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Brown LA, Griffiths JA, Santer P, Jakeman PM, Smith TG. Potential for using simulated altitude as a means of prehabilitation: a physiology study. Anaesthesia 2023; 78:1472-1480. [PMID: 37877784 PMCID: PMC10953332 DOI: 10.1111/anae.16158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 10/26/2023]
Abstract
The current pandemic of surgical complications necessitates urgent and pragmatic innovation to reduce postoperative morbidity and mortality, which are associated with poor pre-operative fitness and anaemia. Exercise prehabilitation is a compelling strategy, but it has proven difficult to establish that it improves outcomes either in isolation or as part of a multimodal approach. Simulated altitude exposure improves performance in athletes and offers a novel potential means of improving cardiorespiratory and metabolic fitness and alleviating anaemia within the prehabilitation window. We aimed to provide an initial physiological foundation for 'altitude prehabilitation' by determining the physiological effects of one week of simulated altitude (FI O2 15%, equivalent to approximately 2438 m (8000 ft)) in older sedentary volunteers. The study used a randomised, double-blind, sham-controlled crossover design. Eight participants spent counterbalanced normoxic and hypoxic weeks in a residential hypoxia facility and underwent repeated cardiopulmonary exercise tests. Mean (SD) age of participants was 64 (7) y and they were unfit, with mean (SD) baseline anaerobic threshold 12 (2) ml.kg-1 .min-1 and mean (SD) peak V̇O2 15 (3) ml.kg-1 .min-1 . Hypoxia was mild (mean (SD) Sp O2 93 (2) %, p < 0.001) and well-tolerated. Despite some indication of greater peak exercise capacity following hypoxia, overall there was no effect of simulated altitude on anaerobic threshold or peak V̇O2 . However, hypoxia induced a substantial increase in mean (SD) haemoglobin of 1.5 (2.7) g.dl-1 (13% increase, p = 0.028). This study has established the concept and feasibility of 'altitude prehabilitation' and demonstrated specific potential for improving haematological fitness. Physiologically, there is value in exploring a possible role for simulated altitude in pre-operative optimisation.
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Affiliation(s)
| | - J. A. Griffiths
- Nuffield Department of AnaesthesiaOxford University Hospitals NHS Foundation TrustOxfordUK
| | - P. Santer
- Department of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMAUSA
| | - P. M. Jakeman
- Health Research Institute and Department of Physical Education and Sport SciencesUniversity of LimerickLimerickIreland
| | - T. G. Smith
- Centre for Human and Applied Physiological SciencesKing's College LondonLondonUK
- Department of AnaesthesiaGuy's and St Thomas' NHS Foundation TrustLondonUK
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Torkian P, Jalaeian H, Wallace S, Shrestha P, Talaie R, Golzarian J. Post-Embolization Hemoglobin Changes: When to Consider Re-intervention. Cardiovasc Intervent Radiol 2023; 46:617-625. [PMID: 36869220 DOI: 10.1007/s00270-023-03386-1] [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: 09/29/2022] [Accepted: 02/05/2023] [Indexed: 03/05/2023]
Abstract
PURPOSE Decline in hemoglobin (Hgb) levels is common post-embolization, but there is no consensus on the classification of patients based on risk for re-bleeding or re-intervention. The current study evaluated post-embolization Hgb level trends with the goal of understanding the factors predictive of re-bleeding and re-intervention. MATERIALS AND METHODS All patients who underwent embolization for gastrointestinal (GI), genitourinary, peripheral, or thoracic arterial hemorrhage from 01/2017 to 01/2022 were reviewed. Data included demographics, periprocedural pRBC transfusion (TF) or pressor requirements, and outcome. Lab data consisted of Hgb values pre-embolization, immediately post-embolization, and daily values on days 1-10 after embolization. Hgb trends were compared between patients across TF and re-bleeding outcomes. Regression model was used to examine factors predictive of re-bleeding and magnitude of Hgb reduction post-embolization. RESULTS A total of 199 patients were embolized for active arterial hemorrhage. Perioperative Hgb level trends were similar for all sites and between TF + and TF- patients, showing a decline reaching a nadir within 6 days post-embolization followed by an upward trend. Maximum Hgb drift was predicted by GI embolization (p = 0.018), TF before embolization (p = 0.001), and use of vasopressor (p = 0.000). Patients with Hgb drop > 15% within the first two days post-embolization had a higher chance of having a re-bleeding episode (p = 0.04). CONCLUSION Perioperative Hgb trends showed a consistent downward drift followed by an upward shift, irrespective of TF requirement status or site of embolization. Using a cut-off value of 15% Hgb reduction within the first two days post-embolization may be helpful to assess re-bleeding risk.
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Affiliation(s)
- Pooya Torkian
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA.
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Stephanie Wallace
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
| | - Prashant Shrestha
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
| | - Reza Talaie
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
| | - Jafar Golzarian
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
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Weng M, Guo M, Li T, Zhou C, Sun C, Yue Y, Liao Q, Cai S, Lu X, Zhou D, Miao C. Anemia tolerance versus blood transfusion on long-term outcomes after colorectal cancer surgery: A retrospective propensity-score-matched analysis. Front Oncol 2022; 12:940428. [PMID: 36046042 PMCID: PMC9421070 DOI: 10.3389/fonc.2022.940428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/25/2022] [Indexed: 12/24/2022] Open
Abstract
Background Perioperative anemia and transfusion are intertwined with each other, and both have adverse impacts on the survival of colorectal cancer (CRC) patients. But the treatment of anemia still relies on transfusion in several countries, which leads us to question the effects of anemia tolerance and transfusion on the long-term outcomes of CRC patients. We investigated the combined effect of preoperative anemia and postoperative anemia and of preoperative anemia and blood transfusion, which imposes a greater risk to survival, to compare the effects of anemia tolerance and transfusion on overall survival (OS) and disease-free survival (DFS) in patients undergoing CRC surgery. Methods A retrospective propensity-score-matched analysis included patients with CRC undergoing elective surgery between January 1, 2008, and December 31, 2014. After propensity-score matching, Kaplan–Meier survival analysis and univariable and multivariable Cox proportional hazards models were used to study the prognostic factors for survivals. In univariate and multivariate Cox regression analysis, two novel models were built. Results Of the 8,121 patients with CRC, 1,975 (24.3%) and 6,146 (75.7%) patients presented with and without preoperative anemia, respectively. After matching, 1,690 patients remained in each group. In the preoperative anemia and postoperative anemia model, preoperative anemia and postoperative anemia was independent risk factor for OS (HR, 1.202; 95% CI, 1.043–1.385; P=0.011) and DFS (HR, 1.210; 95% CI, 1.050–1.395; P=0.008). In the preoperative anemia and transfusion model, preoperative anemia and transfused was the most dangerous independent prognostic factor for OS (HR, 1.791; 95% CI, 1.339–2.397; P<0.001) and DFS (HR, 1.857; 95% CI, 1.389–2.483; P<0.001). In patients with preoperative anemia, the OS and DFS of patients with transfusion were worse than those of patients without transfusion (P=0.026 in OS; P=0.037 in DFS). Conclusions Preoperative anemia and blood transfusion imposed a greater risk to OS and DFS in patients undergoing CRC surgery, indicating that the harm associated with blood transfusion was greater than that associated with postoperative anemia. These findings should encourage clinicians to be vigilant for the timely prevention and treatment of anemia, by appropriately promoting toleration of anemia and restricting the use of blood transfusion in patients with CRC.
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Affiliation(s)
- Meilin Weng
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Perioperative Stress and Protection, Zhongshan Hospital Fudan University, Shanghai, China
- Department of Anesthesiology, Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Miaomiao Guo
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Perioperative Stress and Protection, Zhongshan Hospital Fudan University, Shanghai, China
| | - Ting Li
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Perioperative Stress and Protection, Zhongshan Hospital Fudan University, Shanghai, China
| | - Changming Zhou
- Department of Cancer Prevention, Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Caihong Sun
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Perioperative Stress and Protection, Zhongshan Hospital Fudan University, Shanghai, China
| | - Ying Yue
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Perioperative Stress and Protection, Zhongshan Hospital Fudan University, Shanghai, China
| | - Qingwu Liao
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Perioperative Stress and Protection, Zhongshan Hospital Fudan University, Shanghai, China
| | - Sanjun Cai
- Department of Colorectal Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Xihua Lu
- Department of Anesthesiology, Affiliated Cancer Hospital of Zhengzhou University, Henan, China
- *Correspondence: Changhong Miao, ; Di Zhou, ; Xihua Lu,
| | - Di Zhou
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Perioperative Stress and Protection, Zhongshan Hospital Fudan University, Shanghai, China
- *Correspondence: Changhong Miao, ; Di Zhou, ; Xihua Lu,
| | - Changhong Miao
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Perioperative Stress and Protection, Zhongshan Hospital Fudan University, Shanghai, China
- *Correspondence: Changhong Miao, ; Di Zhou, ; Xihua Lu,
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Kanga K, Dickson E, Van Huellen H, De Las Casas R, Cadd M, Stanworth SJ, Grant-Casey J, Sugavanam A. Under-recognised burden of postoperative anaemia in patients undergoing emergency abdominal surgery in the UK. Br J Anaesth 2021; 127:e105-e108. [PMID: 34330412 DOI: 10.1016/j.bja.2021.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Kate Kanga
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK.
| | - Edward Dickson
- Nottingham Digestive Diseases Centre Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - Hans Van Huellen
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Ruth De Las Casas
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Matthew Cadd
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John Grant-Casey
- National Comparative Audit of Blood Transfusion, NHS Blood and Transplant, Oxford, UK
| | - Anita Sugavanam
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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