Rotational thromboelastometry–guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Significant blood loss and coagulopathy are often encountered during adult spinal deformity (ASD) surgery, and the optimal intraoperative transfusion algorithm is debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy and improve transfusion practices. The objective of this study was to investigate the effect of ROTEM-guided blood product management on perioperative blood loss and transfusion requirements in ASD patients undergoing correction with pedicle subtraction osteotomy (PSO).</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors retrospectively reviewed patients with ASD who underwent single-level lumbar PSO at the University of Virginia Health System. All patients who received ROTEM-guided blood product transfusion between 2015 and 2017 were matched in a 1:1 ratio to a historical cohort treated using conventional laboratory testing (control group). Co-primary outcomes were intraoperative estimated blood loss (EBL) and total blood product transfusion volume. Secondary outcomes were perioperative transfusion requirements and postoperative subfascial drain output.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The matched groups (ROTEM and control) comprised 17 patients each. Comparison of matched group baseline characteristics demonstrated differences in female sex and total intraoperative dose of intravenous tranexamic acid (TXA). Although EBL was comparable between ROTEM versus control (3200.00 ± 2106.24 ml vs 3874.12 ± 2224.22 ml, p = 0.36), there was a small to medium effect size (Cohen’s d = 0.31) on EBL reduction with ROTEM. The ROTEM group had less total blood product transfusion volume (1624.18 ± 1774.79 ml vs 2810.88 ± 1847.46 ml, p = 0.02), and the effect size was medium to large (Cohen’s d = 0.66). This difference was no longer significant after adjusting for TXA (β = −0.18, 95% confidence interval [CI] −1995.78 to 671.64, p = 0.32). More cryoprecipitate and less fresh frozen plasma (FFP) were transfused in the ROTEM group patients (cryoprecipitate units: 1.24 ± 1.20 vs 0.53 ± 1.01, p = 0.03; FFP volume: 119.76 ± 230.82 ml vs 673.06 ± 627.08 ml, p &lt; 0.01), and this remained significant after adjusting for TXA (cryoprecipitate units: β = 0.39, 95% CI 0.05 to 1.73, p = 0.04; FFP volume: β = −0.41, 95% CI −772.55 to −76.30, p = 0.02). Drain output was lower in the ROTEM group and remained significant after adjusting for TXA.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>For ASD patients treated using lumbar PSO, more cryoprecipitate and less FFP were transfused in the ROTEM group compared to the control group. These preliminary findings suggest ROTEM-guided therapy may allow early identification of hypofibrinogenemia, and aggressive management of this may reduce blood loss and total blood product transfusion volume. Additional prospective studies of larger cohorts are warranted to identify the appropriate subset of ASD patients who may benefit from intraoperative ROTEM analysis.</jats:p></jats:sec>

Rotational Thromboelastometry Predicts Transfusion Requirements in Total Joint Arthroplasties

“…FIBTEM MCF has been also used in several ROTEM-based algorithms for individualized hemostatic therapy to decrease transfusion requirements. [28][29][30][31][32][33][34][35][36][37] However, since studies aiming to identify the FIBTEM MCF value that predicts better and increased probability for transfusion are lacking, the cut-off value that has been used in those algorithms is not consistent. In some algorithms the cut-off value was selected based on author's preference, whereas in many others a value close to the reported lower reference range was chosen (►Table 6).…”

Pathway for Enhanced Recovery after Spinal Surgery-A Systematic Review of Evidence for use of Individual Components

“…In a study of patients undergoing major spinal surgery ROTEM (ROtational ThromboElastoMetry) device used with TXA was found to lead to a significantly lower blood loss and lower transfusion of packed red blood cells as compared to the TXA alone (123). Other studies have demonstrated the utility of ROTEM in decreasing the rate of blood product transfusion (124, 125).…”

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

“…In a study of patients undergoing major spinal surgery ROTEM (ROtational ThromboElastoMetry) device used with TXA was found to lead to a significantly lower blood loss and lower transfusion of packed red blood cells as compared to the TXA alone [126]. Studies have demonstrated the utility of ROTEM in decreasing the rate of blood product transfusion [127,128].…”