Association between perioperative surgical home implementation and transfusion patterns in adolescents with idiopathic scoliosis undergoing spinal fusion

Abstract

Background

Blood transfusions in patients with adolescent idiopathic scoliosis after fusion have been associated with increased morbidity, mortality, and cost.

Objective

The aim of this study was to evaluate the association between implementation of blood‐conservation strategies within the perioperative surgical home on transfusion rates for patients with adolescent idiopathic scoliosis undergoing spinal fusion.

Methods

213 patients (44 pre‐perioperative surgical home, 169 post‐perioperative surgical home) who underwent posterior spine fusion for adolescent idiopathic scoliosis between June 23, 2014, and July 30, 2017, were enrolled in this case control study. The perioperative surgical home implemented in March 2015 involved evidence‐based perioperative interventions to create a standardized clinical pathway including judicious use of crystalloid management, restrictive transfusion strategy, routine use of cell saver, and standardized administration of anti‐fibrinolytics. The primary outcome was odds of perioperative transfusion. Secondary outcomes included volumes of crystalloid, albumin, cell saver, packed red blood cells as well as calculated blood loss. Other variables that were documented included antibrinolytic total dose, mean arterial pressure, temperature, laboratory values, intrathecal morphine dosing, and surgical time. Statistical methods include t test and logistic regression.

Results

For the post‐perioperative surgical home, the odds of perioperative transfusion were 0.30 (95% CI 0.13–0.70), as compared to pre‐perioperative surgical home. In terms of secondary outcomes, calculated blood loss was significantly lower in the post‐perioperative surgical home patients (27.0 ml/kgmL pre‐perioperative surgical home vs. 22.8mL/kg post‐perioperative surgical home; mean difference = ‐0.24 (‐0.44, ‐0.04)). Although no difference was noted in amount of intraoperative cell saver or albumin administered, a reduction was noted in mean intraoperative crystalloid given post‐perioperative surgical home (41.4 mL/kg ± 20.4 mL/kg pre‐perioperative surgical home vs. 28.0mL/kg ± 13.7 mL/kg post‐perioperative surgical home; log mean difference = 0.37 (95%CI 0.21 – 0.53), P <0.001). Post‐perioperative surgical home patients also had a significantly higher temperature nadir (mean difference=‐0.47 (95%CI ‐0.70 – ‐0.23); P <0.001), received a significantly higher total antifibrinolytic dose (mean difference=‐3939 (95%CI ‐5364 ‐ ‐2495); P <0.001), and were exposed to shorter surgical times (mean difference=0.72 (95%CI 0.36 – 1.09); P <0.001).

Conclusions

Implementation of blood‐conservation strategies as part of a perioperative surgical home for patients with adolescent idiopathic scoliosis undergoing posterior spine fusion resulted in significant decrease in perioperative blood transfusions.

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