A major contributor to the high morbidity and mortality associated with adult reconstructive spine procedures is high-volume blood loss suffered intraoperatively.¹,²,³,⁴,⁵,⁶ The literature contains several published reports of blood loss exceeding the patient’s preoperative estimated blood volume during corrective fusions for idiopathic scoliosis.⁷,⁸,⁹,¹⁰,¹¹ This phenomenon has been reported more recently in the treatment of adult spinal deformity as well, especially in cases that require a three-column osteotomy.¹²,¹³,¹⁴ Overall, the risk of intraoperative adverse events related to postoperative complications has been found to be as high as 10.2%, and several reports have correlated blood loss with the postoperative risk of complications.¹³ For example, increased blood loss has been associated with higher risk of surgical site infection.¹⁵ Some studies have also shown that after 5-6 hours of surgery, a patient’s coagulation cascade progresses rapidly toward disseminated intravascular coagulation (DIC), and others have shown that operative times >5 hours put patients at increased risk of infection.¹⁶,¹⁷,¹⁸ Given the inherent risk of high-volume blood loss during reconstructive spine surgery and the high postoperative morbidity associated with this blood loss, most surgeons have incorporated various blood conservation strategies into their operative work-flow, including intraoperative blood cell salvage systems, antifibrinolytic agents, and recombinant factor VIIa.

Although the incorporation of intraoperative blood conservation strategies is important to a comprehensive blood loss management strategy, there are numerous modifiable risk factors that impact the overall risk of perioperative high-volume blood loss as well. Procedural factors, for example, have a major impact on estimated blood loss (EBL). These factors include the surgical approach (open vs minimally invasive, posterior vs anterolateral), the severity and acuity of the curves present, the rigidity of the curves and whether the case will require three-column osteotomies, the presence of a single or two attending surgeons, and whether the procedure is planned to be staged or completed all the same day. There are also several patient-specific factors to consider; patient size and estimated blood volume, history of coagulopathies, history of taking medications that affect the coagulation cascade, contraindications to the use of tranexamic acid, and history of major bleeding or venous thromboembolism in other surgical procedures. With so many preoperative variables and intraoperative management strategies to consider for each individual case, it can be easy to flounder in a pattern of inconsistent and/or
incomplete blood loss management strategies. These types of work processes subsequently lend themselves very well to standard work and lean process improvement methodologies.

As is done in any standard work process, the first step in standardizing the management strategy for intraoperative blood loss is to deconstruct the entire strategy into a value stream map so that work processes currently in place can readily be defined in terms of their relative value to the overall process. Figure 1, for example, demonstrates the value stream map for the Seattle Spine Team’s Major Spine Protocol (SST-MSP), with complications directly related to blood loss and coagulopathy circled in red so they can be traced back to the processes in place to prevent them. As can be seen in Figure 1, risk of hypotensive sequelae is addressed by both a multidisciplinary preoperative conference (where medical risk factors predisposing someone to hypotensive sequelae are identified and optimized) and the intraoperative protocol to track coagulopathy and blood loss. Intraoperative blood loss is directly addressed by a two-attending surgeon approach to major spine cases as well as the intraoperative blood loss protocol. Intraoperative coagulopathy is additionally managed by a dedicated complex spine anesthesia team.¹⁹