Perioperative blood transfusion and the clinical outcomes of patients undergoing cholangiocarcinoma surgery: a systematic review and meta-analysis

Several studies have reported different results on the association between perioperative blood transfusion (PBT) and clinical outcomes for patients undergoing cholangiocarcinoma surgery. So far, no systematic review and meta-analysis have focused on this inconsistent issue. Therefore, we carried out a systematic review and meta-analysis to evaluate the association between PBT and the clinical outcomes of cholangiocarcinoma surgery patients. EMBASE, PubMed, Web of Science, and the Cochrane Library were searched from their inception to 6 April 2016 to evaluate the relationship between PBT and clinical outcomes for patients undergoing cholangiocarcinoma surgery. The pooled hazard ratio (HR) with a 95% confidence interval (CI) was calculated using the Cochrane Collaboration's RevMan 5.3 software. A total of 10 studies (1719 patients) were included in the meta-analysis. Pooled analysis showed that PBT was associated with worse 5-year survival rate (HR=1.67, 95% CI=1.41-1.98, P<0.0001) and median overall survival (OS) (HR=1.45, 95% CI=1.14-1.83, P=0.002) in the patients who underwent cholangiocarcinoma surgery. Subgroup analysis showed that intraoperative blood transfusion was also associated with worse 5-year survival rate (HR=1.95, 95% CI=1.49-2.57, P<0.00001). Intraoperative blood transfusion is associated with poor OS for patients undergoing cholangiocarcinoma surgery because it will increase the risk of death. Postoperative blood transfusion may not be associated with OS. In addition, the relationship between PBT and the postoperative complication rate of cholangiocarcinoma surgery is still unclear.

[Blood transfusion during heart surgery. A retrospective nested case-control study]

OBJECTIVE

To assess the correlation between intraoperative packed red blood cells transfusion and adverse outcome in a Spanish cohort of cardiac surgery patients.

METHODS

Retrospective observational multicentre study. An analysis was performed on the data from 927 cardiac surgery patients treated in 24 Spanish hospitals in 2007. Patients who received intraoperative transfusions were compared with non-transfused patients. Multivariate analyses were performed (including, among others, several items from the Euroscore, surgery type, basal renal status and haemoglobin levels, and Thakar score).

RESULTS

Every transfusion of packed red cells was associated with increased postoperative risk of acute kidney damage at 72 hours after surgery, prolonged mechanical ventilation, and need for haemodynamic support. Moreover, transfused patients showed an increased in-hospital mortality rates (Adjusted OR: 1.30; 95% CI: 1.19-1.42), as well as longer hospital stays (almost 4 days).

CONCLUSIONS

In this cohort of patients, intraoperative transfusion might independently predict higher risk of early acute kidney damage, prolonged postoperative mechanical ventilation, and a need for haemodynamic support, and reduced short term survival (adjusted OR for mortality: 1.30; 95% CI: 1.19-1.42), and longer hospital stays (4 days longer).

Use of graphical statistical process control tools to monitor and improve outcomes in cardiac surgery

BACKGROUND

Graphical Statistical Process Control (SPC) tools have been shown to promptly identify significant variations in clinical outcomes in a range of health care settings. We explored the application of these techniques to qualitatively inform the routine cardiac surgical morbidity and mortality (M&M) review process at a single site.

METHODS

Baseline clinical and procedural data relating to 4774 consecutive cardiac surgical procedures, performed between the 1st January 2003 and the 30th April 2011, were retrospectively evaluated. A range of appropriate performance measures and benchmarks were developed and evaluated using a combination of CUmulative SUM (CUSUM) charts, Exponentially Weighted Moving Average (EWMA) charts and Funnel Plots. Charts have been discussed at the unit's routine M&M meetings. Risk adjustment (RA) based on EuroSCORE has been incorporated into the charts to improve performance.

RESULTS

Discrete and aggregated measures, including Blood Product/Reoperation, major acute post-procedural complications and Length of Stay/Readmission<28 days have proved to be usable measures for monitoring outcomes. Monitoring trends in minor morbidities provides a valuable warning of impending changes in significant events. Instances of variation in performance have been examined and could be related to differences in individual operator performance via individual operator curves.

CONCLUSION

SPC tools facilitate near "real-time" performance monitoring allowing early detection and intervention in altered performance. Careful interpretation of charts for group and individual operators has proven helpful in detecting and differentiating systemic vs. individual variation.

Risk factors and outcomes of acute renal failure after open cardiac surgery

The incidence, risk factors, and outcome of acute renal failure following open cardiac surgery were assessed prospectively in 5,164 consecutive patients undergoing open heart surgery between March 2006 and February 2011. Acute postoperative renal failure (creatinine >1.5 mg·dL−1 within 3 days after surgery) developed in 64 (1.2%) patients with normal preoperative renal function (study group). A control group of 238 cardiac surgery patients who had postoperative creatinine levels ≤1.5 mg·dL−1 were selected randomly during the study period. A prospective case-control analysis of these 302 patients was performed. The mean age was 56.3 ± 12.5 years; 191 (63.2%) were men and 111 (36.8%) were women. Pre-, intra- and postoperative risk factors for acute renal failure were evaluated. Of the patients who developed acute renal failure, 12 (18.8%) died postoperatively, which was significantly higher than the 2.1% mortality among those without acute renal failure. Five of the 10 patients (50%) who needed dialysis died. The most significant prognostic factor for mortality was cardiac dysfunction. This study confirmed that impairment of renal function after cardiac surgery is uncommon without preoperative renal impairment, but carries an increased mortality rate.

Survival and length of stay following blood transfusion in octogenarians following cardiac surgery

Our aim was to assess if peri-operative blood transfusion is an independent risk factor for mortality and morbidity in the elderly. We report the results of a cohort study of all patients aged 80 or more on the day of their emergency or elective cardiac surgery (n = 874), using routinely collected data from January 2003 to November 2007. The primary outcome was all-cause mortality in hospital. The secondary outcomes were duration of stay in the intensive care unit (ICU) and overall hospital stay. Confounding variables were used to build up a risk model using a multivariable logistic regression analysis, and blood transfusion was added to assess whether it had additional predictive value for hospital mortality. Patients were divided into three groups: (i) transfusion of 0-2 units of red blood cells; (ii) transfusion of > 2 units of red blood cells and (iii) transfusion of red blood cells plus other clotting products. The strongest independent predictors of hospital death were logistic EuroSCORE and body mass index. After inclusion of these two variables, the odds ratio for transfusion remained significant. Relative to 0-2 units, the odds ratio for > 2 units was 6.80 (95% CI 2.46-18.8), and for other additional blood products was 14.4 (95% CI 5.34-37.3), with a p value of < 0.001. Duration of stay in the ICU was significantly associated with the amount of blood products administered (median (IQR [range]) ICU stay 1 (1-2 [0-15]) day if transfused 0-2 units of red blood cells, 2 (1-6 [0-128]) days if transfused > 2 units of red blood cells and 3 (1-76 [0-114]) days if other clotting products were used; p value < 0.001). Hospital stay was also associated with the amount of red cells used (p < 0.001).

Cardiac-surgery associated acute kidney injury requiring renal replacement therapy. A Spanish retrospective case-cohort study

Background

Acute kidney injury is among the most serious complications after cardiac surgery and is associated with an impaired outcome. Multiple factors may concur in the development of this disease. Moreover, severe renal failure requiring renal replacement therapy (RRT) presents a high mortality rate. Consequently, we studied a Spanish cohort of patients to assess the risk factors for RRT in cardiac surgery-associated acute kidney injury (CSA-AKI).

Methods

A retrospective case-cohort study in 24 Spanish hospitals. All cases of RRT after cardiac surgery in 2007 were matched in a crude ratio of 1:4 consecutive patients based on age, sex, treated in the same year, at the same hospital and by the same group of surgeons.

Results

We analyzed the data from 864 patients enrolled in 2007. In multivariate analysis, severe acute kidney injury requiring postoperative RRT was significantly associated with the following variables: lower glomerular filtration rates, less basal haemoglobin, lower left ventricular ejection fraction, diabetes, prior diuretic treatment, urgent surgery, longer aortic cross clamp times, intraoperative administration of aprotinin, and increased number of packed red blood cells (PRBC) transfused. When we conducted a propensity analysis using best-matched of 137 available pairs of patients, prior diuretic treatment, longer aortic cross clamp times and number of PRBC transfused were significantly associated with CSA-AKI.

Patients requiring RRT needed longer hospital stays, and suffered higher mortality rates.

Conclusion

Cardiac-surgery associated acute kidney injury requiring RRT is associated with worse outcomes. For this reason, modifiable risk factors should be optimised and higher risk patients for acute kidney injury should be identified before undertaking cardiac surgery.