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Spinal Deformity Surgery in Patients Refusing Blood Transfusion

Spinal Deformity Surgery in Patients Refusing Blood Transfusion Krishn M. Sharma, MD; Marjorie M. Mariller, MD, MPH; Andrew Casden, MD; Fabian Bitan, MD; Paul Kuflik, MD; Michael G. Neuwirth, MD The Spine Institute of New York at Beth Israel Medical Center

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Spinal Deformity Surgery in Patients Refusing Blood Transfusion

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  1. Spinal Deformity Surgery in Patients Refusing Blood Transfusion Krishn M. Sharma, MD; Marjorie M. Mariller, MD, MPH; Andrew Casden, MD; Fabian Bitan, MD; Paul Kuflik, MD; Michael G. Neuwirth, MD The Spine Institute of New York at Beth Israel Medical Center Presented at Scientific Meetings: Scoliosis Research Society (SRS) and International Meeting on Advanced Spine Techniques (IMAST)

  2. Background • Operative blood loss is of great concern to surgeons • Spinal deformity surgery is associated with significant blood loss (ranging 1-3L and sometimes >3L during osteotomies) • Several factors play a role: • Age • Underlying disease • Number of levels fused

  3. Background • These complex cases frequently result in the need for blood transfusion even though techniques exist to reduce blood loss • Transfusing allogenic blood is associated with risk of disease transmission. • For religious or other reasons some adult and pediatric spine surgery patients refuse blood or blood-products all together

  4. Objective • In order to better serve our population of patients in the bloodless program, we conducted a study looking at the outcome of Scoliosis surgery in patients who refuse transfusion.

  5. Methods • Retrospective review of inpatient hospital records, outpatient charts, and radiographs of 19 patients enrolled in the bloodless surgery program between 2000 and 2003 who underwent spinal deformity surgery.

  6. Results • All 19 patients consented to use of cell saver but refused all other blood products. The average age of the patients was 17 (range 10-36) with 68% being women.

  7. Results

  8. Results • All patients were treated with hypotensive anesthesia and red blood cell salvage. • The decision to use erythropoietin and supplemental iron was made pre-operatively by the primary care physician.

  9. Results

  10. Results: Complications • There were two intra-operative complications: • one patient had a transient loss of SSEP/MEP signals, which corrected with removal of the rods. • one patient had his surgery abandoned due to significant blood loss. • There were three major post-operative complications, all occurring in patients with neuromuscular scoliosis. No complication appeared to be related to blood loss or the refusal of blood transfusion.

  11. Results

  12. Results • The hemoglobin dropped on average 3.2 g/dL from a mean pre-operative level of 14g/dL to a mean postoperative level of 10.8g/dL. • No patient showed clinical signs or symptoms of anemia at discharge and no patient required a blood transfusion. • The major curve averaged 65° in the coronal plane. Mean curve correction was 58%, fusing from two to 17 levels (including the pelvis).

  13. Results

  14. Conclusions • Current surgical and blood conservation techniques make reconstructive spinal surgery in patients refusing blood transfusion safely possible without compromising results. • Red blood cell recycling (“cell-saver”) is a well accepted method of returning a portion of lost blood back to the patient (including among patients who refuse blood or blood product transfusion) without incurring the risks of allogenic transfusion.

  15. Conclusions • Several pharmacological methods of minimizing blood loss exist including aprotinin and aminocaproic acid. • Controlled hypotension and relative hemodilution were standard techniques employed in our patients.

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