David Mari, DO,
Pediatric Medical Director
Naval Medical Center Portsmouth
Disclosure information not submitted.
Abhik Biswas, MD, FAAP
Medical Director, Inpatient Pediatrics
Cape Fear Valley Medical Center, United States
Disclosure information not submitted.
Title: Fluid Restriction and TXA Bundle during Adolescent Spinal Surgery Affects Anemia and Coagulopathy
Introduction: Adolescent Idiopathic Scoliosis can be corrected with Posterior Spinal Fusion Surgery (PSF). With PSF surgery there is significant increase in bleeding, coagulopathy, and transfusion requirements. We postulate that a standardized intraoperative protocol using restricted intravenous (IV) fluids and bolus Tranexamic Acid (TXA) dose would have an effect on postoperative anemia and coagulation cascade.
Methods: This is a retrospective study of 44 patients, ages 11-21, who underwent PSF and recovered in the PICU from June 2011 to November 2019. A PSF protocol was initiated as part of a Process Improvement initiative at our institution based upon multiple pediatric centers’ practices. Eighteen patients were studied prior to the PSF protocol and 26 patients were studied on the PSF protocol. Protocol consisted of restricting IV fluids to 1500 mL and giving IV TXA 10-30 mg/kg over 15 minutes intraoperatively. Postoperatively both groups did not have fluid restriction, were given isotonic maintenance IV fluids, and did not receive medications that would alter the coagulation cascade.
Results: Protocol group compared to pre-protocol group were found to have statistically significant decrease in hemoglobin on postoperative day 1 (11 vs 11.35 g/dL, P= < .001), day 2 (10.2 vs 10.65 g/dL, P= < .001), and day 3 (9 vs 11 g/dL, P=.0299); lower PT, PTT, and INR on post-operative day 1 (PT 14.8 vs 15.9 secs, P= < .001; PTT 27.9 vs 32.1 secs, P= < .001; INR 1.2 vs 1.3, P= < .001) and day 2 (PT 15.4 vs 16 secs, P=.29; PTT 32.2 vs 34 secs, P=.0043; INR 1.2 vs 1.3, P=.0043); and lower fibrinogen on postoperative day 2 (290 vs 570 mg/dL, P=.0007). Protocol group, compared to pre-protocol group, was noted to have increase platelet counts on postoperative days 1-3 (248 vs 187.5 x 109/L, P= < .001; 203 vs 173.5 x 109/L, P= < .001; and 184 vs 142 x 109/L, P=.0003). There was no difference in IV fluids (P= >.999) and blood products (P= >.999) given, and estimated blood loss postoperatively (P=.8432).
Conclusions: By restricting intraoperative IV fluids and giving IV TXA in PSF surgery leads to lower hemoglobin, PT, PTT, and fibrinogen levels. This did not result in less blood loss, or blood products and IV fluids given postoperatively.