Post-Operative Blood Salvage and Autotransfusion for Adult Spinal Deformity: A Randomized Controlled Trial
STUDY DESIGN Randomized controlled trial. OBJECTIVE To determine whether post-operative blood salvage and autotransfusion vs. traditional closed suction drainage reduces the rate of homologous blood transfusions in patients undergoing surgery for adult spinal deformity. SUMMARY OF BACKGROUND DATA The use of intra-operative blood salvage has become commonplace in spine surgery; however, the collection and reinfusion of blood drained from the wound post-operatively has not been employed routinely due to increased cost and questionable benefit. METHODS Adult patients undergoing long posterior fusions were randomized to either a blood salvage and reinfusion system (OrthoPat - Group 1) or a standard subfascial closed suction drain (Group 2). Blood collected in Group 1 was reinfused according to the manufacturer's protocol. Reinfusion drains were converted to standard closed suction drains when output was less than 50cc over 4 hours, and drains were removed when output was minimal. Patients received autologous or homologous blood transfusions when Hg < 8 g/dL or they had symptomatic anemia. RESULTS 34 patients were randomized into Group 1 and 36 patients into Group 2. There were no differences in pre-operative or intra-operative parameters. Patients in Group 1 had higher hemoglobin levels on POD #2 and POD #3 compared to those in Group 2. However, there was no significant difference in the percentage of patients requiring homologous blood transfusion between the two groups (41% Group 1 vs. 60% Group 2, p = 0.17). Similarly a subgroup analysis in patients with EBL > 2000cc also showed no difference in homologous blood transfusion rates (67% Group 1 vs. 76% Group 2, p = 0.58). There were no differences in the rate or type of post-operative complications. CONCLUSIONS Post-operative blood salvage and reinfusion results in a higher hemoglobin level in the early post-operative period, but does not significantly reduce the need for homologous blood transfusion. LEVEL OF EVIDENCE 1.
The use of Epoetin alfa in complex spine deformity surgery
STUDY DESIGN A prospective, randomized trial comparing Epoetin alfa (Procrit) with placebo saline injection to determine effectiveness in increasing erythropoietic recovery in complex spine deformity surgery. OBJECTIVES To determine if Epoetin alfa can allow preoperative autologous donation completion more effectively and reduce perioperative homologous blood transfusion. SUMMARY OF BACKGROUND DATA The use of Epoetin alfa has been studied, primarily in the arthroplasty literature, for its effectiveness in decreasing transfusion requirements and increasing hemoglobin levels. It has not been studied in patients undergoing complex spine deformity surgery. METHODS A total of 48 patients were prospectively randomized into an Epoetin alfa group and a control group. All patients attempted to donate 4 units of preoperative autologous donation at weekly intervals; 40,000 units of Epoetin alfa were injected subcutaneously at the time of preoperative autologous donation in the Epoetin alfa group. Hematocrit levels were recorded weekly during the donation process and daily in the preoperative period. RESULTS Preoperative autologous donation was completed more effectively in the patients receiving Epoetin alfa. Epoetin alfa resulted in statistically higher hematocrit levels during preoperative autologous donation and perioperatively (P < 0.005). Homologous transfusion was decreased by 2.4 units and hospital stay was 1.8 days shorter in patients receiving Epoetin alfa. CONCLUSION Patients who received Epoetin alfa were able to complete preoperative autologous donation more effectively, increase erythropoietic recovery, decrease homologous transfusion requirements, and had shorter hospital stays.
The efficacy of antifibrinolytics in the reduction of blood loss during complex adult reconstructive spine surgery
STUDY DESIGN Controlled study to assess the efficacy of aprotinin and Amicar in reducing blood loss during complex spinal fusions. OBJECTIVES To compare blood loss and the clotting profile with a thromboelastogram in patients with spinal deformities undergoing sequential anterior and posterior spinal fusions treated intraoperatively with either aprotinin or Amicar. SUMMARY OF BACKGROUND DATA Spinal fusion for correction of adult spinal deformities is associated with large blood losses despite the implementation of multiple factors to reduce this blood loss. The antifibrinolytics aprotinin and Amicar have both been shown to reduce blood loss in other surgical procedures with the potential for large blood loss. Hence, we compared their efficacy for reducing blood loss in complex spinal fusions. METHODS Sixty patients for elective sequential anteroposterior thoracolumbosacral fusions were randomly assigned to three groups: control, aprotinin, and Amicar. Patients were assessed for blood loss, transfusion requirements, postoperative complications, and coagulation profile using a thromboelastogram. RESULTS The study demonstrated a significant reduction in total blood loss (aprotinin 3628 mL, Amicar 4056 mL, control 5181 mL) and transfusion requirements using the half-dose aprotinin regimen compared with Amicar or control. Aprotinin also preserved the thromboelastogram mean clot formation time, clot strength, and clotting index compared with Amicar or control. CONCLUSIONS For complex spinal operations with large blood losses, the half-dose aprotinin regimen will reduce blood loss and the need for blood components and may have a role in reducing postoperative lung injury.