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Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study.

Publication ,  Journal Article
Buell, TJ; Taylor, DG; Chen, C-J; Dunn, LK; Mullin, JP; Mazur, MD; Yen, C-P; Shaffrey, ME; Shaffrey, CI; Smith, JS; Naik, BI
Published in: Neurosurg Focus
April 1, 2019

OBJECTIVESignificant blood loss and coagulopathy are often encountered during adult spinal deformity (ASD) surgery, and the optimal intraoperative transfusion algorithm is debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy and improve transfusion practices. The objective of this study was to investigate the effect of ROTEM-guided blood product management on perioperative blood loss and transfusion requirements in ASD patients undergoing correction with pedicle subtraction osteotomy (PSO).METHODSThe authors retrospectively reviewed patients with ASD who underwent single-level lumbar PSO at the University of Virginia Health System. All patients who received ROTEM-guided blood product transfusion between 2015 and 2017 were matched in a 1:1 ratio to a historical cohort treated using conventional laboratory testing (control group). Co-primary outcomes were intraoperative estimated blood loss (EBL) and total blood product transfusion volume. Secondary outcomes were perioperative transfusion requirements and postoperative subfascial drain output.RESULTSThe matched groups (ROTEM and control) comprised 17 patients each. Comparison of matched group baseline characteristics demonstrated differences in female sex and total intraoperative dose of intravenous tranexamic acid (TXA). Although EBL was comparable between ROTEM versus control (3200.00 ± 2106.24 ml vs 3874.12 ± 2224.22 ml, p = 0.36), there was a small to medium effect size (Cohen's d = 0.31) on EBL reduction with ROTEM. The ROTEM group had less total blood product transfusion volume (1624.18 ± 1774.79 ml vs 2810.88 ± 1847.46 ml, p = 0.02), and the effect size was medium to large (Cohen's d = 0.66). This difference was no longer significant after adjusting for TXA (β = -0.18, 95% confidence interval [CI] -1995.78 to 671.64, p = 0.32). More cryoprecipitate and less fresh frozen plasma (FFP) were transfused in the ROTEM group patients (cryoprecipitate units: 1.24 ± 1.20 vs 0.53 ± 1.01, p = 0.03; FFP volume: 119.76 ± 230.82 ml vs 673.06 ± 627.08 ml, p < 0.01), and this remained significant after adjusting for TXA (cryoprecipitate units: β = 0.39, 95% CI 0.05 to 1.73, p = 0.04; FFP volume: β = -0.41, 95% CI -772.55 to -76.30, p = 0.02). Drain output was lower in the ROTEM group and remained significant after adjusting for TXA.CONCLUSIONSFor ASD patients treated using lumbar PSO, more cryoprecipitate and less FFP were transfused in the ROTEM group compared to the control group. These preliminary findings suggest ROTEM-guided therapy may allow early identification of hypofibrinogenemia, and aggressive management of this may reduce blood loss and total blood product transfusion volume. Additional prospective studies of larger cohorts are warranted to identify the appropriate subset of ASD patients who may benefit from intraoperative ROTEM analysis.

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Published In

Neurosurg Focus

DOI

EISSN

1092-0684

Publication Date

April 1, 2019

Volume

46

Issue

4

Start / End Page

E17

Location

United States

Related Subject Headings

  • Treatment Outcome
  • Tranexamic Acid
  • Thrombelastography
  • Spine
  • Scoliosis
  • Retrospective Studies
  • Pilot Projects
  • Osteotomy
  • Neurology & Neurosurgery
  • Middle Aged
 

Citation

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Buell, T. J., Taylor, D. G., Chen, C.-J., Dunn, L. K., Mullin, J. P., Mazur, M. D., … Naik, B. I. (2019). Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study. Neurosurg Focus, 46(4), E17. https://doi.org/10.3171/2019.1.FOCUS18572
Buell, Thomas J., Davis G. Taylor, Ching-Jen Chen, Lauren K. Dunn, Jeffrey P. Mullin, Marcus D. Mazur, Chun-Po Yen, et al. “Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study.Neurosurg Focus 46, no. 4 (April 1, 2019): E17. https://doi.org/10.3171/2019.1.FOCUS18572.
Buell, Thomas J., et al. “Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study.Neurosurg Focus, vol. 46, no. 4, Apr. 2019, p. E17. Pubmed, doi:10.3171/2019.1.FOCUS18572.
Buell TJ, Taylor DG, Chen C-J, Dunn LK, Mullin JP, Mazur MD, Yen C-P, Shaffrey ME, Shaffrey CI, Smith JS, Naik BI. Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study. Neurosurg Focus. 2019 Apr 1;46(4):E17.

Published In

Neurosurg Focus

DOI

EISSN

1092-0684

Publication Date

April 1, 2019

Volume

46

Issue

4

Start / End Page

E17

Location

United States

Related Subject Headings

  • Treatment Outcome
  • Tranexamic Acid
  • Thrombelastography
  • Spine
  • Scoliosis
  • Retrospective Studies
  • Pilot Projects
  • Osteotomy
  • Neurology & Neurosurgery
  • Middle Aged