title: Massive blood loss in elective spinal and orthopedic surgery: Retrospective review of intraoperative transfusion strategy.
abstract: OBJECTIVE
  To evaluate the perioperative dynamics of hematologic changes and transfusion ratio in patients undergoing a major spinal surgery accompanied with massive bleeding defined as blood loss >5 liters.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Operating room of a university-affiliated hospital.
  
  
  METHODS
  Adult patients who underwent elective neurosurgical, orthopedic, or combined spinal surgical procedure between 2008 and 2012.
  
  
  METHODS
  Patients who underwent a major spinal or orthopedic surgery and who experienced major bleeding (>5 L) during surgery were identified and selected for final analysis. The following information was analyzed: demographics, clinical diagnoses, hematologic parameters, estimated intraoperative blood loss, blood product transfusions, and survival 1 year after surgery.
  
  
  RESULTS
  During the study period, 25 patients, who underwent 28 spinal procedures, experienced intraoperative blood loss >5 L. Mean patient age was 50.5 years and 56.4% were males. The majority of patients underwent procedures to manage spinal metastases. Median estimated intraoperative blood loss was 11.25 L (IQR 6.35-22 L) and median number of units (U) transfused was 24.5 U (IQR 14.0-32.5 U) of packed red blood cells (RBCs), 24.5 U (IQR 14.0-34.0 U) of fresh frozen plasma (FFP), and 4.5 U (IQR 3.0-11.5 U) of platelets (PLTs). The blood product transfusion ratio was 1 and 4 for RBC:FFP, and RBC:PLT, respectively. Hematocrit, hemoglobin, PLTs, partial thromboplastin, prothrombin time, INR, and, fibrinogen varied significantly throughout the procedures. However, acid-base status did not change significantly during surgery. Patients' survival at 1 year was 79.17%.
  
  
  CONCLUSIONS
  Our results indicate that a 1:1 RBC:FFP and 4:1 RBC:PLT transfusion ratio was associated with significant intraoperative variations in coagulation variables but stable intraoperative acid-base parameters. This transfusion ratio helped clinicians to achieve postoperative coagulation parameters not significantly different to those at baseline. Future studies should assess if more liberal transfusion strategies or point of care monitoring might be warranted in patients undergoing spinal surgery at risk of major blood loss.
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: Demicha.Rankin@osumc.edu.
authors.forename: Demicha
authors.initials: D
authors.lastname: Rankin
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: Alix.ZuletaAlarcon@osumc.edu.
authors.forename: Alix
authors.initials: A
authors.lastname: Zuleta-Alarcon
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: Suren.Soghomonyan@osumc.edu.
authors.forename: Suren
authors.initials: S
authors.lastname: Soghomonyan
authors.affiliation: Center for Biostatistics, The Ohio State University, Columbus, OH, USA. Electronic address: Mahmoud.Abdel-Rasoul@osumc.edu.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Abdel-Rasoul
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: Karina.Woodling@osumc.edu.
authors.forename: Karina
authors.initials: K
authors.lastname: Castellon-Larios
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: Sergio.Bergese@osumc.edu.
authors.forename: Sergio D
authors.initials: SD
authors.lastname: Bergese
mesh_terms: D000328:Adult; D000368:Aged; D001777:Blood Coagulation; D016063:Blood Loss, Surgical / Q000401:mortality / Q000706:statistics & numerical data*; D001803:Blood Transfusion / Q000379:methods* / Q000706:statistics & numerical data; D017558:Elective Surgical Procedures / Q000009:adverse effects*; D005260:Female; D006400:Hematocrit; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D019637:Orthopedic Procedures / Q000009:adverse effects*; D019990:Perioperative Care / Q000379:methods* / Q000706:statistics & numerical data; D011517:Prothrombin Time; D012189:Retrospective Studies; D013120:Spinal Cord Neoplasms / Q000601:surgery*
chemical_list: D006454:Hemoglobins
keywords: Massive blood loss; Massive transfusion; Spine surgery