Efficacy of intraoperative cell salvage in spine surgery: a meta-analysis
J Neurosurg Spine. 2020;:1-9
OBJECTIVE Intraoperative cell salvage systems, or cell savers, are widely used for the management of blood loss in patients undergoing spine surgery. However, recent studies report conflicting evidence of their efficacy. The purpose of the meta-analysis was to investigate the efficacy of cell savers in reducing blood transfusion requirements in patients undergoing spine surgery. METHODS Both retrospective and prospective studies that investigated the efficacy of cell savers in reducing transfusion requirements in spine surgery patients when compared with control patients were identified from MEDLINE, Embase, Cochrane Collaboration Library, Google Scholar, and Scopus databases. Outcome data extracted included number of patients receiving allogenic transfusions (transfusion rate); units of allogenic transfusions; postoperative hemoglobin; costs; operative time; and complications. RevMan 5 software was used to perform statistical analyses. A random-effects model was used to calculate pooled odds ratios (with 95% CIs) and weighted mean differences (WMDs [95% CI]) for dichotomous and continuous variables, respectively. RESULTS Eighteen studies with 2815 patients in total were included in the meta-analysis. During spine surgery, the use of intraoperative cell salvage did not reduce the intraoperative (OR 0.66 [95% CI 0.30, 1.41]), postoperative (OR -0.57 [95% CI 0.20, 1.59]), or total transfusion (OR 0.92 [95% CI 0.43, 1.98]) rate. There was a reduction in the number of allogenic units transfused intraoperatively by a mean of 0.81 (95% CI -1.15, -0.48). However, there were no differences in the number of units transfused postoperatively (WMD -0.02 [95% CI -0.41, 0.38]) or the total units transfused (WMD 0.08 [95% CI -1.06, 1.22]). There were also no differences in operative time (WMD 19.36 [95% CI -2.43, 42.15]) or complications reported (OR 0.79 [95% CI 0.46, 1.37]) between groups. A difference in postoperative hemoglobin (WMD 0.54 [95% CI 0.11, 0.98]) between both groups was observed. CONCLUSIONS Cell saver is efficacious at reducing intraoperative allogenic units transfused. There is no difference in transfusion rates, postoperative units transfused, and the total number of units transfused. Further cost analysis studies are necessary to evaluate the cost-effectiveness of this method of blood conservation. CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: meta-analysis; strength of recommendation: low.
Patients undergoing spine surgery (18 studies, n=2815).
Use of intraoperative cell salvage.
The use of intraoperative cell salvage did not reduce the intraoperative, or total transfusion rate. There was a reduction in the number of allogenic units transfused intraoperatively by a mean of 0.81. However, there were no differences in the number of units transfused postoperatively or the total units transfused. There were also no differences in operative time or complications reported between groups. A difference in postoperative hemoglobin between both groups was observed.
Medically induced hypertension, hypervolaemia and haemodilution for the treatment and prophylaxis of vasospasm following aneurysmal subarachnoid haemorrhage: systematic review
British Journal of Neurosurgery. 2018;:1-8.
PURPOSE Arterial vasospasm is a major cause of death and long-term disability following subarachnoid haemorrhage (SAH). The use of medically induced hypertension, hypervolaemia and/or haemodilution is widely practiced for prophylaxis and treatment of vasospasm following SAH. We aimed to determine if the quality of available research is adequate to inform use of haemodynamic management strategies to prevent or treat vasospasm following SAH. METHODS Individual searches of the following databases were conducted: The Cochrane Database of Systematic Reviews, The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and OpenSIGLE. Pertinent randomised clinical trials and cohort studies comparing any element or combination thereof: medically induced hypertension, hypervolaemia, and haemodilution were included. Data were extracted using standardised proformas and risk of bias assessed using a domain-based risk of bias assessment tool. RESULTS 348 study reports were identified by our literature search. Eight studies were included, three of which examined both volume expansion and medically induced hypertension. Three randomised clinical trials and two cohort studies examining prophylactic volume expansion were included. Two trials of prophylactic medically induced hypertension and two cohort studies were included. One trial and one cohort study of medically induced hypertension for treatment of established vasospasm was included. These trials demonstrated no significant difference in any of the clinical outcome measures studied. No trials of blood transfusion were included. CONCLUSIONS There is currently insufficient evidence to determine the efficacy or non-efficacy of intravenous volume expansion, medically induced hypertension or blood transfusion for the treatment or prophylaxis of vasospasm following SAH. All of these approaches have been associated with adverse events, of unclear incidence. The current evidence base therefore cannot be used to reliably inform clinical practice. This is a priority for further research.
Cell salvage used in scoliosis surgery: is it really effective?
World Neurosurgery. 2017;101:568-576
BACKGROUND Scoliosis surgery is usually associated with large volume of intraoperative blood loss and cell salvage is commonly used to filter and retranfusion autologous blood to patients. However, the efficacy of using cell salvage in scoliosis surgery is still controversial. OBJECTIVE The purpose of this study is to make clear that intraoperative use of cell salvage is effective to decrease the volume of perioperative allogenic blood transfusion in scoliosis surgery. METHOD A meta-analysis was conducted to identify the relevant studies from PubMed, EMbase, Medline, Cochrane library and Google scholar till July 2016. All randomized trials and controlled clinical studies comparing the clinical outcomes of using cell salvage versus noncell salvage in scoliosis surgery were retrieved for the meta-analysis. The data were analyzed by RevMan 5.3. RESULTS A total of 7 studies with 562 patients were included in this meta-analysis. Based on the analysis, the volumes of perioperative and postoperative allogenic RBCs transfusion in cell salvage group were significantly less than those in control group (P = 0.04 and P = 0.01). However, no significant difference was detected in the amount of intraoperative allogenic RBCs transfusion and the risk of patients needing allogenic blood transfusion between the two groups (P = 0.14 and P = 0.61). Both the hemoglobin and hematocrit levels on the first day after surgery were significantly higher in cell salvage group than those in control group (P = 0.002 and P < 0.001). But no significant differences were noted in neither hemoglobin nor hematocirt level at the time of discharge between the two groups (P = 0.76 and P = 0.32). One of the included study reported the number of patients with complications related to transfusion in the two groups, which was not significant different (P = 0.507). CONCLUSIONS Cell salvage significantly reduced the volumes of perioperative and postoperative allogenic RBCs transfusion in scoliosis surgery and increased the hemoglobin and hematocrit levels on the first day postoperatively. In addition, it seemed not increase the rate of transfusion complications during the surgery.
The Use of Closed Suction Drainage in Lumbar Spinal Surgery: Is It Really Necessary?
World Neurosurgery. 2016;90:109-115
BACKGROUND Closed wound suction drainage after spine surgery is commonly used in clinical practice. However, no consensus has been reached for using drainage versus nondrainage after lumbar spinal surgery until now. OBJECTIVE The purpose of this study was to determine the clinical outcomes of using closed suction drainage versus nondrainage after lumbar spinal surgery. METHODS We conducted a systematic review and meta-analysis to identify relevant studies from PubMed, MEDLINE, EMBASE, Cochrane Library, and Google scholar up to September 2015. All randomized, quasi-randomized, and controlled clinical studies, which compared the clinical outcomes of using closed suction drainage versus nondrainage in patients who underwent lumbar spinal surgery, were included. Data extraction and quality assessment were according to Cochrane Collaboration guidelines. RESULTS Five studies involving 1295 patients were included in this meta-analysis. By pooling the clinical outcomes, there were no significant differences between patients with drainage and nondrainage in terms of the incidence of wound infection (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.47-4.71; P = 0.50), wound hematoma (OR, 0.45; 95% CI, 0.01-29.31, P = 0.71), and reoperation (OR, 1.36; 95% CI, 0.22-8.27; P = 0.74). Drainage after lumbar surgery was associated with more blood loss and significantly greater blood transfusions (OR, 3.68; 95% CI, 1.80-7.54; P < 0.01) compared with nondrainage. However, more patients contracted postoperative fever in the nondrainage group than did those in drainage group. CONCLUSIONS Based on this systematic review and meta-analysis, there is insufficient evidence to suggest routine use of prophylactic closed suction drainage after lumbar spinal surgery. However, a decision to use or not use drainage should be individualized for each patient because many factors affect the outcomes.
Indications and outcomes of cell saver in adolescent scoliosis correction surgery: a systematic review
STUDY DESIGN Systematic Review. OBJECTIVE To determine the indications and outcomes for intraoperative cell salvage during adolescent scoliosis correction surgery by systematically reviewing all available evidence. SUMMARY OF BACKGROUND DATA Several blood conservation strategies exist to minimize the consequences of blood loss due to scoliosis correction surgery. The utility of intraoperative cell salvage has been contested in the literature with respect to benefits and cost. High quality randomized control trials are needed to help surgeons make an informed decision about including Cell Saver into their practice. METHODS The databases Medline, Embase, Ovid Healthstar, and PubMed were searched for English language literature investigating Cell Saver use during adolescent scoliosis correction surgery, mean ages 10-19 inclusively. Qualitative and quantitative findings from relevant studies are presented. RESULTS There were seven eligible studies that directly compared the use of Cell Saver (349 patients) against a Control (non-Cell Saver) group (244 patients). The majority of the demographic and hematologic data were consistent between both groups. The average volume of blood that was re-infused into patients in the Cell Saver group was 453.8 ml. Patients in the Cell Saver group received significantly fewer allogenic blood transfusions than the Control group, with 32.6% less intraoperatively, 45.9% less postoperatively, and 47.3% less perioperatively. On average, Cell Saver patients received 1.0 fewer unit of allogenic blood compared to the Control group patients. CONCLUSION Cell Saver reduces the demand for allogenic transfusion. This review supports the use of Cell Saver if the associated monetary costs are expected to be less than the cost of transfusing one unit of allogenic blood. LEVEL OF EVIDENCE 4.
The Outcome of Using Closed Suction Wound Drains in Patients Undergoing Lumbar Spine Surgery: A Systematic Review
Global Spine Journal. 2015;5(6):479-85
Study Design Systematic review. Objective Determine whether closed suction wound drains decrease the incidence of postoperative complications compared with no drain use in patients undergoing spine surgery for lumbar degenerative conditions. Methods Electronic databases and reference lists of key articles were searched up through January 22, 2015, to identify studies comparing the use of closed suction wound drains with no drains in spine surgery for lumbar degenerative conditions. Outcomes assessed included the cumulative incidence of epidural hematoma, superficial and deep wound infection, and postoperative blood transfusion. The overall strength of evidence across studies was based on precepts outlined by the Grades of Recommendation Assessment, Development and Evaluation Working Group. Results Five heterogeneous studies, three randomized controlled trials, and two cohort studies form the evidence basis for this report. There was no difference in the incidence of hematoma, superficial wound infection, or deep infection in patients with compared with patients without closed suction wound drains after lumbar surgery. The upper bounds of the 95% confidence interval for hematoma ranged from 1.1 to 16.7%; for superficial infection, 1.0 to 7.3%; and for deep infection, 1.0 to 7.1%. One observational study reported a 3.5-fold increase in the risk of blood transfusion in patients with a drain. The overall strength of evidence for these findings is considered low or insufficient. Conclusions Conclusions from this systematic review are limited by the quality of included studies that assessed the use of closed suction wound drains in lumbar spine surgeries for degenerative conditions. We believe that spine surgeons should not routinely rely on closed suction wound drains in lumbar spine surgery until a higher level of evidence becomes available to support its use.