Patient-, Procedure-, and Hospital-Related Risk Factors of Allogeneic and Autologous Blood Transfusion in Pediatric Spinal Fusion Surgery in the United States

Lam, Sandi; Pan, I‐Wen; Harris, Dominic A.; Sayama, Christina; Luerssen, Thomas G.; Jea, Andrew

doi:10.1097/brs.0000000000000816

Cited by 24 publications

(18 citation statements)

References 20 publications

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“…No significant variations in overall or subgroup compliance rates were shown in subgroups of age, sex, type of insurance, and diagnosis, though there were significant differences in AP compliance by race. Findings of racial disparity in pediatric surgical care are not unique; 1,6,7 reasons for this disparity in AP compliance are unclear and warrant further study. As substratification with specific patient comorbidities was not conducted in this study, it may be that there were specific clinical concerns or indications requiring prolonged antibiotic use beyond the recommended < 24-hour duration in guidelines.…”

Section: Discussionmentioning

confidence: 95%

Impact of antibiotic prophylaxis for intrathecal baclofen pump surgery in pediatric patients

Pan

Kuo

Luerssen

et al. 2015

FOC

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OBJECT This study explored antibiotic prophylaxis (AP) in pediatric patients undergoing intrathecal baclofen pump (ITBP) surgery and factors associated with perioperative AP compliance with clinical guidelines. METHODS Data were obtained from the Pediatric Health Information System. The study cohort comprised patients who underwent ITBP surgery within 3 days of admission, between July 1, 2004, and March 31, 2014, with a minimum prior screening period and follow-up of 180 days. Exclusion criteria were prior infection, antibiotic use within 30 days of admission, and/or missing financial data. Chi-square tests and multivariate logistic regressions were used to determine factors associated with compliance with AP guidelines in ITBP surgeries. RESULTS A total of 1,534 patients met the inclusion criteria; 91.5% received AP and 37.6% received dual coverage or more. Overall bundled compliance comprised 2 components: 1) perioperative antibiotic administration and 2) < 24-hour postoperative antibiotic course. The most frequently used antibiotics in surgery were cefazolin (n = 873, 62.2%) and vancomycin (n = 351, 25%). Documented bundled AP compliance rates were 70.2%, 62.0%, 66.0%, and 55.2% in West, South, Midwest, and Northeast regions of the US, respectively. Compared with surgeries in the Northeast, procedures carried out in the West (OR 2.0, 95% C11.4-2.9, p < 0.001), Midwest (OR 1.6, 95% C11.1-2.3, p = 0.007), and South (OR 1.5, 95% C11.1-2.0, p = 0.021) were more likely to have documented AP compliance. Black (OR 0.74, 95% CI 0.55-1.00, p = 0.05) and Hispanic (OR 0.63, 95% CI 0.47-0.86, p = 0.004) patients were less likely to have documented AP compliance in ITBP surgeries than white patients. There were no significant differences in compliance rate by age, sex, type of insurance, and diagnosis. AP process measures were associated with shorter length of stay, lower hospitalization costs, and lower 6-month rates of surgical infection/complication. One of the 2 noncompliance subgroups, missed preoperative antibiotic administration, was correlated with a significantly higher 6-month surgical complication/infection rate (27.03%) compared with bundled compliance (20.00%, p = 0.021). For the other subgroup, prolonged antibiotic use > 24 hours postoperatively, the rate was insignificantly higher (22.00%, p = 0.368). Thus, of direct relevance to practicing clinicians, missed preoperative antibiotics was associated with 48% higher risk of adverse complication/infection outcome in a 6-month time frame. Adjusted hospitalization costs associated with baclofen pump surgery differed significantly (p < 0.001) with respect to perioperative antibiotic practices: 22.83, 29.10, 37.66 (× 1000 USD) for bundled compliance, missed preoperative antibiotics, and prolonged antibiotic administration, respectively. CONCLUSIONS Significant variation in ITBP antibiotic prophylaxis was found. Documented AP compliance was associated with higher value of care, showing favorable clinical and financial outcomes. Of most impact to clinical outcome, missed preoperative antibiotics was significantly associated with higher risk of 6-month surgical complication/infection. Prolonged antibiotic use was associated with significantly higher hospital costs compared with those with overall bundled antibiotic compliance. Future research is warranted to examine factors associated with practice variation and how AP compliance is associated with outcomes and quality, aiming for improving delivery of care to pediatric patients undergoing ITBP procedures.

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Section: Discussionmentioning

confidence: 95%

Impact of antibiotic prophylaxis for intrathecal baclofen pump surgery in pediatric patients

Pan

Kuo

Luerssen

et al. 2015

FOC

Self Cite

View full text Add to dashboard Cite

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“…Due to the reported differences in transfusion practices between races in adults in major surgery and the paucity of information in pediatrics, we set out to study potential racial disparities among patients undergoing pediatric scoliosis surgery at our institution to determine if a measurable difference existed that may suggest an increased transfusion risk in minorities. Our retrospective review of medical records allowed for reliable identification of Black and White patients, however “Other” races were not consistently identified and therefore were grouped together for analysis.…”

Section: Discussionmentioning

confidence: 99%

“…Given the inconsistent methodology in measuring intraoperative estimated blood loss, 1 surrogate that has been used in this population is blood transfusion requirement . Conservative studies estimate that at least 25% of pediatric spine surgeries require intraoperative blood transfusion . Minimizing blood transfusion is beneficial as transfusions have been associated in adult and pediatric literature with increased morbidity, including risk of surgical site infections (SSI), longer hospitalizations, and increased cost …”

Section: Introductionmentioning

confidence: 99%

“…In the adult literature, there is evidence that African‐American or Black patients are more likely to require intraoperative blood transfusion than Caucasian or White patients during major surgery . One recent large database review suggested that Black children have an increased chance of receiving transfusion when compared to White children during surgical spinal fusion, though they were unable to incorporate certain known risk factors in their analysis. Concern regarding these findings led us to examine the possible relationship between those who self‐identified as Black race and increased estimated blood loss and blood transfusion in primary pediatric scoliosis surgery at our institution.…”

Section: Introductionmentioning

confidence: 99%

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Analysis of the impact of race on blood transfusion in pediatric scoliosis surgery

Maher

Zhou

Cooter

et al. 2018

Pediatric Anesthesia

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“…Factors associated with blood loss in PSF for scoliosis or kyphosis have been investigated mostly in retrospective studies . These studies have implicated the following patient and surgical risk factors for blood loss: Cobb angle >50°, female gender, African American race, anemia, known bleeding disorders, abnormal coagulation profiles, neuromuscular scoliosis, operative time, posterior lumbar fusion, number of levels fused, and use of Ponte osteotomies . Ryan and colleagues found that children with scoliosis have a high prevalence of abnormalities in screening coagulation laboratory tests obtained preoperatively compared with healthy patients, primarily the prothrombin time .…”

Section: Introductionmentioning

confidence: 99%

Coagulative function assessed preoperatively via the clot formation and lysis assay as a prognostic factor for blood loss in adolescents undergoing posterior spinal fusion for idiopathic scoliosis

Fernández

Neustadt

Hahn

et al. 2019

Pediatric Anesthesia

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Background 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. Aim 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. Methods 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). Results 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). Conclusion 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.

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Patient-, Procedure-, and Hospital-Related Risk Factors of Allogeneic and Autologous Blood Transfusion in Pediatric Spinal Fusion Surgery in the United States

Abstract: 4.

Cited by 24 publications

References 20 publications

Impact of antibiotic prophylaxis for intrathecal baclofen pump surgery in pediatric patients

Impact of antibiotic prophylaxis for intrathecal baclofen pump surgery in pediatric patients

Analysis of the impact of race on blood transfusion in pediatric scoliosis surgery

Coagulative function assessed preoperatively via the clot formation and lysis assay as a prognostic factor for blood loss in adolescents undergoing posterior spinal fusion for idiopathic scoliosis

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