approval from their cardiologist or primary care provider. Multiple regression analysis was performed and corrected for age, sex, antiplatelet therapy, number of levels decompressed/fused/instrumented, preoperative hematocrit, and postoperative hematocrit. Results showed that preoperative antiplatelet therapy, despite at least 7 days of discontinuation, is a statistically significant predictor (P=.04) of increased intraoperative blood loss. Blood transfusion was not associated with antiplatelet use but was associated with the number of levels fused, age, and low preoperative hematocrit (all P<.01). There were no recorded complications in either group. The authors conclude that antiplatelet therapy is associated with an increased risk of intraoperative blood loss in spine patients despite discontinuation at least 7 days preoperatively, but the clinical significance of this is unclear given the lack of association with blood transfusions and perioperative complications. [Orthopedics. 2016; 39(4):e695-e700.].
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Mebel D, Akagami R, Flexman AM. Use of Tranexamic Acid Is Associated with Reduced Blood Product Transfusion in Complex Skull Base Neurosurgical Procedures: A Retrospective Cohort Study. Anesth Analg 2016; 122:503-8. [PMID: 26554461 DOI: 10.1213/ane.0000000000001065] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Compared with other procedures, complex skull base neurosurgery has the potential for increased intraoperative blood loss yet coagulation near eloquent cranial structures should be minimized. The safety and efficacy of the antifibrinolytic, tranexamic acid in elective neurosurgical procedures is not known. Our primary objective was to determine the relationship between the use of tranexamic acid and transfusion at our institution. Our secondary objective was to determine the incidence of adverse events associated with the use of tranexamic acid. METHODS In this retrospective cohort study, we included all patients who underwent complex skull base neurosurgical procedures at our institution between 2001 and 2013. Tranexamic acid was introduced during these procedures in 2006. Patient and surgical variables, transfusion data, and adverse events in the perioperative period were abstracted from the medical record. The rates of transfusion and adverse events were compared between patients who did and did not receive tranexamic acid. Multivariate regression was used to identify independent predictors of perioperative transfusion. RESULTS We compared 245 patients who received tranexamic acid with 274 patients who did not receive the drug during the study period. The 2 groups were similar, with the exception that patients who received tranexamic acid had larger tumors (mean, 3.5 vs 2.9 cm; P < 0.001) and longer procedures (mean, 7.2 vs 6.2 hours, P < 0.001). The rate of perioperative transfusion in patients who received tranexamic acid was lower (7% vs 13%, P = 0.04). After adjusting for preoperative hemoglobin, tumor diameter, and surgical procedure category, the use of tranexamic acid was independently predictive of perioperative transfusion (adjusted odds ratio, 0.32; 95% confidence interval, 0.15-0.65, P = 0.002). The rates of thromboembolic events and seizure were similar between the 2 groups. CONCLUSIONS Our results demonstrate that tranexamic acid use is associated with reduced transfusion rates in our study population, with no apparent increase in seizure or thrombotic complications. Our data support the need for further randomized clinical trials to evaluate the efficacy and safety of tranexamic acid on perioperative blood loss during complex skull base neurosurgery.
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Affiliation(s)
- Dmitry Mebel
- From the *Department of Anesthesiology, Pharmacology and Therapeutics University of British Columbia, Vancouver, British Columbia, Canada; and †Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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McCunniff PT, Young ES, Ahmadinia K, Ahn UM, Ahn NU. Smoking is Associated with Increased Blood Loss and Transfusion Use After Lumbar Spinal Surgery. Clin Orthop Relat Res 2016; 474:1019-25. [PMID: 26642788 PMCID: PMC4773328 DOI: 10.1007/s11999-015-4650-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 11/23/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Little is known about the association between smoking and intraoperative blood loss and perioperative transfusion use in patients undergoing spinal surgery. However, we found that although many of the common complications and deleterious effects of smoking on surgical patients had been well documented, the aspect of blood loss seemingly had been overlooked despite data reported in nonorthopaedic sources to suggest a possible connection. QUESTIONS/PURPOSES We asked: (1) Is smoking associated with increased estimated blood loss during surgery in patients undergoing lumbar spine surgery? (2) Is smoking associated with increased perioperative transfusion usage? METHODS Between 2005 and 2009, 581 lumbar decompression procedures (with or without fusion) were performed at one academic spine center. Of those, 559 (96%) had sufficient chart documentation to categorize patients by smoking status, necessary intra- and postoperative data to allow analysis with respect to bleeding and transfusion-related endpoints, and who did not meet exclusion criteria. Exclusion criteria included: patients whose smoking status did not fit in our two categories, patients with underlying coagulopathy, patients receiving anticoagulants (including aspirin and platelet inhibitors), history of hepatic disease, history of platelet disorder or other blood dyscrasias, and patient or family history of any other known bleeding disorder. Smoking history in packs per day was obtained for all subjects. We defined someone as a smoker if the patient reported smoking up until the day of their surgical procedure; nonsmokers were patients who quit smoking at least 6 weeks before surgery or had no history of smoking. We used a binomial grouping for whether patients did or did not receive a transfusion perioperatively. Age, sex, number of levels of discectomies, number of levels decompressed, number of levels fused, and use of instrumentation were recorded. The same approaches were used for transfusions in all patients regardless of smoking history; decisions were made in consultation between the surgeon and the anesthesia team. Absolute indications for transfusion postoperatively were: a hemoglobin less than 7 g/dL, continued symptoms of dizziness, tachycardia, decreased exertional tolerance, or hypotension that failed to respond to fluid resuscitation. Multiple linear regression analyses correcting for the above variables were performed to determine associations with intraoperative blood loss, while logistic regression was used to analyze perioperative transfusion use. RESULTS After controlling for potentially relevant confounding variables noted earlier, we found smokers had increased estimated blood loss compared with nonsmokers (mean, 328 mL more for each pack per day smoked; 95% CI, 249-407 mL; p < 0.001). We also found that again correcting for confounders, smokers had increased perioperative transfusion use compared with nonsmokers (odds ratio, 13.8; 95% CI, 4.59-42.52). CONCLUSIONS Smoking is associated with increased estimated surgical blood loss and transfusion use in patients undergoing lumbar spine surgery. Patients who smoke should be counseled regarding these risks and on smoking cessation before undergoing lumbar surgery. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Peter T. McCunniff
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Ernest S. Young
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Kasra Ahmadinia
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
| | - Uri M. Ahn
- New Hampshire NeuroSpine Institute, Bedford, NH USA
| | - Nicholas U. Ahn
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5043 USA
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Shander A, Ozawa S, Hofmann A. Activity-based costs of plasma transfusions in medical and surgical inpatients at a US hospital. Vox Sang 2016; 111:55-61. [DOI: 10.1111/vox.12386] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/17/2015] [Accepted: 01/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- A. Shander
- Department of Anesthesiology; Critical Care and Hyperbaric Medicine; Englewood Hospital and Medical Center; Englewood NJ USA
- Clinical Professor of Anesthesiology; Medicine and Surgery; Icahn School of Medicine at Mount Sinai; New York NY USA
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
| | - S. Ozawa
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
| | - A. Hofmann
- School of Surgery; Faculty of Medicine Dentistry and Health Sciences; University of Western Australia; Perth WA Australia
- Centre for Population Health Research; Curtin Health Innovation Research Institute; Curtin University; Perth WA Australia
- Institute of Anaesthesiology; University Hospital and University of Zurich; Zurich Switzerland
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
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Kato S, Chikuda H, Ohya J, Oichi T, Matsui H, Fushimi K, Takeshita K, Tanaka S, Yasunaga H. Risk of infectious complications associated with blood transfusion in elective spinal surgery-a propensity score matched analysis. Spine J 2016; 16:55-60. [PMID: 26499767 DOI: 10.1016/j.spinee.2015.10.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 08/10/2015] [Accepted: 10/12/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although the negative aspects of blood transfusion are increasingly recognized, less is known about transfusion-related risks in spinal surgery. PURPOSE This study was designed to determine whether perioperative allogeneic blood transfusion is associated with increased risk of infectious complications after elective spinal surgery. STUDY DESIGN A retrospective cohort study with propensity score matched analysis was carried out. PATIENT SAMPLE Data of patients with spinal canal stenosis and spondylolisthesis who underwent elective lumbar surgeries (decompression or fusion) were obtained from the Diagnosis Procedure Combination database, a nationwide administrative inpatient database in Japan. OUTCOME MEASURES Clinical outcomes included in-hospital death and the occurrence of infectious complications (surgical site infection [SSI], respiratory tract infection, urinary tract infection, and sepsis). METHODS Patients' clinical information, including sex, age, type of hospital, preoperative comorbidities, duration of anesthesia, cell saver use, and volume of allogeneic blood transfused, were investigated. Patients transfused with >840 mL (6 units) were excluded. Propensity scores for receiving transfusion were calculated, with one-to-one matching based on estimated propensity scores to adjust for patients' baseline characteristics. The proportions of complications were compared in patients with and without transfusions. This study was funded by grants from the Ministry of Health, Labour and Welfare, Japan. RESULTS Of the 84,650 patients identified, 5,289 patients (6.1%) received transfusions, with 4,436 (5.2%) receiving up to 840 mL. One-to-one propensity score matching resulted in 4,275 pairs with and without transfusion. Patients transfused were at increased risk of SSI (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.4-2.5; p<.001) and urinary tract infection (OR, 2.5; 95% CI, 1.5-4.2; p<.001) than those not transfused. CONCLUSIONS Allogeneic blood transfusion after elective lumbar surgery was associated with increased risks of SSI and urinary tract infection.
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Affiliation(s)
- So Kato
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Junichi Ohya
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeshi Oichi
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Antifibrinolytic Use and Blood Transfusions in Pediatric Scoliosis Surgeries Performed at US Children’s Hospitals. ACTA ACUST UNITED AC 2015; 28:E460-6. [DOI: 10.1097/bsd.0b013e3182a22a54] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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David G, Lim S, Gunnarsson C, Kocharian R, Roy S. Similar patient outcomes yet different hospital costs between flowable hemostatic agents. J Med Econ 2015; 18:735-45. [PMID: 25907200 DOI: 10.3111/13696998.2015.1044994] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION SURGIFLO and FLOSEAL are absorbable gelatin-based products that form hemostatic matrices. These products are indicated as adjuncts to hemostasis when control of bleeding by conventional surgical techniques (such as suture, ligature or cautery) is ineffective or impractical. This study analyzed the effect of surgery time and the choice of product on cost to the hospital and patient outcomes. METHODS The data source was the Premier Hospital database from January 1, 2010-June 30, 2012. Eligible patients were ≥18 years of age with a spinal fusion or refusion surgery with either SURGIFLO (Ethicon Inc.) or FLOSEAL (Baxter International Inc.). The hospital Charge Master was used to identify the amount of flowable product, whether it included Thrombin, and the cost. Multivariable models were performed on overall cost and likelihood of surgical complications. All models were adjusted for patient demographics and severity as well as hospital, and surgical characteristics. RESULTS A total of 24,882 patient records from 121 hospitals were analysed, which included 15,088 FLOSEAL records and 9794 SURGIFLO records, with 1498 SURGIFLO with Thrombin patients. Little or no differences in surgical complications were found between surgeries with SURGIFLO vs. surgery with FLOSEAL. Regression models showed a reduction in cost of $65 associated with use of SURGIFLO with Thrombin and an additional $21 reduction in hospital cost for each additional hour of surgery. Modeling which accounts for hospital fixed effects suggest that, in addition to a gap of ∼$300 favoring SURGIFLO with Thrombin, every additional hour of surgery was associated with an additional reduction in hospital costs of ∼$26. CONCLUSIONS While the choice of flowable product had no effect on clinical outcomes, use of SURGIFLO was associated with hospital cost savings for flowable product. These savings increased with the length of surgery, even when controlling for the amount of flowable product (mL) used.
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Affiliation(s)
- Guy David
- a a The Wharton School, University of Pennsylvania , Philadelphia , PA , USA
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Li C, Yang M, Wang C, Wang C, Fan J, Chen Z, Wei X, Zhang G, Bai Y, Zhu X, Xie Y, Li M. Preoperative factors predicting intraoperative blood loss in female patients with adolescent idiopathic scoliosis. Medicine (Baltimore) 2015; 94:e359. [PMID: 25569653 PMCID: PMC4602827 DOI: 10.1097/md.0000000000000359] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In this article, a retrospective analysis of 161 female patients with adolescent idiopathic scoliosis (AIS) is performed who underwent posterior correction and fusion using all-pedicle screw instrument.The aim of this article is to find out preoperative factors that influence intraoperative blood loss (IOBL) in female patients with AIS.The IOBL in posterior correction and fusion surgery for patients with idiopathic scoliosis greatly varies. The variables affecting the IOBL also greatly vary among different studies.Medical records of all female patients with AIS who underwent posterior correction and fusion operations using the all-pedicle screw system in our hospital from January 2012 to January 2014 were reviewed. Patients with irregular menstruation, who underwent osteotomy, and using coagulants were excluded. Preoperative clinical data, including patient age, height, weight, Risser sign, day after last menstruation, major curve Cobb angle, fulcrum-bending Cobb angle, curve flexibility index, sagittal thoracic Cobb angle, sagittal lumbar Cobb angle, albumin, hemoglobin, platelet, activated partial thromboplastic time (APTT), prothrombin time, thrombin time, fibrinogen, fusion level, menstrual phase, and blood type, were collected. Data were further analyzed using multiple linear regression with forward elimination.A total of 161 patients were included in this study. The mean IOBL was 933.98 ± 158.10 mL (500-2000 mL). Forward selection showed that fulcrum-bending Cobb angle, fusion level, Risser sign, APTT, fibrinogen, and menstrual phase were the preoperative factors that influenced the IOBL in female patients with AIS. Equation of IOBL was built by multiple linear regression: IOBL = -966.228 + 54.738 Risser sign + 18.910 fulcrum-bending Cobb angle + 114.737 fibrinogen + 21.386 APTT - 71.312 team 2 - 177.985 team 3 - 165.082 team 4 + 53.470 fusion level. R = 0.782.Operation for patients with AIS was featured by large IOBL. Large fulcrum-bending Cobb angle, the number of level fused, higher Risser sign, high APTT, high preoperative blood fibrinogen concentration, and premenstrual phase predicted higher IOBL.
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Affiliation(s)
- Chao Li
- From the Department of Spine Surgery (CL, MY, JF, ZC, XW, GZ, YB, XZ, ML); Department of Orthopedics (Chuanfeng W, YX), Changhai Hospital, Shanghai; and Department of Orthopedic Injury (Chao W), General Hospital of Jinan Military Area, Jinan, China
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The effect of blood transfusion on short-term, perioperative outcomes in elective spine surgery. J Clin Neurosci 2014; 21:1579-85. [DOI: 10.1016/j.jocn.2014.03.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 02/24/2014] [Accepted: 03/02/2014] [Indexed: 11/24/2022]
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Changolkar A, Menditto L, Shah M, Puto K, Farrelly E. Comparison of injectable anticoagulants for thromboprophylaxis after cancer-related surgery. Am J Health Syst Pharm 2014; 71:562-9. [DOI: 10.2146/ajhp120711] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Arun Changolkar
- SOAL Pharmatech Solutions, Inc., Philadelphia, PA; at the time of this study he was Manager, U.S. Health Outcomes, GlaxoSmithKline, Philadelphia
| | - Laura Menditto
- Laura A. Menditto LLC, Newtown, PA; at the time of this study she was Director, Cardiovascular, Metabolic, and Oncology U.S. Health Outcomes, GlaxoSmithKline
| | - Manan Shah
- Health Services and Outcomes Research, U.S. Medical, Bristol-Myers Squibb Company, Tampa, FL; at the time of this study he was Director, Health Economics and Outcomes Research, Xcenda, AmerisourceBergen Consulting Services, Palm Harbor, FL
| | - Katarzyna Puto
- Global Health Economics and Outcomes Research, Xcenda; at the time of this study she was Assistant Director, Medical Communications, Xcenda
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Young EY, Ahmadinia K, Bajwa N, Ahn NU. Does chronic warfarin cause increased blood loss and transfusion during lumbar spinal surgery? Spine J 2013; 13:1253-8. [PMID: 23871508 DOI: 10.1016/j.spinee.2013.05.052] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 03/07/2013] [Accepted: 05/28/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The use of oral anticoagulation therapy such as warfarin is projected to increase significantly as the population ages and the prevalence of cardiovascular disease increases. Current recommendations state that warfarin be discontinued before surgery and the international normalized ratio (INR) normalized. PURPOSE To determine if stopping warfarin 7 days before surgery and correcting INR had any effect on intraoperative blood loss or the requirements for blood product transfusion. STUDY DESIGN/SETTING This was a retrospective cohort study in a high-volume tertiary care center. PATIENT SAMPLE Sample comprised 263 consecutive patients who underwent elective lumbar spinal surgery. OUTCOME MEASURE The outcome measures were intraoperative blood loss, intraoperative blood transfusion, postoperative blood transfusion, and the number of blood products transfused. METHODS The records of patients undergoing elective spinal surgery were analyzed for patient demographic data, comorbidities, coagulation panel laboratory findings, operative characteristics, blood loss, and blood transfusion requirements. These included patients undergoing full laminectomies with or without posterolateral fusion and instrumentation. Patients on warfarin were analyzed for the mean dosage of warfarin and underlying pathology that required anticoagulation. All patients on warfarin had their anticoagulation therapy stopped 7 days before surgery and their INR checked preoperatively to confirm normalization. Both univariate and multiple linear regression analyses were performed. RESULTS The patients on warfarin had a mean intraoperative blood loss of 839 mL compared with 441 mL for patients not on warfarin (p<.01). Multiple regression analysis determined that warfarin and number of spinal levels decompressed/fused/instrumented were predictors for increased blood loss (R(2)=0.37). Patients on warfarin also had increased postoperative blood transfusions (23.1% compared with 7.4%, p=.04). There was no significant difference between groups in terms of intraoperative blood transfusion or number of units transfused. CONCLUSIONS Patients on chronic anticoagulation therapy with warfarin who have their therapy stopped 7 days before surgery and have their INR normalized still demonstrated increased intraoperative blood loss and requirement for postoperative transfusion. Surgeons should be aware of the increased propensity of these patients to bleed despite adherence to protocols and should attempt to mitigate this risk.
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Affiliation(s)
- Ernest Y Young
- Department of Orthopaedics, Case Western Reserve University School of Medicine and University Hospitals Case Medical Center, 1585 Rydalmount Rd, Cleveland Heights, OH 44118, USA.
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Lykissas MG, Crawford AH, Chan G, Aronson LA, Al-Sayyad MJ. The effect of tranexamic acid in blood loss and transfusion volume in adolescent idiopathic scoliosis surgery: a single-surgeon experience. J Child Orthop 2013; 7:245-9. [PMID: 24432083 PMCID: PMC3672458 DOI: 10.1007/s11832-013-0486-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 02/11/2013] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Intraoperative blood loss in scoliosis surgery often requires transfusions. Autogenous blood decreases but does not eliminate risks typically associated with allogenic blood transfusion. Costs associated with transfusions are significant. Tranexamic acid (TXA) has been shown to decrease blood loss in cardiac and joint surgery. Few studies have examined its use in pediatric spine surgery, and the results are inconsistent. The aim of this study was to determine whether TXA decreases intraoperative blood loss and transfusion requirements in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion by a single surgeon. METHODS The medical records and operative reports of surgically treated patients with adolescent idiopathic scoliosis between 2000 and 2009 were retrospectively reviewed. The inclusion criteria were: (1) patients who underwent instrumented posterior spinal fusion, (2) had complete medical records, and (3) were treated by the same surgeon. Forty-nine patients who met the inclusion criteria were divided into two groups: Group A (25 patients) received TXA, while Group B (24 patients) did not receive TXA. RESULTS After controlling for age at the time of surgery, gender, and number of vertebral levels fused, the mean intraoperative blood loss was significantly lower in Group A (537 ml) than in Group B (1,245 ml) (p = 0.027). The mean volume of blood transfused intraoperatively was 426 and 740 ml for Group A and Group B, respectively. The difference was not statistically significant after controlling for age, gender, and number of levels fused (p = 0.078). CONCLUSION TXA significantly decreased intraoperative blood loss in posterior spinal fusions performed for adolescent idiopathic scoliosis.
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Affiliation(s)
- Marios G. Lykissas
- Division of Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2017, Cincinnati, OH 45229 USA
| | - Alvin H. Crawford
- Division of Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2017, Cincinnati, OH 45229 USA
| | - Gilbert Chan
- Division of Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2017, Cincinnati, OH 45229 USA
| | - Lori A. Aronson
- Division of Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2017, Cincinnati, OH 45229 USA
| | - Mohammed J. Al-Sayyad
- Division of Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2017, Cincinnati, OH 45229 USA
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Lecker I, Wang DS, Romaschin AD, Peterson M, Mazer CD, Orser BA. Tranexamic acid concentrations associated with human seizures inhibit glycine receptors. J Clin Invest 2012. [PMID: 23187124 DOI: 10.1172/jci63375] [Citation(s) in RCA: 135] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Antifibrinolytic drugs are widely used to reduce blood loss during surgery. One serious adverse effect of these drugs is convulsive seizures; however, the mechanisms underlying such seizures remain poorly understood. The antifibrinolytic drugs tranexamic acid (TXA) and ε-aminocaproic acid (EACA) are structurally similar to the inhibitory neurotransmitter glycine. Since reduced function of glycine receptors causes seizures, we hypothesized that TXA and EACA inhibit the activity of glycine receptors. Here we demonstrate that TXA and EACA are competitive antagonists of glycine receptors in mice. We also showed that the general anesthetic isoflurane, and to a lesser extent propofol, reverses TXA inhibition of glycine receptor-mediated current, suggesting that these drugs could potentially be used to treat TXA-induced seizures. Finally, we measured the concentration of TXA in the cerebrospinal fluid (CSF) of patients undergoing major cardiovascular surgery. Surprisingly, peak TXA concentration in the CSF occurred after termination of drug infusion and in one patient coincided with the onset of seizures. Collectively, these results show that concentrations of TXA equivalent to those measured in the CSF of patients inhibited glycine receptors. Furthermore, isoflurane or propofol may prevent or reverse TXA-induced seizures.
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Affiliation(s)
- Irene Lecker
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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Sherman CH, Macivor DC. Blood utilization: fostering an effective hospital transfusion culture. J Clin Anesth 2012; 24:155-63. [PMID: 22414711 DOI: 10.1016/j.jclinane.2011.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 06/07/2011] [Accepted: 06/09/2011] [Indexed: 11/17/2022]
Abstract
An effective hospital transfusion culture should encourage clinicians to consider the possibility of transfusion in their patients well before the need actually arises, and to plan ahead in an attempt to use blood products most efficiently. Strategies for improved blood utilization include timely and adequate preoperative assessment of risk, optimization of baseline hemoglobin, anticipation of potential transfusion problems, intraoperative techniques to minimize blood loss, blood conservation technologies, transfusion guidelines and targeted therapy, point of care testing, and massive transfusion protocols. Attention to these elements promotes a safe and cost-effective transfusion culture.
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Affiliation(s)
- Carolyn Hyatt Sherman
- Department of Anesthesiology, Chandler Medical Center, University of Kentucky, Lexington, KY 40536, USA.
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Efficacy of preoperative autologous blood donation for elective posterior lumbar spinal surgery. Spine (Phila Pa 1976) 2011; 36:E1736-43. [PMID: 21992934 DOI: 10.1097/brs.0b013e3182194a42] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE Evaluate the transfusion patterns associated with preoperative autologous blood donation (PABD) during posterior lumbar spinal surgery. SUMMARY OF BACKGROUND DATA There is a paucity of evidence in the literature examining the utility of PABD in elective adult lumbar spinal surgery. METHODS Medical records of 541 patients treated for spinal stenosis between January 1997 and February 2000 were reviewed. Patients were divided into donors (PABD; n = 413) and nondonors (non PABD [NPABD]; n = 128). RESULTS Average preoperative hemoglobin (Hb) in the NPABD group was 0.62 units more than in the PABD group (95% confidence interval [CI] = 0.30-0.94). For PABD patients, there was a negative correlation (-0.3) between preoperative Hb and number of units donated. PABD patients who donated 1 and 2 units of blood were, respectively, 7.5 and 9 times more likely to be transfused within the first 24 hours than NPABD patients. NPABD patients were 25 times more likely to need a transfusion of allogeneic blood than PABD patients who donated at least 2 units of blood. Autologous donation was an independent predictor of perioperative blood loss (P < 0.05). Patients who donated at least 2 units of blood lost approximately 1.3 units of Hb more than NPABD patients. The odds of wastage for a PABD patient who had a decompression with noninstrumented fusion were 8.64 times that of a PABD patient who had a decompression with instrumented fusion. CONCLUSION Autologous blood donation induced preoperative anemia and resulted in a lower transfusion threshold than allogeneic blood usage. In addition, we found that autologous donation significantly increased blood loss in the preoperative period as measured by Hb lost. Usage of autologous blood was significantly more efficient in patients who underwent instrumented fusion than in patients with less complex surgery.
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Role of quality improvement in prevention of inappropriate transfusions. Qual Manag Health Care 2011; 20:298-310. [PMID: 21971027 DOI: 10.1097/qmh.0b013e3182315d22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Many different methods are used to manage surgical bleeding and reduce transfusion. Techniques vary by institution, resulting in inconsistent outcomes. We reviewed the current literature on the quality and costs of transfusions, focusing on prevention and management of transfusions during surgery, and provide recommendations on future directions for quality improvement (QI). DATA SOURCES Ovid, PubMed, and Scopus. STUDY SELECTION Key words included QI, blood loss, transfusion, hemostasis, and costs. Inclusion criteria were English language, publication between 1999 and 2010, and primary end points of blood loss, transfusion, or hemostasis. DATA EXTRACTION A total of 1331 abstracts were reviewed; 43 met the inclusion criteria. RESULTS A variety of bleeding management (BM) techniques were identified, with multiple studies suggesting that algorithms combining pre-, peri-, and postoperative interventions have the greatest potential to minimize transfusions. Most studies assessing the economic impact of BM interventions excluded resources beyond blood acquisition cost and longer-term complications, which may underestimate transfusion costs and bias estimates of the cost-effectiveness of interventions. Despite consensus on avoiding inappropriate transfusions, little agreement exists on optimal use of interventions. CONCLUSIONS Multifaceted algorithms show promising results. Future QI should focus on reducing practice variation via evidence-based guidelines for effective use of BM interventions.
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Stokes ME, Ye X, Shah M, Mercaldi K, Reynolds MW, Rupnow MFT, Hammond J. Impact of bleeding-related complications and/or blood product transfusions on hospital costs in inpatient surgical patients. BMC Health Serv Res 2011; 11:135. [PMID: 21627788 PMCID: PMC3126703 DOI: 10.1186/1472-6963-11-135] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 05/31/2011] [Indexed: 11/29/2022] Open
Abstract
Background Inadequate surgical hemostasis may lead to transfusion and/or other bleeding-related complications. This study examines the incidence and costs of bleeding-related complications and/or blood product transfusions occurring as a consequence of surgery in various inpatient surgical cohorts. Methods A retrospective analysis was conducted using Premier's Perspective™ hospital database. Patients who had an inpatient procedure within a specialty of interest (cardiac, vascular, non-cardiac thoracic, solid organ, general, reproductive organ, knee/hip replacement, or spinal surgery) during 2006-2007 were identified. For each specialty, the rate of bleeding-related complications (including bleeding event, intervention to control for bleeding, and blood product transfusions) was examined, and hospital costs and length of stay (LOS) were compared between surgeries with and without bleeding-related complications. Incremental costs and ratios of average total hospital costs for patients with bleeding-related complications vs. those without complications were estimated using ordinary least squares (OLS) regression, adjusting for demographics, hospital characteristics, and other baseline characteristics. Models using generalized estimating equations (GEE) were also used to measure the impact of bleeding-related complications on costs while accounting for the effects related to the clustering of patients receiving care from the same hospitals. Results A total of 103,829 cardiac, 216,199 vascular, 142,562 non-cardiac thoracic, 45,687 solid organ, 362,512 general, 384,132 reproductive organ, 246,815 knee/hip replacement, and 107,187 spinal surgeries were identified. Overall, the rate of bleeding-related complications was 29.9% and ranged from 7.5% to 47.4% for reproductive organ and cardiac, respectively. Overall, incremental LOS associated with bleeding-related complications or transfusions (unadjusted for covariates) was 6.0 days and ranged from 1.3 to 9.6 days for knee/hip replacement and non-cardiac thoracic, respectively. The incremental cost per hospitalization associated with bleeding-related complications and adjusted for covariates was highest for spinal surgery ($17,279) followed by vascular ($15,123), solid organ ($13,210), non-cardiac thoracic ($13,473), cardiac ($10,279), general ($4,354), knee/hip replacement ($3,005), and reproductive organ ($2,805). Conclusions This study characterizes the increased hospital LOS and cost associated with bleeding-related complications and/or transfusions occurring as a consequence of surgery, and supports implementation of blood-conservation strategies.
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Elgafy H, Bransford RJ, McGuire RA, Dettori JR, Fischer D. Blood loss in major spine surgery: are there effective measures to decrease massive hemorrhage in major spine fusion surgery? Spine (Phila Pa 1976) 2010; 35:S47-56. [PMID: 20407351 DOI: 10.1097/brs.0b013e3181d833f6] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To determine the definition and incidence of significant hemorrhage in adult spine fusion surgery, and to assess whether measures to decrease hemorrhage are effective. SUMMARY OF BACKGROUND DATA Significant hemorrhage and associated comorbidities in spine fusion surgery have not yet been clearly identified. Several preoperative and intraoperative techniques are currently available to reduce blood loss and transfusion requirements such as cell saver (CS), recombinant factor VIIa, and perioperative antifibrinolytic agents, such as aprotinin, tranexamic acid, and epsilon-aminocaproic acid. Their effectiveness and safety in spine surgery is uncertain. METHODS A systematic review of the English-language literature was undertaken for articles published between January 1990 and April 2009. Electronic databases and reference lists of key articles were searched to identify published studies examining blood loss in major spine surgery. Two independent reviewers assessed the quality of the literature using the Grading of Recommendations Assessment, Development, and Evaluation criteria. Disagreements were resolved by consensus. RESULTS A total of 90 articles were initially screened, and 17 ultimately met the predetermined inclusion criteria. No studies were found that attempted to define significant hemorrhage in adult spine surgery. We found that there is a high level of evidence that antifibrinolytic agents reduce blood loss and the need of transfusion in adult spine surgery; however, the safety profile of these agents is unclear. There is very low evidence to support the use of CS, recombinant factor VIIa, activated growth factor platelet gel, or normovolemic hemodilution as a method to prevent massive hemorrhage in spine fusion surgery. CONCLUSION There is no consensus definition of significant hemorrhage in adult spine fusion surgery. However, definition in the anesthesiology literature of massive blood loss is somewhat arbitrary but is commonly accepted to entail loss of 1 volume of the patient's total blood (60 mL/kg in adults) in <24 hours. On the basis of the current literature, there is little support for routine use of CS during elective spinal surgery. Concerns related to the use of aprotinin were such that our panel of experts unanimously recommended against its use in spine surgery on the basis of the reports of increased complications. With respect to the antifibrinolytics of the lysine analog class (tranexamic acid and aminocaproic acid), on the basis of the available efficacy and safety data, we recommend that they be considered as possible agents to help reduce major hemorrhage in adult spine surgery.
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Affiliation(s)
- Hossein Elgafy
- Department of Orthopaedics, University of Toledo Medical Center, Toledo, OH 43614-5807, USA.
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Blanchette CM, Joshi AV, Szpalski M, Gunzburg R, Du Bois M, Donceel P, Saunders WB. Burden of blood transfusion in knee and hip surgery in the US and Belgium. J Med Econ 2009; 12:171-9. [PMID: 19622009 DOI: 10.3111/13696990903172760] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Transfusion services in orthopaedic surgery can lead to unnecessary complications and increased healthcare costs. The objective of this study was to assess treatments and costs associated with blood and blood product transfusions in a historical cohort of 189,457 inpatients in the US and 34,987 inpatients in Belgium undergoing knee or hip surgery. METHODS Descriptive analysis, logistic regression and ordinary least squares regression were used to describe the factors associated with the use and cost of allogeneic blood transfusion. RESULTS Hospitalisation costs for joint replacement surgery totalled $12,718 (SD=6,356) and averaged 4.33 days in the US, while costs in Belgium were $6,526 (SD=3,192) and averaged 17.1 days. The use of low molecular weight heparin and tranexamic acid was much higher in Belgium than the US (36% and 99% compared to 0% and 40%, respectively). Patients in the US spent 12.7 (p<0.0001) fewer days in the hospital, 0.3 (p<0.0001) fewer days in the intensive care unit and were 88% less likely to have allogeneic blood transfusions (OR=0.22, 95% CI 0.22-0.23), but incurred $6,483 (p<0.0001) more costs per hospitalisation than patients in Belgium. CONCLUSIONS While hospital costs for patients were greater in the US, length of stay was shorter and patients were less likely to have transfusion services than those patients in Belgium. While this study is limited by factors inherent to observational studies, such as omitted variable bias, misclassification, and disease comorbidity, there are substantial differences in the use of blood products between Belgium and the US.
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Schein J, Janagap-Benson C, Grant R, Sikirica V, Doshi D, Olson W. A comparison of levofloxacin and moxifloxacin use in hospitalized community-acquired pneumonia (CAP) patients in the US: focus on length of stay. Curr Med Res Opin 2008; 24:895-906. [PMID: 18419876 DOI: 10.1185/030079908x273408] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Length of stay (LOS) and hospitalization costs were compared among patients admitted for community-acquired pneumonia (CAP) and initially treated with either levofloxacin 750 mg intravenous (IV) or with moxifloxacin 400 mg IV. Hospital-related complications and relationship of LOS and comorbidities were descriptively examined. METHODS A retrospective database study was conducted of adult patients admitted for CAP and given levofloxacin 750 mg IV or moxifloxacin 400 mg IV through the first 3 days of hospitalization, using the Premier Perspective comparative database. Cohorts were matched 1:1 by hospital geographic location, by coarse caliper propensity scores using all baseline covariates, and by Mahalanobis metric matching based on age and severity (All Patient Refined-Diagnosis-related Groups Severity of Illness (APR-DRG SOI) index). Comparisons between groups were further adjusted for characteristics that remained imbalanced after matching using generalized estimating equation methodology. RESULTS The initial sample of 3868 patients (levofloxacin = 827; moxifloxacin = 3041) was reduced to 1594 (797 patients per treatment group) after matching. Analyses of matched cohorts showed that the mean hospital LOS was significantly shorter for patients treated with levofloxacin 750 mg IV than for those patients treated with moxifloxacin 400 mg IV (5.8 vs. 6.4 days, respectively; least squares mean difference = 0.54 days; p = 0.020). Hospitalization costs were also lower for the levofloxacin 750 mg IV-treated patients (least squares mean difference = US$129; p = 0.753). There were no significant differences in the percentage of patients experiencing complications. LIMITATIONS Although claims databases provide large sample sizes and reflect routine care, they do have several inherent limitations. Since randomization of subjects is not possible, adequate statistical techniques must be used to ensure treatment groups are balanced with respect to patient and clinical characteristics. In addition, data may be missing or miscoded. CONCLUSIONS This retrospective study suggests that among patients hospitalized with CAP, initial treatment with levofloxacin 750 mg IV is associated with a significantly shorter mean hospital LOS compared with treatment with moxifloxacin 400 mg IV. The clinical implications of a shorter hospital LOS include improved patient and economic outcomes.
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Affiliation(s)
- Jeff Schein
- Ortho-McNeil Janssen Scientific Affairs, LLC, Raritan, NJ, USA
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Shorr AF, Sarnes MW, Peeples PJ, Stanford RH, Happe LE, Farrelly E. Comparison of cost, effectiveness, and safety of injectable anticoagulants used for thromboprophylaxis after orthopedic surgery. Am J Health Syst Pharm 2008; 64:2349-55. [PMID: 17989444 DOI: 10.2146/ajhp070178] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The cost, effectiveness, and safety of injectable anticoagulants used for thromboprophylaxis after orthopedic surgery were compared. METHODS This retrospective, observational, cross-sectional, cohort analysis of inpatient billing data was conducted from the institutional perspective. Patients who received dalteparin, enoxaparin, fondaparinux, or unfractionated heparin after orthopedic surgery were included in the analysis. The primary outcome measure was the mean aggregated cost per patient treated with each injectable anticoagulant. Secondary outcomes included the percentages of patients in each treatment group who had a venous thromboembolism (VTE) or major bleeding episode. RESULTS Mean total adjusted costs were significantly lower for fondaparinux ($18,019) compared with other anticoagulants, with unfractionated heparin being the most costly ($20,835). Relative adjusted cost differences were 1.4% (p = 0.0127), 1.8% ( p = 0.0105), and 14.6% (p < 0.0001) higher for enoxaparin, dalteparin, and unfractionated heparin, respectively, compared with fondaparinux. Significantly fewer fondaparinux-treated patients had a VTE event compared with the other treatment groups. The use of dalteparin was associated with fewer major bleeding events, and no significant differences in the rate of major bleeding events were observed among groups treated with fondaparinux, enoxaparin, or unfractionated heparin. CONCLUSION A retrospective analysis of inpatient billing data showed that, among orthopedic surgery patients, fondaparinux was associated with lower institutional cost and a lower frequency of VTE than were dalteparin, enoxaparin, and unfractionated heparin. Dalteparin was associated with a lower rate of major bleeding events than was fondaparinux, but there were no significant differences in such events among fondaparinux, enoxaparin, and unfractionated heparin.
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Affiliation(s)
- Andrew F Shorr
- Pulmonary and Critical Care, Washington Hospital Center, Washington, DC 20010, USA.
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