O2116: Evaluating Cell Salvage Use for Hip and Lower Extremity Surgery in Children with Cerebral Palsy

Background: Single event multilevel surgery (SEMLS) is the standard-of-care for children with cerebral palsy (CP) but involves prolonged procedures with increased blood loss. Intraoperative cell salvage is thought to reduce transfusion requirements, however indications for usage are not well-defined with wide practice variation. Our purpose was to determine when cell salvage would be beneficial during hip and lower extremity SEMLS.

Methods: One-hundred-eighty-seven patients with CP across all GMFCS levels who underwent hip and lower extremity SEMLS were identified consecutively over a 5-year period at our institution: 28% (53/187) did not have cell salvage set up, 42% (79/187) had cell salvage set up but not spun down, and 29% (55/187) had cell salvage set up and spun down. Median age was 9.6 years (range, 4.0 to 19.5 years) and 65% were male. Bivariate analysis followed by multivariable logistic regression determined significant associations between patient/surgical factors and cell salvage status. Chi-square and Fisher’s exact tests assessed significant differences in intra- and post-op transfusion between groups.

Results: Compared to those without cell salvage set up, patients with cell salvage set up were younger (p < 0.001) and had a higher estimated blood loss to body mass index ratio (EBL/BMI, p< 0.001), a greater proportion of bilateral procedures (p=0.004), increased GMFCS levels (p < 0.001), and higher ASA scores (p=0.007). Those who had cell salvage set up were also significantly more likely to have a pelvic osteotomy (p < 0.001), open hip reduction (p=0.002), femoral osteotomy (p < 0.001), tranexamic acid (p < 0.001), and longer surgeon operative time (p < 0.001).

Compared to patients with cell salvage set up but not spun down, patients with cell salvage spun down were older (p=0.01) and had higher EBL/BMI (p < 0.001), a greater proportion of pelvic osteotomies (p=0.05), and longer surgeon operative time (p=0.001; Table 1). Patients who had cell salvage spun down had a significantly higher rate of postoperative transfusions compared to patients who did not have cell salvage set up (29% vs 9%, p=0.01).

Conclusion: Patient characteristics associated with the decision to set up cell salvage included younger age, higher GMFCS level, and higher ASA score. Surgical characteristics included higher EBL/BMI, bilaterality, hip procedures, tranexamic acid, and longer surgeon operative time. However, cell salvage actually appeared necessary only for cases with higher EBL/BMI, pelvic osteotomies, longer surgeon operative times, and older patients, as indicated by those who had cell salvage spun down. Thus, surgeons are encouraged to reevaluate their use of cell salvage during SEMLS with the risk factors identified in this study to help decrease hospital resource utilization and OR costs, as only a small minority of cell salvage actually went on to be spun down at our institution and patients who received cell salvage did not have lower rates of postoperative transfusion.