Use and efficacy of antifibrinolytic agents in patients undergoing growth-friendly surgery for neuromuscular scoliosis

TL;DR

This study examines the use of antifibrinolytic agents in children with neuromuscular scoliosis undergoing spine surgery, finding no significant impact on blood loss or transfusion rates.

Contribution

The study provides new insights into the use and outcomes of antifibrinolytic agents in a medically fragile pediatric population undergoing growth-friendly spine surgery.

Findings

Antifibrinolytic agents were used in 36% of surgeries, with tranexamic acid being the most common.

There was no significant difference in blood loss, cell saver volume, or transfusion rates between patients who received antifibrinolytic agents and those who did not.

Postoperative transfusion rates were high but not significantly different between groups.

Abstract

There is a paucity of data on the use, efficacy, and safety of antifibrinolytic agents (AF) in patients with neuromuscular scoliosis undergoing growth-friendly instrumentation. Previous studies have shown mixed results of AF agents in young patients with neuromuscular conditions, and other authors have expressed concerns regarding adverse effects in this medically fragile population. The purpose of this study was to investigate the rate of use of AF agents for growth-friendly surgery in patients with neuromuscular scoliosis, and assess its impact on blood loss and transfusion requirements.

This is a retrospective cohort study of patients from a multicenter spine study group with neuromuscular scoliosis that underwent an index growth-friendly procedure. Patients with a history of venous thromboembolism and those undergoing revision surgery or lengthening surgery were excluded. Perioperative data were collected including patient demographics, type of instrumentation, use and type of AF agent, estimated blood loss (EBL), use and volume of cell saver, and intraoperative blood transfusion. Univariate statistics were used to determine differences.

This study included 335 patients with a mean age of 7 years (SD: 2.6). Of these patients, 176 patients were managed with VEPTR/TGR instrumentation and 159 patients were managed with MCGR instrumentation. AF agents were used in 36% of index cases. In cases with AF use, TXA was the most frequently used agent (TXA:68%, ACA:21%). The use of AF increased over the study period from less than 10% before 2010 to 75% in 2020 (R2 = 0.31). There was no statistical difference in EBL between patients who received AF agents compared to patients that did not receive AF agents (AF = 184.9 ml, no AF = 103 ml, p = 0.23). In addition, there was no difference in cell saver volume (AF = 127 ml, no AF = 145 ml, p = 0.88). The overall rate of intraoperative blood transfusion was low (8.5%). In this cohort, there was no significant difference in transfusion rates between groups (AF = 7.6%, no AF = 8.7%, p = 0.7). There was a high rate of postoperative blood transfusion (51.4%) in this cohort; however, there was no significant difference in postoperative transfusion rates between groups (AF = 62.1%, no AF = 50.5%, p = 0.62).

AF agents are being used for patients undergoing growth-friendly procedures with TXA being the most commonly used AF. However, there is no significant difference in EBL, cell saver volume, and intraoperative or postoperative transfusion rates between patients that do or do not receive AF agents for these procedures. Additional studies are needed to validate these results, as well as determine their efficacy, safety, and value in this medically fragile group.

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