Incorporation of Blood and Fluid Management Within an Enhanced Recovery after Surgery Protocol in Complex Spine Surgery

Abstract

Study design retrospective review. Objective Enhanced Recovery After Surgery (ERAS) is a multidisciplinary set of evidence-based interventions to reduce morbidity and accelerate postoperative recovery. Complex spine surgery carries high risks of perioperative blood loss, blood transfusion, and suboptimal fluid states. This study evaluates the efficacy of a perioperative fluid and blood management component comprised of a restrictive transfusion policy, goal directed fluid management, number of tranexamic acid (TXA) utilization, and autologous blood transfusion within our ERAS protocol for complex spine surgery. Methods A retrospective review compared patients undergoing elective complex spine surgery prior to and following implementation of an ERAS protocol with intraoperative blood and fluid management. Outcomes included incidence of blood transfusion, estimated blood loss, intraoperative crystalloids administered, frequency of intraoperative TXA utilized, incidence of patients extubated within the operating room (OR), intensive care unit (ICU) admission, and hospital length of stay. Results Following implementation, the rate of blood transfusion decreased by 11.7%( P = .017) and average crystalloid infusion was reduced 680 mL per case( P < .001). Intraoperative blood loss decreased on average 342 mL per case( P = .001) and TXA use increased significantly by 25%( P < .001). Postoperative ICU admissions declined by 8.5%( P = .071); extubation within the OR increased by 13.3%( P = .005). Conclusions This protocol presents a unique perspective with the inclusion of an interdisciplinary and comprehensive blood and fluid management protocol as an integral part of our ERAS pathway for complex spine surgery. These results indicate that a standardized approach is associated with reduced rates of blood transfusion and optimized fluid states which was correlated with decreased postoperative ICU admissions.

Comparisons of Electrolyte Balance Efficacy of Two Gelatin-Balanced Crystalloid for Surgery Patients Under General Anesthesia: A Multi-Center, Prospective, Randomized, Single-Blind, Controlled Study

“…A growing number of studies have recommended restrictive fluid replacement to avoid potential risk factors in the perioperative period, reduce postoperative complications, and improve prognosis. 14 , 15 Fluid loss can be induced by primary diseases, anesthesia, surgery, and bleeding. The volume of fluid infusion and the types of electrolytes replaced by infusion should be respectively matched with the volume and electrolyte composition of the fluid lost.…”

“…While inflexible fluid management scheme is a less favored option, 22 restrictive fluid therapy in the perioperative period may help reduce complications and shorten hospital stay. 15 , 16 , 22 , 23 Furthermore, preoperative fasting and restricted drinking may cause pathological changes after surgery such as anemia, water and electrolyte disorders, and insufficient effective circulating blood volume, etc. 24 Moreover, Succinyl gelatin has the side effect of electrolyte disturbance because it contains saline solution in which the level of CL − and Na + is higher than that in normal plasma.…”