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Ukeba D, Ishikawa Y, Yamada K, Ohnishi T, Tachi H, Tha KK, Iwasaki N, Sudo H. Bone Marrow Aspirate Concentrate Combined with Ultra-Purified Alginate Bioresorbable Gel Enhances Intervertebral Disc Repair in a Canine Model: A Preclinical Proof-of-Concept Study. Cells 2024; 13:987. [PMID: 38891119 PMCID: PMC11172114 DOI: 10.3390/cells13110987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024] Open
Abstract
Although discectomy is commonly performed for lumbar intervertebral disc (IVD) herniation, the capacity for tissue repair after surgery is limited, resulting in residual lower back pain, recurrence of IVD herniation, and progression of IVD degeneration. Cell-based therapies, as one-step procedures, are desirable for enhancing IVD repair. This study aimed to investigate the therapeutic efficacy of a combination of newly developed ultra-purified alginate (UPAL) gel and bone marrow aspirate concentrate (BMAC) implantation for IVD repair after discectomy. Prior to an in vivo study, the cell concentration abilities of three commercially available preparation kits for creating the BMAC were compared by measuring the number of bone marrow mesenchymal stem cells harvested from the bone marrow of rabbits. Subsequently, canine-derived BMAC was tested in a canine model using a kit which had the highest concentration rate. At 24 weeks after implantation, we evaluated the changes in the magnetic resonance imaging (MRI) signals as well as histological degeneration grade and immunohistochemical analysis results for type II and type I collagen-positive cells in the treated IVDs. In all quantitative evaluations, such as MRI and histological and immunohistochemical analyses of IVD degeneration, BMAC-UPAL implantation significantly suppressed the progression of IVD degeneration compared to discectomy and UPAL alone. This preclinical proof-of-concept study demonstrated the potential efficacy of BMAC-UPAL gel as a therapeutic strategy for implementation after discectomy, which was superior to UPAL and discectomy alone in terms of tissue repair and regenerative potential.
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Affiliation(s)
- Daisuke Ukeba
- Department of Orthopedic Surgery, Hokkaido University Hospital, N14W5, Sapporo, Hokkaido 060-8638, Japan; (D.U.); (Y.I.); (K.Y.); (T.O.); (H.T.); (N.I.)
| | - Yoko Ishikawa
- Department of Orthopedic Surgery, Hokkaido University Hospital, N14W5, Sapporo, Hokkaido 060-8638, Japan; (D.U.); (Y.I.); (K.Y.); (T.O.); (H.T.); (N.I.)
| | - Katsuhisa Yamada
- Department of Orthopedic Surgery, Hokkaido University Hospital, N14W5, Sapporo, Hokkaido 060-8638, Japan; (D.U.); (Y.I.); (K.Y.); (T.O.); (H.T.); (N.I.)
| | - Takashi Ohnishi
- Department of Orthopedic Surgery, Hokkaido University Hospital, N14W5, Sapporo, Hokkaido 060-8638, Japan; (D.U.); (Y.I.); (K.Y.); (T.O.); (H.T.); (N.I.)
| | - Hiroyuki Tachi
- Department of Orthopedic Surgery, Hokkaido University Hospital, N14W5, Sapporo, Hokkaido 060-8638, Japan; (D.U.); (Y.I.); (K.Y.); (T.O.); (H.T.); (N.I.)
| | - Khin Khin Tha
- Laboratory for Biomarker Imaging Science, Graduate School of Biomedical Science and Engineering, Hokkaido University, N15 W7, Kita-ku, Sapporo 060-8638, Japan;
| | - Norimasa Iwasaki
- Department of Orthopedic Surgery, Hokkaido University Hospital, N14W5, Sapporo, Hokkaido 060-8638, Japan; (D.U.); (Y.I.); (K.Y.); (T.O.); (H.T.); (N.I.)
| | - Hideki Sudo
- Department of Orthopedic Surgery, Hokkaido University Hospital, N14W5, Sapporo, Hokkaido 060-8638, Japan; (D.U.); (Y.I.); (K.Y.); (T.O.); (H.T.); (N.I.)
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Hammon DE, Chidambaran V, Templeton TW, Pestieau SR. Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Paediatr Anaesth 2023; 33:894-904. [PMID: 37528658 DOI: 10.1111/pan.14735] [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: 05/12/2022] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.
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Affiliation(s)
- Dudley E Hammon
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Thomas W Templeton
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sophie R Pestieau
- Department of Anesthesiology, Washington National, Washington, DC, USA
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The Incidence and Risk Factors for Allogeneic Blood Transfusions in Pediatric Spine Surgery: National Data. Healthcare (Basel) 2023; 11:healthcare11040533. [PMID: 36833065 PMCID: PMC9956304 DOI: 10.3390/healthcare11040533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/29/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
(1) Background: Pediatric spinal surgery is a blood-intensive procedure. In order to introduce a rational blood management program, identifying the risk factors for transfusions is mandatory. (2) Methods: Data from the national database covering the period from January 2015 to July 2017 were analyzed. The available data included the demographics, characteristics of the surgeries performed, length of stay, and in-house mortality. (3) Results: The total number of patients used for the analysis was 2302. The primary diagnosis was a spinal deformity (88.75%). Most fusions were long, with four levels or more (89.57%). A total of 938 patients received a transfusion; thus, the transfusion rate was 40.75%. The present study identified several risk factors; the most significant was a number of levels fused greater than 4 (RR 5.51; CI95% 3.72-8.15; p < 0.0001), followed by the deformity as the main diagnosis (RR 2.69; CI95% 1.98-3.65; p < 0.0001). These were the two most significant factors increasing the odds of a transfusion. Other factors associated with an increased risk of transfusion were elective surgery, the female sex, and an anterior approach. The mean length of stay in days was 11.42 (SD 9.93); this was greater in the transfused group (14.20 vs. 9.50; p < 0.0001). (4) Conclusions: The rate of transfusions in pediatric spinal surgery remains high. A new patient blood management program is necessary to improve this situation.
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Ivasyk I, Chatterjee A, Jordan C, Geiselmann MT, Chang PS, Kamel H, Khormaee S. Evaluation of the safety of tranexamic acid use in pediatric patients undergoing spinal fusion surgery: a retrospective comparative cohort study. BMC Musculoskelet Disord 2022; 23:651. [PMID: 35804327 PMCID: PMC9264589 DOI: 10.1186/s12891-022-05604-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 06/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Pediatric spinal fusion may be associated with significant intraoperative blood loss, leading to complications from transfusion, hypoperfusion and coagulopathy. One emerging strategy to mediate these risks is by utilization of the anti-fibrinolytic agent tranexamic acid (TXA). However, concerns regarding potential adverse reactions, specifically postoperative seizures and thrombotic events, still exist. To assess these risks, we examined the perioperative morbidity of TXA use in a large national database. Methods Retrospective data from pediatric patients (age 18 years or younger), discharged between January 2013 to December 2015, who underwent primary or revision posterior spinal fusions, was collected from the Premier Perspective database (Premier, Charlotte, NC). Patients were stratified by TXA use and records were assessed for complications of new onset seizures, strokes, pulmonary embolisms (PE) or deep vein thromboses (DVT) occurring during the perioperative period. Results In this cohort of 2,633 pediatric patients undergoing posterior spinal fusions, most often to treat adolescent idiopathic scoliosis, 15% received TXA. Overall, adverse events were rare in this patient population. The incidence of seizure, stoke, PE, or DVT in the control group was 0.54% (95% CI, 0.31% to 0.94%) and not significantly different from the TXA group. There was no significant difference in the incidence of DVTs, and no incidences of stroke in either group. There were no new-onset seizures or PEs in patients who received TXA. Conclusions The use of TXA was not associated with an increased risk of adverse events including seizure, stroke, PE, and DVT. Our findings support the safety of TXA use in pediatric patients undergoing spinal fusion surgery.
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Affiliation(s)
- Iryna Ivasyk
- Weill Cornell Medical College, New York, NY, USA
| | | | - Catherine Jordan
- Department of Psychology, Thompson Rivers University, Kamloops, BC, Canada
| | - Matthew T Geiselmann
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York, USA
| | - Peter S Chang
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
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Oladeji AK, Minaie A, Landau AJ, Hosseinzadeh P. Blood loss in hip reconstructive surgery in children with cerebral palsy: when do I need to be prepared for blood transfusion? J Pediatr Orthop B 2022; 31:175-181. [PMID: 34678853 DOI: 10.1097/bpb.0000000000000926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The hip is the second most common joint involved in pediatric patients with cerebral palsy (CP). Hip reconstructive procedures are performed to improve function and comfort level. Blood loss can occur leading to blood transfusion in close to 1/3 of children with CP undergoing hip reconstruction. The purpose of this study was to report the rate and risk factors for blood transfusion after hip reconstruction in a large cohort of children with CP. We conducted a retrospective chart review of pediatric patients at our tertiary referral children's hospital who underwent reconstructive hip osteotomy over an 8-year period. Binary logistic regression was employed to compare and model differences in transfusion between age greater than 4 or 6 years and the number of osteotomies. A total of 180 patients met our inclusion criteria. Thirty-seven patients (20.6%) received blood transfusion. Incidence of transfusion increased as number of osteotomies increased from 1 to 4 (3.7%, 7.3%, 34.0%, 58.3%, respectively). We did not find a significant effect of age greater than 4 or 6 years on the rate of blood transfusion (P = 0.676 and P = 0.323, respectively). The number of osteotomies was a significant factor in the rate of blood transfusion in both models (P < 0.001). Number of osteotomies and not age was a significant risk factor in the rate of blood transfusion. This data can help the orthopedic surgeons in preoperative planning for the possibility of blood transfusion in these patients.
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Affiliation(s)
- Afolayan K Oladeji
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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Wei Y, Zhang Y, Jin T, Wang H, Li J, Zhang D. Effects of Tranexamic Acid on Bleeding in Pediatric Surgeries: A Systematic Review and Meta-Analysis. Front Surg 2021; 8:759937. [PMID: 34722626 PMCID: PMC8548606 DOI: 10.3389/fsurg.2021.759937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/15/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Major pediatric surgeries can cause severe intraoperative blood loss. This meta-analysis aims to evaluate the efficacy of tranexamic acid (TXA) in pediatric surgeries. Methods: We searched PubMed, Embase, Web of Science, and Cochrane Library from the conception to March 31, 2021 to identify eligible randomized controlled trials (RCTs) that evaluated the efficacy of TXA in pediatric surgeries. Two reviewers choosed studies, evaluated quality, extracted data, and assessed the risk of bias independently. Mean difference (MD) was calculated as the summary statistic for continuous data. We used a random-effects model to measure mean effects. Data were generated from the corresponding 95% confidence interval (CI) using RevMan 5.3 software. Primary outcomes included intraoperative and postoperative blood loss, red blood cell (RBC) transfusion as well as fresh frozen plasma (FFP) transfusion. Results: Fifteen studies enrolling 1,332 patients were included in this study. The pooled outcomes demonstrated that TXA was associated with a decreased intraoperative (MD = −1.57 mL/kg, 95% CI, −2.54 to −0.60, P = 0.002) and postoperative (MD = −7.85 mL/kg, 95% CI, −10.52 to −5.19, P < 0.001) blood loss, a decreased intraoperative (MD = −7.08 mL/kg, 95% CI, −8.01 to −6.16, P < 0.001) and postoperative (MD = −5.30 mL/kg, 95% CI, −6.89 to −3.70, P < 0.001) RBC transfusion, as well as a decreased intraoperative (MD = −2.74 mL/kg, 95% CI, −4.54 to −0.94, P = 0.003) and postoperative (MD = −6.09 mL/kg, 95% CI, −8.26 to −3.91, P < 0.001) FFP transfusion in pediatric surgeries. However, no significant difference was noted between two groups in duration of surgery (MD = −12.51 min, 95% CI −36.65 to 11.63, P = 0.31). Outcomes of intraoperative and postoperative blood loss and the duration of surgery in included studies were not pooled due to the high heterogeneity. Conclusion: This meta-analysis demonstrated that TXA was beneficial for bleeding in pediatric surgeries.
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Affiliation(s)
- Yiyong Wei
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yajun Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Tao Jin
- Department of Anesthesiology, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, China
| | - Haiying Wang
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jia Li
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Anesthesiology, Xi'an Jiao Tong University-Affiliated Honghui Hospital, Xi'an, China
| | - Donghang Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
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McVey MJ, Lau W, Naraine N, Zaarour C, Zeller R. Perioperative blood conservation strategies for pediatric scoliosis surgery. Spine Deform 2021; 9:1289-1302. [PMID: 33900586 DOI: 10.1007/s43390-021-00351-1] [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: 03/28/2020] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Mark J McVey
- Departments of Anesthesia, University of Toronto, Toronto, ON, Canada. .,Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Department of Physics, Ryerson University, Toronto, ON, Canada.
| | - W Lau
- Transfusion Medicine SickKids Hospital, Toronto, ON, Canada
| | - N Naraine
- Transfusion Medicine SickKids Hospital, Toronto, ON, Canada
| | - C Zaarour
- Departments of Anesthesia, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - R Zeller
- Department of Pediatric Orthopedic Surgery, The Hospital for Sick Children, 555 Univesity Avenue, Toronto, ON, M5G 1X8, Canada
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Park SM, Kang DR, Lee JH, Jeong YH, Shin DA, Yi S, Ha Y, Kim KN. Efficacy and Safety of a Thrombin-Containing Collagen-Based Hemostatic Agent in Spinal Surgery: A Randomized Clinical Trial. World Neurosurg 2021; 154:e215-e221. [PMID: 34246825 DOI: 10.1016/j.wneu.2021.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE When common hemostatic methods, such as suturing, cautery, and compression, fail to arrest bleeding during surgery, various local hemostatic agents are used. We aimed to evaluate the hemostatic efficacy and safety of CollaStat (Dalim Tissen Co. Ltd., Seoul, Korea), a novel thrombin-containing, collagen-based topical haemostatic agent used in spinal surgery, by comparing it with Floseal (Baxter Healthcare, Deerfield, Illinois, USA). METHODS We performed a randomized controlled trial in 78 patients who underwent spinal surgery. The participants were randomly assigned to either an intervention group (use of CollaStat) or a control group (use of Floseal). We compared successful haemostasis rate, time to hemostasis, length of hospital stay, amount of fluid drainage, and rate of adverse events between the 2 groups. RESULTS The hemostasis success rate was 94.87% in the intervention group and 97.44% in the control group. The hemostatic efficacy and safety of CollaStat were found to be noninferior to those of Floseal since the higher limit (11.09%) of the confidence interval (CI) for the difference with Floseal was greater than the prespecified noninferiority margin of -13%. There were no statistically significant differences at the 5% level in hemostasis time, number of hemostatic agents used, hospitalization period, and amount of drainage between the 2 groups. Also, there was no incidence of medical device-related serious adverse events or adverse events in both groups. CONCLUSIONS The hemostatic efficacy and safety of CollaStat were found to be noninferior to those of Floseal. Therefore CollaStat can be safely and effectively used in spinal surgery.
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Affiliation(s)
- Sang Man Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Dae Ryong Kang
- Department of Precision Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Jun Hyeok Lee
- Department of Biostatistics, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Yeong Ha Jeong
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Seong Yi
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea.
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Bonanni S, Sipp BL, Schwend RM. Anaphylaxis after injecting a hemostatic agent containing gelatin into vertebral bone under pressure-a warning. Spine Deform 2021; 9:1191-1196. [PMID: 33460023 DOI: 10.1007/s43390-020-00273-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 12/14/2020] [Indexed: 11/29/2022]
Abstract
STUDY DESIGN Case series. PURPOSE The use of topical hemostatic agents is common in spinal deformity surgery. While beneficial, emerging case data shows gelatin-containing agents causing intra-operative complications. We present two patients who developed anaphylaxis after injection of these gelatin-containing hemostatic agents into the vertebral body using manual pressure. In the literature, while anaphylactic reactions associated with the use of animal-derived gelatin has been implicated; the risk of injecting these products into the closed vascular cavity of the vertebral body with subsequent embolization into systemic circulation bears emphasis. This report is to meant to make the surgical team aware of the risks of injecting hemostatic agents using manual pressure into the vertebral body and to highlight a plausible mechanism for the phenomenon. METHODS Two children with spinal deformity undergoing posterior spinal fusion procedures with the use of gelatin-containing hemostatic agents injected into the vertebral body through the pedicle are described. RESULTS Both patients had gelatin-containing hemostatic agent solution injected under manual pressure through the vertebral pedicle to prevent excessive bleeding. Anaphylaxis occurred soon thereafter, resulting in emergent cessation of the surgery and initiation of medical resuscitation. In both cases, tryptase levels obtained just after the event were elevated. CONCLUSION Patients with an allergy to or prior history of exposure to zoologic products undergoing spine surgery may be at risk of anaphylaxis if the gelatin-containing hemostatic agent is injected under manual pressure into the closed space of the vertebral body. This allows rapid entry into the venous circulation. We recommend that the surgeon perform a thorough history of a patient's allergies and use extreme caution when injecting these topical hemostatic products into the vertebral body. LEVEL OF EVIDENCE IV.
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BECCHETTI F, NASTO LA, KOTZEVA S. Blood loss management in pediatric spinal surgery for scoliosis. MINERVA ORTHOPEDICS 2021; 72. [DOI: 10.23736/s2784-8469.20.04050-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
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Mihas A, Ramchandran S, Rivera S, Mansour A, Asghar J, Shufflebarger H, George S. Safe and effective performance of pediatric spinal deformity surgery in patients unwilling to accept blood transfusion: a clinical study and review of literature. BMC Musculoskelet Disord 2021; 22:204. [PMID: 33607982 PMCID: PMC7896412 DOI: 10.1186/s12891-021-04081-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pediatric deformity surgery traditionally involves major blood loss. Patients refusing blood transfusion add extra clinical and medicolegal challenges; specifically the Jehovah's witnesses population. The objective of this study is to review the safety and effectiveness of blood conservation techniques in patients undergoing pediatric spine deformity surgery who refuse blood transfusion. METHODS After obtaining institutional review board approval, we retrospectively reviewed 20 consecutive patients who underwent spinal deformity surgery and refused blood transfusion at a single institution between 2014 and 2018. We collected pertinent preoperative, intraoperative and most recent clinical and radiological data with latest follow-up (minimum two-year follow-up). RESULTS Twenty patients (13 females) with a mean age of 14.1 years were identified. The type of scoliotic deformities were adolescent idiopathic (14), juvenile idiopathic (1), neuromuscular (3) and congenital (2). The major coronal Cobb angle was corrected from 55.4° to 11.2° (80% correction, p < 0.001) at the latest follow-up. A mean of 11.4 levels were fused and 5.6 levels of Pontes osteotomies were performed. One patient underwent L1 hemivertebra resection and three patients had fusion to pelvis. Estimated blood loss, percent estimated blood volume loss, and cell saver returned averaged 307.9 mL, 8.5%, and 80 mL, respectively. Average operative time was 214 min. The average drop in hemoglobin after surgery was 2.9 g/dL. The length of hospital stay averaged 5.1 days. There were no intraoperative complications. Three postoperative complications were identified, none related to their refusal of transfusion. One patient had in-hospital respiratory complication, one patient developed a late infection, and one patient developed asymptomatic radiographic distal junctional kyphosis. CONCLUSIONS Blood conservation techniques allow for safe and effective spine deformity surgery in pediatric patients refusing blood transfusion without major anesthetic or medical complications, when performed by an experienced multidisciplinary team. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Alexander Mihas
- Florida International University Herbert Wertheim College of Medicine, 11200 SW 8th Street, Miami, FL, 33199, USA
| | - Subaraman Ramchandran
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA.
| | - Sebastian Rivera
- Department of Orthopedic Surgery, Jackson Memorial Hospital, University of Miami, 1611 NW 12th Avenue, Miami, FL, 33136, USA
| | - Ali Mansour
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
| | - Jahangir Asghar
- Cantor Spine Institute, 3000 Bayview Drive Suite 200, Fort Lauderdale, FL, 33306, USA
| | - Harry Shufflebarger
- Paley Orthopedic and Spine Institute at St. Mary's Medical Center, 901 45th Street, West Palm Beach, FL, 33407, USA
| | - Stephen George
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
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Kaushal N, Orland KJ, Schwartz AM, Wilson JM, Fletcher ND, Patel A, Menapace B, Ramirez M, Wetzel M, Devito D, Murphy J. Effects of race on blood loss in spinal fusions for adolescent idiopathic scoliosis. J Neurosurg Pediatr 2021; 27:213-217. [PMID: 33157524 DOI: 10.3171/2020.7.peds2049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 07/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can be associated with significant blood loss. It has been suggested that blood loss is greater in different racial groups. The purpose of this study was to evaluate differences in blood loss between African American and Caucasian patients undergoing PSF for AIS. METHODS A retrospective review was performed of patients aged 10-18 years with AIS who were treated with PSF from 2014 to 2017 at a single children's healthcare system. Patient demographic, radiographic, and operative data were obtained from medical records. Intraoperative blood loss was calculated using the formula described by Waters et al. Patients who declined reporting their race or had prior spinal surgery, neuromuscular or syndromic diagnoses, a history of cardiac or thoracic surgery, or a bleeding disorder were excluded. Blood loss variables were log-transformed for normality and modeled using multivariable linear regression. RESULTS A total of 433 PSFs for AIS qualified for the analysis. The average age was 14.1 years, and 73.7% of the patients were female. With respect to race, 44.6% identified themselves as African American. There was no significant difference in blood loss (p = 0.31) or blood loss per level fused (p = 0.36) in African American patients. African American patients, however, did have significantly lower preoperative hemoglobin and hematocrit levels and greater operating room time than Caucasian patients (p < 0.001). There was no difference between race and transfusion rate. CONCLUSIONS There appears to be no relationship between race and blood loss during PSF for AIS. Standardized protocols for minimizing perioperative blood loss can be applied to both Caucasian and African American patients.
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Affiliation(s)
- Neil Kaushal
- 1Department of Orthopaedics at Rutgers, New Jersey Medical School, Newark, New Jersey
| | - Keith J Orland
- 2Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew M Schwartz
- 2Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | - Jacob M Wilson
- 2Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | - Nicholas D Fletcher
- 3Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Georgia
| | - Anuj Patel
- 2Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | - Bryan Menapace
- 4Department of Orthopaedic Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio; and
| | - Michelle Ramirez
- 5Department of Orthopedic Surgery, Atlanta Medical Center, Atlanta, Georgia
| | - Martha Wetzel
- 3Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Georgia
| | - Dennis Devito
- 3Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Georgia
| | - Joshua Murphy
- 3Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Georgia
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Wang H, Wang K, Lv B, Xu H, Jiang W, Zhao J, Kang M, Dong R, Qu Y. Establishment and assessment of a nomogram for predicting blood transfusion risk in posterior lumbar spinal fusion. J Orthop Surg Res 2021; 16:39. [PMID: 33430895 PMCID: PMC7798229 DOI: 10.1186/s13018-020-02053-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/28/2020] [Indexed: 12/29/2022] Open
Abstract
Background The aim of this study was to determine the risk factors and develop a nomogram for blood transfusions after posterior lumbar spinal fusion (PSL). Methods We conducted a retrospective, single-center study based on 885 patients receiving PSL, and data was obtained from May 2015 to September 2019. Univariable and multivariable logistics regression analysis were conducted to identify risk factors for blood transfusion, and a nomogram was constructed to individually evaluate the risk of blood transfusion. Discrimination, calibration, and clinical usefulness were validated by the receiver operating characteristics (ROC), C-index, calibration plot, and decision curve analysis, respectively. Bootstrapping validation was performed to assess the performance of the model. Results Of 885 patients, 885 were enrolled in the final study population, and 289 received blood transfusion. Statistical analyses showed that low preoperative hemoglobin (Hb), longer time to surgery, operative time, levels of fusion > 1, longer surgery duration, and higher total intraoperative blood loss (IBL) were the risk factors for transfusion. The C-index was 0.898 (95% CI 0.847–0.949) in this dataset and 0.895 in bootstrapping validation, respectively. Calibration curve showed satisfied discrimination and calibration of the nomogram. Decision curve analysis (DCA) shown that the nomogram was clinical utility. Conclusions In summary, we investigated the relationship between the blood transfusion requirement and predictors: levels of fusion, operative time, time to surgery, total intraoperative EBL, and preoperative Hb level. Our nomogram with a robust performance in the assessment of risk of transfusion can contribute to clinicians in making clinical decision. However, external validation is still needed in the further. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-020-02053-2.
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Affiliation(s)
- Haosheng Wang
- Department of Orthopedics, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin Province, People's Republic of China
| | - Kai Wang
- Department of Orthopedics, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin Province, People's Republic of China
| | - Bin Lv
- Department of Orthopedics, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu Province, People's Republic of China
| | - Haotian Xu
- Department of Orthopedics, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin Province, People's Republic of China
| | - Weibo Jiang
- Department of Orthopedics, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin Province, People's Republic of China
| | - Jianwu Zhao
- Department of Orthopedics, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin Province, People's Republic of China
| | - Mingyang Kang
- Department of Orthopedics, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin Province, People's Republic of China
| | - Rongpeng Dong
- Department of Orthopedics, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin Province, People's Republic of China
| | - Yang Qu
- Department of Orthopedics, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin Province, People's Republic of China.
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Yohe N, Ciminero M, Solomito M, Lee MC. Impact of Pediatric Subspecialty Training on Perioperative Complications in Adolescent Idiopathic Scoliosis Surgery. Orthopedics 2020; 43:e454-e459. [PMID: 32745224 DOI: 10.3928/01477447-20200721-11] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/25/2019] [Indexed: 02/03/2023]
Abstract
This was a retrospective study of data prospectively collected from 2012 to 2016 from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. The objective was to evaluate the effect of pediatric fellowship training on 30-day perioperative morbidity and mortality following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Several pathways exist in North America by which physicians acquire the clinical and technical skills to manage AIS surgically. Previous work has noted that surgeons with pediatric fellowship training tend to perform the bulk of pediatric spine surgeries. However, no study has been performed that examines if pediatric fellowship training (PFT) has an impact on early postoperative outcomes. A total of 14,194 AIS surgical patients were identified from the ACS NSQIP database. A cohort receiving isolated PSF was abstracted from this group and separated into 3 groups according to surgeon training: (1) ped+ (with PFT, n=4455); (2) ped-(without PFT, n=325); and (3) ped+match (patients selected from ped+ matched to ped- for age, sex, and fusion levels, n=325). The groups were compared for 30-day perioperative morbidity and mortality. No significant differences were noted for the 3 groups in terms of wound infections, length of hospital stay, readmissions, and unplanned returns to the operating room. Ped+match and ped- groups had no difference in neurologic injury rates. However, the ped+ and ped+match groups had significantly lower rates of blood transfusion and average volume of blood lost compared with the ped- group. Surgeons with pediatric fellowship training have a significantly lower average blood loss volume and blood transfusion rate in PSF for AIS than surgeons without such training. Understanding that different training pathways for surgeons may directly impact operative outcomes invites further examination of surgical education in North America to improve training consistency. [Orthopedics. 2020;43(5):e454-e459.].
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15
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Efficacy of topical versus intravenous tranexamic acid in spinal deformity. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:3044-3050. [DOI: 10.1007/s00586-020-06572-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
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Salazar JH, Goldstein SD, Swarup A, Boss EF, Van Arendonk KJ, Abdullah F. Transfusions in Children’s Surgery: Characterization and Development of a Model for Benchmarking. J Surg Res 2020; 252:47-56. [DOI: 10.1016/j.jss.2019.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/05/2019] [Accepted: 11/23/2019] [Indexed: 11/25/2022]
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Hogue G, DeWitt L, Grzywna A, Hresko MT, Hedequist D, Karlin L, Emans J, Le H, Miller P, Glotzbecker M. Does bracing for adolescent idiopathic scoliosis affect operative results? Spine Deform 2020; 8:427-432. [PMID: 32291582 DOI: 10.1007/s43390-020-00066-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 12/21/2019] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVES We hypothesize that preoperative bracing for idiopathic scoliosis results in increased stiffness, as measured by reduced correction on bending films, ultimately leading to decreased surgical correction. Bracing is the primary nonoperative treatment for immature AIS patients with mild to moderate curves. For patients who fail bracing and proceed to operative intervention, it is unknown whether their nonoperative treatment impacts their surgical results. METHODS We conducted a single-center, retrospective, comparative study on 181 consecutive adolescent idiopathic scoliosis patients, aged 11-17 years, who underwent posterior spine fusion between 2011 and 2013. Patient flexibility was measured as percent change in the curve angle of the spine from standing to supine bend. Overall curve correction was calculated as the preoperative to postoperative change in standing coronal measure divided by the preoperative measurement and reported as a percentage. RESULTS One hundred and twelve subjects (62%) underwent bracing prior to fusion. Braced patients had similar preoperative major Cobb angles than unbraced patients (56.5 vs 59.0, p = 0.07). Preoperatively, braced patients achieved less primary curve correction in bending films (33.6%) than unbraced patients (40.6%, p = 0.003). Postoperatively, Cobb angle correction was not different between the braced (75.7%) and unbraced group (77.2%) overall (p = 0.41). There was no difference in blood loss (p = 0.14) or surgical time (p = 0.96) between braced and unbraced groups when adjusted for surgeon and number of levels fused. CONCLUSIONS While braced patients may demonstrate less preoperative flexibility, there is no evidence that braced patients experience decreased curve correction compared to unbraced patients. Bracing treatment did not impact operative results, as indicated by similar Cobb angle correction, estimated blood loss, and surgical time in both groups. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Grant Hogue
- Department of Orthopaedics, Children's Health at University Hospital, San Antonio, TX, USA
| | - Leah DeWitt
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Alexandra Grzywna
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - M Timothy Hresko
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Daniel Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Lawrence Karlin
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - John Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Hai Le
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Patricia Miller
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Michael Glotzbecker
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA.
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Abstract
Anesthetic management of pediatric orthopedic patients is uniquely challenging. Approach to the pediatric patient must consider heightened preoperative anxiety and its postoperative behavioral and pain effects. Frequent respiratory infections can complicate timing of surgery and anesthetic care. Perioperative pain management usually involves a multimodal pharmacologic approach with the goal of minimizing opioid requirements. Regional anesthesia is valuable for postoperative pain control. Safety of its use in the pediatric population has been confirmed in recent studies. Included for discussion are fractures, slipped capital femoral epiphysis, club foot, and scoliosis.
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Affiliation(s)
- Jeffrey P Wu
- Department of Anesthesiology, Jersey Shore University Medical Center, 1945 Route 33, Neptune, NJ 07753, USA.
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Factors affecting length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2020; 8:51-56. [PMID: 31960355 DOI: 10.1007/s43390-020-00042-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 05/21/2019] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE Determine factors that influence hospital length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Standardized care pathways decrease variability in care, improve patient outcomes, and decrease cost. Specifically, global care pathway development using Lean process mapping for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been shown to lead to a significant decrease in postoperative length of stay. Assessment of variables that affect length of stay after pathway implementation may identify opportunities for additional process refinement to further decrease postoperative length of stay and improve pathway efficiency. METHODS A standardized care pathway was implemented at our institution for all patients undergoing posterior spinal fusion for AIS. This pathway was developed using the Lean process mapping technique to create evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care. Patient and care-related variables in these time periods were assessed to determine those factors that significantly affected postoperative length of stay. RESULTS Preoperative factors associated with a prolonged postoperative length of stay included patient ethnicity (non-Hispanic > Hispanic, p = 0.035) and gender (female > male, p = 0.039). Significant intraoperative factors included longer surgical time (p < 0.001), increased number of fusion levels (p = 0.034), and higher volume of crystalloid administered (p = 0.011). Significant postoperative factors were higher average pain scores on the first postoperative day (p < 0.001) and higher cumulative morphine use (p < 0.001). CONCLUSIONS Use of a standardized care pathway for the treatment of patients with AIS can decrease postoperative length of stay. Despite a carefully designed pathway, variability persists in aspects of care that can impact length of stay, including surgical efficiency, intraoperative fluid and blood management, and postoperative pain management. Continued process improvement focused on these variables will likely further improve the effectiveness of standardized pathways for patients with AIS. LEVEL OF EVIDENCE Level III.
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Dick AG, Pinder RJ, Lyle SA, Ember T, Mallinson C, Lucas J. Reducing Allogenic Blood Transfusion in Pediatric Scoliosis Surgery:: Reporting 15 Years of a Multidisciplinary, Evidence-Based Quality Improvement Project. Global Spine J 2019; 9:843-849. [PMID: 31819850 PMCID: PMC6882095 DOI: 10.1177/2192568219837488] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
STUDY DESIGN Retrospective review of prospectively collected spinal surgery and transfusion databases. OBJECTIVES To evaluate the efficacy of a care pathway developed at our institution since 2003 with a focus on reducing the need for blood transfusions in children undergoing scoliosis correction surgery. The care pathway includes nurse-led clinics facilitating preoperative hemoglobin optimization, intraoperative cell salvage, the use of tranexamic acid, and a transfusion criteria awareness program. METHODS Retrospective review of our institution's prospectively recorded spinal surgery and transfusion databases including all cases of scoliosis surgery in patients 18 years and younger between 2001 and 2015. RESULTS A total of 1039 procedures were included in the analysis. Overall, 24.4% of patients received a transfusion. The proportion of patients transfused was 89.2% in 2001-2003, 39.6% in 2004-2006, 16.5% in 2007-2009, 15.6% in 2010-2012, and 20.1% in 2013-2015. The volume of blood products transfused in those undergoing transfusion was 9.1 units in 2001-2003, 4.8 units in 2004-2006, 5.0 units in 2007-2009, 2.3 units in 2010-2012, and 2.1 units in 2013-2015. A multivariate logistic regression demonstrated adjusted odds ratios for the probability of receiving any transfusion of 5.45 (95% confidence interval 3.62-8.11) for patients with neuromuscular diagnoses and 11.17 (5.02-24.86) for those undergoing combined anterior and posterior surgical approach. CONCLUSIONS We have demonstrated over a 15-year period that the introduction of a multifaceted, multidisciplinary pathway can dramatically and sustainably reduce the need for blood transfusions and their attendant risks in pediatric scoliosis surgery. This data lends weight to the adoption of such a care pathway in pediatric scoliosis surgery.
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Affiliation(s)
- Alastair G. Dick
- Guy’s & St Thomas’ NHS Foundation Trust, London, UK,Alastair G. Dick, Department of Spinal Surgery, Guy’s & St Thomas’ NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK.
| | | | | | - Tom Ember
- Guy’s & St Thomas’ NHS Foundation Trust, London, UK
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Bosch P, Kenkre TS, Soliman D, Londino JA, Novak NE. Comparison of the Coagulation Profile of Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion With and Without Tranexamic Acid. Spine Deform 2019; 7:910-916. [PMID: 31732001 DOI: 10.1016/j.jspd.2019.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/03/2019] [Accepted: 04/16/2019] [Indexed: 11/29/2022]
Abstract
STUDY DESIGN Prospective, observational cohort study. OBJECTIVE To improve the understanding of coagulation and bleeding mechanisms during spinal deformity surgery. SUMMARY OF BACKGROUND DATA Fibrinolysis is the mechanism of bleeding for adolescent idiopathic scoliosis undergoing posterior spinal fusion. Antifibrinolytics have become popular; however, literature to support their use remains mixed. The mechanism of action has not been demonstrated. METHODS The coagulation profile of 88 adolescent idiopathic scoliosis patients undergoing posterior spinal fusion was analyzed. Standard coagulation laboratory investigations and thromboelastograms were drawn hourly through the case. Fifty-eight patients received no antifibrinolytic, whereas 30 patients received tranexamic acid by standardized protocol. The coagulation parameters, estimated blood loss, and transfusion requirements were compared in the two groups. RESULTS The two cohorts had no differences in demographic or surgical characteristics. Mean age was 13.6 years, 83% were female, a mean of 11.1 levels were fused, and the mean duration of surgery was 209 minutes. The tranexamic acid cohort did not demonstrate a decrease in blood loss. The transfusion rate, however, dropped from 47% in the non-tranexamic acid cohort to 23% in the tranexamic acid cohort (p = .03). Standard coagulation parameters did not differ between the groups. Fibrinolysis was diminished in the tranexamic acid cohort as measured by a Fibrinolysis score (mean maximum value 2.0 without tranexamic acid vs. 0.7 with tranexamic acid, p < .0001) and the lysis percent at 30 minutes by thromboelastogram (elevated to 3.9% without tranexamic acid vs. 1.2% with tranexamic acid at the 3-hour mark, p = .05). CONCLUSIONS This study provides confirmation of antifibrinolytic activity during posterior spinal fusion for adolescent idiopathic scoliosis. The presented data of fibrinolysis are proposed as standard measurements for future work on controlling blood loss during scoliosis surgery. LEVEL OF EVIDENCE Level 2, prospective comparative study.
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Affiliation(s)
- Patrick Bosch
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA.
| | - Tanya S Kenkre
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Public Health Building, 130 De Soto St, Pittsburgh, PA 15261, USA
| | - Doreen Soliman
- Department of Anesthesia, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA
| | - Joanne A Londino
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA
| | - Natalie E Novak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA
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Cronin JA, Oetgen ME, Gordish-Dressman H, Martin BD, Khan N, Pestieau SR. Association between perioperative surgical home implementation and transfusion patterns in adolescents with idiopathic scoliosis undergoing spinal fusion. Paediatr Anaesth 2019; 29:611-619. [PMID: 30801879 DOI: 10.1111/pan.13617] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Blood transfusions in patients with adolescent idiopathic scoliosis after fusion have been associated with increased morbidity, mortality, and cost. OBJECTIVE The aim of this study was to evaluate the association between implementation of blood-conservation strategies within the perioperative surgical home on transfusion rates for patients with adolescent idiopathic scoliosis undergoing spinal fusion. METHODS Two hundred and thirteen patients (44 preperioperative surgical home, 169 postperioperative surgical home) who underwent posterior spine fusion for adolescent idiopathic scoliosis between 23 June 2014, and 30 July 2017, were enrolled in this case control study. The perioperative surgical home implemented in March 2015 involved evidence-based perioperative interventions to create a standardized clinical pathway including judicious use of crystalloid management, restrictive transfusion strategy, routine use of cell saver, and standardized administration of anti-fibrinolytics. The primary outcome was odds of perioperative transfusion. Secondary outcomes included volumes of crystalloid, albumin, cell saver, packed red blood cells as well as calculated blood loss. Other variables that were documented included antibrinolytic total dose, mean arterial pressure, temperature, laboratory values, intrathecal morphine dosing, and surgical time. Statistical methods included t test and logistic regression. RESULTS For the postperioperative surgical home, the odds of perioperative transfusion were 0.30 (95% CI 0.13-0.70), as compared to preperioperative surgical home. In terms of secondary outcomes, calculated blood loss was significantly lower in the postperioperative surgical home patients (27.0 mL/kg preperioperative surgical home vs 22.8 mL/kg postperioperative surgical home; mean difference = -0.24 [-0.44, -0.04]). Although no difference was noted in the amount of intraoperative cell saver or albumin administered, a reduction was noted in mean intraoperative crystalloid given postperioperative surgical home (41.4 mL/kg ± 20.4 mL/kg preperioperative surgical home vs 28.0 mL/kg ± 13.7 mL/kg postperioperative surgical home; log mean difference = 0.37 [95% CI 0.21-0.53], P < 0.001). Postperioperative surgical home patients also had a significantly higher temperature nadir (mean difference = -0.47 [95% CI -0.70 to -0.23]; P < 0.001), received a significantly higher total anti-fibrinolytic dose (mean difference = -3939 [95% CI -5364 to -2495]; P < 0.001), and were exposed to shorter surgical times (mean difference = 0.72 [95% CI 0.36-1.09]; P < 0.001). CONCLUSIONS Implementation of blood-conservation strategies as part of a perioperative surgical home for patients with adolescent idiopathic scoliosis undergoing posterior spine fusion resulted in significant decrease in perioperative blood transfusions.
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Affiliation(s)
- Jessica A Cronin
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Health System, Washington, District of Columbia
| | - Matthew E Oetgen
- Division of Orthopaedic Surgery and Sports Medicine, Children's National Health System, Washington, District of Columbia
| | - Heather Gordish-Dressman
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia
| | - Benjamin D Martin
- Division of Orthopaedic Surgery and Sports Medicine, Children's National Health System, Washington, District of Columbia
| | - Nergis Khan
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Health System, Washington, District of Columbia
| | - Sophie R Pestieau
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia
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