Abstract
BackgroundRoutine use of antifibrinolytic agents in spine surgery is still an issue of debate.ObjectiveTo gather scientific evidence for the efficacy and safety of antifibrinolytic agents including aprotinin, tranexamic acid (TXA) and epsilon aminocaproic acid (EACA, traditionally known as Amicar) in reducing perioperative blood loss and transfusion requirements in scoliosis surgery.MethodsWe conducted a systematic review and meta-analysis for randomized controlled trials (RCTs), retrospective case-control studies, and retrospective cohort studies on the use of antifibrinolytic agents in scoliosis surgery by searching in the MEDLINE and EMBASE databases and the Cochrane Database of Systematic Reviews and Controlled Trials of papers published from January 1980 through July 2014. Safety of the antifibrinolytic agents was evaluated in all included studies, while efficacy was evaluated in RCTs.ResultsEighteen papers with a total of 1,158 patients were eligible for inclusion in this study. Among them, 8 RCTs with 450 patients were included for evaluation of pharmacologic efficacy (1 RCT was excluded because of a lack of standard deviation data). Mean blood loss was reduced in patients with perioperative use of antifibrinolytic agents by 409.25 ml intraoperatively (95% confidence interval [CI], 196.57–621.94 ml), 250.30 ml postoperatively (95% CI, 35.31–465.30), and 601.40 ml overall (95% CI, 306.64–896.16 ml). The mean volume of blood transfusion was reduced by 474.98 ml (95% CI, 195.30–754.67 ml). The transfusion rate was 44.6% (108/242) in the patients with antifibrinolytic agents and 68.3% (142/208) in the patients with placebo. (OR 0.38; 95% CI; 0.25–0.58; P<0.00001, I2 = 9%). All studies were included for evaluation of safety, with a total of 8 adverse events reported overall (4 in the experimental group and 4 in the control group).ConclusionThe systematic review and meta-analysis indicated that aprotinin, TXA, and EACA all significantly reduced perioperative blood loss and transfusion requirements in scoliosis surgery. There was no evidence that the use of antifibrinolytic agents was a risk factor for adverse events, especially thromboembolism, in scoliosis surgery.
Highlights
Scoliosis, which is defined as a lateral curvature of the spine, is the most common deformity of the spine and has been focused for centuries by physicians[1]
Mean blood loss was reduced in patients with perioperative use of antifibrinolytic agents by 409.25 ml intraoperatively (95% confidence interval [CI], 196.57–621.94 ml), 250.30 ml postoperatively, and 601.40 ml overall
Antifibrinolytic Agents in Scoliosis Surgery volume of blood transfusion was reduced by 474.98 ml
Summary
Scoliosis, which is defined as a lateral curvature of the spine, is the most common deformity of the spine and has been focused for centuries by physicians[1]. Multi-segmental spinal instrumentation and fusion, and sometimes osteotomy were effective methods of correcting scoliosis, but were commonly associated with massive blood loss requiring blood transfusion[2,3,4,5,6,7]. Either allogenic or autologous blood transfusions can increase the length of hospital stay and medical cost. Since the 1990s, antifibrinolytic agents, such as aprotinin, tranexamic acid (TXA) and epsilon aminocaproic acid (EACA), have been suggested to use in complex surgery to reduce bleeding. More and more evidence revealed that these antifibrinolytic agents were successful to reduce perioperative blood loss and blood transfusion requirements in major pediatric surgery, cardiac surgery, total hip replacement arthroplasty and total knee replacement arthroplasty[13,14,15]. Routine use of antifibrinolytic agents in spine surgery is still an issue of debate
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