Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P86. ROTEM-guided transfusion during pedicle subtraction osteotomy for adult spinal deformity: a propensity score-matched cohort analysis

Abstract

BACKGROUND CONTEXT Surgical correction of adult spinal deformity (ASD) is often associated with significant blood loss and coagulopathy. Optimal intraoperative transfusion algorithm remains debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy, and hence improve transfusion practices during surgery. PURPOSE To investigate the effects of ROTEM-guided therapy on intraoperative estimated blood loss (EBL) and transfusion requirements in patients who underwent pedicle subtraction osteotomy (PSO) for ASD. STUDY DESIGN/SETTING Retrospective chart review of a prospectively maintained, single-center, multisurgeon database. PATIENT SAMPLE Consecutive ASD patients. OUTCOME MEASURES Primary outcomes: intraoperative EBL and total volume of blood product transfused. Secondary outcomes: packed red blood cells (pRBC), platelets, cryoprecipitate, and fresh frozen plasma (FFP) transfused during surgery. METHODS All ASD patients who underwent single-level lumbar PSO with ROTEM-guided transfusion at our institution were matched in a 1:1 ratio to a historical cohort with the conventional clinical and point-of-care (POC) transfusion algorithm. Covariates for matching were age, body mass index, revision operation status, number of instrumented levels, number of transforaminal lumbar interbody fusions, number of Smith-Petersen osteotomies, and preoperative hemoglobin. RESULTS The matched groups comprised 17 patients each, and comparison of baseline demographic and surgical parameters demonstrated more women (p=.04) and a higher total intraoperative dose of intravenous tranexamic acid (TXA) administered (p=.03) in the ROTEM group. Although not significant, EBL was lower in the ROTEM group (3200.00±2106.24vs. 3874.12±2224.22 mL; p=.36), with small-to-medium effect size (Cohen's d=0.31). Prior to adjusting for TXA, ROTEM-based transfusion was associated with lower volume of total blood products transfused (1624.18±1774.79vs. 2810.88±1847.46 mL; p=.02), with medium-to-large effect size (Cohen's d=0.66). This difference was no longer significant after adjustment for TXA (β=−0.18; 95% CI [−1995.78 to 671.64]; p=.32). pRBC and platelet transfusions were comparable between the matched cohorts. The ROTEM group was associated with greater number of cryoprecipitate units (1.24±1.20vs. 0.53±1.01 units; p=.03) and lower FFP (119.76±230.82vs. 673.06±627.08 mL; p CONCLUSIONS Compared to the conventional transfusion criteria, the use of ROTEM-guided transfusion algorithm in lumbar PSO for surgical correction of ASD was associated with greater number of cryoprecipitate units and lower FFP volume transfused. ROTEM-guided transfusion allowed early identification and treatment of hypofibrinogenemia, and aggressive management of this complication may reduce intraoperative EBL and total volume of blood products transfused.