Predicting Blood Loss and Transfusion Requirement in Patients Undergoing Surgery for Musculoskeletal Tumors

Abstract 4384

The management of musculoskeletal tumors has evolved markedly over the past 30 years, with improvements in surgical techniques, staging and chemotherapeutic advances delivering improved survival and functional outcomes, both in the setting of primary malignant bone tumors and in the palliation of tumors metastatic to bone. Advances in surgical technique as well as pre-operative chemotherapy has meant that most patients are now able to undergo limb-sparing surgery. Whilst clearly desirable to improve functional outcome, limb-sparing surgery is however more technically challenging and is associated with greater blood loss than amputation.

There is a paucity of data concerning blood utilization in the setting of major musculoskeletal tumor surgery. We retrospectively analyzed a database containing 1322 consecutive surgeries in 1222 patients over a 14 year timeframe, performed at a quaternary referral center in Melbourne, Australia. The following factors were significantly associated with high blood utilization: Chordomas, sacral and pelvic tumors, lower starting haemoglobin, tumors >5cm in size and high American Society of Anesthesiologists (ASA) score. The ASA score also clearly correlated with 30 day mortality. Pre-operative planning in these patients is critical to ensure adequate blood supply, minimize wastage and optimize the patient's general health prior to surgery. As such, based on modeling from our data, we propose a maximum surgical blood order schedule based on the presence or absence of the above factors.

Allogeneic blood transfusion, while a potentially life-saving intervention, is associated with major complications, including transmission of infectious agents and immunological complications. Longer-term, transfusion has been reported to result in immunomodulation and potentially a higher risk of tumor recurrence. Clearly, minimization of blood loss and avoidance of un-necessary transfusion is desirable. There is also a lack of data surrounding interventions designed to minimize blood loss in musculoskeletal tumor surgery, especially when compared to similar studies performed in major orthopedic surgery for benign conditions. These would be ideal targets for future randomized studies in the high-risk groups we have identified.