by Elizabeth Hofheinz, M.P.H., M.Ed.
Recent work from the Raleigh Orthopaedic Clinic, Hospital for Special Surgery, Weill Cornell Medical College, OrthoArizona, and the FOCOS Hospital in Ghana has pitted postoperative blood salvage and autotransfusion against traditional closed suction drainage to see which one is superior in reducing the rate of homologous blood transfusions in adult spinal deformity patients.
Evan Sheha, M.D., a spine surgeon at HSS, commented to OSN, “Given the significant blood loss associated with spinal deformity surgery and the inherent risks of allogeneic blood transfusion, the use of intraoperative cell salvage as a means to reduce the incidence of postoperative homologous transfusion has been shown to be both clinically and cost effective and is routinely used at our institution. However, at the time this study was conceived, the theoretical advantages of postoperative cell salvage and reinfusion – i.e. decreased risk of blood-borne disease transmission or surgical site infection, transfusion reaction, cost, etc. – in spinal deformity surgery had not been studied.”
A total of 34 patients who had long posterior fusions were randomized to Group 1 (a blood salvage and reinfusion system known as OrthoPat), while 35 patients’ surgeries involved a standard subfascial closed suction drain (Group 2).
The researchers found no differences in preoperative or intraoperative parameters. They wrote, “Patients in Group 1 had higher hemoglobin levels on postoperative day (POD) 2 and POD 3 compared to those in Group 2. However, there was no significant difference in the percentage of patients requiring homologous blood transfusion between the two groups (41% Group 1 vs. 60% Group 2, P1⁄40.17). Similarly, a subgroup analysis in patients with estimated blood loss >2000mL also showed no difference in homologous blood transfusion rates (67% Group 1 vs. 76% Group 2, P1⁄40.58). There were no differences in the rate or type of postoperative complications.”
“While the direct and indirect costs of homologous blood transfusion will certainly vary between hospital systems, some estimates place the cost of blood transfusion between $500 and $1200,” stated co-author, Venu Nemani, M.D., a spine surgeon at Virginia Mason in Seattle, Washington, to OSN. “Though we did not conduct a formal cost analysis in this study, the cost of the postoperative blood salvage equipment, which was significantly higher at the time of the study, was not justified by the lack of clinical benefit.”
The ”benefits” debate
Han Jo Kim, M.D., a spine surgeon at HSS, was also a co-author on the study. He commented to OSN, “The debate primarily surrounds the cost effectiveness of using postoperative blood salvage, but that is assuming, of course, that it confers a clinical benefit. Despite the theoretical benefits of postoperative blood salvage and retransfusion, we found no significant difference in either the rates of postoperative allogeneic transfusion or the amount of blood transfused between the two groups.”
“We found that patients receiving cell salvage had significantly higher total drain output (46% higher) and higher drain output in the first 24 hours (65% higher). While the exact reasons for this finding are unclear, we hypothesized that this is likely secondary to potentially deleterious effects of receiving salvaged blood on coagulation and fibrinolysis.”
Dr. Sheha, “Though our study did not support the routine use of postoperative blood salvage in spinal deformity surgery, it has been shown to confer a clinical benefit in several total joint arthroplasty studies, suggesting that it may have a clinical utility that was not captured in this study. As both perioperative blood conservation strategies and blood salvage technology will continue to evolve, our findings should not preclude the future study of postoperative blood salvage and reinfusion in spine surgery.”