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Grabala P, Gregorczyk J, Fani N, Galgano MA, Grabala M. Surgical Treatment Strategies for Severe and Neglected Spinal Deformities in Children and Adolescents without the Use of Radical Three-Column Osteotomies. J Clin Med 2024; 13:4824. [PMID: 39200966 PMCID: PMC11355333 DOI: 10.3390/jcm13164824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 08/13/2024] [Accepted: 08/14/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Severe spinal deformity manifests as a pronounced deviation from the normal curvature of the spine in the frontal, sagittal, and horizontal planes, where the coronal plane curvature exceeds 90 degrees and may coincide with hyperkyphotic deformity. The most severe deformities exhibit rigidity, with flexibility below 30%. If left untreated or improperly treated, these deformities can result in serious complications associated with progression of the curvature. A combination of surgical techniques is frequently employed to attain optimal outcomes and minimize the risk of complications. The overall medical condition of the patient, their capacity to endure extensive procedures, the expertise of the surgeon, and the resources available all play significant roles in determining the course of management. A systematic and thorough review of the relevant literature was conducted utilizing a variety of electronic databases. The primary objective of this study was to scrutinize the surgical techniques commonly employed in complex spine surgeries for the management of severe scoliosis without resection vertebral body techniques, with higher potential risk of major complications, including permanent neurological deficit. Conclusions: Halo-gravity traction, halo femoral traction, and all techniques for releases of the spine (anterior, posterior, or combine), as well as thoracoplasty, have demonstrated significant effectiveness in managing severe and rigid idiopathic scoliosis. The combination of several of these methods can lead to optimal alignment correction without the need to perform high-risk techniques involving three-column osteotomies. Surgeons must customize the indications based on factors such as available resources, characteristics of the deformity, and the patient's individual profile. Surgical correction of severe scoliosis without vertebral body resection surgeries decreases the potential risks related to neurological and pulmonary complications while providing significant clinical improvement outcomes. The powerful Ponte osteotomy is indicated for severe scoliosis, curves with poor flexibility, for better restoration of hypokyphosis, and decrease of hyperkyphosis. These corrective techniques combined with HGT or temporary internal distraction rods are recommended as viable options for managing individuals with severe rigid spine deformity characteristics. Therefore, they also should be considered and performed by a proficient surgical team. The presence of neuromonitoring is crucial throughout these procedures.
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Affiliation(s)
- Pawel Grabala
- Department of Pediatric Orthopedic Surgery and Traumatology, Medical University of Bialystok Children’s Clinical Hospital, Waszyngtona 17, 15-274 Bialystok, Poland
- Paley European Institute, Al. Rzeczypospolitej 1, 02-972 Warsaw, Poland
| | - Jerzy Gregorczyk
- Medical Faculty, Medical University of Warsaw, 02-091 Warsaw, Poland; (J.G.); (N.F.)
| | - Negin Fani
- Medical Faculty, Medical University of Warsaw, 02-091 Warsaw, Poland; (J.G.); (N.F.)
| | - Michael A. Galgano
- Department of Neurosurgery, University of North Carolina, Chapel Hill, NC 27516, USA;
| | - Michał Grabala
- 2nd Clinical Department of General and Gastroenterogical Surgery, Medical University of Bialystok Clinical Hospital, ul. M. Skłodowskiej-Curie 24a, 15-276 Bialystok, Poland;
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Theissen A, Folléa G, Garban F, Carlier M, Pontone S, Lassale B, Boyer B, Noll E, Arthuis C, Ducloy-Bouthors AS, Cotte E, Veziant J, Retur N, Sarma S, Faure-Munoz A, Evans I, Pitard A, Kindo M, Rineau E. Perioperative Patient Blood Management (excluding obstetrics): Guidelines from the French National Authority for Health. Anaesth Crit Care Pain Med 2024; 43:101404. [PMID: 38992466 DOI: 10.1016/j.accpm.2024.101404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/27/2024] [Accepted: 05/02/2024] [Indexed: 07/13/2024]
Abstract
The French National Authority for Health (HAS) recently issued guidelines for patient blood management (PBM) in surgical procedures. These recommendations are based on three usual pillars of PBM: optimizing red cell mass, minimizing blood loss and optimizing anemia tolerance. In the preoperative period, these guidelines recommend detecting anemia and iron deficiency and taking corrective measures well in advance of surgery, when possible, in case of surgery with moderate to high bleeding risk or known preoperative anemia. In the intraoperative period, the use of tranexamic acid and some surgical techniques are recommended to limit bleeding in case of high bleeding risk or in case of hemorrhage, and the use of cell salvage is recommended in some surgeries with a major risk of transfusion. In the postoperative period, the limitation of blood samples is recommended but the monitoring of postoperative anemia must be carried out and may lead to corrective measures (intravenous iron in particular) or more precise diagnostic assessment of this anemia. A "restrictive" transfusion threshold considering comorbidities and, most importantly, the tolerance of the patient is recommended postoperatively. The implementation of a strategy and a program for patient blood management is recommended throughout the perioperative period in healthcare establishments in order to reduce blood transfusion and length of stay. This article presents an English translation of the HAS recommendations and a summary of the rationale underlying these recommendations.
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Affiliation(s)
- Alexandre Theissen
- Anesthésie-Réanimation Chirurgicale, Clinique Saint François, groupe Vivalto, Nice, France
| | - Gilles Folléa
- Société Française de Transfusion Sanguine, Paris, France
| | - Frédéric Garban
- Service d'hématologie, CHU de Grenoble Alpes CS10217, 38043 Grenoble, France
| | - Monique Carlier
- Agence Régionale de Santé Grand-Est, Châlons-en-Champagne, France
| | - Silvia Pontone
- Département Anesthésie-Réanimation, APHP Hôpital Universitaire Robert Debré, Paris, France
| | - Bernard Lassale
- Hémovigilance et Sécurité Transfusionnelle, Hôpital Universitaires de Marseille, Marseille, France
| | - Bertrand Boyer
- Département de chirurgie orthopédique, CHU de Saint Etienne, Hôpital Nord, 42055 Saint-Etienne, France
| | - Eric Noll
- Département d'Anesthésie-Réanimation, Hôpital Hautepierre, Hôpitaux Universitaires de Strasbourg, 67200 Strasbourg, France
| | - Chloé Arthuis
- Service de Gynécologie-Obstétrique et Diagnostic Anténatal, Santé Atlantique Saint Herblain, Université de Nantes, Nantes, France
| | - Anne-Sophie Ducloy-Bouthors
- Anesthésie-Réanimation Obstétricale, Hôpital Jeanne de Flandre, CHU de Lille, France; Lille university Groupe de recherche sur les formes injectables et les technologies associées GRITA ULR 7365 FR59 Lille, France
| | - Eddy Cotte
- Service de chirurgie digestive et oncologique, Hôpital Lyon-Sud, CHU de Lyon, Pierre-Bénite Cedex, France
| | - Julie Veziant
- Département de chirurgie digestive et oncologique, Université et CHU de Lille, 59000 Lille, France
| | | | | | - Alexandra Faure-Munoz
- Unité de chirurgie et d 'anesthésie ambulatoire, Centre Hospitalier d'Albi, Albi, France
| | | | - Alexandre Pitard
- Haute Autorité de Santé, service des bonnes pratiques, Saint-Denis La Plaine, France
| | - Michel Kindo
- Service de Chirurgie CardioVasculaire, Transplantation et Assistance Cardiaques, Hôpitaux Universitaires de Strasbourg, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Emmanuel Rineau
- Département d'Anesthésie-Réanimation du CHU d'Angers, Faculté de Santé de l'Université d'Angers, Angers, France; Univ Angers, MITOVASC Inserm U1083 - CNRS 6015, Equipe CARME, Angers, France.
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3
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Wang L, Xia Q, Ni W, Zhuang D, Tong X, Jiang L, Mao Y. Predicting delayed extubation and transfer to the intensive care unit in children undergoing posterior fusion surgery for scoliosis : A retrospective observational study. DIE ANAESTHESIOLOGIE 2024; 73:398-407. [PMID: 38575771 DOI: 10.1007/s00101-024-01391-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/22/2023] [Accepted: 01/02/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Delayed extubation and transfer to the intensive care unit (ICU) in children undergoing major scoliosis surgery may increase postoperative complications, prolong hospital stay, and increase medical expenses; however, whether a child will require delayed extubation or transfer to the ICU after scoliosis orthopedic surgery is not fully understood. In this study, we reviewed the risk factors for delayed extubation and transfer to the ICU after scoliosis orthopedic surgery in children. METHOD The electronic medical records of pediatric patients (≤ 18 years) who underwent posterior spinal fusion surgery between January 2018 and November 2021 were reviewed and analyzed. Patient characteristics (age, sex, body mass index, American Society of Anesthesiologists, ASA, grade, preoperative lung function, and congenital heart disease), preoperative Cobb angle, scoliosis type, correction rate, vertebral fusion segments, pedicle screws, surgical osteotomy, intraoperative bleeding, intraoperative allogeneic transfusion, intraoperative hemoglobin changes, intraoperative mean arterial pressure changes, intraoperative tidal volume (ml/kg predicted body weight), surgical time, postoperative extubation, and transfer to the ICU were collected. The primary outcomes were delayed extubation and transfer to the ICU. Multivariate logistic regression models were used to determine the risk factors for delayed extubation and ICU transfer. RESULTS A total of 246 children who satisfied the inclusion criteria were enrolled in this study, of whom 23 (9.3%) had delayed extubation and 81 (32.9%) were transferred to the ICU after surgery. High ASA grade (odds ratio [OR] 5.42; 95% confidence interval [CI] 1.49-19.78; p = 0.010), high Cobb angle (OR 1.04; 95% CI 1.02-1.07; p < 0.001), moderate to severe pulmonary dysfunction (OR 10.9; 95% CI 2.00-59.08; p = 0.006) and prolonged surgical time (OR 1.01; 95% CI 1.00-1.03; p = 0.040) were risk factors for delayed extubation. A high Cobb angle (OR 1.02; 95% CI 1.01-1.04; p = 0.004), high intraoperative bleeding volume (OR 1.06; 95% CI 1.03-1.10; p = 0.001), allogeneic transfusion (OR 3.30; 95% CI 1.24-8.83; p = 0.017) and neuromuscular scoliosis (OR 5.38; 95% CI 1.59-18.25; p = 0.007) were risk factors for transfer to the ICU. A high Cobb angle was a risk factor for both delayed extubation and ICU transfer. Age, sex, body mass index, number of vertebral fusion segments, correction rate, and intraoperative tidal volume were not associated with delayed postoperative extubation and ICU transfer. CONCLUSION The most common risk factor for delayed extubation and ICU transfer in pediatric patients who underwent posterior spinal fusion was a high Cobb angle. Determining risk factors for a poor prognosis may help optimize perioperative respiratory management strategies and planning of postoperative care for children undergoing complicated spinal surgery.
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Affiliation(s)
- Lai Wang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Qin Xia
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Wenwen Ni
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, 200031, Shanghai, China
| | - Di Zhuang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Xianya Tong
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China
| | - Lai Jiang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China.
| | - Yanfei Mao
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China.
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Lee J, Park S, Lee JG, Choo S, Koo BN. Efficacy of intraoperative blood salvage and autotransfusion in living-donor liver transplantation: a retrospective cohort study. Korean J Anesthesiol 2024; 77:345-352. [PMID: 38467466 PMCID: PMC11150109 DOI: 10.4097/kja.23599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 01/30/2024] [Accepted: 02/21/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Liver transplantation (LT) may be associated with massive blood loss and the need for allogeneic blood transfusion. Intraoperative blood salvage autotransfusion (IBSA) can reduce the need for allogeneic blood transfusion. This study aimed to investigate the effectiveness of blood salvage in LT. METHODS Among 355 adult patients who underwent elective living-donor LT between January 1, 2019, and December 31, 2022, 59 recipients without advanced hepatocellular carcinoma received IBSA using Cell Saver (CS group). Based on sex, age, model for end-stage liver disease (MELD) score, preoperative laboratory results, and other factors, 118 of the 296 recipients who did not undergo IBSA were matched using propensity score (non-CS group). The primary outcome was the amount of intraoperative allogenic red blood cell (RBC) transfusion. Comparisons were made between the two groups regarding the amount of other blood components transfused and postoperative laboratory findings. RESULTS The transfused allogeneic RBC for the CS group was significantly lower than that of the non-CS group (1,506.0 vs. 1,957.5 ml, P = 0.026). No significant differences in the transfused total fresh frozen plasma, platelets, cryoprecipitate, and estimated blood loss were observed between the two groups. The postoperative allogeneic RBC transfusion was significantly lower in the CS group than in the non-CS group (1,500.0 vs. 2,100.0 ml, P = 0.039). No significant differences in postoperative laboratory findings were observed at postoperative day 1 and discharge. CONCLUSIONS Using IBSA during LT can effectively reduce the need for perioperative allogeneic blood transfusions without causing subsequent coagulopathy.
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Affiliation(s)
- Jongchan Lee
- Yonsei University College of Medicine, Seoul, Korea
| | - Sujung Park
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Geun Lee
- Department of Transplantation Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sungji Choo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Eisler L, Hassan F, Lenke LG, Chihuri S, Hod EA, Li G. Allogeneic Red Blood Cell Transfusion and Infectious Complications Following Pediatric Spinal Fusion: NSQIP-P Analysis. JB JS Open Access 2022; 7:JBJSOA-D-22-00038. [PMID: 36285249 PMCID: PMC9586922 DOI: 10.2106/jbjs.oa.22.00038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Substantial bleeding occurs during spinal fusion surgery in the pediatric population, and many patients receive allogeneic red blood cell transfusion (ARBT) for the treatment of resulting perioperative anemia. ARBT is thought to increase vulnerability to postoperative infections following major surgical procedures, but studies of this relationship in children undergoing spinal fusion have yielded conflicting results.
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Affiliation(s)
- Lisa Eisler
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Columbia University, New York, NY,Email for corresponding author:
| | - Fthimnir Hassan
- Department of Orthopedic Surgery, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Columbia University, New York, NY
| | - Lawrence G. Lenke
- Department of Orthopedic Surgery, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Columbia University, New York, NY
| | - Stanford Chihuri
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Columbia University, New York, NY
| | - Eldad A. Hod
- Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Columbia University, New York, NY
| | - Guohua Li
- Departments of Anesthesiology and Epidemiology, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Columbia University, New York, NY
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Sharma R, Huang Y, Dizdarevic A. Blood Conservation Techniques and Strategies in Orthopedic Anesthesia Practice. Anesthesiol Clin 2022; 40:511-527. [PMID: 36049878 DOI: 10.1016/j.anclin.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Orthopedic surgery procedures involving joint arthroplasty, complex spine, long bone and pelvis procedure, and trauma and oncological cases can be associated with a high risk of bleeding and need for blood transfusion, making efforts to optimize patient care and reduce blood loss very important. Patient blood management programs incorporate efforts to optimize preoperative anemia, develop transfusion protocols and restrictive hemoglobin triggers, advance surgical and anesthesia practice, and use antifibrinolytic therapies. Perioperative management of anticoagulant therapies, a multidisciplinary decision-making task, weighs in risks and benefits of thromboembolic risk and surgical bleeding and is patient- and surgery-specific.
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Affiliation(s)
- Richa Sharma
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 West 168th Street, PH 5, New York, NY 10032, USA. https://twitter.com/Drsharma_richa
| | - Yolanda Huang
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 West 168th Street, PH 5, New York, NY 10032, USA
| | - Anis Dizdarevic
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 West 168th Street, PH 5, New York, NY 10032, USA.
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Length of stay, readmission, and mortality after primary surgery for pediatric spinal deformities: a 10-year nationwide cohort study. Spine J 2021; 21:653-663. [PMID: 33429087 DOI: 10.1016/j.spinee.2021.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 12/01/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Extended length of stay (extLOS) and unplanned readmissions after first time pediatric spinal deformity surgery are a considerable challenge to both the patient and the health-care system. To our knowledge, only a limited number of nationwide studies reporting short-term comorbidity with complete follow-up exist. PURPOSE The purpose of this study was to identify the postoperative complications leading to extLOS, readmissions, and mortality within 90 days after surgery. Furthermore, to identify risk factors for readmission. DESIGN Retrospective national cohort study. PATIENT SAMPLE A nationwide registry study including all pediatric spinal deformity patients (≤21 years of age) undergoing primary surgery during 2006-2015 (n=1,310). OUTCOME MEASURES Reasons for extLOS and 90-day readmissions as well as mortality risk. METHODS Patients were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Data on length of stay (LOS), readmissions, and mortality within 90 days were retrieved from the DNPR. Patients were categorized in six groups according to etiology. Reasons for extLOS and readmission were collected from medical records and discharge summaries. RESULTS For the 1,310 patients, the median LOS was 8 days (interquartile range 7-9). Etiologies were idiopathic deformity (53%), neuromuscular deformity (23%), congenital/structural deformity (9%), spondylolisthesis (7%), Scheuermann kyphosis (5%), and syndromic deformity (3%). A total of 274 (21%) patients had extLOS and the most common reason was pain/mobilization issues but with considerable variation between etiologies; Scheuermann kyphosis (91%), idiopathic (59%), syndromic (44%), spondylolisthesis (38%), and congenital (30%). Pulmonary complications were the primary reason for extLOS in the neuromuscular group (22%). The 90-day readmission rate was 6%; 67% of readmissions were medical, mainly infections unrelated to the surgical site (23%); 33% of readmissions were surgical and 14% of patients required revision surgery. Neuromuscular deformity, spondylolisthesis, Scheuermann kyphosis, and LOS >9 days were independent risk factors for readmission; odds ratio (OR) 4.4 (95% confidence interval: 2.2-9.1, p<.01), OR 3.0 (1.1-8.0, p=.03), OR 4.9 (1.7-13.6, p<.01), and OR 1.8 (1.0-3.1, p=.04), respectively. The 90-day mortality risk was 0.4%. CONCLUSIONS In this nationwide cohort, pain/mobilization issues are the most common reason for extLOS. The most common reason for readmission is infection unrelated to the surgical site. Readmission after pediatric spinal surgery is related to the etiology and increased focus on patients operated for neuromuscular deformity, spondylolisthesis and Scheuermann kyphosis is warranted.
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Mihas A, Ramchandran S, Rivera S, Mansour A, Asghar J, Shufflebarger H, George S. Safe and effective performance of pediatric spinal deformity surgery in patients unwilling to accept blood transfusion: a clinical study and review of literature. BMC Musculoskelet Disord 2021; 22:204. [PMID: 33607982 PMCID: PMC7896412 DOI: 10.1186/s12891-021-04081-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pediatric deformity surgery traditionally involves major blood loss. Patients refusing blood transfusion add extra clinical and medicolegal challenges; specifically the Jehovah's witnesses population. The objective of this study is to review the safety and effectiveness of blood conservation techniques in patients undergoing pediatric spine deformity surgery who refuse blood transfusion. METHODS After obtaining institutional review board approval, we retrospectively reviewed 20 consecutive patients who underwent spinal deformity surgery and refused blood transfusion at a single institution between 2014 and 2018. We collected pertinent preoperative, intraoperative and most recent clinical and radiological data with latest follow-up (minimum two-year follow-up). RESULTS Twenty patients (13 females) with a mean age of 14.1 years were identified. The type of scoliotic deformities were adolescent idiopathic (14), juvenile idiopathic (1), neuromuscular (3) and congenital (2). The major coronal Cobb angle was corrected from 55.4° to 11.2° (80% correction, p < 0.001) at the latest follow-up. A mean of 11.4 levels were fused and 5.6 levels of Pontes osteotomies were performed. One patient underwent L1 hemivertebra resection and three patients had fusion to pelvis. Estimated blood loss, percent estimated blood volume loss, and cell saver returned averaged 307.9 mL, 8.5%, and 80 mL, respectively. Average operative time was 214 min. The average drop in hemoglobin after surgery was 2.9 g/dL. The length of hospital stay averaged 5.1 days. There were no intraoperative complications. Three postoperative complications were identified, none related to their refusal of transfusion. One patient had in-hospital respiratory complication, one patient developed a late infection, and one patient developed asymptomatic radiographic distal junctional kyphosis. CONCLUSIONS Blood conservation techniques allow for safe and effective spine deformity surgery in pediatric patients refusing blood transfusion without major anesthetic or medical complications, when performed by an experienced multidisciplinary team. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Alexander Mihas
- Florida International University Herbert Wertheim College of Medicine, 11200 SW 8th Street, Miami, FL, 33199, USA
| | - Subaraman Ramchandran
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA.
| | - Sebastian Rivera
- Department of Orthopedic Surgery, Jackson Memorial Hospital, University of Miami, 1611 NW 12th Avenue, Miami, FL, 33136, USA
| | - Ali Mansour
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
| | - Jahangir Asghar
- Cantor Spine Institute, 3000 Bayview Drive Suite 200, Fort Lauderdale, FL, 33306, USA
| | - Harry Shufflebarger
- Paley Orthopedic and Spine Institute at St. Mary's Medical Center, 901 45th Street, West Palm Beach, FL, 33407, USA
| | - Stephen George
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
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9
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Kaushal N, Orland KJ, Schwartz AM, Wilson JM, Fletcher ND, Patel A, Menapace B, Ramirez M, Wetzel M, Devito D, Murphy J. Effects of race on blood loss in spinal fusions for adolescent idiopathic scoliosis. J Neurosurg Pediatr 2021; 27:213-217. [PMID: 33157524 DOI: 10.3171/2020.7.peds2049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 07/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can be associated with significant blood loss. It has been suggested that blood loss is greater in different racial groups. The purpose of this study was to evaluate differences in blood loss between African American and Caucasian patients undergoing PSF for AIS. METHODS A retrospective review was performed of patients aged 10-18 years with AIS who were treated with PSF from 2014 to 2017 at a single children's healthcare system. Patient demographic, radiographic, and operative data were obtained from medical records. Intraoperative blood loss was calculated using the formula described by Waters et al. Patients who declined reporting their race or had prior spinal surgery, neuromuscular or syndromic diagnoses, a history of cardiac or thoracic surgery, or a bleeding disorder were excluded. Blood loss variables were log-transformed for normality and modeled using multivariable linear regression. RESULTS A total of 433 PSFs for AIS qualified for the analysis. The average age was 14.1 years, and 73.7% of the patients were female. With respect to race, 44.6% identified themselves as African American. There was no significant difference in blood loss (p = 0.31) or blood loss per level fused (p = 0.36) in African American patients. African American patients, however, did have significantly lower preoperative hemoglobin and hematocrit levels and greater operating room time than Caucasian patients (p < 0.001). There was no difference between race and transfusion rate. CONCLUSIONS There appears to be no relationship between race and blood loss during PSF for AIS. Standardized protocols for minimizing perioperative blood loss can be applied to both Caucasian and African American patients.
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Affiliation(s)
- Neil Kaushal
- 1Department of Orthopaedics at Rutgers, New Jersey Medical School, Newark, New Jersey
| | - Keith J Orland
- 2Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew M Schwartz
- 2Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | - Jacob M Wilson
- 2Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | - Nicholas D Fletcher
- 3Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Georgia
| | - Anuj Patel
- 2Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | - Bryan Menapace
- 4Department of Orthopaedic Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio; and
| | - Michelle Ramirez
- 5Department of Orthopedic Surgery, Atlanta Medical Center, Atlanta, Georgia
| | - Martha Wetzel
- 3Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Georgia
| | - Dennis Devito
- 3Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Georgia
| | - Joshua Murphy
- 3Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Georgia
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10
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Al-Mohrej OA, Al-Torbaq B, Hshem R, Sayer J, Al-Rabiah AM, Al-Zayed ZS. Cell salvage within adult and pediatric idiopathic scoliosis surgery: A random cross-sectional study. SICOT J 2020; 6:41. [PMID: 33030426 PMCID: PMC7543688 DOI: 10.1051/sicotj/2020038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/22/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION This study aimed to evaluate the use of a cell savage and its impact on the amount of allogenic blood transfused to the patients during idiopathic scoliosis surgery. METHODS A total of 142 randomly selected patients with scoliosis had been included in this study. The adult group consisted of 78 patients, and the pediatric group, 64 patients. Both groups were divided into subgroups (pre-cell saver era and cell saver era). Data on the following parameters were collected: amount of blood transfused intraoperatively, within 24 h postoperatively, and overall. The number of patients who received transfusion was counted as the number of patients who avoided any transfusion. For statistical purposes, we performed unpaired student t-test, chi-square test, and Mann-Whitney test. RESULTS There was no significant difference in adult groups perioperatively. In the pediatric group, there was a statistically significant difference intraoperatively. Economic analysis of blood management showed positive numbers for both groups, where more than 1 unit of blood was transfused. CONCLUSIONS Statistical analysis showed the cost-effectiveness of the perioperative use of cell salvage during pediatric scoliosis surgery. Overall, the use of cell salvage during scoliosis surgery had a positive impact on both blood management and patient recovery.
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Affiliation(s)
- Omar A Al-Mohrej
- Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Center, 12713 Riyadh, Saudi Arabia
| | - Bayan Al-Torbaq
- Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Center, 12713 Riyadh, Saudi Arabia
| | - Raed Hshem
- Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Center, 12713 Riyadh, Saudi Arabia
| | - Jason Sayer
- Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Center, 12713 Riyadh, Saudi Arabia
| | - Anwar M Al-Rabiah
- Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Center, 12713 Riyadh, Saudi Arabia
| | - Zayed S Al-Zayed
- Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Center, 12713 Riyadh, Saudi Arabia
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Pennington Z, Ehresman J, Westbroek EM, Lubelski D, Cottrill E, Sciubba DM. Interventions to minimize blood loss and transfusion risk in spine surgery: A narrative review. Clin Neurol Neurosurg 2020; 196:106004. [DOI: 10.1016/j.clineuro.2020.106004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/04/2020] [Accepted: 06/06/2020] [Indexed: 12/26/2022]
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Wijdicks SPJ, Tromp IN, Yazici M, Kempen DHR, Castelein RM, Kruyt MC. A comparison of growth among growth-friendly systems for scoliosis: a systematic review. Spine J 2019; 19:789-799. [PMID: 30290228 DOI: 10.1016/j.spinee.2018.08.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The optimal method for surgical treatment of early onset scoliosis is currently unknown. Although the aim of growth-friendly systems is to reduce the curve and maintain growth, there is no consensus on how to measure spinal growth during and after the treatment. Different measurements of different segments (T1-S1, T1-T12, instrumented length) are used for different time points to evaluate growth. The aim of this review is to assess what measurements are used and to compare the growth-friendly systems based on spinal growth during treatment. METHODS The electronic MEDLINE, EMBASE, and Cochrane databases were systematically searched for original articles that reported growth for traditional growing rods (TGR), vertical expandable prosthetic titanium rib expansion technique (VEPTR), Shilla, magnetically controlled growing rods (MCGR), and Luque-trolley systems. All measurements were recorded, and weighted averages calculated in centimeter per year were compared. RESULTS We included 52 studies (26 TGR, 12 MCGR, 6 VEPTR, 4 Luque trolley, 1 Shilla, and 3 mixed). Often only one segment was reported (T1-S1 length in 22 studies, T1-T12 length in two studies, and instrumented length in five studies). The remaining 22 studies reported T1-S1 length in combination with T1-T12 length (15 studies) or instrumented length (eight studies). Spinalgrowth achieved by initial correction only was a considerable 3.9 cm (based on 34 studies) as well as the spinal growth achieved by the final fusion surgery (2.3 cm in four studies). To specifically assess growth achieved with the system, length gain after initial surgery and before final fusion in growth system graduates was considered. Only four TGR studies reported on this "true" spinal growth with 0.6 and 0.3 cm/y in the T1-S1 and T1-T12 segment, respectively. CONCLUSIONS Reporting on spinal growth is currently inadequate and does not allow a good comparison of different techniques. However, all systems often report growth similar to Dimeglio's T1-S1 spinal growth of 1 cm/y. It should be recognized though that a considerable portion of the reported spinal growth is the result of the initial and final surgical correction and not due to the growth-friendly implant.
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Affiliation(s)
- Sebastiaan P J Wijdicks
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Isabel N Tromp
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Muharrem Yazici
- Faculty of Medicine, Department of Orthopaedics, Sihhiye, Ankara, 06100 Turkey
| | - Diederik H R Kempen
- Surgery, Onze Lieve Vrouwe Gasthuis, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - René M Castelein
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Moyo C Kruyt
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Fletcher ND, Marks MC, Asghar JK, Hwang SW, Sponseller PD, Newton PO. Development of Consensus Based Best Practice Guidelines for Perioperative Management of Blood Loss in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. Spine Deform 2019; 6:424-429. [PMID: 29886914 DOI: 10.1016/j.jspd.2018.01.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/03/2018] [Indexed: 11/17/2022]
Abstract
STUDY DESIGN Delphi process with multiple iterative rounds using a nominal group technique. OBJECTIVE The aim of this study was to use expert opinion to achieve consensus on various methods for minimizing blood loss in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). BACKGROUND DATA Perioperative blood loss management represents a critical component of safely performing PSF in children with AIS. Little consensus exists on ways to mitigate excessive blood loss after PSF. METHODS An expert panel composed of 21 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. RESULTS Consensus was reached to support 21 best practice guideline measures for perioperative management of blood loss in patients undergoing PSF for AIS. Areas included preoperative assessment and preparation, intraoperative strategies to decrease blood loss, and postoperative transfusion indications. CONCLUSION We present a consensus-based best practice guideline consisting of 21 recommendations for strategies to minimize and manage blood loss during PSF. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.
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Affiliation(s)
- Nicholas D Fletcher
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA.
| | - Michelle C Marks
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA
| | - Jahangir K Asghar
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA
| | - Steven W Hwang
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA
| | - Paul D Sponseller
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA
| | - Peter O Newton
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA
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Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The primary goal was to evaluate risk factors related to increased blood loss in adolescent idiopathic surgery (AIS) surgery with the secondary goal being to evaluate the financial implications around the use of intraoperative cell salvage (ICS) and the routine preallocation of autogenous blood products. SUMMARY OF BACKGROUND DATA Deformity correction for AIS is a complex procedure and can be associated with significant blood loss. METHODS A retrospective cohort study was conducted on consecutive patients between the ages of 10 and 18 years who underwent posterior spinal fusion of 7-12 levels over a 3-year period between January 2013 and December 2015. Demographic information and surgical characteristics were recorded. All patients had a preoperative type and cross of 2 units and ICS was used in all cases. Charges for preoperative type and cross and ICS were also measured. Univariate and multivariable analyses were performed to identify pertinent variables affecting blood loss. RESULTS In total, 134 patients met inclusion criteria. ICS was used in all cases. In total, 51 patients were transfused cell saver blood intraoperatively/postoperatively at the discretion of the surgeon. On average 133 mL were returned to the patient. No complications related to ICS were observed. Multivariable analysis identified male sex, lower body mass index and higher surgical time to be associated with increased blood loss (P<0.05). All 134 patients had a preoperative type and cross, with an average charge to patient of $311. Patients were charged $1037 for intraoperative use of ICS and $242 for centrifugation. Patients who had allogeneic transfusion were charged $1047. CONCLUSIONS Several blood conservation strategies, including use of ICS, exist to minimize the consequences of blood loss. Routine use of preoperative type and cross may be avoided except in cases where significant blood loss is anticipated-that is adolescent male individuals, those with a lower body mass index and in whom a longer surgical time is anticipated.
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Blood conservation techniques in scoliosis surgery. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kim HJ, Park HS, Jang MJ, Koh WU, Song JG, Lee CS, Yang HS, Ro YJ. Predicting massive transfusion in adolescent idiopathic scoliosis patients undergoing corrective surgery: Association of preoperative radiographic findings. Medicine (Baltimore) 2018; 97:e10972. [PMID: 29851849 PMCID: PMC6392981 DOI: 10.1097/md.0000000000010972] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Corrective surgery with a posterior approach for adolescent idiopathic scoliosis (AIS) is often accompanied by considerable bleeding. Massive transfusion after excessive hemorrhage is associated with complications such as hypothermia, coagulopathy, and acid-base imbalance. Therefore, prediction and prevention of massive transfusion are necessary to improve the clinical outcome of AIS patients. We aimed to identify the factors associated with massive transfusion in AIS patients undergoing corrective surgery. We also evaluated the clinical outcomes after massive transfusion.We included and analyzed AIS patients who underwent corrective surgery with a posterior approach from January 2008 to February 2015. We retrospectively reviewed the electronic medical records of 765 consecutive patients. We performed multivariable logistic regression analysis to assess the factors related to massive transfusion. Furthermore, we compared the effects of massive transfusion on clinical outcomes, including postoperative morbidity and hospital stay.Of 765 patients, 74 (9.7%) received massive transfusion. Body mass index (odds ratio [OR] 0.782, 95% confidence interval [CI] 0.691-0.885, P < .001) and the number of fused vertebrae (OR 1.322, 95% CI 1.027-1.703, P = .03) were associated with massive transfusion. In the comparison among the different Lenke curve types, Lenke type 4 showed the highest prevalence of massive transfusion. Patients in the massive transfusion group showed a higher incidence rate of postoperative morbidity and prolonged hospital stay.Massive transfusion was required in 9.7% of AIS patients who underwent corrective surgery with a posterior approach. A lower body mass index and higher number of fused vertebrae were associated with massive transfusion. Massive transfusion is related to poor clinical outcomes in AIS patients.
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Affiliation(s)
- Ha-Jung Kim
- Department of Anesthesiology and Pain Medicine
| | | | | | - Won Uk Koh
- Department of Anesthesiology and Pain Medicine
| | | | - Choon-Sung Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Luque-Oliveros M. Haematological alterations in the cardiac patient after use of an autotransfusion system. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:74-80. [PMID: 29129323 DOI: 10.1016/j.redar.2017.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 09/06/2017] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE There are studies that declare blood recovered with the autotransfusion system that is potentially heparinised and mixed with other drugs, can cause haematological alterations in the patient, according to existing evidence. The proposal was to compare the haematological values of the patients before reinfusing red blood cells from the cell saver and 12h after reinfusion. MATERIAL AND METHODS Observational analytical study of 479 patients who underwent cardiac surgery where the cell saver was used. Haematological variables were collected before reinfusion and 12h after reinfusion. RESULTS Statistically significant haematological values before reinfusion and 12h after reinfusion were: haemoglobin (9.5 to 12.5g/dL), haematocrit (26 to 38%), platelets (214.2 to 164.210^3/μL), total proteins (7.6 to 5.1g/dL), PCR (8.5 to 22.1mg/L) and D-dimer (493.3 to 875.5μg/L) with P<.05. CONCLUSIONS With the use of the cell saver an increase was observed of haemoglobin, haematocrit, PCR and D-dimer values together with a decrease in platelet and total protein numbers.
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Affiliation(s)
- M Luque-Oliveros
- Bloque Quirúrgico y Anestesia Reanimación, Hospital Universitario Virgen Macarena, Sevilla, España.
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Ferroni MC, Correa AF, Lyon TD, Davies BJ, Ost MC. The use of intraoperative cell salvage in urologic oncology. Rev Urol 2017; 19:89-96. [PMID: 28959145 PMCID: PMC5610358 DOI: 10.3909/riu0721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Intraoperative cell salvage (IOCS) has been used in urologic surgery for over 20 years to manage intraoperative blood loss and effectively minimize the need for allogenic blood transfusion. Concerns about viability of transfused erythrocytes and potential dissemination of malignant cells have been addressed in the urologic literature. We present a comprehensive review of the use of IOCS in urologic oncologic surgery. IOCS has been shown to preserve the integrity of erythrocytes during processing and effectively provides cell filtration to mitigate the risk of tumor dissemination. Its use is associated with reduction in the overall need for allogenic blood transfusion, which clinically reduces the risk of hypersensitivity reactions and disease transmission, and may have important implications on overall oncologic outcomes. In the context of a variety of urologic malignancies, including prostate, urothelial, and renal cancer, the use of IOCS appears to be safe, without risk of tumor spread leading to metastatic disease or differences in cancer-specific and overall survival. IOCS has been shown to be an effective intraoperative blood management strategy that appears safe for use in urologic oncology surgery. The ability to reduce the need for additional allogenic blood transfusion may have significant impact on immune-mediated oncologic outcomes.
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Affiliation(s)
- Matthew C Ferroni
- Department of Urology, University of Pittsburgh Medical CenterPittsburgh, PA
| | - Andres F Correa
- Department of Urology, University of Pittsburgh Medical CenterPittsburgh, PA
| | - Timothy D Lyon
- Department of Urology, University of Pittsburgh Medical CenterPittsburgh, PA
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh Medical CenterPittsburgh, PA
| | - Michael C Ost
- Department of Urology, University of Pittsburgh Medical CenterPittsburgh, PA
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