A Comparison of Cell Salvage Strategies in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

The impact of blood conservation techniques on transfusion requirements for posterior adolescent idiopathic scoliosis corrections: do we need a routine cross-match for the operation?

PURPOSE

Various strategies are utilised to reduce blood loss and allogenic blood transfusion for posterior instrumented correction of Adolescent Idiopathic Scoliosis (AIS). The aim of this study was to evaluate post-operative blood transfusion requirements to determine whether routine cross matching of blood is essential.

METHODS

This is a prospective case series of 84 patients who underwent posterior correction of AIS between September 2016 and March 2018. We reviewed demographic, operative, radiological data and transfusion requirements. Results of transfusion requirements in 44 patients who underwent Ponte osteotomies (F:M = 36:8; mean age 14.8 years) were compared with 40 patients (F:M = 9:31; mean age 14.4 years) who did not and provided the control group. A transfusion trigger of 80 mg/dl with clinical caveats was utilised. Cross matching and procurement costs of allogenic blood/unit were ascertained.

RESULTS

Five patients required postoperative blood transfusion on days 2 or 3. Anaesthetic time (p = 0.0003) and preoperative Cobb angle (p = 0.0166) were significant variables between both groups and post-operative Hb (p = 0.0084) and number of levels fused (p = 0.0312) being significant in patients requiring transfusion. Unutilised units on the day of the operation incurred £30,030 (£380/patient or £154/unit) in operational costs.

CONCLUSION

Our audit demonstrates that transfusion on the day of the operation was not required. We recommend that routine crossmatching is not essential for primary posterior correction for AIS with blood conservation techniques. Blood grouping with availability of urgent blood is sufficient at the onset of operation. This has financial implications and cost savings.

LEVELS OF EVIDENCE

III.

Perioperative blood conservation strategies for pediatric scoliosis surgery

PURPOSE

Many pediatric patients with severe scoliosis requiring surgery have baseline anemia. Pediatric scoliosis fusion surgery is associated with perioperative blood loss requiring transfusion. As such, many patients in this surgical population could benefit from a perioperative blood conservation program.

METHODS

Here we present a narrative review of perioperative blood conservation strategies for pediatric scoliosis surgery involving nurses, transfusion medicine physicians, anesthesiologists, surgeons, dieticians, perfusionists and neurophysiologists spanning the pre-, intra- and postoperative phases of care.

RESULTS

The review highlights how perioperative blood conservation strategies, have the potential to minimize exposures to exogenous blood products. Further, we describe a relevant example of blood conservation related to the care of a Jehovah's Witness patient undergoing staged scoliosis repair. Lastly, we outline areas which would benefit from clinical studies to further elucidate perioperative blood conservation interventions and their outcomes relevant to pediatric scoliosis surgery patients.

CONCLUSION

Interdisciplinary communication and meticulous blood conservation strategies are proving to be a means of reducing if not eliminating the need for allogeneic blood products for surgical correction of pediatric scoliosis.

Blood Loss Trends and Financial Implications in Adolescent Idiopathic Scoliosis

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.

The safety, efficacy, and cost-effectiveness of intraoperative cell salvage in metastatic spine tumor surgery

BACKGROUND CONTEXT

Metastatic spine tumor surgery (MSTS) is associated with substantial blood loss, therefore leading to high morbidity and mortality. Although intraoperative cell salvage with leukocyte depletion filter (IOCS-LDF) has been studied as an effective means of reducing blood loss in other surgical settings, including the spine, no study has yet analyzed the efficacy of reinfusion of salvaged blood in reducing the need for allogenic blood transfusion in patients who have had surgery for MSTS.

PURPOSE

This study aimed to analyze the efficacy, safety, and cost-effectiveness of using IOCS-LDF in MSTS.

STUDY DESIGN

This is a retrospective controlled study.

PATIENT SAMPLE

A total of 176 patients undergoing MSTS were included in the study.

METHODS

All patients undergoing MSTS at a single center between February 2010 and December 2014 were included in the study. The primary outcome measure was the use of autologous blood transfusion. Secondary outcome measures included hospital stay, survival time, complications, and procedural costs. The key predictor variable was whether IOCS-LDF was used during surgery. Logistic and linear regression analyses were conducted by controlling variables such as tumor type, number of diseased vertebrae, approach, number and site of stabilized segments, operation time, preoperative anemia, American Society of Anesthesiologists (ASA) grade, age, gender, and body mass index (BMI). No funding was obtained and there are no conflicts of interest to be declared.

RESULTS

Data included 63 cases (IOCS-LDF) and 113 controls (non-IOCS-LDF). Intraoperative cell salvage with LDF utilization was substantively and significantly associated with a lower likelihood of allogenic blood transfusion (OR=0.407, p=.03). Intraoperative cell salvage with LDF was cost neutral (p=.88). Average hospital stay was 3.76 days shorter among IOCS-LDF patients (p=.03). Patient survival and complication rates were comparable in both groups.

CONCLUSIONS

We have demonstrated that the use of IOCS-LDF in MSTS reduces the need for postoperative allogenic blood transfusion while maintaining satisfactory postoperative hemoglobin. We recommend routine use of IOCS-LDF in MSTS for its safety, efficacy, and potential cost benefit.

Predictive factors of intraoperative cell salvage during pediatric scoliosis surgery. Cell saver during scoliosis surgery in children

INTRODUCTION

Blood-saving strategy during spinal surgery in children often includes recombinant erythropoietin (rEPO) and antifibrinolytic therapapy (AFT). The aim of this study was to investigate the efficacy of intraoperative blood salvage in decreasing homologous blood transfusion.

MATERIAL AND METHODS

Using the prospective data from patients operated during a one year period for scoliosis correction, we calculate the predictable hematocrit at day postoperative 1 without the use of blood salvage and compare it to the target hematocrit transfusion according to patient's status. Predictors analyzed were: age, weight, surgical indication, Cobb's angle, ASA status, preoperative hemoglobin, number of level fused, sacral fusion and thoracoplasty. Statistical analyses were performed using a classification tree analysis.

RESULTS

This study included 147 patients. Blood salvage was estimated avoiding homologous blood transfusion in 17 patients. Predictors of the efficacy of blood salvage were: neuromuscular indications, number of level fused and BMI. Blood salvage was found totally ineffective in: patients with no neuromuscular diseases with either: surgeries interesting<13 levels fused or surgeries interesting>13 levels with a preoperative BMI ≥ 21. In all other cases, blood salvage can decrease homologous transfusion. The model exhibited 97% of accurate for the prediction if the inefficacy of blood salvage. The AUCROC of the model was 0.93 [95% confidence interval 0.9 to 0.99] and the overall validation was 60.1% of explained variability.

CONCLUSION

The present study indicates that blood salvage is ineffective under certain circumstances. More studies are mandatory to confirm these results.

Blood transfusion in the surgical treatment of adolescent idiopathic scoliosis-a single-center experience of patient blood management in 210 cases

BACKGROUND

The surgical treatment of adolescent idiopathic scoliosis can be associated with substantial blood loss, requiring allogeneic red blood cell (RBC) transfusion. This study describes the use of RBC and the effect of a standardized perioperative patient blood management program.

STUDY DESIGN AND METHODS

Patients treated with posterior instrumented fusion were consecutively enrolled over a 6-year period. Patient blood management strategies were implemented in 2011, including prophylactic tranexamic acid, intraoperative permissive hypotension, restrictive fluid therapy (including avoidance of synthetic colloids), restrictive RBC trigger according to institutional standardized protocol, the use of cell savage, and goal-directed therapy according to thrombelastography.

RESULTS

In total, 210 patients were included. 64 patients (31%) received RBC transfusions. A decline in the intraoperative rate of RBC transfusion was observed, from 77% in 2011 to 13% in 2016 (p < 0.001). Patients in the transfusion group had a significantly larger major curve, lower preoperative hemoglobin, higher estimated blood loss, and an increased use of crystalloid volume resuscitation. Multiple logistic regression showed that significant predictors for RBC transfusion were preoperative hemoglobin level (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.27-0.57), estimated blood loss (OR, 1.26; 95% CI, 1.15-1.42), and year of surgery (indicating the effect of patient blood management) (OR per year, 0.76; 95% CI, 0.58-0.99).

CONCLUSION

A perioperative patient blood management program substantially reduced the need for RBC transfusion. A preoperative evaluation of anemia is essential to further minimize transfusion rates.

Incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with neuromuscular scoliosis: A STROBE-compliant retrospective observational analysis

Factors influencing massive blood loss for neuromuscular scoliosis (NMS) patients.Despite advances in surgical and anesthetic techniques, scoliosis surgery is still associated with intraoperative massive blood loss, which can result in postoperative mortality and morbidity. The aim of this study was to assess the incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with NMS.A retrospective review of adolescents who underwent posterior spinal instrumentation and fusion for NMS was performed. Perioperative variables and data were recorded. Massive blood loss was defined as an estimated blood loss that exceeds 30% of total blood volume.We obtained data for 114 patients, of whom 63 (55%) had intraoperative massive blood loss. Compared with those without, patients with massive blood loss were more likely to be older, have lower body mass indexes (BMIs), larger Cobb angles, more fused levels, more osteotomy procedures, and prolonged duration of operation. Logistic regression analysis identified the number of fused levels to be more than 12 (P = 0.003, odds ratio = 6.614, 95% confidence interval [CI]: 1.891-23.131), BMI lower than 16.8 kg/m (P = 0.025, odds ratio = 3.293, 95% CI: 1.159-9.357), age greater than 15 years (P = 0.014, odds ratio = 3.505, 95% CI: 1.259-9.761), and duration of operation longer than 4.4 hours (P = 0.016, odds ratio = 3.746, 95% CI: 1.428-9.822) as influencing factors. Patients with massive blood loss are associated with more intraoperative colloids infusion and blood transfusions (red blood cell and fresh frozen plasma), as well as postoperative drainage volume.In adolescents with NMS who underwent posterior spinal instrumentation and fusion operations, intraoperative massive blood loss is common. The number of fused levels, BMI, age, and duration of operation are factors influencing intraoperative massive blood loss.