Blood Conservation Techniques Research Articles

Blood Conservation: Exploring Alternatives to Blood Transfusions.

The conservation of blood products and the use of alternatives to blood transfusion are the best practice. Patients treated with blood conservation techniques will have a reduced risk of blood-borne diseases and a reduced risk of human error that can occur during blood processing. The bedside nurse plays a vital role in educating the patient and the caregiver regarding risks, benefits, and alternatives. A combination of techniques explored focuses on minimizing blood loss, building the patient's own blood supply, or both. Medications, herbs, and supplements can increase bleeding and place the patient at risk for a transfusion. Evidence from a variety of sources indicates that postoperative patients who receive a blood transfusion will have a harder time with wound healing and overall recovery. Allogeneic blood transfusions can induce clinically significant immunosuppression, as well as other effects in recipients, to include a re-occurrence of cancer. For the Jehovah's Witnesses patient, receiving blood transfusions against their conscience is equal to rape. Therefore, appropriate management entails an understanding of ethical and legal issues involved. Providing meticulous medical care, such as essential interventions and techniques to reduce blood loss, can minimize the risk of subsequent need for blood transfusions and decrease the financial burden to the health care system and its consumers.

Impact of intraoperative high-volume autologous blood collection on allogeneic transfusion during and after cardiac surgery: a propensity score matched analysis.

Perioperative use of allogeneic blood products is associated with higher morbidity, mortality, and hospital costs after cardiac surgery. Blood conservation techniques such as acute normovolemic hemodilution (ANH) report variable success. We hypothesized that large-volume ANH with limited hemodilution would reduce allogeneic blood transfusion compared to the standard practice. Retrospective observational study of cardiac surgery patients at the University of Maryland Medical Center between January 2014 and September 2017. Using the institutional Society of Thoracic Surgeons database 91 autologous and 981 control patients who underwent coronary artery bypass grafting, aortic valve replacement, or both were identified. After propensity matching of 13 preoperative characteristics, 84 autologous and 84 control patients were evaluated. Our primary endpoint was avoidance of blood transfusion during index hospitalization, and secondary endpoints were postoperative bleeding and major adverse outcomes. The median harvest volumes in the ANH and control groups were 1100 mL and 400 mL, respectively. Of the ANH group, 25% received any transfusion versus 45.2% of the control group after propensity score matching (p < 0.006). When controlling for preoperative platelet count, the transfusion rate ratios for ANH were 0.58 (95% confidence interval, 0.39-0.88) for RBCs and 0.63 (0.44-0.89) for non-RBC components, which were both found to be statistically significant. There was no difference found in major adverse events. These results suggest that large-volume ANH is beneficial in reducing both RBC and non-RBC component usage in cardiac surgery. A further prospective validation is warranted.

Myocardial oxygen balance during acute normovolemic hemodilution: A novel compartmental modeling approach

BackgroundHemodilution was introduced initially as a blood conservation technique to reduce allogeneic blood transfusion in patients undergoing surgical procedures. Although the technique has been approved by the National Institute of Health consensus panel, limits of hemodilution under anesthetic conditions have not been established as they have in animal models. MethodsA novel multi-compartmental modeling approach has been proposed that includes the effect of anesthesia to quantify the effect of hemodilution on myocardial oxygen balance during myocardial ischemia. ResultsThe results showed that isovolemic hemodilution would cause detrimental effects around a hematocrit of 15%. Even though the fall in oxygen content caused by the decrease in hemoglobin concentration was compensated by an increase in coronary blood flow induced by hypoxic vasodilation and decreased viscosity, the endocardial tissue received less oxygen compared to the epicardial regions, and this sub-endocardial ischemia eventually led to cardiac failure. Statistical analysis also showed that the type of acellular replacement fluid failed to affect the heart rate, the stroke index or the cardiac index during hemodilution, and supplemental oxygen improved the endocardial oxygen supply. ConclusionThe model validates the clinical conclusions that sub-endocardial ischemia causes cardiac failure under extreme hemodilution conditions and the model can also be easily integrated into other human simulators.

Blood conservation techniques in scoliosis surgery

Blood conservation techniques have largely been implemented to improve outcomes of scoliosis surgery, though there still remains some debate as to which particular techniques should be implemented and how efficacious they are in avoiding allogeneic blood transfusion. The most common domains of blood conservation include autologous blood donation, cell salvage, normovolemic hemodilution, and intraoperative antifibrinolytic use. While autologous blood donation has been a staple of care among such techniques, recent research has suggested that it may not decrease the risk of allogeneic blood transplant, and may, in fact, increase the risk. Thus, it has largely been phased out in scoliosis surgery. Cell saving techniques are widely used and have largely demonstrated decreased transfusion necessity, thus warranting its continued use. Normovolemic hemodilution has limited data regarding its efficacy in scoliosis surgery, though some of the available data support its efficacy. Further research is required before any definitive recommendation can be made. Finally, antifibrinolytics clearly have a role in limiting blood loss in scoliosis surgery, with tranexamic acid serving as the most studied example. In conclusion, there is still no definitive answer to the question of how blood can be best conserved in the setting of scoliosis surgery, and effective treatment regimens should involve multiple strategies.

Feasibility of autologous intraoperative blood collection and retransfusion in small children with complex congenital heart defects undergoing cardiopulmonary bypass.

Allogeneic blood product transfusion is common in pediatric patients undergoing cardiopulmonary bypass although it is associated with an increased risk for adverse events. Furthermore, numerous donor exposures may affect future blood transfusion needs and human leukocyte antigen matching for patients who may ultimately require cardiac transplantation. Autologous intraoperative blood collection and retransfusion is a known method of blood preservation, but has not been extensively practiced in pediatric patients. In this study we assess the feasibility of this blood conservation technique in small children with complex congenital heart defects undergoing cardiopulmonary bypass. After Institutional Review Board approval, we retrospectively reviewed the medical records of children weighing <10kg who underwent cardiopulmonary bypass over a 2-year period. Eighteen patients underwent autologous intraoperative blood collection and retransfusion and comprised the study group. Eighteen control patients were chosen by a 1:1 matched design using preoperative hematocrit, surgical procedure, and body weight. Multiple corresponding demographic and surgical variables, transfusion data, and clinical outcomes were compared. Patient demographics, operative parameters and preoperative laboratory, and coagulation values were similar between the two groups. Despite the removal of autologous blood, study patients did not require more inotropic support prior to cardiopulmonary bypass. They also did not experience a significant increase in bleeding as measured by 24-hour postoperative chest tube output. Study patients were exposed to significantly fewer donor units intraoperatively and within the first 24hours postoperatively. The use of autologous intraoperative blood collection and retransfusion is a feasible option for small children with complex congenital heart defects undergoing cardiopulmonary bypass. Study patients received significantly fewer donor exposures without an increase in postoperative bleeding. Children who require multiple cardiac surgeries or eventually transplantation could benefit from this blood conservation technique.

Current Status of the Use of Salvaged Blood in Metastatic Spine Tumour Surgery.

To review the current status of salvaged blood transfusion (SBT) in metastatic spine tumour surgery (MSTS), with regard to its safety and efficacy, contraindications, and adverse effects. We also aimed to establish that the safety and adverse event profile of SBT is comparable and at least equal to that of allogeneic blood transfusion. MEDLINE and Scopus were used to search for relevant articles, based on keywords such as “cancer surgery,” “salvaged blood,” and “circulating tumor cells.” We found 159 articles, of which 55 were relevant; 20 of those were excluded because they used other blood conservation techniques in addition to cell salvage. Five articles were manually selected from reference lists. In total, 40 articles were reviewed. There is sufficient evidence of the clinical safety of using salvaged blood in oncological surgery. SBT decreases the risk of postoperative infections and tumour recurrence. However, there are some limitations regarding its clinical applications, as it cannot be employed in cases of sepsis. In this review, we established that earlier studies supported the use of salvaged blood from a cell saver in conjunction with a leukocyte depletion filter (LDF). Furthermore, we highlight the recent emergence of sufficient evidence supporting the use of intraoperative cell salvage without an LDF in MSTS.

Intra-operative cell salvage in urological surgery: a systematic review and meta-analysis of comparative studies.

To evaluate systematically the safety and efficacy of intra-operative cell salvage (ICS) in urology. A search of Medline, Embase and Cochrane Library to August 2017 was performed using methods pre-published on PROSPERO. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible titles were comparative studies published in English that used ICS in urology. Primary outcomes were allogeneic transfusion rates (ATRs) and tumour recurrence. Secondary outcomes were complications and cost. Fourteen observational studies were identified, with a total of 4 536 patients. ICS was compared with no the blood conservation technique (seven studies), preoperative autologous donation (PAD; five studies) or both (two studies). Cohorts underwent open prostatectomy (11 studies), open cystectomy (two studies) or open partial nephrectomy (one study). Meta-analysis was possible only for ATRs within prostatectomy studies. In this setting, ICS reduced ATR compared with no the blood conservation technique (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.76) but not PAD (OR 0.76, 95% CI 0.39-1.31). In the non-prostatectomy setting, ATRs amongst patients who underwent ICS were significantly higher or similar in one and two studies, respectively. Tumour recurrence was found to be significantly less common (two studies), similar (eight studies) or not measured (four studies). All six studies reporting complications found no difference in their ICS cohorts. Regarding cost, one study from 1995 found ICS more expensive than PAD, while two more recent studies found ICS to be cheaper than no blood conservation technique. As a result of inter-study heterogeneity, meta-analyses were not possible for recurrence, complications or cost. Low-level evidence exists that, compared with other blood conservation techniques, ICS reduces ATR and cost while not affecting complications. It does not appear to increase tumour recurrence post-prostatectomy, although follow-up durations were short. Small study sizes and short follow-ups mean conclusions cannot be drawn with regard to recurrence after nephrectomy or cystectomy. Randomized trials with long-term follow-up evaluating ICS in urology are required.

The Impact of Three Different Wash Solutions on Autotransfusion Products

Many blood conservation techniques and strategies have been implemented to aid in decreasing the use of allogenic blood utilization during pediatric cardiothoracic surgery. Use of techniques, such as acute normovolemic hemodilution, retrograde autologous prime, venous autologous prime, and autotransfuion, may lead to a decrease in the need for allogenic blood products. Autotransfusion has become a standard of care for all cardiothoracic surgical procedures requiring cardiopulmonary bypass (CPB). Although widely used, there is still debate over which wash solution will produce the most physiologically normal autotransfusion product. Pediatric patients can be at a higher risk for electrolyte imbalance intraoperatively and postoperatively. In an attempt to minimize this, we sought out to evaluate three different wash solutions and how they would affect the final autotransfusion product. This comparison consisted of three wash solutions; .9% sodium chloride, Normosol-R™, and Plasma-Lyte A. Based on the evaluation of all wash solutions, Plasma-Lyte A produced the most physiological normal final autotransfusion product in regards to electrolytes.

The impact of intra-operative cell salvage during open radical prostatectomy.

BackgroundTo examine the effect of intra-operative cell salvage (ICS) in open radical prostatectomy.MethodsIn this retrospective cohort study, all patients undergoing open radical prostatectomy for malignancy at our institution between 10/04/2013 and 10/04/2017 were enrolled. Patients were grouped and compared based on whether they received ICS. Primary outcomes were allogeneic transfusion rates, and disease recurrence. Secondary outcomes were complications and transfusion-related cost.ResultsFifty-nine men were enrolled; 30 used no blood conservation technique, while 29 employed ICS. There were no significant differences between groups in age, pre- or post-operative haemoglobin, Charlson comorbidity index, operation duration or length of stay. Tumour characteristics were also similar between groups, including pre-operative prostate specific antigen, post-operative Gleason score, T-stage, nodal status and rates of margin positivity. Compared with controls, the ICS group had longer follow up (945 vs. 989 days; P=0.0016). The control and ICS groups were not significantly different in rates of tumour recurrence (6 vs. 3 patients; P=0.30) or complications (10 vs. 5 patients; P=0.16). While the proportion of patients receiving allogenic transfusion was similar (9 vs. 6 patients; P=0.41), fewer red blood products transfused (40 vs. 12 units) meant transfusion related costs were lower in ICS patients (AUD $47,666 vs. $37,429).ConclusionsICS reduced transfusion related costs, without affecting allogeneic transfusion rates, tumour recurrence or complication rates. These findings extend the literature supporting ICS in oncological surgery. Prospective randomised studies are needed to confirm the existing level III evidence.

Safety and feasibility of elective liver resection in adult Jehovah's Witnesses: the Henri Mondor Hospital experience

BackgroundElective liver resection (LR) in Jehovah’s Witness (JW) patients, for whom transfusion is not an option, involves complex ethical and medical issues and surgical difficulties. MethodsConsecutive data from a LR program for liver tumors in JWs performed between 2014 and 2017 were retrospectively reviewed. A systematic review of the literature with a pooled analysis was performed. ResultsTen patients were included (median age = 61 years). None needed preoperative erythropoietin. Tumor biopsy was not performed. Major hepatectomy was performed in 4 patients. The median estimated blood loss was 200 mL. A cell-saver was installed in 2 patients, none received saved blood. The median hemoglobin values before and at the end of surgery were 13.4 g/dL and 12.6 g/dL, respectively (p = 0.04). Nine complications occurred in 4 patients, but no postoperative hemorrhage occurred. In-hospital mortality was nil. Nine studies including 35 patients were identified in the literature; there was reported no mortality and low morbidity. None of the patients were transfused. ConclusionsBy using a variety of blood conservation techniques, the risk/benefit ratio of elective liver resection for liver was maintained in selected adult JW patients. JW faith should not constitute an absolute exclusion from hepatectomy.

Comprehensive blood conservation program in a new congenital cardiac surgical program allows bloodless surgery for the Jehovah Witness and a reduction for all patients.

Cardiac surgery on Jehovah's Witnesses (JW) can be challenging, given the desire to avoid blood products. Establishment of a blood conservation program involving the pre-, intra- and post-operative stages for all patients may lead to a minimized need for blood transfusion in all patients. Pre-operatively, all JW patients were treated with high dose erythropoietin 500 IU/kg twice a week. JW patients were compared to matching non-JW patients from the congenital cardiac database, two per JW to serve as control. Blood use, ventilation time, bypass time, pre-operative hematocrit, first in intensive care unit (ICU) and at discharge and 24 hour chest drainage were compared. Pre-operative huddle, operating room huddle and post-operative bedside handoff were done with the congenital cardiac surgeon, perfusionist, anesthesiologist and intensive care team in all patients for goal alignment. Five JW patients (mean weight 24.4 ± 25.0 Kg, range 6.3 - 60 Kg) were compared to 10 non-JW patients (weight 22.0 ± 22.8 Kg, range 6.2 - 67.8 Kg). There was no difference in bypass, cross-clamp, time to extubation (0.8 vs. 2.1 hours), peak inotrope score (2.0 vs. 2.3) or chest drainage. No JW patient received a blood product compared to 40% of non-JW. The pre-operative hematocrit (Hct) was statistically greater for the JW patients (46.1 ± 3.3% vs. 36.3 ± 4.7%, p<0.001) and both ICU and discharge Hct were higher for the JW (37 ± 1.8% vs 32.4 ± 8.0% and 41 ± 8.1% vs 34.8 ± 7.9%), but did not reach statistical significance. All patients had similar blood draws during the hospitalization (JW x 18 mL/admission vs non-JW 20 mL/admission). The continuous application and development of blood conservation techniques across the continuum of care allowed bloodless surgery for JW and non-JW patients alike. Blood conservation is a team sport and to make significant strides requires participation and input by all care providers.

Current practices in perioperative blood management for patients undergoing liver resection: a survey of surgeons and anesthesiologists

Objective: The development of new techniques and blood management strategies in liver resection, and the multidisciplinary nature of perioperative transfusion decision-making, creates an opportunity for practice variation. The aim of this study was to describe the current practices in perioperative blood management, and explore differences between surgeons and anesthesiologists. Methods: A survey was circulated to Canadian liver surgeons and anesthesiologists. The survey focused on management of pre-operative anemia, blood conservation strategies, estimation of blood loss, and transfusion decision-making in a multidisciplinary setting. Results: 198 physicians received the survey, with 117 responding (59.1%). Most responding surgeons (66.7%) perform over 20 liver resections per year, while most responding anesthesiologists (90%) take part in less than 20. The most common blood conservation strategy used is administration of anti-fibrinolytics (63% used them at least occasionally). The most important factor for anesthesiologists when deciding on an intraoperative transfusion was hemoglobin value (47.2%), for surgeons, it was patient hemodynamics (33.4%). Compared to when they started their career, 60.5% of respondents felt they were less likely to transfuse a patient now. Almost 40% of respondents replied that they had no specific management for preoperative anemia, or that someone else managed it. Conclusion: The results of our survey provide insights into current transfusion practice and decision making in liver resection, including a comparison between anesthesiologist and surgeon transfusion behaviour. The findings reflect trends toward restrictive transfusion strategies, and promote the development of improved blood conservation techniques and clinical practice guidelines.

Blood Loss in Orthopedic Surgery: A Historical Review

Joint arthroplasty since its inception has been associated with substantial blood loss and this blood loss has led to high allogenic transfusion rates as well as the development of hemarthrosis. Once hemarthrosis occurs, joint infection, wound complications, and increased recovery time also occur. The administration of allogenic blood products is not without risk and has been associated with incorrect blood crossmatching, transmission of both bacterial and viral pathogens, anaphylactic reactions, immunosuppression, and fluid overload. Postoperative anemia coupled with the resulting increase in transfusion requirements increases morbidity, mortality, length of hospital stay as well as overall health care costs. These factors have driven orthopedic surgeons to modify existing technology as well as propose new devices and protocols in an effort to maximize positive outcomes for their patients. The result is a robust, multimodal approach to blood conservation which is constantly changing and improving. This article chronicles the history of blood conservation techniques, analyzes their advantages and disadvantages and brings to light the cutting edge technology which modern medicine has produced to combat this problem.

Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

The Pediatric Craniofacial Collaborative Group established the Pediatric Craniofacial Surgery Perioperative Registry to elucidate practices and outcomes in children with craniosynostosis undergoing complex cranial vault reconstruction and inform quality improvement efforts. The aim of this study is to determine perioperative management, outcomes, and complications in children undergoing complex cranial vault reconstruction across North America and to delineate salient features of current practices. Thirty-one institutions contributed data from June 2012 to September 2015. Data extracted included demographics, perioperative management, length of stay, laboratory results, and blood management techniques employed. Complications and outlier events were described. Outcomes analyzed included total blood donor exposures, intraoperative and perioperative transfusion volumes, and length of stay outcomes. One thousand two hundred twenty-three cases were analyzed: 935 children aged less than or equal to 24 months and 288 children aged more than 24 months. Ninety-five percent of children aged less than or equal to 24 months and 79% of children aged more than 24 months received at least one transfusion. There were no deaths. Notable complications included cardiac arrest, postoperative seizures, unplanned postoperative mechanical ventilation, large-volume transfusion, and unplanned second surgeries. Utilization of blood conservation techniques was highly variable. The authors present a comprehensive description of perioperative management, outcomes, and complications from a large group of North American children undergoing complex cranial vault reconstruction. Transfusion remains the rule for the vast majority of patients. The occurrence of numerous significant complications together with large variability in perioperative management and outcomes suggest targets for improvement.

A review of the application of autologous blood transfusion.

Autologous blood transfusion (ABT) has been gradually attracting more attention due to the increasingly prominent problem of blood transfusion safety and blood shortage in recent years. With the rapid development of blood conservation techniques, blood component separation technology, blood transfusion medicine and a constant increase in clinical needs, ABT technology has been expanded and innovated to a large degree. In this study, the development of preoperative autologous blood donation (PABD), acute normovolemic hemodilution (ANH), intraoperative and postoperative autotransfusion, and other new technologies and theories are reviewed and existing questions are analyzed. Challenges and applications are also discussed in order to provide reference for peers.

A novel approach to modeling acute normovolemic hemodilution

Acute normovolemic hemodilution (ANH) was introduced as a blood conservation technique to reduce patient exposure to allogenic blood transfusion during surgery. Despite years of research and experience, the best practice procedure, efficacy and safety of ANH remain in question. In this work, a numerical model is developed for the ANH procedure based upon a multi-compartmental, fluid model of the body. The model also analyzes the most commonly used acellular fluids for ANH or for fluid therapy following hemorrhage. The model allows user input of critical ANH parameters, providing the ability to simulate the patient׳s response in real time to many clinical scenarios, using various types of resuscitation fluids. First, the patient׳s response to a representative, clinical ANH protocol and surgery was simulated. Then, the effect of several variables was investigated including: type/amount of resuscitation fluid, number of blood units collected during ANH, and amount of surgical blood loss. Our simulations highlighted the importance of osmotic molecules within the blood in preventing excessive fluid retention and initiating fluid clearance after surgery. The developed model can be utilized as a tool to simulate and optimize a variety of proposed protocol related to the ANH procedure and surgery. It can also be utilized as an educational or training tool to become familiar with the ANH procedure.

Blood Conservation Techniques and Platelet Function in Cardiac Surgery

Blood Conservation Techniques and Platelet Function in Cardiac Surgery

Management of operative blood loss in spinal deformity surgery

Background: Surgery for spinal deformity is associated with high levels of blood loss that may be increased with certain patient factors and complex or revision procedures that include osteotomies. Major blood loss is a vital consideration in patients undergoing complex spine surgery not only because of direct hemodynamic consequences but also because of the potential complications associated with allogeneic blood administration. The purpose of this review is to describe the current evidence supporting blood conservation techniques in spinal deformity surgery. Methods: A MEDLINE search for all articles concerning blood conservation techniques in spine surgery was undertaken. The literature search was limited to articles in English. Results: Major blood conservation techniques in spinal deformity surgery after thorough review of patient factors (i.e. patient age, sex, surgical indication, use of anticoagulant medications, baseline hematologic laboratory values, etc.), include preoperative autologous blood donation, erythropoietin supplementation, controlled intraoperative hypotension, anesthesia, perioperative autologous cell salvage, use of antifibrinolytics, acute normovolemic hemodilution, and postoperative blood salvage. Conclusions: A number of preoperative, intraoperative, and postoperative considerations for blood salvage exist. Techniques such as the use of antifibrinolytics, controlled hypotension, and perioperative autologous cell salvage are strong options to decrease the blood loss burden for each patient. Other techniques, such as preoperative autologous blood donation, have limited supporting data and should be used only in specific patients. A thorough consideration of these techniques can lead to lower surgical morbidity and better patient outcomes.

Transfusion-free management of gastrointestinal bleeding: the experience of a bloodless institute.

The Institute for Patient Blood Management and Bloodless Medicine at the Englewood Hospital has considerable experience in managing patients with gastrointestinal bleeding who do not accept blood-derived products. We present our data and experience over the last 8 years in managing such patients. There is paucity of data on management and outcomes of gastrointestinal bleeding in patients who do not accept blood-derived products. We performed a retrospective study of patients from 2003 to 2011 presenting with gastrointestinal bleeding who do not accept blood-derived products. Inclusion criteria were either overt bleeding with a presenting hemoglobin (Hb) of <12 g/dL or a decrease in Hb of >1.5 g/dL. Ninety-six patients who met the inclusion criteria were included. Forty-one upper and 48 lower gastrointestinal bleeding sources were identified. Mean Hb was 8.8 g/dL and mean nadir was 6.9 g/dL. Among 37 patients (80.5%) with Hb ≤6.0 g/dL, 30 (81%) survived. Four of 7 patients (57%) with a Hb <3 g/dL survived. The overall mortality rate was 10.4%. In unadjusted logistic regression models, age [1.06 (1.01-1.12 y)], admission to ICU [6.37(1.27-31.9)], and anticoagulation use [6.95 (1.57-30.6)] were associated with increased mortality. Initial Hb [0.68 (0.51-0.92)] and nadir Hb [0.48 (0.29-0.78)] inversely predicted mortality. These results suggest that transfusion-free management of gastrointestinal hemorrhage can be effective with mortality comparable with the general population accepting medically indicated transfusion. Management of these patients is challenging and requires a dedicated multidisciplinary team approach knowledgeable in techniques of blood conservation.

Surgical Management of Scoliosis in JehovahÂ’s Witness Patients: One InstitutionÂ’s Experience

Introduction: Blood loss is a major cause of morbidity in scoliosis surgery. Jehovah’s Witnesses pose a unique challenge, as their religious convictions restrict them from receiving blood products. There is a paucity of literature regarding blood conservation protocols in pediatric Jehovah’s Witness patients undergoing scoliosis surgery. Methods: Ten consecutive Jehovah’s Witness patients under 21 years of age, who underwent posterior spinal fusion for scoliosis between 1995 and 2013, were retrospectively evaluated. Medical charts were used to assess curve type and magnitude, blood conservation techniques used, operative time, estimated blood loss (EBL), hemoglobin levels and postoperative complications. Results: Diagnoses included 5 idiopathic, 3 syndromic, and 2 neuromuscular scoliosis. An average of 11.5 levels were fused with 58% curve correction. The mean operative time was 325 minutes. Commonly employed blood conservation techniques were electrocautery (100%), cell saver (70%), supplemental iron (70%), and epinephrinesoaked gauze (60%). Anti-fibrinolytics were consistently used in 4 cases since 2010, and the bipolar sealer device in 5 cases since 2007. Hemodilution and hypotensive anesthesia were used in 2 and one case, respectively. EBL was 544 ml. No surgery was aborted due to blood loss. The preoperative and nadir postoperative hemoglobin levels averaged 14.1 and 9.8 g/dL, respectively. There were 4 postoperative complications, which were unrelated to blood loss. At a mean 4-year follow-up, all patients were stable. Conclusion: Posterior spinal fusion can be safely performed in standard fashion in the pediatric Jehovah’s Witness population. The variety of blood conservation techniques has increased over recent years. More aggressive techniques such as hemodilution and hypotensive anesthesia are not always imperative for efficacious surgery. Our institution is currently establishing a blood conservation protocol for spinal deformity surgery.