Hematuria associated with low-volume cell saver in pediatric orthopaedics

Postoperative Blood Salvage and Autotransfusion for Adult Spinal Deformity: A Randomized Controlled Trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

The aim of this study was to determine whether postoperative blood salvage and autotransfusion versus traditional closed suction drainage reduces the rate of homologous blood transfusions in patients undergoing surgery for adult spinal deformity.

SUMMARY OF BACKGROUND DATA

The use of intraoperative blood salvage has become commonplace in spine surgery; however, the collection and reinfusion of blood drained from the wound postoperatively have not been employed routinely because of increased cost and questionable benefit.

METHODS

Adult patients undergoing long posterior fusions were randomized to either a blood salvage and reinfusion system (OrthoPat - Group 1) or a standard subfascial closed suction drain (Group 2). Blood collected in Group 1 was reinfused according to the manufacturer's protocol. Reinfusion drains were converted to standard closed suction drains when output was <50 mL during 4 hours, and drains were removed when output was minimal. Patients received autologous or homologous blood transfusions when hemoglobin (Hg) <8 g/dL or they had symptomatic anemia.

RESULTS

Thirty-four patients were randomized into Group 1 and 36 patients into Group 2. There were no differences in preoperative or intraoperative parameters. Patients in Group 1 had higher hemoglobin levels on postoperative day (POD) 2 and POD 3 compared to those in Group 2. However, there was no significant difference in the percentage of patients requiring homologous blood transfusion between the two groups (41% Group 1 vs. 60% Group 2, P = 0.17). Similarly a subgroup analysis in patients with estimated blood loss >2000 mL also showed no difference in homologous blood transfusion rates (67% Group 1 vs. 76% Group 2, P = 0.58). There were no differences in the rate or type of postoperative complications.

CONCLUSION

Postoperative blood salvage and reinfusion result in a higher hemoglobin level in the early postoperative period, but does not significantly reduce the need for homologous blood transfusion.

LEVEL OF EVIDENCE

1.

Clinical Efficacy of Intra-Operative Cell Salvage System in Major Spinal Deformity Surgery

Objective

The purpose of this study was to determine the efficacy of intra-operative cell salvage system (ICS) to decrease the need for allogeneic transfusions in patients undergoing major spinal deformity surgeries.

Methods

A total of 113 consecutive patients undergoing long level posterior spinal segmental instrumented fusion (≥5 levels) for spinal deformity correction were enrolled. Data including the osteotomy status, the number of fused segments, estimated blood loss, intra-operative transfusion amount by ICS (Cell Saver^®, Haemonetics^©, Baltimore, MA, USA) or allogeneic blood, postoperative transfusion amount, and operative time were collected and analyzed.

Results

The number of patients was 81 in ICS group and 32 in non-ICS group. There were no significant differences in demographic data and comorbidities between the groups. Autotransfusion by ICS system was performed in 53 patients out of 81 in the ICS group (65.4%) and the amount of transfused blood by ICS was 226.7 mL in ICS group. The mean intra-operative allogeneic blood transfusion requirement was significantly lower in the ICS group than non-ICS group (2.0 vs. 2.9 units, p=0.033). The regression coefficient of ICS use was -1.036.

Conclusion

ICS use could decrease the need for intra-operative allogeneic blood transfusion. Specifically, the use of ICS may reduce about one unit amount of allogeneic transfusion in major spinal deformity surgery.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

A meta-analysis was performed.

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acute Kidney Injury Secondary to Cell Saver in Posterior Spinal Fusion

BACKGROUND

Autologous blood transfusion, commonly referred to as cell saver, is frequently used in spinal fusion to salvage red blood cells because of the risk of significant intraoperative blood loss. This case report describes a case of acute kidney injury (AKI) secondary to cell saver use. Our objective is to increase the knowledge about the process of red blood cell salvage and this exceedingly rare complication.

METHODS

Chart and renal biopsy results for a single case were reviewed and reported in this retrospective study.

RESULTS

A healthy 18-year-old male patient underwent posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis with utilization of intraoperative autologous blood transfusion. The patient subsequently developed hematuria and AKI with a peak creatinine of 13.9 mg/dL. An extensive clinical workup, including autoimmune serology, excluded any identifying causes. A renal biopsy showed pigment-induced acute tubular necrosis.

CONCLUSIONS

This case, to our knowledge, is the first and only case report of AKI secondary to cell saver demonstrated by renal biopsy. The literature has shown both the benefit of cell saver by decreasing the need for allogeneic transfusion and the risk of transient hematuria. However, this case demonstrates the importance of monitoring patients for potential complications.

Predictive factors for the use of autologous cell saver transfusion in lumbar spinal surgery

STUDY DESIGN

Retrospective review.

OBJECTIVE

To identify risk factors for cell saver transfusion in lumbar spinal surgery and determine if cell saver transfusions affected intraoperative or postoperative transfusion rates.

SUMMARY OF BACKGROUND DATA

Cell saver has been used to minimize allogeneic blood transfusion in lumbar spinal surgery. Conflicting reports exist, which call into question the efficacy of cell saver use.

METHODS

We reviewed medical records of randomly selected patients who underwent posterolateral fusion with or without transforaminal interbody fusion from July 2010 to June 2011. Transfusion rates and transfusion-related complications were determined. Binary logistic regression was performed to identify risk factors for use of autologous cell saver transfusion.

RESULTS

There were 178 females and 107 males, with a mean age of 57.2 years. Of the 285 cases, 39 had no cell saver available, 147 had cell saver available but no autologous blood was recovered or transfused and 99 had an autologous cell saver transfusion. Patients who had cell saver transfusion had a higher rate of intraoperative allogeneic blood transfusion (52%) compared with those who did not (22%). There was no significant difference in the rate of postoperative transfusions or transfusion-related reactions between patients who did and did not have cell saver transfusion. Patient's age, smoking status, American Society of Anesthesiologists grade, use of anticoagulants preoperatively, primary or revision surgery, iliac crest bone graft harvest, anesthesiologist, or surgeon had no significant effect on cell saver infusion. Body mass index (odds ratio [OR] = 1.06), number of posterolateral fusion levels fused (OR = 2.50), and number of transforaminal interbody fusions performed (OR = 2.41) were independent risk factors for the use of autologous cell saver transfusion.

CONCLUSION

Body mass index, multi-level fusion and transforaminal interbody fusion result in increased use of autologous cell saver transfusion in lumbar spinal surgery. Use of autologous cell saver transfusion did not reduce the requirement for intraoperative or postoperative allogeneic blood transfusion.

LEVEL OF EVIDENCE

2.

Are antifibrinolytics helpful in decreasing blood loss and transfusions during spinal fusion surgery in children with cerebral palsy scoliosis?

STUDY DESIGN

Therapeutic comparative study.

OBJECTIVE

To evaluate the safety and efficacy of antifibrinolytic (AF) agents in reducing blood loss and transfusions during posterior spinal fusion (PSF) in children with cerebral palsy (CP) scoliosis.

SUMMARY OF BACKGROUND DATA

Scoliosis surgery in CP children is associated with substantial blood loss. Few reports on the role of AFs exist.

METHODS

A multicenter, retrospective review of a prospectively collected database of 84 consecutively enrolled patients with CF (age < 18 years) with spinal deformity who underwent PSF and instrumentation. The use of AFs, tranexamic acid (TXA), epsilon-aminocaproic acid (EACA), or none was based on the surgeon preference. Estimated blood loss (EBL), transfusion requirements, and length of stay were recorded. Analysis was performed with the independent-samples t test and 1-way analysis of variance with post hoc Bonferroni analysis.

RESULTS

The average age at the time of surgery was 14.4 ± 2.6 years. The groups were well matched in preoperative major deformity, age, levels fused, and operating time. Forty-four patients received AFs (30 TXA and 14 EACA), and 40 received no antifibrinolytics (NAF). The EBL averaged 1684 mL for the AFs group and 2685 mL for the NAF group (P = 0.002). There was more cell salvage transfusion in the NAF group. No significant differences were found in total transfusion requirements. There was a trend for decreased hospital stay in the AFs group. No adverse effects were seen. On comparison of the 3 groups (NAF, TXA, and EACA), a significant difference was observed between the TXA and the other groups with respect to EBL and cell salvage transfusion.

CONCLUSION

AFs significantly reduced intraoperative EBL associated with PSF, with no adverse effects; however, we could not demonstrate significant differences in total transfusion, except in cell salvage. TXA was more effective than EACA in decreasing the EBL and cell salvage transfusion.

Efficacy of intraoperative cell salvage systems in pediatric idiopathic scoliosis patients undergoing posterior spinal fusion with segmental spinal instrumentation

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

Determine whether intraoperative cell salvage system use during pediatric posterior spinal fusion (PSF) with segmental spinal instrumentation for idiopathic scoliosis decreases intraoperative and perioperative (intraoperative plus postoperative) allogeneic blood transfusion.

SUMMARY OF BACKGROUND DATA

Intraoperative cell salvage and reinfusion can reduce or obviate perioperative allogeneic blood transfusion. Despite these benefits, their efficacy in pediatric PSF is unclear. Reported complications include transient hematuria, altered hemostasis, and electrolyte imbalance.

METHODS

A total of 54 consecutive idiopathic scoliosis patients were studied: 21 non-cell saver and 33 cell saver patients. Data included age, body mass index, Cobb angle, perioperative hemoglobin levels, mean arterial pressure, surgical time, levels fused, perioperative estimated blood loss, and perioperative transfusions. A chi2 and t tests were performed for intraoperative and perioperative allogeneic transfusion between groups. A regression analysis was performed between selected covariates and allogeneic transfusion. Relative risk analysis examined significant covariates regarding allogeneic transfusion rate.

RESULTS

Allogeneic transfusion rates were lower in the cell saver group (6% vs. 55% intraoperative and 18% vs. 55% perioperative, P < 0.05). Mean allogeneic transfusion volumes (mL/kg) were also lower (0.4 vs. 9.1 intraoperative and 1.9 vs. 11.1 perioperative, P < 0.05). Multivariate analysis confirmed these differences were independent of perioperative blood loss, and also demonstrated that surgical time and blood loss were significantly related to allogeneic transfusion volume. The allogeneic transfusion relative risk was 2.04 in patients with surgery >6 hours and 5.87 in patients not receiving cell saver blood. All patients with surgeries >6 hours and estimated blood loss >30% of total blood volume received cell saver system blood.

CONCLUSION

Cell saver use decreased allogeneic transfusion, particularly in surgeries >6 hours with estimated blood loss >30% of total blood volume. This study confirms the utility of routine cell saver use during PSF with segmental spinal instrumentation for idiopathic scoliosis.

Efficacy of intraoperative cell saver in decreasing postoperative blood transfusions in instrumented posterior lumbar fusion patients

STUDY DESIGN

A retrospective study.

OBJECTIVE

To determine the efficacy of using intraoperative cell saver in decreasing the need for blood transfusion.

SUMMARY OF BACKGROUND DATA

Lumbar spine surgery is associated with potential large intraoperative blood loss, which may put patients at risk for blood transfusions. Preoperative autologous blood donation mitigates the need for allogenic blood transfusion, but does not eliminate it. Cell-saver use has been advocated to further reduce the need for transfusion, but recent reports have called its efficacy into question.

METHODS

Data were collected from 188 patients undergoing consecutive instrumented lumbar laminectomy and fusion. One hundred and forty-one of these patients had cell saver used during their procedures, whereas 47 did not. In addition, previously published data from similarly treated patients were used for analysis. Operative blood loss, autologous and allogenic blood transfusions, discharge hematocrit, and patient factors were analyzed.

RESULTS

A significant increase in the number of blood transfusions was found in the cell-saver group. The cell-saver group also had a significantly increased blood loss compared with the non-cell-saver group. Using analysis of covariance, we determined the effect of blood loss on the need for transfusion. The results showed that correcting for blood loss eliminated the significance in the transfusion difference, but cell saver still was not able to decrease the transfusion need. Comparing our current results with our previously published results also demonstrated no benefit of cell saver use.

CONCLUSION

Use of cell saver in instrumented lumbar fusion cases was not able to decrease the need for blood transfusion. Cell-saver use was associated with a significantly higher blood loss.