|Year : 2014 | Volume
| Issue : 2 | Page : 145-149
Application of controlled hypotension combined with autotransfusion in spinal orthomorphia
Li-Wen Zhou, Ming-Qiang Li, Xue-Song Wang, Youyang Wu, Fan Ye, Xihong Ye
Department of Anesthesiology, Xiangyang Central Hospital, Hubei University of Arts and Science, Hubei Province, China
|Date of Web Publication||16-Jun-2014|
Prof. Ming-Qiang Li
Department of Anesthesiology, Xiangyang Central Hospital, Hubei University of Arts and Science, Hubei Province, China
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Idiopathic scoliosis is a common spinal deformity in teenagers, which is managed mainly by orthomorphia. However, due to great trauma, long operative duration and large blood loss, a great amount of blood transfusion is needed during the surgery. Allogeneic blood transfusion should be reduced in order to release blood insufficient, decline blood transfusion expense, as well as avoid transfusion diseases.
Objective: The objective of the following study is to investigate the value of controlled hypotension combined with autotransfusion in idiopathic scoliosis orthomorphia and in order to reduce surgical bleeding and reduction in blood transfusion.
Subjects and Methods: Intra-operative controlled hypotension was performed during posterior orthomorphia surgery on all the 46 cases of idiopathic scoliosis, 17 cases in which were served as the control group, who underwent allogeneic blood transfusion without autotransfusion, whereas the other 29 cases were served as the experimental group, who underwent autotransfusion that including reinfusion of pre-operative deposited autologous blood and intra-operative salvaged autologous blood. The blood loss volume and transfusion status in two groups were observed.
Results and Conclusion: Blood loss volume in the control group was 400-1000 (835.3 ± 167.5) mL and that in the experimental group was 350-1400 (812.1 ± 152.7) mL, there was no marked difference between the two groups (P > 0.05). The volume of allogeneic blood transfusion in the control group was 500-1800 (855.9 ± 321.1) mL, which was greater than that in the experimental group ((0-1300 (337.9 ± 258.3) mL) (P < 0.01). The results suggested that controlled hypotension reduces intraoperative bleeding and post-operative autotransfusion minimizes the need of allogeneic blood transfusion.
Keywords: Autotransfusion, controlled hypotension, idiopathic scoliosis
|How to cite this article:|
Zhou LW, Li MQ, Wang XS, Wu Y, Ye F, Ye X. Application of controlled hypotension combined with autotransfusion in spinal orthomorphia. Anesth Essays Res 2014;8:145-9
|How to cite this URL:|
Zhou LW, Li MQ, Wang XS, Wu Y, Ye F, Ye X. Application of controlled hypotension combined with autotransfusion in spinal orthomorphia. Anesth Essays Res [serial online] 2014 [cited 2022 Oct 2];8:145-9. Available from: https://www.aeronline.org/text.asp?2014/8/2/145/134482
| Introduction|| |
Idiopathic scoliosis, a common spinal deformity among young people, is managed mainly by orthomorphia. However, orthomorphia surgery is associated with great trauma and prolonged operation time and in addition the need of intra-operative exposure and extensive tissue stripping predisposes patients to heavy blood loss, thus requiring transfusion of a great amount of blood. To ease the tension of limited blood source, reduce the cost of blood transfusion, avoid transfusion diseases and minimize allogeneic blood transfusion,  intra-operative controlled hypotension combined with autotransfusion were applied in idiopathic scoliosis orthomorphia surgery, as reported below.
| Subjects and Methods|| |
The study was approved by the ethics committee of the Xiangyang Central Hospital and conducted according to the principles of the Helsinki Declaration. An informed, written consent was obtained from each of the clinical patients included in the study.
A total of 46 cases with idiopathic scoliosis, aged from 11 to 36 years (average 20 years) and weighed from 20 to 62 kg (average 42 kg) were included in this study respectively. They were graded I-II according to the American Society of Anesthesiologists classifying system (no organ lesions, or there were only mild to moderate organ lesions but with good compensatory functions), with 42-105° (average 69°) Cobb angle. All patients received intra-operative controlled hypotension,17 cases among whom were served as the control group, who underwent allogeneic blood transfusion without autotransfusion, while the other 29 cases were served as the experimental group, who underwent autotransfusion, including reinfusion of the autologous blood deposited pre-operatively and that salvaged intra-operatively. In the experimental group, allogeneic blood transfusion was not applied unless autologous blood was insufficient. None of the patients had any blood system diseases. All the patients underwent posterior idiopathic scoliosis orthomorphia surgery and bone graft fusion with internal fixation. Pedicle hook fixation was used for upper thoracic vertebrae in three cases and pedicle screw insertion (7-10 screws) was used in the remaining 43 cases.
Controlled hypotension procedures
Every patient received sodium phenobarbital 0.1 g and atropine 0.5 mg, 30 min before entering the operation room. All patients received general anesthesia. Oxygen inspiration and denitrification began and last for 5 min before anesthesia induction. Midazolam 0.05-0.1 mg/kg, propofol 1 mg/kg, fentanyl 2-4 μg/kg and cisatracurium besylate 0.2 mg/kg were injected intravenously as induction drugs. All the patients received endotracheal intubation.
Propofol was transfused with target controlled infusion pump (target concentration 2-3 μg/mL). Fentanyl was administrated intermittently according to blood pressure (BP) and heart rate. Cisatracurium besylate 0.08-0.15 mg/kg/h was used to maintain muscular flaccidity. Mechanical ventilation of constant volume was maintained. Pulmonary ventilation: tidal volume VT 8-10 mL/kg, breathing rate 12-14 bpm, inspiratory: expiratory 1:2.
In the course of operation, all the patients were administered 0.01% sodium nitroprusside intravenously 0.5-5.0 μg/kg/min for controlled hypotension, maintaining systolic pressure levels at (90 ± 5) mmHg. The radial arterial cannula was connected to a pressure transducer (Mindray PM-9000, China). Systolic and diastolic arterial BP as well as mean arterial pressure was recorded online.
Collection of autologous blood
Autologous blood was collected by means of pre-operative autologous blood deposit and intra-operative autologous blood salvage. Prior to operation, patients in the experimental group who indicated for pre-operative autologous blood deposit were asked for a consent and signed a consent form of autologous blood transfusion (patient selection was based on a comprehensive assessment of general data, body weight, blood routines, etc.). At 1-2 weeks before orthomorphia operation, the patients without any blood collection contraindications began to undergo blood collection from the median cubital vein. Blood collection volume ranged from 200 to 400 mL/session, dependent on the individual's weight and general conditions. Between two collection sessions, there was an interval of over 3 days and blood collection was stopped at 3 days before the operation. The collected blood was processed with anticoagulant sodium citrate and then stored at 4°C and was re-warmed to 38-40°C before re-infused into patients intra-operatively. Patients who underwent pre-operative blood deposit were given an injection of erythropoietin after autologous blood collection,  as well as oral ferrous sulfate tablets 0.3 g, taken 3 times/day.
The patients who did not undergo autologous blood collection were also given an injection of erythropoietin; together with oral ferrous sulfate tablets 0.3 g, taken 3 times/ day.
For intra-operative autologous blood salvage, Wandong BW-8100A blood salvaging system was utilized to collect the oozing blood from the wound into a blood reservoir. Anticoagulant heparin was added during the blood suctioning and the salvaged blood was centrifuged and washed before re-infused into the patients in the experimental group.
When the operation was completed, all patients were sutured intradermically using absorbable suture lines. No post-operative drainage was applied. At 24 h after the operation, patients' vital signs were observed, oxygen saturation and urine volume were measured and blood routines and hepatic, renal and coagulation functions were tested.
All data of the study were processed by SPSS 10.0 software (IBM, USA). The data expressed by mean ± standard deviation. P < 0.05 was considered to be significant.
| Results|| |
Pre-operative and post-operative general data (including age, weight, Cobb angle, hemoglobin, hematocrit, incision length, the number of vertebrae exposed, inserted screws and intra-operative blood loss ) were not significantly different (P > 0.05) between the two groups [Table 1] and [Table 2]. The autologous blood volume collected in the experimental group: pre-operative deposited autologous blood volume was 200-1200 (596.6 ± 217.9) mL, whereas intra-operative salvaged autologous blood volume was 300-600 (434.5 ± 87.9) mL. Blood loss volume included both the blood suctioned into the reservoir intra-operatively and the blood in the gauze.
Blood loss volume in the control group was 400-1000 (835.3 ± 167.5) mL and that in the experimental group was 350-1400 (812.1 ± 152.7) mL (P > 0.05). The volume of allogeneic blood transfusion in the control group was 500-1800 (855.9 ± 321.1) mL and 0-1300 (337.9 ± 258.3) mL in the experimental group, there was a significant difference between the two groups (P < 0.01) [Table 3].
Blood transfusion reactions: None of the patients showed transfusion reactions. At 24 h and 7 days after the operation, both groups showed decreased hemoglobin and hematocrit when compared with the pre-operative values and the difference was significant (P < 0.05); all patients had mild anemia but did not manifest related clinical symptoms, with insignificant difference between two groups [Table 4]. As drainage devices were not placed in patients after operation, it is impossible to include such hidden blood loss as wound oozing and internal bleeding. The need of blood capacity supplementation was determined according to a comprehensive evaluation of patients' 24-h post-operative vital signs, oxygen saturation and urine volume, blood routines, liver and kidney functions.
| Discussion|| |
Idiopathic scoliosis is a common deformity of the spinal column, with orthomorphia surgery being its essential treatment. The preparation of graft bed (including decortication and V-osteotomy of small articular process) and the thoracoplasty require that a great amount of cancellous bone tissues be bitten away and the vertebral lamina surface be decorticated, causing heavy bleeding. In order to avoid the need of transfusion of a great amount of allogeneic blood and to minimize transfusion complications such as allergic reactions, the spread of hepatitis and acquired immunodeficiency syndrome, immune suppression and complications associated with heavy transfusion, , our department carried out, based on the intra-operative controlled hypotension performed in all the patients both in the experimental group and the control group, autologous blood collection on patients in the experimental group, including pre-operative autologous blood deposit and intra-operative autologous blood salvage.
Scoliosis orthomorphia surgery is associated with heavy blood loss, ranging from 800-4100 mL as reported by literature; , by contrast, results of this study showed the blood loss in the control group was 400-1000 (835.3 ± 167.5) mL and that in the experimental group was 350-1400 (812.1 ± 152.7) mL. As can be seen, controlled hypotension has the potential to reduce bleeding and provide a clearer surgical field, quite beneficial for the performance of surgical procedures. Nevertheless, the application of controlled hypotension presents certain risk to vital organs. It can lead to unexplained reduced blood capacity and vasoconstriction in the course of surgery, anemia, hidden coronary artery diseases, or sudden hemorrhage and tension pneumothorax which make patients susceptible to myocardial ischemia or cardiac arrest. Furthermore, controlled hypotension may also lead to insufficient local blood supply to the optic nerves, greatly increasing the possibility of unilateral or complete visual impairment. , Therefore, in the process of controlled hypotension, when blood oozing in the surgical field has been obviously reduced, it is not proper to further lower the BP for a "bloodless surgical field," otherwise, blood perfusion of the vital organs will become insufficient. A study of Shear and Tobias  have showed that a BP level lower than 55-65 mmHg after controlled hypotension would affect blood perfusion of the brain and cause corresponding complications.
Transfusion of pre-operative deposited blood is limited for patients who will undergo selected surgery, including: Patients who have good pre-operative general conditions not requiring emergent operation; patients whose intra-operative blood loss and post-operative blood transfusion needs are predictable; patients whose blood type is rare; patients with a past history of adverse reactions associated with allogeneic blood transfusion; patients who refuse allogeneic blood transfusion because of religious belief; in areas with allogeneic blood shortage. According to American Association of Blood Bank, the pre-collection concentration of hemoglobin should be higher than 110 g/L and that of hematocrit should be higher than 0.33. Blood collection volume per session shall not exceed (450 ± 45) mL, or 12% of the circulating blood volume; for patients whose weight is <50 kg, the blood collection volume should be <8 mL/kg body weight. Blood collection should be started 1 week before surgery; with an inter-session interval not <3 days and the time of the last collection session should precede the surgery at least 72 h. The patients undergoing pre-operative autologous blood deposit require supplementation of iron, an essential element for production of red blood cells. As routine, patients were given erythropoietin and oral ferrous sulfate tablets. Blood collection went smooth in all the patients without any adverse reactions. Current technology only allows the autologous blood to be preserved for 3 weeks and in addition patients are prone to experience a decline of pre-operative hemoglobin and hematocrit after blood collection, therefore, it is impossible to collect a great volume of autologous blood. In this sense, autologous blood transfusion cannot completely replace the extensive clinical application of allogeneic blood transfusion. The intra-operative autologous blood salvage procedures involved the use of a blood recovering system to suction the oozing blood from the wound into a blood reservoir with heparin added during blood suctioning for anticoagulation purpose, the processing of the recovered blood by centrifugation and washing and then the reinfusion of the salvaged red blood cells into the patients. As the recovery rate of blood from the surgical field was 60-80% and the recovery rate of red blood cells from the blood processing procedure was 60-70%, intra-operative autologous blood reinfusion was not necessary for patients in whom the blood loss volume was <500 mL respectively. In addition, because the washing process removes free hemoglobin, blood potassium, fibrin degradation products, platelet activation and degradation products complement activation products, micro-thrombus and cell and tissue fragments, transfusion of washed red blood cells alone may lead to coagulation disorders. A study by Tawes et al.  believed that platelets and clotting factors in the washed blood are markedly decreased, thus re-infusing plenty autologous blood is likely to dilute the blood and cause clotting disorders, consequently leading to bleeding tendency. In a study done by Li et al.  suggested that the appropriate autologous blood transfusion volume should be within 3000 mL and if the volume exceeds 4000 mL, infusion of fresh frozen plasma is warranted. Autologous blood reinfusion has been increasingly used in clinics. There have been studies ,, demonstrated that autologous blood reinfusion not only raised post-operative hemoglobin level, reduces the occurrence of systemic inflammatory response syndrome and infection, but also increases serum creatine kinase-MB level, playing a certain role in myocardial cell repairing. As regards the cost of blood transfusion, transfusion in the control group cost averagely 3450 Chinese Yuan, while the transfusion cost in the experimental group averaged at 2250 Chinese Yuan which included the pre-operative autologous blood deposit cost 160 Chinese Yuan, the intra-operative blood salvage cost 1000 Chinese Yuan and the allogeneic blood transfusion cost (if any). The transfusion costs between the two groups were significantly different, indicating autologous blood reinfusion can promise a great relief of the financial burden. Therefore, it is concluded that in patients who undergo idiopathic scoliosis orthomorphia surgery, controlled hypotension combined with autotransfusion not only promises milder intra-operative bleeding, less allogeneic blood transfusion, minimized transfusion-related complications and absence of blood-borne diseases, but also avoids wasting the autologous blood, which is especially meaningful for patients with RH negative blood type, reducing the financial burden to patients. Controlled hypotension combined with autotransfusion is of high value in idiopathic scoliosis orthomorphia.
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[Table 1], [Table 2], [Table 3], [Table 4]