Effect of Topical Hydrogen Peroxide on Postoperative Blood Loss in Patients Undergoing Laminectomy

 Introduction

Spine surgery may be indicated if non-surgical treatment such as medications and physical therapy fails to relieve symptoms. Surgery is only considered in cases where the source of pain can be determined such as a herniated disc, scoliosis, or spinal stenosis (1).

Spine procedures are associated with substantial blood loss and high incidence of postoperative transfusion, which associated with a several complications, including the transmission of blood-borne infection, thromboembolic events, and immunosuppression (2).

Perioperative methods have been established to decrease the excessive blood loss and the need for blood products.  H2O2 can be used as a chemical hemostasis agent that is easily degraded by tissue catalase to form oxygen and water. It is a widely available topical antiseptic and nontoxic hemostasis agent that produces oxidative burst and local oxygen production (3).

Methods:

This prospective randomized, controlled and single blinded study was approved by the Faculty of Medicine, Minia University local ethical committee. It involved 80 adult patients underwent thoraco-lumbar laminectomy. This study was a single blind as the investigator did not know the nature of the drugs given.

The patients were randomly allocated into two equal groups (40 patients in each group) according to sample size. Randomization was done by arrangement of syringe for each case in 2 closed envelops named group I and II (40 cases in each envelope). The 1st patient received drugs from the 1st envelope (Group I) and the 2nd patient from the 2nd envelope (Group II). This process was repeated in the same manner until the completion of 80 patients. At the end of surgery this closed envelops were opened and the groups were Group I (H group): The incision was soaked with 100 mL of 3% H2O2 solution for 3 minutes, Group II (C group): The incision was soaked by 100 ml normal saline for 3 minutes. The Unknown solutions were prepared and supplied by the supervisor in syringe and coded as (A & B) for Topical administration into wound. The protocol of these letters was opened after the study was finished.

Patients included were with age ranging from 20 to 70 years old of both sexes, with thoracic or lumbar degenerative disease who underwent thoraco-lumbar laminectomy. Exclusion criteria were patients with dural tear accompanied by cerebrospinal fluid leakage detected intraoperatively, Spinal cord tumors and penetrating spinal cord trauma.

In the preparation room, all patients were cannulated, then in the OR they were preoxygenated with 100% oxygen for 3 minutes during which the standard monitors; electrocardiogram, noninvasive blood pressure and pulse oximetry attached to the patient. Operation was done under general anesthesia and patients were intubated with an appropriate size of endotracheal tube by using laryngoscope.

Patients were adequately positioned and ventilated using volume-controlled mode with a tidal volume of 8 ml/kg, respiratory rate 12 and PEEP 5, they were carefully turned prone and chest supports were used and extended from the clavicle to the iliac crest, the abdomen and genitalias were free from pressure, with proper padding of both eyes with soft pads under pressure sites.

 The patients underwent instrumented surgery involving the thoracic or lumbar spine (between T1 and S1) by a posterior midline approach. A standard posterior midline incision and exposure of the posterior vertebral arches, decompression, spino-laminectomy by kerrison rongeur with classic discectomy with or without spinal fixation by inter-body fusion or inter-pedicular screws and postero-lateral bone grafting.

Then subcutaneous suction drains were placed at completion of surgery and maintained for 48 h postoperatively. After the end of operation, patients turned supine. Neuromuscular blockade was reversed with I.V atropine (0.01 mg / Kg) and neostigmine (0.05 mg / kg), after return of spontaneous respiration. All the patients were extubated on table when awake and following commands.

The patients were transferred to the recovery room, then discharged to the neuro-surgery ward and closely monitored 48 hours postoperatively in neurosurgery department. We followed up drains and estimated the blood volume inside them, and lab investigations were recorded (Hemoglobin & Platalets) after the first 24 hrs and after 48 hrs. 

Statistical analysis:

The collected data were coded, tabulated, and statistically analyzed using SPSS program (Statistical Package for Social Sciences) software version 24.

Descriptive statistics were done for parametric quantitative data by mean, standard deviation while they were done for categorical data by number and percentage.

Analyses were done for parametric quantitative data between the two groups using independent T test. Analyses were done for qualitative data using chi squared test. The level of significance was taken at (P value < 0.05).

Sample size calculation:

Patients will be subcategorized into two groups; G power program version (3.1.9) was used to calculate sample size for this study with priory analysis, based on a previous study (Hsieh et al, 2021). The effect size was calculated 0.3 (moderate effect size), alpha error was 0.05 and power of 0.80 was used. The resulted sample size was 80 patients, each group has 40 patients.

 Results

Patients who met the inclusion criteria were included in this study. Demographic data is presented in (Table 1), (table 2) shows surgical data without any significant differences between the two groups.

Discussion

Spine surgery is usually associated with large amount of blood loss and blood transfusion. Effective control of perioperative blood loss and blood transfusion is critical to ensure that patients undergo spine surgery safely and smoothly, particularly for multilevel or complicated spine surgery (4).

This randomized controlled study shows the effectiveness of topical H2O2 on postoperative blood loss in patients who underwent thoraco-lumbar laminectomy.  This study found that the application of H2O2 on wound for 3 minutes before wound closure can decrease postoperative blood loss in drains and preserves higher Hb levels.

      Our findings correlate also with Chen et al., 2020 who studied 2626 patients; the control group (no H2O2 irrigation) included of 1345 patients, and the experimental group (H2O2 irrigation) included 1281 patients; The postoperative drain collection was significantly lower in the experimental group compared to the control group. In Farhang et al., 2019, they suggested the use of a stack of 4×4-in gauze on the surgical tray is saturated with 3% H2O2 and used by the surgeon and surgical assistant throughout the procedure, they used this technique during standard excisions, repairs, and derm-abrasion and recommended H2O2 soaks immediately postoperatively in patients with active bleeding.

Hydrogen peroxide is known to facilitate hemostasis with several accepted mechanisms that include regulating the contractility and barrier function of endothelial cells, activating latent cell surface tissue factor and platelet aggregation, and stimulating platelet derived growth factor activation (5).

We are in agreement with Thejas et al., 2021 who studied the vasoconstrictive and hemostatic properties of H2O2 in tonsillectomy, and reported that the bleeding from the fossa in all the cases included in our study stopped with local pressure and the application of topical agents. None of the cases had a secondary hemorrhage and did not need other ways to control bleeding such as ligation of the external carotid artery, pillar suturing, or oro-pharyngeal packing around the endotracheal tube.

But in Hsieh et al., 2021 which conducted on 60 patients aged–8–68 years were prospectively enrolled for tonsillectomy, they suggested that the intraoperative blood loss was significantly lower in the hydrogen peroxide group than in the adrenaline group, as they added the hemostatic agents during the operation.