Spine procedures are associated with high rates of blood loss which can result in a greater need for transfusions. Repeated exposure to blood products is associated with risks and adverse reactions such as transfusion-related acute lung injury, fluid shifting, and infections. With the higher number of spine procedures and the increasing open surgery times associated with difficult procedures, excessive blood loss has become more prevalent. Perioperative methods have been established to combat the excessive blood loss and decrease the need for blood products. Preoperatively, anemia and coagulopathy screening is standard at least 4 weeks before elective procedures. Erythropoietin, iron loading or transfusions are used to decrease preoperative anemia, a predisposing factor for blood loss. Autologous predonation of blood has been shown to be ineffective and decreases preoperative hemoglobin levels. Intraoperatively, antifibrinolytics such as tranexamic acid and aminocaproic acid are used to decrease blood loss. In addition, fibrinogen concentrates, thromboelastometry, acute normovolemic hemodilution, controlled hypotension, and temperature regulation are some of the techniques used to decrease blood loss and the need for transfusions. Postoperatively, fibrin sealants, shed blood salvage, and erythropoietin or intravenous iron are used in management of blood loss, especially in instances when the patient refuses blood products.
Study Design.
A retrospective database analysis among Medicare beneficiaries
Objective.
The aim of this study was to determine the effect of chronic steroid use and chronic methicillin-resistant Staphylococcus aureus (MRSA) infection on rates of surgical site infection (SSI) and mortality in patients 65 years of age and older who were treated with lumbar spine fusion.
Summary of Background Data.
Systemic immunosuppression and infection focus elsewhere in the body are considered risk factors for SSI. Chronic steroid use and previous MRSA infection have been associated with an increased risk of SSI in some surgical procedures, but their impact on the risk of infection and mortality after lumbar fusion surgery has not been studied in detail.
Methods.
The PearlDiver insurance-based database (2005–2012) was queried to identify 360,005 patients over 65 years of age who had undergone lumbar spine fusion. Of these patients, those who had been taking oral glucocorticoids chronically and those with a history of chronic MRSA infection were identified. The rates of SSI and mortality in these two cohorts were compared with an age- and risk-factor matched control cohort and odds ratio (OR) was calculated.
Results.
Chronic oral steroid use was associated with a significantly increased risk of 1-year mortality [OR = 2.06, 95% confidence interval (95% CI) 1.13–3.78, P = 0.018] and significantly increased risk of SSI at 90 days (OR = 1.74, 95% CI 1.33–1.92, P < 0.001) and 1 year (OR = 1.88, 95% CI 1.41–2.01, P < 0.001). Chronic MRSA infection was associated with a significantly increased risk of SSI at 90 days (OR = 6.99, 95% CI 5.61–9.91, P < 0.001) and 1 year (OR = 24.0, 95%CI 22.20–28.46, P < 0.001) but did not significantly impact mortality.
Conclusion.
Patients over 65 years of age who are on chronic oral steroids or have a history of chronic MRSA infection are at a significantly increased risk of SSI following lumbar spine fusion.
Level of Evidence: 3
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