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Blood transfusion following major orthopaedic surgery in cerebral palsy: a retrospective analysis
Matthias Z H Lu1, Susan M Reid2, Kristopher Lundine1
1Department of Orthopaedic Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.
Insights
Children with cerebral palsy (CP) undergoing major orthopedic surgery often require red blood cell (RBC) transfusions. Patient blood management (PBM) strategies can be improved to optimize surgical outcomes and reduce transfusion needs in these high-risk patients.
Area of Science:
- Orthopedic Surgery
- Pediatric Hematology
- Patient Blood Management
Background:
- Children with cerebral palsy (CP) frequently develop progressive musculoskeletal issues requiring corrective surgery.
- Major orthopedic surgeries in CP patients carry a high risk of significant blood loss and red blood cell (RBC) transfusion.
- There is considerable variation in the application of perioperative patient blood management (PBM) strategies.
Purpose of the Study:
- To investigate the factors associated with RBC transfusion in pediatric CP patients undergoing major orthopedic surgery.
- To identify areas for improvement in PBM strategies and inform the development of optimized care pathways.
Main Methods:
- Retrospective review of pediatric patients with CP undergoing spinal fusion or single event, multilevel surgery (SEMLS) between 2010-2015.
- Data collection included demographics, Gross Motor Function Classification System (GMFCS) level, surgical details, PBM utilization, and transfusion rates.
- Univariable analysis was used to identify factors contributing to RBC transfusion.
Main Results:
- 37% of patients (n=134) received RBC transfusions; 12% were anemic preoperatively with only 19% having ferritin levels checked.
- Higher GMFCS levels, sodium valproate use, longer surgical duration, spinal fusion, pelvic instrumentation, and more osteotomies were linked to increased transfusion rates.
- Intraoperative tranexamic acid and cell salvage use varied significantly between spinal fusion (89%, 81%) and SEMLS (22%, 3%) cohorts.
Conclusions:
- Over one-third of pediatric CP patients undergoing major orthopedic surgery required RBC transfusion.
- Patients with more severe CP (higher GMFCS) and those undergoing complex, lengthy procedures faced the highest transfusion risk.
- There is a substantial opportunity to enhance PBM practices to optimize patient preparation and minimize transfusion requirements.
Background:
Progressive musculoskeletal pathology is ubiquitous among children with cerebral palsy (CP). Corrective surgery places them at risk of major blood loss and red blood cell (RBC) transfusion. Significant variability exists in uptake of perioperative patient blood management (PBM) strategies. This study aimed to examine factors contributing to RBC transfusion and assist in future development of care pathways.
Methods:
A retrospective review at a tertiary paediatric hospital was undertaken to identify patients with CP undergoing either primary spinal fusion or single event, multilevel surgery (SEMLS) between 2010 and 2015. Solely soft tissue procedures were excluded. Data collected included demographics, Gross Motor Function Classification System level, surgical details, perioperative PBM and transfusion rates. Univariable analysis was performed to assess contributing factors to RBC transfusion.
Results:
A total of 36 spinal fusion and 98 SEMLS patients were included. Preoperatively, 12% were anaemic, but only 19% had a ferritin checked. Overall, 49 patients (37%) received RBC transfusions. Intraoperative usage of tranexamic acid and cell salvage was 89% and 81%, respectively, for the spine cohort, and 22% and 3% for the SEMLS cohort. Successively higher Gross Motor Function Classification System levels, sodium valproate usage, longer surgical times, spinal fusion, pelvis instrumentation and more osteotomies were associated with RBC transfusion.
Conclusion:
More than one-third of CP patients who underwent major orthopaedic surgery received RBC transfusion. As expected, the more severely affected patients undergoing longer procedures were at highest risk. Significant improvements can be made in PBM to help optimize patients for surgery and minimize the need for transfusion.
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