Akinobu Suzuki

Hidetomi Terai

Hiroaki Nakamura

Hiromitsu Toyoda

Hiroyuki Yasuda

Koji Tamai

Shou Dozono

Scoliosis

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Which is the best schedule of autologous blood storage for preoperative adolescent idiopathic scoliosis patients?

RESEARCH Open Access
Which is the best schedule of autologous blood
storage for preoperative adolescent idiopathic
scoliosis patients?
Koji Tamai*, Hidetomi Terai, Hiromitsu Toyoda, Akinobu Suzuki, Hiroyuki Yasuda, Shou Dozono, Hiroaki Nakamura
From 10th International Research Society of Spinal Deformities (IRSSD)
Sapporo, Japan. 29 June - 2 July 2014
Abstract
Background: It is critically important for AIS patients to avoid perioperative allogeneic blood transfusions. Toward
this aim, many institutes use autologous blood storage to perform perioperative transfusions. However, there is no
standard timeline for collecting blood for storage. Therefore, the objective of this prospective cohort study was to
compare the outcome of two different schedules for collecting autologous blood before operation in adolescent
idiopathic scoliosis (AIS) patients.
Methods: Inclusion criteria are AIS patients, younger than 20 years old, female, operated between 2009 and 2013
with posterior spinal fusion and instrumentation who had 1600 mL autologous blood collected before operation. A
total of 61 patients were participated in this study. They were randomly divided into 2 groups based on the
storage interval. Weekly group (1W-G) consisted of 30 patients with a total of 1600mL blood collected weekly
beginning 4 weeks before the operation. Biweekly group (2W-G) consisted of 31 patients with a total of 1600 mL
blood collected biweekly beginning 8 weeks before the operation. The instrumented levels, total bleeding,
complications during blood transfusion, and hematological examinations (RBC, Hb, Hct, MCH, MCV, MCHC) were
evaluated. A hematological examination was performed before blood collection, before the operation, and on
postoperative days 1, 3, and 7. Vasovagal reflex (VVR) was evaluated as complications during blood drawing.
Result: Mean age, height, and weight did not differ significantly between the 2 groups. There were no significant
differences in instrumented levels, bleeding during operation, after operation, and collected blood during
operation. With the autologous blood, allogeneic blood transfusion was completely avoided. VVR was more
frequent in the biweekly group significantly (1W-G 4.2% vs 2W-G 15.3%). In terms of hematological examination, all
values showed no significant differences between two groups in the pre-drawing and the pre-operation stage.
However, the postoperative Hb and Hct values were higher in the weekly group. Also, MCV and MCHC showed
the same behavior with higher values in the weekly group.
Conclusion: A weekly schedule of autologous blood storage is better than a biweekly storage schedule.
Introduction
Spinal fusion with instrumentation is among the most
common surgical procedures that are often associated
with substantial blood loss and the necessity of blood
transfusion. The Nationwide Inpatient Sample (NIS) data-
base analysis by Yoshihara [1] demonstrated that 37.9%
patients who underwent spinal fusion of more than 9 ver-
tebrae had received some kinds of transfusion during and
after operation. We believe that it is very important for
adolescent idiopathic scoliosis (AIS) patients to avoid peri-
operative allogeneic blood transfusions to avoid the risk of
transmission of chronic infections. Toward this aim, our
institute have regularly uses stored autologous blood for
perioperative transfusions. Generally, blood collection
starts 4 weeks before the operation to match with the time
* Correspondence: tamaik1983_s58_04_22@yahoo.co.jp
Department of Orthopedic Surgery, Osaka City University Graduate School of
Medicine, Osaka, Japan
Tamai et al. Scoliosis 2015, 10(Suppl 2):S11
http://www.scoliosisjournal.com/content/10/S2/S11
© 2015 Tamai et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
limit of maintaining the quality of citrate phosphate dex-
trose-adenine 1 (CPDA-1). According to autologous blood
transfusion guidelines, the maximum permissible total
amount of preoperative autologous blood is 1600 mL.
[2-4], There is however, no standardised timeline for col-
lecting blood for storage. We hypothesized that a longer
period for collecting autologous blood would allow
patients to have sufficient time to recover from the
induced anemia preoperatively. To verify our hypothesis,
we compared prospectively two different schedules for col-
lecting autologous blood; one was to collect 1600 mL on
weekly schedule, and the other was to collect on a
biweekly schedule.
Patients and methods
Patients
Inclusion criteria of this study were AIS girls younger than
20 years old and operated between 2009 and 2013 with
posterior spinal fusion and instrumentation. Male and reo-
peration cases were excluded. A total of 61 patients were
included in this study. They were randomly divided into 2
groups based on the blood storage interval. Weekly group
(1W-G) consisted of 30 patients who had 1600 mL autolo-
gous blood collected at weekly interval beginning 4 weeks
before the operation (Figure 1). Biweekly group (2W-G)
consisted of 31 patients who had 1600 mL autologous
blood collected biweekly beginning 8 weeks before the
operation. (Figure 2). 40mg of Saccharated ferric oxide
and 12000IU of epoetin alfa were given to each of the col-
lections in both groups. Mean age, height, and weight did
not differ significantly between the 2 groups (Table 1).
Patients participated voluntarily in this study, having
signed to attest their informed consent. This research
received approval from the Ethical Commission of our
institute, Osaka City University Graduate School of
Medicine.
Outcome
Instrumented levels, total bleeding, complications during
drawing, and hematological examinations (RBC, Hb,
Figure 1 The storage schedule of 1W-G
Figure 2 The storage schedule of 2W-G: In the latter two times, we collected 800ml per a time using 400ml of autologous blood transfusion
which is collected in first and second times
Tamai et al. Scoliosis 2015, 10(Suppl 2):S11
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Hct, MCH, MCV, MCHC) were evaluated. A hematolo-
gical examination was performed before drawing, before
the operation, and on postoperative days 1, 3, and 7.
Vasovagal reflex (VVR) was evaluated as a complication
during drawing according to following grading; Grade1:
Blood pressure drop or bradycardia>40/min. Grade2:
blood pressure drop <90mmHg, bradycardia <40/min or
unconsciousness. Grade3: convulsions or incontinence
[5]. (Table 2)
Statistical analysis
Statistical analyses were performed with SPSS, version
12.0.1, for a personal computer (SPSS Inc., Chicago, IL).
Mann–Whitney U test and Fisher’s exact test was used
to analyze significant differences between these groups at
each time point. Significance was set at a P value of 0.05.
Results
There were no significant differences between the two
groups in instrumented levels, bleeding during operation,
after operation, and perioperative autologous blood collec-
tions (Table 3). All autologous blood was used peri-opera-
tively, thus avoiding totally the need for any allogeneic
blood transfusion. VVR was more frequently found in the
biweekly group (1W-G 4.2% vs 2W-G 15.3%, p<0.001).
(Table 4) No significant differences was found in the rou-
tine haematological tests in the pre-drawing and the pre-
operation stage. However, the postoperative Hb and Hct
values were higher in the weekly group (Figure 3). Also
MCV and MCHC showed the same behavior with higher
values in the weekly group (Figure 3).
Discussion
We compared two schedules to collect autologous blood
with the hypothesis that a longer schedule would help
patients to recover faster from severe anemia after their
operation, because they have enough time to recover from
anemia before operation and to take nutrient like iron
which is necessary for production new red blood cell. How-
ever, contrary to our hypothesis, the shorter schedule
group showed faster recovery from anemia than longer
group in this result. Two potential explanations for this
phenomenon are the freshness of autologous blood and the
behavior of the endogenic erythropoietin. Concerning the
freshness of autologous blood, d’Almeida reported the via-
bility of stored RBCs of rat and human with CPDA-1 med-
ium [6]. They mentioned that post-transfusion viability in
rat cells was 79%, 26% and 5% after 1, 2 and 4 weeks of sto-
rage respectively and human RBC deformability decreased
significantly by 34% after 4 weeks of storage. In our trial,
800 mL of the blood from the biweekly group was older
than that of the weekly group. This could lead to an
increased amount of lower-viability blood cells in the
biweekly group, resulting in lesser effectivc transfusion.
Furthermore, improvement of anemia in the weekly group
was found to be more rapid than biweekly group. This may
be due to better stimulation of endogenic erythropoietin
Table 1 Preoperative patients data
Weekly group (1W-
G)
Biweekly group (2w-
G)
n 30 31
age (year
old)
15.5±3.1 15.4±2.3 N.S.
(p=0.20)
height (cm) 155.8±5.9 156.1±2.3 N.S.
(p=0.82)
weight (kg) 46.7±5.8 46.1±6.1 N.S.
(p=0.81)
Mean±SD N.S.: not significant
Table 2 Grading of VVR
Obligatory symptoms Other symptoms
Grade1 blood pressure drop pallor, cold sweats and
nausea
bradycardia >40/min
Grade2 blood pressure drop
<90mmHg
vomiting
bradycardia <40/min
unconsciousness
Grade3 convulsions
incontinence
Table 3 Perioperative parameter which affect to post-
operative anemia
Instrumentation Bleeding
During
operation
Bleeding
after
operation
Collected blood
During
operation
1W-
G
9.7±2.0 level 1316±927 ml 797±301 ml 527±403 ml
2W-
G
10.5±1.7 level 1405±878 ml 643±281 ml 644±377 ml
N.S.(p=0.14) N.S.(p=0.70) N.S.(p=0.07) N.S.(p=0.10)
Mean±SD N.S.: not significant
Table 4 Incidence of VVR
Grade I Grade II Grade
III
Total
1W-
G
n=30 3.3% 0.8% 0% 4.2%
(number of
times)
(4/120) (1/120) (0/120) (5/120)
2W-
G
n=31 10.5% 0.048 0% 15.3%
(number of
times)
(13/124) (6/124) (0/124) (19/124)
**
p<0.001
**
p<0.001
**
p<0.001
Tamai et al. Scoliosis 2015, 10(Suppl 2):S11
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production in the weekly group than in the biweekly group,
resulting in quick recovery of the weekly group.
In addition, biweekly group shows higher incidence of
VVR than weekly group. Generally, grade 2 or 3 VVR inci-
dence is reported in less than 1% of patients [5]. Compar-
ing these reports, weekly group whose incidence of VVR
(grade2 or 3) was 0.83% Vs the biweekly group of 4.84%.
There are some limitations in the present prospective
study. First, we did not evaluate endogenic erythropoietin
and iron concentrations. Secondly, the postoperative fol-
low-up period was 7 days. Finally, although this is the first
study of comparing schedule to collect autologous blood
prospectively, we compared just only two schedules.
Further studies should attempt to investigate further the
best schedule to collect autologous blood for AIS patients.
Conclusion
We concluded that a weekly schedule of pre-operative
autologous blood storage is better than a biweekly sto-
rage schedule in terms of postoperative recovery of ane-
mia and complications.
This is the extended abstract of IRSSD 2014 program
book [7].
Consent
Written informed consent was obtained from the patient
and their parents for publication of this paper and any
accompanying images. A copy of the written consent is
available for review by the Editor-in-Chief of this journal.
Competing interests
The author declares that they have no competing interests.
Authors’ contributions
KT the corresponding author measured analysed the data and wrote the
manuscript. HT collected and maintained. HT, AS and HY assisted in data
analysing and interpretation. HN reviewed and edited the manuscript. All
authors read and approved the final manuscript.
Declarations
Publication charges for this collection were funded by IRSSD 2014 Sapporo.
This article has been published as part of Scoliosis Volume 10 Supplement 2,
2015: Research into Spinal Deformities 9: Short Papers from the IRSSD 2014
Meeting. The full contents of the supplement are available online at http://
www.scoliosisjournal.com/supplements/10/S2.
Published: 11 February 2015
References
1. Yoshihara H, Yoneoka D: Predictors of allogeneic blood transfusion in
spinal fusion in the United States, 2004-2009. Spine 2014, 15(39):304-10.
2. Standards for blood banks and transfusion services. Bethesda MD :
American Association of Blood Banks;Silva MA , 23 2004:.
3. Technical Manual. Bethesda MD : American Association of Blood Banks;
Brecher ME , 15 2005:.
4. Council of Europe: Guide to the preparation, use and quality assurance
of blood components. Strasbourg Cedex : Council of Europe Publishing;, 9
2003.
5. Inaba S: Analysis of a questionnaire on adverse reactions to blood
donation in Japan. Transfus Apher Sci 2013, 48(1):21-34.
Figure 3 Result of hematological examination
Tamai et al. Scoliosis 2015, 10(Suppl 2):S11
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Page 4 of 5
6. d’Almeida MS: A comparison of biochemical and functional alterations of
rat and human erythrocytes stored in CPDA-1 for 29 days: implications
for animal models of transfusion. Transfusion Medicine 2000, 10:291-303.
7. Koji Tamai, Hidetomi Terai, Hiromitsu Toyoda, Hiroyuki Yasuda,
Shou Dozono, Yoshikazu Shinohara, Hiroaki Nakamura: Which is the best
schedule of autologous blood storage for pre-operative AIS patients? -
every week or every 2 weeks-. Scoliosis 2015, 10(Suppl 1):O57.
doi:10.1186/1748-7161-10-S2-S11
Cite this article as: Tamai et al.: Which is the best schedule of
autologous blood storage for preoperative adolescent idiopathic
scoliosis patients? Scoliosis 2015 10(Suppl 2):S11.
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Which is the best schedule of autologous blood storage for preoperative adolescent idiopathic scoliosis patients?

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