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Kim AH, Mo KC, Harris AB, Lafage R, Neuman BJ, Hostin RA, Soroceanu A, Kim HJ, Klineberg EO, Gum JL, Gupta MC, Hamilton DK, Schwab F, Burton D, Daniels A, Passias PG, Hart RA, Line BG, Ames C, Lafage V, Shaffrey CI, Smith JS, Bess S, Lenke L, Kebaish KM. High-Dose TXA Is Associated with Less Blood Loss Than Low-Dose TXA without Increased Complications in Patients with Complex Adult Spinal Deformity. J Bone Joint Surg Am 2024:00004623-990000000-01231. [PMID: 39361771 DOI: 10.2106/jbjs.23.01323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
BACKGROUND Tranexamic acid (TXA) is commonly utilized to reduce blood loss in adult spinal deformity (ASD) surgery. Despite its widespread use, there is a lack of consensus regarding the optimal dosing regimen. The aim of this study was to assess differences in blood loss and complications between high, medium, and low-dose TXA regimens among patients undergoing surgery for complex ASD. METHODS A multicenter database was retrospectively analyzed to identify 265 patients with complex ASD. Patients were separated into 3 groups by TXA regimen: (1) low dose (<20-mg/kg loading dose with ≤2-mg/kg/hr maintenance dose), (2) medium dose (20 to 50-mg/kg loading dose with 2 to 5-mg/kg/hr maintenance dose), and (3) high dose (>50-mg/kg loading dose with ≥5-mg/kg/hr maintenance dose). The measured outcomes included blood loss, complications, and red blood cell (RBC) units transfused intraoperatively and perioperatively. The multivariable analysis controlled for TXA dosing regimen, levels fused, operating room time, preoperative hemoglobin, 3-column osteotomy, and posterior interbody fusion. RESULTS The cohort was predominantly White (91.3%) and female (69.1%) and had a mean age of 61.6 years. Of the 265 patients, 54 (20.4%) received low-dose, 131 (49.4%) received medium-dose, and 80 (30.2%) received high-dose TXA. The median blood loss was 1,200 mL (interquartile range [IQR], 750 to 2,000). The median RBC units transfused intraoperatively was 1.0 (IQR, 0.0 to 2.0), and the median RBC units transfused perioperatively was 2.0 (IQR, 1.0 to 4.0). Compared with the high-dose group, the low-dose group had increased blood loss (by 513.0 mL; p = 0.022) as well as increased RBC units transfused intraoperatively (by 0.6 units; p < 0.001) and perioperatively (by 0.3 units; p = 0.024). The medium-dose group had increased blood loss (by 491.8 mL; p = 0.006) as well as increased RBC units transfused intraoperatively (by 0.7 units; p < 0.001) and perioperatively (by 0.5 units; p < 0.001) compared with the high-dose group. CONCLUSIONS Patients with ASD who received high-dose intraoperative TXA had fewer RBC transfusions intraoperatively, fewer RBC transfusions perioperatively, and less blood loss than those who received low or medium-dose TXA, with no differences in the rates of seizure or thromboembolic complications. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew H Kim
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Kevin C Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | | | | | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis School of Medicine, Sacramento, California
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, Louisville, Kentucky
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Frank Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Doug Burton
- Department of Orthopedic Surgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Alan Daniels
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Peter G Passias
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | | | - Breton G Line
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Christopher I Shaffrey
- Department of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Lawrence Lenke
- Department of Orthopedic Surgery, The Spine Hospital, Columbia University, New York, NY
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
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Deng B, Li X, Xie P, Luo X, Yan X. Intravenous versus topical tranexamic acid in spinal surgery: a systematic review and meta-analysis. J Orthop Surg Res 2024; 19:512. [PMID: 39192283 PMCID: PMC11348596 DOI: 10.1186/s13018-024-04989-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 08/06/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND The administration of tranexamic acid (TXA) during spinal surgery has been shown to reduce blood loss. However, the efficacy and safety of intravenous TXA (ivTXA) and topical TXA (tTXA) are poorly documented. The present meta-analysis aimed to compare the efficacy and safety of ivTXA and tTXA administration in spinal surgery. METHODS Potentially relevant academic articles were identified from PubMed, Ovid, Cochrane Library, CNKI database, and Wanfang Data from the date of inception until March 1, 2024. Randomized controlled trials (RCTs) and nonrandomized controlled trials (non-RCTs) were included in our meta-analysis if they compared the efficacy and safety of ivTXA versus tTXA administration during spinal surgery. Secondary sources were identified from the references of the included literature. The meta-analysis was performed in accordance with the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. Data were summarized using RevMan 5.3 software from Denmark. RESULTS Four RCTs and one non-RCT met our inclusion criteria. The pooled outcomes demonstrated that ivTXA groups compared with tTXA groups had significantly less amount of total blood loss [weighted mean difference (WMD)=-159.55, 95% CI (-181.91,-137.19), P < 0.00001], hidden blood loss [WMD=-132.27, 95% CI (-159.81, -104.72), P < 0.00001], intraoperative blood loss [WMD=-86.22, 95% CI (-99.13, -73.31), P < 0.00001, I2 = 96%], and more high postoperative hemoglobin level [WMD = 8.96, 95% CI (5.18, 12.75), P < 0.00001, I2 = 29%], and less transfusion rate [risk ratio (RR) = 1.11, 95% CI (0.81,1.52), P = 0.50, I2 = 94%]. The pooled results showed no significant difference in thromboembolic events (deep venous thrombosis and pulmonary embolism) between the two groups. CONCLUSION Our meta-analysis demonstrated that ivTXA was more effective than tTXA in inducing hemostatic effect during spinal surgery. However, the risk of a thrombotic event was not different between the two administration methods of TXA. More high quality RCTs are needed to further confirm our conclusions.
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Affiliation(s)
- Bo Deng
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Xudong Li
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Peng Xie
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Xiaozhong Luo
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Xueliang Yan
- Department of Spine Surgery, The Second Affiliated Hospital of South China University, Hengyang, 421000, China.
- School of Life Science, Central South University, Changsha, 410000, China.
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Liu X, Ma Z, Wang H, Zhang X, Li S, Zhang M, An J, Luo Z. Effectiveness and Safety of High-Dose Tranexamic Acid in Adolescent Idiopathic Scoliosis Surgery: A Meta-Analysis and Systematic Review. World Neurosurg 2024; 191:39-48. [PMID: 39111654 DOI: 10.1016/j.wneu.2024.07.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Accepted: 07/29/2024] [Indexed: 09/02/2024]
Abstract
OBJECTIVE This systematic review and meta-analysis of randomized controlled trials and retrospective controlled studies aims to evaluate the efficacy and safety of high-dose tranexamic acid (TXA) in spinal correction surgery for adolescent idiopathic scoliosis patients. METHODS In March 2024, a comprehensive search was conducted in PubMed, Web of Science, Embase, and Cochrane databases to identify randomized controlled trials and retrospective controlled studies comparing the effects of high-dose TXA on blood loss and transfusion requirements during spinal correction surgery. RESULTS This meta-analysis included 10 studies encompassing a total of 741 patients. The pooled results indicated that the use of high-dose TXA significantly reduced intraoperative blood loss [weighted mean difference (WMD) = -519.83, 95% CI (-724.74, -314.92), P < 0.00001], transfusion rate [RR = 0.28, 95% CI (0.17, 0.45), P < 0.00001], total blood loss [WMD = -891.09, 95% CI (-1623.92, -158.26), P = 0.02], and postoperative blood loss [WMD = -105.91, 95% CI (-141.29, -70.52), P < 0.00001]. There was no significant difference in operative time [WMD = -18.96, 95% CI (-40.20, 2.28), P = 0.08] and blood loss per segment [WMD = -50.51, 95% CI (-102.19, 1.17), P = 0.06]. Both groups had a comparable incidence of thromboembolic events. CONCLUSIONS Our meta-analysis suggests that the use of high-dose TXA reduces intraoperative blood loss, transfusion rate, total blood loss, and postoperative blood loss in spinal correction surgery for adolescent idiopathic scoliosis patients. However, there were no significant differences in operative time and blood loss per segment.
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Affiliation(s)
- Xin Liu
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China; Key Laboratory of Bone and Joint Disease Research of Gansu Provincial, Lanzhou, China
| | - Zhong Ma
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China; Key Laboratory of Bone and Joint Disease Research of Gansu Provincial, Lanzhou, China
| | - Hao Wang
- Gansu University of Chinese Medicine, Lanzhou, China
| | - Xianxu Zhang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China; Key Laboratory of Bone and Joint Disease Research of Gansu Provincial, Lanzhou, China
| | - Shicheng Li
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China; Key Laboratory of Bone and Joint Disease Research of Gansu Provincial, Lanzhou, China
| | - Mingtao Zhang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China; Key Laboratory of Bone and Joint Disease Research of Gansu Provincial, Lanzhou, China
| | - Jiangdong An
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China
| | - Zhiqiang Luo
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China.
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Luo H, Yang Y, Wang Z, Ma L, Xie C. Efficacy and safety of tranexamic acid in cervical spine surgery: a systematic review and meta-analysis. Front Neurol 2024; 15:1405773. [PMID: 38770522 PMCID: PMC11102962 DOI: 10.3389/fneur.2024.1405773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 04/25/2024] [Indexed: 05/22/2024] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic drug associated with reduced blood loss in a range of surgical specialties. This meta-analysis aimed to compare the efficacy and safety of TXA in cervical surgery, focusing on its effects on intraoperative blood loss and related outcomes. Methods We searched the PubMed, EMBASE, Medline, and Cochrane Library databases to identify all literature related to TXA used in cervical spinal surgery. Intraoperative blood loss, postoperative drainage volume, total blood loss, postoperative hematological variables, and complications were analyzed. Results Eight trials met the inclusion criteria. The pooled results showed that intraoperative blood loss, total blood loss, and postoperative drainage volume were significantly lower in the TXA group than in the control group. The hemoglobin and hematocrit on postoperative day 1 was significantly higher in the TXA group than in the control group. There was no significant difference in complications between the two groups. Conclusion The available evidence indicates that TXA effectively reduces blood loss in cervical spinal surgery while maintaining a favorable safety profile, without increasing associated risks. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023459652.
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Affiliation(s)
- Hua Luo
- Department of Orthopedic, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Yu Yang
- Department of Orthopedic, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Zhitao Wang
- Department of Pharmacy, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Lingping Ma
- Department of Operation Room, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Chengxin Xie
- Department of Orthopedic, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
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Akosman I, Lovecchio F, Fourman M, Sarmiento M, Lyons K, Memtsoudis S, Kim HJ. Is High-Dose Tranexamic Safe in Spine Surgery? A Systematic Review and Meta-Analysis. Global Spine J 2023; 13:2085-2095. [PMID: 36592635 PMCID: PMC10556905 DOI: 10.1177/21925682221148686] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
STUDY DESIGN Literature review and meta-analysis. OBJECTIVES Single-center series may be underpowered to detect whether high-dose (HD) tranexamic acid (TXA) confers a higher risk of complications. We sought to determine the safety and efficacy of HD TXA as compared to low-dose (LD) or placebo. METHODS A systematic literature review was performed to find studies where spine surgery patients were given HD TXA (loading dose ≥30 mg/kg). Complication rates were pooled, and meta-analyses performed on outcomes of interest. Articles were evaluated for risk of bias and a strength of evidence assessment was given for each conclusion. RESULTS Twenty three studies (n = 2331) were included. The pooled medical complication rate was 3.2% in pediatric patients, 8.2% in adults. Using lower dose TXA or placebo as the reference, meta-analysis showed no difference in medical complications (n = 1,723, OR 1.22 [95% CI, .78 to 1.22]; P = .388; I2 = 0%) or thrombotic events (n = 1158 patients, OR 1.27 [95% CI, .71 to 2.63]; P = .528; I2 = 0%). Compared to LD, HD TXA was associated with less intraoperative blood loss (823 patients, WMD = -285 [95% CI, -564 to -5.90]; P = .0454; I2 = 86%), fewer perioperative transfusions (n = 505, OR .28 [95% CI, .082 to .96]; P = .043; I2 = 76%) and lower perioperative transfusion volumes (n = 434, WMD -227.7 mL [95% CI, -377.3 to -78.02]; P = .0029; I2 = 0%). CONCLUSION Compared to LD TXA or placebo, there is moderate evidence that HD is not associated with an increased risk of medical complications. Compared to LD, there is moderate evidence that HD reduces transfusion requirements. High-Dose TXA can be safely utilized in healthy patients undergoing major spine surgery.
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Affiliation(s)
| | - Francis Lovecchio
- Department of Orthopaedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Mitchell Fourman
- Department of Orthopaedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Manuel Sarmiento
- Department of Orthopaedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Keith Lyons
- Department of Orthopaedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Stavros Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY, USA
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Reyes-Sánchez A, Domínguez-Soto A, Zárate-Kalfópulos B, Guerra-Garza J, Gordillo-Pérez R, Huffman C, Rosales-Olivarez LM, Alpízar-Aguirre A, García-Ramos CL. Single Dose of Tranexamic Acid Effectively Reduces Blood Loss in Patients Undergoing Spine Surgery: A Prospective Randomized Controlled Trial. World Neurosurg 2023; 175:e964-e968. [PMID: 37080453 DOI: 10.1016/j.wneu.2023.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE To evaluate the efficacy of oral administration of tranexamic acid (TXA) in spine surgery to achieve blood loss reduction. METHODS Sixty patients undergoing major surgery of the spine were randomly assigned into 2 groups. Group 1 was assigned as the control group and the other group comprised patients who received oral administration of TXA 2 hours before surgery. Outcome measures included intraoperative blood loss, postoperative blood loss, hematologic parameters, blood transfusion needed, and surgical complications. RESULTS Sixty patients linked up with the inclusion criteria. Intraoperative blood loss was significantly lower in the TXA oral group than in the control group; total blood loss in the TXA group was 930.66 ± 614 mL, which was lower than in the control group, with 1075.66 ± 956.11 mL. The mean reduction of hemoglobin was almost the same in both groups. Similarly, the total transfusion package received was lower, and the number of complications and length of stay were akin in both groups. A logistic regression model was performed with patients who had blood loss >1000 mL and surgery time >230 minutes. This result was related to the risk of bleeding, with an odds ratio of 1.31, 95% confidence interval, 1.004-1.023, P = 0.004, independent of the group. CONCLUSIONS Oral TXA is as an effective measure for reducing total blood loss among patients undergoing elective spine surgery.
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Affiliation(s)
| | | | | | - Javier Guerra-Garza
- Spine Surgery Division, National Institute of Rehabilitation, Mexico City, Mexico
| | - Rocio Gordillo-Pérez
- Spine Surgery Division, National Institute of Rehabilitation, Mexico City, Mexico
| | - Curtis Huffman
- Assistant Professor. Development Studies Program, National Autonomous University of Mexico, Mexico City, Mexico
| | | | | | - Carla L García-Ramos
- Spine Surgery Division, National Institute of Rehabilitation, Mexico City, Mexico.
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Nichols G, Andrade E, Gregoski M, Herrera FA, Armstrong MB. Local Infiltration of Tranexamic Acid in Breast Reduction for Symptomatic Macromastia. Ann Plast Surg 2023; 90:S366-S370. [PMID: 36856723 PMCID: PMC11166195 DOI: 10.1097/sap.0000000000003456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND With a surge of tranexamic acid (TXA) use in the plastic surgery community and a constant demand for breast reduction for symptomatic macromastia, questions about the benefits and risks emerge. The aims of this study are to evaluate and compare outcomes of patients undergoing breast reduction while receiving local TXA as opposed to standard procedure without TXA and to assess intraoperative bleeding and operative time. METHODS A retrospective review of breast reductions at a single institution from June 2020 to December 2021 was performed. The breast was infiltrated with tumescent solution at the time of surgery, with or without TXA. The population was divided into 2 groups: the TXA receiving group and tumescent only group. Demographics, intraoperative bleeding, operative time, complications, and drain duration were compared between groups. T test and χ 2 test analyses were performed on IBM SPSS.TM. RESULTS A total of 81 patients and 162 breasts were included. Mean age among patients was 30 ± 13.44 years. Mean SN-N distance was 32.80 ± 3.62 cm. Average resected breast specimen weight was 903.21 ± 336.50 g. Mean operating room time was 159 minutes. Intraoperative blood loss and operative time were not statistically different between groups ( P = 0.583 and P = 0.549, respectively). T-junction dehiscence was lower in the TXA group ( P = 0.016). Incidence of suture granulomas was lower in the TXA group ( P = 0.05). Drain duration was statistically significantly higher in the TXA group ( P = 0.033). CONCLUSIONS No decreases in intraoperative blood loss, operative time, or hematoma were seen after local administration of TXA during breast reduction. The rate of overall complications was not increased by using TXA, and incidence of T-junction dehiscence was lower in the TXA group lending to TXA's relatively safe profile. More research is necessary to further elucidate the TXA-related benefits in standard breast reductions.
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Affiliation(s)
- Georgina Nichols
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina
| | - Erika Andrade
- College of Medicine, Medical University of South Carolina
| | - Mathew Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Fernando A. Herrera
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina
- College of Medicine, Medical University of South Carolina
| | - Milton B. Armstrong
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina
- College of Medicine, Medical University of South Carolina
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Hindman BJ, Gold CJ, Ray E, Wendt LH, Ten Eyck P, Berger JI, Olinger CR, Banks MI, Sanders RD, Howard MA, Woodroffe RW. Surgeon-Specific Treatment Selection Bias and Heterogeneous Perioperative Practices in an Observational Spine Surgery Study. A Statistical Tutorial with Implications for Analysis of Observational Studies of Perioperative Interventions. World Neurosurg 2023; 173:e168-e179. [PMID: 36773808 DOI: 10.1016/j.wneu.2023.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND It is essential that treatment effects reported from retrospective observational studies are as reliable as possible. In a retrospective analysis of spine surgery patients, we obtained a spurious result: tranexamic acid (TXA) had no effect on intraoperative blood loss. This statistical tutorial explains how this result occurred and why statistical analyses of observational studies must consider the effects of individual surgeons. METHODS We used an observational database of 580 elective adult spine surgery patients, supplemented with a review of perioperative medication records. We tested whether common statistical methods (multivariable regression or propensity score-based methods) could adjust for surgeons' selection bias in TXA administration. RESULTS Because TXA administration (frequency, timing, and dose) and surgeon were linked (collinear), estimating and testing the independent effect of TXA on outcome using multivariable regression without including surgeon as a variable would provide biased (spurious) results. Likewise, because of surgeon/TXA linkage, assumptions of propensity score-based analysis were violated, statistical methods to improve comparability between groups failed, and spurious blood loss results were worsened. Others numerous differences among surgeons existed in intraoperative and postoperative practices and outcomes. CONCLUSIONS In observational studies in which individual surgeons determine whether their patients receive the treatment of interest, consideration must be given to inclusion of surgeon as an independent variable in all analyses. Failure to include the surgeon in an analysis of observational data carries a substantial risk of obtaining spurious results, either creating a spurious treatment effect or failing to detect a true treatment effect.
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Affiliation(s)
- Bradley J Hindman
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
| | - Colin J Gold
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Emanuel Ray
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Linder H Wendt
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa, USA
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa, USA
| | - Joel I Berger
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Catherine R Olinger
- Department of Orthopedics and Rehabilitation, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Matthew I Banks
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Robert D Sanders
- Central Clinical School and National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Royce W Woodroffe
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Álvarez-Galovich L, Ley Urzaiz L, Martín-Benlloch JA, Calatayud Pérez J. Recommendations for enhanced post-surgical recovery in the spine (REPOC). Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:83-93. [PMID: 36240991 DOI: 10.1016/j.recot.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/26/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION/OBJECTIVES Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programs to lumbar fusion surgery, a meant benchmark we call REPOC. METHODOLOGY A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries. CONCLUSIONS This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment.
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Affiliation(s)
- L Álvarez-Galovich
- Servicio de Cirugía Ortopédica y Traumatología, Unidad de Columna, Hospital Universitario Fundación Jiménez Díaz, Madrid, España.
| | - L Ley Urzaiz
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J A Martín-Benlloch
- Servicio de Cirugía Ortopédica y Traumatología, Unidad de Columna. Hospital Universitario Dr. Peset de Valencia, Valencia, España
| | - J Calatayud Pérez
- Servicio de Neurocirugía, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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Alvarez-Galovich L, Ley Urzaiz L, Martín-Benlloch JA, Calatayud Pérez J. [Translated article] Recommendations for enhanced post-surgical recovery in the spine (REPOC). Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T83-T93. [PMID: 36535345 DOI: 10.1016/j.recot.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/01/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION/OBJECTIVES Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programmes to lumbar fusion surgery, a meant benchmark we call REPOC. METHODOLOGY A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries. CONCLUSIONS This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment.
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Affiliation(s)
- L Alvarez-Galovich
- Servicio de Cirugía Ortopédica y Traumatología, Unidad de Columna, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain.
| | - L Ley Urzaiz
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J A Martín-Benlloch
- Servicio de Cirugía Ortopédica y Traumatología, Unidad de Columna. Hospital Universitario Dr. Peset de Valencia, Valencia, Spain
| | - J Calatayud Pérez
- Servicio de Neurocirugía, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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Farzanegan G, Ahmadpour F, Khoshmohabbat H, Khadivi M, Rasouli HR, Eslamian M. The Effect of Topical Tranexamic Acid on Intraoperative Blood Loss in Patients Undergoing Posterior Lumbar Laminectomy and Discectomy: A Randomized, Double-Blind, Controlled Trial Study. Asian Spine J 2022; 16:857-864. [PMID: 35184518 PMCID: PMC9827208 DOI: 10.31616/asj.2021.0285] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/09/2021] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN Randomized, double-blind, controlled trial study. PURPOSE This study aimed to evaluate the safety and efficacy of topical tranexamic acid (TXA) on intraoperative blood loss (IBL) in patients that have degenerative lumbar canal stenosis and undergo posterior lumbar laminectomy and discectomy. OVERVIEW OF LITERATURE The volume of IBL is directly proportional to potential surgical complications. Recent reports have shown that the topical use of antifibrinolytic drugs, such as TXA, during surgery might decrease IBL and improve patient outcomes. METHODS A total of 104 patients with lumbar canal stenosis were enrolled in this randomized, double blinded clinical trial. Participants were randomized and divided into two groups: TXA (54 cases) and control (50 cases). In the TXA group, a TXA solution was used for washing and soaking, whereas, in the control group, irrigation of wound was with normal saline. IBL, pre- and postoperative coagulative studies, operation time, conventional hemostatic agent usage, systemic complications, and length of hospitalization were consecutively recorded. All participants were followed for an additional two months to gather data on their recovery status and time to return to work (RTW). RESULTS At baseline, there was no difference in clinical or lab findings, between the groups. IBL and use of hemostatic agents were significantly decreased in TXA group, as compared to the control group (p=0.001 and p=0.011, respectively). Systemic complications, length of hospitalization, and RTW were not significantly different between groups (p=0.47, p=0.38, and p=0.08, respectively). CONCLUSIONS This study showed that topical use of TXA during surgery may decrease IBL and minimize the use of hemostatic materials during posterior midline-approach laminectomy and discectomy, without increasing the potential for complications seen with intravenous TXA usage.
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Affiliation(s)
| | - Fathollah Ahmadpour
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran,
Iran
| | - Hadi Khoshmohabbat
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran,
Iran
| | - Masoud Khadivi
- Spine Center of Excellence, Yas Hospital, Tehran University of Medical Sciences, Tehran,
Iran
| | - Hamid Reza Rasouli
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran,
Iran
| | - Mohammad Eslamian
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran,
Iran
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Gyi R, Cho BC, Hensley NB. Patient Blood Management in Vascular Surgery. Anesthesiol Clin 2022; 40:605-625. [PMID: 36328618 DOI: 10.1016/j.anclin.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.
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Affiliation(s)
- Richard Gyi
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Brian C Cho
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA; Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Nadia B Hensley
- Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA.
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Clohisy JCF, Lenke LG, Dafrawy MHE, Wolfe RC, Frazier E, Kelly MP. Randomized, controlled trial of two tranexamic acid dosing protocols in adult spinal deformity surgery. Spine Deform 2022; 10:1399-1406. [PMID: 35751772 DOI: 10.1007/s43390-022-00539-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/28/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an anti-fibrinolytic effective in reducing blood loss in orthopedic surgery. The appropriate dosing protocol for adult spinal deformity (ASD) surgery is not known. The purpose of this study was to evaluate two TXA protocols [low dose (L): 10 mg/kg bolus, 1 mg/kg/hr infusion; high dose (H): 50 mg/kg, 5 mg/kg/hr] in complex ASD surgery. METHODS Inclusion criteria were ASD reconstructions with minimum 10 fusion levels or planned 3-column osteotomy (3CO). Standard demographic and surgical data were collected. Intraoperative estimated blood loss (EBL) was calculated by suction canisters minus irrigation plus estimated blood lost in sponges, estimated to the nearest 50 mL. Serious adverse events (SAE) were defined a priori as: venothromboembolic event (VTE), cardiac arrhythmia, myocardial infarction, renal dysfunction, and seizure. All SAE were recorded. Simple t tests compared EBL between groups. Mean EBL by total blood volume (TBV), transfusion volume, complications related to TXA were secondary outcomes. RESULTS Sixty-two patients were enrolled and 52 patients completed the study; 25 were randomized to H and 27 to L. Demographic and surgical variables were not different between the two groups. EBL was not different between groups (H: 1596 ± 933 cc, L: 2046 ± 1105 cc, p = 0.12, 95% CI: - 1022 to 122 cc). EBL as a percentage of TBV was lower for the high-dose group (H: 29.5 ± 14.8%, L: 42.5 ± 26.2%, p = 0.03). Intraoperative transfusion volume (H: 961 ± 505 cc, L: 1105 ± 808 cc, p = 0.5) and post-operative transfusion volume (H: 513 ± 305 cc, L: 524 ± 245 cc, p = 0.9) were not different. SAE related to TXA were not different (p = 0.7) and occurred in 2 (8%) H and 3 (11%) L. There was one seizure (H), 2 VTE, and 2 arrhythmias. CONCLUSION No differences in EBL, transfusion volume, nor SAE were observed between H and L dose TXA protocols. High dose was associated with decreased TBV loss (13%). Further prospective study, with pharmacologic analysis, is required to determine appropriate TXA dosage in ASD surgeries. LEVEL OF EVIDENCE Therapeutic Level II. TRIAL REGISTRATION The study was registered at Clinicaltrials.gov (NCT02053363) February 3, 2014.
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Affiliation(s)
- John C F Clohisy
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Rachel C Wolfe
- Perioperative Services and Surgical Critical Care, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Elfaridah Frazier
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael P Kelly
- Rady Children's Hospital, University of California, 3020 Children's Way, San Diego, CA, 92123, USA.
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Zheng B, Zheng B, Niu H, Wang X, Lv G, Li J, Wang J. Effect Analysis of Preoperative Intravenous Tranexamic Acid Combined With Intraoperative Immersion in Reducing Perioperative Blood Loss of One Stage Posterior Thoracolumbar Tuberculosis. Front Surg 2022; 9:852589. [PMID: 35813048 PMCID: PMC9260174 DOI: 10.3389/fsurg.2022.852589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background To investigate the efficacy and safety of preoperative intravenous tranexamic acid (TXA) combined with intraoperative immersion in reducing perioperative blood loss in one-stage posterior thoracolumbar tuberculosis. Methods All patients were divided into four groups: Group A received an intravenous drip of TXA before surgery, group B received multiple local immersions during the operation, group C received an intravenous drip combined with multiple local immersions, and the control group (group CG) were not treated with TXA during the same period. The total blood loss (TBL), intraoperative blood loss (IBL), hidden blood loss (HBL), postoperative drainage volume, maximum hemoglobin drop value (max Hb drop), liver and kidney function, coagulation indexes, blood transfusion rate, hospital stay and incidence of complications were compared among the four groups. Results TBL, IBL, HBL, max Hb drop, POD1 drainage, and POD2 drainage in group A, group B, and group C were significantly lower than those in group CG. TBL, IBL, HBL and max Hb drop were group C < group A < group B < group CG. The drainage volume of group C was significantly lower than that of the other groups. There was no significant difference in blood coagulation index (PT, D-D) or liver and kidney function (ALT, Cr) among the four groups. There was no difference in postoperative hospital stay between group A and group B, but it was significantly lower in group C than in the other three groups. All patients achieved satisfactory bone graft fusion at the last follow-up. Conclusion Preoperative intravenous drip of TXA combined with intraoperative multiple immersion can effectively reduce perioperative blood loss while not increasing the risk of thrombosis without affecting liver and kidney function, coagulation function or tuberculosis prognosis.
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Affiliation(s)
- Bowen Zheng
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Musculoskeletal Tumor Center, Peking University People's Hospital, Peking University, Beijing, China
| | - Boyv Zheng
- Department of Orthopedics Surgery, General Hospital of the Central Theater Command, Wuhan, China
| | - Huaqing Niu
- Department of Orthopedics Surgery, General Hospital of the Central Theater Command, Wuhan, China
| | - Xiaobin Wang
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Guohua Lv
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jing Li
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Correspondence: Jing Li Jingyu Wang
| | - Jingyu Wang
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Correspondence: Jing Li Jingyu Wang
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Haddad AF, Ames CP, Safaee M, Deviren V, Lau D. The Effect of Systemic Tranexamic Acid on Hypercoagulable Complications and Perioperative Outcomes Following Three-Column Osteotomy for Adult Spinal Deformity. Global Spine J 2022; 12:423-431. [PMID: 32969252 PMCID: PMC9121167 DOI: 10.1177/2192568220953812] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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 Retrospective cohort study. OBJECTIVE Thoracolumbar 3-column osteotomy (3CO) is a powerful technique for correction of rigid adult spinal deformity (ASD). However, it can be associated with high-volume blood loss. This study seeks to investigate the efficacy and safety of tranexamic acid (TXA) in 3CO ASD patients. METHODS ASD patients who underwent 3CO from 2006 to 2019 were retrospectively reviewed. Outcomes were compared between TXA and non-TXA patients, and TXA doses. RESULTS A total of 365 ASD patients were included: 181 TXA and 184 non-TXA. The mean age was 64.6 years and 60.5% were female. Operative time was shorter in the TXA group (295.6 vs 320.2 minutes, P < .001). However, TXA was not associated with shorter operative time (β = -6.5 minutes, 95% CI -29.0 to 15.9, P = .567) after accounting for surgeon experience. There was no difference in blood loss (2020.2 vs 1914.1 mL, P = .437) between groups. Overall complications (37.0% vs 33.2%, P = .439), including hypercoagulable (2.2% vs 3.8%, P = .373) and cardiac (13.3% vs 7.1%, P = .050) complications were similar between groups. TXA was not independently associated with blood loss or TXA-related complications. Both groups had comparable intensive care unit (2.5 vs 2.0 days, P = .060) and hospital (8.9 vs 8.2 days, P = .190) stays. There were no differences in outcomes between TXA dosing subgroups. CONCLUSIONS Systemic TXA use during 3CO for ASD surgery was not associated with decreased blood loss. TXA patients had shorter operative times, but this was driven mainly by surgeon experience on multivariate analysis. Routine use of TXA is safe and does not increase the incidence of hypercoagulable complications even at high doses.
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Affiliation(s)
| | | | - Michael Safaee
- University of California, San Francisco, San Francisco, CA, USA
| | - Vedat Deviren
- University of California, San Francisco, San Francisco, CA, USA
| | - Darryl Lau
- University of California, San Francisco, San Francisco, CA, USA
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Ma J, Huang Z, Huang Q, Zhou Z, Pei F, Shen B. Tranexamic acid combined with compression dressing reduces blood loss in gluteal muscle contracture surgery. BMC Surg 2022; 22:46. [PMID: 35148736 PMCID: PMC8832768 DOI: 10.1186/s12893-022-01497-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/25/2022] [Indexed: 02/08/2023] Open
Abstract
Background Blood loss and incision-related complications caused by the surgical procedure to release gluteal muscle contracture (GMC) put negative effects on the surgical outcomes. Current procedures to prevent blood loss and complications are not satisfactory. The current study aimed to determine whether tranexamic acid (TXA) in combination with pressure dressing reduce the amount of blood loss, the rate of incision-related complications, and the rate of readmission for patients undergoing surgeries to release GMC. Methods 49 GMC patients were finally included in the study and were randomly divided into two groups: study group and control group. Patients in both groups received minimally invasive surgery to release GMC except that in the study group, patients were administered a dosage of 20 mg/kg of intravenous TXA preoperatively, and 2 subsequent dosages of TXA at 10 mg/kg at two time points: 3 and 6 h after the first dose. Gauze soaked with TXA was used to pack the wound for 10 min before the incision closure. Then the wound was pressure-wrapped with a hip-spica bandage for 24 h after the surgery in the study group. Results The level of UBL in the study group was significantly lower compared to that in the control group. Similar results were also found for UMHD and UMAD. The incision-related postoperative complications were greatly decreased in the study group compared to those of the control group as well. So was the 30-day readmission rate. All patients in both groups reached “excellent” or “good” level with respect to the postoperative function evaluation. Conclusions Intravenous and topical application of TXA combined with 24 h pressure hip-spica bandage reduces perioperative blood loss, rate of incision-related complications, and the rate of readmission for GMC patients undergoing minimally invasive surgical releasing procedure. Trial Registration Chinese Clinical and Trial Registry ChiCTR2000039216, registration date 2020/10/22, retrospectively registered
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Affiliation(s)
- Jun Ma
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - ZeYu Huang
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Qiang Huang
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - ZongKe Zhou
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - FuXing Pei
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Bin Shen
- Department of Orthopedics Surgery, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China.
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Huang L, Li P, Gu X, Zhao R, Ma X, Wei X. The administration of tranexamic acid for corrective surgery involving eight or more spinal levels: A systematic review and meta-analysis. Asian J Surg 2021; 45:681-688. [PMID: 34930653 DOI: 10.1016/j.asjsur.2021.06.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/18/2021] [Accepted: 06/15/2021] [Indexed: 11/17/2022] Open
Abstract
As the number of fusion levels increases, the complexity of spinal correction surgery also increases. Thus, we conducted this study to determine the safety and efficacy of tranexamic acid (TXA) involving eight or more spinal fusion levels. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines, a search of the PubMed, Embase, CENTRAL, Web of Science, and ClinicalTrials.gov databases was conducted for relevant studies published prior to May 30, 2019. The primary outcomes, including blood loss and transfusion requirement, and the secondary outcomes, including general indices, postoperative hemoglobin, and coagulation function, were analyzed using Rev Man 5.3.5 software and STATA version 12.0. Eight randomized controlled trials (473 participants) were included in the study. Compared to the control treatments, TXA reduced intraoperative blood loss, total blood loss, transfusion volume, and prothrombin time. There were no significant differences between the TXA and non-TXA groups in transfusion rate, operative time, hospital stay, complications, hemoglobin level, and other coagulation function parameters. In the pediatric subgroup analysis, TXA additionally improved hemoglobin levels, platelet count, and prothrombin time international normalized ratio. The present meta-analysis showed that TXA reduced blood loss and transfusion volume in both adults and children. In pediatric patients, TXA led to a greater benefit in postoperative hemoglobin levels and coagulation function. Intravenous TXA is safe and effective in children with eight or more spinal corrective levels.
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Affiliation(s)
- Lingan Huang
- Department of Orthopedics, Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, No. 382 Wuyi Road, Xinghualing District, Taiyuan, 030000, People's Republic of China
| | - Pengcui Li
- Department of Orthopedics, Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, No. 382 Wuyi Road, Xinghualing District, Taiyuan, 030000, People's Republic of China
| | - Xiaodong Gu
- Department of Orthopedics, Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, No. 382 Wuyi Road, Xinghualing District, Taiyuan, 030000, People's Republic of China
| | - Ruipeng Zhao
- Department of Orthopedics, Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, No. 382 Wuyi Road, Xinghualing District, Taiyuan, 030000, People's Republic of China
| | - Xiang Ma
- Department of Anesthesiology, Shanxi Medical University, Taiyuan, 030000, People's Republic of China
| | - Xiaochun Wei
- Department of Orthopedics, Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, No. 382 Wuyi Road, Xinghualing District, Taiyuan, 030000, People's Republic of China.
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Brown NJ, Choi EH, Gendreau JL, Ong V, Himstead A, Lien BV, Shahrestani S, Ransom SC, Tran K, Tafreshi AR, Sahyouni R, Chan A, Oh MY. Association of tranexamic acid with decreased blood loss in patients undergoing laminectomy and fusion with posterior instrumentation: a systematic review and meta-analysis. J Neurosurg Spine 2021; 36:686-693. [PMID: 34740174 DOI: 10.3171/2021.7.spine202217] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tranexamic acid (TXA) is an antifibrinolytic agent associated with reduced blood loss and mortality in a wide range of procedures, including spine surgery, traumatic brain injury, and craniosynostosis. Despite this wide use, the safety and efficacy of TXA in spine surgery has been considered controversial due to a relative scarcity of literature and lack of statistical power in reported studies. However, if TXA can be shown to reduce blood loss in laminectomy with fusion and posterior instrumentation, more surgeons may include it in their armamentarium. The authors aimed to conduct an up-to-date systematic review and meta-analysis of the efficacy of TXA in reducing blood loss in laminectomy and fusion with posterior instrumentation. METHODS A systematic review and meta-analysis, abiding by PRISMA guidelines, was performed by searching the databases of PubMed, Web of Science, and Cochrane. These platforms were queried for all studies reporting the use of TXA in laminectomy and fusion with posterior instrumentation. Variables retrieved included patient demographics, surgical indications, involved spinal levels, type of laminectomy performed, TXA administration dose, TXA route of administration, operative duration, blood loss, blood transfusion rate, postoperative hemoglobin level, and perioperative complications. Heterogeneity across studies was evaluated using a chi-square test, Cochran's Q test, and I2 test performed with R statistical programming software. RESULTS A total of 7 articles were included in the qualitative study, while 6 articles featuring 411 patients underwent statistical analysis. The most common route of administration for TXA was intravenous with 15 mg/kg administered preoperatively. After the beginning of surgery, TXA administration patterns were varied among studies. Blood transfusions were increased in non-TXA cohorts compared to TXA cohorts. Patients administered TXA demonstrated a significant reduction in blood loss (mean difference -218.44 mL; 95% CI -379.34 to -57.53; p = 0.018). TXA administration was not associated with statistically significant reductions in operative durations. There were no adverse events reported in either the TXA or non-TXA patient cohorts. CONCLUSIONS TXA can significantly reduce perioperative blood loss in cervical, thoracic, and lumbar laminectomy and fusion procedures, while demonstrating a minimal complication profile.
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Affiliation(s)
- Nolan J Brown
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Elliot H Choi
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Julian L Gendreau
- 3Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Vera Ong
- 4Department of Neurosurgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
| | - Alexander Himstead
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Brian V Lien
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Shane Shahrestani
- 5Keck School of Medicine of University of Southern California, Los Angeles, California.,6Medical Scientist Training Program, California Institute of Technology, Pasadena, California
| | - Seth C Ransom
- 7College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Katelynn Tran
- 8University of Southern California, Los Angeles, California
| | - Ali R Tafreshi
- 9Department of Neurological Surgery, Geisinger Health System, Danville, Pennsylvania; and
| | - Ronald Sahyouni
- 10Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Alvin Chan
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Michael Y Oh
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
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20
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Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 34:257-276. [PMID: 34483301 DOI: 10.1097/ana.0000000000000799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/14/2021] [Indexed: 11/25/2022]
Abstract
Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.
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21
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Yuan L, Jiang Y, Liu Y, Zeng Y, Chen Z, Li W. Cost-Benefit Analysis of Using A Single Dose of Tranexamic Acid in Degenerative Lumbar Scoliosis Patients Undergoing Long-Segment Spinal Fusion Surgery: A Retrospective Study. Med Sci Monit 2021; 27:e930352. [PMID: 34424890 PMCID: PMC8394591 DOI: 10.12659/msm.930352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Degenerative lumbar scoliosis (DLS) patients undergoing posterior long-segment spinal fusion surgery often require perioperative blood transfusions, and previous studies have reported that increased complications and additional costs accompany these transfusions. One method for decreasing transfusions is the administration of tranexamic acid (TXA). We sought to evaluate the costs and benefits of preoperative administration of 1 g of intravenous TXA, without maintenance, in DLS patients undergoing long-segment spinal fusion surgery. Material/Methods Patients who received TXA (TXA group) were compared with patients who did not receive TXA (NTXA group) with regard to blood loss, units of packed red blood cells (PRBC) transfused, hemostasis costs, and perioperative complications. The benefits and costs were estimated through analysis of the spending on NTXA and TXA patients, and were compared. The difference between the cost per patient in the 2 groups was designated as the net cost-benefit. Then, both groups were substratified into non-osteotomy and osteotomy subgroups for further analysis. Results Of the 173 patients who met the inclusion criteria, 54 TXA patients had significantly reduced perioperative blood loss and total hemostasis costs compared with NTXA patients (n=119). In the group without osteotomy (n=72), TXA (n=13) reduced perioperative blood loss but did not significantly decrease PRBC units and hemostasis costs. However, in patients undergoing osteotomy (n=101), a remarkable net cost savings of ¥648.77 per patient was shown in the TXA group (n=41) (P<0.001). This was because patients undergoing osteotomy in the TXA group received fewer PRBC units (3.7 vs 5.7, P=0.001). Conclusions A single dose of TXA significantly decreased perioperative blood loss and total hemostasis costs for DLS patients undergoing osteotomy. Furthermore, TXA led to no additional net costs in patients without osteotomy.
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Affiliation(s)
- Lei Yuan
- Department of Orthopedics, Peking University Third Hospital, Beijing, China (mainland).,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China (mainland).,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China (mainland)
| | - Yu Jiang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China (mainland).,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China (mainland).,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China (mainland)
| | - Yinhao Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China (mainland).,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China (mainland).,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China (mainland)
| | - Yan Zeng
- Department of Orthopedics, Peking University Third Hospital, Beijing, China (mainland).,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China (mainland).,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China (mainland)
| | - Zhongqiang Chen
- Department of Orthopedics, Peking University Third Hospital, Beijing, China (mainland).,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China (mainland).,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China (mainland)
| | - Weishi Li
- Department of Orthopedics, Peking University Third Hospital, Beijing, China (mainland).,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China (mainland).,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China (mainland)
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Ockerman A, Vanassche T, Garip M, Vandenbriele C, Engelen MM, Martens J, Politis C, Jacobs R, Verhamme P. Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review. Thromb J 2021; 19:54. [PMID: 34380507 PMCID: PMC8356407 DOI: 10.1186/s12959-021-00303-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications. METHODS An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles. FINDINGS TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma. CONCLUSIONS TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.
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Affiliation(s)
- Anna Ockerman
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium.
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Melisa Garip
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Jeroen Martens
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Verhamme
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Tranexamic acid given into wound reduces postoperative drainage, blood loss, and hospital stay in spinal surgeries: a meta-analysis. J Orthop Surg Res 2021; 16:401. [PMID: 34158096 PMCID: PMC8220711 DOI: 10.1186/s13018-021-02548-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 06/09/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Although intravenous tranexamic acid administration (ivTXA) has prevailed in clinical antifibrinolytic treatment, whether it increases thromboembolic risks has remained controversial. As a potent alternative to ivTXA, topical use of TXA (tTXA) has been successfully applied to attenuate blood loss in various surgical fields while minimizing systemic exposure to TXA. This meta-analysis was conducted to gather scientific evidence for tTXA efficacy on reducing postoperative drainage, blood loss, and the length of hospital stay in spine surgeries. OBJECTIVES To examine whether topical use of TXA (tTXA) reduces postoperative drainage output and duration, hidden blood loss, hemoglobin level drop, hospital stay, and adverse event rate, we reviewed both randomized and non-randomized controlled trials that assessed the aforementioned efficacies of tTXA compared with placebo in patients undergoing cervical, thoracic, or lumbar spinal surgeries. METHODS An exhaustive literature search was conducted in MEDLINE and EMBASE databases from January 2000 through March 2020. Measurable outcomes were pooled using Review Manager (RevMan) version 5.0 in a meta-analysis. RESULTS Significantly reduced postoperative drainage output (weighted mean difference [WMD]= - 160.62 ml, 95% confidence interval (95% CI) [- 203.41, - 117.83]; p < .00001) and duration (WMD= - 0.75 days, 95% CI [- 1.09, - 0.40]; p < .0001), perioperative hidden blood loss (WMD= - 91.18ml, 95% CI [- 121.42, - 60.94]; p < .00001), and length of hospital stay (WMD= - 1.32 days, 95% CI [- 1.90, - 0.74]; p < .00001) were observed in tTXA group. Pooled effect for Hb level drop with tTXA vs placebo crossed the equivalent line by a mere 0.05 g/dL, with the predominant distribution of 95% confidence interval (CI) favoring tTXA use. CONCLUSIONS With the most comprehensive literature inclusion up to the present, this meta-analysis suggests that tTXA use in spinal surgeries significantly reduces postoperative drainage, hidden blood loss, and hospital stay duration. The pooled effect also suggests that tTXA appears more effective than placebo in preserving postoperative Hb level, which needs further validation by future studies.
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Licina A, Silvers A, Laughlin H, Russell J, Wan C. Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components. BMC Anesthesiol 2021; 21:74. [PMID: 33691620 PMCID: PMC7944908 DOI: 10.1186/s12871-021-01281-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 02/16/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review. METHODS We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway. RESULTS We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components. CONCLUSIONS We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.
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Affiliation(s)
- Ana Licina
- Austin Health, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - Andrew Silvers
- Monash Health, Clayton, Australia, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria Australia
| | | | - Jeremy Russell
- Department of Neurosurgery, Austin Health, Melbourne, Victoria, Australia
| | - Crispin Wan
- Royal Hobart Hospital, Hobart, Tasmania, Australia
- St Vincent’s Hospital, Melbourne, Australia
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Shrestha IK, Ruan TY, Lin L, Tan M, Na XQ, Qu QC, Chen JC, Si YY, Tao JP. The efficacy and safety of high-dose tranexamic acid in adolescent idiopathic scoliosis: a meta-analysis. J Orthop Surg Res 2021; 16:53. [PMID: 33446219 PMCID: PMC7807519 DOI: 10.1186/s13018-020-02158-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Background This study aimed to evaluate the efficacy and safety of using high-dose intravenous tranexamic acid (TXA) to reduce blood loss in idiopathic scoliosis surgery. Methods This study was a meta-analysis, which consisted of retrospective cohort studies (RCSs) and randomized control trials (RCTs) found by searching electronic databases, namely PubMed, Web of Science, The Cochrane Central Register of Controlled Trials (CENTRAL), and the Google Scholar Database, dating from 1960 to 2019. The points of interest included total blood loss, a need for transfusion and transfusion criteria, surgery time, and the evidence of intraoperative and postoperative complications, such as seizures or thromboembolic events. The weighted mean differences (WMD) and 95% confidence interval (CI) of blood loss in the TXA intervention group compared to the control or placebo group were extracted and combined using the random effects model. Results In this meta-analysis, there was a total of three RCSs and two RCTs, which involved 334 patients. The results showed that blood loss is significantly reduced, with a weighted mean difference in the TXA group (WMD = − 525.14, P = 0.0000, CI ranged from − 839.83, − 210.44, I2 = 82%). Heterogeneity was assessed using the random effects model. Conclusions A high dose of intravenous TXA reduced blood loss during adolescent idiopathic scoliosis surgery and did not lead to any significant thromboembolic event. Therefore, a high dose appears to be effective and safe for adolescent idiopathic scoliosis surgery. However, more high-quality research based on larger randomized controlled trials is still needed.
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Affiliation(s)
- Indra K Shrestha
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Tian-Yi Ruan
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Lan Lin
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Miao Tan
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Xue-Qing Na
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Qi-Cai Qu
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Jian-Chun Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Yong-Yu Si
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China.
| | - Jian-Ping Tao
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China.
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Perioperative and Anesthetic Considerations for Patients with Degenerative Spine Disease. Anesthesiol Clin 2021; 39:19-35. [PMID: 33563381 DOI: 10.1016/j.anclin.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The demand for spine surgery has dramatically increased over the last 2 decades. As the population ages and surgical and anesthetic techniques advance, the perioperative care of spine surgery patients poses challenges to anesthesiologists. Perioperative outcomes in terms of a decrease in complication rates and total health care expenditures have directed perioperative care to focus on enhanced recovery after surgery protocols, which many institutions have adopted. The role of anesthesiologists in the care of patients undergoing spine surgery is expanding beyond intraoperative care; consequently, a multidisciplinary approach is the best direction for optimal patient care.
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27
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Dunn LK, Chen CJ, Taylor DG, Esfahani K, Brenner B, Luo C, Buell TJ, Spangler SN, Buchholz AL, Smith JS, Shaffrey CI, Nemergut EC, Durieux ME, Naik BI. Postoperative Low-Dose Tranexamic Acid After Major Spine Surgery: A Matched Cohort Analysis. Neurospine 2020; 17:888-895. [PMID: 33401867 PMCID: PMC7788407 DOI: 10.14245/ns.2040114.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/22/2020] [Accepted: 05/08/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE This was a retrospective, cohort study investigating the efficacy and safety of continuous low-dose postoperative tranexamic acid (PTXA) on drain output and transfusion requirements following adult spinal deformity surgery. METHODS One hundred forty-seven patients undergoing posterior instrumented thoracolumbar fusion of ≥ 3 vertebral levels at a single institution who received low-dose PTXA infusion (0.5-1 mg/kg/hr) for 24 hours were compared to 292 control patients who did not receive PTXA. The cohorts were propensity matched based on age, sex, American Society of Anesthesiologist physical status classification, body mass index, number of surgical levels, revision surgery, operative duration, and total intraoperative TXA dose (n = 106 in each group). Primary outcome was 72-hour postoperative drain output. Secondary outcomes were number of allogeneic blood transfusions. RESULTS There was no significant difference in postoperative drain output in the PTXA group compared to control (660 ± 420 mL vs. 710 ± 490 mL, p = 0.46). The PTXA group received significantly more crystalloid (6,100 ± 3,100 mL vs. 4,600 ± 2,400 mL, p < 0.001) and red blood cell transfusions postoperatively (median [interquartile range]: 1 [0-2] units vs. 0 [0-1] units; incidence rate ratio [95% confidence interval], 1.6 [1.2-2.2]; p = 0.001). Rates of adverse events were comparable between groups. CONCLUSION Continuous low-dose PTXA infusion was not associated with reduced drain output after spinal deformity surgery. No difference in thromboembolic incidence was observed. A prospective dose escalation study is warranted to investigate the efficacy of higher dose PTXA.
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Affiliation(s)
- Lauren K. Dunn
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Davis G. Taylor
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Brian Brenner
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Charles Luo
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Thomas J. Buell
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Sarah N. Spangler
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Avery L. Buchholz
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Justin S. Smith
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Christopher I. Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Edward C. Nemergut
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Marcel E. Durieux
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Bhiken I. Naik
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
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杨 小, 郝 定, 王 晓, 高 文, 惠 浩. [Efficacy and safety of tranexamic acid sequential rivaroxaban on blood loss in elderly patients during lumbar interbody fusion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1158-1162. [PMID: 32929910 PMCID: PMC8171734 DOI: 10.7507/1002-1892.202002041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/17/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the effect and safety of tranexamic acid sequential rivaroxaban on perioperative blood loss and preventing thrombosis for elderly patients during lumbar interbody fusion (LIF) with a prospective randomized controlled study. METHODS Between April and October 2019, the elderly patients with lumbar degenerative diseases requiring LIF were included in the study, among which were 80 patients met the selection criteria. According to the antifibrinolysis and anticoagulation protocols, they were randomly divided into a tranexamic acid sequential rivaroxaban group (trial group) and a simple rivaroxaban group (control group) on average. Finally, 69 patients (35 in the trial group and 34 in the control group) were included for comparison. There was no significant difference in general data ( P>0.05) such as gender, age, body mass index, disease duration, diseased segment, type of disease, and preoperative hemoglobin between the two groups. The operation time, intraoperative blood loss, drainage within 3 days after operation, perioperative total blood loss, and proportion of blood transfusion patients were compared between the two groups, as well as postoperative venous thrombosis of lower extremities, pulmonary embolism, and bleeding-related complications. RESULTS The operations of the two groups completed successfully, and there was no significant difference in the operation time ( P>0.05); the intraoperative blood loss, drainage within 3 days after operation, and perioperative total blood loss in the trial group were significantly lower than those in the control group ( P<0.05). The proportion of blood transfusion patients in the trial group was 25.71% (9/35), which was significantly lower than that in the control group [52.94% (18/34)] ( χ 2=5.368, P=0.021). Postoperative incision bleeding occurred in 4 cases of the trial group and 3 cases of the control group, and there was no significant difference in bleeding-related complications between the two groups ( P=1.000). There was 1 case of venous thrombosis of the lower extremities in each group after operation, and there was no significant difference in the incidence between the two groups ( P=1.000). Besides, no pulmonary embolism occurred in the two groups. CONCLUSION Perioperative use of tranexamic acid sequential rivaroxaban in elderly LIF patients can effectively reduce the amount of blood loss and the proportion of blood transfusion patients without increasing the risk of postoperative thrombosis.
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Affiliation(s)
- 小卫 杨
- 西安交通大学附属红会医院脊柱外科(西安 710054)Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P.R.China
| | - 定均 郝
- 西安交通大学附属红会医院脊柱外科(西安 710054)Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P.R.China
| | - 晓东 王
- 西安交通大学附属红会医院脊柱外科(西安 710054)Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P.R.China
| | - 文杰 高
- 西安交通大学附属红会医院脊柱外科(西安 710054)Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P.R.China
| | - 浩 惠
- 西安交通大学附属红会医院脊柱外科(西安 710054)Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P.R.China
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Esfahani K, Dunn LK, Naik BI. Blood Conservation for Complex Spine and Intracranial Procedures. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Xiong Z, Liu J, Yi P, Wang H, Tan M. Comparison of Intravenous versus Topical Tranexamic Acid in Nondeformity Spine Surgery: A Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:7403034. [PMID: 32219141 PMCID: PMC7085364 DOI: 10.1155/2020/7403034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 01/14/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Tranexamic acid (TXA), an antifibrinolytic agent, interferes with fibrinolysis and has been used for many years to reduce blood loss during spine surgery. The purpose of our meta-analysis was to compare the effect of intravenous versus topical administration of TXA in patients undergoing nondeformity spine surgery. METHODS We searched multiple databases, including PubMed, Embase, the Cochrane library, CNKI, WanFang database, and VIP to find studies that met the inclusion criteria. A meta-analysis was performed according to the guidelines of the Cochrane Reviewer's Handbook. RESULTS Eight randomized controlled trials (RCTs) were identified, including 660 patients. The surgical methods used in the included studies were nondeformity spine surgery. No significant differences were found in the two groups regarding total blood loss, intraoperative blood loss, hidden blood loss, hematocrit, hemoglobin, fibrinogen, postoperative prothrombin time (PT), postoperative activated partial thromboplastin time (APTT), drainage volume, and blood transfusion rate. There were statistically significant differences in the two groups in terms of preoperative PT (MD = -0.39, 95% CI: [-0.63, -0.15], P=0.002) and preoperative APTT (MD = 1.12, 95% CI: [0.57, 1.68], P=0.002) and preoperative APTT (MD = 1.12, 95% CI: [0.57, 1.68]. CONCLUSION During nondeformity spine surgery, intravenous administration of TXA did not have a significant effect on the decrease of blood loss and blood transfusion rate compared with the topical group. According to the pooled analysis of PT and APTT, intravenous and topical application of TXA may have different effects on the coagulation pathway. More high-quality RCTs are needed to explore the optimal dosage, method, timing in the future in order to recommend TXA widespread use in spine surgery.
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Affiliation(s)
- Zhencheng Xiong
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100029, China
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Junyuan Liu
- Peking University Aerospace School of Clinical Medicine, Beijing 100029, China
| | - Ping Yi
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Hao Wang
- Beijing University of Chinese Medicine, Beijing 100029, China
| | - Mingsheng Tan
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100029, China
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing 100029, China
- Beijing University of Chinese Medicine, Beijing 100029, China
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Anesthetic management of complex spine surgery in adult patients: a review based on outcome evidence. Curr Opin Anaesthesiol 2020; 32:600-608. [PMID: 31461735 DOI: 10.1097/aco.0000000000000765] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to review the evidence regarding the anesthetic management of blood loss, pain control, and position-related complications of adult patients undergoing complex spine procedures. RECENT FINDINGS The most recent evidence of the anesthetic management of complex spine surgery was identified with a systematic search and graded. In our review, prophylactic tranexamic acid and optimal prone positioning were shown to be effective blood conservation strategies with minimal risks to the patients. Cell saver was cost-effective in complex surgeries with expected blood loss of greater than 500 ml. As for pain control, most interventions only produced mild analgesic effects, suggesting a multimodal approach is necessary to achieve optimal pain control after spine surgery. Regional techniques and NSAIDs were effective but because of their risks, their usage should be discussed with the surgical team. Further studies are required to assess the effectiveness, cost-effectiveness, and risks associated with combined uses of different analgesic interventions. On the basis of the available evidence, we recommend a combined use of gabapentinoids, ketamine, and opioids to achieve optimal analgesia. Lastly, literature for position-related injuries is heavily relied on case reports and the Anesthesia Closed Claim Study because of their rarity. Therefore, we advocate for a structured team-based approach with checklists to minimize position-related complications. SUMMARY As the number and complexity of spine procedures are being performed worldwide is increasing, we suggested to bundle the aforementioned effective interventions as part of an ERAS spine protocol to improve the patient outcome of spine surgery.
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Khanna P, Sarkar S, Garg B. Anesthetic considerations in spine surgery: What orthopaedic surgeon should know! J Clin Orthop Trauma 2020; 11:742-748. [PMID: 32879562 PMCID: PMC7452283 DOI: 10.1016/j.jcot.2020.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/26/2022] Open
Abstract
With clinical innovation and technological advancement, the paradigm of surgical procedures on the spine and spinal cord along with the perioperative management are rapidly evolving. Irrespective of different modes the anesthetic management of spine surgery is challenging in view of significant blood loss, prolong procedure, position-related complications, and complex pain management. The enhanced recovery after surgery (ERAS) for this kind of surgery is yet to be finalized. The aim of this article is to highlight the current evidence-based major perioperative considerations for patients undergoing spine surgery.
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Affiliation(s)
- Puneet Khanna
- Department of Anaesthesia, Pain Medicine & Critical Care, AIIMS, New Delhi, India
- Corresponding author.
| | - Soumya Sarkar
- Department of Anaesthesia, Pain Medicine & Critical Care, AIIMS, New Delhi, India
| | - Bhavuk Garg
- Department of Orthopaedics, AIIMS, New Delhi, India
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Raman T, Varlotta C, Vasquez-Montes D, Buckland AJ, Errico TJ. The use of tranexamic acid in adult spinal deformity: is there an optimal dosing strategy? Spine J 2019; 19:1690-1697. [PMID: 31202836 DOI: 10.1016/j.spinee.2019.06.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/20/2019] [Accepted: 06/11/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT ASD (Adult spinal deformity) surgery often entails complex osteotomies and realignment procedures, particularly in the setting of rigid deformities. Although previous studies have established the efficacy of tranexamic acid (TXA), data evaluating the widely variable dosing regimens remains sparse. PURPOSE To improve understanding of blood loss and transfusion requirements for low-dose and high-dose TXA regimens for adult spinal deformity (ASD) surgery. STUDY DESIGN/SETTING This is a retrospective cohort study of 318 ASD patients who received TXA. Outcome measures include estimated blood loss (EBL), perioperative transfusion requirement, and complications. METHODS A retrospective review was conducted on 318 ASD patients: 258 patients received a low-dose regimen of TXA (10 or 20 mg/kg loading dose with a 1 or 2 mg/kg/h maintenance dose) and 60 patients received a high-dose regimen of TXA (40 mg/kg loading dose with a 1 mg/kg/h maintenance dose, 30 mg/kg loading dose with a 10 mg/kg/h maintenance dose, or 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose). RESULTS Compared with the low-dose TXA group, the high-dose TXA group had significantly decreased EBL (1402 vs. 1793 mL, p=.009), blood volume lost (30.3 vs. 39.4%, p=.01), intraoperative packed red blood cell (pRBC) transfusion (0.9 vs. 1.6 U, p<.0001), and intraoperative platelet transfusion (0 vs. 0.1 U, p<.0001). High-dose TXA was predictive of 515 cc less EBL (p=.002), 11.4% less blood volume lost (p=.004), and 1 U pRBC less transfused intraoperatively (p<.0001) than the low-dose TXA group. The high-dose TXA group had a higher incidence of postop atrial fibrillation (5 vs. 0%, p<.0001) and myocardial infarction (1.7 vs. 0%, p=.04). CONCLUSIONS Varying dosing regimens of TXA are utilized for ASD surgery, with a prevailing theme of dosing ambiguity. These data demonstrate that high-dose TXA is more effective than low-dose TXA in reducing blood loss and blood product transfusion requirement in ASD surgery. Importantly, rates of MI and postop AF were higher in the high-dose TXA group.
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Affiliation(s)
- Tina Raman
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.
| | - Chris Varlotta
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Dennis Vasquez-Montes
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Aaron J Buckland
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Thomas J Errico
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
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Bai J, Zhang P, Liang Y, Wang J, Wang Y. Efficacy and safety of tranexamic acid usage in patients undergoing posterior lumbar fusion: a meta-analysis. BMC Musculoskelet Disord 2019; 20:390. [PMID: 31470844 PMCID: PMC6717333 DOI: 10.1186/s12891-019-2762-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/14/2019] [Indexed: 12/26/2022] Open
Abstract
Background The purpose of this meta-analysis is to evaluate the efficacy and safety of tranexamic acid (TXA) for patients with degenerative lumbar disc herniation, stenosis or instability undergoing posterior lumbar fusion (PLF) surgery. Methods We searched PubMed, Embase, and Cochrane Library until May 1, 2018. Two reviewers selected studies, assessed quality, extracted data, and evaluated the risk of bias independently. Weighted mean difference (WMD) and relative risk (RR) were calculated as the summary statistics for continuous data and dichotomous data, respectively. We chose fixed-effects or random-effects models based on I2 statistics. RevMan 5.0 and STATA 14.0 software were used for data analysis. Results Nine studies enrolling 713 patients for the study. The pooled outcomes demonstrated that TXA can decrease total blood loss (TBL) in patients underwent PLF surgery [WMD = -250.68, 95% CI (− 325.06, − 176.29), P<0.001], intraoperative blood loss (IBL) [WMD = -72.57, 95% CI (− 103.94, − 41.20), P<0.001], postoperative blood loss (PBL) [WMD = -127.57, 95% CI (− 149.39, − 105.75), P<0.001], and the loss of hemoglobin (Hb) in postoperative 24 h [WMD = -0.31, 95% CI (− 0.44, − 0.18), P<0.001]. However, there is no significant difference between two groups in transfusion rate [RR =0.34, 95% CI (0.09, 1.28), P = 0.11], and none thrombotic event was happened in the two groups. Conclusion Our meta-analysis demonstrated that TXA can decrease the Hb loss, TBL, IBL, PBL, and without increasing the risk of thrombotic event in patients with degenerative lumbar disc herniation, stenosis or instability underwent PLF surgery. However, there was no significant difference in blood transfusion rates between the two groups.
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Affiliation(s)
- Jianzhong Bai
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China.,Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Pei Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Yuan Liang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Jingcheng Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China.
| | - Yongxiang Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China.
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The Safety and Efficacy of Tranexamic Acid in Adult Spinal Deformity Surgery: A Systematic Review and Meta-Analysis. Drugs 2019; 79:1679-1688. [DOI: 10.1007/s40265-019-01185-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Does Prophylactic Administration of TXA Reduce Mean Operative Time and Postoperative Blood Loss in Posterior Approach Lumbar Spinal Fusion Surgery Performed for Degenerative Spinal Disease? Clin Spine Surg 2019; 32:E353-E358. [PMID: 30640750 DOI: 10.1097/bsd.0000000000000770] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a level III retrospective cohort study. OBJECTIVE To investigate association between prophylactic tranexamic acid (TXA) administration before 1 and 2-level posterior lumbar interbody fusion operations and perioperative blood loss (including intraoperative blood loss and postoperative drain output), mean operative time, postoperative transfusion, and postoperative venous thromboembolic events. SUMMARY OF BACKGROUND DATA TXA is a systemic antifibrinolytic that competitively inhibits lysine binding sites on plasminogen, reversibly blocking its binding to fibrin and impeding fibrinolysis and clot degradation. TXA's role in routine spinal surgery remains poorly described. Most spinal literature on perioperative TXA administration has considered operations performed for major adult and pediatric spinal deformity. METHODS Two groups, a study group composed of 75 patients who underwent 1 and 2-level posterior lumbar interbody fusion operations for degenerative indications who received TXA before the start of the procedure, and a control group composed of 75 patients who underwent similar surgeries for the same indications and did not receive TXA preoperatively, were retrospectively enrolled. Demographic, laboratory, and surgical data were collected and analyzed. RESULTS No statistically significant differences were found between groups with respect to surgery type, home anticoagulation, postoperative anticoagulation, preoperative hemoglobin and hematocrit, estimated intraoperative blood loss, postoperative day 2 drain output, postoperative day 3 drain output, rate of postoperative transfusion, and rate of postoperative thromboembolic events. Statistically significant reductions were noted in the TXA group with regards to postoperative day 1 drain output (P<0.0041), total postoperative drain output (P=0.027), and mean surgical time (P<0.0001). CONCLUSIONS In the present study, perioperative TXA administration was associated with reduced postoperative drain output and surgical time. Further higher-level studies are required to investigate the safety and utility of TXA's routine use in 1 and 2-level posterior lumbar fusion operations performed for degenerative indications.
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Does Tranexamic Acid Improve Bleeding, Transfusion, and Hemoglobin Level in Patients Undergoing Multilevel Spine Surgery? A Systematic Review and Meta-Analysis. World Neurosurg 2019; 127:289-301. [DOI: 10.1016/j.wneu.2019.02.170] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 12/26/2022]
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Abstract
Background: Significant blood loss is still one of the most frequent complications in spinal surgery, which often necessitates blood transfusion. Massive perioperative blood loss and blood transfusion can create additional risks. Aprotinin, tranexamic acid (TXA), and epsilon-aminocaproic acid (EACA) are antifibrinolytics currently offered as prophylactic agents to reduce surgery-associated blood loss. The aim of this study was to evaluate the efficacy and safety of aprotinin, EACA, and low/high doses of TXA in spinal surgery, and assess the use of which agent is the most optimal intervention using the network meta-analysis (NMA) method. Methods: Five electronic databases were searched, including PubMed, Cochrane Library, ScienceDirect, Embase, and Web of Science, from the inception to March 1, 2018. Trials that were randomized and compared results between TXA, EACA, and placebo were identified. The NMA was conducted with software R 3.3.2 and STATA 14.0. Results: Thirty randomized controlled trial (RCT) studies were analyzed. Aprotinin (standardized mean difference [SMD]=−0.65, 95% credibility intervals [CrI;−1.25, −0.06]), low-dose TXA (SMD = −0.58, 95% CrI [−0.92, −0.25]), and high-dose TXA (SMD = −0.70, 95% CrI [−1.04, −0.36]) were more effective than the respective placebos in reducing intraoperative blood loss. Low-dose TXA (SMD = −1.90, 95% CrI [−3.32, −0.48]) and high-dose TXA (SMD = −2.31, 95% CrI [−3.75, −0.87]) had less postoperative blood loss. Low-dose TXA (SMD = −1.07, 95% CrI [−1.82, −0.31]) and high-dose TXA (SMD = −1.07, 95% CrI [−1.82, −0.31]) significantly reduced total blood loss. However, only high-dose TXA (SMD = −2.07, 95% CrI [−3.26, −0.87]) was more effective in reducing the amount of transfusion, and was significantly superior to low-dose TXA in this regard (SMD = −1.67, 95% CrI [−3.20, −0.13]). Furthermore, aprotinin (odds ratio [OR] = 0.16, 95% CrI [0.05, 0.54]), EACA (OR = 0.46, 95% CrI [0.22, 0.97]) and high dose of TXA (OR = 0.34, 95% CrI [0.19, 0.58]) had a significant reduction in transfusion rates. Antifibrinolytics did not show a significantly increased risk of postoperative thrombosis. Results of ranking probabilities indicated that high-dose TXA had the greatest efficacy and a relatively high safety level. Conclusions: The antifibrinolytic agents are able to reduce perioperative blood loss and transfusion requirement during spine surgery. And the high-dose TXA administration might be used as the optimal treatment to reduce blood loss and transfusion.
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The Efficacy and Safety of Prophylactic Intravenous Tranexamic Acid on Perioperative Blood Loss in Patients Treated with Posterior Lumbar Interbody Fusion. World Neurosurg 2019; 125:e198-e204. [DOI: 10.1016/j.wneu.2019.01.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/31/2018] [Accepted: 01/02/2019] [Indexed: 12/19/2022]
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Gong M, Liu G, Chen L, Chen R, Xiang Z. The Efficacy and Safety of Intravenous Tranexamic Acid in Reducing Surgical Blood Loss in Posterior Lumbar Interbody Fusion for the Adult: A Systematic Review and a Meta-Analysis. World Neurosurg 2019; 122:559-568. [DOI: 10.1016/j.wneu.2018.09.115] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/12/2018] [Accepted: 09/15/2018] [Indexed: 10/28/2022]
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Nasser R, Kosty JA, Shah S, Wang J, Cheng J. Risk Factors and Prevention of Surgical Site Infections Following Spinal Procedures. Global Spine J 2018; 8:44S-48S. [PMID: 30574437 PMCID: PMC6295823 DOI: 10.1177/2192568218806275] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
STUDY DESIGN Focused literature review. OBJECTIVE The objective of this article was to help identify potential risk factors as well as strategies to help prevent surgical site infections (SSIs) in spine surgery. METHODS An article search was performed using PubMed, EMBASE, and the Cochrane database of systematic reviews using the terms "surgery" OR "surgical" AND "spine" OR "spinal" AND "infection". Systematic review articles, meta-analyses, and clinical trials with more than 100 patients were reviewed. RESULTS Both patient and perioperative factors contribute to the development of SSIs. Patient factors such as smoking, obesity, diabetes, Methicillin-resistant Staphylococcus aureus (MRSA) colonization, and malnutrition are all modifiable risk factors that can lead to SSIs. Procedural steps, including preoperative MRSA screening and treatment for colonization, preoperative antibiotics, skin preparation, minimizing operative time, antibiotic or betadine irrigation, avoiding personnel turnover, and postoperative wound care have also been shown to decrease infection rates. CONCLUSION There are several measures a spine practitioner may be able to take in the preoperative, intraoperative, and postoperative settings. Protocols to counsel patients regarding modification of preexisting risk factors and ensure adequate antimicrobial therapy in the perioperative period may be developed to reduce SSIs in spine surgery.
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Affiliation(s)
- Rani Nasser
- University of Cincinnati, Cincinnati, OH, USA,Rani Nasser, Department of Neurological Surgery, University of Cincinnati, Cincinnati, OH 45219, USA.
| | | | - Sanjit Shah
- University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey Wang
- University of Southern California, Los Angeles, CA, USA
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Mu X, Wei J, Wang C, Ou Y, Yin D, Liang B, Qiu D, Li Z. Intravenous Administration of Tranexamic Acid Significantly Reduces Visible and Hidden Blood Loss Compared with Its Topical Administration for Double-Segment Posterior Lumbar Interbody Fusion: A Single-Center, Placebo-Controlled, Randomized Trial. World Neurosurg 2018; 122:e821-e827. [PMID: 30391759 DOI: 10.1016/j.wneu.2018.10.154] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Tranexamic acid (TXA) significantly reduces the visible and hidden blood loss associated with joint replacement. At present, many studies have examined the safety and effectiveness of the intravenous or topical administration of TXA after posterior lumbar surgery. However, randomized and controlled trials examining the presence of differences in the effect of TXA on the visible and hidden blood loss between these 2 modes of administration are lacking. The current study investigated the effects of intravenous and topical administrations of TXA on the visible and hidden blood loss of patients undergoing posterior lumbar interbody fusion (PLIF). METHODS In a single-center, placebo-controlled, randomized design, a total of 150 patients with lumbar degenerative disease who underwent PLIF between September 2015 and August 2017 volunteered for this study. Of these patients, 126 fulfilled the inclusion criteria and were randomly assigned to 1 of 3 groups: the intravenous administration group (n = 45, group A), the topical administration group (n = 39, group B), or the placebo group (n = 42, group C). SPSS, version 17.0, was used to analyze the patient data, their blood biochemical indices, blood loss, and the number of blood transfusions across the 3 groups during the perioperative period. RESULTS The postoperative drainage volume, number of blood transfusions, length of hospital stay, and extubation time significantly differed between group C and both groups A and B (P < 0.05); however, no significant differences were noted between groups A and B (P > 0.05). Intraoperative blood loss and visible or hidden blood loss as well as the levels of postoperative hemoglobin and hematocrit significantly differed among the 3 groups (P < 0.01). The results of the visual analogue scale, prothrombin time, and fibrinogen content did not significantly differ among the 3 groups (P > 0.05). CONCLUSIONS For patients undergoing double-segment PLIF, both administrations of TXA can reduce blood loss, extubation time, and the length of hospital stay. Moreover, intravenous administration can reduce both visible and hidden blood loss more efficiently.
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Affiliation(s)
- Xiaoping Mu
- Department of Orthopaedics, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Jianxun Wei
- Department of Orthopaedics, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Chenglong Wang
- Graduate School, Guangxi University of Chinese Medicine, Nanning, Guangxi, China
| | - Yufu Ou
- Department of Orthopaedics, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China.
| | - Dong Yin
- Department of Orthopaedics, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Bin Liang
- Department of Orthopaedics, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Dezan Qiu
- Department of Orthopaedics, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Zhuhai Li
- Department of Orthopaedics, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
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