Blood loss (BL) during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) may be estimated using a variety of unproven techniques. Patient care and research on BL are likely impacted by a lack of standardization. A novel FDA-approved blood volume (BV) analysis system (BVA-100 Blood Volume Analyzer) allows rapid processing with > 97% accuracy. The purpose of this study was to investigate common methods for BL estimation.
BV assessment was performed with the BVA-100. After obtaining a baseline sample of 5 mL of blood, 1 mL of I-131-labeled albumin was injected intravenously over 1 min. Five milliliter blood samples were then collected at 12, 18, 24, 30, and 36 min post-injection. Intravenous fluid was minimized to maintain euvolemia. Salvaged blood was not administered during surgery. BL was estimated using several common techniques and compared to the BV measurements provided by the BVA-100 (BVABL).
Thirty AIS patients were prospectively enrolled with major curves of 54° and underwent fusions of 10 levels. BL based on the BVA-100 (BVABL) was 519.2 [IQR 322.9, 886.2] mL. Previously published formulas all failed to approximate BVABL. Multiplying the cell saver volume return by 3 (CS3) approximates BVABL well with a Spearman correlation coefficient and ICC of 0.80 and 0.72, respectively. An extrapolated cell salvage-based estimator also showed high intraclass correlation coefficient (ICC) and Spearman coefficients with less bias than CS3.
Published formulaic approaches do not approximate true blood loss. Multiplying the cell saver volume by 3 or using the cell salvage-based estimator had the highest correlation coefficient and ICC.
Level of evidence
Prospective cohort Level 2.
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Bourke DL, Smith TC (1974) Estimating allowable hemodilution. Anesthesiology 41(6):609–612. https://doi.org/10.1097/00000542-197412000-00015
Brecher ME, Monk T, Goodnough LT (1997) A standardized method for calculating blood loss. Transfusion 37(10):1070–1074. https://doi.org/10.1046/j.1537-2995.1997.371098016448.x
Camarasa MA, Olle G, Serra-Prat M et al (2006) Effectiveness of a preoperative autologous blood donation program in total knee replacement. Med Clin (Barc) 127(15):572–573. https://doi.org/10.1157/13094000
Gross JB (1983) Estimating allowable blood loss: corrected for dilution. Anesthesiology 58(3):277–280. https://doi.org/10.1097/00000542-198303000-00016
Waters JH, Lee JS, Karafa MT (2004) A mathematical model of cell salvage compared and combined with normovolemic hemodilution. Transfusion 44(10):1412–1416. https://doi.org/10.1111/j.1537-2995.2004.04050.x
Stahl DL, Groeben H, Kroepfl D et al (2012) Development and validation of a novel tool to estimate peri-operative blood loss. Anaesthesia 67(5):479–486. https://doi.org/10.1111/j.1365-2044.2011.06916.x
Lemee J, Scalabre A, Chauleur C et al (2020) Visual estimation of postpartum blood loss during a simulation training: a prospective study. J Gynecol Obstet Hum Reprod 49(4):101673. https://doi.org/10.1016/j.jogoh.2019.101673
Rothermel LD, Lipman JM (2016) Estimation of blood loss is inaccurate and unreliable. Surgery 160(4):946–953. https://doi.org/10.1016/j.surg.2016.06.006
Jesus LE, Ramos BA, Rangel M et al (2015) Blood loss assessment in pediatric surgery: visual versus gravimetric methods: an experimental study. Paediatr Anaesth 25(6):645–646. https://doi.org/10.1111/pan.12602
Chua S, Ho LM, Vanaja K et al (1998) Validation of a laboratory method of measuring postpartum blood loss. Gynecol Obstet Invest 46(1):31–33. https://doi.org/10.1159/000009992
Diaz V, Abalos E, Carroli G (2018) Methods for blood loss estimation after vaginal birth. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD010980.pub2
Lopez-Picado A, Albinarrate A, Barrachina B (2017) Determination of perioperative blood loss: accuracy or approximation? Anesth Analg 125(1):280–286. https://doi.org/10.1213/ANE.0000000000001992
Sharareh B, Woolwine S, Satish S et al (2015) Real time intraoperative monitoring of blood loss with a novel tablet application. Open Orthop J 9:422–426. https://doi.org/10.2174/1874325001509010422
Yang B, Yang O, Guzman J et al (2015) Intraoperative, real-time monitoring of blood flow dynamics associated with laser surgery of port wine stain birthmarks. Lasers Surg Med 47(6):469–475. https://doi.org/10.1002/lsm.22369
Nowicki PD, Ndika A, Kemppainen J et al (2018) Measurement of intraoperative blood loss in pediatric orthopaedic patients: evaluation of a new method. J Am Acad Orthop Surg Glob Res Rev 2(5):e014. https://doi.org/10.5435/JAAOSGlobal-D-18-00014
Manzone TA, Dam HQ, Soltis D et al (2007) Blood volume analysis: a new technique and new clinical interest reinvigorate a classic study. J Nucl Med Technol 35(2):55–63. https://doi.org/10.2967/jnmt.106.035972
Fouad-Tarazi F, Calcatti J, Christian R et al (2007) Blood volume measurement as a tool in diagnosing syncope. Am J Med Sci 334(1):53–56. https://doi.org/10.1097/MAJ.0b013e318063c6f7
Yu M, Pei K, Moran S et al (2011) A prospective randomized trial using blood volume analysis in addition to pulmonary artery catheter, compared with pulmonary artery catheter alone, to guide shock resuscitation in critically ill surgical patients. Shock 35(3):220–228. https://doi.org/10.1097/SHK.0b013e3181fc9178
Nelson M, Green J, Spiess B et al (2018) Measurement of blood loss in cardiac surgery: still too much. Ann Thorac Surg 105(4):1176–1181. https://doi.org/10.1016/j.athoracsur.2017.11.023
Waters JH, Lee JS, Karafa MT (2002) A mathematical model of cell salvage efficiency. Anesth Analg 95(5):1312–1317. https://doi.org/10.1097/00000539-200211000-00040
Bland JM, Altman DG (1999) Measuring agreement in method comparison studies. Stat Methods Med Res 8(2):135–160. https://doi.org/10.1177/096228029900800204
Dworkin HJ, Premo M, Dees S (2007) Comparison of red cell and whole blood volume as performed using both chromium-51-tagged red cells and iodine-125-tagged albumin and using I-131-tagged albumin and extrapolated red cell volume. Am J Med Sci 334(1):37–40. https://doi.org/10.1097/MAJ.0b013e3180986276
Guay J, Haig M, Lortie L et al (1994) Predicting blood loss in surgery for idiopathic scoliosis. Can J Anaesth 41(9):775–781. https://doi.org/10.1007/BF03011583
Verma K, Errico T, Diefenbach C et al (2014) The relative efficacy of antifibrinolytics in adolescent idiopathic scoliosis: a prospective randomized trial. J Bone Joint Surg Am 96(10):e80. https://doi.org/10.2106/JBJS.L.00008
Verma K, Lonner B, Dean L et al (2013) Reduction of mean arterial pressure at incision reduces operative blood loss in adolescent idiopathic scoliosis. Spine Deform 1(2):115–122. https://doi.org/10.1016/j.jspd.2013.01.001
Cahill PJ, Samdani AF, Brusalis CM et al (2018) Youth and experience: the effect of surgeon experience on outcomes in cerebral palsy scoliosis surgery. Spine Deform 6(1):54–59. https://doi.org/10.1016/j.jspd.2017.05.007
Gornitzky AL, Flynn JM, Muhly WT et al (2016) A rapid recovery pathway for adolescent idiopathic scoliosis that improves pain control and reduces time to inpatient recovery after posterior spinal fusion. Spine Deform 4(4):288–295. https://doi.org/10.1016/j.jspd.2016.01.001
Muhly WT, Sankar WN, Ryan K et al (2016) Rapid recovery pathway after spinal fusion for idiopathic scoliosis. Pediatrics. https://doi.org/10.1542/peds.2015-1568
Fletcher ND, Andras LM, Lazarus DE et al (2017) Use of a novel pathway for early discharge was associated with a 48% shorter length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. J Pediatr Orthop 37(2):92–97. https://doi.org/10.1097/BPO.0000000000000601
Fletcher ND, Murphy JS, Austin TM et al (2021) Short term outcomes of an enhanced recovery after surgery (ERAS) pathway versus a traditional discharge pathway after posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform. https://doi.org/10.1007/s43390-020-00282-3
Fletcher ND, Shourbaji N, Mitchell PM et al (2014) Clinical and economic implications of early discharge following posterior spinal fusion for adolescent idiopathic scoliosis. J Child Orthop 8(3):257–263. https://doi.org/10.1007/s11832-014-0587-y
Sanders AE, Andras LM, Sousa T et al (2017) Accelerated discharge protocol for posterior spinal fusion patients with adolescent idiopathic scoliosis decreases hospital postoperative charges 22. Spine (Phila Pa 1976) 42(2):92–97. https://doi.org/10.1097/BRS.0000000000001666
Yang J, Skaggs DL, Chan P et al (2020) High satisfaction in adolescent idiopathic scoliosis patients on enhanced discharge pathway. J Pediatr Orthop 40(3):e166–e170. https://doi.org/10.1097/BPO.0000000000001436
Jones JG, Wardrop CA (2000) Measurement of blood volume in surgical and intensive care practice. Br J Anaesth 84(2):226–235. https://doi.org/10.1093/oxfordjournals.bja.a013407
Guinn NR, Broomer BW, White W et al (2013) Comparison of visually estimated blood loss with direct hemoglobin measurement in multilevel spine surgery. Transfusion 53(11):2790–2794. https://doi.org/10.1111/trf.12119
Sehat KR, Evans RL, Newman JH (2004) Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br 86(4):561–565
International Committee for Standardization in Haematology (1980) Recommended methods for measurement of red-cell and plasma volume. J Nucl Med 21(8):793–800
Fodor GH, Habre W, Balogh AL et al (2019) Optimal crystalloid volume ratio for blood replacement for maintaining hemodynamic stability and lung function: an experimental randomized controlled study. BMC Anesthesiol 19(1):21. https://doi.org/10.1186/s12871-019-0691-0
Seo EH, Park HJ, Piao LY et al (2020) Immune response in fluid therapy with crystalloids of different ratios or colloid for rats in haemorrhagic shock. Sci Rep 10(1):8067. https://doi.org/10.1038/s41598-020-65063-4
Spahn DR, Bouillon B, Cerny V et al (2013) Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 17(2):R76. https://doi.org/10.1186/cc12685
Spahn DR, Bouillon B, Cerny V et al (2019) The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 23(1):98. https://doi.org/10.1186/s13054-019-2347-3
Rossaint R, Bouillon B, Cerny V et al (2016) The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 20:100. https://doi.org/10.1186/s13054-016-1265-x
Funding was provided through the Harrison Foundation.
Conflict of interest
Nicholas Fletcher: Reports consulting fees from Orthopaediatrics, Nuvasive, and Medtronic; speakers fees from Orthopaediatrics, Nuvasive, and Zimmer Biomet; Grant Support from the Harrison Foundation and POSNA; Board Membership with the Children’s Healthcare of Atlanta. Laura Gilbertson: Declares no conflicts of interest. Robert Bruce: Declares no conflicts of interest. Humphrey Lam: Declares no conflicts of interest. Matthew Lewis: Declares no conflicts of interest. Thomas Austin: Declares no conflicts of interest.
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Fletcher, N.D., Gilbertson, L.E., Bruce, R.W. et al. Blood loss estimation during posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform (2021). https://doi.org/10.1007/s43390-021-00440-1
- Adolescent idiopathic scoliosis
- Blood loss estimation
- Cell saver
- Cell salvage
- Blood volume analyzer