Elsevier

The Spine Journal

Volume 3, Issue 5, September–October 2003, Pages 388-393
The Spine Journal

Review article
Perioperative blood and blood product management for spinal deformity surgery☆

https://doi.org/10.1016/S1529-9430(02)00554-5Get rights and content

Abstract

BACKGROUND CONTEXT: Spinal deformity surgery, like many other orthopedic procedures, involves significant operative blood loss. In order to avoid the necessity of bank blood transfusions, many blood management strategies have been devised.

PURPOSE: The goal of this review is to analyze the utility of current blood management strategies.

STUDY DESIGN/SETTING: Review paper.

METHODS: Using Medline reviews, pertinent data on blood management agents and strategies were assembled.

RESULTS: Techniques can be organized into preoperative, intraoperative and postoperative categories. Preoperative techniques include autologous blood donation and red cell augmentation. In addition to some established surgical and anesthesia techniques, recent pharmacologic agents have become available to include thrombotic agents and antifibrinolytics, which surgeons may add to their intraoperative armamentarium. A brief mention of postoperative blood salvage drains is also included.

CONCLUSIONS: The judicious use of the agents and techniques can significantly reduce the need for blood transfusions in the setting of spinal deformity surgery.

Introduction

Blood management in the perioperative period is primarily aimed at minimizing the need for allogenic blood transfusion. Recent advances have improved intraoperative blood management options. However, blood management in spinal deformity surgery should be considered as a compendium of tools or options that may be best used preoperatively in the planning or preparation stage, intraoperatively with minimization/control of blood loss or postoperatively during recovery (Table 1).

This requires a thorough knowledge of the current blood management options, as well as an understanding of ongoing research and the agents under development. In addition, an awareness of the cost–benefit ratio of these products is necessary.

Section snippets

Preoperative planning

Preoperative preparation primarily involves autologous blood donation or red cell mass augmentation. Preoperative donation has been widely used for many years and currently is the main blood conservation strategy used for spinal deformity surgery, as well as other orthopedic procedures 1, 2. The obvious advantages of autologous donations are the safety of the blood in terms of disease transmission and transfusion reactions. Various authors have reported the decreased use of allogenic blood

Intraoperative blood management strategies

Intraoperative blood management can be divided into four broad categories: surgical techniques and strategies, thrombotic and antifibrinolytic agents, hemodilution and blood salvage.

Surgical techniques and strategies

One mainstay of orthopedic surgical practice is proper patient positioning. Relton and Hall [15] reported a significant decrease in intraoperative inferior vena cava pressure secondary to use of the Relton-Hall frame. By leaving the abdomen free in the prone position, there is decreased inferior vena cava pressure and thus decreased venous plexus filling around the spinal cord. Theoretically, there is also decreased vertebral venous pressure and, consequently, reduced intraoperative blood loss

Thrombotic, antifibrinolytic and other investigational adjuncts

Thrombotic and antifibrinolytic pharmacologic agents are also aimed at minimizing intraoperative blood loss. One common topical agent is thrombin, which catalyzes the conversion of fibrinogen to fibrin to form a fibrin clot. It is most often used as a spray in conjunction with Gelfoam, an absorbable gelatin sponge (Upjohn Pharmaceutical Company, Kalamazoo, MI). Other topical thrombotic agents include microfibrillar collagen, distributed as Avitene (Davol, Crans- ton, RI); oxidized regenerated

Hemodilution

Acute normovolemic hemodilution includes collecting whole blood in the immediate preoperative period or intraoperatively while concurrently maintaining intravascular volume with crystalloid. This acutely lowers blood viscosity while enhancing venous return to the heart, thus improving both total and capillary refill [48]. This technique has been shown in a number of studies to be safe. Its efficacy has also been demonstrated in spine surgery 24, 49. However, there have been no prospective,

Blood salvage and replacement strategies

The two methods of blood salvage include the intraoperative collection of blood by aspiration and the postoperative collection by drainage before subsequent autotransfusion. The safety of both procedures is well established in the orthopedic literature 51, 52, 53, 54. Several intraoperative blood salvage devices are currently in use. These include the Cell Saver (Haemonetics, Braintree, MA) and the Consta Vac Blood Conservation System (Stryker, Kalamazoo, MI). After collection, the blood is

Oxygen carriers and red blood cell substitutes

Various factors currently drive the interest in oxygen carriers as a viable blood management tool. These factors include the high cost and potential exposure of traditional blood donation programs, as well as the chronic shortage of blood donors. In addition, the clinical application of oxygen carriers in the battlefield setting has unlimited potential for the military. Currently, the two classes of oxygen carriers include the hemoglobin-based oxygen carriers and the temporary oxygen carriers,

Cost effectiveness

Perhaps the greatest area of controversy in blood management is the cost effectiveness of the various techniques and strategies. Inevitably, any discussion of this nature elicits various economic, moral and ethical viewpoints, and must include the various direct and indirect costs of technological advances. We present only a few considerations as related to blood management.

Any preoperative blood-management planning for spine surgery must start with a generalized estimate of predicted blood

Conclusions

In summary, optimal blood management strategies will continue to evolve over the following years, and their efficacy and cost effectiveness will continue to be debated.

References (61)

  • L.T. Goodnough et al.

    Increased preoperative collection of autologous blood with recombinant human erythropoietin therapy

    N Engl J Med

    (1989)
  • M.E. Keating

    Instructional course lectures, The American Academy of Orthopaedic Surgeons—current options and approaches for blood management in orthopaedic surgery

    J Bone Joint Surg

    (1999)
  • P.L. Storring et al.

    The international standard for recombinant DNA-derived erythropoeitin:collaborative study for four recombinant DNA-derived erythropoeitins and two highly purified human urinary erythropoeitins

    J Endocrinol

    (1992)
  • J.R. De Andrade et al.

    Baseline hemoglobin as a predictor of risk of transfusion and response to epoetin alfa in orthopaedic surgery patients

    Am J Orthop

    (1996)
  • P.M. Faris et al.

    The effects of recombinant human erythropoeitin on perioperative transfusion requirements in patients having a major orthopaedic operation

    J Bone Joint Surg

    (1996)
  • F. Mercuriali et al.

    Use of erythropoeitin to increase the volume of autologous blood donated by orthopedic patients

    Transfusion

    (1993)
  • Canadian Orthopedic Perioperative Erythropoeitin Study Group

    Effectiveness of perioperative recombinant human erythropoeitin in elective hip replacement

    Lancet

    (1993)
  • D.J. Murray et al.

    Transfusion management in pediatric and adolescent scoliosis surgery. Efficacy of autologous blood

    Spine

    (1997)
  • J.E.S. Relton et al.

    An operation frame for spinal fusion. A new apparatus designed to reduce hemorrhage during operation

    J Bone Joint Surg

    (1967)
  • T.C. Lee et al.

    Effect of patient position and hypotensive anesthesia on inferior vena cava pressure

    Spine

    (1998)
  • G.A. Nuttall et al.

    Predictors of blood transfusion in spinal instrumentation and fusion surgery

    Spine

    (2000)
  • W.J. Gardner

    The control of bleeding during operation by induced hypotension

    JAMA

    (1946)
  • T.W. McNeill et al.

    Controlled hypotensive anesthesia in scoliosis surgery

    J Bone Joint Surg

    (1974)
  • R.J. Mandel et al.

    Hypotensive anesthesia and autotransfusion in spinal surgery

    Clin Orthop

    (1981)
  • S.M. Lawhon et al.

    Controlled hypotensive anesthesia during spinal surgery. A retrospective study

    Spine

    (1984)
  • N.J. Patel et al.

    Induced moderate hypotensive anesthesia for spinal fusion and Harrington-rod instrumentation

    J Bone Joint Surg

    (1984)
  • M.A. Myers et al.

    Visual loss as a complication of spine surgery

    Spine

    (1997)
  • S. Hur et al.

    Acute normovolemic hemodilution combined with hypotensive anesthesia and other techniques to avoid homologous transfusion in spinal fusion surgery

    Spine

    (1992)
  • H.B. Kram et al.

    Fibrin glue achieves hemostasis in patients with coagulation disorders

    Arch Surg

    (1989)
  • Spence RK. Surgical red blood cell transfusion practice policies. Blood Management Practice Guidelines Conference. Am J...

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    ☆

    FDA device/drug status: not applicable. Nothing of value received from a commercial entity related to this research. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Army or the Department of Defense. The authors are employees of the United States government. This work was prepared as part of their official duties, and as such, there is no copyright to be transferred.

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