Estudio del uso de los parámetros gasométricos y hemodinámicos para optimizar la oxigenación tisular durante la hemorragia intraoperatoria en la cirugía de escoliosis

Resumen

Introduction: The scoliosis surgery is associated with an important hemorrhage and might require of blood transfusions. Nowadays, there are different strategies included in the “Patient Blood Management” (PBM) to decrease allogenic blood transfusion. From diverse studies, the variability of methods employed to guide fluid therapy and to decrease perioperative hemorrhage is remarkable. There are not studies to reveal variables capable of anticipating whether tissue oxygenation is going to respond or not to fluid load, use of vasoconstrictors, chronotropic medication or to packed red blood cell transfusion during this surgery. The aim of this study is to evaluate if an algorithm of optimization of perfusion and tissue oxygenation maintains an optimal oxygenation of tissues, decreases the hemorrhage, the fluid therapy and blood transfusions during this kind of surgery; in comparison to fluid therapy guided by classical hemodynamic parameters. This algorithm is guided by oxygen saturation, which considers the brain oxygenation (ScO2) and regional oxygenation (SsO2); combined with ΔCO2 venous-arterial (ΔCO2), central venous oxygen saturation (SvcO2) and hemoglobin during scoliosis surgery of the adolescent population. The secondary outcomes are the comparison of 2 programs of PBM in terms of intraoperative hemorrhage, perioperative blood transfusion and hospital stay; and to evaluate the risk factors for hemorrhage and transfusion. Materials and methods: 70 consecutive patients aged between 13 and 18 years old were included into the study. These patients underwent posterior single-step double-rod scoliosis surgery of the adolescent in the University Hospital Miguel Servet. There were 2 study groups: the first one was a retrospective group, called the PBM-Autodonation group (Group_A) [Years 2012 and 2013. In this group, the PBM includes autodonation and hemoglobin optimization] The second one is a prospective group, called the PBM-Optimization (Group_O) [Years 2014 and 2015. The PBM does not include autodonation. It includes hemoglobin optimization, intraoperative tranexamic acid use, fluid therapy guided by the perfusion algorithm and tissue oxygenation (SO2 derived from Hoffman, ΔCO2, SvcO2 and hemoglobin), normal body temperature and the delay in the administration of prophylactic LMWH (Low Molecular Weight Heparin) at 48h postoperatively]. In both PBM, the transfusion was restrictive. Hemorrhage volume, fluid therapy and intraoperative blood transfusion were compared. Fluid therapy was guided either by the already mentioned algorithm (prospective group) or by the usual hemodynamic parameters (retrospective group). Furthermore, in the prospective group, the reaction to fluid therapy and erythrocyte transfusion was analyzed in relation with the different tissue oxygen saturation parameters that are included in algorithm. Results: The intraoperative hemorrhage in Group_A was 1032±200 ml, in Group_O was 749±324 ml; difference 282,84 ml; CI95% (147-418); p<0,001. In Group O there were less patients that required autologous or allogenic blood transfusions (100% vs 62%); p<0,001; CI95% 0,62 (0,47-0,8). There were not differences in relation with allogenic blood transfusion (p>0,05), neither in the hospital stay (p<0,05) between the 2 PBM programs. The multivariant analysis showed that the predictive independent risk factors to develop a hemorrhage greater than 20% of total blood volume (15ml/kg) were the following: PBM-Autodonation (Group_A) and use more than 40 ml/kg crystalloids. The multivariant analysis showed that the predictive independent risk factors to have allogenic blood transfusions were the following: To have a preoperative hemoglobin concentration ≤13g/dL, to have an intraoperative hemorrhage >30% of total blood volume (>20ml/kg) and to reach a hemoglobin concentration of 8,25 g/dL. The combination of SvcO2 and SO2 of Hoffman ≤65%, along with DCO2 >6 mmHg and values of hemoglobin >8g/dL are predictors of a good response to fluids (p<0,001) and the SvcO2 and SO2 of Hoffman ≤65% together with a hemoglobin concentration <8,25 g/dL predict the reaction to erythrocyte transfusion (p<0,001). Conclusions: The PBM program of peri- and intraoperative optimization that was used on the prospective cohort group allows to decrease the hemorrhage and transfusion in regard to the historic PBM program with autodonation. The transfusion of allogenic blood could reduce the hemoglobin optimization up to point of 13,5-14 g/dL before the surgery. 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