title: Transfusion medicine management for reconstructive spinal repair in a patient with von Willebrand's disease and a history of heavy surgical bleeding.
abstract: METHODS
  A case report of a multidisciplinary approach to a second reconstructive back surgery in a patient with von Willebrand's disease, flatback syndrome, and a history of heavy surgical bleeding is presented.
  
  
  OBJECTIVE
  To review the perioperative planning and assessment of hemostasis and transfusion medicine management, including administration of Humate P, a Factor VIII preparation with high von Willebrand factor content.
  
  
  BACKGROUND
  Reconstructive spinal procedures may require significant transfusion support even in patients with normal preoperative hemostasis. In addition to the hemostatic problem caused by von Willebrand's disease, the reported patient requested minimal exposure to allogeneic blood products because of hepatitis C infection acquired from previous transfusions.
  
  
  METHODS
  The multidisciplinary team included the patient, hematologist, blood bank medical director, anesthesiologist, and operating surgeon. Preoperative assessment showed a Type 2A von Willebrand's disease variant. A careful planning process included a test infusion of desmopressin and extensive autologous donations of red cells, plasma, and platelets, which were collected before the procedure.
  
  
  RESULTS
  Anterior and posterior spine fusions were performed during a 14-hour procedure. Hemostasis and clinical response were excellent. Humate P was administered perioperatively as assessed by the baseline Factor VIII and von Willebrand's disease levels, the plasma volume, the half-life of infused Humate P, and the anticipated risk and tolerance for bleeding. The estimated blood loss was 5 L. Replacement included 9 units of autologous red cells, 6 units of autologous plasma, 2 autologous plateletpheresis collections, a single allogeneic plateletpheresis product, and 17,000 units of Humate P administered over the perioperative period.
  
  
  CONCLUSIONS
  Using a careful multidisciplinary approach, excellent hemostasis can be achieved with minimal exposure to untreated allogeneic blood products during aggressive spinal surgery in a patient with a clinically significant congenital coagulopathy.
authors.affiliation: Transfusion Medicine, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA.
authors.forename: C D
authors.initials: CD
authors.lastname: Bolan
authors.forename: M E
authors.initials: ME
authors.lastname: Rick
authors.forename: D W
authors.initials: DW
authors.lastname: Polly
mesh_terms: D016063:Blood Loss, Surgical; D001803:Blood Transfusion; D005169:Factor VIII / Q000627:therapeutic use; D005260:Female; D006487:Hemostasis; D006801:Humans; D008499:Medical Records; D008875:Middle Aged; D010348:Patient Care Team; D010983:Plateletpheresis; D013122:Spinal Diseases / Q000150:complications* / Q000601:surgery* / Q000628:therapy; D013123:Spinal Fusion; D013131:Spine / Q000601:surgery*; D014842:von Willebrand Diseases / Q000150:complications*
chemical_list: D005169:Factor VIII