A bleeding assessment tool correlates with intraoperative blood loss in children and adolescents undergoing major spinal surgery

Predictors of perioperative blood loss in primary posterior hemivertebra resection for pediatric patients with congenital scoliosis

Several studies have elucidated the risk factors of intraoperative bleeding. However, the total blood loss (visible and hidden loss) and related risk factors were seldom reported. In this study, we aimed to identify predictors of massive blood loss in posterior hemivertebra resection for pediatric patients. Clinical records were retrospectively reviewed for 108 pediatric patients who underwent primary posterior hemivertebra resection and spinal fusion for congenital scoliosis from June 2017 to June 2019. Intraoperative blood loss was recorded and hidden blood loss was calculated by deducting the intraoperative loss from the total blood loss calculated using specific formula. Perioperative information was collected for multivariable linear regression analysis to determine the independent risk factors of the blood loss. The mean total blood loss was 575.0 ± 318.0 ml during the perioperative period, accounting for 42.1% of the estimated blood volume. The intraoperative and hidden loss were 337.6 ± 179.5 ml and 237.4 ± 204.8 ml, respectively, accounting for 58.7 and 41.3% of the total loss. Multivariable linear regression indicated that age, preoperative Cobb angle, operative time, and number of fused levels were independent risk factors of the total blood loss. Patients with operative time ≥145 minutes, fused levels ≥4, and preoperative Cobb angle ≥40° have an increased risk of massive blood loss. The perioperative blood loss of surgery for congenital scoliosis was considerable, with a high percentage of hidden blood loss. Patients with severe deformity, more fused levels, and longer operative time had higher risk of massive blood loss.

Comparative study of the effect of two different doses of remifentanil on bleeding control in lumbar fusion surgery: A randomized clinical trial

Objectives

Spinal fusion surgery completely prevents movement or friction between the two vertebrae. Remifentanil, a selective drug agonist, suppresses and decreases the vasomotor system upon release of histamine. In this study, the efficacy of remifentanil infusion at doses of 0.1 and 0.3 μg/kg/min in the control of low blood pressure was compared.

Methods

In this randomized clinical trial, 110 candidates for selective spinal fusion surgery were entered and randomized into 2 groups. The first group received 0.1 μg/kg/min and in the second group 0.3 μg/kg/min remifentanil. The systolic and diastolic blood pressure, pulse rate, SPO2, and surgeon's satisfaction were measured and compared between groups.

Results

the systolic blood pressure was significantly lower in patients receiving 0.3 μg of remifentanil by the time 30, 45, 60, and 90 min during the surgeries (P < 0.05). No significant difference was observed in terms of PR (P = 0.19) and SPO2 (P = 0.41) between the two groups. We also observed significantly higher duration of surgeries (P = 0.002), duration of anesthesia (P = 0.009), significantly higher bleeding volume (P < 0.001), higher fluid intake (P = 0.01) and higher transfused blood (P = 0.01) in patients that received 0.1 μg remifentanil compared to other patients.

Conclusion

Here we showed that administration of 0.3 μg/kg/min remifentanil was associated with significantly lower systolic blood pressure during the surgeries. On the other hand, patients that received 0.1 μg/kg/min remifentanil had significantly higher duration of surgeries, duration of anesthesia, significantly higher bleeding volume, higher fluid intake, and also higher transfused blood.

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Spinal fusion surgery completely prevents movement or friction between the two vertebrae.

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Remifentanil, a selective drug agonist, suppresses and decreases the vasomotor system.

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0.3 μg/kg/min remifentanil was associated with significantly lower systolic blood pressure.

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Patients that received 0.1 μg/kg/min remifentanil had significantly higher duration of surgeries.

Contribution of Coagulopathy on the Risk of Bleeding After Central Venous Catheter Placement in Critically Ill Thrombocytopenic Patients

Supplemental Digital Content is available in the text.

Critically ill patients often undergo central venous catheter placement during thrombocytopenia and/or coagulopathy. It is unclear whether severe coagulopathy increases the risk of postprocedural bleeding in critically ill patients with severe thrombocytopenia.

Preoperative hematocrit and platelet count are associated with blood loss during spinal fusion for children with neuromuscular scoliosis

AIM

To assess the relationship of preoperative hematology laboratory results with intraoperative estimated blood loss and transfusion volumes during posterior spinal fusion for pediatric neuromuscular scoliosis.

METHODS

Retrospective chart review of 179 children with neuromuscular scoliosis undergoing spinal fusion at a tertiary children's hospital between 2012 and 2017. The main outcome measure was estimated blood loss. Secondary outcomes were volumes of packed red blood cells, fresh frozen plasma, and platelets transfused intraoperatively. Independent variables were preoperative blood counts, coagulation studies, and demographic and surgical characteristics. Relationships between estimated blood loss, transfusion volumes, and independent variables were assessed using bivariable analyses. Classification and Regression Trees were used to identify variables most strongly correlated with outcomes.

RESULTS

In bivariable analyses, increased estimated blood loss was significantly associated with higher preoperative hematocrit and lower preoperative platelet count but not with abnormal coagulation studies. Preoperative laboratory results were not associated with intraoperative transfusion volumes. In Classification and Regression Trees analysis, binary splits associated with the largest increase in estimated blood loss were hematocrit ≥44% vs. <44% and platelets ≥308 vs. <308 × 10⁹/L.

CONCLUSIONS

Preoperative blood counts may identify patients at risk of increased bleeding, though do not predict intraoperative transfusion requirements. Abnormal coagulation studies often prompted preoperative intervention but were not associated with increased intraoperative bleeding or transfusion needs.

A Useful Model for Predicting Intraoperative Blood Loss in Metastatic Spine Tumor Surgery

STUDY DESIGN

A retrospective study was performed.

OBJECTIVE

As predictors of intraoperative blood loss have not yet been well defined, the objective of the present study is to develop a model to predict the amount of intraoperative blood loss in metastatic spine tumor surgery.

SUMMARY OF BACKGROUND DATA

Massive blood loss is a huge challenge in metastatic spine tumor surgery. Misjudgment of intraoperative blood loss in preoperative planning may result in disastrous consequences.

MATERIALS AND METHODS

Enrolled in this retrospective analysis were 392 patients who received 423 surgeries of vertebrectomy and reconstruction in our hospital between 2011 and 2017. Risk factors for high-volume blood loss were identified by univariate and multivariate linear regression. The optimal regression model was selected to predict the amount of intraoperative blood loss. Correlation analysis between predicted and actual blood loss in the test cohort was performed to verify the performance of the new model.

RESULTS

The overall mean blood loss was 1756±1218 mL, with spinal metastases from thyroid cancer most prominent, followed by renal cancer. The model was developed based on 5 independent risk factors influencing intraoperative blood loss: primary tumor, tumor site, level of instrumentation, level of vertebrectomy, and resection method. In the test cohort, the correlation coefficient (r) between predicted and actual blood loss was 0.606.

CONCLUSIONS

This study presented a relatively reliable method to predict the amount of intraoperative blood loss in metastatic spine tumor surgery, which may help surgeons address blood loss-related issues in preoperative planning.

Changes in and significance of platelet function and parameters in Kawasaki disease

Kawasaki disease (KD) is a systemic febrile, inflammatory vascular disease of unknown etiology. The coronary artery abnormality (CAA) caused by KD has become the most commonly acquired heart disease in children. Initial treatment of intravenous immunoglobulin (IVIG) can reduce the incidence of CAA. Thrombocytosis is common during the course of KD, but changes in and significances of platelet function and parameters are unclear. In this study, we enrolled 120 patients, including 40 patients with KD, 40 febrile controls, and 40 afebrile controls. The platelet function was assessed using the platelet function analyzer (PFA)-200. Platelet parameters, including platelet count (PLT), mean platelet volume (MPV), platelet distribution width (PDW), and platelet hematocrit (PCT) were measured. In the febrile period, the PDW and MPV were lower in KD patients (P < 0.05). The platelet function did not change significantly during the febrile period of KD but weakened in the defervescence phase. No significant differences between the CAA and normal groups, and between IVIG resistance and response groups. The diagnostic cutoff value of the PDW level for predicting KD was 10.85 fL with a sensitivity of 55% and a specificity of 77.5% (area under curve (AUC) = 0.690, 95% confidence interval (CI): 0.574–0.806, P < 0.01). Besides, the MPV level was 9.55 fL with sensitivity of 75% and specificity of 70% (AUC = 0.733, 95%CI: 0.620–0.846, P < 0.001). This is the first longitudinal study of platelet function changes in KD patients using PFA-200. Besides, lower PDW and MPV may be available markers for early diagnosis of KD.

Screening for undiagnosed bleeding disorders in post-tonsillectomy bleed patients: Retrospective review and systematic review of the literature

OBJECTIVES

There is currently no standard for screening children with post-tonsillectomy bleeds (PTB) for coagulopathy disorders. This study aims to identify children with occult coagulopathy diagnosed at PTB and to identify factors associated with diagnosis. A systematic review of the literature further identified trends in this topic.

METHODS

A retrospective chart review of patients returning to the operating room for PTB at a tertiary children's hospital was undertaken from 2012 to 2016. A systematic review using Medline OVID was subsequently performed.

RESULTS

Of 12,503 tonsillectomies, 311 children (52% male, mean age 8 years) required surgery for PTB (2.5% rate). Twenty-one patients (7%) had multiple episodes. Only two patients (0.6%) (both with known coagulopathy) underwent pre-tonsillectomy labs and 260 (84%) had labs at PTB. Six patients (2%) were diagnosed with a new coagulopathy, most commonly von Willebrand's Disease (vWD) in five (2%). Three patients (1%) were diagnosed at first PTB and three (1%) at second PTB. Of the three diagnosed at second PTB, two had normal partial thromboplastin time (PTT). In systematic review, 1243 manuscripts were reviewed and 8 papers discussing this topic are presented.

CONCLUSION

Occult coagulopathy was rarely diagnosed at PTB, but this may be limited by inconsistent screening. PT and PTT are not sensitive tests for vWD, and normal coagulation labs may lead to delayed diagnosis. The literature reveals occult coagulopathy is rare but often diagnosed after severe or recurrent hemorrhage. In order to provide efficient care and medical management, a standardized algorithm and sensitive labs for screening PTB patients are needed.

High-volume, Multilevel Local Anesthetics-Epinephrine Infiltration in Kyphoscoliosis Surgery: Blood Conservation

INTRODUCTION

Scoliosis surgery is usually associated with severe bleeding. Various systemic strategies for blood conservation were applied, while the local techniques get less attention. The preemptive use of sufficient volume for proper tissue infiltration at two levels was applied. The local epinephrine may control bleeding without reliance upon deliberate hypotension, permitting a higher tissue perfusion.

MATERIALS AND METHODS

This prospective study included 46 patients scheduled for posterior spinal fusion for scoliosis correction. Patients were randomized into two groups. group I received a cocktail of high volume (100 ml/each 10 cm of wound length) of local anesthetics and epinephrine tumescent infiltration at the subcutaneous (SC) followed by intramuscular level bilaterally. Group C received saline infiltration in the same technique. Statistically, data were analyzed according to its distribution using the t-test, Mann-Whitney, and Chi-square tests as appropriate.

RESULTS

There was a significant reduction in blood loss (38%), reduced blood and fluid transfusion (36% and 23%), and reduced operative time (23%), with higher surgeon satisfaction. The surgical field visibility (Fromme's scale) was much better during SC and muscular dissection in Group I, while it was fair during the bony work. The satisfactory field in spite of higher mean blood pressure in Group I greatly omitted the reliance upon deliberate hypotension.

CONCLUSION

The high-volume multilevel infiltration of epinephrine cocktail can provide a significant blood and operative time conservation in kyphoscoliosis surgery.