Effect Of Ultra-Short-Term Treatment of Patients with Iron Deficiency Or Anemia Undergoing Adolescent Scoliosis Correction, A Randomized Controlled Prospective Study.

Effect Of Ultra-Short-Term Treatment of Patients with Iron Deficiency Or Anemia Undergoing Adolescent Scoliosis Correction, A Randomized Controlled Prospective Study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect Of Ultra-Short-Term Treatment of Patients with Iron Deficiency Or Anemia Undergoing Adolescent Scoliosis Correction, A Randomized Controlled Prospective Study. Amany Faheem Omara, Ahmed Kamal Taha, Amgad Elshikh, Ibraheem Ahmed Shamhout, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3824571/v2 This work is licensed under a CC BY 4.0 License Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Abstract Background Blood transfusions are necessary in spine fusion surgery for scoliosis. Objectives The study aimed to evaluate the response of patients with iron deficiency or anemia undergoing adolescent scoliosis correction to ultra-short-term treatment with ferric carboxymaltose, subcutaneous erythropoietin & vitamin B12, and oral folic acid. Methods Forty-four patients aged 13 to 45 years with adolescent idiopathic scoliosis for surgical posterior fusion spine surgery were divided into therapy group received a gradual intravenous infusion of 20 mg/kg ferric carboxymaltose, 40.000-unit subcutaneous erythropoietin, 1 mg subcutaneous vitamin B12, and 5 mg oral folic acid one day before surgery and control group got a placebo treatment. The number of red blood cell and platelet transfusions received during the first postoperative seven days, the perioperative hemoglobin [HB], platelet, and leucocyte count [RTC], reticulocyte hemoglobin content [RTC-HB], the need for fresh frozen plasma units, and intraoperative blood loss were recorded. Results The therapy group had significantly less intraoperative blood loss, lower number of patients who required platelet, fresh frozen plasma, and RBCs transfusions than in the control group. The therapy group considerably enhanced postoperative total leukocyte count and platelet count. In the therapy group, postoperative HB, RTC, and RTC-HB values were considerably greater than in the control group. Conclusion Preoperative combined administration of ferric carboxymaltose, erythropoietin, vitamin B12, and folic acid in adolescent idiopathic scoliosis correction one day before the surgery, could improve postoperative outcomes by optimizing preoperative anemia, reducing intraoperative blood loss and the number of patients requiring blood products and shorter intensive care unit stay. Adolescent Anemia Erythropoietin Scoliosis Folic acid. Figures Figure 1 Figure 2 Figure 3 Background Surgical correction of adolescent idiopathic scoliosis [AIS] using multiple screws at different pedicle levels through a posterior approach is performed. The length of the fusion, the length of the procedure, and the amount of soft tissue exposed vary significantly, even though this implementation. is typically regarded as safe and with few surgical complications. Red blood cells [RBCs] transfusions are necessary both during and after fusion surgery for scoliosis as blood loss is another issue. [ 1 ] Cell Saver, recombinant factor VIIa, and anti-fibrinolytic medications (aprotinin, tranexamic acid, and epsilon-aminocaproic acid) are common methods to reduce blood loss during the perioperative phase. [ 2 ] All patients scheduled for elective surgery whose blood loss is projected to be greater than 500 mL should have their hemoglobin measured before surgery and be evaluated if anemia is discovered. [ 3 ] Patient blood management [PBM] is a 10-year-old evidence-based interdisciplinary approach aimed at improving patient outcomes while lowering the necessity of RBCs transfusions. PBM encompasses numerous preventive methods to limit bleeding risks, reduce iatrogenic blood loss, and adjust decision thresholds for optimal blood treatment administration. [ 4 ] The purpose of this study was to see how patients with iron deficiency or anemia who were undergoing adolescent scoliosis correction responded to ultra-short-term treatment with the intravenous infusions of ferric carboxymaltose, subcutaneous erythropoietin, subcutaneous vitamin B12, and oral folic acid. Methods The prospective double-blind, controlled randomized trial was prospectively registered on ClinicalTrials.gov with the ID: NCT04343170 at the date of 13/04/2020, after approval of the Tanta University ethical committee [Approval code: 33679/2/20]. After that, this trial was conducted on 44 patients aged 13 to 45 years with adolescent idiopathic scoliosis slated for surgical treatment by posterior fusion spine surgery at Tanta University Hospitals from April 2020 to February 2021. Patients with isolated iron deficiency [diagnosed by a decrease of ferritin < 100 mcg/L and serum iron < 50 ug/dl, transferrin saturation 450ug/dl without anemia] or iron deficiency anemia [same laboratory finding with Hb = 12g/dL in females and Hb = 13g/dL in males, and low RBCs count] were included. Depending on the patient's age, written informed consent was sought from the patient's parents or the patient themselves. Patients with renal and hepatic impairments, those with known allergies to iron - carboxymaltose, and those with Hb concentrations less than nine g/L in both genders were excluded from the study. Forty-four patients were divided into two equal groups at random allocation [22 patients each]. The randomization was carried out using computer-generated randomization software that was inserted inside a closed opaque envelope. Patients in the therapy group received a combination treatment one day before the surgery including a slow intravenous infusion of 20 mg/kg ferric carboxymaltose [Ferinject, Vifor, Switzerland] (maximum of 1000 mg) diluted in 250 ml normal saline over 30 minutes, and 40.000 Unit subcutaneous erythropoietin [Epoform, EPICO], 1 mg subcutaneous vitamin B12 [depovit B12,1000mcg/ml Amriya for Pharmaceutical Industries S.A.E], and 5 mg oral folic acid [acidum folicum, EPICO]. Patients in the control group received a placebo treatment one day before the surgery that included a slow intravenous infusion of 250 normal saline over 30 minutes, two subcutaneous injections of one mL saline, and an oral sugar tablet. The study’s blindness was achieved by intravenous administering iron or 0.9% saline using a black infusion set behind a screen. A nurse not included in data capture or data entry was responsible for the preparation of medications required for the study methodology. Both groups' patient demographics [age, gender, duration of surgery, and the number of screws implanted] were documented. Vital signs were checked every 5 minutes during the medication infusion and for up to 15 minutes after it was completed. The number of RBCs and platelet units transfused during the first 7 days postoperatively, the perioperative level of Hb, the reticulocyte, platelet, and leucocyte count, the reticulocyte Hb content, the need for fresh frozen plasma units, serum creatinine, intraoperative calculated blood loss calculated by Blood volume loss formula [López-Picado's formula], [ 5 ] the length of ICU stay, the incidence of acute kidney injury and infections requiring antibiotics were recorded in both groups. López-Picado's formula: $$\:\text{B}\text{l}\text{o}\text{o}\text{d}\:\text{l}\text{o}\text{s}\text{s}\:\left[\text{m}\text{L}\right]=\frac{\left[\text{E}\text{B}\text{V}\times\:\left(\text{H}\text{c}\text{t}\text{i}\:-\text{H}\text{c}\text{t}\text{f}\:\right)+\text{t}\text{r}\text{a}\text{n}\text{s}\text{f}\text{u}\text{s}\text{e}\text{d}\:\text{R}\text{B}\text{C}\:\text{v}\text{o}\text{l}\text{u}\text{m}\text{e}\right]}{\text{H}\text{c}\text{t}\text{m}\text{e}\text{a}\text{n}}$$ EBV is the estimated blood volume [determined using the ICSH formula] Hcti is the initial hematocrit, Hctf is the final hematocrit, and Hct means the mean hematocrit [between initial and final]. The transfused RBCs volume is calculated as follows. 1 Unit packed homologous RBCs = 450 mL × haematocrit of the transfused blood. 1 Unit packed autologous RBCs = 450 mL × haematocrit in the pre-surgical anaesthesia consultation. ICSH formula: Female: BV [mL] = Plasma volume [mL] + red cell volume [mL] = [weight [kg] 0,425 ×height [cm] 0,725 ]×0,007184×2,217 + age [years]×1,06 Male: BV [mL] = Plasma volume [mL] + red cell volume [mL]=[weight[kg] 0,425 ×wheight [cm] 0,725 ] ×0,007184×3,064 − 825 The primary outcome was the percentage of patients who did not require blood transfusions during surgery or within the first seven days after surgery, including the operating day. The length of stay in an ICU, the incidence of acute kidney injury, infection with antibiotic therapy request, perioperative reticulocyte count, reticulocyte hemoglobin content [RTC-HB], platelet and leucocyte counts, creatinine, and calculated RBCs loss were all secondary outcomes. Statistical analysis - The G*Power program v 3.1.9.2 [University of Düsseldorf, Düsseldorf, Germany] was used to calculate the sample size. Based on the following factors, the sample size required for each category is 22 cases: 0.05 error and 80% power of the trial to demonstrate a 40% decrease in the requirement for blood transfusion [the primary outcome] with group A compared to group B [50% according to a prior study, [ 6 ] and 2 cases were added to each group to overcome dropout Data was entered into the computer and processed with IBM SPSS software version 20.0. IBM Corp., Armonk, NY. Categorical data were represented as percentages. When comparing two groups of categorical variables, the Chi-square test was used. Alternatively, when more than 20% of the cells had an expected count of less than 5, the Fisher Exact adjustment test was used. The Shapiro-Wilk and Kolmogorov-Smirnov tests were used to assess the normality of continuous data. For regularly distributed quantitative variables, quantitative data were presented as a range [minimum and maximum], mean, standard deviation, and median. When comparing two groups, the student t-test was employed, and when comparing two periods, the Paired t-test was utilized. The Mann-Whitney test, on the other hand, was used for not regularly distributed quantitative variables. For non-normally distributed quantitative variables, the Mann-Whitney test was employed to compare two groups. The obtained results were declared significant at the 5% level. Results Fifty sex patients were evaluated for eligibility; 12 were eliminated from the study [seven patients had a history of iron allergy, and five refused to participate], and the remaining 44 patients were randomly allocated into two groups [22 patients each], as shown in consort flow chart [Figure 1 ]. Baseline patient characteristics such as age, gender, and surgery time were well balanced across therapy and control groups [p = 0.934, 0.750, and 0.749, respectively]. Also, there was no significant difference between the two groups in the number of patients with anemia and iron deficiency, as well as the number of screws implanted [p = 1.000 and 0.497, respectively]. Preoperative ferritin and creatinine levels were equivalent in both groups [p = 0.647 and 0.214, respectively]. Only one patient in the control group suffered an acute kidney injury [AKI], and neither group had a postoperative infection. The mean intraoperative blood loss in the therapy group was significantly lower than in the control group [p = 0.024], and this was associated with a significant decrease in the number of patients who required platelet, fresh frozen plasma [FFP], and RBCs infusions, as well as a significant decrease in the number of RBCs units required [p < 0.001 for all]. The total duration of the ICU stay period was shorter in the therapy group than in the control group [Table 1 and Figs. 2 & 3 ]. Table 1 Comparison between the two studied groups according to different parameters. Control [n = 22] Therapy [n = 22] p Age [years] Mean ± SD. 21.5 ± 4 21.6 ± 4 0.934 Gender Male (no., %) 14 [63.6%] 15 [68.2%] 0.750 Female (no., %) 8 [36.4%] 7 [31.8%] Duration of surgery [hr.] Mean ± SD. 5.4 ± 1 5.5 ± 0.7 0.749 Type Anemia 8 [36.4%] 8 [36.4%] 1.000 Deficiency 14 [63.6%] 14 [63.6%] Intraoperative blood loss Mean ± SD. 1469.1 ± 279.3 1307.7 ± 154.9 0.024* Number of screws Mean ± SD. 13 ± 2.3 12.5 ± 2.3 0.497 Pre-ferritin Mean ± SD. 110 ± 27.9 107.1 ± 20.4 0.647 Creatinine Mean ± SD. 1.1 ± 0.4 0.98 ± 0.3 0.214 AKI 1 [4.5%] 0 [0%] 1.000 Infections 0 [0%] 0 [0%] – ICU stays Mean ± SD. Median (Min. – Max.) 3 ± 1.5 3 (1–5) 0.4 ± 0.5 0 (0–1) < 0.001* * Statistically significant. SD: Standard deviation. ICU: intensive care unit. AKI: acute kidney injury. FFP: fresh frozen plasma. RBCs: red blood cells. PLT: platelet. Hrs: hours. ICU: intensive care unit. Both groups presented statistically significant increases in postoperative total leucocytic count [TLC], platelet, HB, RTC, and RTC-HB values [all p < 0.001]. However, when comparing the two groups, only postoperative HB, RTC, and RTC-HB were substantially higher in the therapy group than in the control group [p < 0.001 for all] [Table 2 ]. Table 2 Comparison between the two studied groups according to laboratory investigations. Control [n = 22] Therapy [n = 22] p TLC Pre Mean ± SD. 4840.2 ± 1200.4 4958 ± 1076.1 0.734 Post Mean ± SD. 6688.2 ± 2287.9 7075.8 ± 1753 0.532 p 1 < 0.001 * < 0.001 * Platelets Pre Mean ± SD. 242.8 ± 24.7 231 ± 33.6 0.191 Post Mean ± SD. 149.3 ± 38.2 151.7 ± 40.3 0.840 p 1 < 0.001* < 0.001* Hemoglobin Pre Mean ± SD. 11.4 ± 0.8 11.4 ± 1.1 0.987 Post Mean ± SD. 10 ± 0.64 13.1 ± 0.82 < 0.001* p 1 < 0.001* < 0.001* RTC Pre Mean ± SD. 2.45 ± 0.16 2.50 ± 0.37 0.567 Post Mean ± SD. 4.65 ± 0.53 3.82 ± 0.62 < 0.001* p 1 < 0.001* < 0.001* RTC-HB Pre Mean ± SD. 35.3 ± 2.2 36.3 ± 4.3 0.318 Post Mean ± SD. 37.6 ± 3.4 41.5 ± 2.6 < 0.001* p 1 0.001* < 0.001* * Statistically significant. SD: Standard deviation. TLC: total leucocytic count. RTC: reticulocytes count. RTC-HB: reticulocyte hemoglobin. p1: comparing between Pre and Post in each group. P: comparing between both groups. Discussion Scoliosis correction can be associated with severe intraoperative blood loss and a high rate of anesthetic and surgical complications. [ 7 ] The quantity of preoperative anemia leads to transfusion of intra and postoperative allogeneic blood to avoid hemodynamic [hypotension, tachycardia] or neurologic [unfavorable neuromonitoring changes] instability. [ 8 ] Preoperative anemia especially combined with spine surgery can lead to unfavorable outcomes such as an increased length of hospital stay, transfusion complications, infection, and mortality incidence. [ 9 ] Severe anemia caused by acute surgical blood loss and their treatment with blood product transfusions is associated with renal, cardiac, and neurological morbidities, in addition to the cost of screening blood products for developing countries. Because of the undesirable consequences, it is a less desirable alternative for anemia control. [ 10 ] The current study results showed significantly lower intraoperative blood loss in the Therapy group with a significant reduction in the number of patients requiring platelet, FFP, and RBCs transfusions, RBCs unit, and shorter ICU stay. Although the average required units of RBCs were 3 which is not associated with coagulopathy. The authors follow the local protocol in our hospital regarding blood transfusion [RBCS, platelet, and FFP regime 1:1:1]. Combined therapy improves postoperative TLC, platelet, HB, RTC, and RTC-HB values considerably. Iron supplementation is another popular way of treating preoperative anemia. Preoperative anemia caused by iron deficiency or chronic disease may react better to intravenous iron treatment, depending on the timeframe before surgery, iron tolerance, and iron status. [ 10 ] Furthermore, erythropoietin [EPO] therapy is one of the most recent techniques to improve preoperative anemia. EPO receptor-stimulating drugs are recombinant versions of EPO that are administered to enhance red blood cell formation. [ 11 ] Understanding the physiological characteristics of the hormone can explain the improved effect of EPO on iron. The bone marrow stem cells are activated by EPO to form reticulocytes and mobilize iron stores. The increased mobilization of iron owing to hemoglobin production results in an iron deficiency. Another clinical interpretation could be the worldwide iron deficiency, which causes a scarcity of iron stores and a lower response to EPO therapy alone. Iron integration with EPO may enhance the therapeutic response, resulting in an earlier and better correction of preoperative anemia. The anemia caused by chronic disease and cancer could be treated by iron and EPO combination therapy successfully. [ 12 – 14 ] More modern iron formulations, including ferric carboxymaltose and ferric derisomaltose, allow for regulated iron delivery to the reticuloendothelial system, reducing the quantity of harmful free iron that circulates. Improvements in Hb concentration, functional performance, and quality of life are all brought on by intravenous iron, which also reduces the need for transfusions for many chronic illnesses. [ 15 ] In patients with anemia or iron deficiency, an abrupt decrease in RBCs most frequently results from hemolysis or an acute hemorrhage. Reticulocytes are used by the bone marrow to measure erythropoietic response; there will be an increase in both the proportion and absolute number of reticulocytes. [ 16 ] Extended hemorrhage patients have been known to develop leukocytosis. In the first week following acute blood loss, TLC is high because of a sustained rise in the neutrophil population. [ 17 ] Both vitamin B12 and folic acid deficiencies, which both contribute to macrocytic anemia, should be assessed in patients who are being tested for folic acid deficiency. When the body's need for folate increases due to conditions like hemolytic anemia, pregnancy, puberty, or severe blood loss, folate deficiency is frequently observed. [ 18 ] For erythropoiesis to occur, iron, folate, and vitamin B12 are necessary. Vitamin B12 and folate are crucial for erythroblasts to divide during differentiation. A lack of folate or vitamin B12 hinders DNA synthesis, reduces the formation of purines and thymidylates, and causes erythroblast death, which leads to anemia from ineffective erythropoiesis. Iron is essential to produce hemoglobin by erythroblasts. [ 19 ] Optimization of stores of elements for RBCs synthesis with a single dose of combined therapy especially with no reported side effects of a single dose of combination therapy before. Similarly, the efficacy of combination therapy of erythropoietin and intravenous iron in a small study of 74 anemic patients scheduled for valvular heart disease surgery was previously demonstrated. [ 20 ] Spahn et al., single-center, randomized, double-blind, parallel-group controlled trial, patients undergoing elective heart surgery with anemia, support current findings. RBCs and total allogeneic blood product transfusions in patients with preoperative anemia or isolated iron deficiency were minimized by an ultra-short-term combination treatment which consisted of intravenous iron, subcutaneous erythropoietin alpha, vitamin B12, and oral folic acid. The mechanism was by accelerating the hemopoietic response, this response was ensured by a significantly higher reticulocyte count and reticulocyte Hb content. These patients were monitored already at the first postoperative day and were observed at least until postoperative day 5. This is the most plausible mechanism for lower RBCs transfusions. [ 21 ] Furthermore, Penny-Dimri et al. found that preoperative erythropoietin administration in patients scheduled for cardiac surgery reduced the incidence of acute renal injury, which was observed in the current investigation. [ 22 ] According to another study by Oh et al., the incidence of mortality and end-stage renal disease in patients with acute kidney injury following coronary artery bypass grafting were lowered by erythropoietin treatment. [ 23 ] Furthermore, when compared to placebo, patients undergoing major orthopedic surgery who utilized EPO 300 units/kg per day for 10 days prior to the procedure, on the day of the operation, and for four days thereafter showed a nearly six-fold lower risk of allogeneic transfusion. [ 24 , 25 ] Alsaleh et al., meta-analysis investigated the effectiveness of erythropoiesis-stimulating agents [ESAs, including erythropoietin] concerned with lowering allogeneic blood transfusions [ABT] and maintaining hemoglobin levels in patients having knee or hip arthroplasty. The use of preoperative ESAs minimized the requirement for ABT. There was a significant difference in mean hemoglobin between the ESA and control groups postoperatively. [ 26 ] To reduce the incidence of allogenic blood transfusion and its associated problems in patients scheduled for total hip or knee arthroplasty, Zhao et al. conducted a meta-analysis on the use of erythropoietin prior to surgery in patients enrolled for complete hip or knee arthroplasty. The use of preoperative erythropoietin was linked to lower ABT exposure and higher postoperative hemoglobin concentrations, the investigators found. [ 27 ] Lin et al. systematic review study discovered that allogenic transfusion rates were lowered by a short preoperative erythropoietin regimen or a single dose of erythropoietin in combination with IV iron during the pre-or peri-operative period. [ 28 ] The degree of anemia, the clinical impact of hypoxia, the symptoms of organ ischemia, and the patient's comorbidities are all taken into consideration when deciding whether to transfuse blood. This is done pragmatically on a case-by-case basis depending on the circumstances of each patient. Their pathophysiology and circulation volume status balance these elements. At this point, additional anemia treatments must be considered. [ 15 ] This study has some distinct advantages. Complete blindness was successfully achieved, Patients with preoperative anemia or isolated iron deficiency had equal chances for distribution between the therapy and placebo groups according to stratification. The infusion bag was covered and concealed behind a screen while the medication was administered through black tubing. The physician who gave the treatment was blinded concerning patient enrollment, patient treatment, or data collection. The physician in charge of data collection was uninformed of patient group assignment because the randomization mechanism alerted the physician in charge of patient treatment via text message. Furthermore, surgeons, intensive-care unit experts, and postoperative ward physicians were fully unaware of group assignments. One drawback of our trial was the small number of patients, which may have reduced our statistical power. We also did not analyze the potential long-term adverse effects associated with erythropoietin therapy. EPO therapy, for example, has previously been shown to increase tumor growth. The authors advised larger-scale studies comparing different EPO/iron therapy timing regimes and longer patient follow-up. Conclusions The study concluded that patients undergoing scoliosis surgery can benefit from meticulous interdisciplinary planning and implementation of perioperative blood conservation methods. To reduce the necessity of perioperative blood transfusions, preoperative anemia screening, and management should be considered an integral aspect of perioperative PBM. Finally, preoperative anemia can be effectively managed with minimal exposure to allogeneic transfusions by using ultrashort duration of EPO, iron, vitamin B12, and folic acid combination therapy, which effectively minimizes transfusion requirements. To enhance surgical outcomes, surgeons should actively adopt existing therapies that help to avoid transfusions and their associated dangers, conserve blood, and treat preoperative anemia. Declarations Conflicts of interest: The authors have no conflicts of interest to declare. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Funding statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Acknowledgments: none Data availability: data avalible with aouthers but not for sharing as this is part of patient confidintiality. References Ohrt-Nissen S, Bukhari N, Dragsted C, Gehrchen M, Johansson PI, Dirks J et al (2017) Blood transfusion in the surgical treatment of adolescent idiopathic scoliosis—a single‐center experience of patient blood management in 210 cases. Transfusion 57(7):1808–1817. 10.1111/trf.14137 Singh J, Kapoor D, Srivastava M, Singh M (2013) Anaesthetic management in a child with an atypical triad for reconstructive scoliosis surgery. Indian J Anesth 57(6):596–598 Munting K, Klein A (2019) Optimisation of pre-operative anemia in patients before elective major surgery–why, who, when and how? 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Med 95(27):e4122 Lin DM, Lin ES, Tran M-H (2013) Efficacy and safety of erythropoietin and intravenous iron in perioperative blood management: a systematic review. Transfus Med Rev 27(4):221–234. 10.1016/j.tmrv.2013.09.001 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3824571","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":266539896,"identity":"4134b2b4-1b81-4849-80c5-1e992d67b2fa","order_by":0,"name":"Amany Faheem Omara","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYNACG4YEIMn4IMFAQo6BgYcYLWlgLcwGHwosjEnSwiY540NFYgMhLfzTDj97zJNgl8fP3p0gzWMgkb7h+NmDDz4w2MnpNmDXInE7zdyYJyG5WLLn7AZjoJbcDWfykg1nMCQbmx3AYc3tBDNp3h/MiRtu5G5IBms5kGMmzcNwIHEbDi3yt9O/SfMk1Cfuv/92w2GQwwzOv8GvxeA2yMyEw4kbJHg3Ns4wkEgwuEHAFsPbOWWScxKOJ844k7uZ4YOBhOHMG2+MDWcY4PaL3O30bRJvEqoT+9vPbv+R8KdOnu98juGDDxV2cji9DwRMKBGhAFZpgFs5CDD+QObJN+BXPQpGwSgYBSMPAABzjWJwgqOOAQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-9025-632X","institution":"Assistant professor of Anesthesiology and Intensive Care, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tanta University, Al Gharbia governate, Tanta, Egypt.","correspondingAuthor":true,"prefix":"","firstName":"Amany","middleName":"Faheem","lastName":"Omara","suffix":""},{"id":397535067,"identity":"3e732924-871f-4e18-8fb2-699332b4c7b6","order_by":1,"name":"Ahmed Kamal Taha","email":"","orcid":"","institution":"Lecturer of Anesthesiology and Intensive Care, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tanta University, Al Gharbia governate, Tanta, Egypt.","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Kamal","lastName":"Taha","suffix":""},{"id":397535068,"identity":"5de143f3-bcc7-4ba6-b160-1cb9dce61a81","order_by":2,"name":"Amgad Elshikh","email":"","orcid":"","institution":"Lecturer of Anesthesiology and Intensive Care, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tanta University, Al Gharbia governate, Tanta, Egypt.","correspondingAuthor":false,"prefix":"","firstName":"Amgad","middleName":"","lastName":"Elshikh","suffix":""},{"id":397535069,"identity":"3b1c1b89-8dd6-49f8-a3e5-acfad4131e0f","order_by":3,"name":"Ibraheem Ahmed Shamhout","email":"","orcid":"","institution":"Assistant professor of Neurosurgery, Department of Neurosurgery, Faculty of Medicine, the Tanta University, Tanta, Al Gharbia governate, Egypt.","correspondingAuthor":false,"prefix":"","firstName":"Ibraheem","middleName":"Ahmed","lastName":"Shamhout","suffix":""},{"id":397535070,"identity":"5171dc13-bb16-418b-b928-e16de01e0e7c","order_by":4,"name":"Tarek Abdel-Hay Mostafa","email":"","orcid":"","institution":"Assistant professor of Anesthesiology and Intensive Care, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tanta University, Al Gharbia governate, Tanta, Egypt.","correspondingAuthor":false,"prefix":"","firstName":"Tarek","middleName":"Abdel-Hay","lastName":"Mostafa","suffix":""}],"badges":[],"createdAt":"2023-12-30 17:29:13","currentVersionCode":2,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-3824571/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-3824571/v2","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":74096285,"identity":"b3a1d794-ea01-4cf2-851f-de7b3d9fda16","added_by":"auto","created_at":"2025-01-17 17:17:16","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":103859,"visible":true,"origin":"","legend":"\u003cp\u003eConsort flow chart.\u003c/p\u003e","description":"","filename":"Figure1Consortflowchart.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3824571/v2/66bfe6f14110c0f3fd818592.jpg"},{"id":74097243,"identity":"ad39d34d-efc6-49a2-a291-f719c078201f","added_by":"auto","created_at":"2025-01-17 17:25:16","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56112,"visible":true,"origin":"","legend":"\u003cp\u003eFFP, PLT, and RBC are needed in the two groups.\u003c/p\u003e","description":"","filename":"Figure2FFPPLTRBCneedsinthetwogroups.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3824571/v2/ba46eb21d93c0ad79328aa49.jpg"},{"id":74096291,"identity":"b2267cb2-3161-485e-8f97-18d1c060b2fb","added_by":"auto","created_at":"2025-01-17 17:17:16","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21542,"visible":true,"origin":"","legend":"\u003cp\u003eTransfused RBC units in the two groups.\u003c/p\u003e","description":"","filename":"Figure3transfusedRBCunitsinthetwogroups.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3824571/v2/e6888caaf83e4f7b84ec50af.jpg"},{"id":74097426,"identity":"353ac19b-741c-447c-b4ed-a8626b932094","added_by":"auto","created_at":"2025-01-17 17:33:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":885198,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3824571/v2/e03afa3f-18e5-4731-b13b-d6622a512a98.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"Effect Of Ultra-Short-Term Treatment of Patients with Iron Deficiency Or Anemia Undergoing Adolescent Scoliosis Correction, A Randomized Controlled Prospective Study.","fulltext":[{"header":"Background","content":"\u003cp\u003eSurgical correction of adolescent idiopathic scoliosis [AIS] using multiple screws at different pedicle levels through a posterior approach is performed. The length of the fusion, the length of the procedure, and the amount of soft tissue exposed vary significantly, even though this implementation. is typically regarded as safe and with few surgical complications. Red blood cells [RBCs] transfusions are necessary both during and after fusion surgery for scoliosis as blood loss is another issue. \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCell Saver, recombinant factor VIIa, and anti-fibrinolytic medications (aprotinin, tranexamic acid, and epsilon-aminocaproic acid) are common methods to reduce blood loss during the perioperative phase. \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAll patients scheduled for elective surgery whose blood loss is projected to be greater than 500 mL should have their hemoglobin measured before surgery and be evaluated if anemia is discovered. \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e Patient blood management [PBM] is a 10-year-old evidence-based interdisciplinary approach aimed at improving patient outcomes while lowering the necessity of RBCs transfusions. PBM encompasses numerous preventive methods to limit bleeding risks, reduce iatrogenic blood loss, and adjust decision thresholds for optimal blood treatment administration.\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe purpose of this study was to see how patients with iron deficiency or anemia who were undergoing adolescent scoliosis correction responded to ultra-short-term treatment with the intravenous infusions of ferric carboxymaltose, subcutaneous erythropoietin, subcutaneous vitamin B12, and oral folic acid.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e The prospective double-blind, controlled randomized trial was prospectively registered on ClinicalTrials.gov with the ID: NCT04343170 at the date of 13/04/2020, after approval of the Tanta University ethical committee [Approval code: 33679/2/20]. After that, this trial was conducted on 44 patients aged 13 to 45 years with adolescent idiopathic scoliosis slated for surgical treatment by posterior fusion spine surgery at Tanta University Hospitals from April 2020 to February 2021. Patients with isolated iron deficiency [diagnosed by a decrease of ferritin\u0026thinsp;\u0026lt;\u0026thinsp;100 mcg/L and serum iron\u0026thinsp;\u0026lt;\u0026thinsp;50 ug/dl, transferrin saturation\u0026thinsp;\u0026lt;\u0026thinsp;20% with an increased level of total binding capacity\u0026thinsp;\u0026gt;\u0026thinsp;450ug/dl without anemia] or iron deficiency anemia [same laboratory finding with Hb\u0026thinsp;=\u0026thinsp;12g/dL in females and Hb\u0026thinsp;=\u0026thinsp;13g/dL in males, and low RBCs count] were included. Depending on the patient's age, written informed consent was sought from the patient's parents or the patient themselves.\u003c/p\u003e \u003cp\u003ePatients with renal and hepatic impairments, those with known allergies to iron - carboxymaltose, and those with Hb concentrations less than nine g/L in both genders were excluded from the study.\u003c/p\u003e \u003cp\u003eForty-four patients were divided into two equal groups at random allocation [22 patients each]. The randomization was carried out using computer-generated randomization software that was inserted inside a closed opaque envelope. Patients in the therapy group received a combination treatment one day before the surgery including a slow intravenous infusion of 20 mg/kg ferric carboxymaltose [Ferinject, Vifor, Switzerland] (maximum of 1000 mg) diluted in 250 ml normal saline over 30 minutes, and 40.000 Unit subcutaneous erythropoietin [Epoform, EPICO], 1 mg subcutaneous vitamin B12 [depovit B12,1000mcg/ml Amriya for Pharmaceutical Industries S.A.E], and 5 mg oral folic acid [acidum folicum, EPICO]. Patients in the control group received a placebo treatment one day before the surgery that included a slow intravenous infusion of 250 normal saline over 30 minutes, two subcutaneous injections of one mL saline, and an oral sugar tablet. The study\u0026rsquo;s blindness was achieved by intravenous administering iron or 0.9% saline using a black infusion set behind a screen. A nurse not included in data capture or data entry was responsible for the preparation of medications required for the study methodology.\u003c/p\u003e \u003cp\u003eBoth groups' patient demographics [age, gender, duration of surgery, and the number of screws implanted] were documented. Vital signs were checked every 5 minutes during the medication infusion and for up to 15 minutes after it was completed. The number of RBCs and platelet units transfused during the first 7 days postoperatively, the perioperative level of Hb, the reticulocyte, platelet, and leucocyte count, the reticulocyte Hb content, the need for fresh frozen plasma units, serum creatinine, intraoperative calculated blood loss calculated by Blood volume loss formula [L\u0026oacute;pez-Picado's formula], \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e the length of ICU stay, the incidence of acute kidney injury and infections requiring antibiotics were recorded in both groups.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eL\u0026oacute;pez-Picado's formula:\u003c/h2\u003e \u003cp\u003e \u003cdiv id=\"Equa\" class=\"Equation\"\u003e \u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:\\text{B}\\text{l}\\text{o}\\text{o}\\text{d}\\:\\text{l}\\text{o}\\text{s}\\text{s}\\:\\left[\\text{m}\\text{L}\\right]=\\frac{\\left[\\text{E}\\text{B}\\text{V}\\times\\:\\left(\\text{H}\\text{c}\\text{t}\\text{i}\\:-\\text{H}\\text{c}\\text{t}\\text{f}\\:\\right)+\\text{t}\\text{r}\\text{a}\\text{n}\\text{s}\\text{f}\\text{u}\\text{s}\\text{e}\\text{d}\\:\\text{R}\\text{B}\\text{C}\\:\\text{v}\\text{o}\\text{l}\\text{u}\\text{m}\\text{e}\\right]}{\\text{H}\\text{c}\\text{t}\\text{m}\\text{e}\\text{a}\\text{n}}$$\u003c/div\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eEBV is the estimated blood volume [determined using the ICSH formula]\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHcti is the initial hematocrit, Hctf is the final hematocrit, and Hct means the mean hematocrit [between initial and final].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe transfused RBCs volume is calculated as follows.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e1 Unit packed homologous RBCs\u0026thinsp;=\u0026thinsp;450 mL \u0026times; haematocrit of the transfused blood.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e1 Unit packed autologous RBCs\u0026thinsp;=\u0026thinsp;450 mL \u0026times; haematocrit in the pre-surgical anaesthesia consultation.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eICSH formula:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFemale:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eBV [mL]\u0026thinsp;=\u0026thinsp;Plasma volume [mL]\u0026thinsp;+\u0026thinsp;red cell volume [mL] = [weight [kg]\u003csup\u003e0,425\u003c/sup\u003e\u0026times;height [cm]\u003csup\u003e0,725\u003c/sup\u003e]\u0026times;0,007184\u0026times;2,217\u0026thinsp;+\u0026thinsp;age [years]\u0026times;1,06\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMale:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eBV [mL]\u0026thinsp;=\u0026thinsp;Plasma volume [mL]\u0026thinsp;+\u0026thinsp;red cell volume [mL]=[weight[kg]\u003csup\u003e0,425\u003c/sup\u003e\u0026times;wheight [cm]\u003csup\u003e0,725\u003c/sup\u003e] \u0026times;0,007184\u0026times;3,064\u0026thinsp;\u0026minus;\u0026thinsp;825\u003c/p\u003e \u003cp\u003eThe primary outcome was the percentage of patients who did not require blood transfusions during surgery or within the first seven days after surgery, including the operating day. The length of stay in an ICU, the incidence of acute kidney injury, infection with antibiotic therapy request, perioperative reticulocyte count, reticulocyte hemoglobin content [RTC-HB], platelet and leucocyte counts, creatinine, and calculated RBCs loss were all secondary outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003eThe G*Power program v 3.1.9.2 [University of D\u0026uuml;sseldorf, D\u0026uuml;sseldorf, Germany] was used to calculate the sample size. Based on the following factors, the sample size required for each category is 22 cases: 0.05 error and 80% power of the trial to demonstrate a 40% decrease in the requirement for blood transfusion [the primary outcome] with group A compared to group B [50% according to a prior study,\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e and 2 cases were added to each group to overcome dropout\u003c/p\u003e \u003cp\u003eData was entered into the computer and processed with IBM SPSS software version 20.0. IBM Corp., Armonk, NY. Categorical data were represented as percentages. When comparing two groups of categorical variables, the Chi-square test was used. Alternatively, when more than 20% of the cells had an expected count of less than 5, the Fisher Exact adjustment test was used. The Shapiro-Wilk and Kolmogorov-Smirnov tests were used to assess the normality of continuous data. For regularly distributed quantitative variables, quantitative data were presented as a range [minimum and maximum], mean, standard deviation, and median. When comparing two groups, the student t-test was employed, and when comparing two periods, the Paired t-test was utilized. The Mann-Whitney test, on the other hand, was used for not regularly distributed quantitative variables. For non-normally distributed quantitative variables, the Mann-Whitney test was employed to compare two groups. The obtained results were declared significant at the 5% level.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFifty sex patients were evaluated for eligibility; 12 were eliminated from the study [seven patients had a history of iron allergy, and five refused to participate], and the remaining 44 patients were randomly allocated into two groups [22 patients each], as shown in consort flow chart [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBaseline patient characteristics such as age, gender, and surgery time were well balanced across therapy and control groups [p\u0026thinsp;=\u0026thinsp;0.934, 0.750, and 0.749, respectively].\u003c/p\u003e \u003cp\u003eAlso, there was no significant difference between the two groups in the number of patients with anemia and iron deficiency, as well as the number of screws implanted [p\u0026thinsp;=\u0026thinsp;1.000 and 0.497, respectively]. Preoperative ferritin and creatinine levels were equivalent in both groups [p\u0026thinsp;=\u0026thinsp;0.647 and 0.214, respectively]. Only one patient in the control group suffered an acute kidney injury [AKI], and neither group had a postoperative infection. The mean intraoperative blood loss in the therapy group was significantly lower than in the control group [p\u0026thinsp;=\u0026thinsp;0.024], and this was associated with a significant decrease in the number of patients who required platelet, fresh frozen plasma [FFP], and RBCs infusions, as well as a significant decrease in the number of RBCs units required [p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all]. The total duration of the ICU stay period was shorter in the therapy group than in the control group [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u0026amp; \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between the two studied groups according to different parameters.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e[n\u0026thinsp;=\u0026thinsp;22]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTherapy\u003c/p\u003e \u003cp\u003e[n\u0026thinsp;=\u0026thinsp;22]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge [years]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.934\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale (no., %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 [63.6%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 [68.2%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (no., %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 [36.4%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 [31.8%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of surgery [hr.]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.749\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 [36.4%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 [36.4%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 [63.6%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 [63.6%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraoperative blood loss\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1469.1\u0026thinsp;\u0026plusmn;\u0026thinsp;279.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1307.7\u0026thinsp;\u0026plusmn;\u0026thinsp;154.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.024*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of screws\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.497\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePre-ferritin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110\u0026thinsp;\u0026plusmn;\u0026thinsp;27.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107.1\u0026thinsp;\u0026plusmn;\u0026thinsp;20.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.647\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCreatinine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAKI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [4.5%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 [0%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInfections\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 [0%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 [0%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eICU stays\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003cp\u003eMedian (Min. \u0026ndash; Max.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003cp\u003e3 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Statistically significant. SD: Standard deviation. ICU: intensive care unit. AKI: acute kidney injury. FFP: fresh frozen plasma. RBCs: red blood cells. PLT: platelet. Hrs: hours. ICU: intensive care unit.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBoth groups presented statistically significant increases in postoperative total leucocytic count [TLC], platelet, HB, RTC, and RTC-HB values [all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. However, when comparing the two groups, only postoperative HB, RTC, and RTC-HB were substantially higher in the therapy group than in the control group [p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between the two studied groups according to laboratory investigations.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e[n\u0026thinsp;=\u0026thinsp;22]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTherapy\u003c/p\u003e \u003cp\u003e[n\u0026thinsp;=\u0026thinsp;22]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eTLC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4840.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1200.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4958\u0026thinsp;\u0026plusmn;\u0026thinsp;1076.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.734\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6688.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2287.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7075.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1753\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.532\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csub\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003ePlatelets\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePre\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e242.8\u0026thinsp;\u0026plusmn;\u0026thinsp;24.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e231\u0026thinsp;\u0026plusmn;\u0026thinsp;33.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e149.3\u0026thinsp;\u0026plusmn;\u0026thinsp;38.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e151.7\u0026thinsp;\u0026plusmn;\u0026thinsp;40.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csub\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eHemoglobin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePre\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.987\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csub\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eRTC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePre\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.567\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csub\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eRTC-HB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePre\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.318\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csub\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Statistically significant. SD: Standard deviation. TLC: total leucocytic count. RTC: reticulocytes count. RTC-HB: reticulocyte hemoglobin. p1: comparing between Pre and Post in each group. P: comparing between both groups.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eScoliosis correction can be associated with severe intraoperative blood loss and a high rate of anesthetic and surgical complications. \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e The quantity of preoperative anemia leads to transfusion of intra and postoperative allogeneic blood to avoid hemodynamic [hypotension, tachycardia] or neurologic [unfavorable neuromonitoring changes] instability. \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e Preoperative anemia especially combined with spine surgery can lead to unfavorable outcomes such as an increased length of hospital stay, transfusion complications, infection, and mortality incidence.\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSevere anemia caused by acute surgical blood loss and their treatment with blood product transfusions is associated with renal, cardiac, and neurological morbidities, in addition to the cost of screening blood products for developing countries. Because of the undesirable consequences, it is a less desirable alternative for anemia control.\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe current study results showed significantly lower intraoperative blood loss in the Therapy group with a significant reduction in the number of patients requiring platelet, FFP, and RBCs transfusions, RBCs unit, and shorter ICU stay. Although the average required units of RBCs were 3 which is not associated with coagulopathy. The authors follow the local protocol in our hospital regarding blood transfusion [RBCS, platelet, and FFP regime 1:1:1]. Combined therapy improves postoperative TLC, platelet, HB, RTC, and RTC-HB values considerably.\u003c/p\u003e \u003cp\u003eIron supplementation is another popular way of treating preoperative anemia. Preoperative anemia caused by iron deficiency or chronic disease may react better to intravenous iron treatment, depending on the timeframe before surgery, iron tolerance, and iron status.\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurthermore, erythropoietin [EPO] therapy is one of the most recent techniques to improve preoperative anemia. EPO receptor-stimulating drugs are recombinant versions of EPO that are administered to enhance red blood cell formation.\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eUnderstanding the physiological characteristics of the hormone can explain the improved effect of EPO on iron. The bone marrow stem cells are activated by EPO to form reticulocytes and mobilize iron stores. The increased mobilization of iron owing to hemoglobin production results in an iron deficiency. Another clinical interpretation could be the worldwide iron deficiency, which causes a scarcity of iron stores and a lower response to EPO therapy alone. Iron integration with EPO may enhance the therapeutic response, resulting in an earlier and better correction of preoperative anemia. The anemia caused by chronic disease and cancer could be treated by iron and EPO combination therapy successfully. \u003csup\u003e[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMore modern iron formulations, including ferric carboxymaltose and ferric derisomaltose, allow for regulated iron delivery to the reticuloendothelial system, reducing the quantity of harmful free iron that circulates. Improvements in Hb concentration, functional performance, and quality of life are all brought on by intravenous iron, which also reduces the need for transfusions for many chronic illnesses. \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn patients with anemia or iron deficiency, an abrupt decrease in RBCs most frequently results from hemolysis or an acute hemorrhage. Reticulocytes are used by the bone marrow to measure erythropoietic response; there will be an increase in both the proportion and absolute number of reticulocytes. \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eExtended hemorrhage patients have been known to develop leukocytosis. In the first week following acute blood loss, TLC is high because of a sustained rise in the neutrophil population. \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBoth vitamin B12 and folic acid deficiencies, which both contribute to macrocytic anemia, should be assessed in patients who are being tested for folic acid deficiency. When the body's need for folate increases due to conditions like hemolytic anemia, pregnancy, puberty, or severe blood loss, folate deficiency is frequently observed. \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFor erythropoiesis to occur, iron, folate, and vitamin B12 are necessary. Vitamin B12 and folate are crucial for erythroblasts to divide during differentiation. A lack of folate or vitamin B12 hinders DNA synthesis, reduces the formation of purines and thymidylates, and causes erythroblast death, which leads to anemia from ineffective erythropoiesis. Iron is essential to produce hemoglobin by erythroblasts. \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOptimization of stores of elements for RBCs synthesis with a single dose of combined therapy especially with no reported side effects of a single dose of combination therapy before.\u003c/p\u003e \u003cp\u003eSimilarly, the efficacy of combination therapy of erythropoietin and intravenous iron in a small study of 74 anemic patients scheduled for valvular heart disease surgery was previously demonstrated.\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSpahn et al., single-center, randomized, double-blind, parallel-group controlled trial, patients undergoing elective heart surgery with anemia, support current findings. RBCs and total allogeneic blood product transfusions in patients with preoperative anemia or isolated iron deficiency were minimized by an ultra-short-term combination treatment which consisted of intravenous iron, subcutaneous erythropoietin alpha, vitamin B12, and oral folic acid. The mechanism was by accelerating the hemopoietic response, this response was ensured by a significantly higher reticulocyte count and reticulocyte Hb content. These patients were monitored already at the first postoperative day and were observed at least until postoperative day 5. This is the most plausible mechanism for lower RBCs transfusions. \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurthermore, Penny-Dimri et al. found that preoperative erythropoietin administration in patients scheduled for cardiac surgery reduced the incidence of acute renal injury, which was observed in the current investigation.\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAccording to another study by Oh et al., the incidence of mortality and end-stage renal disease in patients with acute kidney injury following coronary artery bypass grafting were lowered by erythropoietin treatment.\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurthermore, when compared to placebo, patients undergoing major orthopedic surgery who utilized EPO 300 units/kg per day for 10 days prior to the procedure, on the day of the operation, and for four days thereafter showed a nearly six-fold lower risk of allogeneic transfusion. \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlsaleh et al., meta-analysis investigated the effectiveness of erythropoiesis-stimulating agents [ESAs, including erythropoietin] concerned with lowering allogeneic blood transfusions [ABT] and maintaining hemoglobin levels in patients having knee or hip arthroplasty. The use of preoperative ESAs minimized the requirement for ABT. There was a significant difference in mean hemoglobin between the ESA and control groups postoperatively.\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo reduce the incidence of allogenic blood transfusion and its associated problems in patients scheduled for total hip or knee arthroplasty, Zhao et al. conducted a meta-analysis on the use of erythropoietin prior to surgery in patients enrolled for complete hip or knee arthroplasty. The use of preoperative erythropoietin was linked to lower ABT exposure and higher postoperative hemoglobin concentrations, the investigators found. \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLin et al. systematic review study discovered that allogenic transfusion rates were lowered by a short preoperative erythropoietin regimen or a single dose of erythropoietin in combination with IV iron during the pre-or peri-operative period. \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe degree of anemia, the clinical impact of hypoxia, the symptoms of organ ischemia, and the patient's comorbidities are all taken into consideration when deciding whether to transfuse blood. This is done pragmatically on a case-by-case basis depending on the circumstances of each patient. Their pathophysiology and circulation volume status balance these elements. At this point, additional anemia treatments must be considered. \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study has some distinct advantages. Complete blindness was successfully achieved, Patients with preoperative anemia or isolated iron deficiency had equal chances for distribution between the therapy and placebo groups according to stratification. The infusion bag was covered and concealed behind a screen while the medication was administered through black tubing.\u003c/p\u003e \u003cp\u003eThe physician who gave the treatment was blinded concerning patient enrollment, patient treatment, or data collection. The physician in charge of data collection was uninformed of patient group assignment because the randomization mechanism alerted the physician in charge of patient treatment via text message. Furthermore, surgeons, intensive-care unit experts, and postoperative ward physicians were fully unaware of group assignments.\u003c/p\u003e \u003cp\u003eOne drawback of our trial was the small number of patients, which may have reduced our statistical power. We also did not analyze the potential long-term adverse effects associated with erythropoietin therapy. EPO therapy, for example, has previously been shown to increase tumor growth. The authors advised larger-scale studies comparing different EPO/iron therapy timing regimes and longer patient follow-up.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe study concluded that patients undergoing scoliosis surgery can benefit from meticulous interdisciplinary planning and implementation of perioperative blood conservation methods. To reduce the necessity of perioperative blood transfusions, preoperative anemia screening, and management should be considered an integral aspect of perioperative PBM. Finally, preoperative anemia can be effectively managed with minimal exposure to allogeneic transfusions by using ultrashort duration of EPO, iron, vitamin B12, and folic acid combination therapy, which effectively minimizes transfusion requirements. To enhance surgical outcomes, surgeons should actively adopt existing therapies that help to avoid transfusions and their associated dangers, conserve blood, and treat preoperative anemia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of interest:\u003c/h2\u003e \u003cp\u003eThe authors have no conflicts of interest to declare. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding statement:\u003c/h2\u003e \u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAcknowledgments:\u003c/h2\u003e \u003cp\u003enone\u003c/p\u003e\u003ch2\u003eData availability:\u003c/h2\u003e \u003cp\u003edata avalible with aouthers but not for sharing as this is part of patient confidintiality.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOhrt-Nissen S, Bukhari N, Dragsted C, Gehrchen M, Johansson PI, Dirks J et al (2017) Blood transfusion in the surgical treatment of adolescent idiopathic scoliosis\u0026mdash;a single‐center experience of patient blood management in 210 cases. 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JBJS 78(1):62\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/00004623-199601000-00009\u003c/span\u003e\u003cspan address=\"10.2106/00004623-199601000-00009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsaleh K, Alotaibi GS, Almodaimegh HS, Aleem AA, Kouroukis CT (2013) The use of preoperative erythropoiesis-stimulating agents (ESAs) in patients who underwent knee or hip arthroplasty: a meta-analysis of randomized clinical trials. J Arthroplasty 28(9):1463\u0026ndash;1472\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao Y, Jiang C, Peng H, Feng B, Li Y, Weng X (2016) The effectiveness and safety of preoperative use of erythropoietin in patients scheduled for total hip or knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. 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Transfus Med Rev 27(4):221\u0026ndash;234. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.tmrv.2013.09.001\u003c/span\u003e\u003cspan address=\"10.1016/j.tmrv.2013.09.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adolescent, Anemia, Erythropoietin, Scoliosis, Folic acid.","lastPublishedDoi":"10.21203/rs.3.rs-3824571/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3824571/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBlood transfusions are necessary in spine fusion surgery for scoliosis.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThe study aimed to evaluate the response of patients with iron deficiency or anemia undergoing adolescent scoliosis correction to ultra-short-term treatment with ferric carboxymaltose, subcutaneous erythropoietin \u0026amp; vitamin B12, and oral folic acid.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eForty-four patients aged 13 to 45 years with adolescent idiopathic scoliosis for surgical posterior fusion spine surgery were divided into therapy group received a gradual intravenous infusion of 20 mg/kg ferric carboxymaltose, 40.000-unit subcutaneous erythropoietin, 1 mg subcutaneous vitamin B12, and 5 mg oral folic acid one day before surgery and control group got a placebo treatment. The number of red blood cell and platelet transfusions received during the first postoperative seven days, the perioperative hemoglobin [HB], platelet, and leucocyte count [RTC], reticulocyte hemoglobin content [RTC-HB], the need for fresh frozen plasma units, and intraoperative blood loss were recorded.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe therapy group had significantly less intraoperative blood loss, lower number of patients who required platelet, fresh frozen plasma, and RBCs transfusions than in the control group. The therapy group considerably enhanced postoperative total leukocyte count and platelet count. In the therapy group, postoperative HB, RTC, and RTC-HB values were considerably greater than in the control group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePreoperative combined administration of ferric carboxymaltose, erythropoietin, vitamin B12, and folic acid in adolescent idiopathic scoliosis correction one day before the surgery, could improve postoperative outcomes by optimizing preoperative anemia, reducing intraoperative blood loss and the number of patients requiring blood products and shorter intensive care unit stay.\u003c/p\u003e","manuscriptTitle":"Effect Of Ultra-Short-Term Treatment of Patients with Iron Deficiency Or Anemia Undergoing Adolescent Scoliosis Correction, A Randomized Controlled Prospective Study.","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2025-01-17 17:17:11","doi":"10.21203/rs.3.rs-3824571/v2","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2024-01-11 18:16:48","doi":"10.21203/rs.3.rs-3824571/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d573fc9-2dd9-4d68-8911-dbe9e62ddbfa","owner":[],"postedDate":"January 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-23T04:01:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-17 17:17:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v2","identity":"rs-3824571","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3824571","identity":"rs-3824571","version":["v2"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}