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Chan V, Gausper A, Chan-Tai-Kong A, Liu AM, Etigunta S, Scheer JK, Andras LM, Skaggs DL. Development and validation of a pediatric spine surgical invasiveness index. Spine Deform 2025:10.1007/s43390-025-01106-y. [PMID: 40358891 DOI: 10.1007/s43390-025-01106-y] [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: 02/13/2025] [Accepted: 05/03/2025] [Indexed: 05/15/2025]
Abstract
PURPOSE Surgical invasiveness indices have been used in adult spine surgery to characterize the invasiveness of complex procedures and for risk stratification. This has not been studied in the pediatric population. The purpose of this study was to develop and validate a surgical invasiveness index for pediatric spinal deformity surgery. METHODS The National Surgical Quality Improvement Program (NSQIP) Pediatric database was queried between the years 2016-2022. Patients were included if they were <18 years of age, received posterior or anterior-posterior spinal fusion surgery, and had a diagnosis of spinal deformity. The study cohort was divided into a derivation cohort and a validation cohort. A multivariable linear regression analysis was performed to identify surgical components associated with operative time. Surgical components of interest included number of posterior fusion levels, number of anterior fusion levels, pelvic instrumentation, posterior column osteotomies, three-column osteotomies, and prior spinal deformity surgery. Statistically significant variables were used to establish a pediatric spinal deformity surgical invasiveness index. The score was assessed and validated using linear and logistic regression analysis and receiver operating characteristic curve analysis on operative time and allogeneic transfusion. RESULTS There were 37,658 patients included (Derivation cohort: 26,372; Validation cohort: 11,286). In the linear regression analysis, more posterior fusion levels (7-12 levels: 0.54, p<0.001;>12 levels: 1.40, p<0.001), anterior fusion 1-3 levels (2.42, p<0.001), anterior fusion ≥4 levels (2.93, p<0.001), pelvic instrumentation (0.79, p<0.001), and previous spinal deformity surgery (0.44, p<0.001) were associated with longer operative time. Each level of posterior column osteotomy (0.13, p<0.001) and three-column osteotomy (0.61, p<0.001) were associated with increased operative time. Points were assigned to each surgical component: 7-12 posterior fusion levels (4 pts), >12 posterior fusion levels (11 pts), anterior fusion 1-3 levels (19 pts), anterior fusion ≥4 levels (23 pts), pelvic instrumentation (6 pts), previous spinal deformity surgery (3 pts), posterior column osteotomy (1 pt per level), and three-column osteotomy (5 pts per level). In the derivation cohort, each point was associated with an increase in operative time by 0.13 hours (R2=0.16, p<0.001). In the validation cohort, each point was associated with an increase in operative time by 0.12 hours (R2=0.15, p<0.001). In the derivation cohort, the area under the curve (AUC) for operative time ≥8 hours and allogeneic transfusion were 0.74 and 0.71, respectively. In the validation cohort, the AUC for operative time ≥8 hours and allogeneic transfusion were 0.74 and 0.70, respectively. CONCLUSION A pediatric spinal deformity surgical invasiveness index was created and predictive of prolonged operative time and allogeneic transfusion. This is the first quantitative tool to measure the extent of surgical interventions in pediatric spine surgery.
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Affiliation(s)
- Vivien Chan
- Spine Center, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Ste 900, Los Angeles, CA, 90048, USA.
| | - Adeesya Gausper
- Spine Center, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Ste 900, Los Angeles, CA, 90048, USA
| | - Andrew Chan-Tai-Kong
- Division of Neurosurgery, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Andy M Liu
- Spine Center, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Ste 900, Los Angeles, CA, 90048, USA
| | - Suhas Etigunta
- Spine Center, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Ste 900, Los Angeles, CA, 90048, USA
| | - Justin K Scheer
- Spine Center, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Ste 900, Los Angeles, CA, 90048, USA
| | - Lindsay M Andras
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - David L Skaggs
- Spine Center, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Ste 900, Los Angeles, CA, 90048, USA
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Chan V, Etigunta S, Malhotra AK, Shumilak G, Lebel DE, Illingworth KD, Skaggs DL. Are abnormal preoperative hematological screening tests associated with allogeneic transfusion in idiopathic scoliosis surgery? Spine Deform 2025:10.1007/s43390-025-01078-z. [PMID: 40117065 DOI: 10.1007/s43390-025-01078-z] [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: 11/09/2024] [Accepted: 03/05/2025] [Indexed: 03/23/2025]
Abstract
PURPOSE Previous studies have suggested routine preoperative laboratory assessment may be unnecessary or excessive. The primary aim of this study was to determine the association between abnormal preoperative laboratory screening tests on allogeneic transfusion in pediatric patients receiving posterior spinal fusion for idiopathic scoliosis correction. METHODS The NSQIP Pediatric database for years 2016-2022 was used. Patients who were (1) < 18 years old, (2) received posterior arthrodesis for idiopathic scoliosis correction, and (3) had recorded preoperative laboratory tests were included in this study. Preoperative bloodwork values of interest were hematocrit, albumin, platelet count, international normalized ratio (INR), and partial thromboplastin time (PTT). Descriptive statistics were used to characterize patient demographics, surgical metrics, and preoperative laboratory values. Rate of allogeneic transfusion was stratified by laboratory value cut-offs and compared using G-test. Standardized cut-offs were used to define abnormal values. A multivariable logistic regression analysis was used to assess the impact of abnormal bloodwork values on rate of allogeneic transfusion. RESULTS There were 6057 patients included in this study. The mean age was 13.8 years. There were 13.6% that received allogeneic transfusion. The mean transfusion volume was 62.1 mL. Patients with abnormal preoperative INR (13.1% vs. 20.0%; p < 0.001), hematocrit < 35 (12.4% vs. 25.9%; p < 0.001), and albumin < 3.4 (13.4% vs. 25.8%; p = 0.004) had higher rates of transfusion. In the multivariable logistic regression analysis, INR > 1.2 (OR 1.4, p = 0.023) and hematocrit < 35 (OR 2.3, p < 0.001) were significantly associated with higher odds of allogeneic transfusion. CONCLUSION Preoperative INR and hematocrit values can aid in risk stratification for allogeneic transfusion requirements. PTT and platelet count did not significantly impact perioperative transfusion rates or volumes.
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Affiliation(s)
- Vivien Chan
- Spine Center, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Ste 900, Los Angeles, CA, 90048, USA.
| | - Suhas Etigunta
- Spine Center, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Ste 900, Los Angeles, CA, 90048, USA
| | - Armaan K Malhotra
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Geoffrey Shumilak
- Division of Critical Care Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - David E Lebel
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Kenneth D Illingworth
- Spine Center, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Ste 900, Los Angeles, CA, 90048, USA
| | - David L Skaggs
- Spine Center, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Ste 900, Los Angeles, CA, 90048, USA
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Scorer A, Chahal R, Ellard L, Myles PS, Bradley WP. Effective utilisation of rapid infusion catheters in perioperative care: a narrative review. BJA OPEN 2025; 13:100365. [PMID: 39906702 PMCID: PMC11791164 DOI: 10.1016/j.bjao.2024.100365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Accepted: 11/19/2024] [Indexed: 02/06/2025]
Abstract
The Rapid Infusion Catheter (RIC) has transformed intravenous (i.v.) access, allowing for rapid fluid delivery peripherally. It may negate the need for a central vein sheath to be placed. This review explores the clinical utility of RICs while addressing technical considerations and potential risks. The RIC is a large-bore i. v. sheath available in two sizes. Its maximal flow rate is 1200 ml min-1, making it advantageous in significant blood loss scenarios such as trauma and major surgeries. Insertion involves the Seldinger technique. Monitoring and maintaining the RIC is crucial to detect and address immediate complications such as occlusions, infiltration, phlebitis, and extravasation of infusate. Although the related complications share similarities with those of other peripheral i. v. cannulae, they have a lower risk of occlusion and accidental displacement. Catheter removal should be considered once the patient is stable or alternative access is available to avoid infectious complications. Removal of the RIC needs to be performed by those educated in RIC management. Maximal flow rate is an essential factor in assessing the performance of i. v. cannulae, and studies have shown that RICs outperform other peripheral and central catheters in this regard. In conclusion, RIC offers advantages over large-bore central venous access for large-volume rapid infusions, including ease of insertion and reduced severe complications. The RIC demonstrates lower thrombosis rates and a different complication profile than peripherally inserted central catheters. Understanding the characteristics and applications of RICs can help healthcare professionals make informed decisions about their use in various medical scenarios.
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Affiliation(s)
- Adam Scorer
- Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
| | - Rani Chahal
- Department of Critical Care, University of Melbourne, VIC, Australia
- Department of Anaesthesia, Perioperative and Pain Medicine, The Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Louise Ellard
- Department of Critical Care, University of Melbourne, VIC, Australia
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
- Safe Airway Society, Australia & New Zealand, Australia
| | - Paul S. Myles
- Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - William P.L. Bradley
- Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Anaesthetic Advisory Committee, Epworth Healthcare, Melbourne, VIC, Australia
- Anaesthetic Subcommittee, Victorian Perioperative Consultative Council, Safer Care Victoria, Melbourne, VIC, Australia
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Chan V, Shumilak G, Malhotra AK, Lebel DE, Skaggs DL. Can Intra-Operative Cell Salvage Reduce the Rate of Allogeneic Transfusion in Pediatric Spinal Deformity Surgery? Global Spine J 2024:21925682241309287. [PMID: 39690436 DOI: 10.1177/21925682241309287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2024] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The objective of this study was to characterize the association between cell-salvage and allogeneic transfusion rate in pediatric patients undergoing posterior arthrodesis for scoliosis. METHODS NSQIP Pediatric database years 2016-2022 was used. Patients under the age of 18 who received posterior arthrodesis with 7 or more surgical levels for spinal deformity correction were included. Rates of cell-salvage and allogeneic transfusion were determined. We assessed the impact of cell-salvage on the rate of allogeneic transfusion using chi-square test and multivariable logistic regression. RESULTS There were 34,241 patients in this study. The rate of allogeneic transfusion was 21.6% (n = 7407). The allogeneic transfusion rates for idiopathic, neuromuscular, and congenital/syndromic scoliosis were 12.3%, 50.8%, and 25.9%, respectively. Cell-salvage was used in 71.1% of patients (n = 24,344). In the multivariable regression analysis, longer operative time (P < .001), non-idiopathic scoliosis (P < .001), hematocrit less than 35 (P < .001), and ≥13 surgical levels (P < .001) were associated with higher odds of allogeneic transfusion. Use of cell-salvage (P < .001), increasing age (P < .001), and increasing patient weight (P < .001) were associated with significantly lower odds of allogeneic transfusion. In a subanalysis, use of cell-salvage was associated with reduced rate of allogeneic transfusion in patients with idiopathic scoliosis. Cell-salvage was not associated with reduced rates of allogeneic transfusion in neuromuscular and congenital/syndromic scoliosis. CONCLUSION This is the largest study investigating the impact of cell-salvage on rate of allogeneic transfusion in pediatric spinal deformity surgery. Use of cell-salvage is associated with reduced allogeneic transfusion rates in idiopathic scoliosis surgery.
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Affiliation(s)
- Vivien Chan
- Cedars Sinai Spine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Geoffrey Shumilak
- Division of Critical Care Medicine, University of Saskatchewan, Saskatoon, Canada
| | | | - David E Lebel
- Department of Neurosurgery, University of Toronto, Toronto, Canada
| | - David L Skaggs
- Cedars Sinai Spine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Kanhangad MP, Ramachandra Theja V, Bhat SN. Role of tranexamic acid in reducing peri-operative blood loss in open spine surgeries. Musculoskelet Surg 2024; 108:443-447. [PMID: 38819771 PMCID: PMC11582204 DOI: 10.1007/s12306-024-00826-0] [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: 01/22/2024] [Accepted: 05/15/2024] [Indexed: 06/01/2024]
Abstract
Spine surgeries are associated with significant blood loss due to the extensive soft tissue dissection, bony decompression, and prolonged surgical time. Excessive bleeding may require blood transfusions and thereby increase the risk of adverse transfusion reactions. Therefore, minimizing peri-operative bleeding is important for spine surgeons to reduce post-operative morbidity. Tranexamic acid (TXA) is a synthetic anti-fibrinolytic drug, which helps in reducing perioperative blood loss in major surgeries. The evidence on the efficacy of this agent in all manner of spine surgeries is not sufficient. Hence this study was conducted to determine the efficacy of TXA on perioperative blood loss in major spinal surgeries. In a prospective study, two groups of patients with similar surgical profiles who were posted for all manner of open spine surgeries were included. One group received one gram of intravenous TXA while the others did not. Intra- and post-operative assessments included noting levels of surgery, duration of surgery, assessment of blood loss, intra- and/or post- operative blood transfusion, and blood collected in surgical drain at the end of 24 h. The intra-operative blood loss, frequency of intra-operative blood transfusion, post-operative Hemoglobin drop, and surgical drain output were found to be significantly lower in patients who received TXA. In spine surgeries, TXA was found to be effective in reducing intra-operative blood loss, need for intra-operative blood transfusion and post-operative Hb drop. Also, TXA had reduced surgical drain output significantly between the two groups.
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Affiliation(s)
- Madhava Pai Kanhangad
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - V Ramachandra Theja
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Shyamasunder N Bhat
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
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Hasan MS, Leong MH, Lee ZY, Chiu CK, Chan CYW, Kwan MK, Yunus SN. Association of single bolus versus bolus followed by infusion of tranexamic acid with blood loss in adolescent idiopathic scoliosis surgery. Perioper Med (Lond) 2024; 13:94. [PMID: 39350225 PMCID: PMC11443673 DOI: 10.1186/s13741-024-00452-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Accepted: 09/18/2024] [Indexed: 10/04/2024] Open
Abstract
BACKGROUND Adolescent idiopathic scoliosis (AIS) corrective surgery may involve significant blood loss and blood transfusion requirements. Antifibrinolytic agents such as tranexamic acid (TXA) have been used to reduce blood loss, but its optimal dose is uncertain. The objective of this study is to determine the estimated blood loss and rate of blood transfusion between two groups of AIS patients receiving TXA as a single bolus versus bolus followed by infusion in scoliosis surgery. METHODS This was a retrospective analysis of a single bolus versus bolus followed by infusion of TXA in AIS surgery. AIS patients undergoing posterior spinal fusion (PSF) from December 2018 to September 2019 at a tertiary university hospital were identified. Inclusion criteria were patients aged between 10 and 21 years who received either a single bolus of 30 mg/kg TXA (Group A) or a single bolus of 30 mg/kg followed by continuous infusion of 10 mg/kg/h of TXA (Group B). Patient demographics, operative data, estimated blood loss, blood transfusion rate, and complications were recorded. RESULTS A total of 129 AIS patients were included. All operative surgeries were performed by two senior consultants. The mean age was 14.8 ± 3.4 years old, and 89.1% were female. The Cobb angle, number of fusion levels, number of screws, length of skin incision, and duration of surgery were comparable between the two groups. There was no difference in the total estimated blood loss between the two groups: 723.3 ± 279.4 mL (range: 175.0-1607.0 mL) in Group A and 819.4 ± 302.6 mL (range: 330.0-1556.0 mL) in Group B (p = 0.065). There were no complications, and none received blood transfusion. CONCLUSION TXA when administered as a single bolus or bolus followed by infusion in AIS patients undergoing PSF surgery was associated with similar estimated total surgical blood loss and blood transfusion requirement.
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Affiliation(s)
- Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Mew Har Leong
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Chee Kidd Chiu
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Chris Yin Wei Chan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Mun Keong Kwan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Siti Nadzrah Yunus
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
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Deng B, Li X, Xie P, Luo X, Yan X. Intravenous versus topical tranexamic acid in spinal surgery: a systematic review and meta-analysis. J Orthop Surg Res 2024; 19:512. [PMID: 39192283 PMCID: PMC11348596 DOI: 10.1186/s13018-024-04989-1] [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: 06/27/2024] [Accepted: 08/06/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND The administration of tranexamic acid (TXA) during spinal surgery has been shown to reduce blood loss. However, the efficacy and safety of intravenous TXA (ivTXA) and topical TXA (tTXA) are poorly documented. The present meta-analysis aimed to compare the efficacy and safety of ivTXA and tTXA administration in spinal surgery. METHODS Potentially relevant academic articles were identified from PubMed, Ovid, Cochrane Library, CNKI database, and Wanfang Data from the date of inception until March 1, 2024. Randomized controlled trials (RCTs) and nonrandomized controlled trials (non-RCTs) were included in our meta-analysis if they compared the efficacy and safety of ivTXA versus tTXA administration during spinal surgery. Secondary sources were identified from the references of the included literature. The meta-analysis was performed in accordance with the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. Data were summarized using RevMan 5.3 software from Denmark. RESULTS Four RCTs and one non-RCT met our inclusion criteria. The pooled outcomes demonstrated that ivTXA groups compared with tTXA groups had significantly less amount of total blood loss [weighted mean difference (WMD)=-159.55, 95% CI (-181.91,-137.19), P < 0.00001], hidden blood loss [WMD=-132.27, 95% CI (-159.81, -104.72), P < 0.00001], intraoperative blood loss [WMD=-86.22, 95% CI (-99.13, -73.31), P < 0.00001, I2 = 96%], and more high postoperative hemoglobin level [WMD = 8.96, 95% CI (5.18, 12.75), P < 0.00001, I2 = 29%], and less transfusion rate [risk ratio (RR) = 1.11, 95% CI (0.81,1.52), P = 0.50, I2 = 94%]. The pooled results showed no significant difference in thromboembolic events (deep venous thrombosis and pulmonary embolism) between the two groups. CONCLUSION Our meta-analysis demonstrated that ivTXA was more effective than tTXA in inducing hemostatic effect during spinal surgery. However, the risk of a thrombotic event was not different between the two administration methods of TXA. More high quality RCTs are needed to further confirm our conclusions.
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Affiliation(s)
- Bo Deng
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Xudong Li
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Peng Xie
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Xiaozhong Luo
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Xueliang Yan
- Department of Spine Surgery, The Second Affiliated Hospital of South China University, Hengyang, 421000, China.
- School of Life Science, Central South University, Changsha, 410000, China.
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Park SY, Kang T, Jeong WK, Song JE. Prevalence, Risk Factors, and Postoperative Infection Rates of Blood Transfusion in Lumbar Spinal Fusion Surgery: A Nationwide Population-Based Study. J Clin Med 2024; 13:4867. [PMID: 39201008 PMCID: PMC11355348 DOI: 10.3390/jcm13164867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 08/12/2024] [Accepted: 08/15/2024] [Indexed: 09/02/2024] Open
Abstract
Study Design: Retrospective cohort study. Objectives: Effects of blood loss that requires blood transfusion after lumbar spinal fusion remain an important issue. Blood transfusions are used commonly in cases of significant blood loss in lumbar spinal fusion but are associated with adverse effects. The objective was to assess the rate of blood transfusion and the associated risk after lumbar spinal fusion from 2013 to 2018. Methods: In this nationwide population-based cohort study, the Korean Health Insurance Review and Assessment Service database was reviewed retrospectively from 2013 to 2018. Data were extracted from patients who underwent lumbar spinal fusion without history of lumbar spinal surgery in the preceding year. The primary outcome was the rate of blood transfusion within 1 week of surgery. In addition, the risk factors for blood transfusion and the rate of postoperative infection were evaluated. Results: A total of 188,581 patients underwent lumbar spinal fusion between 2013 and 2018. A significant decline in blood transfusions was observed during the study period (56.38-47.51%). The presence of comorbidities was associated with an increased risk of blood transfusion. Patients who underwent the posterior approach were more likely to receive blood transfusion than patients who underwent the anterior or anterior and posterior approach. Receiving blood transfusion was associated with postoperative infection. Conclusions: In the present study, the prevalence, risk factors, and postoperative infection rates associated with blood transfusion in lumbar spinal fusion were identified. Spine surgeons should consider these risk factors in patients at high risk of blood transfusion.
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Affiliation(s)
- Si Young Park
- Department of Orthopedics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
| | - Taewook Kang
- Department of Spine Surgery, Cheil Orthopedic Hospital, Seoul 06075, Republic of Korea
| | - Woong Kyo Jeong
- Department of Orthopedics, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea;
| | - Ji Eun Song
- Department of Biostatistics, Korea University College of Medicine, Seoul 02841, Republic of Korea;
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Honda A, Iizuka Y, Michihata N, Uda K, Mieda T, Takasawa E, Ishiwata S, Kakuta Y, Tomomatsu Y, Ito S, Inomata K, Matsui H, Fushimi K, Yasunaga H, Chikuda H. Effect of Intraoperative Tranexamic Acid on Perioperative Major Hemorrhage Requiring Transfusion in Patients Undergoing Elective Spine Surgery: A Propensity Score-Matched Analysis Using a National Inpatient Database. Global Spine J 2024; 14:804-811. [PMID: 36006871 PMCID: PMC11192125 DOI: 10.1177/21925682221123317] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES This study aimed to examine whether the use of intravenous TXA in elective spine surgery is associated with reduced perioperative massive hemorrhage requiring transfusion. METHODS We extracted all patients who underwent decompression with or without fusion surgery for the cervical, thoracic, and lumbar spine between April 2012 and March 2019. The primary outcome was the occurrence of massive hemorrhage requiring transfusion, defined as at least 560 mL of blood transfusion within 2 days of spine surgery or the requirement of additional blood transfusion from 3-7 days postoperatively. Secondary outcomes were the occurrence of thrombotic complications (pulmonary embolism, acute coronary syndrome, and stroke) and postoperative hematoma requiring additional surgery. RESULTS We identified 83,821 eligible patients, with 9747 (12%) patients in the TXA group. Overall, massive hemorrhage requiring transfusion occurred in 781 (.9%) patients. Propensity score matching yielded 8394 pairs. In the matched cohort, the TXA group had a lower proportion of massive hemorrhage requiring transfusion than the control group (.7% vs 1.1%; P = .002). There was no significant difference in the occurrence of thrombotic complications and postoperative hematoma requiring additional surgery between both groups. The multivariable regression analysis also showed that the use of TXA was associated with significantly lower proportions of massive hemorrhage requiring transfusion (odds ratio, .62; 95% confidence interval, .43-.90; P = .012). CONCLUSIONS In this analysis using real-world data, TXA use in elective spinal surgery was associated with reduced perioperative massive hemorrhage requiring transfusion without increasing thrombotic complications. LEVEL OF EVIDENCE Prognostic Level Ⅲ.
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Affiliation(s)
- Akira Honda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuaki Uda
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tokue Mieda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Eiji Takasawa
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Sho Ishiwata
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yohei Kakuta
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yusuke Tomomatsu
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Shunsuke Ito
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Kazuhiro Inomata
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
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Lang FF, Liu LY, Wang SW. Predictive modeling of perioperative blood transfusion in lumbar posterior interbody fusion using machine learning. Front Physiol 2023; 14:1306453. [PMID: 38187137 PMCID: PMC10767743 DOI: 10.3389/fphys.2023.1306453] [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: 10/04/2023] [Accepted: 11/06/2023] [Indexed: 01/09/2024] Open
Abstract
Background: Accurate estimation of perioperative blood transfusion risk in lumbar posterior interbody fusion is essential to reduce the number, cost, and complications associated with blood transfusions. Machine learning algorithms have the potential to outperform traditional prediction methods in predicting perioperative blood transfusion. This study aimed to construct a machine learning-based perioperative transfusion risk prediction model for lumbar posterior interbody fusion in order to improve the efficacy of surgical decision-making. Methods: We retrospectively collected clinical data on 1905 patients who underwent lumbar posterior interbody fusion surgery at the Second Hospital of Shanxi Medical University between January 2021 and March 2023. All the data was randomly divided into a training set and a validation set, and the "feature_importances" method provided by eXtreme Gradient Boosting (XGBoost) algorithm was applied to select statistically significant features on the training set to establish five machine learning prediction models. The optimal model was identified by utilizing the area under the curve (AUC) and the probability calibration curve on the validation set. Shapley additive explanations (SHAP) and local interpretable model-agnostic explanations (LIME) were employed for interpretable analysis of the optimal model. Results: In the postoperative outcomes of patients, the number of hospital days in the transfusion group was longer than that in the non-transfusion group. Additionally, the transfusion group experienced higher total hospital costs, 90-day readmission rates, and complication rates within 90 days after surgery than the non-transfusion group. A total of 9 features were selected for the models. The XGBoost model performed best with an AUC value of 0.958. The SHAP values showed that intraoperative blood loss, intraoperative fluid infusion, and number of fused segments were the top 3 most important features affecting perioperative blood transfusion in lumbar posterior interbody fusion. The LIME algorithm was used to interpret the individualized prediction. Conclusion: Surgery, ASA class, levels fused, total intraoperative blood loss, operative time, and preoperative Hb are viable predictors of perioperative blood transfusion in lumbar posterior interbody fusion. The XGBoost model has demonstrated superior predictive efficacy compared to the traditional logistic regression model, making it a more effective decision-making tool for perioperative blood transfusion.
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Affiliation(s)
- Fang-Fang Lang
- School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Li-Ying Liu
- School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Shao-Wei Wang
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
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Beckers G, Manon J, Lejeune G, Gläser M, Kaminski L, Cornu O, Van Cauter M. How to avoid systematic postoperative blood test after total hip arthroplasty: A new risk scoring system compared to Wu's score. Orthop Traumatol Surg Res 2023; 109:103597. [PMID: 36931503 DOI: 10.1016/j.otsr.2023.103597] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Routine laboratory studies are often performed following total hip arthroplasty (THA). However, lately, their necessity has been challenged and risk factors for postoperative transfusion are still debated. Recently, a risk scoring system to single out patients that should have a postoperative blood test has been published by Wu et al. The purposes of this retrospective study were: (1) to validate this recently published risk scoring system to identify patients who should have a postoperative laboratory test; (2) to single out risk factors of postoperative transfusion; (3) to determine if another score can more accurately predict the need for postoperative transfusion. HYPOTHESIS Wu et al.'s risk scoring system can accurately identify patients who should have a postoperative blood test. METHODS In all, 1693 patients who underwent primary THAs between June 2015 and October 2020 were screened for potential eligibility to include 1000 patient for analysis. Preoperative and postoperative blood tests were done for every patient. Clinical information and laboratory results were retrospectively collected and analyzed. A descriptive analysis followed by univariate and multivariate analysis were sequentially performed. A multiple logistic regression model was employed to determine a formula predicting the transfusion risk called THABUS for Total Hip Arthroplasty Blood test Usefulness Score. The risk scoring system for complete blood count published by Wu et al. in may 2020 was performed for every patient and compared to the THABUS predictive model. RESULTS The transfusion rate was 2.3% (23/1000). The risk-scoring system published by Wu and al. showed that a laboratory test was necessary for 60.6% (606/1000) however 13% (3/23) of the patients who needed a blood transfusion were missed by the risk-scoring system, giving it a sensitivity of 86.95% and a specificity of 40%. Increasing age, arterial hypertension, female gender, low preoperative hemoglobin, ASA score≥2 and diagnosis of osteonecrosis of the femoral head were significantly associated with postoperative transfusion. The THABUS formula can predict the risk for transfusion with a sensibility of 96.65% and a specificity of 75.54%. In our cohort of 1000 patients, following the THABUS formula would have led to 261 postoperative blood test and cost savings of 32,132$. Only one patient (4.3%) was missed by our new score. The THABUS formula is significantly better than Wu et al.'s complete blood count score in identifying both patient that will need a transfusion (p<0.01) and those who shouldn't have a postoperative blood test (p<0.001). Medical intervention because of creatinine or electrolytes abnormality was needed in 0.3% (3/1000) of patients. DISCUSSION In this study Wu et al.'s recently published complete blood count risk-scoring system was not validated. However, in the studied population the THABUS formula can accurately target patients who might need a transfusion. The use of the THABUS formula could reduce hospitalization costs without compromising the patients' safety. LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
- Gautier Beckers
- Department of Orthopaedic and Trauma surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Julie Manon
- Experimental and Clinical Research Institute (IREC), Neuro-Musculo-Skeletal Pole (NMSK), Université Catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Gauthier Lejeune
- Department of Orthopaedic and Trauma surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Maximilian Gläser
- Department of Orthopaedic and Trauma surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Ludovic Kaminski
- Department of Orthopaedic and Trauma surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Olivier Cornu
- Department of Orthopaedic and Trauma surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 10, 1200, Brussels, Belgium; Experimental and Clinical Research Institute (IREC), Neuro-Musculo-Skeletal Pole (NMSK), Université Catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Maité Van Cauter
- Department of Orthopaedic and Trauma surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 10, 1200, Brussels, Belgium; Experimental and Clinical Research Institute (IREC), Neuro-Musculo-Skeletal Pole (NMSK), Université Catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
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12
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Tezuka F, Sakai T, Imagama S, Takahashi H, Takaso M, Aizawa T, Otani K, Okuda S, Kato S, Kanemura T, Kawaguchi Y, Konishi H, Suda K, Terai H, Nakanishi K, Nishida K, Machino M, Miyakoshi N, Murakami H, Yamato Y, Yukawa Y. Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan. Spine Surg Relat Res 2023; 7:428-435. [PMID: 37841038 PMCID: PMC10569803 DOI: 10.22603/ssrr.2023-0015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/13/2023] [Indexed: 10/17/2023] Open
Abstract
INTRODUCTION The number of patients on antithrombotic drugs for coronary heart disease or cerebrovascular disease has been increasing with the aging of society. We occasionally need to decide whether to continue or discontinue antithrombotic drugs before spine surgery. The purpose of this study is to understand the current perioperative management of antithrombotic drugs before elective spine surgery in Japan. METHODS In 2021, members of the Japanese Society for Spine Surgery and Related Research (JSSR) were asked to complete a web-based questionnaire survey that included items concerning the respondents' surgical experience, their policy regarding discontinuation or continuation of antithrombotic drugs, their reasons for decisions concerning the management of antithrombotic drugs, and their experience of perioperative complications related to the continuation or discontinuation of these drugs. RESULTS A total of 1,181 spine surgeons returned completed questionnaires, giving a response rate of 32.0%. JSSR board-certified spine surgeons comprised 75.1% of the respondents. Depending on the management policy regarding antithrombotic drugs for each comorbidity, approximately 73% of respondents discontinued these drugs before elective spine surgery, and about 80% also discontinued anticoagulants. Only 4%-5% of respondents reported continuing antiplatelet drugs, and 2.5% reported continuing anticoagulants. Among the respondents who discontinued antiplatelet drugs, 20.4% reported having encountered cerebral infarction and 3.7% reported encountering myocardial infarction; among those who discontinued anticoagulants, 13.6% reported encountering cerebral embolism and 5.4% reported encountering pulmonary embolism. However, among the respondents who continued antiplatelet drugs and those who continued anticoagulants, 26.3% and 27.2%, respectively, encountered an unexpected increase in intraoperative bleeding, and 10.3% and 8.7%, respectively, encountered postoperative spinal epidural hematoma requiring emergency surgery. CONCLUSIONS Our findings indicate that, in principle, >70% of JSSR members discontinue antithrombotic drugs before elective spine surgery. However, those with a discontinuation policy have encountered thrombotic complications, while those with a continuation policy have encountered hemorrhagic complications.
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Affiliation(s)
- Fumitake Tezuka
- Department of Orthopedics, Tokushima University, Tokushima, Japan
| | - Toshinori Sakai
- Department of Orthopedics, Tokushima University, Tokushima, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Takahashi
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University, School of Medicine, Kanagawa, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Koji Otani
- Department of Orthopedic Surgery, Fukushima Medical University, Fukushima, Japan
| | - Shinya Okuda
- Department of Orthopedics, Hoshigaoka Medical Center, Hirakata, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Tokumi Kanemura
- Department of Orthopaedic Surgery, Konan Kosei Hospital, Aichi, Japan
| | | | - Hiroaki Konishi
- Department of Orthopedics, Nagasaki Rosai Hospital, Sasebo, Japan
| | - Kota Suda
- Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Nakanishi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Kotaro Nishida
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Nagoya City University, Nagoya, Japan
| | - Yu Yamato
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Shizuoka, Japan
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13
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Brown NJ, Pennington Z, Himstead AS, Yang CY, Chakravarti S, Gendreau J, Kurtz J, Shahrestani S, Pham MH, Osorio JA. Safety and Efficacy of High-Dose Tranexamic Acid in Spine Surgery: A Retrospective Single-Institution Series. World Neurosurg 2023; 177:e18-e25. [PMID: 37141940 DOI: 10.1016/j.wneu.2023.04.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE Currently, tranexamic acid (TXA) is the most widely used antifibrinolytic agent in spine surgery and has been proven to reduce perioperative blood loss. However, the safety of high-dose regimens remains in established. METHODS A retrospective chart review was performed to identify all adult patients who underwent spine surgery with high-dose TXA (50 mg/kg loading dose, mg/kg/h maintenance dose) between September 2019 and March 2020. RESULTS Thirty-six patients were treated with intraoperative high-dose TXA during the study period. The mean age was 56.6 (range: 22-82). Average body mass index was 27.2 (5.1) kg/m2. Average preoperative Charlson Comorbidity Index was 3.0 (2.7). The mean number of spinal levels operated on was 6.9 (4.3). Seven cases (19.4%) were revision surgeries. The mean intraoperative blood loss was 587.1 (900.0) mL, and total blood loss was 623.8 (991.9) mL. Postoperatively, time to ambulation was on average 1.7 (1.7) days. The mean total length of stay was 9.8 days (7.9, range 2-41). The most common indication for surgery was tumor (n = 9, 25%), followed by fracture (n = 8, 22.2%), deformity (n = 7, 19.4%), pseudarthrosis (n = 6, 16.7%), and symptomatic lumbar disc herniation (n = 2, 5.6%). There were no thromboembolic or other significant complications among the 36 patients. CONCLUSIONS This retrospective case series demonstrates that the use of high-dose TXA provides is potentially safe and efficacious in adult patients undergoing complex spine surgeries. However, further investigations are required before the true safety and optimal dosing can be determined for high-dose TXA.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Zach Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Chen Yi Yang
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Sachiv Chakravarti
- Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland, USA
| | - Julian Gendreau
- Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland, USA
| | - Joshua Kurtz
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Shane Shahrestani
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Martin H Pham
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - Joseph A Osorio
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA.
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14
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Mohanty S, Sardar ZM, Hassan FM, Reyes J, Coury JR, Lombardi JM, Lehman RA, Lenke LG. High Cell Saver Autotransfusion is Associated With Perioperative Medical Complications in Adult Spinal Deformity Patients. Spine (Phila Pa 1976) 2023; 48:1234-1244. [PMID: 37280746 DOI: 10.1097/brs.0000000000004743] [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] [Received: 03/08/2023] [Accepted: 05/19/2023] [Indexed: 06/08/2023]
Abstract
STUDY DESIGN A retrospective, propensity-matched observational study. OBJECTIVE To assess the impact of cell saver (CS) homologous transfusion on perioperative medical complications in adult patients undergoing spinal deformity surgery. SUMMARY OF BACKGROUND DATA Despite many endorsing its use, many analyses still refute the efficacy of CS on decreasing total perioperative allogenic red blood cell transfusions, cost efficiency, and its effect on perioperative complications. METHODS Adult patients who underwent spinal deformity surgery at a single center between 2015 and 2021 were retrospectively reviewed. Patient-specific, operative, radiographic, and 30-day complications/readmission data were collected for further analysis. Two methods were utilized to test our hypothesis: (1) absolute threshold model: two cohorts created among patients who received ≥550 mL of CS intraoperatively and those who received less; (2) adjusted ratio model: two cohorts created dependent on the ratio of CS to estimated blood loss (EBL). Propensity-score matching and various statistical tests were utilized to test the association between CS and perioperative medical complications. RESULTS Two hundred seventy-eight patients were included in this analysis with a mean age of 61.3±15.7yrs and 67.6% being female. Using the first method, 73 patients received ≥550 mL of CS, and 205 received less. Propensity-score matching resulted in 28 pairs of patients. 39.3% of patients with ≥550 mL CS required readmission within 30 days compared with 3.57% of patients in the <550 mL cohort ( P =0.016), despite a nearly identical proportion of patients requiring intraoperative blood transfusions ( P >0.9999). Using the second method, 155 patients had CS/EBL<0.33 and 123 with CS/EBL ≥0.33. 5.16% and 21.9% among patients with CS/EBL<0.33 and CS/EBL≥0.33, respectively, were readmitted by the 30-day marker ( P <0.0001). CONCLUSIONS Our findings indicate that greater CS volumes transfused are associated with higher rates of 30-day readmissions. Thus, surgeons should consider limiting CS volume intraoperatively to 550 mL and when greater volumes are required or preferred, ensuring that the ratio of CS:EBL remains under 0.33.
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Affiliation(s)
- Sarthak Mohanty
- Department of Orthopaedic Surgery, The Och Spine Hospital/Columbia University Irving Medical Center, New York, NY
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15
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Heard JC, Siegel N, Yalla GR, Lambrechts MJ, Lee Y, Sherman M, Wang J, Dambly J, Baker S, Bowen G, Mangan JJ, Canseco JA, Kurd MF, Kaye ID, Hilibrand AS, Vaccaro AR, Kepler CK, Schroeder GD. Predictors of Blood Transfusion in Patients Undergoing Lumbar Spinal Fusion. World Neurosurg 2023; 176:e493-e500. [PMID: 37257651 DOI: 10.1016/j.wneu.2023.05.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/20/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To determine risk factors for perioperative blood transfusion after lumbar fusion surgery. METHODS After institutional review board approval, a retrospective cohort study of adult patients who underwent lumbar fusion at a single, urban tertiary academic center was retrospectively retrieved. Our primary outcome, blood transfusion, was collected via chart query. A receiver operating characteristic curve was used to evaluate the regression model. A P-value < 0.05 was considered statistically significant. RESULTS Of the 3,842 patients, 282 (7.3%) required a blood transfusion. For patients undergoing posterolateral decompression and fusion, predictors of transfusion included age (P < 0.001) and more levels fused (P < 0.001). A higher preoperative hemoglobin level (P < 0.001) and revision surgery (P = 0.005) were protective of blood transfusion. For patients undergoing transforaminal lumbar interbody fusion, greater Elixhauser comorbidity index (P < 0.001), longer operative time (P = 0.040), and more levels fused (P = 0.030) were independent predictors of the need for blood transfusion. Patients with a higher body mass index (P = 0.012) and preoperative hemoglobin level (P < 0.001) had a reduced likelihood of receiving a transfusion. For circumferential fusion, greater age (P = 0.006) and longer operative times (P = 0.015) were independent predictors of blood transfusion, while a higher preoperative hemoglobin level (P < 0.001) and male sex (P = 0.002) were protective. CONCLUSIONS Our analysis identified older age, lower body mass index, greater Elixhauser comorbidity index, longer operative duration, more levels fused, and lower preoperative hemoglobin levels as independent predictors of requiring a blood transfusion following lumbar spinal fusion. Different surgical approaches were not found to be associated with transfusion.
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Affiliation(s)
- Jeremy C Heard
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nicholas Siegel
- Department of Orthopaedic Surgery, Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Goutham R Yalla
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Washington University at St. Louis, St. Louis, Missouri, USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
| | - Matthew Sherman
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jasmine Wang
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Julia Dambly
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Sydney Baker
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Grace Bowen
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - John J Mangan
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mark F Kurd
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ian D Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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16
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Kato S, Miyahara J, Matsubayashi Y, Taniguchi Y, Doi T, Kodama H, Higashikawa A, Takeshita Y, Fukushima M, Ono T, Hara N, Azuma S, Iwai H, Oshina M, Sugita S, Hirai S, Masuda K, Tanaka S, Oshima Y. Predictors for hemostatic thrombin-gelatin matrix usage in spine surgery: a multicenter observational study. BMC Musculoskelet Disord 2023; 24:289. [PMID: 37055735 PMCID: PMC10099820 DOI: 10.1186/s12891-023-06408-8] [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: 12/23/2022] [Accepted: 04/07/2023] [Indexed: 04/15/2023] Open
Abstract
STUDY DESIGN A prospective cohort study. OBJECTIVES Thrombin-gelatin matrix (TGM) is a rapid and potent hemostatic agent, but it has some limitations, including the cost and its preparation time. The purpose of this study was to investigate the current trend in the use of TGM and to identify the predictors for TGM usage in order to ensure its proper use and optimized resource allocation. METHODS A total of 5520 patients who underwent spine surgery in a multicenter study group within a year were included in the study. The demographic factors and the surgical factors including spinal levels operated, emergency surgery, reoperation, approach, durotomy, instrumented fixation, interbody fusion, osteotomy, and microendoscopy-assistance were investigated. TGM usage and whether it was routine or unplanned use for uncontrolled bleeding were also checked. A multivariate logistic regression analysis was used to identify predictors for unplanned use of TGM. RESULTS Intraoperative TGM was used in 1934 cases (35.0%), among which 714 were unplanned (12.9%). Predictors of unplanned TGM use were female gender (adjusted odds ratio [OR]: 1.21, 95% confidence interval [CI]: 1.02-1.43, p = 0.03), ASA grade ≥ 2 (OR: 1.34, 95% CI: 1.04-1.72, p = 0.02), cervical spine (OR: 1.55, 95% CI: 1.24-1.94, p < 0.001), tumor (OR: 2.02, 95% CI: 1.34-3.03, p < 0.001), posterior approach (OR: 1.66, 95% CI: 1.26-2.18, p < 0.001), durotomy (OR: 1.65, 95% CI: 1.24-2.20, p < 0.001), instrumentation (OR: 1.30, 1.03-1.63, p = 0.02), osteotomy (OR: 5.00, 2.76-9.05, p < 0.001), and microendoscopy (OR: 2.24, 1.84-2.73, p < 0.001). CONCLUSIONS Many of the predictors for unplanned TGM use have been previously reported as risk factors for intraoperative massive hemorrhaging and blood transfusion. However, other newly revealed factors can be predictors of bleeding that is technically challenging to control. While routine usage of TGM in these cases will require further justification, these novel findings are valuable for implementing preoperative precautions and optimizing resource allocation.
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Affiliation(s)
- So Kato
- Department of Orthopaedic Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Junya Miyahara
- Department of Orthopaedic Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yoshitaka Matsubayashi
- Department of Orthopaedic Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yuki Taniguchi
- Department of Orthopaedic Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toru Doi
- Department of Orthopaedic Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroyasu Kodama
- Department of Spine and Orthopedic Surgery, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Akiro Higashikawa
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kizukisumiyoshi- cho, Nakahara-ku, Kawasaki, 211-8510, Japan
| | - Yujiro Takeshita
- Department of Orthopedic Surgery, Organization of Occupational Health and Safety Yokohama Rosai Hospital, 3211 Kozukue-Chō, Kōhoku-Ku, 222-0036, Yokohama, Japan
| | - Masayoshi Fukushima
- Spine center, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, 105-8470, Tokyo, Japan
| | - Takashi Ono
- Department of Spinal Surgery, Community Health-Care Organization Tokyo Shinjuku Medical Center, 5-1 Tsukudo-cho, Shinjuku-ku, 162-8543, Tokyo, Japan
| | - Nobuhiro Hara
- Department of Orthopedic Surgery, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino, 180-8610, Tokyo, Japan
| | - Seiichi Azuma
- Department of Orthopedic Surgery, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, 330-8553, Saitama, Japan
| | - Hiroki Iwai
- Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa Edogawa-ku, 133- 0056, Tokyo, Japan
| | - Masahito Oshina
- Department of Orthopedic Surgery, NTT Medical Center Tokyo, 5-9-22 Higashi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Shurei Sugita
- Department of Orthopedic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, 113-8677, Tokyo, Japan
| | - Shima Hirai
- Department of Orthopedic Surgery, Sagamihara National Hospital, 18-1 Sakuradai, Minami-ku, 252-0392, Sagamihara, Kanagawa, Japan
| | - Kazuhiro Masuda
- Department of Orthopedic Surgery, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, 183-8524, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Intravenous Tranexamic Acid Reduces Blood Loss in Multilevel Spine Surgeries. J Am Acad Orthop Surg 2023; 31:e226-e230. [PMID: 36469851 DOI: 10.5435/jaaos-d-22-00738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/12/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Complex spine surgeries are associated with notable blood loss requiring numerous strategies to preserve blood volume. Tranexamic acid (TXA) is efficacious in reducing blood loss when used topically during surgery, intravenously with or without postoperative maintenance treatment. We aimed to evaluate the effect of preoperative weight-independent intravenous administration of 1 g intravenous TXA on perioperative blood loss in lumbar microdiskectomy, single-level lumbar spinal fusion, and multilevel lumbar decompression (two or more levels). METHODS This is a retrospective cohort study comparing patients who underwent microdiskectomy, single-level lumbar fusion, and multilevel laminectomies with and without preoperative IV TXA administration between 2016 and 2020. RESULTS Two hundred ten patients underwent spine surgery without preoperative IV TXA administration between 2016 and 2018 compared with 109 patients who received preoperative 1 g of IV TXA between 2018 and 2020. Preoperative IV TXA treatment did not change blood loss after microdiskectomy, 77.2 ± 53.9 mL and 77.2 ± 95.2 mL, respectively ( P = 0.792). Preoperative IV TXA treatment reduced blood loss after multilevel lumbar laminectomy and lumbar posterior spinal fusion with a transforaminal intervertebral fusion (PSF and TLIF) ( P = 0.004 and P = 0.0001, respectively). The same effect was found for intraoperative blood loss and postoperative drainage, with preoperative TXA administration reducing intraoperative blood loss and postoperative drainage for the multilevel lumbar laminectomy and lumbar PSF and TLIF cohorts. No IV TXA treatment adverse events were registered in all cohorts. CONCLUSION A routine administration of preoperative weight-independent 1 g intravenous TXA protocol is efficacious and safe in reducing perioperative blood loss for lumbar multilevel laminectomies and PSF and TLIFs.
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Kanhere AP, Lambrechts MJ, Issa TZ, Karamian BA, Hendow CJ, Reddy YC, Slota PJ, D'Antonio ND, Kaye ID, Canseco JA, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. The Effect of Tranexamic Acid on Operative and Postoperative Blood Loss in Transforaminal Lumbar Interbody Fusions. World Neurosurg 2022; 166:e443-e450. [PMID: 35840090 DOI: 10.1016/j.wneu.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of this retrospective cohort study was to evaluate the effect of tranexamic acid (TXA) on reducing perioperative blood loss and length of stay after transforaminal lumbar interbody fusion (TLIF). Spine surgery is associated with the potential for significant blood loss, and adequate hemostasis is essential to visualizing crucial structures during the approach and procedure. Although TXA use has been extensively studied in the pediatric and adult spinal deformity literature, there is a dearth of literature on its efficacy in reducing blood loss for patients who undergo 1- to 3-level TLIF. METHODS All patients requiring 1- to 3-level TLIF who received a preoperative loading dose of TXA were grouped and compared with patients who didn't receive TXA. Demographic, surgical, and laboratory values were collected and analyzed. Continuous and categorical variables were analyzed with χ2, Kruskal-Wallis, or analysis of variance tests, depending on normality and data type. Multiple linear regressions were developed to determine independent predictors of the estimated blood loss (EBL), total blood loss, drain output, and length of stay. Statistical significance was set at P < 0.05. RESULTS Patients who received preoperative TXA had more comorbidities (P = 0.006), longer surgery length (P < 0.001), and longer length of stay (P = 0.004). TXA was independently associated with a decreased day 0, 1, 2, and total drain output (P < 0.001, P = 0.001, P = 0.007, P < 0.001, respectively), but was not associated with a change in EBL, total blood loss, or length of stay. CONCLUSIONS The application of preoperative TXA for patients undergoing 1- to 3-level TLIF reduced drain output in the first 2 postoperative days, but it did not affect hospital length of stay, total blood loss, or EBL.
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Affiliation(s)
- Arun P Kanhere
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Tariq Ziad Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chelsea J Hendow
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yashas C Reddy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paul J Slota
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Use of a Multifunctional Cocktail for Postoperative Bleeding and Pain Control in Spinal Fusion: A Randomized, Double-blind, Controlled Trial. Spine (Phila Pa 1976) 2022; 47:1328-1335. [PMID: 34610611 DOI: 10.1097/brs.0000000000004249] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/31/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, randomized, double-blind controlled trial. OBJECTIVE To explore the effect of multifunctional cocktail for bleeding and pain control after spinal fusion. SUMMARY OF BACKGROUND DATA Managing postoperative bleeding and pain after spinal fusion remains a challenge. Topical application of tranexamic acid or anesthetic agents for bleeding or pain management just started recently, and the multifunctional cocktail for bleeding and pain control simultaneously after spinal fusion have never been published. METHODS Ninety patients who underwent posterior spinal fusion were enrolled in this study. The multifunctional cocktail was injected into the incision before wound closure in the cocktail group. In the control group, an equal volume of normal saline was injected and a patient-controlled analgesic pump was used. Visual analogue scale score; opioid consumption; intraoperative, postoperative, hidden and total blood loss; volume of drainage, hematocrit levels of drainage; hemoglobin levels; and complications were compared between the two groups. RESULTS There were no differences in the visual analogue scale within 48 hours after surgery between the two groups. However, the opioid dosages in the control group were higher than those in the cocktail group. The postoperative blood loss, total blood loss, and hidden blood loss were lower in the cocktail group than in the control group. The drainage volume showed no differences between the two groups; however, the hematocrit level of drainage at 24 hours after surgery was lower in the cocktail group than in the control group. The hemoglobin level was higher in the cocktail group than in the control group at postoperative day 3. Thirteen patients with unbearable nausea and vomiting in the control group, whereas no complications in the cocktail group. CONCLUSION Topical application of a multifunctional cocktail that we designed provides an effective and safe method for reducing pain and bleeding after spinal fusion.
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Turcotte JJ, Holbert SE, Orlov MD, Patton CM, Annapolis. Development and validation of a risk-based algorithm for preoperative type and screen testing in spine surgery. Spine J 2022; 22:1472-1480. [PMID: 35452836 DOI: 10.1016/j.spinee.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/15/2022] [Accepted: 04/09/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT With improvements in surgical techniques and perioperative management, transfusion rates after spine surgery have decreased over time. Given this trend, routine preoperative ABO/Rh type and antibody screen (T&S) laboratory testing may not be warranted in all patients undergoing spine surgery. PURPOSE The aim of the current study is to evaluate risk factors for intra/postoperative transfusion in patients undergoing a variety of spine procedures and to develop an algorithm for selectively ordering preoperative T&S testing in appropriate patients. STUDY DESIGN/SETTING This is a single institution, retrospective observational study of patients undergoing emergent or elective spine surgery. External validation of the algorithm was performed on a national sample of patients undergoing spine surgery from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) national database. PATIENT SAMPLE A total of 5,947 surgeries from January 1, 2016 to December 31, 2019 at a single institution, and 166,113 surgeries from the 2016 to 2018 ACS-NSQIP database. OUTCOME MEASURES The primary outcome measure was performance of intraoperative or postoperative transfusion. METHODS Using the institutional sample, univariate statistics (chi-square tests, fisher's exact test, 2-sided independent sample tests) were performed to compare demographics, comorbidities, and surgical details (case type, number of levels treated, etc.) between patients who did and did not require intra- or postoperative transfusion. Transfusion rates were calculated and compared across procedure types. Multivariate logistic regression was performed to identify independent predictors of transfusion and the model's accuracy was evaluated using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. A risk-based algorithm suggesting no preoperative T&S in low transfusion risk procedures, routine preoperative T&S in high-risk procedures, and further assessment in medium risk thoracolumbar fusion procedures was created. The algorithm's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were evaluated when it was applied to both the institutional and national samples. Potential cost savings from reducing T&S orders were calculated. RESULTS In the institutional sample, 120 patients (2.0%) required intraoperative or postoperative transfusion. The highest rates of transfusion were found in corpectomy (10.5%) and anterior/posterior cervical fusion (6.9%) procedures. In the multivariate logistic regression model, the presence of a preoperative coagulation defect or hemorrhagic condition (OR: 7.149, p<.001) and 6+ level surgery (OR: 7.511, p<.001) were the strongest predictors of transfusion. Overall, the model generated an AUC of 0.882, indicating excellent predictive accuracy. When applied to the institutional cohort, the risk-based algorithm had a sensitivity of 78.3%, specificity of 80.5%, PPV of 7.6%, and NPV of 99.4% for evaluating likelihood of transfusion. Using the algorithm 4,717 T&S tests would have been eliminated (79.3%), resulting in a cost savings of $179,246. Application of the model to the ACS-NSQIP cohort resulted in a sensitivity of 61.9%, specificity of 84.6%, PPV of 15.6%, and NPV of 98.0%. CONCLUSIONS The routine use of preoperative ABO/Rh type and antibody screen testing does not appear to be warranted in patients undergoing spine surgery. A risk-based approach to preoperative type and screen testing may eliminate unnecessary tests and generate significant cost savings with minimal disruption to clinical care.
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Affiliation(s)
- Justin J Turcotte
- Department of Orthopedics, Luminis Health Anne Arundel Medical Center, Annapolis MD, USA.
| | - S Elliott Holbert
- Department of Orthopedics, Luminis Health Anne Arundel Medical Center, Annapolis MD, USA
| | - Maxim D Orlov
- Department of Anesthesiology, Luminis Health Anne Arundel Medical Center, Annapolis MD, USA
| | - Chad M Patton
- Department of Orthopedics, Luminis Health Anne Arundel Medical Center, Annapolis MD, USA
| | - Annapolis
- Department of Orthopedics; Department of Anesthesiology
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Li Z, Yu B, Zhang J, Shen J, Wang Y, Qiu G, Cheng X. Does Abnormal Preoperative Coagulation Status Lead to More Perioperative Blood Loss in Spinal Deformity Correction Surgery? Front Surg 2022; 9:841680. [PMID: 35937609 PMCID: PMC9354489 DOI: 10.3389/fsurg.2022.841680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
This study aims to analyze the potential association between the preoperative coagulation status and perioperative blood loss in spinal deformity correction surgery. The preoperative coagulation status and estimated blood loss (EBL) during operation, postoperative wound drainage, and allogeneic transfusion during and after operation were recorded and analyzed. Among the 164 patients, 26 had a longer prothrombin time (PT), 13 had a lower fibrinogen level, 55 had a longer activated partial thromboplastin time (APTT), and 2 had a longer thrombin time (TT), and the platelet count (PLT) was all normal or higher than the normal level. The mean EBL per surgical level was 77.8 ml (range, 22–267 ml), and the mean drainage per surgical level was 52.7 ml (range, 7–168 ml). Fifty-five patients and 12 patients underwent allogeneic transfusion during and after the operation, respectively. The differences in EBL per surgical level, mean drainage per surgical level, the occurrences of allogeneic transfusion during and after operation between the patients with a longer PT, lower fibrinogen level, longer APTT or longer TT, and the normal controls were not significant (all P’s > 0.05). The Spearman correlation analysis showed that there was no correlation between PT, fibrinogen, APTT, TT or PLT with EBL per surgical level, mean drainage per surgical level, or allogeneic transfusion during and after the operation (all P’s > 0.05). The abnormal preoperative coagulation status but not hemophilia does not lead to more perioperative blood loss or a higher rate of perioperative allogeneic transfusion in spinal deformity correction surgery.
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Zaborovskii N, Schlauch A, Ptashnikov D, Mikaylov D, Masevnin S, Smekalenkov O, Shapton J, Kondrashov D. Hardware Failure in Spinal Tumor Surgery: A Hallmark of Longer Survival? Neurospine 2022; 19:84-95. [PMID: 35378583 PMCID: PMC8987542 DOI: 10.14245/ns.2143180.590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/16/2022] [Indexed: 11/19/2022] Open
Abstract
Objective: Instrumentation failure in spine tumor surgery is a common reason for revision operation. Increases in patient survival demand a better understanding of the hardware longevity. The study objective was to investigate risk factors for instrumentation failure requiring revision surgery in patients with spinal tumors.Methods: A retrospective cohort from a single tertiary care specialty hospital from January 2005 to January 2021, for patients with spinal primary or metastatic tumors who underwent surgical intervention with instrumentation. Demographic and treatment data were collected and analyzed. Kaplan-Meier analysis was performed for overall survival, and separate univariate and multivariate regression analysis was performed.Results: Three hundred fifty-one patients underwent surgical intervention for spinal tumor, of which 23 experienced instrumentation failure requiring revision surgery (6.6%). Multivariate regression analysis identified pelvic fixation (odds ratio [OR], 10.9), spinal metastasis invasiveness index (OR, 1.11), and survival of greater than 5 years (OR, 3.6) as significant risk factors for hardware failure. One- and 5-year survival rates were 57% and 8%, respectively.Conclusion: Instrumentation failure after spinal tumor surgery is a common reason for revision surgery. Our study suggests that the use of pelvic fixation, invasiveness of the surgery, and survival greater than 5 years are independent risk factors for instrumentation failure.
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Affiliation(s)
- Nikita Zaborovskii
- Vreden National Medical Research Center of Traumatology and Orthopedics, Saint-Petersburg, Russia
- Saint-Petersburg State University, Saint-Petersburg, Russia
| | - Adam Schlauch
- San Francisco Orthopaedic Residency Program, San Francisco, CA, USA
| | - Dmitrii Ptashnikov
- Vreden National Medical Research Center of Traumatology and Orthopedics, Saint-Petersburg, Russia
- North-Western State Medical University named after I.I.Mechnikov, Saint-Petersburg, Russia
| | - Dmitrii Mikaylov
- Vreden National Medical Research Center of Traumatology and Orthopedics, Saint-Petersburg, Russia
| | - Sergei Masevnin
- Vreden National Medical Research Center of Traumatology and Orthopedics, Saint-Petersburg, Russia
| | - Oleg Smekalenkov
- Vreden National Medical Research Center of Traumatology and Orthopedics, Saint-Petersburg, Russia
| | - John Shapton
- San Francisco Orthopaedic Residency Program, San Francisco, CA, USA
| | - Dimitriy Kondrashov
- Dignity Health - Saint Mary’s Hospital, San Francisco, CA, USA
- Corresponding Author Dimitriy Kondrashov https://orcid.org/0000-0002-3390-6648 Dignity Health - Saint Mary’s Hospital, SF Spine Surgeons, 1 Shrader Street, Suite 600, San Francisco, CA 94117, USA
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Huec JL, AlEissa S, Bowey A, Debono B, El-Shawarbi A, Fernández-Baillo N, Han K, Martin-Benlloch A, Pflugmacher R, Sabatier P, Vanni D, Walker I, Warren T, Litrico S. Hemostats in Spine Surgery: Literature Review and Expert Panel Recommendations. Neurospine 2022; 19:1-12. [PMID: 35378578 PMCID: PMC8987560 DOI: 10.14245/ns.2143196.598] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/10/2022] [Indexed: 01/05/2023] Open
Abstract
Bleeding in spine surgery is a common occurrence but when bleeding is uncontrolled the consequences can be severe due to the potential for spinal cord compression and damage to the central nervous system. There are many factors that influence bleeding during spine surgery including patient factors and those related to the type of surgery and the surgical approach to bleeding. There are a range of methods that can be employed to both reduce the risk of bleeding and achieve hemostasis, one of which is the adjunct use of hemostatic agents. Hemostatic agents are available in a variety of forms and materials and with considerable variation in cost, but specific evidence to support their use in spine surgery is sparse. A literature review was conducted to identify the pre-, peri-, and postsurgical considerations around bleeding in spine surgery. The review generated a set of recommendations that were discussed and ratified by a wider expert group of spine surgeons. The results are intended to provide a practical guide to the selection of hemostats for specific bleeding situations that may be encountered in spine surgery.
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Affiliation(s)
- J.C. Le Huec
- Spine Unit, Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France,Corresponding Author J.C. Le Huec https://orcid.org/0000-0002-0463-6706 Spine Unit, Polyclinique Bordeaux Nord Aquitaine, Université Bordeaux, 33000, Bordeaux, France
| | - S. AlEissa
- King Saud bin Abdulaziz University for Health Sciences Riyadh, Riyadh, Saudi Arabia
| | - A.J. Bowey
- Department of Orthopaedic Spinal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - B. Debono
- Paris-Versailles Spine Center (Centre Francilien du Dos), Ramsay Santé - Hôpital Privé de Versailles, Versailles, France
| | | | - N. Fernández-Baillo
- Spine Unit, Department of Orthopedic Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - K.S. Han
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A. Martin-Benlloch
- Department of Orthopaedic Surgery, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - R. Pflugmacher
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Germany
| | - P. Sabatier
- Department of Neurosurgery, Clinique des Cèdres, Cornebarrieu, France
| | - D. Vanni
- G-spine 4, Spine Surgery Division, I.R.C.C.S. Istituto Ortopedico Galeazzi, Milan, Italy
| | - I. Walker
- Triducive Partners Limited, Hertfordshire, UK
| | - T. Warren
- Triducive Partners Limited, Hertfordshire, UK
| | - S. Litrico
- Department of Spine Surgery, Pasteur II Hospital, Centre Hospitalo-Universitaire de Nice, Nice, France
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Barrie U, Youssef CA, Pernik MN, Adeyemo E, Elguindy M, Johnson ZD, Ahmadieh TYE, Akbik OS, Bagley CA, Aoun SG. Transfusion guidelines in adult spine surgery: a systematic review and critical summary of currently available evidence. Spine J 2022; 22:238-248. [PMID: 34339886 DOI: 10.1016/j.spinee.2021.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/09/2021] [Accepted: 07/26/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Red blood cell transfusion can be associated with complications in medical and surgical patients. Acute anemia in ambulatory patients undergoing surgery can also impede wound healing and independent self-care. Current transfusion threshold guidelines are still based on evidence derived from critically-ill intensive care unit medical patients and may not apply to spine surgery candidates. PURPOSE We aimed to provide the reader with a synthesis of the best available evidence to recommend transfusion trigger thresholds and guidelines in adult patients undergoing spine surgery. STUDY DESIGN/SETTING This is a systematic review. OUTCOME MEASURES Physiological measure: Blood transfusion thresholds and associated posttransfusion complications (morbidity, mortality, length of stay, infections, etc) of the published articles. PATIENT SAMPLE Adult spine surgery patients. METHODS A systematic review of the literature using the PubMed, Google Scholar, and Web of Science electronic databases was made according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Focus was set on papers discussing thresholds for blood transfusion in adult surgical spine patients, as well as complications associated with transfusion after acute surgical blood loss in the operating room or postoperative period. Publications discussing pediatric cases, blood type analyses, blood loss prevention strategies and protocols, systematic reviews and letters to the editor were excluded. RESULTS A total of 22 articles fitting our search criteria were reviewed. Patients who received blood transfusion in these studies were older, of female gender, had more severe comorbidities except for smoking, and had prolonged surgical time. Blood transfusion was associated with multiple adverse postoperative complications, including a higher rate of superficial or deep surgical site infections, sepsis, urinary and pulmonary infections, cardiovascular complications, return to the operating room, and increased postoperative length of stay and 30 day readmission. Analysis of transfusion thresholds from these studies showed that a pre-operative hemoglobin (Hb) of > 13 g/dL, and an intraoperative and post-operative Hb nadir above 9 and 8 g/dL, respectively, were associated with better outcomes and fewer wound infections than lower thresholds (Level B Class III). Additionally, it was generally recommended to transfuse autologous blood that was < 28 days old, if possible, with a limit of 2 to 3 units to minimize patient morbidity and mortality. CONCLUSIONS Blood transfusion thresholds in surgical patients may be specialty-specific and different than those used for critically-ill medical patients. For adult spine surgery patients, red blood cell transfusion should be avoided if Hb numbers remain > 9 and 8 g/dL in the intraoperative and direct post-operative periods, respectively.
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Affiliation(s)
- Umaru Barrie
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA.
| | - Carl A Youssef
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Mark N Pernik
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Emmanuel Adeyemo
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Mahmoud Elguindy
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Zachary D Johnson
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Tarek Y El Ahmadieh
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA
| | - Omar S Akbik
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA; University of Texas Southwestern Medical Center, Spine Center, Dallas, TX-75235, USA5
| | - Carlos A Bagley
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA; University of Texas Southwestern Medical Center, Department of Orthopedic Surgery, Dallas, TX-75235, USA; University of Texas Southwestern Medical Center, Spine Center, Dallas, TX-75235, USA5
| | - Salah G Aoun
- University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, TX-75235, USA; University of Texas Southwestern Medical Center, Spine Center, Dallas, TX-75235, USA5
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25
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Liu B, Pan J, Zong H, Wang Z. Establishment and Verification of a Perioperative Blood Transfusion Model After Posterior Lumbar Interbody Fusion: A Retrospective Study Based on Data From a Local Hospital. Front Surg 2021; 8:695274. [PMID: 34527694 PMCID: PMC8435709 DOI: 10.3389/fsurg.2021.695274] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/27/2021] [Indexed: 01/28/2023] Open
Abstract
Objective: We aimed to analyze the related risk factors for blood transfusion and establish a blood transfusion risk model during the per-ioperative period of posterior lumbar interbody fusion (PLIF). It could provide a reference for clinical prevention and reduction of the risk of blood transfusion during the peri-operative period. Methods: We retrospectively analyzed 4,378 patients who underwent PLIF in our hospital. According to whether they were transfused blood or not, patients were divided into the non-blood transfusion group and the blood transfusion group. We collected variables of each patient, including age, sex, BMI, current medical history, past medical history, surgical indications, surgical information, and preoperative routine blood testing. We randomly divide the whole population into training group and test group according to the ratio of 4:1. We used the multivariate regression analyses get the independent predictors in the training set. The nomogram was established based on these independent predictors. Then, we used the AUC, calibration curve and DCA to evaluate the nomogram. Finally, we verified the performance of the nomogram in the validation set. Results: Three or more lumbar fusion segments, preoperative low hemoglobin, with hypertension, lower BMI, and elder people were risk factors for blood transfusion. For the training and validation sets, the AUCs of the nomogram were 0.881 (95% CI: 0.865-0.903) and 0.890 (95% CI: 0.773-0.905), respectively. The calibration curve shows that the nomogram is highly consistent with the actual observed results. The DCA shows that the nomogram has good clinical application value. The AUC of the nomogram is significantly larger than the AUCs of independent risk factors in the training and validation set. Conclusion: Three or more lumbar fusion segments, preoperative low hemoglobin, with hypertension, lower BMI, and elder people are associated with blood transfusion during the peri-operative period. Based on these factors, we established a blood transfusion nomogram and verified that it can be used to assess the risk of blood transfusion after PLIF. It could help clinicians to make clinical decisions and reduce the incidence of peri-operative blood transfusion.
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Affiliation(s)
- Bo Liu
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Junpeng Pan
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hui Zong
- Department of Neurology, The People's Hospital of Qingyun, Dezhou, China
| | - Zhijie Wang
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Chen CJ, Shah AA, Hsiue PP, Subhash AK, Lord EL, Park DY, Stavrakis AI. Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome) After Primary Spinal Fusion: An Analysis of Outcomes and Risk Factors from 2005 to 2014. World Neurosurg 2021; 155:e612-e620. [PMID: 34481105 DOI: 10.1016/j.wneu.2021.08.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ogilvie syndrome (OS) is a rare but serious condition seen in the postoperative period. This was an epidemiologic study using data from the National Inpatient Sample from 2005 to 2014 to look at incidence, risk factors, and outcomes associated with OS after primary spine fusion. METHODS International Classification of Diseases, Ninth Revision codes were used to identify patients who underwent spine fusion surgery. Patients were separated into 2 cohorts based on the diagnosis of OS. Outcome measures and risk factors for cohorts were analyzed using multivariate logistic regression and compared. RESULTS Over the 10-year study period, 3,884,395 patients underwent primary spine fusion surgery. Among these, 0.04% developed OS during the index hospitalization. The greatest incidence seen in primary fusion involved the thoracic spine (0.15%). OS was more common after spine fusion for spine deformity (P < 0.001). Patients with OS were more likely to be men (P < 0.001), older (P < 0.0001), and have more comorbidities (P < 0.0001). Patients with OS were more likely to require postoperative blood transfusions (odds ratio [OR], 3.39; 95% confidence interval [CI], 2.51-4.59; P < 0.001) and sustain any complication (OR, 4.20; 95% CI, 3.17-5.57; P < 0.001). Patients with OS had a longer length of stay (15.7 vs. 3.9 days; P < 0.001) and increased average hospitalization cost ($63,037.03 vs. $26,792.19; P < 0.001). The development of OS was associated with fluid electrolyte disorder (OR, 4.06; 95% CI, 2.99-5.51; P < 0.001). CONCLUSIONS OS is a rare but serious complication of primary spine fusion surgery. Identifying the specific risk factors, symptoms, and potential complications related to OS is critical to aid in decreasing the significant morbidity associated with its development.
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Affiliation(s)
- Clark J Chen
- Department of Orthopaedic Surgery, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.
| | - Akash A Shah
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Peter P Hsiue
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Ajith K Subhash
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Elizabeth L Lord
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Alexandra I Stavrakis
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
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Clark KW, Luhmann SJ. Utility of preoperative labs in posterior spinal fusions for idiopathic scoliosis. Spine Deform 2021; 9:1379-1385. [PMID: 33844194 DOI: 10.1007/s43390-021-00341-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/27/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Review of 216 consecutive idiopathic scoliosis (IS) patients undergoing posterior spinal fusion (PSF) demonstrated 94.9% having abnormal lab values, but only 3.9% were referred for further evaluation. A limited set of preoperative laboratory testing costing $234/patient, and thorough, adjunct review of patient/family history could identify potentially significant comorbidities preoperatively in this study. A savings of $1556/patient from current laboratory testing was identified. METHODS The laboratory tests routinely obtained preoperatively were investigated: abnormal preoperative laboratory outcomes were identified and further documented if additional action was taken defined as a referral to another medical provider, performance of additional lab testing or counseling, or if there was alteration of the surgical plan. RESULTS Overall, 94.9% (n = 205) of patients had one or more abnormal pre-operative lab values. Further actions occurred in 11.7% (n = 24) of all abnormal lab values with 3.9% (n = 8) of these being referred to other healthcare providers. Sixteen abnormal lab values underwent further testing or treatment: 11 nicotine tests, two UCx, one UA, one PT/PTT, and one bovine gelatin RAST. Eight abnormal tests prompted referral to another provider: three CBC, three platelet function tests, one UCx, and one UA. Based on these data, standard preoperative Hgb/Hct, platelet function tests, and bovine RAST (If the surgical plan involves use of bovine gelatin products) appear to be adequate to identify potential significant comorbidities in IS patients undergoing PSF for only $234/patient, a cost savings of $1556/patient from current protocol. CONCLUSION Based on this study of 216 patients, a limited preoperative laboratory testing and thorough, adjunct review of patient/family history appears to be adequate to identify potential comorbidities preoperatively in this study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Kevin W Clark
- Department of Orthopaedic Surgery, St Louis Children's Hospital, Washington University School of Medicine, 1 Children's Place, Suite 4S60, Saint Louis, MO, 63110, USA
| | - Scott J Luhmann
- Department of Orthopaedic Surgery, St Louis Children's Hospital, Washington University School of Medicine, 1 Children's Place, Suite 4S60, Saint Louis, MO, 63110, USA.
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Darveau SC, Pertsch NJ, Toms SA, Weil RJ. Short term outcomes associated with patients requiring blood transfusion following elective laminectomy and fusion for lumbar stenosis: A propensity-matched analysis. J Clin Neurosci 2021; 90:184-190. [PMID: 34275547 DOI: 10.1016/j.jocn.2021.05.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/25/2021] [Accepted: 05/27/2021] [Indexed: 12/01/2022]
Abstract
Perioperative blood transfusion has been associated with poor outcomes but the impacts of transfusion after fusion for lumbar stenosis have not been well-described. We assessed this effect in a large cohort of patients from 2012 to 2018 in the National Surgical Quality Improvement Program (NSQIP). We evaluated baseline characteristics including demographics, comorbidities, hematocrit, and operative characteristics. We generated propensity scores using baseline characteristics and patients were matched to approximate randomization. We assessed odds of 30-day outcomes including prolonged length-of-stay (LOS), complications, discharge to facility, readmission, reoperation, and death using logistic regression. We identified 16,329 eligible patients who underwent lumbar fusion for stenosis; 1,926 (11.8%) received a transfusion. Before matching, there were multiple differences in baseline covariates including age, gender, BMI, ASA class, medical comorbidities, hematocrit, coagulation indices, platelets, operative time, fusion technique, number of levels fused, and osteotomy. However, after matching, no significant differences remained. In the matched cohorts, transfusion was associated with increased prolonged LOS (OR 1.66, 95% CI 1.45-1.91, p < 0.001), minor complication (OR 1.60, 95% CI 1.20-2.12, p = 0.001), major complication (OR 1.51, 95% CI 1.16-1.98, p = 0.003), any complication (OR 1.54, 95% CI 1.24-1.92, p < 0.001), discharge to facility (OR 1.70, 95% CI 1.48-1.95, p < 0.001), 30-day readmission (OR 1.56, 95% CI 1.23-1.99, p < 0.001), and 30-day reoperation (OR 1.85, 95% CI 1.35-2.53, p < 0.001). Although transfusion is performed based on perceived clinical need, this study contributes to growing evidence that it is important to balance the risks of perioperative blood transfusion with its benefits.
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Affiliation(s)
- Spencer C Darveau
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States.
| | - Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States
| | - Steven A Toms
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
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Amin RM, Puvanesarajah V, Chaudhry YP, Best MJ, Rao SS, Frank SM, Hasenboehler EA. Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration. World J Orthop 2021; 12:292-300. [PMID: 34055586 PMCID: PMC8152439 DOI: 10.5312/wjo.v12.i5.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/18/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery.
AIM To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients.
METHODS In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05.
RESULTS Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort.
CONCLUSION The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.
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Affiliation(s)
- Raj M Amin
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA 94305, United States
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
| | - Yash P Chaudhry
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA 19122, United States
| | - Matthew J Best
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MD 02114, United States
| | - Sandesh S Rao
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
| | - Steven M Frank
- Department of Anesthesiology, Critical Care Medicine, Baltimore, MD 21205, United States
| | - Erik A Hasenboehler
- Department of Orthopaedics, Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
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Lewen MO, Berry J, Johnson C, Grace R, Glader L, Crofton C, Leahy I, Pallikonda N, Litvinova A, Staffa SJ, Glotzbecker M, Emans J, Hresko MT, Ellen M, Troy M, Singer SJ, Ferrari L. Preoperative hematocrit and platelet count are associated with blood loss during spinal fusion for children with neuromuscular scoliosis. J Perioper Pract 2021; 32:74-82. [PMID: 33826437 DOI: 10.1177/1750458920962634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess the relationship of preoperative hematology laboratory results with intraoperative estimated blood loss and transfusion volumes during posterior spinal fusion for pediatric neuromuscular scoliosis. METHODS Retrospective chart review of 179 children with neuromuscular scoliosis undergoing spinal fusion at a tertiary children's hospital between 2012 and 2017. The main outcome measure was estimated blood loss. Secondary outcomes were volumes of packed red blood cells, fresh frozen plasma, and platelets transfused intraoperatively. Independent variables were preoperative blood counts, coagulation studies, and demographic and surgical characteristics. Relationships between estimated blood loss, transfusion volumes, and independent variables were assessed using bivariable analyses. Classification and Regression Trees were used to identify variables most strongly correlated with outcomes. RESULTS In bivariable analyses, increased estimated blood loss was significantly associated with higher preoperative hematocrit and lower preoperative platelet count but not with abnormal coagulation studies. Preoperative laboratory results were not associated with intraoperative transfusion volumes. In Classification and Regression Trees analysis, binary splits associated with the largest increase in estimated blood loss were hematocrit ≥44% vs. <44% and platelets ≥308 vs. <308 × 109/L. CONCLUSIONS Preoperative blood counts may identify patients at risk of increased bleeding, though do not predict intraoperative transfusion requirements. Abnormal coagulation studies often prompted preoperative intervention but were not associated with increased intraoperative bleeding or transfusion needs.
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Affiliation(s)
- Margaret O Lewen
- Department of Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Jay Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Connor Johnson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachael Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Laurie Glader
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charis Crofton
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Izabela Leahy
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nikhil Pallikonda
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Litvinova
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Glotzbecker
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - John Emans
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Timothy Hresko
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary Ellen
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Troy
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara J Singer
- Department of Organizational Behavior and Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lynne Ferrari
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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The "Spinal Metastasis Invasiveness Index": A Novel Scoring System to Assess Surgical Invasiveness. Spine (Phila Pa 1976) 2021; 46:478-485. [PMID: 33273437 DOI: 10.1097/brs.0000000000003823] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE The aim of this study was to develop a surgical invasiveness index for metastatic spine tumor surgery (MSTS) that can serve as a standardized tool in predicting intraoperative blood loss and surgical duration; for the purpose of ascertaining resource requirements and aiding in patient education. SUMMARY OF BACKGROUND DATA Magnitude of surgery is important in the metastatic spine disease (MSD) population since these patients have a continuing postoperative oncological process; a consideration that must be taken into account to maintain or improve quality of life. Surgical invasiveness indices have been established for general spine surgery, adult deformity, and cervical deformity, but not yet for spinal metastasis. METHODS Demographic, oncological, and procedural data were collected from consecutive patients that underwent MSTS. Binary logistic regression, using median values for surgical duration and intraoperative estimated blood loss (EBL), was used to determine statistical significance of variables to be included in the "spinal metastasis invasiveness index" (SMII). The corresponding weightage of each of these variables was agreed upon by experienced spine surgeons. Multivariable regression analysis was used to predict operative time and EBL while controlling for demographical, procedural, and oncological characteristics. RESULTS Two hundred and sixty-one MSD patients were included with a mean age of 59.7-years and near equal sex distribution. The SMII strongly predicted extended surgical duration (R2 = 0.28, P < 0.001) and high intraoperative blood loss (R2 = 0.18, P < 0.001). When compared to a previously established surgical invasiveness index, the SMII accounted for more variability in the outcomes. For every unit increase in score, there was a 42-mL increase in mean blood loss (P < 0.001) and 5-minute increase in mean operative time (P < 0.001). CONCLUSION Long surgical duration and high blood loss were strongly predicted by the newly developed SMII. The use of the SMII may aid in preoperative risk assessment with the goal of improving patient outcomes and quality of life.Level of Evidence: 4.
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Hanada K, Ahmad A, Shadi H, Wajdi A, Haitham S, Wesam K, Lamees A, Qamar M, Rami A. Castigating intraoperative bleeding: Tranexamic acid, a new ally. Asian J Neurosurg 2021; 16:51-55. [PMID: 34211866 PMCID: PMC8202383 DOI: 10.4103/ajns.ajns_339_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/28/2020] [Accepted: 10/15/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction: The field of instrumented spinal procedures is associated with substantial blood volume losses, which is one of the major hazards we encounter; this would lead to a greater need for blood products transfusions. The frequent use of these products can have negative consequences due to body fluid shifting, and donor-host rejection. Thus, it has become mandatory to establish strategies to maintain blood volume and minimize losses. Several strategies have been approved to control the disproportionate blood loss. Objective: This study aims to assess the effectiveness of tranexamic acid in reducing intraoperative bleeding during our spine instrumented surgeries, while addressing complications associated. Methods: In this retrospective analysis was steered of 153- consecutive patients treated in the neurosurgical- spine unit of King Hussein hospital, King Hussein Medical Center (KHMC), between April 2017 to January 2020, patients who underwent instrumented surgery for different spinal pathologies at our institute were reviewed. Results: During the analysis period, 153-patients who underwent interbody fusion, were allocated into two groups. The mean instrumented segments were 2.8 level (range 1-5 levels). The demographical data of patients of both groups analyzed. The mean span of operating time was (212.74 ± 41.85 min) for group I, while for the control group mean length was (208.09min ±42.03). Study showed that the mean drop in the hemoglobin concentration postoperatively was statistically significant comparing the two groups. Analysis of blood volume in suction container showed that group I had: 470 ml ±153.06 ml; while in control group volume was: 1560 ml ± 567.59 ml, which showed significant difference (p = 0.002). Comparing the drainage volumes at 12 hours postoperatively displayed no statistically significant differences (p = 0.69) concerning the two groups. Minor adverse effects allied with the tranexamic acid administration. Conclusions: In summary, perioperative bleeding deemed one of the most important threat for patients. Tranexamic acid is proved excellent in controlling perioperative bleeding, harboring few contraindications. Future large studies are still needed to elaborate on unanswered issues.
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Affiliation(s)
- Krashan Hanada
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Alhasan Ahmad
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Hammadeen Shadi
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Alnajada Wajdi
- Department of Radiation Oncology, Queen Alia Military Hospital, Royal Medical Services, Amman, Jordan
| | - Saraireh Haitham
- Department of Radiation Oncology, Queen Alia Military Hospital, Royal Medical Services, Amman, Jordan
| | - Khresat Wesam
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Arabiyat Lamees
- Department of Plastic Surgery, Farah Medical Center, Royal Medical Services, Amman, Jordan
| | - Malabeh Qamar
- Department of Radiology, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Alqroom Rami
- Department of Neurosurgery, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
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Tayari H, Flaherty D, Yamaoka TT, Auckburally A. Assessment of pulse co-oximetry technology after in vivo adjustment in anaesthetized dogs. Vet Anaesth Analg 2021; 48:297-304. [PMID: 33610477 DOI: 10.1016/j.vaa.2020.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/16/2020] [Accepted: 08/21/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare values of haemoglobin concentration (SpHb), arterial haemoglobin saturation (SpO2) and calculated arterial oxygen content (SpOC), measured noninvasively with a pulse co-oximeter before and after in vivo adjustment (via calibration of the device using a measured haemoglobin concentration) with those measured invasively using a spectrophotometric-based blood gas analyser in anaesthetized dogs. STUDY DESIGN Prospective observational clinical study. ANIMALS A group of 39 adult dogs. METHODS In all dogs after standard instrumentation, the dorsal metatarsal artery was catheterised for blood sampling, and a pulse co-oximeter probe was applied to the tongue for noninvasive measurements. Paired data for SpHb, SpO2 and SpOC from the pulse co-oximeter and haemoglobin arterial oxygen saturation (SaO2) and arterial oxygen content (CaO2) from the blood gas analyser were obtained before and after in vivo adjustment. Bland-Altman analysis for repeated measurements was used to evaluate the bias, precision and agreement between the pulse co-oximeter and the blood gas analyser. Data are presented as mean differences and 95% limits of agreement (LoA). RESULTS A total of 39 data pairs were obtained before in vivo adjustment. The mean invasively measured haemoglobin-SpHb difference was -2.7 g dL-1 with LoA of -4.9 to -0.5 g dL-1. After in vivo adjustment, 104 data pairs were obtained. The mean invasively measured haemoglobin-SpHb difference was -0.2 g dL-1 with LoA of -1.1 to 0.6 g dL-1. The mean SaO2-SpO2 difference was 0.86% with LoA of -0.8% to 2.5% and that between CaO2-SpOC was 0.66 mL dL-1 with LoA of -2.59 to 3.91 mL dL-1. CONCLUSIONS Before in vivo adjustment, pulse co-oximeter derived values overestimated the spectrophotometric-based blood gas analyser haemoglobin and CaO2 values. After in vivo adjustment, the accuracy, precision and LoA markedly improved. Therefore, in vivo adjustment is recommended when using this device to monitor SpHb in anaesthetised dogs.
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Affiliation(s)
- Hamaseh Tayari
- ChesterGates Veterinary Specialists CVS (UK) Ltd, Chester, UK.
| | - Derek Flaherty
- Southern Counties Veterinary Specialist (SCVS) (UK) Independent Vetcare Ltd, Ringwood, UK
| | | | - Adam Auckburally
- Southern Counties Veterinary Specialist (SCVS) (UK) Independent Vetcare Ltd, Ringwood, UK
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Predictors of transfusion in adults undergoing elective posterior thoracolumbar spinal fusion: a retrospective case series. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000000941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chow JH, Chancer Z, Mazzeffi MA, McNeil JS, Sokolow MJ, Gaines TM, Reif MM, Trinh AT, Wellington IJ, Camacho JE, Bruckner JJ, Tanaka KA, Ludwig S. Impact of Preoperative Platelet Count on Bleeding Risk and Allogeneic Transfusion in Multilevel Spine Surgery. Spine (Phila Pa 1976) 2021; 46:E65-E72. [PMID: 33306659 DOI: 10.1097/brs.0000000000003737] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This was an observational cohort study of patients receiving multilevel thoracic and lumbar spine surgery. OBJECTIVE The aim of this study was to identify which patients are at high risk for allogeneic transfusion which may allow for better preoperative planning and employment of specific blood management strategies. SUMMARY OF BACKGROUND DATA Multilevel posterior spine surgery is associated with a significant risk for major blood loss, and allogeneic blood transfusion is common in spine surgery. METHODS A univariate logistic regression model was used to identify variables that were significantly associated with intraoperative allogeneic transfusion. A multivariate forward stepwise logistic regression model was then used to measure the adjusted association of these variables with intraoperative transfusion. RESULTS Multilevel thoracic and lumbar spine surgery was performed in 921 patients. When stratifying patients by preoperative platelet count, patients with pre-operative thrombocytopenia and severe thrombocytopenia had a significantly higher rate of transfusion than those who were not thrombocytopenic. Furthermore, those with severe thrombocytopenia had a higher rate of red blood cells, fresh frozen plasma, and platelet transfusion than those with higher platelet counts. Multivariate logistic regression found that preoperative platelet count was the most significant contributor to transfusion, with a platelet count ≤100 having an adjusted odds ratio (OR) of transfusion of 4.88 (95% confidence interval [CI] 1.58-15.02, P = 0.006). Similarly, a platelet count between 101and 150 also doubled the risk of transfusion with an adjusted OR of 2.02 (95% CI 1.01-4.04, P = 0.047). The American Society of Anesthesiologists classification score increased the OR of transfusion by 2.5 times (OR = 2.52, 95% CI 1.54-4.13), whereas preoperative prothrombin time and age minimally increased the risk. CONCLUSION Preoperative thrombocytopenia significantly contributes to intraoperative transfusion in multilevel thoracic lumbar spine surgery. Identifying factors that may increase the risk for transfusion could be of great benefit in better preoperative counseling of patients and in reducing overall cost and postoperative complications by implementing strategies and techniques to reduce blood loss and blood transfusions. LEVEL OF EVIDENCE 2.
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Affiliation(s)
| | | | | | - John S McNeil
- University of Virginia School of Medicine, Charlottesville, VA
| | | | - Tyler M Gaines
- University of Maryland School of Medicine, Baltimore, MD
| | | | | | | | - Jael E Camacho
- University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Steven Ludwig
- University of Maryland School of Medicine, Baltimore, MD
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Arun-Kumar V, Naresh-Babu J. Is There a Role for Preoperative Local Infiltration of Tranexamic Acid in Elective Spine Surgery? A Prospective Randomized Controlled Trial Analyzing the Efficacy of Intravenous, Local Infiltration, and Topical Administration of Tranexamic Acid. Global Spine J 2021; 11:21-27. [PMID: 32875830 PMCID: PMC7734265 DOI: 10.1177/2192568219888446] [Citation(s) in RCA: 17] [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: 12/30/2022] Open
Abstract
STUDY DESIGN Randomized control trial. OBJECTIVE The purpose of the study is to evaluate the safety and efficacy of tranexamic acid in reducing blood loss when administered through various routes in instrumented spine surgeries. METHODS A total of 104 patients undergoing instrumented spine surgery were randomly assigned to 4 groups (n = 26 in each group). Groups included (1) ivTXA-intravenous administration of tranexamic acid (TXA) 1 hour prior to surgery, (2) loTXA-local infiltration of TXA bilaterally into the paraspinal musculature prior to incision, (3) tTXA-topical application of TXA just before wound closure, and (4) control group. Outcome measures included intraoperative blood loss, postoperative blood loss, need for blood transfusion, length of hospital stay, and hematological parameters. RESULTS All the 3 different modes of TXA administration were found to be effective in reducing blood loss in the treated groups compared with the control group. Intraoperative blood loss was significantly reduced in ivTXA (223.6 ± 40.1 mL, P < .0001) and loTXA (256.07 ± 119 mL, P = .0039) groups when compared with controls (344 ± 88.5 mL).The postoperative blood loss was least in tTXA followed by ivTXA, loTXA, and controls. There was 67% reduction in need for blood transfusion in tTXA group, 55.5% reduction in ivTXA group, and 33% reduction in loTXA group when compared with the control group. CONCLUSION In instrumented spine surgery, ivTXA and loTXA were found to be equally effective in reducing the intraoperative blood loss. The tTXA has better postoperative blood conserving effects. This is the first study to detail about safety and efficacy on local infiltration of TXA in spine surgery, which is an effective and safe method for reducing intraoperative blood loss.
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Affiliation(s)
- Viswanadha Arun-Kumar
- Mallika Spine Centre, Guntur, Andhra Pradesh, India,Viswanadha Arun-Kumar, Mallika Spine Centre, 12-12-30, Old Club Road, Kothapet, Guntur, Andhra Pradesh, India.
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Two Doses of Tranexamic Acid Reduce Blood Loss in Primary Posterior Lumbar Fusion Surgery: A Randomized-controlled Trial. Clin Spine Surg 2020; 33:E593-E597. [PMID: 32349059 DOI: 10.1097/bsd.0000000000000999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Tranexamic acid (TXA) has been widely used in hip and knee arthroplasty to reduce perioperative blood loss and blood transfusion, but the dosage and efficacy of TXA in posterior lumbar spinal surgery are not fully clear. The aim of this study was to investigate the efficacy and safety of TXA and to determine whether 2 doses of TXA could reduce the blood loss in primary single-segment or double-segment posterior lumbar fusion surgery. MATERIALS AND METHODS A total of 150 patients with lumbar degenerative disease undergoing posterior lumbar interbody fusion surgery between October 2017 and February 2019 were randomized to 3 groups. Group A was treated with 0.9% normal saline solution without TXA, group B was treated with a 15 mg/kg loading dose intravenous infusion 30 minutes before surgery, and group C was treated with a 15 mg/kg loading dose intravenous infusion 30 minutes before surgery; then, the same dose was administered again 3 hours later. The assessed outcomes were the operation time, the total blood loss, the hidden blood loss, postoperative drainage, blood transfusions, incidence of venous thromboembolism, and incision infection. RESULTS The total blood loss, the hidden blood loss, and postoperative drainage were the lowest in group C. The amount of intraoperative blood loss was similar among the 3 groups. The hemoglobin and hematocrit values of the third postoperative day were the highest in group C. No significant differences in the incidence of complications and adverse events from TXA use were observed among the 3 groups. The use of TXA, the operation time, and the number of fusion segments were identified as risk factors related to total blood loss. CONCLUSION Two doses of TXA significantly reduced the total blood loss, the hidden blood loss and postoperative drainage, and decreased hemoglobin and hematocrit drop in patients undergoing posterior lumbar fusion without increasing the risk of complications.
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Validation of a surgical invasiveness index in patients with lumbar spinal disorders registered in the Spine Tango registry. 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; 30:1-12. [PMID: 33231779 DOI: 10.1007/s00586-020-06651-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/26/2020] [Accepted: 10/21/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Being able to quantify the invasiveness of a surgical procedure is important to weigh up its associated risks, since invasiveness governs the blood loss, operative time and likelihood of complications. Mirza et al. (Spine (Phila Pa 1976) 33:2651-2661, 2008) published an invasiveness index for spinal surgery. We evaluated the validity of a modified version of the Mirza invasiveness index (mMII), adapted for use with registry data. METHODS A cross-sectional analysis was performed with data acquired from the Spine Tango registry including 21,634 patients. The mMII was calculated as the sum of six possible interventions on each vertebral level: decompression, fusion and stabilization either on anterior or posterior structures. The association between the mMII and blood loss, operative time and complications was evaluated using multiple regression, adjusting for possible confounders. RESULTS The mean (± SD) mMII was 3.9 ± 5.0 (range 0-40). A 1-point increase in the mMII was associated with an additional blood loss of 12.8% (95% CI 12.6-13.0; p < 0.001) and an increase of operative time of 10.4 min (95% CI 10.20-10.53; p < 0.001). The R2 for the blood loss model was of 43% and for operative time, 47%. The mean mMII was significantly (p < 0.001) higher in patients with surgical complications (4.5 ± 5.6) and general medical complications (6.5 ± 7.0) compared to those without (3.8 ± 4.9). Our results were comparable to those reported in the original publication of Mirza et al. CONCLUSION: The mMII appeared to be a valid measure of surgical invasiveness in our study population. It can be used in predictor models and to adjust for surgical case-mix when comparing outcomes in different studies or different hospitals/surgeons in a registry.
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McKenna M, Abdelaal A. Group & save sampling in lumbar decompression: A review into current practice. J Perioper Pract 2020; 31:15-17. [PMID: 33225836 DOI: 10.1177/1750458920950664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The risks, benefits and technical aspects of surgery require careful consideration. One element of this is the requirement of postoperative blood transfusion. Patients who undergo elective lumbar decompression are at a low risk of requiring a postoperative transfusion yet undergo multiple preoperative group & save tests. For those who are at a low risk of bleeding, a single group & save sample may be adequate. This review analysed the postoperative blood loss and transfusion rate associated with lumbar decompression surgery without fusion in one institution. A subsequent cost analysis and review of the literature was performed. The aim was to assess whether single group & save sampling, within the context of lumbar decompression, was cost effective and amenable to the patient without impacting patient care. Average blood loss was estimated as a drop in Hb of 12.3g/dl. Six patients (14%) had Hb loss of over 20g/dl. No patients underwent a blood transfusion. Through examination of medical records, we found that 65% of patients (35) were suitable for single group & save sampling, estimating a saving of £2415.95 (53%). Selective group & save testing holds economic potential and safeguards patients from undergoing unnecessary testing. The next step after this review would be a prospective multi-centre study.
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Affiliation(s)
- M McKenna
- 97644Royal Gwent Hospital, Newport, UK
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Zhou Y, Fu X, Yang M, Ke S, Wang B, Li Z. Hidden blood loss and its possible risk factors in minimally invasive transforaminal lumbar interbody fusion. J Orthop Surg Res 2020; 15:445. [PMID: 32993729 PMCID: PMC7525988 DOI: 10.1186/s13018-020-01971-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/23/2020] [Indexed: 01/12/2023] Open
Abstract
Background With respect to spinal surgeries, elucidating absolute and relative amount of hidden blood loss (HBL) is of great importance in order to avoid aforementioned potential complications. To evaluate HBL and its possible risk factors among patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for lumbar degenerative diseases. Methods Between June 2018 and March 2019, 137 consecutive patients with lumbar degenerative disease, who underwent operation with MIS-TLIF technique, were enrolled in this study. The patient’s demographic characteristics and blood loss-related parameters were collected, respectively. The Pearson or Spearman correlation analysis was used to investigate an association between patient’s characteristics and HBL. Multivariate linear regression analysis was used to confirm independent risk factors of HBL. Results A total of 137 patients (86 males and 51 females, age range 19–78 years) were reviewed in our hospital. A substantial amount of HBL (488.4 ± 294.0 ml, 52.5% of TBL) occurred after MIS-TLIF. Multivariate linear regression showed that the age, muscle thickness, the Patients’ Society of Anesthesiologists (ASA) classification, patient’s blood volume (PBV), total blood loss (TBL), postoperative (i.e., day 2 or 3) hematocrit (Hct), Hct loss, and fibrinogen level were independent risk factors for HBL (P1 = 0.000, P2 = 0.002, P3 = 0.006, P4 = 0.002, P5 = 0.003, P6 = 0.048, P7 = 0.004, P8 = 0.000). Conclusion A large amount of HBL was incurred in patients undergoing MIS-TLIF. More importantly, the age, muscle thickness, ASA classification, PBV, TBL, postoperative Hct, Hct loss, and fibrinogen level were independent risk factors for HBL in MIS-TLIF. HBL and its risk factors should be paid more attention to during the perioperative period.
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Affiliation(s)
- Yuanxing Zhou
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.,Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic Diseases, Dalian, Liaoning Province, People's Republic of China
| | - Xin Fu
- Department of Neurosurgery, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - Ming Yang
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.,Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic Diseases, Dalian, Liaoning Province, People's Republic of China
| | - Song Ke
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.,Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic Diseases, Dalian, Liaoning Province, People's Republic of China
| | - Bo Wang
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.,Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic Diseases, Dalian, Liaoning Province, People's Republic of China
| | - Zhonghai Li
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China. .,Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic Diseases, Dalian, Liaoning Province, People's Republic of China.
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Yang L, Jia X, Yang J, Kang J. Tranexamic acid reduces blood cost in long-segment spinal fusion surgery: A randomized controlled study protocol. Medicine (Baltimore) 2020; 99:e22069. [PMID: 32925743 PMCID: PMC7489668 DOI: 10.1097/md.0000000000022069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Long-segment spinal fusion surgery was associated with substantial perioperative blood loss which may increase hospitalization expenses and mortality rates. Substantial studies have reported that tranexamic acid (TXA) could reduce blood products and cost after joint arthroplasty surgery. However, there still exists controversy regarding the efficacy of TXA in long-segment spinal fusion surgery. We performed this protocol to design a randomized controlled study to evaluate the efficacy of TXA in decreasing transfusion rate of allogeneic blood products and transfusion cost in degenerative lumbar scoliosis patients. METHODS This study was carried out as a double-blinded, randomized clinical trial on patients with degenerative lumbar scoliosis who prepared for long-segment spinal fusion surgery from December 2018 to December 2019. It was authorized via the Institutional Review Committee in Southwest Medical University (ky2019225). Eighty patients were divided randomly into 2 groups (Experimental group = 40, control group = 40). The patients in the experimental group received 1000 mg of TXA mixed in 100 mL normal saline as a single dose intravenously over 20 minutes before the skin incision was made. Control group received equivalent normal saline without TXA. Primary outcomes included total blood loss, estimated intraoperative blood loss, hematocrit and hemoglobin decline, postoperative drain amount, intra-/postoperative allogeneic transfusion amount and rate, and total transfusion cost. Secondary outcomes included surgical time, thrombotic complications including deep vein thrombosis and pulmonary embolism. All the needed analyses were implemented through utilizing SPSS for Windows Version 20.0. RESULTS Table showed the relevant clinical outcomes between experimental group and control group. CONCLUSION We hypothesized that TXA was effective and safe in reducing blood transfusion and cost in long-segment spinal fusion surgery. TRIAL REGISTRATION This study protocol was registered in Research Registry (researchregistry5854).
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Affiliation(s)
- Linyu Yang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University
| | - Xufeng Jia
- Department of Orthopedics, the People's Hospital of Jianyang City, Sichuan, China
| | - Jian Yang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University
| | - Jianping Kang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University
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Vestermark GL, Rowe TM, Martin JR, Odum SM, Springer BD, Fehring TK. In the Era of Tranexamic Acid, are Type and Screens for Primary Total Joint Arthroplasty Obsolete? J Arthroplasty 2020; 35:2363-2366. [PMID: 32451280 DOI: 10.1016/j.arth.2020.04.056] [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: 01/15/2020] [Revised: 04/13/2020] [Accepted: 04/19/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Advances in technique and perioperative blood management have improved transfusion rates following unilateral primary total joint arthroplasty and led some centers to change their preoperative blood ordering protocols. The purpose of this study is to determine whether deleting type and screens (T&S) from preoperative order sets was safe for patients undergoing primary total knee (TKA) and total hip arthroplasty (THA) and to identify patients who required allogenic blood transfusion. METHODS Prospectively collected data were reviewed to identify any patient with a hemoglobin (Hgb) drawn within 30 days of surgery who received a transfusion following a unilateral primary TKA or THA. RESULTS A total of 1255 patients met inclusion criteria. Of the total, 682 (54%) were TKAs and 573 (46%) were THAs. The mean preoperative Hgb was 11.5 g/dL with an average delta Hgb of 3.6 g/dL on postoperative day 1. No patient required an intraoperative transfusion. Fourteen patients (mean age and body mass index, 67.9 and 29.0) required a transfusion (1.1%) for postoperative blood loss anemia. Of those transfused, 13 (93%) of the patients underwent THA with the mean estimated blood loss of 378.6 mL. The total cost for a patient obtaining a T&S is $191.27. CONCLUSION In our series, the risk of blood transfusion was rare (1.1%) and occurred only secondary to postoperative blood loss anemia. There were no cases of intraoperative complication requiring urgent or emergent blood transfusion. Removing T&S from standard order sets for patients undergoing primary TKA or THA appears to be a safe and cost-effective practice.
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Affiliation(s)
| | | | | | - Susan M Odum
- OrthoCarolina Research Institute, Charlotte, NC; Atrium Health Musculoskeletal Institute, Chicago, IL
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The Practice of Continuation of Anti-platelet Therapy During the Perioperative Period in Lumbar Minimally Invasive Spine Surgery (MISS): How Different Is the Morbidity in This Scenario? Spine (Phila Pa 1976) 2020; 45:673-678. [PMID: 32358305 DOI: 10.1097/brs.0000000000003357] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cohort. OBJECTIVE To evaluate perioperative morbidity in patients undergoing minimally invasive spine surgery of the lumbar spine while continuing the antiplatelet drug (APD) perioperatively as compared with those not continuing these drugs and those not on these drugs. SUMMARY OF BACKGROUND DATA While discontinuation of antiplatelet drugs carries with it the risk of thrombosis of the cardiac stents, myocardial infarction, peripheral vascular occlusion, cerebro-vascular events and other thrombotic complications, continuation of these drugs has the risk of intra spinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression. METHODS This institutional review board approved study included 1587 patients from 2011 to 2018. Perioperative parameters were analyzed for 216 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy, 240 patients who continued to take APD daily through the perioperative period and 1131 patients who were never exposed to APD therapy. The operative time, intraoperative estimated blood loss, length of hospital stay, incidence of clinically evident hematoma, and transfusion of blood products were also recorded and compared in three cohorts. RESULTS The patients who continued taking APD in the perioperative period had a longer length of hospital stay on average (2.5 ± 0.67 vs. 1.59 ± 0.76 and 1.67 ± 0.83, P < 0.05), whereas there was no significant difference in the operative time, estimated blood loss, the amount of blood products transfused, and overall intra and postoperative complication rate. There were no instances of postoperative wound soakage or neurological deficit suggestive of possible spinal epidural hematomas in either of the study groups. CONCLUSION The current study has observed no appreciable increase in perioperative morbidities including bleeding related complication rates in patients undergoing lumbar minimally invasive spine surgery while continuing to take APD compared with patients who either discontinued APD prior to surgery or those not taking APD. LEVEL OF EVIDENCE 4.
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Multicenter Evaluation of the Quantra QPlus System in Adult Patients Undergoing Major Surgical Procedures. Anesth Analg 2020; 130:899-909. [DOI: 10.1213/ane.0000000000004659] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Chang X, Li Q, Tang H. Use of preoperative erythropoietin therapy to facilitate autologous blood donation in orthopedic surgery: A meta-analysis. Medicine (Baltimore) 2020; 99:e18577. [PMID: 31914036 PMCID: PMC6959933 DOI: 10.1097/md.0000000000018577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Autologous blood transfusion helps to avoid or reduce the need for allogenic blood transfusion in patients undergoing major surgery. We examined the value of erythropoietin therapy to support preoperative autologous blood donation (PABD) in patients undergoing orthopedic surgery. METHODS For this systematic review and meta-analysis, Medline, Cochrane, EMBASE, and Google Scholar databases were searched from October 26th, 1989 until September 30th, 2017. Primary outcomes were percentages of patients able to donate ≥4 units of blood for autologous transfusion, amount of allogeneic blood transfused, changes in hematocrit and hemoglobin levels from before PABD to immediately before surgery, and adverse events. RESULTS Of 256 studies identified, 18 studies met the inclusion criteria with a total of 1914 patients (mean age 51-69 years), of whom 1153 were treated with erythropoietin. Erythropoietin was associated with a greater percentage of patients able to donate ≥4 units of blood for autologous use compared to controls (OR = 6.00, 95% CI = 3.97 to 9.09, P < .001). Patients receiving preoperative erythropoietin had significantly less of a reduction in hematocrit and hemoglobin levels from before PABD to immediately before surgery compared with controls (hematocrit: mean differences = -1.438, 95% CI = -2.14 to -0.73, P < .001; hemoglobin: mean differences = -1.426, 95% CI = -1.78 to -1.07, P < .001). No significant differences were observed in the amount of allogenic blood transfused between patients receiving erythropoietin and controls (difference in means = -0.220, 95% CI = -0.536 to 0.097, P = .174). Patients who received erythropoietin were less likely to experience dizziness than controls, but the incidence of nausea or fatigue were similar between groups. CONCLUSION Erythropoietin therapy during the PABD period results in less of a reduction in hematocrit and hemoglobin levels and an increase in the percentage of patients able to donate blood preoperatively.
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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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Neuman BJ, Ailon T, Scheer JK, Klineberg E, Sciubba DM, Jain A, Zebala LP, Passias PG, Daniels AH, Burton DC, Protopsaltis TS, Hamilton DK, Ames CP. Development and Validation of a Novel Adult Spinal Deformity Surgical Invasiveness Score: Analysis of 464 Patients. Neurosurgery 2019; 82:847-853. [PMID: 28586476 DOI: 10.1093/neuros/nyx303] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 05/04/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A surgical invasiveness index (SII) has been validated in general spine procedures but not adult spinal deformity (ASD). OBJECTIVE To assess the ability of the SII to determine the invasiveness of ASD surgery and to create and validate a novel ASD index incorporating deformity-specific factors, which could serve as a standardized metric to compare outcomes and risk stratification of different ASD procedures for a given deformity. METHODS Four hundred sixty-four patients who underwent ASD surgery between 2009 and 2012 were identified in 2 multicenter prospective registries. Multivariable models of estimated blood loss (EBL) and operative time were created using deformity-specific factors. Beta coefficients derived from these models were used to attribute points to each component. Scoring was iteratively refined to determine the R2 value of multivariate models of EBL and operative time using adult spinal deformity-surgical (ASD-S) as an independent variable. Similarly, we determined weighting of postoperative changes in radiographical parameters, which were incorporated into another index (adult spinal deformity-surgical and radiographical [ASD-SR]). The ability of these models to predict surgical invasiveness was assessed in a validation cohort. RESULTS Each index was a significant, independent predictor of EBL and operative time (P < .001). On multivariate analysis, ASD-S and ASD-SR explained more variability in EBL and operative time than did the SII (P < .001). The ASD-SR explained 21% of the variation in EBL and 10% of the variation in operative time, whereas the SII explained 17% and 3.2%, respectively. CONCLUSION The ASD-SR, which incorporates deformity-specific components, more accurately predicts the magnitude of ASD surgery than does the SII.
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Affiliation(s)
- Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Tamir Ailon
- Department of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Justin K Scheer
- University of California San Diego School of Medicine, San Diego, California
| | - Eric Klineberg
- Department of Orthopaedics, University of California Davis School of Medicine, Sacramento, California
| | - Daniel M Sciubba
- Department of Neurosurgery, The Johns Hopkins University, Baltimore, Maryland
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Lukas P Zebala
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Peter G Passias
- Department of Orthopaedics, NYU Hospital for Joint Diseases, New York, New York
| | - Alan H Daniels
- Department of Ortho-paedic Surgery, Brown University Alpert Medical School, Rhode Island Hospital, Providence, Rhode Island
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas, Kansas City, Kansas
| | | | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medi-cine, Pittsburgh, Pennsylvania
| | - Christopher P Ames
- Depart-ment of Neurosurgery, University of California San Francisco, San Francisco, California
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Burton DC, Sethi RK, Wright AK, Daniels AH, Ames CP, Reid DB, Klineberg EO, Harper R, Mundis GM, Hlubek RJ, Bess S, Hart RA, Kelly MP, Lenke LG. The Role of Potentially Modifiable Factors in a Standard Work Protocol to Decrease Complications in Adult Spinal Deformity Surgery: A Systematic Review, Part 1. Spine Deform 2019; 7:669-683. [PMID: 31495466 DOI: 10.1016/j.jspd.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 04/01/2019] [Accepted: 04/12/2019] [Indexed: 11/30/2022]
Abstract
STUDY DESIGN Structured Literature Review. OBJECTIVES We sought to evaluate the peer-reviewed literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA Lean Methodology uses Standard Work to improve efficiency and decrease waste and error. ASD is known to have a high surgical complication rate. Several patient and surgical potentially modifiable factors have been suggested to affect complications, including preoperative hemoglobin, bone density, body mass index (BMI), age-appropriate realignment, preoperative albumin/prealbumin, and smoking status. We sought to evaluate the literature for evidence supporting these factors to include in a Standard Work protocol to decrease complications. METHODS Each of these six factors was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). A comprehensive literature search was then performed. The authors reviewed abstracts and analyzed data from included studies. From 456 initial citations with abstract, 173 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 93 included studies. RESULTS We found fair evidence supporting a low preoperative hemoglobin level associated with increased transfusion rates and decreased BMD and increased BMI associated with increased complication rates. Fair evidence supported low albumin/prealbumin associated with increased complications. There was fair evidence associating smoking exposure to increased reoperations, but conflicting evidence associating it with increased complications. There was no evidence in the literature evaluating age-appropriate realignment and complications. CONCLUSION Preoperative hemoglobin, bone density, body mass index, preoperative albumin/prealbumin, and smoking status all are potentially modifiable risk factors that are associated with increased complications in the adult spine surgery population. Developing a Standard Work Protocol for patient evaluation and optimization should include these factors. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
| | - Rajiv K Sethi
- Neuroscience Institute, Virginia Mason Hospital, 1100 Ninth Avenue, Seattle, WA 98101, USA; Department of Health Services, University of Washington, NE Pacific Street, Seattle, WA 98195, USA
| | - Anna K Wright
- Neuroscience Institute, Virginia Mason Hospital, 1100 Ninth Avenue, Seattle, WA 98101, USA
| | - Alan H Daniels
- Department of Orthopedics, Brown University, 222 Richmond Street, Providence, RI 02912, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, 513 Parnassus Avenue, San Francisco, CA 94131, USA
| | - Daniel B Reid
- Department of Orthopedics, Brown University, 222 Richmond Street, Providence, RI 02912, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, 1 Shields Avenue, Davis, CA 95616, USA
| | - Robert Harper
- Department of Orthopedic Surgery, University of California, 1 Shields Avenue, Davis, CA 95616, USA
| | - Gregory M Mundis
- San Diego Spine Foundation, 6190 Cornerstone Ct. E, Suite 212, San Diego, CA 92121, USA
| | - Randall J Hlubek
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's Medical Center, Rocky Mountain Hospital for Children, 2055 High Street, Suite 130, Denver, CO 80205, USA
| | - Robert A Hart
- Swedish Neuroscience Institute, 550 17th Avenue, Suite 540, Seattle, WA 98122, USA
| | - Michael P Kelly
- Department of Orthopaedics, Washington University St. Louis, 1 Brookings Dr., St. Louis, MO 63130, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University, Och Spine Hospital, 5141 Broadway, New York, NY 10034, 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: 1.0] [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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Lee D, Choi SJ, Lee WY, Kim KM, Kim MC, Lee S. Effect of intravenous tranexamic acid on perioperative bleeding and transfusion in spine surgery: systematic review and meta-analysis of randomized controlled trials. Anesth Pain Med (Seoul) 2019. [DOI: 10.17085/apm.2019.14.2.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Dongreul Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Si Jin Choi
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kye-Min Kim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Mun-Cheol Kim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sangseok Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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