Fernandez Allison M, Neustadt Jeffrey B, Hahn Gregory V, Nguyen Anh Thy H, Amankwah Ernest K, Goldenberg Neil A
Department of Anesthesia, Pain and Perioperative Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.
Children's Orthopaedic and Scoliosis Surgery Associates, St. Petersburg, FL, USA.
Paediatr Anaesth. 2019 Nov;29(11):1136-1145. doi: 10.1111/pan.13742. Epub 2019 Oct 14.
Posterior spinal fusion for adolescent idiopathic scoliosis is a complex surgery often associated with clinically significant blood loss leading to perioperative blood transfusion. Knowledge of risk factors for blood loss and transfusion stems mostly from retrospective studies.
We sought to prospectively investigate putative prognostic factors for intraoperative blood loss and perioperative blood transfusion in adolescent idiopathic scoliosis patients undergoing posterior spine fusion, including clinical characteristics, surgical factors, and preoperative assessment of overall coagulative and fibrinolytic functions in plasma using the clot formation and lysis (CloFAL) assay.
Following Internal Review Board approval, adolescents 10 to <21 years old with idiopathic scoliosis undergoing posterior spine fusion were enrolled preoperatively in a single-institutional prospective cohort and biobanking study. Clinical data were collected on patient characteristics, surgical approach, perioperative management, intraoperative estimated blood loss, and blood transfusion through hospital discharge. Coagulative and fibrinolytic functions in plasma were measured on preoperative samples by CloFAL assay (Coagulation Index and modified Fibrinolytic Index). Univariate linear regression and multivariable linear regression were performed to identify predictors of weight-indexed intraoperative estimated blood loss EBL (EBL/kg).
The final study population included 74 patients. Median age was 14.8 years (SD = 2.2). After adjustment for other putative prognostic factors via multivariable linear regression, coagulative function as determined preoperatively by CloFAL Coagulation Index was an independent predictor of intraoperative (EBL)/kg. Specifically, each 10% increase in CloFAL CI was associated with 3% decrease in the geometric mean of EBL/kg (OR 0.97, 95%CI 0.94-0.99, P = .01).
In adolescents undergoing posterior spinal fusion for idiopathic scoliosis, increased coagulative function measured preoperatively using the CloFAL assay is independently associated with decreased intraoperative blood loss. Future studies should expand upon these investigations of plasma coagulative and fibrinolytic capacities in combination with clinical factors, to guide precise preventive strategies against blood loss and blood transfusion in this patient population.
青少年特发性脊柱侧弯后路脊柱融合术是一项复杂手术，常伴有临床上显著的失血，导致围手术期输血。关于失血和输血风险因素的知识大多来自回顾性研究。
我们试图前瞻性地研究接受后路脊柱融合术的青少年特发性脊柱侧弯患者术中失血和围手术期输血的假定预后因素，包括临床特征、手术因素以及使用血栓形成和溶解（CloFAL）试验对血浆中整体凝血和纤维蛋白溶解功能进行术前评估。
经内部审查委员会批准，年龄在10至<21岁、患有特发性脊柱侧弯且接受后路脊柱融合术的青少年在术前被纳入一项单机构前瞻性队列和生物样本库研究。收集了患者特征、手术方式、围手术期管理、术中估计失血量以及直至出院时的输血情况等临床数据。通过CloFAL试验（凝血指数和改良纤维蛋白溶解指数）对术前样本进行血浆凝血和纤维蛋白溶解功能检测。进行单变量线性回归和多变量线性回归以确定体重指数化术中估计失血量（EBL/kg）的预测因素。
最终研究人群包括74例患者。中位年龄为14.8岁（标准差=2.2）。通过多变量线性回归对其他假定预后因素进行调整后，术前通过CloFAL凝血指数确定的凝血功能是术中EBL/kg的独立预测因素。具体而言，CloFAL CI每增加10%，EBL/kg的几何平均值就降低3%（比值比0.97，95%置信区间0.94 - 0.99，P = 0.01）。
在接受特发性脊柱侧弯后路脊柱融合术的青少年中，术前使用CloFAL试验测得的凝血功能增强与术中失血量减少独立相关。未来的研究应结合临床因素，对这些血浆凝血和纤维蛋白溶解能力的研究进行扩展，以指导针对该患者群体的精确失血和输血预防策略。
