How can I manage blood transfusion intraoperatively in a patient undergoing endoscopic spine surgery with a contraindication to 0.9% Normal Saline (NS) solution?

Blood Transfusion in Endoscopic Spine Surgery Without Normal Saline

Use balanced crystalloid solutions such as Lactated Ringer's or Plasmalyte for blood transfusion administration in endoscopic spine surgery when 0.9% normal saline is contraindicated. 1

Recommended Fluid for Blood Transfusion

Lactated Ringer's (LR) or Plasmalyte are safe and effective alternatives to normal saline for blood transfusion. 1, 2, 3

• Multiple high-quality guidelines from the World Journal of Emergency Surgery and British Journal of Anaesthesia strongly recommend balanced crystalloids over 0.9% saline for all intraoperative fluid management, including blood transfusion scenarios. 1
• The British Journal of Anaesthesia specifically recommends administering balanced crystalloids (Ringer Lactate or Plasmalyte) at 2-6 mL/kg/hour during spine surgery, aiming for a slightly positive balance of 1-2 liters by the end of the procedure. 2, 3

Evidence Supporting Lactated Ringer's with Blood Products

Historical concerns about LR causing clotting with blood are not clinically significant in modern practice. 4

• A controlled study comparing whole blood and packed red blood cells rapidly mixed with normal saline versus Lactated Ringer's found no significant difference in infusion time, filter weight, or clot formation between the two solutions. 4
• Visible clot formation only occurred when calcium chloride was added at supraphysiologic concentrations (5g/L), which does not occur with standard LR. 4
• The study concluded that blood bank guidelines should be revised to allow LR use during rapid transfusion of packed red blood cells. 4

Why Avoid Normal Saline

Normal saline causes hyperchloremic metabolic acidosis, renal vasoconstriction, and increased risk of acute kidney injury compared to balanced crystalloids. 1

• The SMART trial demonstrated that patients receiving 0.9% saline had significantly higher incidence of major adverse kidney events (15.4% vs 14.3%) compared to balanced crystalloids. 1
• Large volumes of 0.9% saline lead to renal edema, reduced cortical tissue perfusion, and overall increased postoperative complications. 1
• A registry study of over 30,000 patients undergoing major abdominal surgery showed fewer complications with buffered crystalloids compared to 0.9% saline. 1

Practical Implementation Algorithm

For intraoperative blood transfusion in endoscopic spine surgery:

1. Primary choice: Use Lactated Ringer's or Plasmalyte for all IV access and blood product administration. 1, 2, 3

2. Infusion rate: Administer at 2-6 mL/kg/hour to maintain adequate perfusion while avoiding fluid overload. 2, 3

3. Target fluid balance: Aim for +1-2 liters positive balance by end of surgery to protect renal function. 1, 2

4. Blood transfusion trigger: Maintain hemoglobin >70-90 g/L (individualized based on comorbidities and clinical status). 1

5. Avoid mixing in same line simultaneously: While LR is safe with blood, run blood products through dedicated IV access when possible to optimize flow rates. 4

Common Pitfalls to Avoid

Do not use dextrose-containing solutions with blood products as they cause immediate clumping and hemolysis. 5

• 5% dextrose in water causes immediate clumping with gross hemolysis after 30 minutes. 5
• 5% dextrose in 0.225% saline causes hemolysis within 10 minutes at 37°C. 5

Do not restrict fluids excessively in an attempt to avoid normal saline, as this increases acute kidney injury risk. 1, 2

• A large multicenter trial of 3000 patients showed that stringently restrictive fluid regimens resulted in higher incidence of acute kidney injury compared to modestly liberal regimens. 1, 2

Do not use synthetic colloids or albumin routinely for volume replacement during transfusion. 1

• Strong recommendation against routine use of albumin or synthetic colloids for intraoperative fluid administration based on lack of mortality benefit and potential risks. 1

Specific Considerations for Endoscopic Spine Surgery

Endoscopic spine procedures have lower blood loss and shorter operative times compared to open techniques, reducing overall transfusion requirements. 6

• Endoscopic discectomy demonstrates significantly lower adverse events (0.6% vs 3.4%) and shorter length of stay (0.81 vs 1.15 days) compared to open procedures. 6
• The minimally invasive nature means balanced crystalloid requirements are typically at the lower end of the 2-6 mL/kg/hour range. 2, 3