To assess the relationship of preoperative hematology laboratory results with intraoperative estimated blood loss and transfusion volumes during posterior spinal fusion for pediatric neuromuscular scoliosis.
Methods
Retrospective chart review of 179 children with neuromuscular scoliosis undergoing spinal fusion at a tertiary children’s hospital between 2012 and 2017. The main outcome measure was estimated blood loss. Secondary outcomes were volumes of packed red blood cells, fresh frozen plasma, and platelets transfused intraoperatively. Independent variables were preoperative blood counts, coagulation studies, and demographic and surgical characteristics. Relationships between estimated blood loss, transfusion volumes, and independent variables were assessed using bivariable analyses. Classification and Regression Trees were used to identify variables most strongly correlated with outcomes.
Results
In bivariable analyses, increased estimated blood loss was significantly associated with higher preoperative hematocrit and lower preoperative platelet count but not with abnormal coagulation studies. Preoperative laboratory results were not associated with intraoperative transfusion volumes. In Classification and Regression Trees analysis, binary splits associated with the largest increase in estimated blood loss were hematocrit ≥44% vs. <44% and platelets ≥308 vs. <308 × 109/L.
Conclusions
Preoperative blood counts may identify patients at risk of increased bleeding, though do not predict intraoperative transfusion requirements. Abnormal coagulation studies often prompted preoperative intervention but were not associated with increased intraoperative bleeding or transfusion needs.
AnadioJMSturmPFForslundJM, et al2017A bleeding assessment tool correlates with intraoperative blood loss in children and adolescents undergoing major spinal surgery. Thrombosis Research15282–86
3.
BerryJGAshASCohenEHasanFFeudtnerCHallM2017Contributions of children with multiple chronic conditions to pediatric hospitalizations in the United States: a retrospective cohort analysis.Hospital Pediatrics7 (7) 365–372
4.
BerryJGGoldmannDAMandlKD, et al2011Health information management and perceptions of the quality of care for children with tracheotomy: a qualitative study. BMC Health Servics Research11117
5.
BerryJGRodeanJHallM, et al2016Impact of chronic conditions on emergency department visits of children using Medicaid. The Journal of Pediatrics182267–274
6.
BrennBRTherouxMCDabneyKWMillerF2004Clotting parameters and thromboelastography in children with neuromuscular and idiopathic scoliosis undergoing posterior spinal fusion. Spine29 (15) E310–E314
7.
CaubetJFEmansJBSmithJT, et al (2009)
Increased hemoglobin levels in patients with early onset scoliosis: prevalence and effect of a treatment with Vertical Expandable Prosthetic Titanium Rib (VEPTR). Spine34 (23) 2534–2536
8.
CoranDLRodgersWBKeaneJFHallJEEmansJB1999Spinal fusion in patients with congenital heart disease. Predictors of outcome. Clinical Orthopaedics and Related Research36499–107
9.
EdlerAMurrayDJForbesRB2003Blood loss during posterior spinal fusion surgery in patients with neuromuscular disease: is there an increased risk?Paediatric Anaesthesia13 (9) 818–822
10.
GrossSKeeferVLiebmanJ1968The platelets in cyanotic congenital heart disease. Pediatrics42 (4) 651–658
11.
FeudtnerCChristakisDAConnellFA2000Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980–1997. Pediatrics106 (1 Pt 2) 205–209
12.
FeudtnerCFeinsteinJASatchellMZhaoHKangTI2007Shifting place of death among children with complex chronic conditions in the United States, 1989–2003. JAMA297 (24) 2725–2732
13.
FeudtnerCFeinsteinJAZhongWHallMDaiD2014Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr14199
14.
FeudtnerCSilveiraMJChristakisDA2002Where do children with complex chronic conditions die? Patterns in Washington State, 1980–1998. Pediatrics109 (4) 656–660
15.
FontanalsMO’LearyJDZaarourCSkeltonTFaraoniD2019Preoperative anemia increases the risk of blood cell transfusion and prolonged hospital length of stay in children undergoing spine arthrodesis surgery. Transfusion59 (2) 492–499
16.
JainASponsellerPDShahSA, et al2017Incidence of and risk factors for loss of 1 blood volume during spinal fusion surgery in patients with cerebral palsy. Journal of Pediatric Orthopaedics37 (8) e484-e487
17.
JensenASJohanssonPIIdornL, et al2013The haematocrit–an important factor causing impaired haemostasis in patients with cyanotic congenital heart disease. International Journal of Cardiology167 (4) 1317–1321
18.
JiaRLiNXuBYZhangWGuXPMaZL2017Incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with neuromuscular scoliosis: a STROBE-compliant retrospective observational analysis. Medicine96 (11) e6292
19.
KannanSMeertKLMooneyJFHillman-WisemanCWarrierI2002Bleeding and coagulation changes during spinal fusion surgery: a comparison of neuromuscular and idiopathic scoliosis patients. Pediatric Critical Care Medicine3 (4) 364–369
20.
KeenanWNGriffithsHCleggJ1998Evaluating blood loss in children’s orthopaedic surgery: a simplified method of photometric analysis of eluted swabs. Journal of Pediatric Orthopaedics18 (4) 488–491
21.
KoenkerR1994Confidence intervals for regression quantiles. In: MandlPHuskovaM (Eds) Asymptotic Statistics. Contributions to StatisticsHeidelberg,
Physica
22.
KompDMSparrowAW1970Polycythemia in cyanotic heart disease–a study of altered coagulation. Journal of Pediatrics76 (2) 231–236
23.
LamSKPanIWHarrisDASayamaCMLuerssenTGJeaA2015Patient-, procedure-, and hospital-related risk factors of allogeneic and autologous blood transfusion in pediatric spinal fusion surgery in the United States. Spine40 (8) 560–569
24.
LiNJiaRGuXPMaZL2017Risk factors associated with massive drainage after posterior spinal orthopaedic surgery for adolescent scoliosis. Zhonghua Yi Xue Za Zhi97 (44) 3460–3465
25.
MaurerHMMcCueCMRobertsonLWHagginsJC1975Correction of platelet dysfunction and bleeding in cyanotic congenital heart disease by simple red cell volume reduction. American Journal of Cardiology35 (6) 831–835
26.
MeertKLKannanSMooneyJF2002Predictors of red cell transfusion in children and adolescents undergoing spinal fusion surgery. Spine27 (19) 2137–2142
27.
NuttallGAHorlockerTTSantrachPJOliverWCJrDekutoskiMBBryantS2000Predictors of blood transfusions in spinal instrumentation and fusion surgery. Spine25 (5) 596–601
28.
OrkinSHNathanDGGinsburgDLookATFisherDELuxE2015Nathan and Oski's Hematology and Oncology of Infancy and ChildhoodEd 8.
Philadelphia,
Elsevier
29.
ReeseJALiXHaubenM, et al2010Identifying drugs that cause acute thrombocytopenia: an analysis using 3 distinct methods. Blood116 (12) 2127–2133
30.
ReeseJANguyenLPBuchananGR, et al2013Drug-induced thrombocytopenia in children.Pediatric Blood Cancer60 (12) 1975–1981
31.
rpart: Recursive Partitioning and Regression Trees [computer program] 2017 Version 4.1-11
32.
RumallaKYarbroughCKPugelyAJKoesterLDorwardIG2016Spinal fusion for pediatric neuromuscular scoliosis: national trends, complications, and in-hospital outcomes. Journal of Neurosurgery Spine25 (4) 500–508
33.
RyanKMO'BrienKReganI, et al2015The prevalence of abnormal preoperative coagulation tests in pediatric patients undergoing spinal surgery for scoliosis. Spine Journal15 (6) 1217–1222
34.
SaoudFStoneANutterA, et al2019Validation of a new method to assess estimated blood loss in the obstetric population undergoing cesarean delivery. American Journal of Obstetrics and Gynecology221 (3): 267.e1-267.e6
35.
ShibataJHasegawaJSiemensHJ, et al2003Hemostasis and coagulation at a hematocrit level of 0.85: functional consequences of erythrocytosis. Blood101 (11) 4416–4422
36.
SimonTDBerryJFeudtnerC, et al2010Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics126 (4) 647–655
37.
WaldmanJDCzapekEEPaulMHSchwartzADLevinDLSchindlerS1975Shortened platelet survival in cyanotic heart disease. Journal of Pediatrics87 (1) 77–79
38.
WedemeyerALEdsonJRKrivitW1972Coagulation in cyanotic congenital heart disease.The American Journal of Diseases of Children124 (5) 656–660
39.
ZhengFCammisaFPJrSandhuHSGigrardiFPKhanSN (2002)
Factors predicting hospital stay, operative time, blood loss, and transfusion in patients undergoing revision posterior lumbar spine decompression, fusion, and segmental instrumentation. Spine27 (8) 818–824
