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Bartoszko J, Miles S, Ansari S, Grewal D, Li M, Callum J, McCluskey SA, Lin Y, Karkouti K. Postoperative intravenous iron to treat iron-deficiency anaemia in patients undergoing cardiac surgery: a protocol for a pilot, multicentre, placebo-controlled randomized trial (the POAM trial). BJA OPEN 2024; 11:100303. [PMID: 39161801 PMCID: PMC11332809 DOI: 10.1016/j.bjao.2024.100303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/01/2024] [Indexed: 08/21/2024]
Abstract
Background Iron-deficiency anaemia, occurring in 30-40% of patients undergoing cardiac surgery, is an independent risk factor for adverse outcomes. Our long-term goal is to assess if postoperative i.v. iron therapy improves clinical outcomes in patients with preoperative iron-deficiency anaemia undergoing cardiac surgery. Before conducting a definitive RCT, we first propose a multicentre pilot trial to establish the feasibility of the definitive trial. Methods This internal pilot, double-blinded, RCT will include three centres. Sixty adults with preoperative iron-deficiency anaemia undergoing non-emergency cardiac surgery will be randomised on postoperative day 2 or 3 to receive either blinded i.v. iron (1000 mg ferric derisomaltose) or placebo. Six weeks after surgery, patients who remain iron deficient will receive a second blinded dose of i.v. iron according to their assigned treatment arm. Patients will be followed for 12 months. Clinical practice will not be otherwise modified. For the pilot study, feasibility will be assessed through rates of enrolment, protocol deviations, and loss to follow up. For the definitive study, the primary outcome will be the number of days alive and out of hospital at 90 days after surgery. Ethics and dissemination The trial has been approved by the University Health Network Research Ethics Board (REB # 22-5685; approved by Clinical Trials Ontario funding on 22 December 2023) and will be conducted in accordance with the Declaration of Helsinki, Good Clinical Practices guidelines, and regulatory requirements. Clinical trial registration NCT06287619.
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Affiliation(s)
- Justyna Bartoszko
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
| | - Sarah Miles
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Saba Ansari
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Deep Grewal
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle Li
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Jeannie Callum
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, ON, Canada
| | - Stuart A. McCluskey
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Yulia Lin
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Choi UE, Nicholson RC, Frank SM, Cha S, Cho BC, Lawton JS, Lester LC, Hensley NB. Use of preoperative erythropoietin-stimulating agents is associated with decreased thrombotic adverse events compared to red blood cell transfusion in surgical patients with anaemia. Vox Sang 2024. [PMID: 39168487 DOI: 10.1111/vox.13729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 07/26/2024] [Accepted: 08/04/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND AND OBJECTIVES Preoperative red blood cell (RBC) transfusions increase post-operative venous thromboembolic (VTE) events. Erythropoietin-stimulating agents (ESAs) increase VTE risk in cancer patients; we aimed to assess ESA versus RBC-associated VTE risks in a broad population of surgical patients. MATERIALS AND METHODS We queried TriNetX Diamond Network from 2006 to 2023, comparing patients with anaemia within 3 months preoperatively who received preoperative ESAs with or without intravenous (IV) iron to patients who received preoperative RBCs. Sub-analyses included (1) all surgeries and (2) cardiovascular surgeries. We propensity score matched for demographics, comorbidities, medical services, post-treatment haemoglobin (g/dL) and, for all-surgery comparisons, surgery type. Outcomes included 30-day post-operative mortality, VTE, pulmonary embolism (PE), disseminated intravascular coagulation (DIC) and haemoglobin. RESULTS In our 19,548-patient cohorts, compared with preoperative RBC transfusion, ESAs without IV iron were associated with lower mortality (relative risk [RR] = 0.51 [95% confidence interval (CI), 0.45-0.59]), VTE (RR = 0.57 [0.50-0.65]) and PE (RR = 0.67 [0.54-0.84]). Post-operative haemoglobin was higher in the ESA without IV iron cohort compared with the transfusion cohort (10.0 ± 1.4 vs. 9.4 ± 1.8 g/dL, p = 0.002). Cardiac surgical patients receiving ESAs with or without IV iron had lower risk for post-operative mortality, VTE and PE (p < 0.001) than those receiving RBCs. Post-operative haemoglobin differed between patients receiving ESAs with IV iron versus RBCs (10.1 ± 1.5 vs. 9.4 ± 1.9 g/dL, p = 0.0009). CONCLUSION Compared with surgical patients who were transfused RBCs, ESA recipients had reduced 30-day post-operative risk of mortality, VTE, PE and DIC and increased haemoglobin levels. IV iron given with ESAs improved mortality.
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Affiliation(s)
- Una E Choi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan C Nicholson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephanie Cha
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brian C Cho
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer S Lawton
- Cardiac Surgery Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laeben C Lester
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nadia B Hensley
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Arya S, Howell A, Vernich L, Lin Y, Pavenski K, Freedman J. Re-evaluating treatment thresholds in patient blood management: Female patients experience more perioperative anaemia and higher transfusion rates in major elective surgery. Vox Sang 2024. [PMID: 39048294 DOI: 10.1111/vox.13717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/24/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND AND OBJECTIVES By optimizing erythropoiesis, patient blood management (PBM) programmes can reduce transfusions, lower mortality and provide cost-effective care. While definitions of anaemia have historically varied by sex, for the purposes of PBM, anaemia is defined as a haemoglobin <130 g/L. Our objective was to describe whether perioperative anaemia and transfusion rates in the PBM setting vary by sex. MATERIALS AND METHODS We conducted a retrospective study of the Ontario Nurse Transfusion Coordinators Program (ONTraC) database from 2018 to 2022. ONTraC collects data from 25 Ontario hospitals which together account for >70% of Ontario's provincial blood use (~400,000 units per year). We collected data on patients undergoing elective isolated coronary artery bypass graft surgery (CABG), open heart valve replacement, CABG plus valve replacement, single-knee arthroplasty and single-hip arthroplasty. RESULTS From 2018 to 2022, 17,700 patients were included in the ONTraC program; 47% were females (N = 8376). Across almost all years and procedures, females were found to have a significantly lower pre-operative, nadir and discharge haemoglobin as compared with males, irrespective of PBM interventions. Transfusion rates were significantly higher for females; this was most pronounced in cardiac surgery. CONCLUSION Females experienced more perioperative anaemia and higher transfusion rates. Historic sex-specific definitions of anaemia may contribute to a greater tolerance of anaemia in females. Prioritizing females for multimodal PBM and consistently achieving a pre-operative haemoglobin >130 g/L may reduce the amount of red blood cell (RBC) transfusions that female patients receive.
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Affiliation(s)
- Sumedha Arya
- Canadian Blood Services, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Alanna Howell
- Ontario Nurse Transfusion Coordinators Program (ONTraC), Toronto, Ontario, Canada
- Department of Laboratory Medicine, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
| | - Lee Vernich
- Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Division of Transfusion Medicine & Tissue Bank, Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
| | - John Freedman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Ontario Nurse Transfusion Coordinators Program (ONTraC), Toronto, Ontario, Canada
- Department of Laboratory Medicine, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
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Peri V, Devlin P, Perry L, Richards T, Miles LF. Associations Between Nonanemic Iron Deficiency and Postoperative Outcomes in Cardiac Surgery: A Systematic Review and Meta-Analysis. Anesth Analg 2024; 139:47-57. [PMID: 38241670 DOI: 10.1213/ane.0000000000006822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
BACKGROUND Preoperative screening for iron deficiency is a part of patient blood management protocols. This systematic review, meta-analysis, and meta-regression reviews the association between nonanemic iron deficiency and postoperative outcomes in patients undergoing cardiac surgery. We aimed to determine whether preoperative screening for nonanemic iron deficiency should be recommended in patients undergoing cardiac surgery. METHODS Electronic databases MEDLINE (Ovid), Embase (Ovid), and Scopus were searched from inception until December 9, 2022. Studies were considered for inclusion if they (1) used an observational study design; (2) enrolled adult patients undergoing cardiac surgery; and (3) included an iron-deficient and iron-replete group, defined using serum ferritin and/or transferrin saturation. The primary outcome was the length of acute hospital stay. Secondary outcomes included length of intensive care unit stay, requirement for allogeneic red blood cell transfusion, number of red blood cell units transfused, days alive and at home at postoperative days 30 and 90, all-cause postoperative complications, postoperative infection, mortality, and hospital readmission. Meta-regression was performed to assess the effects of study and patient-level factors on the associations between nonanemic iron deficiency and specific outcomes. Individual study quality was assessed using the Risk of Bias in Non-Randomized Studies of Exposures (ROBINS-E) tool. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used to determine the quality of evidence for each outcome. RESULTS Eight studies (2683 patients) were included. No significant association was observed between nonanemic iron deficiency and any of the primary or secondary outcomes except for an increased requirement for allogeneic red blood cell transfusion (odds ratio [OR], 1.39 [95% confidence interval, CI, 1.16-1.68; P < .001; I2 2.8%]). Meta-regression did not identify any potential sources of heterogeneity to explain variation in individual study results. The quality of evidence was rated as "low" or "very low" for all outcomes. CONCLUSIONS Few high-quality studies are available to assess associations between nonanemic iron deficiency and outcomes after cardiac surgery. Acknowledging these limitations, the presence of preoperative nonanemic iron deficiency was not associated with a change in the primary outcome of length of hospital stay, or any patient-centered secondary outcome compared to those without iron deficiency. There was an association with increased requirement for allogeneic red blood cell transfusion, but this did not impact the reported patient-centered outcomes.
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Affiliation(s)
- Varun Peri
- From the Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Paula Devlin
- From the Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Luke Perry
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Toby Richards
- Department of Anaesthesiology and Perioperative Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Lachlan F Miles
- From the Department of Anaesthesia, Austin Health, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
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Shales S, Das P, Ghorai PA, Sayyed A, Jain S, Narayan P. Pre-operative anaemia-does it influence post-operative outcomes after isolated coronary artery bypass grafting? Indian J Thorac Cardiovasc Surg 2024; 40:410-418. [PMID: 38919176 PMCID: PMC11194226 DOI: 10.1007/s12055-024-01746-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/06/2024] [Accepted: 04/23/2024] [Indexed: 06/27/2024] Open
Abstract
Introduction Preoperative anaemia is prevalent in a number of patients undergoing coronary artery bypass grafting. Studies provide conflicting results due to several reasons including variation in the threshold of haematocrit used to define anaemia. We aimed to assess the independent effect of preoperative anaemia on outcomes in patients undergoing off pump coronary artery bypass grafting (OPCAB). Methods In this retrospective study, patients with a hemoglobin level less than 11g/dl (haematocrit <33%) were considered to have moderate-to-severe anaemia as per the recommendations of the World Health Organization. Association between haematocrit <33% and mortality as well as adverse post-operative outcomes was assessed. Multivariable logistic regression (MLR) was carried out to assess the independent effect of haematocrit<33% on 30-day mortality and other outcomes. Results The study included 4957 consecutive patients undergoing isolated OPCAB surgery between 2015 and 2020. Out of 4957, 635 (12.8%) had haematocrit <33% and 4322 (81.2%) had haematocrit ≥33%. Patients with haematocrit < 33% had a 30-day mortality of 13 (2%) compared to 38 (0.9%) in patients without anaemia and had a greater requirement for blood transfusion (p<0.0001). It was also associated with an increased incidence of renal failure (p<0.0001), tracheostomy (p=.0.012) and risk of re-intubation (p=0.006). On multiple linear regression (MLR), haematocrit < 33% was not an independent predictor of 30-day mortality odds ratio (OR) 1.47, 95% confidence interval (CI) 0.745-2.917; p=0.26. It was however an important independent risk factor for blood transfusion (OR 1.80, 95% CI 1.29-2.50, p<0.001) and renal failure (OR 3.06, 95% CI 1.338-7.012, p=0.008). The receiver operating characteristic (ROC)-area under the curve (AUC) was 0.63 suggesting moderate discriminatory value of haematocrit < 33% for 30-day mortality. Conclusion Haematocrit < 33% is an important risk factor for adverse outcomes following isolated, primary, elective OPCAB. Graphical Abstract Supplementary Information The online version contains supplementary material available at 10.1007/s12055-024-01746-1.
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Affiliation(s)
- Sufina Shales
- Department of Cardiac Surgery, Narayana Health, NH Rabindranath Tagore International Institute of Cardiac Sciences, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
| | - Patralekha Das
- Department of Cardiac Surgery, Narayana Health, NH Rabindranath Tagore International Institute of Cardiac Sciences, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
| | - Paramita Auddya Ghorai
- Department of Cardiac Surgery, Narayana Health, NH Rabindranath Tagore International Institute of Cardiac Sciences, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
| | - Azhar Sayyed
- Department of Cardiac Surgery, Narayana Health, NH Rabindranath Tagore International Institute of Cardiac Sciences, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
| | - Shivangi Jain
- Department of Cardiac Surgery, Narayana Health, NH Rabindranath Tagore International Institute of Cardiac Sciences, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
| | - Pradeep Narayan
- Department of Cardiac Surgery, Narayana Health, NH Rabindranath Tagore International Institute of Cardiac Sciences, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
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Rittenhouse A, Ostendorf M, Johns C, Gerdisch M. Implementing a Preoperative Anemia Optimization Protocol for Cardiovascular Surgery Patients: A Quality Improvement Project. Crit Care Nurse 2024; 44:36-44. [PMID: 38821528 DOI: 10.4037/ccn2024758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
BACKGROUND Patients with anemia have poorer outcomes following cardiac surgery than do those without anemia. To improve outcomes, the Enhanced Recovery After Surgery cardiac recommendations include optimizing patients' condition, including treating anemia, before surgery. LOCAL PROBLEM Despite implementing Enhanced Recovery After Surgery initiatives, a midwestern cardiothoracic surgery group recognized a care gap in preoperative patients with anemia. No standardized protocol was in use. METHODS An anemia optimization protocol was developed for perioperative care of patients with anemia. Data from retrospective medical record review were analyzed to determine relationships between protocol use and secondary outcomes. The protocol was created using best evidence and expert consensus. Cardiac surgery and hematology specialists revised the protocol and agreed on a final version. The protocol was integrated into the consultation process for cardiac surgery patients. RESULTS During the implementation period, 23 of 55 patients with anemia (42%) received interventions via the anemia optimization protocol. The mean quantity of packed red blood cells transfused perioperatively per patient was 1.9 U in the protocol group and 3.5 U in the nonprotocol group. In the subgroup of patients experiencing postoperative acute kidney injury, the mean increase in creatinine level was 0.65 mg/dL in the protocol group and 1.52 mg/dL in the nonprotocol group. Four patients in the protocol group (17%) and 6 patients in the nonprotocol group (19%) experienced postoperative acute kidney injury. CONCLUSION Preoperative anemia is associated with poorer cardiac surgical outcomes. Incorporating the anemia optimization protocol into practice may mitigate the risk of postoperative complications for patients with anemia. Continued use of the protocol is recommended.
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Affiliation(s)
- Ashley Rittenhouse
- Ashley Rittenhouse is a critical care registered nurse, Franciscan Health Indianapolis, Indianapolis, Indiana
| | - Marilyn Ostendorf
- Marilyn Ostendorf is a clinical assistant professor, University of Southern Indiana, Evansville, Indiana
| | - Chanice Johns
- Chanice Johns is a cardiovascular Enhanced Recovery After Surgery coordinator, Franciscan Health Indianapolis
| | - Marc Gerdisch
- Marc Gerdisch is chief of cardiothoracic surgery, Franciscan Health Indianapolis, and an associate clinical professor, Loyola University Medical Center, Maywood, Illinois
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Hosseini M, Griffeth EM, Schaff HV, Klompas AM, Warner MA, Stulak JM, Dearani JA, Lee AT, Lahr BD, Crestanello JA. Analysis of Anemia, Transfusions, and CABG Outcomes in The Society of Thoracic Surgeons National Database. Ann Thorac Surg 2024; 117:1053-1060. [PMID: 38286201 DOI: 10.1016/j.athoracsur.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND This study characterized the association of preoperative anemia and intraoperative red blood cell (RBC) transfusion on outcomes of elective coronary artery bypass grafting (CABG). METHODS Data from 53,856 patients who underwent CABG included in The Society of Thoracic Surgeons (STS) Adult Cardiac Database in 2019 were used. The primary outcome was operative mortality. Secondary outcomes were postoperative complications. The association of anemia with outcomes was analyzed with multivariable regression models. The influence of intraoperative RBC transfusion on the effect of preoperative anemia on outcomes was studied using mediation analysis. RESULTS Anemia was present in 25% of patients. Anemic patients had a higher STS Predicted Risk of Operative Mortality (1.2% vs 0.7%; P < .001). Anemia was associated with operative mortality (odds ratio [OR], 1.27; 99.5% CI, 1.00-1.61; P = .047), postoperative RBC transfusion (OR, 2.28; 99.5% CI, 2.12-2.44; P < .001), dialysis (OR, 1.58; 99.5% CI, 1.19-2.11; P < .001), and prolonged intensive care unit and hospital length of stay. Intraoperative RBC transfusion largely mediated the effects of anemia on mortality (76%), intensive care unit stay (99%), and hospital stay, but it only partially mediated the association with dialysis (34.9%). CONCLUSIONS Preoperative anemia is common in patients who undergo CABG and is associated with increased postoperative risks of mortality, complications, and RBC transfusion. However, most of the effect of anemia on mortality is mediated through intraoperative RBC transfusion.
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Affiliation(s)
- Motahar Hosseini
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Elaine M Griffeth
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alexander T Lee
- Department of Quantitative Health Sciences; Mayo Clinic, Rochester, Minnesota
| | - Brian D Lahr
- Department of Quantitative Health Sciences; Mayo Clinic, Rochester, Minnesota
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
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Radulova-Mauersberger O, von Bechtolsheim F, Teske C, Hempel S, Kroesen L, Pecqueux M, Kahlert C, Weitz J, Distler M, Oehme F. Preoperative anaemia in distal pancreatectomy: a propensity-score matched analysis. Langenbecks Arch Surg 2024; 409:119. [PMID: 38602554 PMCID: PMC11008068 DOI: 10.1007/s00423-024-03300-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/26/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Preoperative anaemia is a prevalent morbidity predictor that adversely affects short- and long-term outcomes of patients undergoing surgery. This analysis aimed to investigate preoperative anaemia and its detrimental effects on patients after distal pancreatectomy. MATERIAL AND METHODS The present study was a propensity-score match analysis of 286 consecutive patients undergoing distal pancreatectomy. Patients were screened for preoperative anaemia and classified according to WHO recommendations. The primary outcome measure was overall morbidity. The secondary endpoints were in-hospital mortality and rehospitalization. RESULTS The preoperative anaemia rate before matching was 34.3% (98 patients), and after matching a total of 127 patients (non-anaemic 42 vs. anaemic 85) were included. Anaemic patients had significantly more postoperative major complications (54.1% vs. 23.8%; p < 0.01), a higher comprehensive complication index (26.2 vs. 4.3; p < 0.01), and higher in-hospital mortality rate (14.1% vs. 2.4%; p = 0.04). Multivariate regression analysis confirmed these findings and identified preoperative anaemia as a strong independent risk factor for postoperative major morbidity (OR 4.047; 95% CI: 1.587-10.320; p < 0.01). CONCLUSION The current propensity-score matched analysis strongly considered preoperative anaemia as a risk factor for major complications following distal pancreatectomy. Therefore, an intense preoperative anaemia workup should be increasingly prioritised.
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Affiliation(s)
- Olga Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Felix von Bechtolsheim
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.
| | - Christian Teske
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Louisa Kroesen
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Mathieu Pecqueux
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
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Warner MA, Hanson AC, Schulte PJ, Sanz JR, Smith MM, Kauss ML, Crestanello JA, Kor DJ. Preoperative Anemia and Postoperative Outcomes in Cardiac Surgery: A Mediation Analysis Evaluating Intraoperative Transfusion Exposures. Anesth Analg 2024; 138:728-737. [PMID: 38335136 PMCID: PMC10949062 DOI: 10.1213/ane.0000000000006765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND Preoperative anemia is associated with adverse outcomes in cardiac surgery, yet it remains unclear what proportion of this association is mediated through red blood cell (RBC) transfusions. METHODS This is a historical observational cohort study of adults undergoing coronary artery bypass grafting or valve surgery on cardiopulmonary bypass at an academic medical center between May 1, 2008, and May 1, 2018. A mediation analysis framework was used to evaluate the associations between preoperative anemia and postoperative outcomes, including a primary outcome of acute kidney injury (AKI). Intraoperative RBC transfusions were evaluated as mediators of preoperative anemia and outcome relationships. The estimated total effect, average direct effect of preoperative anemia, and percent of the total effect mediated through transfusions are presented with 95% confidence intervals and P -values. RESULTS A total of 4117 patients were included, including 1234 (30%) with preoperative anemia. Overall, 437 of 4117 (11%) patients went on to develop AKI, with a greater proportion of patients having preoperative anemia (219 of 1234 [18%] vs 218 of 2883 [8%]). In multivariable analyses, the presence of preoperative anemia was associated with increased postoperative AKI (6.4% [4.2%-8.7%] absolute difference in percent with AKI, P < .001), with incremental decreases in preoperative hemoglobin concentrations displaying greater AKI risk (eg, 11.9% [6.9%-17.5%] absolute increase in probability of AKI for preoperative hemoglobin of 9 g/dL compared to a reference of 14 g/dL, P < .001). The association between preoperative anemia and postoperative AKI was primarily due to direct effects of preoperative anemia (5.9% [3.6%-8.3%] absolute difference, P < .001) rather than mediated through intraoperative RBC transfusions (7.5% [-4.3% to 21.1%] of the total effect mediated by transfusions, P = .220). Preoperative anemia was also associated with longer hospital durations (1.07 [1.05-1.10] ratio of geometric mean length of stay, P < .001). Of this total effect, 38% (22%, 62%; P < .001) was estimated to be mediated through subsequent intraoperative RBC transfusion. Preoperative anemia was not associated with reoperation or vascular complications. CONCLUSIONS Preoperative anemia was associated with higher odds of AKI and longer hospitalizations in cardiac surgery. The attributable effects of anemia and transfusion on postoperative complications are likely to differ across outcomes. Future studies are necessary to further evaluate mechanisms of anemia-associated postoperative organ injury and treatment strategies.
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Affiliation(s)
- Matthew A Warner
- From the Departments of Anesthesiology and Perioperative Medicine
| | | | | | - Juan Ripoll Sanz
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Mark M Smith
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Marissa L Kauss
- From the Departments of Anesthesiology and Perioperative Medicine
| | | | - Daryl J Kor
- From the Departments of Anesthesiology and Perioperative Medicine
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10
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Li MM, Miles S, Callum J, Lin Y, Karkouti K, Bartoszko J. Postoperative anemia in cardiac surgery patients: a narrative review. Can J Anaesth 2024; 71:408-421. [PMID: 38017198 DOI: 10.1007/s12630-023-02650-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/25/2023] [Accepted: 08/08/2023] [Indexed: 11/30/2023] Open
Abstract
PURPOSE Anemia reduces the blood's ability to carry and deliver oxygen. Following cardiac surgery, anemia is very common and affects up to 90% of patients. Nevertheless, there is a paucity of data examining the prognostic value of postoperative anemia. In this narrative review, we present findings from the relevant literature on postoperative anemia in cardiac surgery patients, focusing on the incidence, risk factors, and prognostic value of postoperative anemia. We also explore the potential utility of postoperative anemia as a therapeutic target to improve clinical outcomes. SOURCE We conducted a targeted search of MEDLINE, Embase, and the Cochrane Database of Systematic Reviews up to September 2022, using a combination of search terms including postoperative (post-operative), perioperative (peri-operative), anemia (anaemia), and cardiac surgery. PRINCIPAL FINDINGS The reported incidence of postoperative anemia varied from 29% to 94% across the studies, likely because of variations in patient inclusion criteria and classification of postoperative anemia. Nonetheless, the weight of the evidence suggests that postoperative anemia is common and is an independent risk factor for adverse postoperative outcomes such as acute kidney injury, stroke, mortality, and functional outcomes. CONCLUSIONS In cardiac surgery patients, postoperative anemia is a common and prognostically important risk factor for postoperative morbidity and mortality. Nevertheless, there is a lack of data on whether active management of postoperative anemia is feasible or effective in improving patient outcomes.
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Affiliation(s)
- Michelle M Li
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Sarah Miles
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Jeannie Callum
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, ON, Canada
| | - Yulia Lin
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada.
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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11
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Abreu A, Máximo J, Almeida C, Lourenço A, Leite-Moreira A. The additive effects of anaemia and transfusion on long-term survival after coronary artery bypass surgery. Eur J Cardiothorac Surg 2024; 65:ezad403. [PMID: 38058180 PMCID: PMC10924300 DOI: 10.1093/ejcts/ezad403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/20/2023] [Accepted: 12/05/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES To compare the independent and combined effects of anaemia and red blood cell transfusion on late survival after isolated coronary artery bypass grafting. METHODS Retrospective analysis of 5243 consecutive patients undergoing primary isolated coronary artery bypass grafting, performed from 2000 to 2015, in a Portuguese Academic Hospital. We identified 1649 patients with preoperative anaemia (A+) and 1422 patients who received a perioperative transfusion (T+)-the 4 possible combinations allowed for the creation of 4 subgroups (A-/T-, A-/T+, A+/T- and A+/T+). The primary endpoint was all-cause mortality at 10 years. We employed inverse probability weighting to control for confounding variables. RESULTS Thirty-one percent of the patients had preoperative anaemia, and 27.0% had at least one packed red blood cell transfusion. Inverse probability weighting was effective in eliminating differences in all significant baseline characteristics. The primary endpoint of all-cause mortality at 10 years occurred in 568 patients (20.5%) in the A-/T- group, as compared with 204 (24.4%) in the A-/T+ group (hazard ratio, 1.14; 95% confidence interval, 1.00 to 1.31; P = 0.053), 358 (33.8%) in the A+/T- group (hazard ratio, 1.53; 95% confidence interval, 1.38 to 1.71; P < 0.001), 254 (43.6%) in the A+/T+ group (hazard ratio, 2.25; 95% confidence interval, 1.97 to 2.56; P < 0.001). CONCLUSIONS This longitudinal, population-level study emphasizes the adverse long-term outcomes of preoperative anaemia and perioperative red blood cell transfusion. It stresses the importance of an evidence-based, multimodal and multidisciplinary approach to conserving blood resources and optimizing outcomes in patients at high risk for transfusion.
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Affiliation(s)
- Armando Abreu
- Department of Surgery and Physiology, Cardiovascular R&D Center—UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Cardiothoracic Surgery, São João University Hospital Center, Porto, Portugal
| | - José Máximo
- Department of Surgery and Physiology, Cardiovascular R&D Center—UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Cardiothoracic Surgery, São João University Hospital Center, Porto, Portugal
| | - Cláudia Almeida
- Department of Anesthesiology, São João University Hospital Center, Porto, Portugal
| | - André Lourenço
- Department of Surgery and Physiology, Cardiovascular R&D Center—UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Anesthesiology, São João University Hospital Center, Porto, Portugal
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, Cardiovascular R&D Center—UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Cardiothoracic Surgery, São João University Hospital Center, Porto, Portugal
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12
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Almonacid-Cardenas F, Rivas E, Auron M, Hu L, Wang D, Liu L, Tolich D, Mascha EJ, Ruetzler K, Kurz A, Turan A. Association between preoperative anemia optimization and major complications after non-cardiac surgery: a retrospective analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744474. [PMID: 38043700 DOI: 10.1016/j.bjane.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Anemia is common in the preoperative setting and associated with increased postoperative complications and mortality. However, it is unclear if preoperative anemia optimization reduces postoperative complications. We aimed to assess the association between preoperative anemia optimization and a composite endpoint of major cardiovascular, renal, and pulmonary complications and all-cause mortality within 30 days after noncardiac surgery in adult patients. METHODS In this retrospective analysis preoperative anemia was defined as hemoglobin concentration below 12.0 g.dl-1 in women and 13.0 g.dl-1 in men within 6 months before surgery. A propensity score-based generalized estimating equation analysis was used to determine the association between preoperative anemia optimization and the primary outcome. Moreover, mediation analysis was conducted to investigate whether intraoperative red blood cell transfusion or duration of intraoperative hypotension were mediators of the relation between anemia optimization and the primary outcome. RESULTS Fifty-seven hundred anemia optimized, and 8721 non-optimized patients met study criteria. The proportion of patients having any component of the composite of major complications and all-cause mortality was 21.5% in the anemia-optimized versus 18.0% in the non-optimized, with confounder-adjusted odds ratio estimate of 0.99 (95% CI 0.86‒1.15) for anemia optimization versus non-optimization, p = 0.90. Intraoperative red blood cell transfusion had a minor mediation effect on the relationship between preoperative anemia optimization and the primary outcome, whereas duration of intraoperative hypotension was not found to be a mediator. CONCLUSION Preoperative anemia optimization did not appear to be associated with a composite outcome of major in-hospital postoperative cardiovascular, renal, and pulmonary complications and all-cause in-hospital mortality.
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Affiliation(s)
| | - Eva Rivas
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Universidad de Barcelona, Hospital Clinic of Barcelona, IDIBAPS, Department of Anesthesia, Barcelona, Spain
| | - Moises Auron
- Cleveland Clinic, Department of Blood Management, Cleveland, USA
| | - Lucille Hu
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA
| | - Dong Wang
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Liu Liu
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Deborah Tolich
- Cleveland Clinic, Department of Blood Management, Cleveland, USA
| | - Edward J Mascha
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Kurt Ruetzler
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA
| | - Andrea Kurz
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA
| | - Alparslan Turan
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA.
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Arynov A, Kaidarova D, Kabon B. Alternative blood transfusion triggers: a narrative review. BMC Anesthesiol 2024; 24:71. [PMID: 38395758 PMCID: PMC10885388 DOI: 10.1186/s12871-024-02447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Anemia, characterized by low hemoglobin levels, is a global public health concern. Anemia is an independent factor worsening outcomes in various patient groups. Blood transfusion has been the traditional treatment for anemia; its triggers, primarily based on hemoglobin levels; however, hemoglobin level is not always an ideal trigger for blood transfusion. Additionally, blood transfusion worsens clinical outcomes in certain patient groups. This narrative review explores alternative triggers for red blood cell transfusion and their physiological basis. MAIN TEXT The review delves into the physiology of oxygen transport and highlights the limitations of using hemoglobin levels alone as transfusion trigger. The main aim of blood transfusion is to optimize oxygen delivery, necessitating an individualized approach based on clinical signs of anemia and the balance between oxygen delivery and consumption, reflected by the oxygen extraction rate. The narrative review covers different alternative triggers. It presents insights into their diagnostic value and clinical applications, emphasizing the need for personalized transfusion strategies. CONCLUSION Anemia and blood transfusion are significant factors affecting patient outcomes. While restrictive transfusion strategies are widely recommended, they may not account for the nuances of specific patient populations. The search for alternative transfusion triggers is essential to tailor transfusion therapy effectively, especially in patients with comorbidities or unique clinical profiles. Investigating alternative triggers not only enhances patient care by identifying more precise indicators but also minimizes transfusion-related risks, optimizes blood product utilization, and ensures availability when needed. Personalized transfusion strategies based on alternative triggers hold the potential to improve outcomes in various clinical scenarios, addressing anemia's complex challenges in healthcare. Further research and evidence are needed to refine these alternative triggers and guide their implementation in clinical practice.
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Affiliation(s)
- Ardak Arynov
- Department of Anesthesiology and Intensive Care, Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan.
| | - Dilyara Kaidarova
- Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Medicine and Pain Medicine Medical, University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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14
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Uden H, Büttner F, von Heymann C, Krämer M, Kaufner L, Vorderwülbecke G, Hardt S, Kruppa J, Balzer F, Spies C. Allogeneic Blood Transfusion and Risk of Postoperative Complications in Patients with Mild and Moderate Anemia of Any Cause? A Retrospective Cohort Study in Total Revision Hip Surgery. Transfus Med Hemother 2024; 51:12-21. [PMID: 38314244 PMCID: PMC10836862 DOI: 10.1159/000530135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/26/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Patients undergoing revision total hip surgery (RTHS) have a high prevalence of mild and moderate preoperative anemia, associated with adverse outcomes. The aim of this study was to investigate the association of perioperative allogeneic blood transfusions (ABT) and postoperative complications in preoperatively mild compared to moderate anemic patients undergoing RTHS who did not receive a diagnostic anemia workup and treatment before surgery. Methods We included 1,765 patients between 2007 and 2019 at a university hospital. Patients were categorized according to their severity of anemia using the WHO criteria of mild, moderate, and severe anemia in the first Hb level of the case. Patients were grouped as having received no ABT, 1-2 units of ABT, or more than 2 units of ABT. Need for intraoperative ABT was assessed in accordance with institutional standards. Primary endpoint was the compound incidence of postoperative complications. Secondary outcomes included major/minor complications and length of hospital and ICU stay. Results Of the 1,765 patients, 31.0% were anemic of any cause before surgery. Transfusion rates were 81% in anemic patients and 41.2% in nonanemic patients. The adjusted risks for compound postoperative complication were significantly higher in patients with moderate anemia (OR 4.88, 95% CI: 1.54-13.15, p = 0.003) but not for patients with mild anemia (OR 1.93, 95% CI: 0.85-3.94, p < 0.090). Perioperative ABT was associated with significantly higher risks for complications in nonanemic patients and showed an increased risk for complications in all anemic patients. In RTHS, perioperative ABT as a treatment for moderate preoperative anemia of any cause was associated with a negative compound effect on postoperative complications, compared to anemia or ABT alone. Discussion ABT is associated with adverse outcomes of patients with moderate preoperative anemia before RTHS. For this reason, medical treatment of moderate preoperative anemia may be considered.
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Affiliation(s)
- Henning Uden
- Department of Anesthesia and Intensive Care Medicine, Sana Klinikum Lichtenberg, Berlin, Germany
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Franziska Büttner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian von Heymann
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael Krämer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berufsausübungsgemeinschaft Reinhardt/Krämer, Berlin, Germany
| | - Lutz Kaufner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Hardt
- Centre for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jochen Kruppa
- Hochschule Osnabrück – University of Applied Sciences, Osnabrück, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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15
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Stonnington HO, Shahbandi A, Singh R, Dodd A, Bui NE, Brown NJ, Jubran JH, Bydon M, McClendon J, Patel NP. Postoperative Outcomes for Spinal Fusion Procedures in Pediatric Patients with Anemia: A Retrospective and Multivariate Analysis. World Neurosurg 2024; 182:e45-e56. [PMID: 37952882 DOI: 10.1016/j.wneu.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Preoperative anemia is known to be associated with perioperative complications in many surgical interventions. Here, we examine the effects of preoperative anemia on peri-operative complications and postoperative outcomes in pediatric patients undergoing spinal fusion. METHODS Retrospective analysis was conducted using the American College of Surgeons Pediatric National Surgery Quality Improvement Program Database between 2012-2020. Current Procedural Terminology codes 22800, 22,802, 22,804, 22,840, 22,842, 22,843, and 22,844 were included to represent all primary spinal fusion procedures performed. Patients without preoperative hematocrit (HCT) levels were excluded. Classification of anemia was determined via age- and sex-adjusted HCT levels. Patient demographics, preoperative comorbidities and risk factors, and 30-day postoperative outcomes were compared between the 2 cohorts using univariate analysis. Multivariate logistic regressions were performed to determine if anemia severity was independently associated with worse postoperative outcomes. RESULTS A total of 30,243 pediatric patients were included in this study, with 26,621 not having preoperative anemia and 3622 having preoperative anemia. Pediatric patients with anemia have increased length of stay (LOS) (6.7 ± 9.6 vs. 5 ± 6, P < 0.001), 30-day unplanned reoperation rate (4% vs. 2.8%, P < 0.001), and total blood transfused (489.9 ± 497.8 vs. 423.4 ± 452.6, P < 0.001). Multivariate analysis supported anemia and degree of its severity as an independent predictor of increased length of stay (LOS), reoperation rate, and postoperative complications. CONCLUSIONS Preoperative anemia leads to worse outcomes in pediatric spinal fusion procedures. Utilizing HCT recordings could be factored into the equation for optimal patient selection and prevention of post-operative complications.
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Affiliation(s)
| | | | - Rohin Singh
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
| | - Armaan Dodd
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Nicholas E Bui
- Department of Neurosurgery, Loma Linda School of Medicine, Loma Linda, California, USA
| | - Nolan J Brown
- University of California, Irvine School of Medicine, Irvine, California, USA
| | - Jubran H Jubran
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamal McClendon
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA; Department of Neurosurgery, Phoenix Children's, Phoenix, Arizona, USA
| | - Naresh P Patel
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
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16
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Czarnecka J, Neuschwander A, Aujoulat T, Balmier A, Belcour D, Boulanger B, Bourgain C, Caron M, Kiss G, Larghi M, Lebard C, Mellano V, Larson J, Megroian B, Lefrançois A, Fox S, Pollet A, Bourgoin P, Biland G, Braunberger E, Maccio G, Delmas B. Red Blood Cell Transfusion Requirements Before and After Implementation of a Perioperative Patient Blood Management Program in Adult Patients Undergoing Cardiac Surgery. A Before and After Observational Study. J Cardiothorac Vasc Anesth 2024; 38:73-79. [PMID: 37953174 DOI: 10.1053/j.jvca.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES Anemia and transfusion are common in cardiac surgery patients, and are associated with significant morbidity and mortality. Multiple perioperative interventions have been described to reduce blood transfusion, but are rarely combined altogether. The aim of this study was to compare the incidence of red blood cell (RBC) transfusion in adult patients undergoing cardiac surgery before and after the implementation of a perioperative patient blood management (PBM) program. DESIGN Before-and-after observational study. SETTING Single-center French university teaching hospital. PARTICIPANTS Adult patients scheduled for cardiac surgery. INTERVENTIONS Perioperative patient blood management program including pre-, intra-, and postoperative interventions aimed at identifying and correcting anemia, minimizing blood loss during surgery, and optimizing coagulation. MEASUREMENTS AND MAIN RESULTS Four hundred thirty-four patients were included in the study from January 2021 to July 2022. The incidence of perioperative RBC transfusion (intraoperatively and during the first 2 postoperative days) was significantly reduced from 43% (90/213) in the pre-PBM period to 27% (60/221) in the post-PBM period (p < 0.001). The application of a PBM program was associated with a reduction in perioperative RBC transfusion by multivariate analysis (odds ratio 0.55, 95% CI 0.36-0.85, p = 0.007), and was associated with a reduction in the median number of RBC units transfused within transfused patients (p = 0.025). These effects persisted at day 30 after surgery (p = 0.029). CONCLUSION A perioperative PBM program in adult patients undergoing cardiac surgery was associated with a significant reduction in perioperative RBC transfusion, which persisted at day 30.
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Affiliation(s)
- Jeremie Czarnecka
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Arthur Neuschwander
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France.
| | - Thomas Aujoulat
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Adrien Balmier
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Dominique Belcour
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Boris Boulanger
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Caroline Bourgain
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Margot Caron
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Gabor Kiss
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Mathilde Larghi
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Christophe Lebard
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Vincent Mellano
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Jonathan Larson
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Blandine Megroian
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Anaelle Lefrançois
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Sylvain Fox
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Arnaud Pollet
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Pierre Bourgoin
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France; Department of anesthesiology, University Hospital, Nantes, France
| | - Guillaume Biland
- Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Eric Braunberger
- Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Guillaume Maccio
- French Blood Establishment, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Benjamin Delmas
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
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17
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Lau MPXL, Low CJW, Ling RR, Liu NSH, Tan CS, Ti LK, Kofidis T, MacLaren G, Ramanathan K. Preoperative anemia and anemia treatment in cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2024; 71:127-142. [PMID: 37932652 DOI: 10.1007/s12630-023-02620-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/07/2023] [Accepted: 07/23/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE We aimed to conduct a systematic review and meta-analysis to assess the effects of anemia and anemia severity on patient outcomes in cardiac surgery and determine whether preoperative treatments confer postoperative benefit. SOURCE We searched four international databases for observational and randomized studies published until 1 October 2022. Study quality was assessed via Newcastle-Ottawa scores and the Cochrane Risk-of-Bias 2 tool and certainty of evidence was rated with the Grading of Recommendations, Assessment, Development and Evaluations approach. We conducted random-effects meta-analyses for our primary outcome of mortality, for secondary outcomes including length of stay (LOS) in the hospital and intensive care unit, and for postsurgical complications. As part of a secondary analysis, we analyzed short-term preoperative anemia treatments and conducted trial sequential analysis of randomized trials to assess the efficacy of these treatment programs. PRINCIPAL FINDINGS We included 35 studies (159,025 patients) in our primary meta-analysis. Preoperative anemia was associated with increased mortality (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.2 to 2.9; P < 0.001, high certainty). Study-level meta-regression revealed lower hemoglobin levels and studies with lower proportions of male patients to be associated with increased risk of mortality. Preoperative anemia was also associated with an increase in LOS and postsurgical complications. Our secondary analysis (seven studies, 1,012 patients) revealed short-term preoperative anemia treatments did not significantly reduce mortality (OR, 1.1; 95% CI, 0.65 to 1.9; P = 0.69). Trial sequential analysis suggested that there was insufficient evidence to conclude if treatment programs yield any benefit or harm. CONCLUSIONS Preoperative anemia is associated with mortality and morbidity after cardiac surgery. More research is warranted to test the efficacy of current anemia treatment programs. STUDY REGISTRATION PROSPERO (CRD42022319431); first submitted 17 April 2023.
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Affiliation(s)
- Michele P X L Lau
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Christopher J W Low
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Nigel S H Liu
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Chuen Seng Tan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Lian Kah Ti
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore, Singapore
| | - Theo Kofidis
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, National University Hospital, National University Health System, Singapore, Singapore
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore, Singapore.
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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18
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Guinn N, Tanaka K, Erdoes G, Kwak J, Henderson R, Mazzeffi M, Fabbro M, Raphael J. The Year in Coagulation and Transfusion: Selected Highlights from 2022. J Cardiothorac Vasc Anesth 2023; 37:2435-2449. [PMID: 37690951 DOI: 10.1053/j.jvca.2023.08.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023]
Abstract
This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.
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Affiliation(s)
- Nicole Guinn
- Chief of Neuroanesthesiology, Otolaryngology and Offsite Anesthesia Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Jenny Kwak
- Division of Cardiac Anesthesia, Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL
| | - Reney Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Medical Center, Charlottesville, VA
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miami, FL
| | - Jacob Raphael
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA.
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19
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Zhao BC, Lei SH, Liu JM, Qiu SD, Yao ZW, Liu J, Deng F, Li ZH, Liu KX. Sex-Specific Associations Between Preoperative Hemoglobin and Outcomes After Major Noncardiac Surgery: A Retrospective Cohort Study. Anesth Analg 2023; 137:1019-1028. [PMID: 37713328 DOI: 10.1213/ane.0000000000006661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
BACKGROUND Preoperative anemia is an established risk factor for morbidity and mortality after surgery. Men and women have different hemoglobin concentrations and are at different risks of postoperative complications. However, sex-stratified analysis on the association between preoperative hemoglobin and outcomes after noncardiac surgery has been limited in previous studies. METHODS This was a retrospective cohort study of adult patients undergoing elective major noncardiac surgery in a large academic hospital. The primary outcome was a collapsed composite of postoperative mortality or cardiovascular, renal, pulmonary, and infectious complications during hospitalization. Sex-specific univariable associations between preoperative hemoglobin and the composite outcome were visualized using moving-average and cubic-spline smoothing plots. Multivariable regression models adjusting for patient demographics, comorbidities, medication uses, laboratory tests, and anesthesia/surgery features were used to estimate confounder-adjusted associations. Restricted cubic spline and piecewise linear functions were used to assess the possible nonlinear relationships between preoperative hemoglobin and the outcomes. The interaction between patient sex and hemoglobin on outcomes was assessed using a likelihood-ratio test. RESULTS We included 22,550 patients, with 6.7% (622 of 9268) of women and 9.7% (1293 of 13,282) of men developing the primary outcome. Lower preoperative hemoglobin was associated with a higher incidence of the primary composite outcome in both men and women. Nonlinearity for the association was not statistically significant in either women ( P = .539) or men ( P = .165). The multivariable-adjusted odds ratios per 1 g/dL increase in hemoglobin were 0.93 (95% confidence interval [CI], 0.87-0.98; P = .013) for women and 0.94 (95% CI, 0.90-0.97; P < .001) for men, with no interaction by sex ( Pinteraction = .923). No hemoglobin thresholds were confirmed at which the associations with the primary outcome changed significantly. CONCLUSIONS Low preoperative hemoglobin was associated with a higher risk of complications or mortality after elective noncardiac surgery in both men and women. No differences in the strength of associations between sexes were found. Further studies are needed to assess whether these associations are linear or there are sex-specific thresholds of preoperative hemoglobin concentrations below which postoperative risks begin to increase.
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Affiliation(s)
- Bing-Cheng Zhao
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shao-Hui Lei
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jia-Ming Liu
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shi-Da Qiu
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi-Wen Yao
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jian Liu
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fan Deng
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi-Hao Li
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, China
| | - Ke-Xuan Liu
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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20
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Rasmussen SB, Boyko Y, Ranucci M, de Somer F, Ravn HB. Cardiac surgery-Associated acute kidney injury - A narrative review. Perfusion 2023:2676591231211503. [PMID: 37905794 DOI: 10.1177/02676591231211503] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is a serious complication seen in approximately 20-30% of cardiac surgery patients. The underlying pathophysiology is complex, often involving both patient- and procedure related risk factors. In contrast to AKI occurring after other types of major surgery, the use of cardiopulmonary bypass comprises both additional advantages and challenges, including non-pulsatile flow, targeted blood flow and pressure as well as the ability to manipulate central venous pressure (congestion). With an increasing focus on the impact of CSA-AKI on both short and long-term mortality, early identification and management of high-risk patients for CSA-AKI has evolved. The present narrative review gives an up-to-date summary on definition, diagnosis, underlying pathophysiology, monitoring and implications of CSA-AKI, including potential preventive interventions. The review will provide the reader with an in-depth understanding of how to identify, support and provide a more personalized and tailored perioperative management to avoid development of CSA-AKI.
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Affiliation(s)
- Sebastian Buhl Rasmussen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Yuliya Boyko
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesiology and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Hanne Berg Ravn
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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21
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Leviner DB, Abraham D, Shiner M, Schwartz N, Lavon O, Sharoni E. Implementation of a Short-term Treatment Protocol in Anemic Patients before Cardiac Surgery. Thorac Cardiovasc Surg 2023. [PMID: 37709298 DOI: 10.1055/a-2176-2218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND We assessed whether implementation of an immediate preoperative treatment in anemic patients could result in fewer perioperative packed red blood cell (PRBC) transfusions and improved outcomes in a real-world setting. METHODS From January 1, 2020, to November 31, 2022, we implemented a perioperative protocol for anemic patients (hemoglobin (Hb) level in women <11.5 g/dL, men <12.5 g/dL), which included subcutaneous erythropoietin α, intravenous Iron, and intramuscular vitamin B12 (all given preoperatively) and per os iron and folic acid given once a day postoperatively. We retrospectively compared all patients receiving the protocol to all eligible patients who were operated upon in the 4 years prior to implementation of the protocol. Primary outcome was amount of PRBC transfusions during surgery and index admission. RESULTS In the months after protocol implementation, 114 patients who received the treatment protocol were compared with 236 anemic patients in the 4 years prior to who did not receive the protocol. The treatment reduced total PRBC use (control group median 4 [2-7] units vs. treatment 2 [1-3] units, p < 0.0001) and the incidence of postoperative blood products transfusions (treatment group 58 patients, 50.88% vs. control group 177 patients, 75%, p < 0.0001). Hb prior to discharge was higher among the protocol group (treatment median 9 g/dL [8.3-9.5 g/dL] vs. control 8.6 g/dL [8.1-9.1 g/dL], p = 0.0081). CONCLUSION Despite some differences compared with previously described protocols, the implementation of a perioperative treatment protocol for anemic patients was associated with a reduction in PRBC transfusion in a real-world setting.
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Affiliation(s)
- Dror B Leviner
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa, Israel
| | - Dana Abraham
- Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Maayan Shiner
- Blood Bank Haifa, Carmel Medical Center, Haifa, Israel
| | - Naama Schwartz
- Research Authority, Carmel Medical Center, Haifa, Israel
| | - Ophir Lavon
- Clinical Pharmacology, Carmel Medical Center, Haifa, Israel
| | - Erez Sharoni
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa, Israel
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22
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Salenger R, Hirji S, Rea A, Cangut B, Morton-Bailey V, Gregory AJ, Arora RC, Grant MC, Raphael J, Engelman DT. ERAS Cardiac Society turnkey order set for patient blood management: Proceedings from the AATS ERAS Conclave 2023. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00991-1. [PMID: 37866774 DOI: 10.1016/j.jtcvs.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/05/2023] [Accepted: 10/14/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVES There are multiple published guidelines on comprehensive patient blood management (PBM), centered on the 3 pillars of PBM: managing preoperative anemia, minimizing blood loss, and tolerating intraoperative/postoperative anemia. We sought to create an order set to facilitate widespread implementation of evidence-based PBM for cardiac surgery patients. METHODS Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for PBM. Orders derived from consistent class I, class IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence are presented in italic type. RESULTS Preoperatively, there are strong recommendations to screen and treat preoperative anemia with iron replacement and erythropoietin and to discontinue dual antiplatelet therapy if the patient can safely wait for surgery. Intraoperative orders outline the routine use of an antifibrinolytic agent, cell saver, point of care viscoelastic testing, and use of a standard transfusion algorithm. The order set also reflects strong recommendations intraoperatively and postoperatively for agreed-upon hemoglobin thresholds to consider transfusion of packed red blood cells. A hemoglobin threshold should be adopted according to local team consensus and should trigger a discussion regarding transfusion. CONCLUSIONS The benefit of a multidisciplinary PBM care pathway in cardiac surgery has been well established, yet implementation remains variable. Using recommendations from existing guidelines, we have created a TKO to facilitate the implementation of PBM.
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Affiliation(s)
- Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md.
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Amanda Rea
- Division of Cardiac Surgery, University of Maryland St Joseph Medical Center, Towson, Md
| | - Busra Cangut
- Department of Cardiac Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Vicki Morton-Bailey
- Department of Anesthesia, Providence Anesthesiology Associates, Charlotte, NC
| | - Alexander J Gregory
- Department of Anesthesiology, Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rakesh C Arora
- Division of Cardiac Surgery, Department of Surgery, Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jacob Raphael
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia, Pa
| | - Daniel T Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Mass
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23
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Liu Q, Wu X, Li Y, Wang H, An R, Dou D, Bie D, Jia Y, Yuan S, Yan F, Ding J. Effect of hemoglobin and oxygen saturation on adverse outcomes in children with tetralogy of fallot: a retrospective observational study. BMC Anesthesiol 2023; 23:346. [PMID: 37848817 PMCID: PMC10580598 DOI: 10.1186/s12871-023-02290-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/21/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Tetralogy of Fallot (TOF) is a common cyanotic congenital heart malformation that carries a high risk of right-to-left shunting. Anemia is characterized by decreased hemoglobin (Hb) levels that can affect tissue oxygen delivery and impact postoperative recovery in patients. Chronic hypoxia caused by right-to-left shunting of TOF could lead to compensatory increases in Hb to maintain systemic oxygen balance. This study aims to investigate whether preoperative Hb and blood oxygen saturation (SpO2) can predict adverse outcomes in children undergoing corrective surgery for TOF. METHODS This retrospective study included patients under 18 years of age who underwent corrective surgery for TOF at Fuwai Hospital between January 2016 and December 2018. Adverse outcomes, including in-hospital death, extracorporeal membrane oxygenation implantation, ICU stay > 30 days, and severe complications, were considered as the primary outcome. Univariable and multivariable logistic analyses were performed to identify independent risk factors for adverse outcomes. Propensity score-matched (PSM) analysis was also conducted to minimize the confounding factors. RESULTS A total of 596 children were included in the study, of which 64 (10.7%) experienced adverse outcomes. Hb*SpO2 < aaHb was identified as an independent risk factor for adverse outcomes (OR = 2.241, 95% CI = 1.276-3.934, P = 0.005) after univariable and multivariable logistic analyses. PSM analysis further confirmed the association between Hb*SpO2 < aaHb and adverse outcomes. Patients with Hb*SpO2 < aaHb had a significantly higher incidence of postoperative adverse outcomes, longer time of mechanical ventilation, and hospital stay, as well as higher in-hospital costs. CONCLUSIONS Hb*SpO2 < aaHb is significantly associated with adverse outcomes in children undergoing corrective surgery for TOF. Clinicians can use this parameter to early identify high-risk children and optimize their postoperative management.
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Affiliation(s)
- Qiao Liu
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Xie Wu
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Yinan Li
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Hongbai Wang
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Ran An
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Dou Dou
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Dongyun Bie
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Yuan Jia
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Jie Ding
- Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
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24
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Hensley NB, Holmes SD, Cho BC, Salenger R, Alejo D, Fonner CE, Ad N. Unexpected impact of preoperative anemia in low-risk isolated coronary artery bypass grafting or single-valve surgical patients: Do not overlook these patients in anemia management! J Thorac Cardiovasc Surg 2023:S0022-5223(23)00969-8. [PMID: 37839659 DOI: 10.1016/j.jtcvs.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/27/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE Preoperative anemia is prevalent in cardiac surgery and independently associated with increased risk for short-term and long-term mortality. The purpose of this study was to examine the effect of preoperative hematocrit (Hct) on outcomes in cardiac surgical patients and whether the effect is comparable across levels of Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM). METHODS The study consisted of adult, isolated coronary artery bypass grafting (CABG) or single-valve surgical patients in a statewide registry from 2011 to 2022 (N = 29,828). Regressions were used to assess effect of preoperative Hct on STS-defined major morbidity/mortality including the interaction of Hct and STS PROM as continuous variables. RESULTS Median age was 66 years (58-73 years), STS PROM was 1.02% (0.58%-1.99%), and preoperative Hct was 39.5% (35.8%-42.8%). The sample consisted of 78% isolated CABG (n = 23,261), 10% isolated mitral valve repair/replacement (n = 3119), 12% isolated aortic valve replacement (n = 3448), and 29% were female (n = 8646). Multivariable analyses found that greater Hct was associated with reduced risk of STS-defined morbidity/mortality (odds ratio, 0.96; P < .001). These effects for Hct persisted even after adjustment for intraoperative blood transfusion. The interaction of Hct and STS PROM was significant for morbidity/mortality (odds ratio, 1.01; P < .001). There was a stronger association between Hct levels and morbidity/mortality risk in the patients with the lowest STS risk compared with patients with the greatest STS risk. CONCLUSIONS Patients with lower risk had a greater association between preoperative Hct and major morbidity and mortality compared with patients with greater risk. Preoperative anemia management is essential across all risk groups for improved outcomes.
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Affiliation(s)
- Nadia B Hensley
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Sari D Holmes
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Brian C Cho
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Rawn Salenger
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, and St Joseph's Medical Center, Baltimore, Md
| | - Diane Alejo
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Niv Ad
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
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25
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Cavalli LB, Pearse BL, Craswell A, Anstey CM, Naidoo R, Rapchuk IL, Perel J, Hobson K, Wang M, Fung YL. Determining sex-specific preoperative haemoglobin levels associated with intraoperative red blood cell transfusion in cardiac surgery: a retrospective cohort study. Br J Anaesth 2023; 131:653-663. [PMID: 37718096 DOI: 10.1016/j.bja.2023.06.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/07/2023] [Accepted: 06/16/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Anaemic cardiac surgery patients are at greater risk of intraoperative red blood cell transfusion. This study questions the application of the World Health Organization population-based anaemia thresholds (haemoglobin <120 g L-1 in non-pregnant females and <130 g L-1 in males) as appropriate preoperative optimisation targets for cardiac surgery. METHODS A retrospective cohort study was conducted on adults ≥18 yr old undergoing cardiopulmonary bypass surgery. Logistic regression was applied to define sex-specific preoperative haemoglobin concentrations with reduced probability of intraoperative red blood cell transfusion for cardiac surgery patients. RESULTS Data on 4384 male and 1676 female patients were analysed. Binarily stratified multivariable logistic regression odds of receiving intraoperative red blood cell transfusion increased in cardiac surgery patients >45 yr old (odds ratio [OR] 1.84; 95% confidence interval [CI] 1.33-2.55), surgery urgency <30 days (OR 2.03; 95% CI 1.66-2.48), combined coronary artery bypass grafting and valve surgery, or other surgery types (OR 2.24; 95% CI 1.87-2.67), and female sex (OR 1.92; 95% CI 1.62-2.28). The odds decreased by 8.4% with each 1 g L-1 increase in preoperative haemoglobin (OR 0.92; 95% CI 0.91-0.92). Logistic regression predicted females required a preoperative haemoglobin concentration of 133 g L-1 and males 127 g L-1 to have a 15% probability of intraoperative transfusion. CONCLUSIONS The World Health Organization female anaemia threshold of haemoglobin <120 g L-1 disproportionately disadvantages female cardiac surgery patients. A preoperative haemoglobin concentration ≥130 g L-1 in adult cardiac surgery patients would minimise their overall probability of intraoperative red blood cell transfusion to <15%.
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Affiliation(s)
- Leonardo B Cavalli
- School of Health, University of the Sunshine Coast, Birtinya, QLD, Australia; School of Science, Technology and Engineering, University of the Sunshine Coast, Sippy Downs, QLD, Australia; Sunshine Coast Health Institute, Birtinya, QLD, Australia.
| | - Bronwyn L Pearse
- Blood Management, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Alison Craswell
- School of Health, University of the Sunshine Coast, Birtinya, QLD, Australia; Sunshine Coast Health Institute, Birtinya, QLD, Australia
| | - Christopher M Anstey
- School of Medicine, Sunshine Coast Campus, Griffith University, Birtinya, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Rishendran Naidoo
- Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Ivan L Rapchuk
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Anaesthesia and Perfusion Department, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Joanne Perel
- Pathology Queensland, Queensland Health, Brisbane, QLD, Australia
| | - Kylie Hobson
- Blood Management, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Mingzhong Wang
- School of Science, Technology and Engineering, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Yoke-Lin Fung
- School of Health, University of the Sunshine Coast, Sippy Downs, QLD, Australia
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Bolliger D, Tanaka KA, Steiner LA. Patient blood management programmes: keeping the ball rolling. Br J Anaesth 2023; 131:426-428. [PMID: 37394325 DOI: 10.1016/j.bja.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/01/2023] [Accepted: 06/08/2023] [Indexed: 07/04/2023] Open
Abstract
Patient blood management programmes have been endorsed by the World Health Organization and multiple medical societies. It seems important to review the progress and results of patient blood management programmes so necessary modifications or new initiatives can be added to achieve their major goals. In this issue of the British Journal of Anaesthesia, Meybohm and colleagues show that a nationwide patient blood management programme had an impact and was potentially cost-effective in centres that previously utilised large amounts of allogeneic blood transfusions. Before implementing a programme, each institution might need to identify the area(s) of deficiency with respect to established patient blood management methods, which will warrant specific focus in subsequent clinical practice reviews.
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Affiliation(s)
- Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Luzius A Steiner
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
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Arya S, Xiang T, Tang GH, Pavenski K. Including the patient in patient blood management: Development and assessment of an educational animation tool. Transfusion 2023; 63:1488-1494. [PMID: 37317645 DOI: 10.1111/trf.17458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Patient blood management (PBM) programs are effective at reducing transfusion-associated mortality and morbidity; however, patient engagement within the realm of PBM remains relatively unstudied. Our objectives were to develop a novel educational tool utilizing animation to educate preoperative patients about anemia and to evaluate the effectiveness of this intervention. STUDY DESIGN AND METHODS We created a patient-facing animation for preoperative surgical patients. The animation addressed characters' health journeys from diagnosis to treatment, addressing the role of PBM. We utilized the concept of patient activation as a means to empower patients, and developed the animation to be as accessible as possible. Post-viewing, patients provided feedback utilizing an electronic survey. RESULTS A final version of the animation can be found here: https://vimeo.com/495857315. A total of 51 participants viewed our animation, the majority of whom were planned to undergo joint replacement or cardiac surgery. Almost all (94%, N = 4) agreed that taking an active role in their health was the most important factor in determining their ability to function. The video was felt to be easy to understand (96%, N = 49), and 92% (N = 47) agreed that they had a better understanding of anemia and its treatment. After watching the animation, patients felt more certain that they could follow through with their PBM plan (98%, N = 50). DISCUSSION To the best of our knowledge, there are no other PBM-specific patient education animations. Patients enjoyed learning about PBM though animation, and patient education may lead to better uptake of PBM interventions. We hope that other hospitals will be inspired to pursue this approach.
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Affiliation(s)
- Sumedha Arya
- Department of Medicine, Canadian Blood Services, Medical Affairs and Innovation, University of Toronto, Toronto, Ontario, Canada
| | - Tracy Xiang
- Biomedical Communications, Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Grace H Tang
- Hematology-Oncology Clinical Research Group, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Katerina Pavenski
- Department of Medicine and Laboratory Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine and Laboratory Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Pathobiology, University of Toronto, Toronto, Ontario, Canada
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De Carlini CC, Cantù E, Erba N, Maggiolini S. Gastrointestinal bleeding associated to aortic valve stenosis (Heyde's syndrome): a case series and literature review. Eur Heart J Case Rep 2023; 7:ytad412. [PMID: 37650079 PMCID: PMC10464592 DOI: 10.1093/ehjcr/ytad412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 08/03/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
Background The association among aortic valve stenosis, gastrointestinal bleeding, and anaemia due to arteriovenous malformations, known as Heyde's syndrome (HS), is poorly understood and controversial. Recently, acquired Type 2A von Willebrand syndrome (vWS 2A) was shown to be the most likely aetiological mechanism of anaemia. Case summary We report two cases of HS in whom the percutaneous replacement of the aortic valve was resolutive for iron deficiency anaemia. Discussion Iron deficiency anaemia and aortic stenosis are a common association in the elderly, so much that frequently; in such cases, the correction of the valvulopathy is often excluded as pre-operative anaemia is associated with higher morbidity and mortality. From this perspective, the correct diagnosis of HS is crucial to guide the decision to correct valvulopathy, as valvular substitution is resolutive for both anaemic disorders and aortic stenosis.
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Affiliation(s)
- Caterina Chiara De Carlini
- Cardiology Division, Cardiovascular Department, S.PIO XI Hospital, Largo Mazzini 1, 20832 Desio (MB), Italy
| | - Edoardo Cantù
- Cardiology Division, Cardiovascular Department, San L. Mandic Hospital, Merate (Lc), Italy
| | - Nicoletta Erba
- Hematology Division, Salam Center for Cardiac Surgery, Khartoum, Sudan
| | - Stefano Maggiolini
- Cardiology Division, Cardiovascular Department, San L. Mandic Hospital, Merate (Lc), Italy
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Straus S, Karabdic IH, Grabovica S, Hadzimehmedagic A, Djedovic M, Kabil E, Selimovic T, Granov N. How Important Impact of Low Level of Hematocrit Can Be on Outcome in Patients Undergoing Off Pump Coronary Artery Bypass Surgery? Acta Inform Med 2023; 31:102-106. [PMID: 37711492 PMCID: PMC10498362 DOI: 10.5455/aim.2023.31.102-106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/23/2023] [Indexed: 09/16/2023] Open
Abstract
Background Cardiosurgical patients can be often anemic, and preoperative anaemia is associated with increased postoperative complications, as well as morbidity and mortality. Objective The present study was conducted aiming to determine the influence of lower preoperative hematocrit values on the early postoperative recovery of patients undergoing elective off-pump coronary artery bypass grafting (OPCABG). Methods Our retrospective study included 150 patients who underwent elective OPCABG surgery from September 2021 to December 2022 at the Clinic for Cardiovascular Surgery University of Sarajevo. Patients were divided into two groups, anemic and non-anemic, with anemia defined as hemoglobin level <130g/l males and <120g/l females. Study observed comorbidities and early postoperative data. Results Overall prevalence of anemia in OPCABG patients was 36,6%, more frequent among older patients. Comorbidities as chronic obstructive pulmonary disease, hypertension, ejection fraction was quite similar in both groups, but body mass index was significantly higher in the group of patients with anemia (29.9% vs 28.4%). In early recovery period, vasopressors were more used in patients with anemia (63.6% vs 42.1%) and their doses were higher. Total drainage was higher in patients with anemia (744.45±45.72 ml vs 681.58±349.06 ml). Number of transfusions was higher in the group of patients with anemia: red blood cells (0.89±1.29 vs 0.29±0.84; p<0,05), fresh frozen plasma (0.65±1.13 vs 0.41±1.15; p<0,05) and platelets (0.11±0.57 vs 0,07±0.42; p>0,05). Duration of mechanical ventilation was longer in patients with anemia compared to non-anemic patients (623-91±259.83 minutes vs 469±191.13 minutes). Atrial fibrillation occurred more often in patients with anemia (12.7 vs 7.4%). Length of stay in the intensive care unit was without significant difference. Conclusion Based on our findings, patients who underwent elective OPCABG with lower than normal hematocrit, needed more blood and blood products, more vasopressor drugs in higher doses, longer mechanical ventilation, all which can prolong the patient's recovery and increase the cost of treatment.
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Affiliation(s)
- Slavenka Straus
- Clinic for Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | | | - Sanja Grabovica
- Clinic for Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Amel Hadzimehmedagic
- Clinic for Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Muhamed Djedovic
- Clinic for Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Edin Kabil
- Clinic for Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Tarik Selimovic
- Clinic for Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Nermir Granov
- Clinic for Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Lifgren SA, Fiala RS, Fabbro M. Blood Transfusions in Elective Cardiac Surgery: The Debate Continues. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00344-0. [PMID: 37344249 DOI: 10.1053/j.jvca.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Sofia A Lifgren
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami/Jackson Memorial Hospital, Miami, FL.
| | - Robert Scott Fiala
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami/Jackson Memorial Hospital, Miami, FL
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami/Jackson Memorial Hospital, Miami, FL
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Rubino AS, De Santo LS, Montella AP, Golini Petrarcone C, Palmieri L, Galbiati D, Galdieri N, De Feo M. Prognostic Implication of Preoperative Anemia in Redo Cardiac Surgery: A Single-Center Propensity-Matched Analysis. J Cardiovasc Dev Dis 2023; 10:160. [PMID: 37103039 PMCID: PMC10146465 DOI: 10.3390/jcdd10040160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/02/2023] [Accepted: 04/05/2023] [Indexed: 04/08/2023] Open
Abstract
Preoperative anemia has been associated with increased morbidity and mortality after cardiac surgery, but little is known about its prognostic value in the setting of redo procedure. A retrospective, observational cohort study of prospectively collected data was undertaken on 409 consecutive patients referred for redo cardiac procedures between January 2011 and December 2020. The EuroSCORE II calculated an average mortality risk of 25.7 ± 15.4%. Selection bias was assessed with the propensity-adjustment method. The prevalence of preoperative anemia was 41%. In unmatched analysis, significant differences between the anemic and nonanemic groups emerged in the risk for postoperative stroke (0.6% vs. 4.4%, p = 0.023), postoperative renal dysfunction (29.7% vs. 15.6%, p = 0.001), a need for prolonged ventilation (18.1% vs. 7.2%, p = 0.002), and high-dosage inotropes (53.1% vs. 32.9%, p < 0.001) along with both length of ICU and hospital stay (8.2 ± 15.9 vs. 4.3 ± 5.4 days, p = 0.003 and 18.8 ± 17.4 vs. 14.9 ± 11.1, p = 0.012). After propensity matching (145 pairs), preoperative anemia was still significantly associated with postoperative renal dysfunction, stroke, and the need for high-dosage inotrope cardiac morbidity. Preoperative anemia is significantly associated with acute kidney injury, stroke, and the need for high-dosage inotropes in patients referred for redo procedures.
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Affiliation(s)
- Antonino Salvatore Rubino
- Cardio-Thoraco-Vascular Department, Division of Cardiac Surgery, Papardo Hospital, 98158 Messina, Italy
| | - Luca Salvatore De Santo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
| | - Antonio Pio Montella
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
| | - Caterina Golini Petrarcone
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
| | - Lucrezia Palmieri
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
| | - Denise Galbiati
- Cardiovascular Department, Cardiac Surgery Unit of the IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Nicola Galdieri
- Cardiac Intensive Care Unit, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
| | - Marisa De Feo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
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Yao X, Li N, Lu R, Wang X, Zhang Y, Wang S. Development of a nomogram for predicting nosocomial infections among patients after cardiac valve replacement surgery. J Clin Nurs 2023; 32:1466-1475. [PMID: 35988041 DOI: 10.1111/jocn.16489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/14/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To construct a predictive nomogram of the risk of nosocomial infections among patients after cardiac valve replacement surgery. BACKGROUND Nosocomial infections are a standout challenge that worsens the prognosis of patients after valve replacement surgery. However, studies on the nomogram of nosocomial infections in these patients have remained scarce. DESIGN A retrospective cohort study. METHODS Patients (n = 720) following valve replacement surgery from 2018 to 2019 were selected. LASSO regression and multivariate logistic regression were utilised to ascertain predictors of nosocomial infections. The predictive performance of the nomogram was appraised by calibration and discrimination. Decision and impact curves were used to assess the clinical utility. Internal validation was implemented via 1000 bootstrap samples to mitigate overfitting. TRIPOD guidelines were used in this study. RESULTS One hundred and fifty one patients (20.97%) experienced nosocomial infections following valve replacement surgery. Heart failure, preoperative anaemia, valve material, American Society of Anesthesiologists score ≥ IV, prolonged duration of surgery, duration of mechanical ventilation ≥ 24 h and indwelling nasogastric tube were predictors of nosocomial infections. Using these variables, we developed a predictive nomogram of the occurrence of nosocomial infections and the internal validation results demonstrated good discrimination and calibration of the nomogram. The clinical decision and impact curve revealed significant clinical utility. CONCLUSIONS The present study constructed a nomogram for predicting the risk of nosocomial infections in patients following cardiac valve replacement surgery. This nomogram may strengthen the effective screening of patients at high risk of nosocomial infections. RELEVANCE TO CLINICAL PRACTICE This risk warning tool can assist clinical staff in making decisions and providing individualised infection control measures for patients, which has a significant reference value for clinical practice. NO PATIENT OR PUBLIC CONTRIBUTION The data for this study were obtained from the hospital database, and the entire process of the study did not involve patient participation.
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Affiliation(s)
- Xue Yao
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Na Li
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Ranran Lu
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Xujing Wang
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Yujun Zhang
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Shuhui Wang
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
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Hof L, Choorapoikayil S, Old O, Zacharowski K, Meybohm P. [Implementation of Patient Blood Management as Standard-of-Care]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:231-244. [PMID: 37044107 DOI: 10.1055/a-1789-0944] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Anaemia is among the most common co-morbidity in surgical patients. However, it often remains unrecognized and untreated, which results in an increased requirement for allogeneic blood products and complications. Patient Blood Management offers patient-centred and evidence-based therapies and preventive measures for anaemia. Patient Blood Management is composed of 3 main pillars: pre-operative anaemia management, blood loss reduction and the rational use of allogeneic blood products. The World Health Organization demands the implementation of Patient Blood Management measures since 2010. However, a comprehensive implementation of Patient Blood Management as a standard-of-care is still not achieved. Here, we describe the need for a comprehensive Patient Blood Management implementation and highlight several specific Patient Blood Management measures.
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34
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Benediktsson SB, Karason S, Sigurdsson MI. Haemoglobin levels and outcomes of subgroups of patients with pre-operative anaemia based on red cell size: A retrospective cohort study. Acta Anaesthesiol Scand 2023; 67:422-431. [PMID: 36635957 DOI: 10.1111/aas.14198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 12/28/2022] [Accepted: 01/05/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Pre-operative anaemia is common and associated with adverse outcomes. We hypothesised that pre-operative anaemia would be evident more than 1 month pre-operatively, and that peri-operative changes in haemoglobin and post-operative outcomes differed between red cell size-based subsets of anaemia. METHODS A retrospective single-centre cohort study, including all patients 18 years and older undergoing their first surgery at Landspitali between January 2006 and December 2018 with available measurement of haemoglobin (Hb) within 30 days preceding surgery. Clinical data were compared between patients with subgroups of anaemia classified by mean corpuscular volume (MCV) into microcytic (MCV < 80 fl), normocytic (MCV 80-100 fl), and macrocytic (MCV > 100 fl) anaemia. The development of haemoglobin measurements from a nationwide database was plotted from 1 year pre-operatively to 2 years post-operatively. RESULTS Of 40,979 patients, 10,505 (25.6%) had pre-operative anaemia, of which 1089 (10.4%) had microcytic anaemia, 9243 (88.0%) had normocytic anaemia, and 173 (1.6%) had macrocytic anaemia. Patients within all subgroups of pre-operative anaemia had a higher degree of comorbidity and frailty burden and a low haemoglobin evident for more than 100 days pre-operatively and similar changes post-operatively. Post-operative prolonged recovery of haemoglobin was slower for macrocytic anaemia than other types of anaemia. All groups of patients with anaemia had a higher incidence of 30-day mortality, acute kidney injury, and rate of readmission compared with patients without anaemia. CONCLUSIONS Pre-operative anaemia is evident long prior to the procedure and its association with worse outcomes is similar regardless of red cell size.
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Affiliation(s)
| | - Sigurbergur Karason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Anaesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Anaesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
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Chin K, Joo H, Jiang H, Lin C, Savinova I, Joo S, Alli A, Sklar MC, Papa F, Simpson J, Baker AJ, Mazer CD, Darrah W, Hare GMT. Importance of assessing biomarkers and physiological parameters of anemia-induced tissue hypoxia in the perioperative period. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:186-197. [PMID: 36377057 PMCID: PMC10068554 DOI: 10.1016/j.bjane.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
Anemia is associated with increased risk of Acute Kidney Injury (AKI), stroke and mortality in perioperative patients. We sought to understand the mechanism(s) by assessing the integrative physiological responses to anemia (kidney, brain), the degrees of anemia-induced tissue hypoxia, and associated biomarkers and physiological parameters. Experimental measurements demonstrate a linear relationship between blood Oxygen Content (CaO2) and renal microvascular PO2 (y = 0.30x + 6.9, r2 = 0.75), demonstrating that renal hypoxia is proportional to the degree of anemia. This defines the kidney as a potential oxygen sensor during anemia. Further evidence of renal oxygen sensing is demonstrated by proportional increase in serum Erythropoietin (EPO) during anemia (y = 93.806*10-0.02, r2 = 0.82). This data implicates systemic EPO levels as a biomarker of anemia-induced renal tissue hypoxia. By contrast, cerebral Oxygen Delivery (DO2) is defended by a profound proportional increase in Cerebral Blood Flow (CBF), minimizing tissue hypoxia in the brain, until more severe levels of anemia occur. We hypothesize that the kidney experiences profound early anemia-induced tissue hypoxia which contributes to adaptive mechanisms to preserve cerebral perfusion. At severe levels of anemia, renal hypoxia intensifies, and cerebral hypoxia occurs, possibly contributing to the mechanism(s) of AKI and stroke when adaptive mechanisms to preserve organ perfusion are overwhelmed. Clinical methods to detect renal tissue hypoxia (an early warning signal) and cerebral hypoxia (a later consequence of severe anemia) may inform clinical practice and support the assessment of clinical biomarkers (i.e., EPO) and physiological parameters (i.e., urinary PO2) of anemia-induced tissue hypoxia. This information may direct targeted treatment strategies to prevent adverse outcomes associated with anemia.
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Affiliation(s)
- Kyle Chin
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada; University of Toronto, Department of Physiology, Toronto, Canada
| | - Hannah Joo
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Helen Jiang
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Chloe Lin
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Iryna Savinova
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Canada
| | - Sarah Joo
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Ahmad Alli
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Michael C Sklar
- St. Michael's Hospital, Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto, Canada; University of Toronto, St. Michael's Hospital, Department of Critical Care, Toronto, Canada
| | - Fabio Papa
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Jeremy Simpson
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Canada
| | - Andrew J Baker
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada; St. Michael's Hospital, Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto, Canada; University of Toronto, St. Michael's Hospital, Department of Critical Care, Toronto, Canada
| | - C David Mazer
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada; University of Toronto, Department of Physiology, Toronto, Canada; St. Michael's Hospital, Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto, Canada; University of Toronto, St. Michael's Hospital, Department of Critical Care, Toronto, Canada
| | - William Darrah
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Gregory M T Hare
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada; University of Toronto, Department of Physiology, Toronto, Canada; St. Michael's Hospital, Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, Toronto, Canada; St. Michael's Hospital Center of Excellence for Patient Blood Management, 30 Bond Street, Toronto, Canada.
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36
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Frentiu AA, Mao K, Caruana CB, Raveendran D, Perry LA, Penny-Dimri JC, Ramson DM, Segal R, Bellomo R, Smith JA, Liu Z. The Prognostic Significance of Red Cell Distribution Width in Cardiac Surgery: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2023; 37:471-479. [PMID: 36635145 DOI: 10.1053/j.jvca.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 11/21/2022]
Abstract
RED CELL DISTRIBUTION WIDTH (RDW) is a routinely available biomarker of likely erythropoietic dysfunction, which may be associated with adverse outcomes after cardiac surgery. This systematic review and meta-analysis aimed to clarify the prognostic value of RDW in patients undergoing cardiac surgery. The authors searched MEDLINE, Embase, and the Cochrane Library from inception to May 10, 2022 for studies investigating the association between elevated RDW (as defined by the authors of included studies) and adverse outcomes after cardiac surgery. Herein, the authors extracted maximally adjusted hazard ratios (HRs) and odds ratios (ORs) with associated CIs, and pooled them using random-effects inverse- variance modeling. The authors explored interstudy heterogeneity using metaregression. The authors included 26 studies involving 48,092 patients who had undergone cardiac surgery. Elevated preoperative RDW was associated with long-term mortality (pooled HR 1.63, 95% CI 1.05-2.52), short-term mortality (pooled OR 2.16, 95% CI 1.21-3.87), acute kidney injury (AKI; pooled OR 1.30, 95% CI 1.19-1.41) and postoperative atrial fibrillation (POAF; pooled OR 1.44, 95% CI 1.05-1.96). Some studies suggested a significant association between preoperative RDW elevation and neurologic complications; however, their number was insufficient for meta-analysis. The postoperative RDW levels were less consistently reported and could not be meta-analyzed. In conclusion, the authors found that elevated preoperative RDW was associated with increased short- and long-term mortality, POAF, and AKI after cardiac surgery. Further research is needed to investigate its role in the risk stratification of patients undergoing cardiac surgery.
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Affiliation(s)
- Angela A Frentiu
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, Australia.
| | - Kevin Mao
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia
| | - Carla Borg Caruana
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Dev Raveendran
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia
| | - Luke A Perry
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Australia
| | - Jahan C Penny-Dimri
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, Australia
| | - Dhruvesh M Ramson
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, Australia
| | - Reny Segal
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia; Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Intensive Care, Austin Hospital, Heidelberg, Australia; Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; Monash University School and Public Health and Preventive Medicine, Monash University, Clayton, Australia; Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Heidelberg, Australia
| | - Julian A Smith
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, Australia; Department of Cardiothoracic Surgery, Monash Health, Clayton, Australia
| | - Zhengyang Liu
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Australia
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37
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Schwann TA, Vekstein AM, Engoren M, Grau-Sepulveda M, O'Brien S, Engelman D, Lobdell KW, Gaudino MF, Salenger R, Habib RH. Perioperative Anemia and Transfusions and Late Mortality in Coronary Artery Bypass Patients. Ann Thorac Surg 2023; 115:759-769. [PMID: 36574523 DOI: 10.1016/j.athoracsur.2022.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 08/14/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Perioperative anemia and transfusions are associated with adverse operative outcomes after coronary artery bypass graft surgery (CABG). Their individual association with long-term outcomes is unclear. METHODS Patients aged 65 years and older who had undergone CABG and were in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (n = 504,596) from 2011 to 2018 were linked to Centers for Medicare and Medicaid Service data to assess long-term survival. The association of intraoperative anemia defined by intraoperative nadir hematocrit (nHct) and red blood cell (RBC) transfusions, and their interactions, on long-term mortality were assessed with Kaplan-Meier estimates and multivariable Cox regression. Restricted cubic splines were used to explore the association between nHct as a continuous variable and long-term mortality. RESULTS 258,398 on-pump CABG STS Adult Cardiac Surgery Database patients surviving the perioperative period were linked to Centers for Medicare and Medicaid Service claims files. Per World Health Organization criteria, 41% had preoperative anemia. Mean intraoperative nHct was 24%; RBC transfusion rate was 43.7%. Univariable analysis associated both RBC transfusion and lower nHct with worse survival. Lower nHct was only marginally associated with risk-adjusted mortality: adjusted hazard ratio (AHR) 1.04 (95% CI, 1.01-1.06) and 1.07 (95% CI, 1.00-1.14) at nHct 20% and at nHct 14%, respectively. RBC transfusion was associated with significantly higher adjusted mortality irrespective of timing of transfusion: AHR intraoperative 1.21 (95% CI, 1.18-1.27); AHR postoperative 1.26 (95% CI, 1.22-1.30); AHR both 1.46 (95% CI, 1.40-1.52) and across all levels of nHct. RBC transfusion was not associated with improved survival at any level of nHct. CONCLUSIONS Among Medicare CABG patients, RBC transfusions were associated with increased risk-adjusted late mortality across all levels of nHct whereas intraoperative anemia was only marginally so. Tolerance of lower intraoperative nHct than currently accepted may be preferable to transfusions.
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Affiliation(s)
- Thomas A Schwann
- Department of Surgery, University of Massachusetts-Baystate, Springfield, Massachusetts.
| | - Andrew M Vekstein
- Department of Surgery, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | | | - Sean O'Brien
- Duke Clinical Research Institute, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Daniel Engelman
- Department of Surgery, University of Massachusetts-Baystate, Springfield, Massachusetts
| | - Kevin W Lobdell
- Department of Surgery, Atrium Health, Charlotte, North Carolina
| | - Mario F Gaudino
- Department of Surgery, Weill-Cornell Health, New York, New York
| | - Rawn Salenger
- Department of Surgery, University of Maryland, Baltimore, Maryland
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38
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Kloeser R, Buser A, Bolliger D. Treatment Strategies in Anemic Patients Before Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:266-275. [PMID: 36328926 DOI: 10.1053/j.jvca.2022.09.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 01/14/2023]
Abstract
Both preoperative anemia and the transfusion of red blood cells have been associated with increased morbidity and mortality after cardiac surgery. To reduce the need for blood transfusion during surgery and improve patient outcomes, patient blood management programs have been developed. A primary focus of patient blood management in the preoperative period is the identification, diagnosis, and treatment of preoperative anemia, as anemia is associated with an increased risk of preoperative blood transfusion. In this narrative review, the authors focus on the laboratory screening of anemia before surgery and the evidence and limitations of different treatment strategies in anemic patients scheduled for cardiac surgery. To accurately correct preoperative anemia, the timely detection and definition of the etiology of anemia before elective cardiac surgery are crucial. Multiple randomized studies have been performed using preoperative iron supplementation and/or administration of erythropoiesis-stimulating agents in patients undergoing cardiac surgery. Although preoperative iron substitution in patients with iron deficiency is recommended, the evidence of its effectiveness is limited. In patients with nonpure iron deficiency anemia, combined therapy with erythropoiesis-stimulating agents and intravenous iron is recommended. Combined therapy might effectively reduce the need for red blood cell transfusion, even if applied shortly before cardiac surgery. The therapeutic effect on morbidity and mortality remains unclear. Nonetheless, the timely preoperative assessment of anemia and determination of iron status, eventually leading to targeted therapy, should become a standard of care and might potentially improve patient outcomes.
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Affiliation(s)
- Raphael Kloeser
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, and Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
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39
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Lanigan M, Wilkey A. Current concepts in evaluation and management of preoperative anaemia in patients undergoing thoracic surgery. Curr Opin Anaesthesiol 2023; 36:89-95. [PMID: 36550609 DOI: 10.1097/aco.0000000000001214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to evaluate the current recommendations for management of perioperative anaemia in patients undergoing thoracic surgery, present the impact of anaemia on outcomes in this patient population and suggest an algorithm for evaluating and treating anaemia preoperatively. RECENT FINDINGS Anaemia is a common medical issue noted preoperatively in patients presenting for thoracic surgery and carries significant morbidity. Preoperative anaemia increases the likelihood of receiving a perioperative transfusion, which represents a significant risk factor for morbidity and reduced disease-free survival in lung cancer patients presenting for thoracic surgery. It is also associated with longer hospital lengths of stay and increased risk for reoperation following lung transplantation. An algorithm-based approach to management of anaemia is beneficial and treatment with iron has been shown to reduce transfusions. SUMMARY Patients undergoing thoracic surgery have a high incidence of preoperative anaemia that increases the risk of transfusion and postoperative morbidity. Preoperative evaluation and tailored treatment based on the underlying cause of anaemia reduces the incidence of anaemia prior to surgery and decreases transfusion rates.
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Affiliation(s)
- Megan Lanigan
- University of Minnesota, Department of Anesthesiology, Minneapolis, Minnesota, USA
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40
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Milne B, Gilbey T, Kunst G. Perioperative Management of the Patient at High-Risk for Cardiac Surgery-Associated Acute Kidney Injury. J Cardiothorac Vasc Anesth 2022; 36:4460-4482. [PMID: 36241503 DOI: 10.1053/j.jvca.2022.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/27/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is one of the most common major complications of cardiac surgery, and is associated with increased morbidity and mortality. Cardiac surgery-associated AKI has a complex, multifactorial etiology, including numerous factors such as primary cardiac dysfunction, hemodynamic derangements of cardiac surgery and cardiopulmonary bypass, and the possibility of a large volume of blood transfusion. There are no truly effective pharmacologic therapies for the management of AKI, and, therefore, anesthesiologists, intensivists, and cardiac surgeons must remain vigilant and attempt to minimize the risk of developing renal dysfunction. This narrative review describes the current state of the scientific literature concerning the specific aspects of cardiac surgery-associated AKI, and presents it in a chronological fashion to aid the perioperative clinician in their approach to this high-risk patient group. The evidence was considered for risk prediction models, preoperative optimization, and the intraoperative and postoperative management of cardiac surgery patients to improve renal outcomes.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Tom Gilbey
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine and Metabolic Medicine and Sciences, King's College London, British Heart Foundation Centre of Excellence, Faculty of Life Sciences and Medicine, London, United Kingdom.
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41
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Koster A, Zittermann A, Gummert JF, von Dossow V, Deutsch MA. Transfusions and early outcomes in anaemic patients undergoing off- or on-pump coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2022; 35:6842327. [PMID: 36416155 PMCID: PMC9695756 DOI: 10.1093/icvts/ivac276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/26/2022] [Accepted: 11/22/2022] [Indexed: 11/24/2022] Open
Abstract
We retrospectively compared transfusion rates and early outcomes in 1621 consecutive patients with preoperative anaemia undergoing off-pump coronary artery bypass grafting (OPCAB) or on-pump coronary artery bypass grafting (ONCAB) surgery using a propensity score analysis with inverse probability of treatment weighting. Endpoints were transfusions, early morbidity, and mortality. Surgeries were performed by 45 dedicated OPCAB and/or ONCAB surgeons during the 10-year study period. Operative data did not differ significantly between study groups with the exception of a more frequent use of bilateral internal mammary artery revascularization approach in OPCAB patients than ONCAB patients. OPCAB was associated with fewer transfusions and lower risk for the need of postoperative renal replacement therapy, but higher risk of wound infections than ONCAB. Perioperative stroke risk and 30-day and 1-year mortality did not differ significantly between the groups. Our data in a 'real-world setting' indicate that in patients with preoperative anaemia both ONCAB and OPCAB are feasible surgical approaches regarding early morbidity and mortality.
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Affiliation(s)
- Andreas Koster
- Institute for Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum NRW, Ruhr-University, Bochum, Germany
| | - Armin Zittermann
- Corresponding author. Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Georgstr. 11, 32545 Bad Oeynhausen, Germany. Tel: +49-5731-97-3296; fax: +49-5731-97-2020; e-mail: (A. Zittermann)
| | - Jan F Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University, Bochum, Germany
| | - Vera von Dossow
- Institute for Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum NRW, Ruhr-University, Bochum, Germany
| | - Marcus-André Deutsch
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University, Bochum, Germany
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42
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Réhabilitation améliorée après chirurgie cardiaque adulte sous CEC ou à cœur battant 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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43
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Laermans J, Van Remoortel H, Avau B, Bekkering G, Georgsen J, Manzini PM, Meybohm P, Ozier Y, De Buck E, Compernolle V, Vandekerckhove P. Adverse events of iron and/or erythropoiesis-stimulating agent therapy in preoperatively anemic elective surgery patients: a systematic review. Syst Rev 2022; 11:224. [PMID: 36253838 PMCID: PMC9578279 DOI: 10.1186/s13643-022-02081-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 09/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Iron supplementation and erythropoiesis-stimulating agent (ESA) administration represent the hallmark therapies in preoperative anemia treatment, as reflected in a set of evidence-based treatment recommendations made during the 2018 International Consensus Conference on Patient Blood Management. However, little is known about the safety of these therapies. This systematic review investigated the occurrence of adverse events (AEs) during or after treatment with iron and/or ESAs. METHODS Five databases (The Cochrane Library, MEDLINE, Embase, Transfusion Evidence Library, Web of Science) and two trial registries (ClinicalTrials.gov, WHO ICTRP) were searched until 23 May 2022. Randomized controlled trials (RCTs), cohort, and case-control studies investigating any AE during or after iron and/or ESA administration in adult elective surgery patients with preoperative anemia were eligible for inclusion and judged using the Cochrane Risk of Bias tools. The GRADE approach was used to assess the overall certainty of evidence. RESULTS Data from 26 RCTs and 16 cohort studies involving a total of 6062 patients were extracted, on 6 treatment comparisons: (1) intravenous (IV) versus oral iron, (2) IV iron versus usual care/no iron, (3) IV ferric carboxymaltose versus IV iron sucrose, (4) ESA+iron versus control (placebo and/or iron, no treatment), (5) ESA+IV iron versus ESA+oral iron, and (6) ESA+IV iron versus ESA+IV iron (different ESA dosing regimens). Most AE data concerned mortality/survival (n=24 studies), thromboembolic (n=22), infectious (n=20), cardiovascular (n=19) and gastrointestinal (n=14) AEs. Very low certainty evidence was assigned to all but one outcome category. This uncertainty results from both the low quantity and quality of AE data due to the high risk of bias caused by limitations in the study design, data collection, and reporting. CONCLUSIONS It remains unclear if ESA and/or iron therapy is associated with AEs in preoperatively anemic elective surgery patients. Future trial investigators should pay more attention to the systematic collection, measurement, documentation, and reporting of AE data.
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Affiliation(s)
- Jorien Laermans
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium. .,Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium.,Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Bert Avau
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
| | - Geertruida Bekkering
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.,Center for Evidence-Based Medicine, Leuven, Belgium.,Cochrane Belgium, Leuven, Belgium
| | - Jørgen Georgsen
- South Danish Transfusion Service, Odense University Hospital, Odense C, Denmark
| | - Paola Maria Manzini
- SC Banca del Sangue Servizio di Immunoematologia, University Hospital Città della Salute e della Scienza di Torino, Torino, Italy
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Yves Ozier
- University Hospital of Brest, Brest, France
| | - Emmy De Buck
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium.,Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Veerle Compernolle
- Blood Services, Belgian Red Cross, Mechelen, Belgium.,Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Philippe Vandekerckhove
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.,Belgian Red Cross, Mechelen, Belgium.,Centre for Evidence-Based Health Care, Stellenbosch University, Cape Town, South Africa
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44
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Perioperative Quality Initiative and Enhanced Recovery After Surgery-Cardiac Society Consensus Statement on the Management of Preoperative Anemia and Iron Deficiency in Adult Cardiac Surgery Patients. Anesth Analg 2022; 135:532-544. [PMID: 35977363 DOI: 10.1213/ane.0000000000006148] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.
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45
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Aplicación de un programa de ahorro de sangre en cirugía cardiaca: análisis y resultados. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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46
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Ju JW, Nam K, Hong H, Cheun H, Bae J, Lee S, Cho YJ, Jeon Y. Performance of the ACEF and ACEF II risk scores in predicting mortality after off-pump coronary artery bypass grafting. J Clin Anesth 2022; 79:110693. [DOI: 10.1016/j.jclinane.2022.110693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/11/2022] [Accepted: 02/18/2022] [Indexed: 10/19/2022]
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47
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Kattou F, Montandrau O, Rekik M, Delentdecker P, Brini K, Zannis K, Beaussier M. Critical Preoperative Hemoglobin Value to Predict Anemia-Related Complications After Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:1901-1907. [PMID: 35148943 DOI: 10.1053/j.jvca.2022.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Preoperative anemia is frequent in patients undergoing cardiac surgery and is associated with increased postoperative complications. The purpose of this observational study was to estimate the critical preoperative hemoglobin threshold associated with the occurrence of complications after cardiac surgery. DESIGN A retrospective observational cohort study. SETTING A tertiary-care medical center from January 2019 to April 2020. PARTICIPANTS A total of 1,004 patients undergoing elective cardiac surgery were included. INTERVENTIONS None (observational study). MEASUREMENTS AND MAIN RESULTS The primary study endpoint was to define the hemoglobin threshold that predicted the occurrence of postoperative major complications after elective cardiac surgery. Postoperative complications were a composite criterion, including transient ischemic attack or stroke, myocardial infarction, acute kidney injury, respiratory failure, mediastinitis, or mesenteric ischemia. A discrimination threshold was determined by using receiver operating characteristic curves. The discrimination threshold for hemoglobin concentration with the best sensitivity/specificity ratio for the occurrence of postoperative complications was 13 g/dL for male patients and 11.8 g/dL for female patients. The incidence of postoperative complications was 17.2% in the total population. Independent risks were preoperative hemoglobin concentration, red blood cell transfusion, European System for Cardiac Operative Risk Evaluation II, and the type of surgery. CONCLUSIONS The critical preoperative hemoglobin thresholds associated with the occurrence of postoperative complications with the best sensitivity/specificity ratio were 13 g/dL for men and 11.8 g/dL for women, which were very similar to the World Health Organization criteria defining anemia.
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Affiliation(s)
- Fehmi Kattou
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Olivier Montandrau
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France.
| | - Mohamed Rekik
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Philippe Delentdecker
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Kais Brini
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Konstantinos Zannis
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Marc Beaussier
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
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48
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Frise MC, Holdsworth DA, Sandhu MS, Mellor AJ, Kasim AS, Hancock HC, Maier RH, Dorrington KL, Robbins PA, Akowuah EF. Non-anemic iron deficiency predicts prolonged hospitalisation following surgical aortic valve replacement: a single-centre retrospective study. J Cardiothorac Surg 2022; 17:157. [PMID: 35710500 PMCID: PMC9204877 DOI: 10.1186/s13019-022-01897-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 05/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Iron deficiency has deleterious effects in patients with cardiopulmonary disease, independent of anemia. Low ferritin has been associated with increased mortality in patients undergoing cardiac surgery, but modern indices of iron deficiency need to be explored in this population. Methods We conducted a retrospective single-centre observational study of 250 adults in a UK academic tertiary hospital undergoing median sternotomy for non-emergent isolated aortic valve replacement. We characterised preoperative iron status using measurement of both plasma ferritin and soluble transferrin receptor (sTfR), and examined associations with clinical outcomes. Results Measurement of plasma sTfR gave a prevalence of iron deficiency of 22%. Patients with non-anemic iron deficiency had clinically significant prolongation of total hospital stay (mean increase 2.2 days; 95% CI: 0.5–3.9; P = 0.011) and stay within the cardiac intensive care unit (mean increase 1.3 days; 95% CI: 0.1–2.5; P = 0.039). There were no deaths. Defining iron deficiency as a plasma ferritin < 100 µg/L identified 60% of patients as iron deficient and did not predict length of stay. No significant associations with transfusion requirements were evident using either definition of iron deficiency. Conclusions These findings indicate that when defined using sTfR rather than ferritin, non-anemic iron deficiency predicts prolonged hospitalisation following surgical aortic valve replacement. Further studies are required to clarify the role of contemporary laboratory indices in the identification of preoperative iron deficiency in patients undergoing cardiac surgery. An interventional study of intravenous iron targeted at preoperative non-anemic iron deficiency is warranted.
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Affiliation(s)
- Matthew C Frise
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK. .,Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK.
| | - David A Holdsworth
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Manraj S Sandhu
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Terrell Street, Bristol, BS2 8ED, UK
| | - Adrian J Mellor
- South Tees NHS Foundation Trust, The James Cook University Hospital, Middlesbrough, TS4 3BW, UK
| | - Adetayo S Kasim
- Durham Research Methods Centre, NEDTC Hub, 1st Floor Arthur Holmes Building, Lower Mountjoy, South Road, Durham, DH1 3LE, UK
| | - Helen C Hancock
- Faculty of Medical Sciences, Newcastle Clinical Trials Unit, Newcastle University, 1-2 Claremont Terrace, Newcastle Upon Tyne, NE2 4AE, UK
| | - Rebecca H Maier
- Faculty of Medical Sciences, Newcastle Clinical Trials Unit, Newcastle University, 1-2 Claremont Terrace, Newcastle Upon Tyne, NE2 4AE, UK
| | - Keith L Dorrington
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Peter A Robbins
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK
| | - Enoch F Akowuah
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, The James Cook University Hospital, Middlesbrough, TS4 3BW, UK.,Newcastle University, Newcastle Upon Tyne, NE1 7RU, UK
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49
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Mertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, Chatel D, Cholley B, Curtil A, Grimaud JP, Houel R, Kattou F, Fellahi JL, Guidon C, Guinot PG, Lebreton G, Marguerite S, Ouattara A, Provenchère Fruithiot S, Rozec B, Verhoye JP, Vincentelli A, Charbonneau H. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med 2022; 41:101059. [PMID: 35504126 DOI: 10.1016/j.accpm.2022.101059] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. METHODS Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. CONCLUSIONS Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Julien Amour
- Institut de Perfusion, de Réanimation, d'Anesthésie de Chirurgie Cardiaque Paris Sud, IPRA, Hôpital Privé Jacques Cartier, Massy, France
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France; MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Lionel Camilleri
- Department of Cardiovascular Surgery, CHU Clermont-Ferrand, T.G.I, I.P., CNRS, SIGMA, UCA, UMR 6602, Clermont-Ferrand, France
| | - Thierry Caus
- Department of Cardiac Surgery, UPJV, Amiens University Hospital, Amiens Picardy University Hospital, Amiens, France
| | - Didier Chatel
- Department of Cardiac Surgery (D.C.), Institut du Coeur Saint-Gatien, Nouvelle Clinique Tours Plus, Tours, France
| | - Bernard Cholley
- Anaesthesiology and Intensive Care Medicine, Hôpital Européen Georges-Pompidou, AP-HP, Université de Paris, INSERM, IThEM, Paris, France
| | - Alain Curtil
- Department of Cardiac Surgery, Clinique de la Sauvegarde, Lyon, France
| | | | - Rémi Houel
- Department of Cardiac Surgery, Saint Joseph Hospital, Marseille, France
| | - Fehmi Kattou
- Department of Anaesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France; Faculté de Médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Intensive Care, Dijon University Hospital, Dijon, France; University of Bourgogne and Franche-Comté, LNC UMR1231, Dijon, France; INSERM, LNC UMR1231, Dijon, France; FCS Bourgogne-Franche Comté, LipSTIC LabEx, Dijon, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, Unité mixte de recherche CardioMetabolisme et Nutrition, ICAN, AP-HP, Hôpital Pitié-Salpétrière, Paris, France
| | - Sandrine Marguerite
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, UMR 1034, Biology of Cardiovascular Diseases, F-33600 Pessac, France
| | - Sophie Provenchère Fruithiot
- Department of Anaesthesia, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France; Centre d'Investigation Clinique 1425, INSERM, Université de Paris, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laennec, CHU Nantes, Nantes, France; Université de Nantes, CHU Nantes, CNRS, INSERM, Institut duDu Thorax, Nantes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - André Vincentelli
- Department of Cardiac Surgery, University of Lille, CHU Lille, Lille, France
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Spadaccio C, Nenna A, Candura D, Rose D, Moscarelli M, Al-Attar N, Sutherland F. Total arterial coronary artery bypass grafting in patients with preoperative anemia. J Card Surg 2022; 37:1528-1536. [PMID: 35324020 DOI: 10.1111/jocs.16425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/10/2022] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Blood transfusions after coronary artery bypass grafting (CABG) has been associated to adverse outcomes, especially in anemic patients. However, little is known about the influence of the modality of revascularization. Total arterial revascularization (TAR) was shown to reduce postoperative transfusion when compared to saphenous vein-based (SV)-CABG (LIMA plus one/more SV grafts). We, therefore, aimed to investigate the impact of TAR-CABG versus SV-CABG on blood products use and perioperative outcomes in patients with preoperative anemia, normally at higher risk for postoperative transfusions. METHODS From a cohort of 936 patients with mild preoperative anemia undergoing primary elective on-pump CABG, 166 matched pairs of patients undergoing either TAR- or SV-CABG were obtained. Anemia was defined as hemoglobin level <13 g/dl for men and <12 g/dl for women. The primary endpoint was the evaluation of red packed cells (RPC) use over the entire hospital stay. RESULTS TAR patients showed significantly reduced RPC usage compared with SV (mean difference 0.45 units). TAR patients had a reduced intubation time (mean difference 7.6 h) and were discharged 1.24 days earlier than SV patients. Pneumonia and acute kidney injury were doubled among SV patients. Adjusted regression showed that TAR technique is a predictor of reduced RPC unit use regardless of age and EuroSCORE II (odds ratio: 0.63, p < .01). CONCLUSION Patients with preoperative anemia might benefit from TAR regardless of age or calculated operative risk. TAR-CABG was associated to reduced postoperative use of blood products and postoperative length of stay in comparison with SV-CABG in this subset of patients.
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Affiliation(s)
- Cristiano Spadaccio
- Cardiothoracic Surgery Department, Golden Jubilee National Hospital, Glasgow, UK.,Cardiac Surgery Department, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antonio Nenna
- Cardiac Surgery Department, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Dario Candura
- Cardiac Surgery Department, Leiden University Medical Centrum, Leiden, The Netherlands
| | - David Rose
- Cardiac Surgery Department, Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital (GVM), Cotignola, Ravenna, Italy
| | - Nawwar Al-Attar
- Cardiothoracic Surgery Department, Golden Jubilee National Hospital, Glasgow, UK
| | - Fraser Sutherland
- Cardiothoracic Surgery Department, Golden Jubilee National Hospital, Glasgow, UK
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