Strategies to Minimize Blood Loss and Transfusion in Pediatric Spine Surgery

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Surgical correction of spinal deformity may be accompanied by considerable blood loss. Estimated blood loss varies depending on the etiology of scoliosis1. Patients with idiopathic scoliosis tend to lose less blood (16% to 44% of blood volume) in comparison with patients with scoliosis secondary to a neuromuscular disorder (50% to 75% of blood volume)1. As the length of fusion increases, blood loss also increases. During a posterior spinal fusion for patients with adolescent idiopathic scoliosis, blood loss per minute per level is greatest during osseous resection with facetectomies and decortication; however, the largest contribution to the total estimated blood loss is during instrumentation2.
Controlling blood loss reduces transfusion necessity. Allogenic blood transfusion is expensive; potential risks include viral infection, transfusion reaction, and adverse transfusion-related immunomodulation effects3,4. Patients receiving allogenic transfusions during spine surgery demonstrate increased complication and readmission rates compared with patients who do not receive transfusion5. Even if an allogenic transfusion is not warranted, blood loss can amplify a catabolic state and can cause physiologic stress; it can take up to 21 to 98 days to regenerate lost red blood cells after a surgical procedure in healthy patients6.
The risk of perioperative blood transfusion is multifactorial. Patient age, coexisting medical conditions, type and extent of spinal correction surgical procedure planned, a revision surgical procedure, and/or presence of a neurogenic spinal disorder must be considered during preoperative counseling. Table I demonstrates our recommendations for clinical screening preoperatively to identify high-risk patients.
Modern perioperative blood conservation techniques have reduced blood loss and transfusion requirements in spinal surgical procedures. This review outlines the current perioperative practices to manage and reduce blood loss during posterior spinal fusion for pediatric patients with scoliosis. We present this review in three sections: preoperative, intraoperative, and postoperative management; each subsection is prioritized from most important to least important recommendations.

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