Perioperative Blood Transfusion is Associated with an Increased Mortality in Older Surgical Patients

Effects of prior antiplatelet and/or nonsteroidal anti-inflammatory drug use on mortality in patients undergoing abdominal surgery for abdominal sepsis

BACKGROUND

The effects of prior antiplatelet and/or nonsteroidal anti-inflammatory drug (NSAID) use on mortality in critically ill patients remain unclear. We investigated the relationship between antiplatelet and/or NSAID use and mortality in patients who had undergone surgery for sepsis caused by intra-abdominal infection.

METHODS

We obtained data from adult patients (aged >18 years) admitted to the intensive care unit after abdominal surgery due to intra-abdominal infection. The patients were categorized into those with and without prior antiplatelet and/or NSAID use.

RESULTS

Overall, 241 patients were enrolled, with 76 in the antiplatelet and/or NSAID use group and 165 in the non-use group. The 60-day survival probabilities for the antiplatelet and/or NSAID use and non-use groups were 85.5% and 73.3%, respectively, and this difference was significant (P = .040). In the multivariate analysis of 28-day mortality, higher Acute Physiology and Chronic Health Evaluation II score (P < .001), Simplified Acute Physiology Score III (P < .001), and blood transfusion within 5 days postoperatively (P = .034) were significant mortality risk factors. In the multivariate analysis of 60-day mortality, higher Acute Physiology and Chronic Health Evaluation II score (P = .002), Simplified Acute Physiology Score III (P < .001), and blood transfusion within 5 days postoperatively (P = .006) were also significant mortality risk factors. However, prior drug use (P = .036) was a factor in reducing mortality.

CONCLUSION

Patients with a prior history of antiplatelet and/or NSAID use had a higher 60-day survival than those who did not use these drugs. Prior antiplatelet and/or NSAID use was significantly associated with a reduction in 60-day mortality.

Risk factors of serious postoperative outcomes in patients aged ≥90 years undergoing surgical intervention

Objective

We aimed to identify preoperative and intraoperative factors associated with serious postoperative outcomes, which may help patients and clinicians make better-informed decisions.

Methods

We conducted a retrospective study including all patients aged ≥90 years who underwent surgery between January 1, 2011, and January 1, 2021, at Chongqing University Central Hospital. We assessed 30 pre- and intraoperative demographic and clinical variables. Logistic regression was used to identify the independent risk factors for serious postoperative outcomes in patients aged ≥90 years.

Results

A total of 428 patients were included in our analysis. The mean age was 92.6 years (SD ± 2.6). There were 240 (56.1%) females and 188 (43.9%) males. The most common comorbidities were hypertension (44.9%) and arrhythmias (34.8%). The 30-day hospital mortality was 5.6%, and severe morbidity was 33.2%. Based on the multivariate logistic regression classification analysis of the American Society of Anesthesiologists (ASA)≥ Ⅳ [odds ratio (OR), 5.39, 95% confidence interval (CI), 2.06-14.16, P = .001], emergency surgery (OR, 5.02, 95% CI, 2.85-15.98, P = .001) and chronic heart failure (OR, 6.11, 95% CI, 1.93-13.06, P = .001) were identified as independent risk factors for 30-day hospital mortality, and ASA≥ Ⅳ (OR, 4.56, 95%CI, 2.56-8.15, P < .001), Barthel index (BI) < 35 (OR, 2.28, 95%CI, 1.30-3.98, P = .001), chronic heart failure (OR, 3.67, 95%CI, 1.62-8.31, P = .002), chronic kidney disease (OR, 4.24, 95%CI, 1.99-9.05, P < .001), general anesthesia (OR, 3.31, 95%CI, 1.91-5.76, P < .001), emergency surgery (OR, 3.72, 95%CI, 1.98-6.99, P < .001), and major surgery (OR, 3.44, 95%CI, 1.90-6.22, P < .001) were identified as independent risk factors for serious postoperative complications.

Conclusions

Patients aged ≥90 years with ASA≥ Ⅳ, BI < 35, combined with chronic heart failure or chronic kidney disease, undergoing emergency surgery, major surgery or general anesthesia have a higher risk of serious postoperative outcomes. Identifying these risk factors in an early stage may contribute to our clinical decision-making and improve the quality of treatments.

Short-term outcomes of colorectal cancer surgery in older patients: a novel nomogram predicting postoperative morbi-mortality

PURPOSE

To analyze short-term outcomes of curative-intent cancer surgery in all adult patients diagnosed with colorectal cancer undergoing surgery from January 2010 to December 2019 and determine risk factors for postoperative complications and mortality.

METHODS

Retrospective study conducted at a single tertiary university institution. Patients were stratified by age into two groups: < 75 years and ≥ 75 years. Primary outcome was the influence of age on 30-day complications and mortality. Independent risk factors for postoperative adverse events or mortality were analyzed, and two novel nomograms were constructed.

RESULTS

Of the 1486 patients included, 580 were older (≥ 75 years). Older subjects presented more comorbidities and tumors were located mainly in right colon (45.7%). After matching, no between-group differences in surgical postoperative complications were observed. The 30-day mortality rate was 5.3% for the older and 0.8% for the non-older group (p < 0.001). In multivariable analysis, the independent risk factors for postoperative complications were peripheral vascular disease, chronic pulmonary disease, severe liver disease, postoperative transfusion, and surgical approach. Independent risk factors for 30-day mortality were age ≥ 80 years, cerebrovascular disease, severe liver disease, and postoperative transfusion. The model was internally and externally validated, showing high accuracy.

CONCLUSION

Patients aged ≥ 75 years had similar postoperative complications but higher 30-day mortality than their younger counterparts. Patients with peripheral vascular disease, chronic pulmonary disease, or severe liver disease should be informed of higher postoperative complications. But patients aged ≥ 80 suffering cerebrovascular disease, severe liver disease, or needing postoperative transfusion should be warned of significantly increased risk of postoperative mortality.

Mortality and clinical outcome of Italian patients undergoing orthopaedic surgery: effect of peri-operative blood transfusion

BACKGROUND

Blood transfusion is a relevant issue for elderly and frail patients, as they are often anaemic and have chronic diseases. Transfusion of red blood cells (RBC) can potentially affect morbidity and mortality of elderly patients undergoing major orthopaedic surgery.

MATERIALS AND METHODS

We carried out a retrospective analysis of 2,593 patients undergoing major orthopaedic surgery between 2013 and 2017 in a single research institution in the Region of Apulia. The aims of the study were: 1) to describe the characteristics of transfused patients according to a restrictive or liberal strategy of transfusion and haemoglobin (Hb) triggers and targets; 2) to investigate the effect of RBC transfusion on mortality and complications.

RESULTS

Older, women and patients with American Society of Anesthesiologists (ASA) score 3-4 were more often transfused. Those with lower admission Hb level had a higher risk of being transfused. Hb triggers were associated with the patients' age. A restrictive transfusion strategy was significantly more frequent in patients undergoing primary knee replacement and in those with higher estimated blood loss. We did not observe any significant difference of complications in patients transfused with a liberal vs restrictive strategy. Logistic regression correcting for potential confounders revealed that sex (males more than females), duration of stay in hospital, hip fracture and Charlson score >4 were good predictors of complications and/or mortality. Mortality was significantly higher in males and in older patients with ASA score 3-4.

DISCUSSION

In this large cohort of Italian patients undergoing major orthopaedic surgery males were significantly more exposed than women to complications and in-hospital mortality. Furthermore, those undergoing urgent surgery because of hip fracture had a 3-fold higher chance of complications. Charlson score >4 and ASA 3-4 are good predictors of complications and mortality, respectively.

Predictors for blood loss and transfusion frequency to guide blood saving programs in primary knee- and hip-arthroplasty

Endoprosthetic surgery can lead to relevant blood loss resulting in red blood cell (RBC) transfusions. This study aimed to identify risk factors for blood loss and RBC transfusion that enable the prediction of an individualized transfusion probability to guide preoperative RBC provision and blood saving programs. A retrospective analysis of patients who underwent primary hip or knee arthroplasty was performed. Risk factors for blood loss and transfusions were identified and transfusion probabilities computed. The number needed to treat (NNT) of a potential correction of preoperative anemia with iron substitution for the prevention of RBC transfusion was calculated. A total of 308 patients were included, of whom 12 (3.9%) received RBC transfusions. Factors influencing the maximum hemoglobin drop were the use of drain, tranexamic acid, duration of surgery, anticoagulation, BMI, ASA status and mechanical heart valves. In multivariate analysis, the use of a drain, low preoperative Hb and mechanical heart valves were predictors for RBC transfusions. The transfusion probability of patients with a hemoglobin of 9.0–10.0 g/dL, 10.0–11.0 g/dL, 11.0–12.0 g/dL and 12.0–13.0 g/dL was 100%, 33.3%, 10% and 5.6%, and the NNT 1.5, 4.3, 22.7 and 17.3, while it was 100%, 50%, 25% and 14.3% with a NNT of 2.0, 4.0, 9.3 and 7.0 in patients with a drain, respectively. Preoperative anemia and the insertion of drains are more predictive for RBC transfusions than the use of tranexamic acid. Based on this, a personalized transfusion probability can be computed, that may help to identify patients who could benefit from blood saving programs.

Impact of Surgery on Older Patients Hospitalized With an Acute Abdomen: Findings From the Older Persons Surgical Outcome Collaborative

Background: The impact of surgery compared to non-surgical management of older general surgical patients is not well researched.

Methods: We examined the association between management and adverse outcomes in a cohort of emergency general surgery patients aged > 65 years. This multi-center study included 727 patients (mean+/-SD, 77.1 ± 8.2 years, 54% female) admitted to five UK hospitals. Data were analyzed using multi-level crude and multivariable logistic regression. Outcomes were: mortality at Day 30 and 90, length of stay, and readmission within 30 days of discharge. Covariates assessed were management approach, age, sex, frailty, polypharmacy, anemia, and hypoalbuminemia.

Results: Approximately 25% of participants (n = 185) underwent emergency surgery. Frailty and albumin were associated with mortality at 30 (frailty OR = 3.52 [95% CI 1.66–7.49], albumin OR = 3.78 ([95% CI 1.53–9.31]), and 90 days post discharge (frailty OR = 3.20 [95% CI 1.86–5.51], albumin OR=3.25 [95% CI 1.70–6.19]) and readmission (frailty OR = 1.56 [95% CI (1.04–2.35)]). Surgically managed patients and frailty had increased odds of prolonged hospitalization (surgery OR = 5.69 [95% CI 3.67–8.80], frailty OR = 2.17 [95% CI 1.46–3.23]).

Conclusion: We found the impact of surgery on length of hospitalization in older surgical patients is substantial. Whether early comprehensive geriatric assessment and post-op rehabilitation would improve this outcome require further evaluation.

Interaction of heparin and protamine in presence of overdosage: in vitro study

BACKGROUND

Heparin is used for anticoagulation during cardiopulmonary bypass. After weaning from bypass, protamine is administered to neutralize the effects of heparin and thus reestablish hemostasis. Rotational thrombelastometry has been shown to discriminate between heparin and other impairing effects on coagulation. We analyzed the interaction of heparin and protamine under different conditions of overdosage in an in-vitro trial.

METHODS

Blood samples were taken from 17 healthy volunteers, separated, and spiked in vitro with heparin, protamine for heparin neutralization, an overdosage of protamine, and two dosages of re-heparinization to evaluate heparin effects under the condition of protamine overdosage. All samples were analyzed in a standard ROTEM rotational thromboelastometry device after intrinsic activation with and without addition of heparinase. Coagulation time, maximum clot firmness, and clot formation time were recorded.

RESULTS

Heparin led to prolongation of coagulation and clot formation times in the test without heparinase. Adequate protamine addition normalized the test, and overdosage of protamine led to significant prolongation of both times. Addition of heparin in the presence of protamine overdosage normalized these parameters.

CONCLUSION

We reconfirmed that the ROTEM device enables discrimination of the effects heparin and protamine on coagulation and detection of the coagulation-impairing effects of protamine overdosage. Furthermore, we were able to show a positive effect on coagulation times by heparin in the presence of protamine overdosage. Because this was an in-vitro study, these findings need to be confirmed in vivo, requiring further research.

Colorectal cancer surgery in selected nonagenarians is relatively safe and it is associated with a good long-term survival: an observational study

Background

Advanced age is a risk factor for colorectal cancer, and very elderly patients often need to be surgically treated. This study aimed to analyze the outcomes of a cohort of nonagenarian patients operated on for colorectal cancer.

Methods

Observational study conducted on a cohort of 40 nonagenarian patients, who were treated surgically for colorectal cancer between 2000 and 2018 in our institution. Clinical data, ASA score, Charlson Comorbidity Index, Surgical Mortality Probability Model, tumor characteristics, and nature and technical features of the surgical procedure, were recorded. The Comprehensive Complication Index (CCI) and survival time after the procedure were recorded as outcome variables. Univariate and multivariate analyses were performed in order to define risk factors for postoperative complications and long-term survival.

Results

Out of the 40 patients, 13 (32.5%) were men, 27 (67.5%) women, and mean age 91.6 years (SD ± 1.5). In 24 patients (60%), surgery was elective, and in 16 patients (40%), surgery was emergent. Curative surgery with intestinal resection was performed in 34 patients (85%). In 22 patients (55%), intestinal continuity was restored by performing an anastomosis. The median CCI was 22.6 (IRQ 0.0–42.6). Operative mortality was 10% (4 patients). Cumulative survival at 1, 3, and 5 years was 70%, 47%, and 29%, respectively. In multivariate analysis, only the need for transfusion remained as an independent prognostic factor for complications (p = 0.021) and TNM tumor stage as a significant predictor of survival (HR 3.0, CI95% 1.3–7.2).

Conclusions

Colorectal cancer surgery is relatively safe in selected nonagenarian patients and may achieve long-term survival.

Blood components requests at an orthopedic hospital: a critical survey

Introduction

The correct completion of the blood components request form is the starting point to ensure good transfusion care. Many guidelines have been developed to search for hemoglobin values that trigger the need for transfusion and show the importance of Patient Blood Management, a scientific evidence-based approach in processes where transfusion is a possibility, such as in elective surgeries.

Objective

The cross-sectional study aimed to analyze the transfusion requests at a complex orthopedic hospital over a one-year period.

Method

The completion quality was classified as Good, Regular, Bad or Very Bad, according to the information given by the physician. Transfusion medicine professionals analyzed the transfusion indication reported on the request form and classified it as Correct, Not based on Patient Blood Management (PBM), in accordance or not with the institutional Maximum Surgical Blood Order Schedule, Impossible to evaluate due to lack of information on the form, and Incorrect.

Results

The study categorized the completion quality of 2011 requests as Good (8.80%), Regular (9.30%), Bad (72.75%) and Very Bad (9.15%). Analysis of the indications revealed that 54.90% of the requests were in accordance with the current blood transfusion recommendations, and on 23.12% of the forms this field had not been filled out.

Conclusion

The majority of blood components (63%) requests are in tune with current blood transfusion recommendations, despite the great number of incorrectly completed forms; nevertheless, it is mandatory to reach much better appropriateness rates.