losartan-potassium and Scoliosis

Pediatric scoliosis surgery is associated with considerable blood loss and allogenic transfusions. Transfusions contribute to morbidities and cost. A perioperative pediatric blood management program was implemented at our institution. Patients received preoperative evaluation, cell salvage, topical hemostasis, antifibrinolytics, and hypotensive anesthesia.. The study was a 2-year retrospective cohort review of the program's population from September 2007 through August 2009.. A total of 110 scoliosis surgeries were performed with only 34 and 12% of the patients requiring preoperative oral iron and erythropoietin, respectively. Neuromuscular scoliosis patients had more repaired segments and a larger transfusion rate than idiopathic scoliosis patients (36% vs. 1.7%, p = 0.001). Transfused patients had more blood loss relative to their blood volume (p = 0.001) and blood loss was associated with higher Cobb angles (p = 0.04). Logistic regression revealed that blood loss (p = 0.001), number of segments fused (p = 0.004), and lower patient weight (p = 0.007) are associated with increased odds for transfusion. Twelve patients (10.9%) were identified with low von Willebrand activity with a trend toward higher blood losses (p = 0.07) with lower activity levels.. Transfusion requirements in scoliosis patients are dependent on blood loss as determined by Cobb angles and number of segments fused relative to the patients' blood volume as determined by weight. Implementation of a blood management protocol resulted in a low transfusion rate and unexpectedly led to the preoperative diagnosis of a number of patients with low levels of von Willebrand activity.

Topics: Adolescent; Blood Coagulation Disorders; Blood Loss, Surgical; Blood Transfusion; Blood Volume; Body Weight; Cohort Studies; Dietary Supplements; Erythropoietin; Female; Folic Acid; Hemostasis, Surgical; Humans; Iron; Logistic Models; Male; Outcome Assessment, Health Care; Retrospective Studies; Scoliosis; Spinal Fusion; Thrombophilia

A retrospective review.. To review the effectiveness of blood conservation techniques in the spinal fusion of patients that refuse blood transfusion; specifically the Jehovah's witnesses population.. Spinal surgery can be challenging in patients refusing blood transfusion. There is paucity in the literature examining blood conservation techniques in spinal surgery.. The radiographic and medical records of 19 Jehovah's witnesses patients who underwent spinal deformity surgery at a single institution between 2000 and 2003 were reviewed. Patients were assessed for excessive blood loss (EBL), deformity correction, operative time, perioperative complications, and hospital stay. At latest follow-up (mean, 40 months; range, 8-76) the patients were examined for radiographic fusion, progression and complications.. Spinal fusion was attempted in 19 patients, with a mean age of 17 years (range, 10-36 years). All 19 patients were identified through the "Bloodless Surgery Program." Hypotensive anesthesia, hemodilution, and cell saver was employed for all 19 cases. Erythropoietin with supplemental iron was used in 15 patients. Aprotinin was used in 3 patients. EBL and blood returned by cell saver averaged 855 and 341 mL, respectively. Operative times average 315 minutes. The average drop in hemoglobin from after surgery was 3.1 g/dL. There were 2 intraoperative complications: (i) transient loss of somatosensory evoked potential/motor evoked potential signals; and (ii) one surgery abandoned due to EBL. The average spinal deformity correction was 58%. There were 3 postoperative complications, none related to their refusal of a transfusion. 17 patients were available for radiographic and clinic follow-up of at least 24 months. All displayed radiographic fusion without progression.. These blood conservation techniques allow satisfactory completion of deformity surgery on those patients not willing to be transfused and without major anesthetic or medical complications.

Topics: Adolescent; Adult; Blood Loss, Surgical; Blood Transfusion; Child; Epoetin Alfa; Erythropoietin; Female; Follow-Up Studies; Humans; Jehovah's Witnesses; Kyphosis; Male; Radiography; Recombinant Proteins; Retrospective Studies; Scoliosis; Spinal Fusion; Treatment Refusal; Young Adult

To describe the successful perioperative hemostatic management of a Jehovah's Witness patient with hemophilia B and anaphylactic inhibitors to factor IX, undergoing scoliosis surgery.. A 14 (1/2)-yr-old boy with severe hemophilia B who had a history of anaphylactic inhibitors to factor IX was scheduled to undergo corrective scoliosis surgery. He was initially started on epoetin alfa and iron supplementation to maximize preoperative red cell mass. Additionally, he was placed on a desensitization protocol of recombinant coagulation factor IX (rFIX) and was then treated with activated recombinant coagulation factor VII (rFVIIa) during the postoperative period. Tranexamic acid was given concomitantly. The intraoperative blood loss was approximately 350 mL. The nadir hemoglobin concentration was 111 g.L(-1) on postoperative days one and two. On postoperative day 11, the patient was stable and discharged home with a hemoglobin of 138 g.L(-1). He did not require blood transfusion and no adverse events were observed.. The use of rFIX, rFVIIa, erythropoetin, iron, and tranexamic acid before, during and after scoliosis surgery may be a viable and safe option for hemophilia patients with inhibitors, who refuse blood products.

Topics: Adolescent; Antifibrinolytic Agents; Blood Loss, Surgical; Dietary Supplements; Epoetin Alfa; Erythropoietin; Factor IX; Factor VII; Follow-Up Studies; Hematinics; Hemoglobins; Hemophilia B; Humans; Iron; Jehovah's Witnesses; Male; Recombinant Proteins; Scoliosis; Trace Elements; Tranexamic Acid

A patient with thalassemia minor and idiopathic scoliosis was scheduled for posterior vertebral arthrodesis. The diagnosis of thalassemia minor was made during the preoperative assessment. Preoperative blood cell count displayed the following data: red blood count 5.4 x 106/microL, haemoglobin 11.6 g/dL and hematocrit 36.9%. As corrective surgery for scoliosis is associated with major blood loss, the patient was scheduled for preoperative treatment with human recombinant erythropoietin (rHuEPO), autologous blood donation, intraoperative blood cell salvage and administration of tranexamic acid. The use of rHuEPO was intended to increase hemoglobin (12.1 g/dL) levels at the moment of surgery following the donation of 2 autologous blood units. 1000 mL of salvaged blood were processed. The output line of the blood cell salvage machine did not show any sign of increased red cell haemolysis. The postoperative course was uneventful and the patient was discharged from the postoperative intensive care unit on day 7 after surgery with no allogenic blood transfusion. No references detailing the use of rHuEPO and autologous blood donation preoperatively in patients with thalassemia minor and only one case report discussed the utility of intraoperative blood cell salvage in a patient with thalassemia intermedia. Although further experience is needed, this case report suggests that even for patients with thalassemia minor, methods focused on allogenic blood salvage can be used safely.

Topics: Adolescent; beta-Thalassemia; Blood Preservation; Blood Transfusion, Autologous; Erythrocyte Count; Erythropoietin; Female; Hematocrit; Hemoglobins; Humans; Intraoperative Care; Recombinant Proteins; Scoliosis

This is a retrospective cohort study examining 61 patients with neurogenic scoliosis who underwent anterior and/or posterior spinal instrumentation at the age of 18 and younger.. The purpose of this study is to investigate this finding further by analyzing the effect of recombinant human erythropoietin (rhEPO) on hematocrit, transfusion and complication rates, and the length of intensive care unit (ICU) days in patients with neurogenic scoliosis.. The preoperative use of rhEPO has been shown to decrease perioperative transfusion requirements in many adult and pediatric patients. A recent study at our institution demonstrated the efficacy of rhEPO in pediatric idiopathic scoliosis patients, but suggested the possibility of an "erythropoietin resistance" in the pediatric neurogenic scoliosis population.. The patients' age at the time of surgery, gender, Cobb angle, erythropoietin administration and dosage, hematocrit levels, type of surgery, intraoperative blood loss, duration of surgery, number of vertebrae fused, comorbidities, complications, transfusion status, and the length of ICU days were collected.. Thirty-five (57.3%) children received preoperative rhEPO, whereas 26 patients (42.7%) did not receive rhEPO. The mean preoperative and discharge hematocrit levels in the patients treated with rhEPO were significantly higher than the non-rhEPO group (P = 0.05). There were no significant difference in likelihood of transfusion, complications, and the length of ICU days between the rhEPO and the non-rhEPO groups. A multivariate analysis demonstrated that the number of fused vertebral levels maintained its significance (P = 0.044) and surgical time had a trend toward significance (P = 0.051) in predicting likelihood of transfusion.. The use of rhEPO effectively stimulated erythropoiesis in these patients and yet demonstrated no significant clinical benefit in reducing the likelihood of transfusion in neurogenic patients in this study. More research is necessary to design a transfusion risk reduction protocols that will minimize the exposure of neurogenic scoliosis patients to allogeneic blood products.

Topics: Adolescent; Adult; Anemia; Blood Loss, Surgical; Blood Transfusion; Child; Child, Preschool; Cohort Studies; Erythropoietin; Female; Hematocrit; Humans; Male; Multivariate Analysis; Neuromuscular Diseases; Postoperative Complications; Predictive Value of Tests; Preoperative Care; Recombinant Proteins; Retrospective Studies; Scoliosis

Allogeneic blood transfusions (ABT) are often necessary in elective spine surgery because of perioperative blood loss. Preoperative autologous blood donation (PABD) has emerged as the principal means to avoid or reduce the need for ABT. Consequently, a multicentre study was conducted to determine the yield and efficacy of PABD in spine surgery and the possible role of recombinant human erythropoietin (EPO) in facilitating PABD.. We retrospectively reviewed the hospital charts and blood bank records from all consecutive spine surgery patients who were referred for PABD. Data were obtained from two A-category hospital blood banks and one general hospital. Although we collected data from 1994, the analytic study period was from the last quarter of 1995 to December 2003. Fifty-four (7%) out of 763 patients referred for PABD were rejected, and medical records were available for 680 patients who were grouped into spinal fusion (556; 82%) and scoliosis surgery (124;18%). EPO was administered to 120 patients (17.6%). From 1999 to 2003, PABD steadily increased from 60 to 209 patients per year.. Overall, 92% of the patients were able to complete PABD, 71% were transfused, and almost 80% avoided ABT. PABD was more effective in fusions (86%) than in scoliosis (47%). Blood wastage was 38%, ranging from 18% for scoliosis to 42% for fusions. EPO allowed the results in the anaemic patients to be improved.. Therefore, despite the limitations of this retrospective study, we feel that PABD is an excellent alternative to ABT in spine surgery. However, the effectiveness of PABD may be enhanced if associated with other blood-saving techniques.

Topics: Adult; Blood Banks; Blood Loss, Surgical; Elective Surgical Procedures; Erythropoietin; Female; Humans; Male; Middle Aged; Recombinant Proteins; Retrospective Studies; Scoliosis; Spinal Fusion; Spine; Transplantation, Autologous; Transplantation, Homologous; Treatment Outcome

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Child; Cost-Benefit Analysis; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Length of Stay; Recombinant Proteins; Scoliosis; Spine

Concerns about the transmission of the human immunodeficiency virus (HIV) have driven the evolution of surgical transfusion practices including the use of preoperative erythropoietin (rhEPO). Although there is significant experience documenting the efficacy of preoperative rhEPO in reducing transfusion requirements for adult patients, there is little experience in the pediatric population. With 178 pediatric patients who underwent surgery for spinal deformity, a retrospective cohort study was performed using patient charts, administrative records, and blood bank computer data. Of these patients, 44% received erythropoietin and 55% did not. From the entire population, 17.5% were in the rhEPO treatment group that received homologous blood transfusion compared with 30.6% in the untreated group (p < 0.05). Among the children with idiopathic scoliosis, this effect was more pronounced, with 3.9% of rhEPO patients receiving blood transfusion compared with 23.5% of nontreated patients (p = 0.006). Additionally, rhEPO treatment was associated with a significantly decreased length of stay only for patients in the idiopathic group (9.3 vs. 6.7, p = 0.02). Use of preoperative erythropoietin in pediatric patients undergoing scoliosis surgery resulted in higher preoperative hematocrit levels. Significantly lower rates of transfusion were noted only in the idiopathic group, however. Although there is a possibility of erythropoietin "resistance" in the neuromuscular and congenital patients, alternative explanations for the lack of effect on transfusion rates may include underdosing and biases existent in this nonrandomized retrospective study.

Topics: Adolescent; Blood Transfusion; Chi-Square Distribution; Child; Child, Preschool; Cohort Studies; Controlled Clinical Trials as Topic; Erythropoietin; Female; Humans; Length of Stay; Male; Orthopedics; Predictive Value of Tests; Preoperative Care; Recombinant Proteins; Retrospective Studies; Risk Assessment; Scoliosis; Software; Transplantation, Homologous; Treatment Outcome

Topics: Acquired Immunodeficiency Syndrome; Adolescent; Blood Transfusion, Autologous; Erythropoietin; Evaluation Studies as Topic; Female; Hematocrit; Hemodilution; Humans; Intraoperative Care; Preoperative Care; Recombinant Proteins; Scoliosis

Topics: Adolescent; Christianity; Erythropoietin; Female; Humans; Preoperative Care; Recombinant Proteins; Scoliosis