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Kumar N, Lee EXY, Hui SJ, Kumar L, Jonathan Tan JH, Ashokka B. Does Patient Blood Management Affect Outcomes in Metastatic Spine Tumour Surgery? A Review of Current Concepts. Global Spine J 2024:21925682231167096. [PMID: 38453667 DOI: 10.1177/21925682231167096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE The spine is the most common site of metastases, associated with decreased quality of life. Increase in metastatic spine tumour surgery (MSTS) has caused us to focus on the management of blood, as blood loss is a significant morbidity in these patients. However, blood transfusion is also not without its own risks, and hence this led to blood conservation strategies and implementation of a concept of patient blood management (PBM) in clinical practise focusing on these patients. METHODS A narrative review was conducted and all studies that were related to blood management in metastatic spine disease as well as PBM surrounding this condition were included. RESULTS A total of 64 studies were included in this review. We discussed a new concept of patient blood management in patients undergoing MSTS, with stratification to pre-operative and intra-operative factors, as well as anaesthesia and surgical considerations. The studies show that PBM and reduction in blood transfusion allows for reduced readmission rates, lower risks associated with blood transfusion, and lower morbidity for patients undergoing MSTS. CONCLUSION Through this review, we highlight various pre-operative and intra-operative methods in the surgical and anaesthesia domains that can help with PBM. It is an important concept with the significant amount of blood loss expected from MSTS. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
| | | | - Si Jian Hui
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Laranya Kumar
- Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Jiong Hao Jonathan Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
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Avila MJ, Orenday-Barraza JM, Cavagnaro MJ, Strouse IM, Farhadi DS, Khan N, Hussein A, Baaj AA. Antifibrinolytics use during surgery for oncological spine diseases: A systematic review. Surg Neurol Int 2022; 13:567. [PMID: 36600747 PMCID: PMC9805626 DOI: 10.25259/sni_837_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 11/17/2022] [Indexed: 12/03/2022] Open
Abstract
Background Data exist of the benefits of antifibrinolytics such as tranexamic acid (TXA) in general spine surgery. However, there are limited data of its use in oncological spine patients. Methods A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Cochrane, OVID, and Embase databases were searched. Search terms: "tranexamic acid", "aprotinin," "aminocaproic acid," "spine surgery," "spine tumors," and "spine oncology." Included studies were full text publications written in English with patients treated with either agent or who had surgery for oncological spine disease (OSD). Results Seven hundred results were reviewed form the different databases, seven were selected. A total of 408 patients underwent spine surgery for OSD and received antifibrinolytics. There was a male predominance (55.2%) and mean age ranged from 43 to 62 years. The most common tumor operated was metastatic renal cancer, followed by breast and lung. Most studies administered TXA as a bolus followed by an infusion during surgery. Median blood loss was of 667 mL (253.3-1480 mL). Patients with TXA required 1-2 units less of transfusion and had 56-63 mL less of postoperative drainage versus no TXA. The median incidence of deep venous thrombosis (DVT) was 2.95% (0-7.9%) and for pulmonary embolism (PE) was 4.25% (0-14.3%). The use of TXA reduced intraoperative blood loss, transfusions and reduced postoperative surgical drainage output compared to no TXA use in patients with OSD. Conclusion In this review, we found that TXA may diminish intraoperative blood loss, the need for transfusion and postoperative drainage from surgical drains when used in OSD without major increase in rates of DVT or PE.
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Affiliation(s)
- Mauricio J. Avila
- Department of Neurosurgery, University of Arizona, Tucson, United States.,Corresponding author: Mauricio J. Avila, Department of Neurosurgery, University of Arizona, Tucson, Arizona, United States.
| | | | | | - Isabel M. Strouse
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, United States
| | - Dara S. Farhadi
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, United States
| | - Naushaba Khan
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, United States
| | - Amna Hussein
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, United States
| | - Ali A. Baaj
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, United States
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Groot OQ, van Steijn NJ, Ogink PT, Pierik RJ, Bongers MER, Zijlstra H, de Groot TM, An TJ, Rabinov JD, Verlaan JJ, Schwab JH. Preoperative embolization in surgical treatment of spinal metastases originating from non-hypervascular primary tumors: a propensity score matched study using 495 patients. Spine J 2022; 22:1334-1344. [PMID: 35263662 DOI: 10.1016/j.spinee.2022.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Preoperative embolization (PE) reduces intraoperative blood loss during surgery for spinal metastases of hypervascular primary tumors such as thyroid and renal cell tumors. However, most spinal metastases originate from primary breast, prostate, and lung tumors and it remains unclear whether these and other spinal metastases benefit from PE. PURPOSE To assess the (1) efficacy of PE on the amount of intraoperative blood loss and safety in patients with spinal metastases originating from non-hypervascular primary tumors, and (2) secondary outcomes including perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality. STUDY DESIGN Retrospective propensity-score matched, case-control study at 2 academic tertiary medical centers. PATIENT SAMPLE Patients 18 years of age or older undergoing surgery for spinal metastases originating from primary non-thyroid, non-renal cell, and non-hepatocellular tumors between January 1, 2002 and December 31, 2016 were included. OUTCOME MEASURES The primary outcomes were estimated amount of intraoperative blood loss and complications attributable to PE, such as neurologic injury, wound infection, thrombosis, or dissection. The secondary outcomes included perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality. METHODS In total, 495 patients were identified, of which 54 (11%) underwent PE. After propensity score matching on 21 variables, including primary tumor, number of spinal levels, and surgical treatment, 53 non-PE patients were matched to 53 PE patients. Matching was adequate measured by comparing the matched variables, testing the standardized mean differences (<0.25), and inspecting Kernel density plots. The degree of embolization was noted to be complete, until stasis, or successful in 43 (80%) patients. RESULTS Intraoperative blood loss did not differ between both groups with a median blood loss in liters of 0.6 (IQR, 0.4-1.2) for non-PE patients and 0.9 (IQR, 0.6-1.2) for PE patients (p=.32). No complications occurred during embolization or the time between embolization and surgery. No differences were found in terms of the secondary outcomes. CONCLUSIONS Our data suggest that, although no complications occurred and the embolization procedure can be considered safe, patients with non-hypervascular spinal metastases might not benefit from PE. A larger, prospective study could confirm or refute these study findings and aid in elucidating a subset of spinal metastases that might benefit from PE.
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Affiliation(s)
- Olivier Q Groot
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA; Department of Orthopedic Surgery, University Medical Center Utrecht - Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Nicole J van Steijn
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
| | - Paul T Ogink
- Department of Orthopedic Surgery, University Medical Center Utrecht - Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Robert-Jan Pierik
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
| | - Michiel E R Bongers
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
| | - Hester Zijlstra
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA; Department of Orthopedic Surgery, University Medical Center Utrecht - Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Tom M de Groot
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
| | - Thomas J An
- Department of Radiology, Radiology Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St. Boston, MA 02114, USA
| | - James D Rabinov
- Department of Radiology, Radiology Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St. Boston, MA 02114, USA
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht - Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
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Zec T, Di Napoli R, Fievez L, Ben Aziz M, Ottaiano A, Vittori A, Perri F, Cascella M. Efficacy and Safety of Tranexamic Acid in Cancer Surgery. An Update of Clinical Findings and Ongoing Research. J Multidiscip Healthc 2022; 15:1427-1444. [PMID: 35818514 PMCID: PMC9270886 DOI: 10.2147/jmdh.s337250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/22/2021] [Indexed: 11/23/2022] Open
Abstract
In cancer patients undergoing surgery, tumor biology and anticancer treatments can increase the risk of perioperative bleeding and blood transfusions. Notably, blood transfusions can be potentially associated with an increased risk of life-threatening immune responses, acute lung injury, postoperative infections, and thromboembolism. Moreover, the link between perioperative transfusion and increased risk of cancer recurrence cannot be excluded. On the other hand, cancer patients have an increased risk of thromboembolism due to cancer itself and antineoplastic systemic treatments including chemotherapy and anti-angiogenic drugs. In this complex scenario, effective and safe strategies aimed at the prevention of blood transfusions are warranted. This narrative review addresses the efficacy, and the safety of the synthetic antifibrinolytic agent tranexamic acid (TXA) when used perioperatively in cancer surgery. Although in not oncologic surgery the use of TXA has been extensively studied, in the setting of cancer patients requiring surgery, the evidence is scarce. An overview of the ongoing clinical research is also provided.
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Affiliation(s)
- Tamara Zec
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles, 1000, Belgium
| | - Raffaela Di Napoli
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles, 1000, Belgium
| | - Lydwine Fievez
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles, 1000, Belgium
| | - Mohamed Ben Aziz
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles, 1000, Belgium
| | - Alessandro Ottaiano
- SSD Innovative Therapies for Abdominal Metastases, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, 80100, Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO ROMA, Ospedale Pediatrico Bambino Gesù IRCCS, Piazza S. Onofrio 4, Rome, 00165, Italy
| | - Francesco Perri
- Medical and Experimental Head and Neck Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, 80100, Italy
- Correspondence: Francesco Perri, Email
| | - Marco Cascella
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, 80100, Italy
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Lei T, Bingtao W, Zhaoqing G, Zhongqiang C, Xin L. The efficacy and safety of intravenous tranexamic acid in patients with posterior operation of multilevel thoracic spine stenosis: a prospective randomized controlled trial. BMC Musculoskelet Disord 2022; 23:410. [PMID: 35501751 PMCID: PMC9063045 DOI: 10.1186/s12891-022-05361-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/25/2022] [Indexed: 01/11/2023] Open
Abstract
Background This study was a randomized controlled trial to evaluate efficacy and safety of the usage of intravenous tranexamic acid during posterior operation of multilevel thoracic spine stenosis for controlling perioperative blood loss. Methods Sixty eight patients with multilevel thoracic spine stenosis were randomized into the tranexamic acid group receiving 15 mg/kg body weight before the skin incision was made and 1 mg/kg body weight per hour during operation or the control group receiving the same dose of placebo (0.9% sodium chloride solution) intravenously. Pedicle screw fixation, laminectomy and selective discectomy were performed. Intraoperative and perioperative total blood loss were compared. The necessity and amount for blood transfusion, blood coagulation function, durations of postoperative hospital stays were compared. The complications of tranexamic acid were also investigated such as cardiovascular and cerebrovascular events, lower limb venous thrombosis. Results There were no statistically significant differences in age, gender, body mass index, ASA status, pathology required surgery, preoperative hemoglobin, operation time, laminectomy segments and discectomy segments between the tranexamic acid and control groups. The intraoperative blood loss (455.9 ± 206.6 ml vs 580.6 ± 224.3 ml, p < 0.05) and total blood loss (675.3 ± 170.3 ml vs 936.8 ± 306.4 ml, p < 0.01) in tranexamic acid group were significant lower than those in control group. The means of blood unit transfused (2.5 ± 1.0 vs 4.7 ± 2.4, p < 0.05) and Hb reduction in 48 h (22.5 ± 3.4 g/L vs 25.3 ± 3.9 g/L, p < 0.01) were significantly lower in tranexamic acid group than that in control group. There were no statistically significant differences in blood coagulation function pre-operation or 48 h post-operation between the tranexamic acid and the control groups. The requirements for patients to receive blood transfusion were fewer and durations of post-operational hospital stays were shorter in the tranexamic acid group, however, the difference did not achieve statistical significance. There was no significant difference in superficial or deep venous thrombosis of lower limbs or deterioration of neurological function between tranexamic acid group and control group. Conclusions Application of intravenous tranexamic acid significantly reduces intraoperative and perioperative total blood loss without significant side effects in posterior operation of multilevel thoracic spine stenosis. Trial registration At Chinese Clinal Trial Registry. http://www.chictr.org.cn/, ChiCTR2100054221. Registered on 11/12/2021. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05361-2.
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Affiliation(s)
- Tan Lei
- Department of Orthopaedics, Peking University International Hospital, Life Park Road No 1 Life Science Park of Zhong Guancun, Changping District, Beijing, 102206, China
| | - Wen Bingtao
- Department of Orthopaedics, Peking University International Hospital, Life Park Road No 1 Life Science Park of Zhong Guancun, Changping District, Beijing, 102206, China
| | - Guo Zhaoqing
- Department of Orthopaedics, Peking University International Hospital, Life Park Road No 1 Life Science Park of Zhong Guancun, Changping District, Beijing, 102206, China
| | - Chen Zhongqiang
- Department of Orthopaedics, Peking University International Hospital, Life Park Road No 1 Life Science Park of Zhong Guancun, Changping District, Beijing, 102206, China
| | - Liu Xin
- Department of Orthopaedics, Peking University International Hospital, Life Park Road No 1 Life Science Park of Zhong Guancun, Changping District, Beijing, 102206, China.
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Maethungkul R, Atthakomol P, Phinyo P, Phanphaisarn A, Murakami H, Sangsin A. Adjunctive Topical Tranexamic Acid for Blood Salvage Does Not Reduce Postoperative Blood Loss Compared with Placebo in Patients Who Undergo Palliative Decompressive Spinal Metastasis Surgery: A Randomized Controlled Trial. Spine (Phila Pa 1976) 2022; 47:187-194. [PMID: 34802026 DOI: 10.1097/brs.0000000000004280] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Randomized controlled trial. OBJECTIVE To evaluate the efficacy of adjunctive topical tranexamic acid (tTXA) in reducing postoperative blood loss and packed red cell (PRC) transfusion in patients who underwent palliative decompressive spinal metastasis surgery for malignant epidural spinal cord compression. SUMMARY OF BACKGROUND DATA Palliative decompressive spinal metastasis surgery is associated with massive postoperative blood loss and increased transfusion rate. tTXA reduces blood loss in traumatic or degenerative spinal surgery; however, the role of topical TXA in decompressive spinal metastasis surgery remains controversial. METHOD A total of 65 patients who underwent palliative decompressive thoracolumbar spinal metastasis surgery were included in this study. In 33 patients, 1 g of tTXA (20 mL) was soaked in an absorbable gelatin sponge and placed lateral to the decompressive site. The remaining 32 patients in the control group received the same procedures with normal saline at the same volume, instead of TXA. All of the patients received standard 1 g intravenous TXA, just before initiating the operation. The primary outcome was postoperative blood loss, and the secondary outcomes were postoperative PRC transfusion and complications. RESULTS No differences were found in postoperative blood loss between tTXA and placebo group (P50 778 mL [IQR 347, 1,122 mL] versus P50 490 mL [IQR 295, 920 mL]; P = 0.238). The number of patients requiring postoperative PRC transfusion were quite similar in tTXA and placebo groups (PRC transfusion in 15 patients [45.45%] versus 16 patients [50%]; P = 0.585). No complications related to TXA and absorbable gelatin sponge were observed. CONCLUSION We do not recommend tTXA as an adjunctive treatment for patients undergoing decompressive spinal metastasis surgery since it does not provide additional benefit to prophylactic intravenous TXA in postoperative blood loss and transfusion rate.Level of Evidence: 2.
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Affiliation(s)
- Ronnakrit Maethungkul
- Department of Orthopaedics Surgery, Faculty of Medicine Chiang Mai University, Maharaj Nakorn Chiangmai Hospital, Chiangmai, Thailand
| | - Pichitchai Atthakomol
- Department of Orthopaedics Surgery, Faculty of Medicine Chiang Mai University, Maharaj Nakorn Chiangmai Hospital, Chiangmai, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine and Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Areerak Phanphaisarn
- Department of Orthopaedics Surgery, Faculty of Medicine Chiang Mai University, Maharaj Nakorn Chiangmai Hospital, Chiangmai, Thailand
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Apiruk Sangsin
- Department of Orthopaedics Surgery, Faculty of Medicine Chiang Mai University, Maharaj Nakorn Chiangmai Hospital, Chiangmai, Thailand
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Sofulu O, Ozturk O, Polat M, Buyuktopcu O, Kesimer MD, Erol B. Efficacy and Safety of Tranexamic Acid in Resection and Endoprosthetic Reconstruction of Distal Femoral Osteosarcomas in Children: A Retrospective Cohort Study. J Pediatr Orthop 2021; 41:e686-e691. [PMID: 34231541 DOI: 10.1097/bpo.0000000000001900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study aimed to investigate the effect of intravenous tranexamic acid (TXA) on blood loss and transfusion rates in children who underwent resection and endoprosthetic reconstruction of distal femoral osteosarcomas. METHODS The medical records of 56 patients who underwent resection and endoprosthetic reconstruction for distal femoral osteosarcomas between 2017 and 2019 were retrospectively reviewed. Patients were divided into 2 groups: group 1 consisted of 25 patients (11 male and 14 female, mean age 15.2±3 y) who received preoperative 15 mg/kg intravenous TXA, and group 2 consisted of 31 control patients (18 male and 13 female, mean age 14.3±2.6 y) who did not receive TXA. The groups were compared based on their total blood loss, intraoperative blood loss, hidden blood loss, postoperative drain output, transfusion requirements, preoperative and postoperative hemoglobin (Hb) and hematocrit (Htc) difference, length of hospital stays, operative time, and complications. RESULTS The mean total blood loss was lower in intravenous TXA group (1247.5±300.9 mL) when compared with control group (1715.7±857.0 mL) (P=0.018). The mean intraoperative blood loss in intravenous TXA group (386±109 mL) was lower than that in control group (977.4±610.7 mL) (P<0.001). Postoperative drain output at 24 and 48 hours was 198.0±61.8 and 72.4±27.4 mL in intravenous TXA group, respectively, and was low compared with 268.4±118.2 and 117.1±67.8 mL in control group (P=0.028 and 0.006). The rate of patients requiring transfusion was significantly lower in intravenous TXA group (56%) than in control group (83.9%). Preoperative and postoperative 6, 24, and 72 hours Hb and Htc differences were significantly lower in intravenous TXA group [(-1.7±1.8 g/dL P<0.001; -2.0±1.5 g/dL P<0.001; -2.3±1.7 g/dL P<0.001, for Hb) (-5.7±4.6, P<0.001; -6.9±4.0, P<0.001; -9.6±9.1, P<0.001, for Htc)]. Intravenous TXA group had shorter hospital stay time in comparison to control group (P<0.001). The operative time was significantly longer in the control group (P<0.05). No increase in pulmonary embolism or venous thromboembolism rate was observed with intravenous TXA use. CONCLUSION We conclude that administration of intravenous TXA reduces intraoperative and postoperative blood loss, transfusion rates, and hospital stay in resection and endoprosthetic reconstruction of the distal femoral osteosarcomas in children. TYPE OF STUDY This was a retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Omer Sofulu
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
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Pennington Z, Ehresman J, Schilling A, Feghali J, Hersh AM, Hung B, Kalivas EN, Lubelski D, Sciubba DM. Influence of tranexamic acid use on venous thromboembolism risk in patients undergoing surgery for spine tumors. J Neurosurg Spine 2021; 35:663-673. [PMID: 34388705 DOI: 10.3171/2021.1.spine201935] [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: 10/28/2020] [Accepted: 01/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with spine tumors are at increased risk for both hemorrhage and venous thromboembolism (VTE). Tranexamic acid (TXA) has been advanced as a potential intervention to reduce intraoperative blood loss in this surgical population, but many fear it is associated with increased VTE risk due to the hypercoagulability noted in malignancy. In this study, the authors aimed to 1) develop a clinical calculator for postoperative VTE risk in the population with spine tumors, and 2) investigate the association of intraoperative TXA use and postoperative VTE. METHODS A retrospective data set from a comprehensive cancer center was reviewed for adult patients treated for vertebral column tumors. Data were collected on surgery performed, patient demographics and medical comorbidities, VTE prophylaxis measures, and TXA use. TXA use was classified as high-dose (≥ 20 mg/kg) or low-dose (< 20 mg/kg). The primary study outcome was VTE occurrence prior to discharge. Secondary outcomes were deep venous thrombosis (DVT) or pulmonary embolism (PE). Multivariable logistic regression was used to identify independent risk factors for VTE and the resultant model was deployed as a web-based calculator. RESULTS Three hundred fifty patients were included. The mean patient age was 57 years, 53% of patients were male, and 67% of surgeries were performed for spinal metastases. TXA use was not associated with increased VTE (14.3% vs 10.1%, p = 0.37). After multivariable analysis, VTE was independently predicted by lower serum albumin (odds ratio [OR] 0.42 per g/dl, 95% confidence interval [CI] 0.23-0.79, p = 0.007), larger mean corpuscular volume (OR 0.91 per fl, 95% CI 0.84-0.99, p = 0.035), and history of prior VTE (OR 2.60, 95% CI 1.53-4.40, p < 0.001). Longer surgery duration approached significance and was included in the final model. Although TXA was not independently associated with the primary outcome of VTE, high-dose TXA use was associated with increased odds of both DVT and PE. The VTE model showed a fair fit of the data with an area under the curve of 0.77. CONCLUSIONS In the present cohort of patients treated for vertebral column tumors, TXA was not associated with increased VTE risk, although high-dose TXA (≥ 20 mg/kg) was associated with increased odds of DVT or PE. Additionally, the web-based clinical calculator of VTE risk presented here may prove useful in counseling patients preoperatively about their individualized VTE risk.
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Affiliation(s)
- Zach Pennington
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Jeff Ehresman
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Andrew Schilling
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - James Feghali
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Andrew M Hersh
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Bethany Hung
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Eleni N Kalivas
- 2Department of Pharmacy, Division of Critical Care and Surgery Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Daniel Lubelski
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
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Sloan M, Lee GC. Mortality and Complications in Patients with Metastatic Disease after Primary Total Hip and Total Knee Arthroplasty. J Arthroplasty 2020; 35:3512-3516. [PMID: 32690429 DOI: 10.1016/j.arth.2020.06.080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/26/2020] [Accepted: 06/26/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although palliative therapies such as radiation are usually performed to improve quality of life in patients with metastatic disease, arthroplasty for joint pain may be indicated in some cases. Therefore, the purpose of this study is to evaluate the 30-day mortality risk, the risk of complications including infection and venous thromboembolic events, and the rate of 30-day reoperations and readmissions in patients with metastatic disease undergoing primary total hip and total knee arthroplasty (THA/TKA). METHODS We reviewed the National Surgical Quality Improvement Program database from 2008 to 2018 to evaluate rates of postoperative complications after elective primary THA/TKA in patients with disseminated cancer. After exclusions, 205,007 patients undergoing primary THA and 352,337 undergoing primary TKA were retained for analysis: 942 (0.2%) with disseminated cancer. Chi-square was used to compare proportions between groups. Univariate and multivariate logistic regression was used to model the odds ratio of patients with disseminated cancer compared with those without disseminated cancer. RESULTS After adjustment for covariates, patients with disseminated cancer had a higher risk of death (OR: 5.25, 95% CI: 2.47-11.17), any complication (OR: 1.95, 95% CI: 1.63-2.33), deep venous thrombosis (OR: 2.39, 95% CI: 1.32-4.35), pulmonary embolism (OR: 3.07, 95% CI: 1.52-6.17), cardiovascular complications (OR: 2.98, 95% CI: 1.47-6.04), transfusion (OR: 2.21, 95% CI: 1.82-2.69), reoperations (OR: 1.89, 95% CI: 1.28-2.78), readmissions (OR: 2.51, 95% CI: 1.95-3.23), and longer length of stay (4.3 vs 2.7 days). CONCLUSION Patients with disseminated cancer have significantly elevated risk of complications after elective primary THA/TKA. Understanding the severity of complications is critical to the risk-benefit analysis that confronts patients and surgeons considering surgery. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Matthew Sloan
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Gwo-Chin Lee
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
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Atalay İB, Yapar A, Ulucakoy C, Duman EM, Toğral G, Ozturk R, Güngör BŞ. The Effectiveness of Tranexamic Acid in Patients With Proximal Femoral Tumor Resection Prosthesis. Cureus 2020; 12:e10105. [PMID: 33014639 PMCID: PMC7526757 DOI: 10.7759/cureus.10105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aim: The aim of this study is to evaluate the risk of thromboembolic events and amount of postoperative blood loss and transfusion in patients who received preoperative tranexamic acid (TXA) administration in proximal femoral resection and endoprosthesis of proximal femur malignant lesion. Methods: In this study, the data of 46 patients who underwent extensive resection and proximal femoral tumor prosthesis for proximal femoral bone malignancies were retrospectively reviewed. Patients were divided into two groups according to preoperative 15 mg/kg bolus intravenous administration of TXA. These patients were compared in terms of postoperative blood loss, postoperative bleeding, and transfusion requirements. Results: There were 46 patients (18 female, 28 male) with a mean age of 60.7±14.7 (19-89) years. Fifteen patients (32.6%) were treated with iv TXA. In the TXA group (46.7%), there was a statistically significant decrease in the need for transfusion compared to the patient group (93.5%) without TXA (p=0.001). Postoperative 24th hour, 48th hour,and total drainage blood loss values were found to be significantly lower in the TXA group (p=0.047, p=0.015, and p=0.019, respectively). There was no thromboembolic event observed. Conclusion: Because of proximal femoral malignancy, extensive tumor resection and preoperative bolus 15 mg/kg TXA administration in proximal femoral prosthesis surgery significantly decreased the amount of postoperative bleeding and transfusion requirement without increasing the risk of thromboembolic event. Level of Evidence: Level III - retrospective comparative study.
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Affiliation(s)
- İsmail Burak Atalay
- Orthopedics and Traumatology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Aliekber Yapar
- Orthopedics, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Coskun Ulucakoy
- Orthopedics, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Emek Mert Duman
- Orthopedics and Traumatology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Güray Toğral
- Orthopedics, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Recep Ozturk
- Orthopedics, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Bedii Şafak Güngör
- Orthopedics, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
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Yoo JS, Ahn J, Karmarkar SS, Lamoutte EH, Singh K. The use of tranexamic acid in spine surgery. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S172. [PMID: 31624738 PMCID: PMC6778277 DOI: 10.21037/atm.2019.05.36] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/13/2019] [Indexed: 11/06/2022]
Abstract
Patients undergoing surgical procedures of the spine with associated large volume blood loss often require perioperative blood conservation strategies. Synthetic antifibrinolytic medications such as tranexamic acid (TXA) may reduce blood transfusion requirements and postoperative complications following spinal procedures. Studies investigating the role of TXA in spine surgery have presented promising results and have proven its safety and efficacy. However, further investigation is needed to determine the optimal dosing regimen of TXA. In this article, we provide an overview of the basic science and pharmacology of TXA. A comprehensive summary of the findings from clinical trials and a review of the literature that demonstrate the risks and benefits of TXA in spine surgery are also presented.
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Affiliation(s)
- Joon S Yoo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Sailee S Karmarkar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Eric H Lamoutte
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Damade C, Tesson G, Gilard V, Vigny S, Foulongne E, Gauthé R, Ould-Slimane M. Blood loss and perioperative transfusions related to surgery for spinal tumors. Relevance of tranexamic acid. Neurochirurgie 2019; 65:377-381. [PMID: 31202780 DOI: 10.1016/j.neuchi.2019.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/12/2019] [Accepted: 05/17/2019] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) has been shown to reduce bleeding. Patients with spinal tumors are fragile and acute anemia may be harmful. Tumor excision surgery is reputed to be hemorrhagic and treatment may increase thromboembolic complications. The aim of this study was to compare blood loss with or without perioperative TXA injection. The transfusion-related and postoperative complications were documents. METHOD This retrospective analysis of prospectively collected data involved 83 patients with spinal tumors who underwent decompressive surgery associated with bone fixation. Tranexamic acid was used arbitrarily in 36 of them, while the other 47 did not receive TXA. The overall, intraoperative and postoperative blood loss was recorded. Blood loss was reported relative to the number of fixed levels and the number of levels decompressed by laminectomy. Transfusions were quantified in number of red blood cell packets and erythrocyte volume. Postoperative complications were documented. RESULTS Epidemiological and morphological data were similar between groups. There were no significant differences between the two groups in the overall, intraoperative, and postoperative blood loss. A significant reduction in postoperative bleeding was found in the TXA group when the volume was related to the number of decompressed levels. A significant reduction (P<0.05) in the volume of transfused blood was identified in the treated group. No predictor of blood loss was identified, and no additional complications occurred. CONCLUSION The efficacy of TXA appears to be moderate during spinal tumor surgery since it does not lead to a reduction in perioperative bleeding. However, a significant reduction in transfusion volume was found without an increase in complications.
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Affiliation(s)
- C Damade
- University hospital of Bordeaux, spine unit 1, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - G Tesson
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France
| | - V Gilard
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France; University hospital of Rouen, spine unit, department of neurosurgery, 1, rue de Germont, 76000 Rouen, France
| | - S Vigny
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France
| | - E Foulongne
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France
| | - R Gauthé
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France.
| | - M Ould-Slimane
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France
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Faruk NA, Mohd-Amin MZ, Awang-Ojep DN, Teo YY, Wong CC. Three Level Thoracolumbar Spondylectomy for Recurrent Giant Cell Tumour of the Spine: A Case Report. Malays Orthop J 2018; 12:50-52. [PMID: 30555648 PMCID: PMC6287132 DOI: 10.5704/moj.1811.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Giant cell tumour (GCT) is a benign tumour but can be locally aggressive and with the potential to metastasise especially to the lungs. Successful treatments have been reported for long bone lesions; however, optimal surgical and medical treatment for spinal and sacral lesions are not well established. In treating spinal GCTs, the aim is to achieve complete tumour excision, restore spinal stability and decompress the neural tissues. The ideal surgical procedure is an en bloc spondylectomy or vertebrectomy, where all tumour cells are removed as recurrence is closely related to the extent of initial surgical excision. However, such a surgery has a high complication rate, such as dura tear and massive blood loss. We report a patient with a missed pathological fracture of T12 treated initially with a posterior subtraction osteotomy, who had recurrence three years after the index surgery and subsequently underwent a three level vertebrectomy and posterior spinal fusion.
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Affiliation(s)
- N A Faruk
- Department of Orthopaedics, Sarawak General Hospital, Kuching, Malaysia
| | - M Z Mohd-Amin
- Department of Orthopaedics, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
| | - D N Awang-Ojep
- *Department of Pathology, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
| | - Y Y Teo
- Department of Orthopaedics, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
| | - C C Wong
- Department of Orthopaedics, Sarawak General Hospital, Kuching, Malaysia
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Hui S, Xu D, Ren Z, Chen X, Sheng L, Zhuang Q, Li S. Can tranexamic acid conserve blood and save operative time in spinal surgeries? A meta-analysis. Spine J 2018; 18:1325-1337. [PMID: 29246849 DOI: 10.1016/j.spinee.2017.11.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 10/23/2017] [Accepted: 11/22/2017] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Shangyi Hui
- Department of Anesthesiology Peking Union Medical College Hospital, Beijing 100730, China
| | - Derong Xu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Zhinan Ren
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Xin Chen
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Lin Sheng
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Qianyu Zhuang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Beijing 100730, China.
| | - Shugang Li
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Beijing 100730, China
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High-dose Versus Low-dose Tranexamic Acid to Reduce Transfusion Requirements in Pediatric Scoliosis Surgery. J Pediatr Orthop 2017; 37:e552-e557. [PMID: 29120963 DOI: 10.1097/bpo.0000000000000820] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Our objective was to quantify blood loss and transfusion requirements for high-dose and low-dose tranexamic acid (TXA) dosing regimens in pediatric patients undergoing spinal fusion for correction of idiopathic scoliosis. Previous investigators have established the efficacy of TXA in pediatric scoliosis surgery; however, the dosing regimens vary widely and the optimal dose has not been established. METHODS We retrospectively analyzed electronic medical records for 116 patients who underwent spinal fusion surgery for idiopathic scoliosis by a single surgeon and were treated with TXA. In total, 72 patients received a 10 mg/kg loading dose with a 1 mg/kg/h maintenance dose (low-dose) and 44 patients received 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose (high-dose). Estimated blood loss and transfusion requirements were compared between dosing groups. RESULTS Patient characteristics were nearly identical between the 2 groups. Compared with the low-dose TXA group, the high-dose TXA group had decreased estimated blood loss (695 vs. 968 mL, P=0.01), and a decrease in both intraoperative (0.3 vs. 0.9 units, P=0.01) and whole hospitalization (0.4 vs. 1.0 units, P=0.04) red blood cell transfusion requirements. The higher-dose TXA was associated with decreased intraoperative (P=0.01), and whole hospital transfusion (P=0.01) requirements, even after risk-adjustment for potential confounding variables. CONCLUSIONS High-dose TXA is more effective than low-dose TXA in reducing blood loss and transfusion requirements in pediatric idiopathic scoliosis patients undergoing surgery. LEVEL OF EVIDENCE Level-III, retrospective cohort study.
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16
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Winter SF, Santaguida C, Wong J, Fehlings MG. Systemic and Topical Use of Tranexamic Acid in Spinal Surgery: A Systematic Review. Global Spine J 2016; 6:284-95. [PMID: 27099820 PMCID: PMC4836933 DOI: 10.1055/s-0035-1563609] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/13/2015] [Indexed: 01/17/2023] Open
Abstract
Study Design Combination of narrative and systematic literature reviews. Objectives Massive perioperative blood loss in complex spinal surgery often requires blood transfusions and can negatively affect patient outcome. Systemic use of the antifibrinolytic agent tranexamic acid (TXA) has become widely used in the management of surgical bleeding. We review the clinical evidence for the use of intravenous TXA as a hemostatic agent in spinal surgery and discuss the emerging role for its complementary use as a topical agent to reduce perioperative blood loss from the surgical site. Through a systematic review of published and ongoing investigations on topical TXA for spinal surgery, we wish to make spine practitioners aware of this option and to suggest opportunities for further investigation in the field. Methods A narrative review of systemic TXA in spinal surgery and topical TXA in surgery was conducted. Furthermore, a systematic search (using PRISMA guidelines) of PubMed (MEDLINE), EMBASE, and Cochrane CENTRAL databases as well as World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov (National Institutes of Health), and International Standard Randomized Controlled Trial Number registries was conducted to identify both published literature and ongoing clinical trials on topical TXA in spinal surgery. Results Of 1,631 preliminary search results, 2 published studies were included in the systematic review. Out of 285 ongoing clinical trials matching the search criteria, a total of 4 relevant studies were included and reviewed. Conclusion Intravenous TXA is established as an efficacious hemostatic agent in spinal surgery. Use of topical TXA in surgery suggests similar hemostatic efficacy and potentially improved safety as compared with intravenous TXA. For spinal surgery, the literature on topical TXA is sparse but promising, warranting further clinical investigation and consideration as a clinical option in cases with significant anticipated surgical site blood loss.
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Affiliation(s)
| | - Carlo Santaguida
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada,Krembil Neuroscience Centre, University Health Network, Toronto, Ontario, Canada,Address for correspondence Michael G. Fehlings, MD Suite 4W449, Toronto Western Hospital399 Bathurst Street, Toronto M5T 2S8, OntarioCanada
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Kulkarni AP, Chaukar DA, Patil VP, Metgudmath RB, Hawaldar RW, Divatia JV. Does tranexamic acid reduce blood loss during head and neck cancer surgery? Indian J Anaesth 2016; 60:19-24. [PMID: 26962250 PMCID: PMC4782418 DOI: 10.4103/0019-5049.174798] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background and Aims: Transfusion of blood and blood products poses several hazards. Antifibrinolytic agents are used to reduce perioperative blood loss. We decided to assess the effect of tranexamic acid (TA) on blood loss and the need for transfusion in head and neck cancer surgery. Methods: After Institutional Review Board approval, 240 patients undergoing supramajor head and neck cancer surgeries were prospectively randomised to either TA (10 mg/kg) group or placebo (P) group. After induction, the drug was infused by the anaesthesiologist, who was blinded to allocation, over 20 min. The dose was repeated every 3 h. Perioperative (up to 24 h) blood loss, need for transfusion and fluid therapy was recorded. Thromboelastography (TEG) was performed at fixed intervals in the first 100 patients. Patients were watched for post-operative complications. Results: Two hundred and nineteen records were evaluable. We found no difference in intraoperative blood loss (TA - 750 [600–1000] ml vs. P - 780 [150–2600] ml, P = 0.22). Post-operative blood loss was significantly more in the placebo group at 24 h (P - 200 [120–250] ml vs. TA - 250 [50–1050] ml, P = 0.009), but this did not result in higher number of patients needing transfusions (TA - 22/108 and P - 27/111 patients, P = 0.51). TEG revealed faster clot formation and minimal fibrinolysis. Two patients died of causes unrelated to study drug. Incidence of wound complications and deep venous thrombosis was similar. Conclusion: In head and neck cancer surgery, TA did not reduce intraoperative blood loss or need for transfusions. Perioperative TEG variables were similar. This may be attributed to pre-existing hypercoagulable state and minimal fibrinolysis in cancer patients.
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Affiliation(s)
- Atul P Kulkarni
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Devendra A Chaukar
- Department of Head and Neck Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vijaya P Patil
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajendra B Metgudmath
- Department of Head and Neck Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rohini W Hawaldar
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Dupuis C, Michelet D, Hilly J, Diallo T, Vidal C, Delivet H, Nivoche Y, Mazda K, Dahmani S. Predictive factors for homologous transfusion during paediatric scoliosis surgery. Anaesth Crit Care Pain Med 2015; 34:327-32. [DOI: 10.1016/j.accpm.2015.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 04/10/2015] [Indexed: 02/02/2023]
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Ng BKW, Chau WW, Hung ALH, Hui AC, Lam TP, Cheng JCY. Use of Tranexamic Acid (TXA) on reducing blood loss during scoliosis surgery in Chinese adolescents. SCOLIOSIS 2015; 10:28. [PMID: 26442124 PMCID: PMC4593193 DOI: 10.1186/s13013-015-0052-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 09/13/2015] [Indexed: 01/22/2023]
Abstract
Background Many reports had been received on the application of antifibrinolytic medications on spinal corrective surgery and the surgical outcome evaluations of its efficacy on reducing blood loss. This study aimed to assess the efficacy of tranexamic acid (TXA) in reducing operative blood loss during posterior spinal fusion for the treatment of severe adolescent idiopathic scoliosis (AIS). Methods A retrospective cohort study was carried out on 90 (TXA = 55, Control = 35) AIS girls undergoing posterior spinal surgery. Patients in TXA group used TXA as an antifibrinolytic agent to reduce blood loss, while control group did not. Blood loss, haemoglobin change and amount of blood transfused was estimated from intraoperative measurement by anaesthesiologists. Demographics were compared using Student’s T-test or Chi-square test where appropriate. Linear regression modelling was carried out between the use of TXA and total blood loss with controlling of confounding factors. Results Mean age and mean maximum major curve were 15.2 and 73°, and 15.3 and 63° in TXA and control groups respectively. TXA group showed significantly less intra-operative blood loss than the control group from intraoperative measurement (1.8 L vs. 3.9 L, p < 0.01) and volume of cell saver blood transfused back to patients (0.6 L vs. 1.7 L, p < 0.01). TXA group also showed significantly shorter total time taken for surgery (437 min vs. 502 min, p < 0.01), and total blood loss per surgical segment level (0.1 L vs. 0.3 L, p < 0.01). Regression models showed that the use of TXA decreased total blood loss by 794.3 ml after adjusting for maximum major curve, age, number of segments fused, bone graft, clotting capability, and infusion of coagulation factors. Conclusions Patients undergoing posterior spinal corrective surgery with the use of TXA showed much reduced total blood loss, reduced use of transfused blood, much less cell saver blood transfused back to the patient. The total blood loss was decreased by after using TXA after controlling for maximum major curve, age, surgical parameters, clotting capability, and infusion of coagulation factors.
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Affiliation(s)
- Bobby K W Ng
- Department of Orthopaedics & Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong ; Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T. Hong Kong
| | - W W Chau
- Department of Orthopaedics & Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Alec L H Hung
- Department of Orthopaedics & Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anna Cn Hui
- Department of Surgery, Prince of Wales Hospital, Shatin, Hong Kong
| | - Tze Ping Lam
- Department of Orthopaedics & Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jack C Y Cheng
- Department of Orthopaedics & Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong
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Xie B, Tian J, Zhou DP. Administration of Tranexamic Acid Reduces Postoperative Blood Loss in Calcaneal Fractures: A Randomized Controlled Trial. J Foot Ankle Surg 2015; 54:1106-10. [PMID: 26310621 DOI: 10.1053/j.jfas.2015.07.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Indexed: 02/08/2023]
Abstract
The present randomized controlled trial was undertaken to evaluate the effect of tranexamic acid (TXA) on reducing postoperative blood loss in calcaneal fractures. A total of 90 patients with a unilateral closed calcaneal fracture were randomized to the TXA (n = 45) and control (n = 45) groups. The corresponding groups received 15 mg/kg body weight of TXA or placebo (0.9% sodium chloride solution) intravenously before the skin incision was made. Open reduction and internal fixation was performed for all patients and selective bone grafting was performed. The patients were examined 3 months after surgery. The intraoperative and postoperative blood loss, blood test results, and wound complications were compared between the 2 groups. The complications of TXA were also investigated. No statistically significant differences were found in the baseline characteristics between the TXA and control groups. Also, no significant difference was noted in the intraoperative blood loss between the 2 groups. However, in the TXA group, the postoperative blood loss during the first 24 hours was significantly lower than that in the control group (110.0 ± 160.0 mL versus 320.0 ± 360.0 mL; p < .001). The incidence of wound complications was also reduced compared with that in the control group (7.3% versus 23.8%; p = .036). No significant difference was found in the incidence of thromboembolic events or adverse drug reactions between the 2 groups. We concluded that preoperative single-dose TXA can effectively reduce postoperative blood loss and wound complications in patients with calcaneal fractures and that no significant side effects developed compared with the control group.
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Affiliation(s)
- Bing Xie
- Orthopedist, Department of Orthopedics, Shenyang Military Region General Hospital, Shenyang, People's Republic of China
| | - Jing Tian
- Assistant Professor, Department of Orthopedics, Shenyang Military Region General Hospital, Shenyang, People's Republic of China
| | - Da-peng Zhou
- Professor, Department of Orthopedics, Shenyang Military Region General Hospital, Shenyang, People's Republic of China.
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Afsharimani B, Cabot P, Parat MO. Effect of lysine antifibrinolytics and cyclooxygenase inhibitors on the proteolytic profile of breast cancer cells interacting with macrophages or endothelial cells. Br J Anaesth 2014; 113 Suppl 1:i22-31. [DOI: 10.1093/bja/aet468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Badeaux J, Hawley D. Effectiveness of intravenous tranexamic acid administration in managing perioperative blood loss in patients undergoing spine surgery: a systematic review. ACTA ACUST UNITED AC 2014. [DOI: 10.11124/jbisrir-2014-949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Yang B, Li H, Wang D, He X, Zhang C, Yang P. Systematic review and meta-analysis of perioperative intravenous tranexamic acid use in spinal surgery. PLoS One 2013; 8:e55436. [PMID: 23424632 PMCID: PMC3570541 DOI: 10.1371/journal.pone.0055436] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 12/23/2012] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is well-established as a versatile oral, intramuscular, and intravenous (IV) antifibrinolytic agent. However, the efficacy of IV TXA in reducing perioperative blood transfusion in spinal surgery is poorly documented. METHODOLOGY We conducted a meta-analysis of randomized controlled trials (RCTs) and quasi-randomized (qi-RCTs) trials that included patients for various spinal surgeries, such as adolescent scoliosis surgery administered with perioperative IV TXA according to Cochrane Collaboration guidelines using electronic PubMed, Cochrane Central Register of Controlled Trials, and Embase databases. Additional journal articles and conference proceedings were manually located by two independent researchers. RESULTS Totally, nine studies were included, with a total sample size of 581 patients. Mean blood loss was decreased in patients treated with perioperative IV TXA by 128.28 ml intraoperatively (ranging from 33.84 to 222.73 ml), 98.49 ml postoperatively (ranging from 83.22 to 113.77 ml), and 389.21 ml combined (ranging from 177.83 to 600.60 ml). The mean volume of transfused packed cells were reduced by 134.55 ml (ranging 51.64 to 217.46) (95% CI; P = 0.0001). Overall, the number of patients treated with TXA who required blood transfusions was lower by 35% than that of patients treated with the comparator and who required blood transfusions (RR 0.65; 95% CI; 0.53 to 0.85; P<0.0001, I(2) = 0%). A dose-independent beneficial effect of TXA was observed, and confirmed in subgroup and sensitivity analyses. A total of seven studies reported DVT data. The study containing only a single DVT case was not combined. CONCLUSIONS The blood loss was reduced in spinal surgery patients with perioperative IV TXA treatment. Also the percentage of spinal surgery patients who required blood transfusion was significantly decreased. Further evaluation is required to confirm our findings before TXA can be safely used in patients undergoing spine surgery.
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Affiliation(s)
- Baohui Yang
- Department of Orthopaedic Surgery, The 2nd Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi Province, People’s Republic of China
| | - Haopeng Li
- Department of Orthopaedic Surgery, The 2nd Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi Province, People’s Republic of China
| | - Dong Wang
- Department of Orthopaedic Surgery, The 2nd Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi Province, People’s Republic of China
| | - Xijing He
- Department of Orthopaedic Surgery, The 2nd Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi Province, People’s Republic of China
| | - Chun Zhang
- Department of Orthopaedic Surgery, The 2nd Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi Province, People’s Republic of China
| | - Pinglin Yang
- Department of Orthopaedic Surgery, The 2nd Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi Province, People’s Republic of China
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Cata JP, Gottumukkala V. Blood Loss and Massive Transfusion in Patients Undergoing Major Oncological Surgery: What Do We Know? ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/918938] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with solid malignancies who were not candidates for tumor resections in the past are now presenting for extensive oncological resections. Cancer patients are at risk for thromboembolic complications due to an underlying hypercoagulable state; however, some patients may have an increased risk for bleeding due to the effects of chemotherapy, the administration of anticoagulant drugs, tumor-related fibrinolysis, tumor location, tumor vascularity, and extent of disease. A common potential complication of all complex oncological surgeries is massive intra- and postoperative hemorrhage and the subsequent risk for massive blood transfusion. This can be anticipated or unexpected. Several surgical and anesthesia interventions including preoperative tumor embolization, major vessel occlusion, hemodynamic manipulation, and perioperative antifibrinolytic therapy have been used to prevent or control blood loss with varying success. The exact incidence of massive blood transfusion in oncological surgery is largely unknown and/or underreported. The current literature mostly consists of purely descriptive observational studies. Thus, recommendation regarding specific perioperative intervention cannot be made at this point, and more research is warranted.
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Affiliation(s)
- Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA
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Efficacy of Prophylactic Low Dose of Tranexamic Acid in Spinal Fixation Surgery. J Neurosurg Anesthesiol 2011; 23:290-6. [DOI: 10.1097/ana.0b013e31822914a1] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wedemeyer C, Kauther MD. Hemipelvectomy- only a salvage therapy? Orthop Rev (Pavia) 2011; 3:e4. [PMID: 21808716 PMCID: PMC3144004 DOI: 10.4081/or.2011.e4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 03/03/2011] [Accepted: 03/04/2011] [Indexed: 11/23/2022] Open
Abstract
After the first hemipelvectomy in 1891 significant advances have been made in the fields of preoperative diagnosis, surgical technique and adjuvant treatment in patients with pelvic tumors. The challenging surgical removal of these rare malignant bone or soft tissue tumors accompanied by interdisciplinary therapy is mostly the only chance of cure, but bares the risk of intensive bleeding and infection. The reconstruction after hemipelvectomy is of importance for the later outcome and quality of life for the patient. Here, plastic surgery with microvascular free flaps or local rotational flaps improved the reconstruction and reduced infection rates. Average local recurrence rates of 14% demonstrate good surgical results, but 5 year survival rates of only 50% are described for some tumor entities, showing the importance of a multimodal collaboration. On a basis of a selective literature review the history, indications, treatment options and outcome of hemipelvectomies are presented.
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Anderson MR, Jeng CL, Wittig JC, Rosenblatt MA. Anesthesia for patients undergoing orthopedic oncologic surgeries. J Clin Anesth 2011; 22:565-72. [PMID: 21056818 DOI: 10.1016/j.jclinane.2010.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 02/23/2010] [Accepted: 02/23/2010] [Indexed: 01/28/2023]
Abstract
When planning an anesthetic for patients undergoing orthopedic oncologic surgeries, numerous factors must be considered. Preoperative evaluation may elucidate significant co-morbidities or side effects secondary to chemotherapy or radiation, which can affect anesthetic choices. Procedures vary in length and complexity and pose challenges in both positioning and in planning to minimize blood loss. Many anesthetic techniques are available to provide both intraoperative anesthesia and postoperative analgesia, while the type of thromboprophylaxis and analgesic adjuvants that will be administered needs to be defined. This review focuses on approaches to use when caring for patients undergoing orthopedic oncologic procedures.
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Affiliation(s)
- Michael R Anderson
- Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY 10029-6574, USA
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Epidural spinal cord compression with neurologic deficit associated with intrapedicular application of hemostatic gelatin matrix during pedicle screw insertion. Spine (Phila Pa 1976) 2009; 34:E473-7. [PMID: 19478651 DOI: 10.1097/brs.0b013e3181a56a21] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE In order to demonstrate the dangers of intrapedicular application of a hemostatic gelatin matrix to decrease blood loss during pedicle screw insertion, we present 2 patients who--as a result of inadvertent extravasation of the matrix into the spinal canal--developed epidural spinal cord compression (ESCC) requiring emergent decompression. SUMMARY OF BACKGROUND DATA Variety of hemostatic agents can control bleeding during pedicle screw insertion. We have often used a hemostatic gelatin matrix to decrease bleeding from cannulated pedicles by injecting the material into the pedicle after manually palpating the pedicle. METHODS Medical records and radiographic studies of 2 patients with AIS who underwent surgical treatment of their deformity and developed a neurologic deficit due to extravasation of FloSeal were reviewed. RESULTS A 15 year-old male underwent T4 to L2 posterior spinal fusion (PSF). During pedicle screw insertion, a change in NMEPs and SSEPs was noted. A wake-up test confirmed bilateral LE paraplegia. Screws were removed and no perforations were noted on manual palpation. MRI showed T7 to T10 ESCC. He underwent a T5 to T10 laminectomy and hemostatic gelatin matrix noted in the canal and was evacuated. He was ambulatory at 2 weeks and by 3 months he had complete recovery. The second patient was a 15 year-old female who underwent T4 to L1 PSF. Following screw insertion, deterioration in NMEPs and SSEPs was noted. Screws were removed and SCM data returned to baseline. Except for 3 screws that had an inferior breach (Left T7 and Bilateral T8), screws were reinserted and remainder of the surgery was uneventful. Postoperative examination was normal initially but 2 days later, she developed left LE numbness/weakness. Implants were removed and MRI showed T4 to T9 ESCC.She underwent a left (concave) T4 to T9 hemilaminectomy. Hemostatic gelatin matrix was noted and was evacuated. Six weeks following surgery, she had a complete neurologic recovery. CONCLUSIONS The use of a hemostatic gelatin matrix to decrease bleeding from cannulated pedicles during pedicle screw insertion can result in inadvertent extravasation into the spinal canal resulting in ESCC even in the absence of an apparent medial pedicle breach. Given the dangers associated with the technique, we recommend that gelatin matrix products be used judiciously during pedicle screw insertion.
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Wong J, El Beheiry H, Rampersaud YR, Lewis S, Ahn H, De Silva Y, Abrishami A, Baig N, McBroom RJ, Chung F. Tranexamic Acid Reduces Perioperative Blood Loss in Adult Patients Having Spinal Fusion Surgery. Anesth Analg 2008; 107:1479-86. [DOI: 10.1213/ane.0b013e3181831e44] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gill JB, Chin Y, Levin A, Feng D. The use of antifibrinolytic agents in spine surgery. A meta-analysis. J Bone Joint Surg Am 2008; 90:2399-407. [PMID: 18978408 DOI: 10.2106/jbjs.g.01179] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Antifibrinolytic agents have been shown to decrease the blood loss associated with major orthopaedic surgical procedures. Spine surgery, particularly procedures performed for deformity correction and procedures involving long arthrodesis constructs, can be associated with a large amount of blood loss requiring blood transfusions. The purpose of the present study was to determine if antifibrinolytic agents reduced blood transfusions in patients managed with spine surgery and to see if one agent had a greater effect than another. METHODS A systematic review and meta-analysis of the available literature were performed to investigate the efficacy of aprotinin, tranexamic acid, and epsilon-aminocaproic acid in terms of reducing blood loss and blood transfusions in patients undergoing spine surgery. This meta-analysis was focused on the role of these agents in major spine operations as reported in eighteen clinical trials that included information on the drug dosage, the age of the patient, blood loss, blood transfusions, surgery complexity, and complications. RESULTS Compared with control groups, the treatment groups for all three antifibrinolytic agents maintained lower levels of total blood loss and transfusions associated with spine surgery. The effect size (d) of the differences in total blood loss between the treatment and control groups ranged from -0.668 (95% confidence interval, -0.971 to -0.365) to -0.936 (95% confidence interval, -1.240 to -0.632) across all three agents. The effect size (d) of the differences in total blood transfusions between the treatment and control groups ranged from -0.466 (95% confidence interval, -0.764 to -0.167) to -0.749 (95% confidence interval, -1.046 to -0.453) across all three agents. CONCLUSIONS Aprotinin, tranexamic acid, and epsilon-aminocaproic acid are effective for reducing blood loss and transfusions in patients managed with spine surgery. With the exception of aprotinin, the side-effect profiles of these agents have not been shown to cause any substantial morbidity or to increase the rate of thromboembolic events. Epsilon-aminocaproic acid had a greater effect on reducing blood transfusions as the complexity of surgery increased. The surgeon and/or the anesthesiologist should consider the use of antifibrinolytic agents for patients undergoing spinal procedures in which a large amount of blood loss can be expected; however, at the present time, this is not a United States Food and Drug Administration-approved indication for these agents.
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Affiliation(s)
- J Brian Gill
- Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, 3601 4th Street, MS 9436, Lubbock, TX 79430, USA.
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Effect of fibrin sealant on drain output and duration of hospitalization after multilevel anterior cervical fusion: a retrospective matched pair analysis. Spine (Phila Pa 1976) 2008; 33:E543-7. [PMID: 18628695 DOI: 10.1097/brs.0b013e31817c6c9b] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective matched pair analysis. OBJECTIVE To determine if fibrin sealant can decrease postoperative drain output and length of stay (LOS) after multilevel anterior cervical fusions. SUMMARY OF BACKGROUND DATA Despite careful hemostasis, bleeding after anterior cervical fusion can occur and may be life threatening. Although fibrin sealants are commonly used for hemostasis, no studies have been published on the efficacy of these products in achieving hemostasis after anterior cervical surgery. METHODS A retrospective age-, gender-, and fusion level-matched pair analysis was performed on 30 pairs of patients who underwent anterior cervical fusion >or= 3 levels. In the study group, after adequate hemostasis was obtained, before wound closure 2.0 mL of fibrin sealant was applied as a fine aerosolized spray over and around the plate/fusion sites and the soft tissues to seal the main operative field. A deep drain was used in all patients. Total drain output, time for the drainage to decrease to <or=20 mL per 8 hours shift, LOS, and number of readmissions were determined and analyzed by experienced and independent spine surgeons. RESULTS Total drain output averaged 47 mL in the study group and 98 mL in the control group (P < 0.0001). Time for the drainage to decrease to <or=20 mL per shift averaged 17 hours (range, 8-29 hours) in the study group and 24 hours (range, 7-43 hours) in the control group (P = 0.0054). LOS averaged 1.2 days (range, 1-4 days) in the study group and 2.1 day (range, 1-5 days) in the control group (P < 0.0001). Two patients were readmitted within 4 days of discharge in each group because of swallowing difficulty, dyspnea, or pneumonia (P = 1.000). There were no adverse reactions attributable to the fibrin sealant. CONCLUSION Application of fibrin sealant at the end of multilevel anterior cervical fusion can significantly decrease postoperative drain output and LOS.
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Namazi H, Mozaffarian K. Practice Pearl: A Novel Use of Tranexamic Acid for Decreasing the Blood Loss of Aneurysmal Bone Cyst Ablation. Ann Surg Oncol 2007; 15:383-4. [PMID: 17909908 DOI: 10.1245/s10434-007-9614-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Revised: 08/02/2007] [Accepted: 08/10/2007] [Indexed: 11/18/2022]
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