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Updated: Nov 11 2022

Blood Loss Management in Spine Surgery

3.8

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https://upload.orthobullets.com/topic/422819/images/cox_diagram.jpg
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  • PREOPERATIVE
    • Establish Baseline labs
      • labs
        • CBC
          • hemoglobin & hematocrit
          • platlets
        • Prothrombin time (PT)(INR)
          • determines clotting time for the extrinsic coagulation cascade
            • factors I, II, V, VII, and X
            • normal result is 12-13 seconds
            • reported with International Normalized Ratio (INR)
              • normal range of 0.8 to 1.2
          • not correlated with increased transfusion rates
        • Partial thromboplastin time (PTT)
          • assesses clotting time of the intrinsic clotting cascade
          • factors XII, XI, IX, VIII, X, V, II
          • normal range of 25-39 seconds
          • not correlated with increased transfusion rates
        • Fibrinogen
          • also known as factor I
          • normal range 200-400 mg/dL
          • below normal ranges have been associated with increased transfusion rates
    • Preoperative blood loss estimation
      • allows for cost-effective treatment with cell salvage systems, allogenic blood transfusions, and antifibrinolytic agents
      • factors associated with increased blood loss
        • increased body mass index
        • lower body weight
          • mostly associated with increased transfusion requirements
          • lower starting blood volume
          • factor for pediatric spinal deformity
        • advanced age
        • bleeding diatheses
        • number of spinal levels
          • approximately 200 cc per lumbar level
        • use of instrumentation
        • revision spine surgery
        • iliac crest bone harvest
        • interbody fusions
        • trauma or tumor surgery
        • Cobb angle >50°
        • longer expected surgical time
        • neuromuscular scoliosis
        • >6 levels fused for deformity surgery
        • Ponte osteotomies
        • vertebral column resection osteotomy
          • can lead to 65% total blood volume loss
      • recommend obtaining a preoperative hemoglobin level of 5 g/dL greater than treating surgeons transfusion trigger
    • Establish Baseline
      • labs
        • CBC
          • hemoglobin & hematocrit
          • platlets
        • Prothrombin time (PT)(INR)
          • determines clotting time for the extrinsic coagulation cascade
            • factors I, II, V, VII, and X
            • normal result is 12-13 seconds
            • reported with International Normalized Ratio (INR)
              • normal range of 0.8 to 1.2
          • not correlated with increased transfusion rates
        • Partial thromboplastin time (PTT)
          • assesses clotting time of the intrinsic clotting cascade
          • factors XII, XI, IX, VIII, X, V, II
          • normal range of 25-39 seconds
          • not correlated with increased transfusion rates
        • Fibrinogen
          • also known as factor I
          • normal range 200-400 mg/dL
          • below normal ranges have been associated with increased transfusion rates
    • Hemoglobin optimization
      • goals
        • (focus on reducing allogenic blood transfusion intraoperatively and postoperatively)
          • vitamin supplementation
            • iron
              • major building block of hemoglobin and functions to bind oxygen in the porphyrin ring structure
              • supplementation provides material for hemoglobin synthesis
              • some studies have demonstrated a significant decrease in postoperative transfusions in patients with anemia-reducing vitamins
              • increased side effects
                • constipation
                • heartburn
                • abdominal pain
            • folate and vitamin B12 supplementation
              • are essential vitamins for DNA synthesis that is necessary for erythropoiesis
            • anemia-associated vitamin supplemenation
              • iron 256 mg/day, vitamin C 1 g/day, and folate 5 mg/day for 30-45 days preopeative have been associated with decreased transfusion rates
                • should only be used in patients with specific deficiency
          • erythropoietin (EPO)
            • mechanisms
              • recombinant protein of natural glycoprotein produced by renal pericapillary cells
                • signals bone marrow cells to stimulate RBC production
            • outcomes
              • studies have demonstrated greater efficacy than preoperative autologus blood donation and reinfusion systems
            • costs
              • high cost associated with use
                • treatment cost equivalent to 4 units of allogenic blood transfusion
            • indications
              • recommended for high risk patients
                • preoperative Hb < 13g/dL
                • low body weight (< 50 kg)
                • surgeries when considerable blood loss is expected
            • administration
              • three dosing regimens have been proposed:
                • 600 IU/kg - 4 doses: preoperative days 21, 14, 7, and 0
                • 300 IU/kg - 15 doses: preoperative day 10 to postoperative day 4
                • 150 IU/kg - 9 doses: preoperative day 5 to postoperative day 3
          • preoperative autologous blood donation
            • administration
              • preoperative procurement of 1 to 2 units of autologous blood
              • performed at least 3 weeks from the planned surgery to allow for recovery of Hb levels
            • outcomes
              • current literature does not seem to support efficacy and cost effectiveness in the management of postoperative anemia
                • concerns that there is a high incidence of unused units
                • compulsion to transfuse patient
            • indications
              • may be of benefit in patients with normal Hb (>14 g/dL) undergoing procedures with high expected blood loss
                • may be performed in any patient with Hb > 11 g/dL and body weight >50 kg performed with sufficient time prior to procedure
          • preoperative embolization
            • indications
              • standard treatment for oncology cases with highly vascular tumors
                • renal cell carcinoma
            • technique
              • performed within 24 hours of the procedure
    • Discontinue Anticoagulating Medications
      • goals
        • decrease risk of intraoperative bleeding without causing adverse event
      • NSAIDs
        • inhibit COX-1 and COX-2
      • nonaspirin platlet inhibitors (clopidogrel)
        • commonly prescribed after cardiac stenting
          • elective spine surgery should be postponed after such procedures
            • 6 weeks bare metal stents
            • 6 to 12 months drug-eluting stents
          • if urgent/emergent surgery may consider continuing medication
            • if discontinued, need to discuss risks and benefits
          • Plavix can be resumed 12 to 24 hours after surgery if there is no concern for epidural hematoma
      • long-term anticoagulants
        • risks of discontinueing
          • risk of thromboembolic event with discontinuation prior to procedure
        • Warfarin
          • discontinue 5 days prior to procedure
          • goal INR <1.4
          • resuming immediately after procedure would lead to subtherapeutic INR for 8 to 10 days
            • may consider bridging agent with these patients
        • Low-molecular-weight heparin or unfractionated heparin
          • therapeutic dosing should be postponed minimum of 48 to 72 hours after spine surgergy to prevent epidural hematoma
      • supplements
        • should be discontinued 14 days prior to surgery to minimize intraoperative blood loss
          • decrease platlet aggregation
            • garlic
            • ginkgo
            • ginseng
            • fish oil
            • flax seed oil
            • saw palmetto
          • inhibits clotting
            • chamomile
          • alter coagulation
            • vitamin E
            • vitamin K
            • green tea (contains vitamin K)
      • 8-16Anticoagulating Medications
      • Drug
      • Plasma Half-Life (hours)
      • Effect on Bleeding
      • Minimum Cessation Prior to Surgery (days)
      • Diclofenac
      • 1-2
      • Inhibits COX (reversibly)
      • 1
      • Ibuprofen
      • 2
      • Inhibits COX (reversibly)
      • 1
      • Indomethacin
      • 4-10
      • Inhibits COX (reversibly)
      • 3
      • Ketorolac
      • 5-7
      • Inhibits COX (reversibly)
      • 3
      • Etodolac
      • 6-7
      • Inhibits COX (reversibly)
      • 3
      • Sulindac
      • 8-16
      • Inhibits COX (reversibly)
      • 3
      • Naproxen
      • 12-17
      • Inhibits COX (reversibly)
      • 3
      • Piroxicam
      • 50
      • Inhibits COX (reversibly)
      • 7
      • Celecoxib
      • 11
      • Inhibits COX-2 (reversibly)
      • 1
      • Aspirin
      • 6
      • Inhibits COX (irreversibly)
      • 7
      • Clopidogrel
      • 1
      • Irreversibly inhibits platelet ADP receptors
      • 7
      • Prasugrel
      • 2-15
      • Irreversibly inhibits platelet ADP receptors
      • 7
      • Ticagrelor
      • 7-9
      • Reversibly inhibits platelet ADP receptors
      • 5
      • Ticlopidine
      • 20-50
      • Irreversibly inhibits platelet ADP receptors
      • 14
      • Warfarin
      • 20-60
      • Inhibits vitamin K-dependent clotting factor synthesis
      • 5
      • Enoxaparin (LMWH)
      • 3-5
      • Binds antithrombin and irreversibly blocks thrombin
      • 1
      • Unfractionated heparin
      • 0.5-2
      • Binds antithrombin and irreversibly blocks thrombin
      • 4-5 Hrs
      • Dabigatran
      • 7-14
      • Reversibly blocks thrombin
      • 3
      • Rivaroxaban
      • 5-13
      • Reversibly blocks factor Xa
      • 3
      • Apixaban
      • 9-14
      • Reversibly blocks factor Xa
      • 3
      • Edoxaban
      • 10-14
      • Reversibly blocks factor Xa
      • 3
    • Preoperative blood loss estimation
      • allows for cost-effective treatment with cell salvage systems, allogenic blood transfusions, and antifibrinolytic agents
      • factors associated with increased blood loss
        • increased body mass index
        • lower body weight
          • mostly associated with increased transfusion requirements
          • lower starting blood volume
          • factor for pediatric spinal deformity
        • advanced age
        • bleeding diatheses
        • number of spinal levels
          • approximately 200 cc per lumbar level
        • use of instrumentation
        • revision spine surgery
        • iliac crest bone harvest
        • interbody fusions
        • trauma or tumor surgery
        • Cobb angle >50°
        • longer expected surgical time
        • neuromuscular scoliosis
        • >6 levels fused for deformity surgery
        • Ponte osteotomies
        • vertebral column resection osteotomy
          • can lead to 65% total blood volume loss
      • recommend obtaining a preoperative hemoglobin level of 5 g/dL greater than treating surgeons transfusion trigger
  • Intraoperative Management
    • Hypotensive anesthesia
      • administration of vasodilating agents to a goal systolic blood pressure of 50 - 80 mm Hg or MAP of 60 mm hg
        • well validated in pediatric scoliosis surgery
        • has been shown to decrease intraoperative blood loss by 55% without sequelae
        • reduces blood extravasation through surgical wound
        • does not affect bone bleeding (mostly venous bleeding)
      • complications:
        • concern for possible cord transfusion
          • neuromonitoring changes
          • address by increasing blood pressure, ensuring no halogenated gases, determine last time when gentamicin was given, and increase patient temperature
        • ischemic optic neuropathy
    • Maintenance of normothermia
      • ideal to keep body temperature >36° C
        • decrease in body temperature >1° C can increase blood loss by 16% and increase transfusion rates by 22%
        • hypothermia decreases platlet function and coagulation enzyme activity
      • increase OR temperature if needed
      • minimize exposed skin surface-area until drapping
    • Patient positioning
      • reverse trendelenburg positioning
        • decrease central venous pressure
      • Jackson frames that allows abdomen to hand freely
        • decrease intra-abdominal pressure and pressure on inferior vena cava
          • prevent congestion in Batson venous plexus
    • Tranexamic acid (TXA)
      • lysine derivative that competitively blocks plasmin binding sites on fibrin
        • results in a decrease in fibrinolysis and stabilized clot formation
        • 6 to 10 times more potent than epsilon aminocaproic acid
      • multiple studies have demonstrated a significant reduction in operative blood loss and transfusion rates with perioperative administration
        • no increased risk of DVT and PE
        • does not alter PT and PTT times
      • multiple dosing regimens and routes of administration utilized
        • IV, oral, and topical all appear equally efficacious
      • contraindications:
        • history of CVA
        • allergy
        • severe CAD
      • side effects:
        • seizures
          • binds to glycine and GABA channels leading to a reduced seizure threshold
    • Desmopressin
      • vasopressin analog
        • increases factor VIII and von Willebrand factor
      • limited data in spine surgery
      • useful treating patients with von Willebrand's disease
    • Surgical techniques
      • local anesthetic with epinephrine
        • can prevent dermal bleeding over long cases
          • 1:500,000 epinephrine
      • subperiosteal elevation
        • preserves vasculature of paraspinal muscules
      • electrocautery
        • monopolar
          • soft tissue and periosteal elevation
          • ensure not to violate ligamentum in the interlaminar space
            • could go intradural
        • bipolar
          • ideal for hemostasis near neural structures
            • epidural space
            • coagulating bleeding epidural veins
        • saline-irrigated radiofrequency bipolar hemostatic sealers
          • contracts vascular collagen at temperatures <100° C
            • unipolar cautery reaches temperature >300° C
          • studies have shown substantial blood loss reduction in pediatric deformity surgery
          • increased surgical cost of $493 per case
      • wound-packing
        • surgical areas that are not being addressed should be packed
          • decreases low-pressure bleeding
        • saline-soaked sponges or patties
          • can be combined with thrombin or epinephrine for greater hemostasis control
    • Aminocaproic acid
      • lysine derivative that competitively inhibits plasmin
        • results in decreased fibrinolysis
      • studies have demonstrated decreased blood loss with aminocaproic acid in arthroplasty
      • lower cost than TXA
      • does not decrease seizure threshold
    • Topical hemostatic agents
      • collagen agents
        • stimulate the instrinsic pathway of coagulation cascade to promote hemostasis
        • microfibrillar collagen
          • dry, fine, white powder
          • must be applied with dry surgical instruments to a dry field
      • fibrin sealant
        • consists of two seperate mixtures
          • one contains fibrin and factor XIII
          • one contains thrombin and calcium
        • combining the mixtures creates a fibrin seal where it is sprayed
      • platlet-rich plasma
        • centrifugation of patient's blood to isolate plasma with high contents of platlets, growth factors, and clotting factors
        • proposed benefit of improved hemostasis, wound healing and recovery
      • platlet-poor plasma
        • isolated from centrifugation process
        • combined with thrombin and calcium to provide an autologous fibrin sealant
      • gelfoam sponges
        • manufactured from animal-skin gelatin and processed into sponge-form
        • isolated use exerts mostly mechanical hemostasis against low-pressure bleeders
        • can be soaked with thrombin, which can act as as scaffold for the coagulation cascade
        • excess gelfoam should be removed as it may interfere with bone healing
      • topical hemostatic agents do not appear to be cost-effective in total joint arthroplasty cases
        • beneficial in spine surgery to promote hemostasis without inflicting harm to adjacent neural structures
      • topical TXA
        • typically administered near the end of the procedure to control postoperative bleeding
        • decreases fibrinolysis and stabilizes clot formation
        • may be an alternative route of adminstration in patients with higher risk of complications
          • history of MI, CAD, or CVA
      • gelatin-thrombin matrix
        • commonly used in spine surgery to control epidural bleeding
          • brand names include Floseal and Surgiflo
        • consists of porcine or bovine gelatine matrix combined with human derived thrombin
        • acts of the end stage of the coagulation cascade leading to fibrin formation
    • Reinfusion systems (cell saver)
      • recycles intraoperative blood loss for later transfusion
        • can be transfused intraoperatively during longer procedure
      • shed blood is filtered, washed, and transfused within 6 to 8 hours from the procedure
        • serves as an alternative to allogenic blood transfusion
        • theoretical benefits of minimizing wound complications and hematoma formation
        • need to avoid suctioning antibiotic irrigation, povidone-iodine solution, and irrigation >42° C into the circuit
      • indications:
        • religious beliefs that preclude allogenic blood transfusion
        • large number of autoantibodies that makes allogenic blood stock incompatible
      • contraindications:
        • surgies for malignancy and infection
      • not recommended for routine use in lumbar spine surgery
        • not cost effective unless blood loss ≥500 cc
      • complications:
        • coagulopathy
          • altered composition of the transfused blood containing elevated fibrin split products and inflammatory cytokines (TNF-α and interleukins)
            • especially problematic in unwashed systems
          • can lead to increased wound drainage
          • recommended to transfuse 1 unit of FFP for every 1,000 cc of volume of returned
        • transient hemoglobinuria
        • pulmonary complications
          • due to reperfusion of debris
        • contamination
        • cost
  • Postoperative Management
    • Allogenic blood transfusion
      • preoperative hemoglobin strongest risk factor for postoperative blood transfusion
        • below 13 g/dL more likely
      • other risk factors
        • female gender
        • increased age
        • larger patient size
        • longer procedures
        • lateral releases in total knee arthroplasty
      • 1 unit increased Hb by 1 g/dL
      • no absolute criteria for transfusion
        • transfusion should be considered for anyone with Hb <6 g/dL
        • transfusion should be considered for postoperative patients with Hb 7-8 g/dL
        • routine transfusion should be avoided for Hb > 8 g/dL
          • no increased mortality has been seen with this criteria, even in patients with cardiac history
          • initiate transfusion if patient is symptomatic
            • orthostatic hypotension
            • tachycardia unresponsive to fluids
        • Hb levels between 6 to 8 g/dL should be based on patient factors
          • expectation of continued blood loss
          • intravascular volume status
          • cardiovascular reserve
          • response to anemia
      • complications
        • increased risk of nosocomial infections
          • immunomodulatory effects
            • increased SSI
            • increased UTIs
        • viral transmission
          • hepatitis B - 1:205,000 unit donated
          • hepatitis C - 1:1.8 million units donated
          • human immunodeficiency virus - 1:1.9 million units donated
        • transfusion-related acute lung injury (TRALI)
          • immunologically mediated damage to the lungs
          • can result in adult respiratory distress syndrome
        • acute hemolytic reaction
          • potentially lethal complication
          • results from blood-type mismatch
            • rare complication
    • Allogenic platlet transfusion
      • blood product most likely to be contaminated
        • stored at room temperature
        • infections in 10 cases per million units transfused
        • gram positive organisms most common
      • thrombocytopenia
        • platlet count below 5,000/mm^3
          • give platlets to avoid spontaneous bleeding
        • platlet count below 50,000/mm^3
          • give platlets before surgery
        • platley count above 100,000/mm^3
          • no need to transfuse
    • Postoperative iron supplementation
      • daily oral iron replacement mild acute blood loss anemia
    • Drains
      • theoretically prevents surgical site hematomas
        • potential site for infection or neural compression
      • concern for increased post-operative blood
        • negates the tamponade effect by decreasing intrawound pressure
  • Special Considerations
    • Jehovah's Witness (JW)
      • hold beliefs that blood transfusions are forbidden by the bible
        • some patients may still consent to a blood transfusion
        • some patients may consider the use of cell saver as an alternative to allogenic blood transfusion
      • use of colloids and coagulation factors are not forbidden and a matter of personal choice
      • bovine-derived hemostatic agents are generally approved by JW
        • products derived from human plasma are a personal decision of JW
          • preoperative discussion about the use of the use of these agents
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