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y y y c y y y y 2 2 D v _ Zd d 2 2 v Zd 2 2 2 Supplemental digital material, ArticlePlus
Table 1. Articles excluded.
AuthorYearReason for exclusionBenli ADDIN EN.CITE Benli199951515117Benli, I. T.Akalin, S.Duman, E.Citak, M.Kis, M.1st Department of Orthopaedics and Traumatology, Ankara Social Security Hospital, Turkey.The results of intraoperative autotransfusion in orthopaedic surgeryBull Hosp Jt DisBulletin (Hospital for Joint Diseases (New York, N.Y184-7584AdultAgedBlood Loss, SurgicalBlood Transfusion/adverse effects/statistics & numerical data*Blood Transfusion, AutologousFemaleHematocritHumansIntraoperative PeriodMaleMiddle Aged*OrthopedicsRisk Factors19990018-5647 (Print)10711365http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=10711365 eng281999Reported on all orthopedic surgical proceduresBlais ADDIN EN.CITE ADDIN EN.CITE.DATA 291996Included trauma patientsBoakye ADDIN EN.CITE Boakye200813131317Boakye, M.Patil, C. G.Santarelli, J.Ho, C.Tian, W.Lad, S. P.Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA.Cervical spondylotic myelopathy: complications and outcomes after spinal fusionNeurosurgeryNeurosurgery455-61; discussion 461-2622AdolescentAdultAge FactorsAgedAged, 80 and overCervical VertebraeChildChild, PreschoolComorbidityFemaleHumansInfantInfant, NewbornMaleMiddle AgedMultivariate Analysis*Postoperative ComplicationsSpinal Cord Diseases/*surgerySpinal Fusion/*adverse effectsSpondylolysis/*surgeryTreatment Outcome2008Feb1524-4040 (Electronic)18382324http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18382324 eng302008Did not report on outcomes of interestBrookfield ADDIN EN.CITE Brookfield200844417Brookfield, K. F.Brown, M. D.Henriques, S. M.Buttacavoli, F. A.Seitz, A. P.Department of Orthopaedics, University of Miami Miller School of Medicine, PO Box 016960 (R-2), Miami, FL 33101, USA. kbrookfield@med.miami.eduAllogeneic transfusion after predonation of blood for elective spine surgeryClin Orthop Relat ResClinical orthopaedics and related research1949-534668Blood Loss, Surgical/*statistics & numerical dataBlood Transfusion, Autologous/*statistics & numerical dataFemaleHumansIntraoperative PeriodLaminectomyMaleMiddle AgedRetrospective Studies*Spinal Fusion*Surgical Procedures, Elective2008Aug1528-1132 (Electronic)18500668http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18500668 eng312008Included non-fusion patientsColomina ADDIN EN.CITE Colomina200432323217Colomina, M. J.Bago, J.Pellise, F.Godet, C.Villanueva, C.Department of Anaesthesiology, Hospital Universitario Vall d'Hebron, Area de Traumatologia, Passeig Vall d'Hebron, 119-129, 08035 Barcelona, Spain, 26750mjc@comb.es.Preoperative erythropoietin in spine surgeryEur Spine JS40-913 Suppl 1AdolescentAdultAgedBlood Coagulation/drug effectsBlood Loss, Surgical/*prevention & control*Blood Transfusion, AutologousBlood Viscosity/drug effectsCase-Control StudiesErythropoietin, Recombinant/adverse effects/*therapeutic useFemaleHemoglobins/metabolismHumansMaleMiddle AgedSpine/*surgery2004Oct0940-6719 (Print)15197631http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15197631 eng322004Did not report on outcomes of interestElwatidy ADDIN EN.CITE Elwatidy200870707017Elwatidy, S.Jamjoom, Z.Elgamal, E.Zakaria, A.Turkistani, A.El-Dawlatly, A.Division of Neurosurgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia. smfwat@yahoo.comEfficacy and safety of prophylactic large dose of tranexamic acid in spine surgery: a prospective, randomized, double-blind, placebo-controlled studySpineSpineSpineSpineSpineSpine2577-8033242008Nov 151528-1159 (Electronic)19011538http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19011538 eng332008Included tumor, non-fusion patientsGill ADDIN EN.CITE Gill200811117Gill, J. B.Chin, Y.Levin, A.Feng, D.Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, 3601 4th Street, MS 9436, Lubbock, TX 79430, USA. jbgill@nebraskaspinecenter.comThe use of antifibrinolytic agents in spine surgery. A meta-analysisJ Bone Joint Surg AmThe Journal of bone and joint surgeryJ Bone Joint Surg Am2399-40790116-Aminocaproic Acid/therapeutic useAdolescentAdultAntifibrinolytic Agents/*therapeutic useAprotinin/therapeutic useBlood Loss, Surgical/*prevention & controlHumansMiddle AgedSpine/*surgeryTranexamic Acid/therapeutic use2008Nov1535-1386 (Electronic)18978408http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18978408 eng342008Included pediatric patients, non-fusion patientsKakiuchi ADDIN EN.CITE Kakiuchi200239393917Kakiuchi, M.Department of Orthopaedic Surgery, Osaka Police Hospital, Japan.Intraoperative blood loss during cervical laminoplasty correlates with the vertebral intraosseous pressureJ Bone Joint Surg BrThe Journal of bone and joint surgery518-20844AdultAgedBlood Loss, Surgical/*physiopathologyFemaleHumansIntraoperative Complications/*physiopathologyMaleMiddle AgedNeurosurgical Procedures/*adverse effectsPressureSpine/*physiopathology/*surgery2002May0301-620X (Print)12043771http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12043771 eng352002Included non-fusion patientsNuttall ADDIN EN.CITE Nuttall200049494917Nuttall, G. A.Horlocker, T. T.Santrach, P. J.Oliver, W. C., Jr.Dekutoski, M. B.Bryant, S.Departments of Anesthesiology, Laboratory Medicine, Orthopedic Surgery, and Statistics, Mayo Clinic, Rochester, Minnesota 55905, USA. nuttall.gregory@mayo.eduPredictors of blood transfusions in spinal instrumentation and fusion surgerySpineSpineSpineSpineSpineSpine596-601255AdultAgedBlood Component Transfusion/*statistics & numerical data*Blood Loss, SurgicalErythrocyte CountFemaleHemoglobinsHumansLinear ModelsMaleMiddle AgedMultivariate AnalysisPredictive Value of TestsRetrospective StudiesSpinal Diseases/*surgery*Spinal Fusion2000Mar 10362-2436 (Print)10749636http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=10749636 eng362000Included trauma and tumor patientsRenkens ADDIN EN.CITE ADDIN EN.CITE.DATA 372001Included tumor and non-fusion patientsSchulmana ADDIN EN.CITE Shulman199816716716717Shulman, G.Solanki, D. R.Hadjipavlou, A.Department of Pathology, University of Texas Medical Branch, Galveston 77555-0717, USA. gshulman@utmb.eduAugmented autologous transfusions in major reconstructive spine surgeryJ Clin ApherJournal of clinical apheresisJ Clin ApherJournal of clinical apheresisJ Clin ApherJournal of clinical apheresis62-8132Adult*Blood Transfusion, Autologous/economicsErythrocyte TransfusionFemaleHumansMaleMiddle AgedSpine/*surgery19980733-2459 (Print)9704607http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9704607 eng381998Types of spinal surgical procedures not definedSchulmanb ADDIN EN.CITE Shulman199816816816817Shulman, G.Solanki, D. R.Nicodemus, C. L.Flores, I. M.Hadjipavlou, A. G.Department of Pathology, University of Texas Medical Branch, Galveston 77555-0192, USA.Audit of autotransfusion in spine surgeryInt OrthopInternational orthopaedicsInt OrthopInternational orthopaedicsInt OrthopInternational orthopaedics303-7225Adult*Blood Transfusion, Autologous/economicsCost-Benefit AnalysisErythrocyte TransfusionFemaleHemodilutionHumansMale*Medical AuditPlateletpheresisProspective StudiesQuality ControlReconstructive Surgical ProceduresSpine/*surgery19980341-2695 (Print)9914933http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9914933 eng391998Types of spinal surgical procedures not definedThompson ADDIN EN.CITE ADDIN EN.CITE.DATA 402008Included pediatric patientsYeom ADDIN EN.CITE ADDIN EN.CITE.DATA 412008Did not report on outcomes of interestZufferey ADDIN EN.CITE Zufferey200611111117Zufferey, P.Merquiol, F.Laporte, S.Decousus, H.Mismetti, P.Auboyer, C.Samama, C. M.Molliex, S.Department of Anesthesiology and Intensive Care and EA3065, Thrombosis Research Group, University Hospital of Saint-Etienne, Saint-Etienne, France. paul.zufferey@chu-st-etienne.frDo antifibrinolytics reduce allogeneic blood transfusion in orthopedic surgery?AnesthesiologyAnesthesiology1034-4610556-Aminocaproic Acid/therapeutic useAdultAntifibrinolytic Agents/*therapeutic useAprotinin/therapeutic useBlood TransfusionErythrocyte TransfusionHumans*Orthopedic ProceduresPostoperative Hemorrhage/*prevention & controlRandomized Controlled Trials as TopicTranexamic Acid/therapeutic use2006Nov0003-3022 (Print)17065899http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17065899 eng422006Reported on all orthopedic surgical procedures
Table 2a. Level of Evidence grade for studies reporting rate and outcomes of significant hemorrhage.
Methodological PrincipleBlanchette 2007Cha 2002Chanda 2002Epstein 2006Garcia-Erce 2004Gaus 2008Johnson 1989Reitman 2004Zheng 2002Study designRandomized controlled trialProspective cohort studyRetrospective cohort study(((((Case controlCase-series((((Patients at similar point in the course of their disease or treatment(((((((((Patients followed long enough for outcomes to occur(((((((((Complete follow-up of >80%(((((((((Controlling for extraneous prognostic factors((Evidence LevelIVIIIIVIVIIIIIIIVIIIII
Table 2b. Level of Evidence grade for studies reporting effectiveness of measures to decrease significant hemorrhage
Methodological PrincipleBehrman 1992Castro 2004Krohn 2002Lentschener 1999Okubadejo 2007Sachs 2007Tayyab* 2008Urban 2001Wong 2008Study designRandomized controlled trial(((((Prospective cohort study(Retrospective cohort study((((Case controlCase-seriesStatement of concealed allocation(((Intention to treat((((Independent or blind assessment((Co-interventions applied equally((((((((Complete follow-up of >80%(((((((((Adequate sample size((((((((Controlling for possible confounding(((Prospective study((((((Evidence LevelIIIIIIIIIIIIIIIIIIIII*Control group was not concurrent.
Applies to randomized controlled trials only.
Table 3. Studies reporting frequencies for and outcomes of significant hemorrhage.
Author
(Year)Study
DesignPopulationSurgical treatmentInterventionFrequency or mean of occurrenceRisk Factors (if has impact upon threshold) and OutcomesBlanchette
(2007) Retrospective case-seriesN = 42,029
Median age: 52 yrs
46% male
Comparative Database for inpatient use maintained by Premier Inc., Charlotte, NCCervical or lumbar spinal fusion surgeryNRAllogeneic blood transfusion = 10.7%%
Autologous blood transfusion = 3.2%Outcomes associated with increased risk of ABT:
Discharged to nursing facility, transferred or expired (compared with discharged to home)
Risk factors associated with increased risk of ABT:
Treatment by orthopedic surgeon compared with neurosurgeon
Not having received C S IATCha
(2002) Retrospective cohort
N = 104
Mean age: 66.6 yrs noninstrumented fusion, 50.5 yrs instrumented fusion
43% maleLumbar noninstrumented (n = 52) and instrumented (n = 52) fusionIf possible, patients underwent 2 units of PABDMean blood loss:
Noninstrumented: 1041 ml
Instrumented: 2026 ml
Allogeneic blood transfusion:
Noninstrumented, autodonation: 7/43=16.3%
Noninstrumented, no autodonation: 5/9=55.6%
Instrumented, autodonation: 16/43=37.2%
Instrumented, no autodonation: 7/9=77.7%
Autologous blood transfusion:
Noninstrumented, autodonation: 31/43=72.1%
Instrumented, autodonation: 36/43=83.7%Epstein
(2006)Retrospective case-seriesN = 68
Mean age: 50 yrs
34% maleMultilevel lumbar instrumented fusions for lumbar stenosis with instabilityperioperative normovolemic hemodilution utilizedABT = 23.5% (n = 16), all experienced post-op hypotension with dizziness
Mean operative blood loss:
ABT = 788 ml
No ABT = 746 ml
Mean post-operative Hct:
ABT = 25.4%
No ABT = 28%Garcia-Erce (2004)Retrospective case-seriesN = 556
Mean age: 47
NR% maleInstrumented vertebral fusionUnderwent PABD, 2 units drawn 1 time/wk for 2-5 weeks prior to surgeryABT = 14.4% (n = 80)
Allogeneic or autologous transfusion = 65.9% (n = 366)
Autologous transfusion: 1.36 1.13 units/person
Allogeneic transfusion: 0.34 1.67 units/personGause
(2008)Retrospective cohortN = 188
Mean age: 64 yrs
35% male
Posterior lumbar fusion with instrumentation with (n = 141) and without (n = 47) intraoperative C S
Trans f u s i o n i f H c t d"2 1 % o r H g b d"8 g / d L o r b l o o d p r e s s u r e o r c a r d i a c o u t p u t w a r r a n t e d t r a n s f u s i o n . I n t r a o p e r a t i v e a u t o l o g o u s b l o o d ( C S ) T r a n s f u s i o n r a t e :
C S g r o u p = 8 7 . 2 % ( 1 2 3 / 1 4 1 )
C o n t r o l g r o u p = 7 6 . 6 % ( 3 6 / 4 7 )
i n t r a o p e r a t i v e b l o o d l o s s ( p = . 0 0 0 1 ) :
C S g r o u p = 1 476 ml
Control group = 766 ml
Allogeneic blood transfusion (p=.007):
CS group = 1.6 U
Control group = 0.8 U
Autologous blood transfusion (p=.03):
CS group = 1.2 U
Control group = 0.7 U Reitman (2004)Retrospective case-seriesN = 102
Mean age: 48 yrs
50% malePosterolateral lumbar fusion with internal fixationIAT using C S (n = 56) or no IAT (n = 46). Some pts underwent 1 unit of PABD.Mean blood loss:
IAT = 650 ml
No IAT = 600 ml
Autologous transfusion:
IAT = 20% (n = 11)
No IAT = 41% (n = 19)
ABT:
IAT = 16% (n = 9)
No IAT = 9% (n = 4)Zheng
(2002)Retrospective case-seriesN = 112
Mean age:54 yrs
47% maleRevision lumbar spine decompression and fusion with segmental instrumentationNoneABT = 63% (n = 70)
ABT if postop Hct <30% = 83.3% (n = 45)
Mean blood loss with ABT = 1085 ml, mean blood loss without ABT = 1052 ml
Mean blood loss if Hct <30% = 8 7 4 m l , m e a n b l o o d l o s s i f H c t e"3 0 % = 1 2 7 2 m l A B T w a s a s s o c i a t e d w i t h a l o n g e r h o s p i t a l s t a y ( 6 . 5 v s 5 . 0 d a y s )
A B T w a s a s s o c i a t e d w i t h d i s c h a r g e t o r e h a b i l i t a t i o n ( v s h o m e c a r e )
H c t <