Clinical prediction model for red cell blood transfusion in elective primary posterior lumbar spine fusion

Elective primary lumbar spine fusion is a major surgery with a high risk of perioperative blood loss associated with increased blood component transfusion requirements. Significant blood loss¹ requires a packed red cell (PRC) transfusion of approximately 50–81%². A systematic review² revealed significant postoperative cardiac and noncardiac complications, such as surgical site infection, deep vein thrombosis, pulmonary embolism, myocardial infarction, transient ischemic attack, stroke, respiratory tract infection, and sepsis, in allogeneic transfusion. A prospective randomized controlled trial revealed that preoperative autologous blood donation reduces the risk of allogeneic blood transfusion in patients who undergo elective lumbar spine surgery³. The preoperative cross-matched transfusion ratio (C:T ratio) was overestimated. The high C:T ratio results in the loss of global costs in the management chain of blood processes, such as blood bank resources, time, finances, and human resources^4,5,6. As recommended, cross-match PRC by the maximum surgical blood-order schedule (MSBOS) was indicated for general preparation of PRC in lumbar spine surgery⁷.

Previous potential predictors associated with the risk of PRC transfusion may guide the general adjustment for the cross-match order, such as female sex^8,9,10, older age^8,9, high body mass index (BMI)¹, pulmonary disease or dyspnea^8,9,11, bleeding disorders⁸, anticoagulant/antiplatelet therapy⁸, high American Society of Anesthesiologist (ASA) classification^1,9,12, low preoperative hemoglobin (Hb) levels¹¹, hematocrit (Hct)^8,9, multilevel surgery (laminectomy and fusion)^8,9,11,12,13, long surgical time^8,9,11,12,13, transforaminal lumbar interbody fusion (TLIF)^1,12, and sacrum fusion¹². Recent limited studies¹⁴ revealed that a nanogram for PRC transfusion was not simplified for application, reported only preoperative predictors¹⁵, and did not define the type of fusion³. Intraoperative procedures were strong predictors that affected the accuracy of the prediction model^{1,3,8,9,11,12,13,14,16}, but they were inappropriate in the preoperative prediction model. Lumbar spine magnetic resonance imaging stimulated preoperative procedure planning in a previous cohort¹⁷, similar to actual surgery. This study used preoperative procedural planning in this model.

They overestimated the cross-match PRC, which resulted in a blood reservation shortage, especially during the coronavirus disease 2019 pandemic¹⁸. The MSBOS recommends a general cross-match PRC of two units for lumbar spine surgery¹⁹. PRC transfusions in this spine referral center demonstrated a 43% prevalence. To date, limited data is available regarding the influencing factors in determining an appropriate PRC transfusion for elective primary lumbar spine fusion in developing countries, where healthcare resources are relatively limited. Additionally, the parameters for predicting the probability of PRC transfusion have no practical use in surgical planning. Geographic variations in healthcare resources, socioeconomic status, and ethnicity may affect predictive PRC preparation. This study aimed to develop a preoperative predictive model for appropriate PRC transfusion in elective primary lumbar spine fusion.