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Iijima Y, Kotani T, Sakuma T, Akazawa T, Kishida S, Ueno K, Ise S, Ogata Y, Mizutani M, Shiga Y, Minami S, Ohtori S. Risk factors for allogeneic red blood cell transfusion in adult spinal deformity surgery. Asian Spine J 2024; 18:579-586. [PMID: 39164025 PMCID: PMC11366552 DOI: 10.31616/asj.2024.0080] [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] [Received: 02/26/2024] [Revised: 04/18/2024] [Accepted: 05/13/2024] [Indexed: 08/22/2024] Open
Abstract
STUDY DESIGN Retrospective study. PURPOSE To investigate the risk factors for allogeneic red blood cell (RBC) transfusion in adult spinal deformity (ASD) surgery. OVERVIEW OF LITERATURE Studies have not thoroughly explored the roles of intraoperative hypothermia, autologous blood donation, and hemostatic agent administration, which would provide a better understanding of the risk for perioperative RBC transfusion in ASD surgery. METHODS The medical records of 151 patients with ASD who underwent correction surgery between 2012 and 2021 were retrospectively reviewed. Estimated blood loss and perioperative allogeneic transfusion were examined. Patients were categorized into two groups based on whether they received perioperative allogeneic blood transfusion. Logistic regression analysis was employed to investigate the effect of age, sex, blood type, body mass index, American Society of Anesthesiologists' physical status, preoperative hemoglobin level, autologous blood donation, global spine alignment parameters, preoperative use of anticoagulants or antiplatelet medicine and nonsteroidal anti-inflammatory drugs, number of instrumented fusion levels, total operative duration, three-column osteotomy, lateral interbody fusion, pelvic fixation, intraoperative hypothermia, use of gelatin-thrombin based hemostatic agents, and intraoperative tranexamic acid (TXA) with simultaneous exposure by two attending surgeons. RESULTS The estimated blood loss was 994.2±754.5 mL, and 71 patients (47.0%) received allogeneic blood transfusion. In the logistic regression analysis, the absence of intraoperative TXA use and simultaneous exposure (odds ratio [OR], 26.3; 95% confidence interval [CI], 7.6-90.9; p<0.001), lack of autologous blood donation (OR, 21.2; 95% CI, 4.4-100.0; p<0.001), and prolonged operative duration (OR, 1.6; 95% CI, 1.3-1.9; p<0.001) were significant independent factors for perioperative allogeneic blood transfusion in ASD surgery. CONCLUSIONS Autologous blood storage, intraoperative TXA administration, and simultaneous exposure should be considered to minimize perioperative allogeneic blood transfusion in ASD surgery, particularly in patients with anticipated lengthy surgeries.
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Affiliation(s)
- Yasushi Iijima
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura,
Japan
| | - Toshiaki Kotani
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura,
Japan
| | - Tsuyoshi Sakuma
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura,
Japan
| | - Tsutomu Akazawa
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki,
Japan
| | - Shunji Kishida
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura,
Japan
| | - Keisuke Ueno
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura,
Japan
| | - Shohei Ise
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura,
Japan
| | - Yosuke Ogata
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura,
Japan
| | - Masaya Mizutani
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura,
Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba,
Japan
| | - Shohei Minami
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura,
Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba,
Japan
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Aghajanian S, Mohammadifard F, Kohandel Gargari O, Naeimi A, Bahadorimonfared A, Elsamadicy AA. Efficacy and utility of antifibrinolytics in pediatric spine surgery: a systematic review and network meta-analysis. Neurosurg Rev 2024; 47:177. [PMID: 38644447 DOI: 10.1007/s10143-024-02424-x] [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: 10/14/2023] [Revised: 01/09/2024] [Accepted: 04/16/2024] [Indexed: 04/23/2024]
Abstract
Antifibrinolytics have gained increasing attention in minimizing blood loss and mitigating the risks associated with massive transfusions, including infection and coagulopathy in pediatric patients undergoing spine surgery. Nevertheless, the selection of optimal agent is still a matter of debate. We aim to review the utility of these agents and compare the efficacy of antifibrinolytics in pediatric and adolescent spine surgeries. A comprehensive search was performed in Scopus, Web of Science, and MEDLINE databases for relevant works. Studies providing quantitative data on predefined outcomes were included. Primary outcome was perioperative bleeding between the groups. Secondary outcomes included transfusion volume, rate of complications, and operation time. Twenty-eight studies were included in the meta-analysis incorporating 2553 patients. The use of Tranexamic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 88%), Aprotinin (RoM: 0.54, 95%CI: [0.46-0.64], p < 0.001, I2 = 0%), and Epsilon-aminocaproic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 60%) led to a 29%, 46%, and 29% reduction in perioperative blood loss, respectively. Network meta-analysis revealed higher probability of efficacy with Tranexamic acid compared to Epsilon-aminocaproic acid (P score: 0.924 vs. 0.571). The rate of complications was not statistically different between each two antifibrinolytic agent or antifibrinolytics compared to placebo or standard of care. Our network meta-analysis suggests a superior efficacy of all antifibrinolytics compared to standard of care/placebo in reducing blood loss and transfusion rate. Further adequately-powered randomized clinical trials are recommended to reach definite conclusion on comparative performance of these agents and to also provide robust objective assessments and standardized outcome data and safety profile on antifibrinolytics in pediatric and adolescent pediatric surgeries.
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Affiliation(s)
- Sepehr Aghajanian
- School of Medicine, Alborz University of Medical Sciences, Karaj, Iran.
- Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | | | - Omid Kohandel Gargari
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
- Headache Research Center, Neurology Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Arvin Naeimi
- Student Research Committee, School of Medicine, Guilan University of Medical Sciences, Rasht, Gilan, Iran
| | - Ayad Bahadorimonfared
- Department of Health & Community Medicine, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
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Chen K, Wang L, Gao Q, Masood U, Zeng Z, Yang H, Song Y. Tranexamic acid can reduce blood loss in adolescent scoliosis surgery: a systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:686. [PMID: 37644447 PMCID: PMC10463947 DOI: 10.1186/s12891-023-06811-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 08/18/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) has been widely used in orthopedic surgery, but its efficacy in adolescent scoliosis (AS) surgery remains unclear in the literature. The purpose of this systematic review and meta-analysis is to evaluate the safety and efficacy of TXA compared to placebo treatment during or after AS surgery, by gathering data from randomized both controlled trials (RCTs) and non-RCTs. METHODS English and Chinese electronic databases including PubMed, Web of Science, Embase, Cochrane, CNKI, and Wan Fang database were searched to identify the relevant literature up until August 2022. The primary outcomes were intraoperative blood loss and total blood loss. The secondary outcomes included the need for transfusion, postoperative hemoglobin (Hb) level, and change in Hb level. Stata 17 was used for data analysis and the risk of bias was assessed. We followed the PRISMA checklist to ensure the quality of this article. RESULTS Twelve studies (795 participants) were included in the meta-analysis for intraoperative blood loss during surgery. The results suggest that TXA can reduce the intraoperative blood loss of the patients (MD = -306.40ml, 95%CI = -404.04ml to -208.77ml, p < 0.001). Six studies (2027 patients) were included in the meta-analysis for total blood loss. The pooled result shows that the total blood loss of the TXA group was significantly lower than that of the control group (MD = -779.24ml, 95% CI = -1157.10ml to -410.39ml, p < 0.001). Five studies (419 patients) were included in the meta-analysis for postoperative Hb level and shows a non-significant outcome (MD = 5.09 g/l, 95%CI = 2.92 g/l to 7.25 g/l, p = 0.611). Three studies (268 patients) were included in the meta-analysis for the postoperative Hb level. There is a non-significant decrease in the TXA group (MD = -0.23 g/l, 95%CI = -0.48 g/l to 0.01 g/l, p = 0.319). Eight studies (670 patients) reported data on the need for transfusion after surgery. The overall relative risks (RR) showed a significant difference between the TXA and control group, with a lower risk of transfusion in the TXA group (RR = 0.547, 95%CI = 0.308 to 0.972, p = 0.04). CONCLUSIONS The meta-analysis of the data reveals that TXA usage is associated with a significant reduction in intraoperative and total blood loss, a lower risk of transfusion, and a non-significant change in postoperative Hb levels in AS surgery However, it should be noted that the surgical operation situations varied across different studies. Therefore, further research is required to investigate the effects of TXA on specific subgroups of gender, operation time, and blood transfusion indicators. Overall, our study provides valuable evidence for the clinical management of AS surgery and may inform the development of practice guidelines and protocols for the use of TXA in this setting.
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Affiliation(s)
- Keyu Chen
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Liang Wang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qingyang Gao
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Umar Masood
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Zhimou Zeng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Huiliang Yang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Yueming Song
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
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Abdou M, Kwon JW, Kim HJ, Lee B, Choi YS, Moon SH, Lee BH. Tranexamic Acid and Intraoperative and Postoperative Accumulative Bleeding in Elective Degenerative Spine Surgery. Yonsei Med J 2022; 63:927-932. [PMID: 36168245 PMCID: PMC9520043 DOI: 10.3349/ymj.2022.0163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/07/2022] [Accepted: 08/02/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Spinal surgeries are often associated with a high incidence of perioperative blood loss, which poses several complications. Much current research focuses on the importance of antifibrinolytic drugs during spinal surgeries to reduce blood loss, which can also reduce the risk of the need for blood transfusions. We evaluated the effects of prophylactic, low-dose tranexamic acid (TXA) in spinal fusion surgeries on blood loss, blood transfusions, and associated complications. MATERIALS AND METHODS TXA was administered to 90 patients at a constant infusion rate of 10 mg/kg for 20 minutes after anesthesia induction, followed by a maintenance dose of 1 mg/kg/h until the end of the operation. An additional 91 patients were included as controls. RESULTS There were no significant differences between the study groups in terms of intraoperative blood loss, which was 500 mL for both groups (p>0.999). Also, intraoperative blood transfusion requirements were similar between both groups (p=0.330). Mean blood transfusion amounts were 125±35 mL for patients in the TXA group and 85±25 mL in the control group. However, there was a significant reduction in postoperative blood transfusion (p=0.003) in the TXA group. Only three cases in the TXA group required blood transfusion, while 15 cases in the control group did. CONCLUSION We confirmed that low dose TXA has no effect on intraoperative blood loss volume or blood transfusion requirements and that it can significantly reduce the need for postoperative blood transfusions.
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Affiliation(s)
- Mahmoud Abdou
- Department of Orthopedic Surgery, Fayoum University College of Medicine, Fayoum, Egypt
| | - Ji-Won Kwon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Jin Kim
- Department of Anesthesia, Yonsei University College of Medicine, Seoul, Korea
| | - Bora Lee
- Department of Anesthesia, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Seon Choi
- Department of Anesthesia, Yonsei University College of Medicine, Seoul, Korea
| | - Seong-Hwan Moon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Ho Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea.
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The effect of multiple-dose oral versus intravenous tranexamic acid in reducing postoperative blood loss and transfusion rate after adolescent scoliosis surgery: a randomized controlled trial. Spine J 2021; 21:312-320. [PMID: 33049411 DOI: 10.1016/j.spinee.2020.10.011] [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: 06/10/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT Tranexamic acid (TXA) is widely used in surgery for adolescent idiopathic scoliosis (AIS) and has been proved to be efficacious in reducing intraoperative blood loss (IBL) and the transfusion rate. However, the routine TXA regimen was intraoperative administration alone, in which the concentration of TXA could not cover the whole process of hyperfibrinolysis. And, its ability to control the massive postoperative blood loss (PBL) may be insufficient. Thus, we promoted a multiple-dose regimen of TXA for patients with AIS who underwent surgical correction. PURPOSE The primary aims were (1) to determine whether the multiple-dose regimen of TXA could reduce PBL and the postoperative transfusion rate, and (2) to compare the efficacy of oral administration with intravenous administration. The secondary aims were (3) to evaluate whether this regimen could alleviate inflammatory response, and (4) to assess the occurrence of drug-related side effects. STUDY DESIGN Prospective, double-blinded, randomized controlled trial. PATIENT SAMPLE A total of 108 patients with AIS who underwent posterior scoliosis correction and spinal fusion (PSS) were enrolled in this study. OUTCOME MEASURES The primary parameters were PBL and postoperative transfusion rate. Other parameters such as total blood loss (TBL), maximum hemoglobin (Hb) decrease, volume of drainage, inflammation markers (interleukin-6 [IL-6] and C-reactive protein [CRP]), and occurrence of complications were also collected and compared. Multiple regression analysis was used to examine the variables that affected PBL. METHODS Patients were randomized into three groups. All patients received intravenous TXA 50 mg/kg loading dose and 10 mg/kg/h maintenance dose during surgery. Group A received 1 g oral TXA at 4 hours, 10 hours, and 16 hours postoperatively; group B received 0.5 g intravenous TXA at 6 hours, 12 hours, and 18 hours postoperatively; group C received placebo. RESULTS The mean PBL and postoperative transfusion rate in group A (957.8±378.9 mL, 13.89%) and B (980.3±491.8 mL, 11.11%) were significantly lower than those in group C [1,495.9±449.6 mL, mean differences=538.1 mL, 95% confidence interval (CI), 290.1-786.1 mL, p<0.001; 515.6 mL, 95% CI, 267.6-763.6 mL, p<.001]; (36.11%, p=.029, p=.013). Meanwhile, the mean TBL, maximum Hb decrease, and volume of drainage were also significantly lower in group A and B than in group C. IL-6 and CRP in group A and B were significantly lower than in group C from postoperative days 1 to 3. All these differences were not significant between groups A and B. No drug-related complications were observed in any patient. Multiple regression showed that the application of postoperative TXA and number of screws were significant parameters affecting PBL. CONCLUSIONS A multiple-dose regimen of TXA, either by oral or intravenous application, could be a safe and effective means of controlling PBL and decreasing the postoperative transfusion rate in patients with AIS who underwent scoliosis surgery. In addition, it could inhibit postoperative inflammatory response.
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张 庄, 杨 曦, 汪 雷, 宋 跃. [Progress on the application of tranexamic acid in adolescent spine corrective surgery]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1468-1473. [PMID: 33191708 PMCID: PMC8171701 DOI: 10.7507/1002-1892.202001052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/03/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To review the advances in the application of tranexamic acid (TXA) in adolescent spinal corrective surgery. METHODS The mechanism of action and pharmacokinetic, effectiveness, dosage, safety as well as methods of administration were comprehensively summarized by consulting domestic and overseas related literature about the application of TXA in adolescent spinal corrective surgery in recent years. RESULTS TXA efficaciously reduce intraoperative blood loss, transfusion rate and volume, postoperative drainage volume in adolescent spinal corrective surgery. At present, the most common method of administration in adolescent spinal corrective surgery is that a loading dose is given intravenously before skin incision or induction of anesthesia, followed by a maintenance dose until the end of the surgery. The range of loading dose and maintenance dose is 10-100 mg/kg and 1-10 mg/(kg·h), respectively. No drug related adverse event has been reported in this range. CONCLUSION The effectiveness and safety of TXA in adolescent spinal surgery have been basically confirmed. However, further studies are needed to determine the optimal dosage, method of administration as well as whether it could reduce blood loss after surgery.
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Affiliation(s)
- 庄 张
- 四川大学华西医院骨科/骨科研究所(成都 610041)Department of Orthopedic Surgery/Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 曦 杨
- 四川大学华西医院骨科/骨科研究所(成都 610041)Department of Orthopedic Surgery/Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 雷 汪
- 四川大学华西医院骨科/骨科研究所(成都 610041)Department of Orthopedic Surgery/Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 跃明 宋
- 四川大学华西医院骨科/骨科研究所(成都 610041)Department of Orthopedic Surgery/Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Rasras S, Mohammad Mamizadeh N, Safari H, Kiani A, Rahimi Z. Oral tranexamic acid for bleeding during spinal surgery: A randomized double-blind placebo clinical trial<span style="font-size:12px">Running title: Oral tranexamic acid for spinal surgery</span>. AIMS MEDICAL SCIENCE 2020. [DOI: 10.3934/medsci.2020005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Efficacy of antifibrinolytics in pediatric orthopedic surgery: a systematic review and meta-analysis. J Pediatr Orthop B 2020; 29:97-104. [PMID: 30789535 DOI: 10.1097/bpb.0000000000000599] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antifibrinolytics (AFs) stabilize blood clot formation and reduce bleeding. The purpose of this systematic review and meta-analysis was to determine the impact of AF use on intraoperative blood loss and the need for blood transfusion in pediatric orthopedic surgery. A systematic review was performed using Medline and Embase to identify studies that utilized AFs during pediatric orthopedic surgery. The primary outcome measure was intraoperative blood loss in ml. Secondary outcomes included blood transfusion and thromboembolic events. Pooled estimates were derived from a random-effects model. Heterogeneity was assessed using the Cochrane Q and I statistic. Meta-regression assessed if age or study quality modified the effect of AFs on blood loss. Publication bias was assessed using a funnel plot, Egger regression analysis, and the Kendall τ-test. Twenty studies, with a total of 1356 patients, were included. The mean difference in intraoperative blood loss was 653 ml [95% confidence interval (CI): 464-842 ml, P < 0.001]. Similarly, the mean difference in percent of blood volume lost was 22% less in patients treated with AFs compared with controls (95% CI: 12-32, P < 0.001). Patients treated with AFs had a lower odds of transfusion compared to controls (OR: 0.324; 95% CI: 0.105-0.997, P = 0.049). The use of AF in pediatric orthopedic surgery results in decreased intraoperative blood loss and a lower risk of blood transfusion. The majority of studies included involve spine surgery; the benefits of AFs in extremity surgery in the pediatric population have yet to be delineated. Level of Evidence: Level II.
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Abstract
STUDY DESIGN This study was a retrospective cohort design. OBJECTIVE The objective of this study was to examine the impact of tranexamic acid (TXA) on total perioperative wound output following thoracic and lumbar spinal fusions. SUMMARY OF BACKGROUND DATA TXA has been extensively studied with regard to intraoperative blood loss and transfusion rates. Few studies have looked specifically at the effect of TXA on postoperative drain output. MATERIALS AND METHODS We examined blood loss patterns in 617 consecutive adult patients undergoing lumbar and/or thoracic fusions at a single institution from January 2009 to 2016. These patients were divided into TXA and non-TXA, as well as high-dose and low-dose TXA, groups and analyzed using a propensity score to account for differences between cohorts. RESULTS The TXA and non-TXA groups were demographically similar. The mean number of levels fused was higher in the TXA group (4.8 vs. 3.1 levels, P<0.01). There was a significant reduction in both intraoperative blood loss (77.7 mL per level, P=0.020) and postoperative drain output (83.3 mL per level, P=0.002) in the TXA group when examined on a per level fused basis, but no significant difference without controlling for a number of levels. Postoperative blood loss tended to be higher in the TXA group for surgeries involving >5 levels fused. There was a significantly less blood loss in the high-dose TKA group both intraoperatively (296.4 mL per level fused, P<0.001) and postoperatively (133.4 mL per level fused, P<0.001). CONCLUSIONS TXA significantly reduced both intraoperative and postoperative blood loss in lumbar and thoracic fusions when examined on a per level basis. However, with surgeries involving fusions >5 levels, TXA may increase postoperative drain output, with those losses offset by reduced intraoperative blood loss. High-dose TXA further reduced both intraoperative and postoperative blood loss as compared with low-dose TXA.
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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: 36] [Impact Index Per Article: 7.2] [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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Ma L, Zhang J, Shen J, Zhao Y, Li S, Yu X, Huang Y. Predictors for blood loss in pediatric patients younger than 10 years old undergoing primary posterior hemivertebra resection: a retrospective study. BMC Musculoskelet Disord 2019; 20:297. [PMID: 31228947 PMCID: PMC6589173 DOI: 10.1186/s12891-019-2675-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 06/11/2019] [Indexed: 12/03/2022] Open
Abstract
Background Blood loss during hemivertebra resection may be substantial. Few studies have examined the risk factors of blood loss undergoing hemivertebra resection, especially those in patients under 10 years old. Methods Patients under 10 years old diagnosed with congenital scoliosis and hemivertebra were retrospectively included from January 2014 to October 2017. They all had primary posterior hemivertebra resection at Peking Union Medical College Hospital. Perioperative information was collected and multivariable linear logistic regression was performed to determine the independent risk factors of blood loss. Results One hundred three patients were included. The mean total blood loss was 346 + 178 ml. The percentage of total blood loss to the EBV was 27.0 + 13.3%. Multivariable linear logistic regression indicated that preoperative total Cobb angle (P = 0.046) and the number of fused levels (P < 0.001) were independent risk factors of total blood loss. Preoperative platelet count and preoperative coagulation function were not associated with blood loss in patients undergoing hemivertebra resection. Conclusions Preoperative total Cobb angle and the number of fused levels determined the blood loss for patients undergoing hemivertebra resection.
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Affiliation(s)
- Lulu Ma
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Jianxiong Shen
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yu Zhao
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Shugang Li
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Xuerong Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China.
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
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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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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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Glover CD, Fernandez AM, Huang H, Derderian C, Binstock W, Reid R, Dalesio NM, Zhong J, Stricker PA. Perioperative outcomes and management in midface advancement surgery: a multicenter observational descriptive study from the Pediatric Craniofacial Collaborative Group. Paediatr Anaesth 2018; 28:710-718. [PMID: 29920872 DOI: 10.1111/pan.13418] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS The evolution of Le Fort III and Monobloc procedures with utilization of distraction devices has resulted in shortened surgical times, greater facial advancements, and decreased transfusion requirements. The aim of this observational study was to utilize data from the multicenter Pediatric Craniofacial Surgery Perioperative Registry to present and compare patient characteristics and outcomes in children undergoing midface advancement with distraction osteogenesis. METHODS We queried the Pediatric Craniofacial Surgery Perioperative Registry for children undergoing midface advancement involving distractor application from June 2012 to September 2016. Data extracted included demographics, perioperative management, complications, fluid and transfusion volumes, and length of stay. The extracted patient characteristics and perioperative variables were summarized and compared. RESULTS The query yielded 72 cases from 11 institutions: 49 children undergoing Le Fort III and 23 undergoing Monobloc procedures. Monobloc patients were younger, weighed less, and more likely to have tracheostomies along with elevated intracranial pressure. Greater transfusion was observed in the Monobloc group for nearly all of the transfusion outcomes evaluated. Median ICU and hospital length of stay were 2 and 3 days longer, respectively, in the Monobloc group. Perioperative complications were not uncommon, occurring in 18% of patients in the Le Fort III group and 30% in the Monobloc group. CONCLUSION Monobloc procedures were associated with greater transfusion and longer ICU and hospital length of stay. Perioperative complications were more prevalent in the Monobloc group.
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Affiliation(s)
- Chris D Glover
- Department of Anesthesiology and Perioperative Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Allison M Fernandez
- Department of Anesthesiology, Pain and Perioperative Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Henry Huang
- Department of Anesthesiology and Perioperative Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Christopher Derderian
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Southwestern Medical School, Dallas, TX, USA
| | - Wendy Binstock
- Department of Anesthesia and Critical Care, Comer Children's Hospital, The University of Chicago Medicine, Chicago, IL, USA
| | - Russell Reid
- Department of Surgery, Comer Children's Hospital and The University of Chicago Medicine, Chicago, IL, USA
| | - Nicholas M Dalesio
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - John Zhong
- Department & Pain Management, University of Texas Southwestern Medical Center, Southwestern Medical School, Dallas, TX, USA
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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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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Efficacy and safety of the topical application of tranexamic acid in primary cementless hip arthroplasty: Prospective, randomised, double-blind and controlled study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2017.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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17
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Gerstein NS, Brierley JK, Windsor J, Panikkath PV, Ram H, Gelfenbeyn KM, Jinkins LJ, Nguyen LC, Gerstein WH. Antifibrinolytic Agents in Cardiac and Noncardiac Surgery: A Comprehensive Overview and Update. J Cardiothorac Vasc Anesth 2017; 31:2183-2205. [DOI: 10.1053/j.jvca.2017.02.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Indexed: 12/19/2022]
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18
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Efficacy and safety of the topical application of tranexamic acid in primary cementless hip arthroplasty: prospective, randomised, double-blind and controlled study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 62:47-54. [PMID: 29128416 DOI: 10.1016/j.recot.2017.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 07/19/2017] [Accepted: 09/03/2017] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of topical tranexamic acid topical in cementless total hip arthroplasty from the point of view of bleeding, transfusion requirements and length of stay, and describe the complications of use compared to a control group. MATERIAL AND METHODS A prospective, randomised, double-blinded and controlled study including all patients undergoing cementless total hip arthroplasty in our centre between June 2014 and July 2015. Blood loss was estimated using the formula described by Nadler and Good. RESULTS The final analysis included 119 patients. The decrease in haemoglobin after surgery was lower in the tranexamic acid group (3.28±1.13g/dL) than in the controls (4.03±1.27g/dL, P=.001) and estimated blood loss (1,216.75±410.46mL vs. 1,542.12±498.97mL, P<.001), the percentage of transfused patients (35.9% vs. 19.3%, P<.05) and the number of transfused red blood cell units per patient (0.37±0.77 vs. 0.98±1.77; P<.05). There were no differences between groups in the occurrence of complications or length of stay. CONCLUSIONS The use of topical tranexamic acid in cementless total hip arthroplasty results in a decrease in bleeding and transfusion requirements without increasing the incidence of complications.
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Abstract
Blood management strategies are integral to successful outcomes in many types of orthopaedic surgery. These strategies minimize blood loss and transfusion requirements, ultimately decreasing complications, improving outcomes, and potentially eliminating risks associated with allogeneic transfusion. Practices to achieve these goals include preoperative evaluation and optimization of hemoglobin, the use of pharmacologic agents or anesthetic methods, intraoperative techniques to improve hemostasis and cell salvage, and the use of predonated autologous blood. Guidelines can also help manage allogeneic transfusions in the perioperative period. Although the literature on blood management has focused primarily on arthroplasty and adult spine surgery, pediatric spinal fusion for scoliosis involves a large group of patients with a specific set of risk factors for transfusion and distinct perioperative considerations. A thorough understanding of blood management techniques will improve surgical planning, limit transfusion-associated risks, maintain hemostasis, and optimize outcomes in this pediatric population.
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20
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Willner D, Spennati V, Stohl S, Tosti G, Aloisio S, Bilotta F. Spine Surgery and Blood Loss: Systematic Review of Clinical Evidence. Anesth Analg 2017; 123:1307-1315. [PMID: 27749350 DOI: 10.1213/ane.0000000000001485] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Spine surgery has been growing rapidly as a neurosurgical operation, with an increase of 220% over a 15-year period. Intraoperative blood transfusion is a major outcome determinant of spine procedures. Various approaches, including pharmacologic and nonpharmacologic therapies, have been tested to decrease both intraoperative and postoperative blood loss. The aim of this systematic review is to report clinical evidence on the relationship between intraoperative blood loss (primary outcome) and on transfusion requirements and postoperative complications (secondary outcomes) in patients undergoing spine surgery. A literature search of PubMed database was performed using 5 key words: spine surgery and transfusion; spine surgery and blood loss; spine surgery and blood complications; spine surgery and deep vein thrombosis; and spine surgery and pulmonary embolism. Clinical reports (randomized controlled trials, prospective and retrospective studies, and case reports) were selected. A total of 473 articles were examined; 450 were excluded, and 24 were selected for this systematic review. Selected articles were categorized into 3 subchapters: (1) drugs active on coagulation (12 studies): tranexamic acid, aminocaproic acid, aprotinin, and recombinant activated factor VII; (2) drugs not active on coagulation (5 studies): ketorolac, epoetin alfa, magnesium sulfate, propofol/sevoflurane, and omega-3 and fish oil; (3) nonpharmacologic approaches (7 studies): surgical tips, patient positioning, and general or spinal anesthesia. Several studies have shown a significant reduction in intraoperative bleeding during spine surgery and in the requirement for blood transfusion.
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Affiliation(s)
- Dafna Willner
- From the *Department of Anesthesia and Critical Care Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; and †Department of Anesthesia and Critical Care, Umberto I, La Sapienza University, Rome, Italy
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21
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Saifi C, Laratta JL, Petridis P, Shillingford JN, Lehman RA, Lenke LG. Vertebral Column Resection for Rigid Spinal Deformity. Global Spine J 2017; 7:280-290. [PMID: 28660112 PMCID: PMC5476358 DOI: 10.1177/2192568217699203] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review the evolution, operative technique, outcomes, and complications associated with posterior vertebral column resection. METHODS A literature review of posterior vertebral column resection was performed. The authors' surgical technique is outlined in detail. The authors' experience and the literature regarding vertebral column resection are discussed at length. RESULTS Treatment of severe, rigid coronal and/or sagittal malalignment with posterior vertebral column resection results in approximately 50-70% correction depending on the type of deformity. Surgical site infection rates range from 2.9% to 9.7%. Transient and permanent neurologic injury rates range from 0% to 13.8% and 0% to 6.3%, respectively. Although there are significant variations in EBL throughout the literature, it can be minimized by utilizing tranexamic acid intraoperatively. CONCLUSION The ability to correct a rigid deformity in the spine relies on osteotomies. Each osteotomy is associated with a particular magnitude of correction at a single level. Posterior vertebral column resection is the most powerful posterior osteotomy method providing a successful correction of fixed complex deformities. Despite meticulous surgical technique and precision, this robust osteotomy technique can be associated with significant morbidity even in the most experienced hands.
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Affiliation(s)
- Comron Saifi
- Columbia University Medical Center, The Spine Hospital, New York–Presbyterian Healthcare System, New York, NY, USA,Comron Saifi, MD, Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital, New York–Presbyterian Healthcare System, 5141 Broadway, 3 Field West, New York, NY 10034, USA.
| | - Joseph L. Laratta
- Columbia University Medical Center, The Spine Hospital, New York–Presbyterian Healthcare System, New York, NY, USA
| | - Petros Petridis
- Columbia University Medical Center, The Spine Hospital, New York–Presbyterian Healthcare System, New York, NY, USA
| | - Jamal N. Shillingford
- Columbia University Medical Center, The Spine Hospital, New York–Presbyterian Healthcare System, New York, NY, USA
| | - Ronald A. Lehman
- Columbia University Medical Center, The Spine Hospital, New York–Presbyterian Healthcare System, New York, NY, USA
| | - Lawrence G. Lenke
- Columbia University Medical Center, The Spine Hospital, New York–Presbyterian Healthcare System, New York, NY, USA
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Sun X, Zhu ZZ, Chen X, Liu Z, Wang B, Qiu Y. Posterior Double Vertebral Column Resections Combined with Satellite Rod Technique to Correct Severe Congenital Angular Kyphosis. Orthop Surg 2017; 8:411-4. [PMID: 27627727 DOI: 10.1111/os.12265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 06/30/2016] [Indexed: 11/28/2022] Open
Abstract
This paper presents a highly challenging technique involving posterior double vertebral column resections (VCRs) and satellite rods placement. This was a young adult case with severe angular thoracolumbar kyphosis of 101 degrees, secondary to anterior segmentation failure from T11 to L1 . There were hemivertebrae at T11 and T12 , and a wedged vertebra at L1 . He received double VCRs at T12 and T11 and instrumented fusion from T6 to L4 via a posterior only approach. Autologous grafts and a cage were placed between the bony surfaces of the osteotomy gap. Once closure of osteotomy was achieved, bilateral permanent CoCr rods were placed with addition of satellite rods. Postoperative X-ray demonstrated marked correction of kyphosis. On the 10(th) days after surgery, the patient was able to walk without assistance. In conclusion, double VCRs are effective to correct severe angular kyphosis, and addition of satellite rods may be imperative to enhance instrumentation strength and thus prevent correction loss.
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Affiliation(s)
- Xu Sun
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ze-Zhang Zhu
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.
| | - Xi Chen
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhen Liu
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Bin Wang
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yong Qiu
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
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Colomina M, Koo M, Basora M, Pizones J, Mora L, Bagó J. Intraoperative tranexamic acid use in major spine surgery in adults: a multicentre, randomized, placebo-controlled trial † †This Article is accompanied by Editorial Aew470. Br J Anaesth 2017; 118:380-390. [DOI: 10.1093/bja/aew434] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2016] [Indexed: 11/13/2022] Open
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Effect of Antifibrinolytic Therapy on Complications, Thromboembolic Events, Blood Product Utilization, and Fusion in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2016; 41:E879-E886. [PMID: 27398796 DOI: 10.1097/brs.0000000000001454] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A multicenter, prospective, consecutive database of surgical patients with adult spinal deformity (ASD). OBJECTIVE This study investigated the use of antifibrinolytic (AF) therapy in ASD surgery. SUMMARY OF BACKGROUND DATA AF therapy has been shown to be effective in preventing blood loss in some settings. Its effect on major and minor perioperative complications, blood product utilization, vascular events, and postoperative fusion in patients undergoing ASD surgery remains unclear. METHODS All patients with data on AF use were included. Parameters of blood utilization included transfusion rates and units of packed red blood cells and fresh frozen plasma transfused. Thromboembolic events included stroke, deep vein thrombosis, and pulmonary embolus. Multivariate regression was used, accounting for confounders. RESULTS Four hundred three patients were included. One hundred thirty-seven patients received aminocaproic acid (EACA), 81 received tranexamic acid (TXA), and 185 received no AFs. The use of AF was associated with a decrease in transfusion (EACA: odds ratio [OR] = 0.38, P = 0.043; TXA: OR = 0.31, P = 0.047), a decrease in the number of units of packed red blood cells transfused (EACA: incidence risk ratio [IRR] = 0.45, P = 0.0005; TXA: IRR = 0.7, P = 0.0005), and a decrease in the number of fresh frozen plasma transfused (EACA: IRR = 0.65, P = 0.003; TXA: IRR = 0.67, P = 0.006). AF use was associated with an increase in minor intraoperative complications (EACA: IRR = 2.15, P = 0.008; TXA: IRR = 2.12, P = 0.011). TXA use (but not EACA) was associated with a decrease in the incidence of major perioperative complications compared with no AF (IRR = 0.37, P = 0.019). There was no difference in the incidence of thromboembolic events. CONCLUSION TXA or EACA use was associated with increased minor intraoperative complications. TXA was associated with decreased major perioperative complications. AF was associated with decreased utilization of blood products without an increased rate of thromboembolic events. Given the nature of this study, transfusion threshold was not standardized. Future studies with rigid criteria for transfusion should be prospectively performed to better evaluate the impact of AF during ASD surgery. LEVEL OF EVIDENCE 3.
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Verma K, Kohan E, Ames CP, Cruz DL, Deviren V, Berven S, Errico TJ. A Comparison of Two Different Dosing Protocols for Tranexamic Acid in Posterior Spinal Fusion for Spinal Deformity: A Prospective, Randomized Trial. Int J Spine Surg 2015; 9:65. [PMID: 26767157 DOI: 10.14444/2065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Multilevel spinal fusions have typically been associated with significant blood loss. Previous studies have shown a reduction in blood loss with antifibrinolytics in both adolescent and adult spinal deformity patients. While this has been mirrored in other subspecialties as well, the dosing of TXA remains highly variable. To date, there remains a paucity of data guiding dosing for TXA in spine surgery and orthopedic surgery as a whole. METHODS/DESIGN One hundred and fifty patients from 3 institutions (50 each site) will be consecutively enrolled and randomized to either a high dose of TXA (50mg/kg loading followed by 20mg/kg hourly) or a lose dose (10mg/kg, then 1mg/kg hourly). Both surgeons and patients will be blinded to the treatment group. Primary outcomes will be perioperative blood loss, drain output, and transfusion rate. Secondary outcomes will be length of stay, complications, and overall cost. DISCUSSION The primary goal of this study is to provide level-1 comparative data for two TXA dosing regimens in adult spinal deformity surgery. Management of blood loss remains a critical factor in reducing complications during spinal deformity surgery. The null hypothesis is that there is no difference between high- and low-dose TXA with respect to any of the primary or secondary outcomes.
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Affiliation(s)
- Kushagra Verma
- University of California - San Francisco, San Francisco, CA
| | - Eitan Kohan
- Washington University in St. Louis, St. Louis, MO
| | | | - Dana L Cruz
- NYU Hospital for Joint Disease, New York City, NY
| | - Vedat Deviren
- University of California - San Francisco, San Francisco, CA
| | - Sigurd Berven
- University of California - San Francisco, San Francisco, CA
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Efficacy of Erythropoietin-Beta Injections During Autologous Blood Donation Before Spinal Deformity Surgery in Children and Teenagers. Spine (Phila Pa 1976) 2015; 40:E1144-9. [PMID: 26502101 DOI: 10.1097/brs.0000000000001108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective observational study OBJECTIVE.: To clarify the efficacy of recombinant human erythropoietin-beta (EPO-beta) injections during autologous blood donation (ABD) before spinal deformity surgery in children and teenagers. SUMMARY OF BACKGROUND DATA ABD is preferred for spinal deformity surgery. A few studies have assessed the usefulness of preoperative ABD with EPO-beta in anemic patients. METHODS Fifty-six spinal deformity surgery patients (41 females, 15 males; median age: 15 yrs; range, 5-19 yrs) underwent preoperative ABD. ABD was performed weekly according to the patient's body weight with a subcutaneous EPO-beta injection (24,000 U). The collected blood volumes were compared among the low hemoglobin (low-Hb) (<13 g/dL), mid-Hb (13-13.9 g/dL), and high-Hb (≥14 g/dL) groups using the Kruskal-Wallis test. The effects of EPO-beta injection on the Hb levels were estimated using a linear mixed model. RESULTS The patients underwent a median of four ABD collections (range, two to six). The median collected volume per ABD was 200 mL (range, 40-400 mL). The median total blood collection was 700 mL (range, 160-1,350 mL); the corresponding values were 700 mL, 700 mL, and 800 mL in the low-Hb, mid-Hb, and high-Hb groups, respectively (P = 0.964). The median blood loss was 500 mL (range, 10-2,940 mL); 53 out of 55 patients (96%) did not require unplanned allogeneic transfusion, including 11 out of 12 (92%) cases with blood loss >1,000 mL. The additional recovery of Hb levels with one EPO-beta injection was 0.29 ± 0.14 g/dL (P = 0.039) after adjusting for confounding factors. CONCLUSION ABD with an EPO-beta injection is useful for avoiding allogeneic transfusion during spinal deformity surgery in children and teenagers, and patients in the low-Hb group achieved ABD volumes equivalent to those in the high-Hb group. Thus, an additional recovery of Hb levels of 0.29 g/dL per injection can be expected after 1 week. LEVEL OF EVIDENCE 4.
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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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Efficacy and Safety of Antifibrinolytic Agents in Reducing Perioperative Blood Loss and Transfusion Requirements in Scoliosis Surgery: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0137886. [PMID: 26382761 PMCID: PMC4575115 DOI: 10.1371/journal.pone.0137886] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 08/24/2015] [Indexed: 11/19/2022] Open
Abstract
Background Routine use of antifibrinolytic agents in spine surgery is still an issue of debate. Objective To gather scientific evidence for the efficacy and safety of antifibrinolytic agents including aprotinin, tranexamic acid (TXA) and epsilon aminocaproic acid (EACA, traditionally known as Amicar) in reducing perioperative blood loss and transfusion requirements in scoliosis surgery. Methods We conducted a systematic review and meta-analysis for randomized controlled trials (RCTs), retrospective case-control studies, and retrospective cohort studies on the use of antifibrinolytic agents in scoliosis surgery by searching in the MEDLINE and EMBASE databases and the Cochrane Database of Systematic Reviews and Controlled Trials of papers published from January 1980 through July 2014. Safety of the antifibrinolytic agents was evaluated in all included studies, while efficacy was evaluated in RCTs. Results Eighteen papers with a total of 1,158 patients were eligible for inclusion in this study. Among them, 8 RCTs with 450 patients were included for evaluation of pharmacologic efficacy (1 RCT was excluded because of a lack of standard deviation data). Mean blood loss was reduced in patients with perioperative use of antifibrinolytic agents by 409.25 ml intraoperatively (95% confidence interval [CI], 196.57–621.94 ml), 250.30 ml postoperatively (95% CI, 35.31–465.30), and 601.40 ml overall (95% CI, 306.64–896.16 ml). The mean volume of blood transfusion was reduced by 474.98 ml (95% CI, 195.30–754.67 ml). The transfusion rate was 44.6% (108/242) in the patients with antifibrinolytic agents and 68.3% (142/208) in the patients with placebo. (OR 0.38; 95% CI; 0.25–0.58; P<0.00001, I2 = 9%). All studies were included for evaluation of safety, with a total of 8 adverse events reported overall (4 in the experimental group and 4 in the control group). Conclusion The systematic review and meta-analysis indicated that aprotinin, TXA, and EACA all significantly reduced perioperative blood loss and transfusion requirements in scoliosis surgery. There was no evidence that the use of antifibrinolytic agents was a risk factor for adverse events, especially thromboembolism, in scoliosis surgery.
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Effectiveness of tranexamic acid in reducing blood loss in spinal surgery: a meta-analysis. BMC Musculoskelet Disord 2014; 15:448. [PMID: 25532706 PMCID: PMC4326491 DOI: 10.1186/1471-2474-15-448] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 12/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of present meta-analysis was to evaluate the effectiveness of tranexamic acid (TXA) use in reducing blood loss and the related thrombotic complications in spinal surgery. METHODS Three databases (MEDLINE, EMBASE, and the Cochrane Library) were searched through October 2012 to identify the relevant randomized controlled trials (RCTs) regarding the TXA effective in spinal surgery. Mean differences (MDs) of blood loss, blood transfusions, and postoperative partial thromboplastic time (PTT), odds ratios (ORs) of blood transfusion and thrombotic complication in TXA-treated group compared to placebo group were extracted and combined using random-effect meta-analysis. RESULTS A total of 6 RCTs comprising 411 patients were included in the meta-analysis according to the pre-defined selection criteria. TXA-treated group had significantly less amount of blood loss and blood transfusions per patient, and had smaller proportion of patients who required a blood transfusion compared with the placebo group. The use of TXA can significantly reduce the postoperative PTT with weighted MD of -1.59 [(95% confidence interval (CI):-3.07, -0.10] There is a null association between thrombosis complications and the use of TXA. CONCLUSION We conclude that the use of TXA in patients undergoing spinal surgery appears to be effective in reducing the amount of blood loss, the volume of blood transfusion, the transfusion rate, and the postoperative PTT. However, data were too limited for any conclusions regarding safety. More high-quality RCTs are required before recommending the administered of TXA in spinal surgery.
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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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Re: Newton PO, Bastrom TP, Emans JB, et al. Antifibrinolytic agents reduce blood loss during pediatric vertebral column resection procedures. Spine (Phila Pa 1976). 2012;37:1459–63. Spine (Phila Pa 1976) 2013; 38:1710. [PMID: 24509555 DOI: 10.1097/brs.0b013e31829d455c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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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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