Substantial blood loss during spine surgery can result in increased patient morbidity and mortality. Proper preoperative planning and communication with the patient, anesthesia team, and operating room staff can lessen perioperative blood loss. Advances in intraoperative antifibrinolytic agents and modified anesthesia techniques have shown promising results in safely reducing blood loss. The surgeon's attention to intraoperative hemostasis and the concurrent use of local hemostatic agents also can lessen intraoperative bleeding. Conversely, the use of intraoperative blood salvage has come into question, both for its potential inability to reduce the need for allogeneic transfusions as well as its cost-effectiveness. Allogeneic blood transfusion is associated with elevated risks, including surgical site infection. Thus, desirable transfusion thresholds should remain restrictive.

Spinal fusion surgery for adolescent idiopathic scoliosis (AIS) has been associated with significant blood loss and transfusion requirements. Reduction of mean arterial pressure (MAP) has benefits, but has been debated. This study aimed to analyze hypotensive anesthesia (MAP less than 65 mm Hg) at incision for its effect on blood loss.Retrospective analysis of 327 AIS patients treated by a single surgeon from 2000 to 2008. We recorded demographic, laboratory, and radiographic measurements and perioperative data, including complications. We estimated MAP from the anesthesia flow sheet at incision (I-MAP) and during the entire surgery (Avg MAP). Patients were stratified into 3 groups: low (MAP less than 65), medium (MAP 65-75), or high (MAP greater than 75). We also evaluated the effect of elevated blood pressure at incision. The groups were as follows: reduced (I-MAP less than Avg MAP), stable (I-MAP = Avg MAP), or elevated (I-MAP greater than Avg MAP). We performed comparisons using analysis of variance with Tukey's Multiple Comparison Test. Blood loss was recorded as absolute volume and percent total blood volume (%EBV).Of the 327 patients (mean age, 15 years; range, 10-21 years; 248 females), 129 received blood transfusions (29% allogenic). There was a reduction in blood loss comparing low (584 mL; 14% EBV) versus high I-MAP (871 mL; 20.3% EBV) (p =.03). Likewise, an elevated blood pressure at incision led to increased blood loss: reduced, 510 mL, 11.5% EBV; stable, 735 mL, 17.6% EBV; and elevated, 1,033 mL, 24.9% EBV (p =.000-.02). Operative time was decreased in the low group by up to 48 minutes (p =.002), as was blood loss per minute (2.6 mL/min vs. 3.8 mL/min). There were no complications related to the use of hypotension.Induction of hypotensive anesthesia (MAP less than 65 mm Hg) at incision reduces operative blood loss by 33%. In addition, elevations in blood pressure at incision increase blood loss by 29%, and operative time by 29 minutes.Copyright © 2013 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.

Spine surgery is associated with significant intraoperative blood loss, often leading to transfusion. Patients who receive transfusions have an increased length of stay and risk of perioperative complications. To decrease the transfusion rate, we implemented an evidence-based institution-wide restrictive transfusion blood management guideline. The goal of this study is to describe the impact of this guideline on our spine surgery patients.We analyzed the incidence of transfusion following 3709 single-institution, inpatient spine procedures before and after implementation of a revised blood transfusion protocol. The baseline period (1742 patients) from January 2014 to March 2015 was compared to the study period (1967 patients) of April 2015 to July 2016. One patient was excluded because of incomplete medical records. The revised protocol included establishing a postoperative blood transfusion trigger at hemoglobin < 7g/dL, instituting a computerized provider order entry, and appointing a physician champion to monitor and report progress.Transfusion rate decreased from 16.2% to 9.7% from baseline to study period, respectively (< .001). The number of transfusions in patients with hemoglobin > 7g/dL decreased to 4.9% from 6.1% ( = .09). The rate of transfusions with a prior hemoglobin test increased from 42.0% to 59.1% (< .001). Length of stay was reduced from 3.67 to 3.46 days ( = .04), and postsurgical infection rate was reduced from 1.5% to 0.6% ( = .01). There was no significant difference in total hospital costs following protocol implementation.Implementation of a restrictive transfusion protocol through use of a computerized provider order entry and a physician champion to oversee clinician compliance led to a 40.1% reduction in blood transfusion following spine surgery. Behavior changes were visible with a 40.7% increase in hemoglobin documentation before transfusion, and patients benefited from a reduction in length of stay and postsurgical infection rate. Future study is encouraged to understand the long-term impact of this intervention and its role in hospital expenditure.

The purpose of this meta-analysis of randomized controlled trials (RCTs) and non-RCTs was to gather data to evaluate the efficacy and safety of bipolar sealer versus standard electrocautery in the management of spinal disease.The electronic databases including Embase, PubMed and Cochrane library were searched to identify relevant studies published from the time of the establishment of these databases up to January 2017. The primary outcomes were total blood loss, requirement of transfusion (rate and amount), and operation time. The secondary outcomes were length of hospital stay and postoperative wound infection. Data analysis was conducted with RevMan 5.3 software.A total of five studies involving 500 patients (261 patients in the BS group and 239 in the control group) were included in the meta-analysis. The pooled results revealed that application of bipolar sealer could decrease the total blood loss in spine surgery [WMD = -467.49, 95% CI (685.47 to -249.51); p < 0.05; I  = 91%]. Compared with standard electrocautery, bipolar sealer was associated with lower rates of need for transfusion [OR = 0.30, 95% CI (0.16-0.55), p < 0.05; I  = 0%]. In addition, patients in the BS group were likely to receive less amount of blood transfusion compared with patients in the control group[WMD = -0.73, 95% CI (-1.37 to -0.09), p < 0.05; I  = 76%]. The mean operative time was shorter in the BS groups compared with the control group [SMD = -0.36, 95% CI (-0.60 to -0.13), p < 0.05; I  = 0%]. There was no significant difference in terms of length of hospital stay [WMD = -0.73, 95% CI (-1.96 to 0.51), p = 0.25; I  = 67%] and postoperative wound infection [OR = 0.88, 95% CI (0.31-2.48), p = 0.81; I  = 0.0%] between both groups.The available evidence suggests that bipolar sealer is superior to standard electrocautery with less blood loss, shorter operation time and less transfusion requirement. There is no significant difference between both groups regarding length of hospitalization and wound infection. Hence, bipolar sealer is recommended in spine surgery. Because of the limitation of our study, more well-designed RCTs with large sample are required to provide further evidence of safety and efficacy between bipolar sealer and standard electrocautery in the treatment of spinal disease.

Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.© 2018 Association of Anaesthetists.

Posterior spine fusion is associated with significant intra- and postoperative blood losses. When referring to the total blood loss during spine surgery, the standard is to measure the intraoperative bleeding plus the postoperative drainage. This ignores the "hidden" blood loss that was found to be significant in other fields of surgery.The purpose of this study was to examine whether posterior spine fusion carries a substantial hidden blood loss.A prospective study.We prospectively studied 114 patients undergoing instrumented posterior spinal fusion at one center between January 2011 and April 2011.Total blood loss, visible blood loss, and hidden blood loss.For each patient, the hidden blood loss was calculated by deducting the observed perioperative blood loss from the calculated total blood loss based on the hematocrit changes. We compared the percentage of the hidden blood loss out of the total blood loss for primary versus revision posterior spine fusion.Primary decompression and posterior fusion patients had a mean total true loss of 1,439 mL. Their calculated hidden loss was 600 mL, 42% of the total loss. After revision posterior spinal fusion surgery, the mean total blood loss was 1,606 mL. The mean visible loss was 975 mL, and the mean hidden loss was 631 mL, 39% of the total loss. Thus, there was no statistical difference in the hidden blood loss between primary and revision posterior spinal fusion surgeries (p>.05). We did not find a significant difference in the percentage of the hidden blood loss between patients who underwent one, two, or three or more levels of surgery.After posterior spinal fusion, there may be a large amount of the hidden blood loss.Copyright © 2013 Elsevier Inc. All rights reserved.