Risk Factors for the Postoperative Transfusion of Allogeneic Blood in Orthopedics Patients With Intraoperative Blood Salvage: A Retrospective Cohort Study

The association between perioperative blood transfusions and venous thromboembolism risk following surgical management of hip fractures

Introduction

Despite high rates of transfusion reported among hip fracture patients in the perioperative period, the relationship between perioperative transfusions and VTE has not been thoroughly explored. Therefore, we used a national database to evaluate how perioperative transfusions among patients undergoing surgical management of hip fractures impacted 1) deep vein thrombosis (DVT) and 2) pulmonary embolism (PE) risk.

Methods

The Targeted Hip Fracture Database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients undergoing surgical management of hip fractures from 2016 to 2019. A multivariate logistic regression was conducted using various patient-specific variables to identify risk factors for DVT and PE. A nearest-neighbor propensity score matched (PSM) comparison between patients receiving and not receiving perioperative blood transfusions (1:1) was additionally conducted.

Results

Prior to our PSM, preoperative transfusions were not associated with DVT incidence (OR: 1.48, 95% CI: 0.80-2.50; p = 0.2). However, intra-operative/post-operative transfusions (OR: 1.26, 95% CI: 1.02-1.56; p = 0.00.30) as well as the receipt of both transfusion types (OR: 1.81, 95% CI: 1.10-2.81; p = 0.012) were associated with an increased risk of DVT. The latter of these findings remained significant following PSM (OR: 1.73, 95% CI: 1.04-2.73; p = 0.025). No relationship was demonstrated between PE risk and perioperative transfusion receipt.

Conclusion

Our findings emphasize the importance of perioperative blood management strategies among patients undergoing surgical repair of hip fracture. Specifically, orthopaedic surgeons should aim to optimize hip fracture patients prior to surgical intervention as well as intra-operatively to reduce transfusion incidence.

An insight into the utilization of allogenic blood transfusion and factors affecting blood transfusion in total knee replacement surgery in a tertiary care hospital in Eastern India

BACKGROUND:

Significant blood loss and requirement of allogenic blood transfusion during or after total knee replacement (TKR) have been reported. Incidence of blood transfusion in TKR is highly variable and depends on several factors. We investigated the blood utilization in patients undergoing TKR in our hospital and depicted the important risk factors that determine the need of allogenic blood transfusion in primary unilateral TKR.

MATERIALS AND METHODS:

The study included 1241 consecutive patients undergoing primary unilateral total knee arthroplasty. All the surgeries were performed by a single surgical team of orthopedists following standard procedure. Patient and disease details were obtained from patient file and hospital information system. Compatibility test was performed in blood bank before blood reservation following mandatory guidelines. Details of test, blood issue, and blood transfusion were documented in the blood bank.

RESULTS:

Of 1241 enrolled patients, 1069 (86.2%) were female. The median age of patients was 66 years with mean preoperative hemoglobin of 9.9 g/dL. Allogenic blood transfused was needed in 223 (17.9%) patients. Diabetes mellitus, hypertension, thyroid disorders, and chronic heart diseases were the major comorbid conditions. Risk factors such as gender, American Society of Anesthesiologists score, preoperative hemoglobin, and intraoperative and postoperative blood losses were significantly associated with blood transfusion.

CONCLUSION:

The risk factors determining blood transfusion in TKR vary between studies, however, all centers should establish standard operating procedures describing the surgical procedure and transfusion support in TKR. In addition, each center may develop specific blood management strategy to rationalize blood transfusion in TKR and overall successful care in TKR.

[Patient safety during endoprosthetic training : Does the training of surgeons in primary hip arthroplasty at certified endoprosthesis centres lead to increased complications?]

Hintergrund

Ziel der Studie war die Untersuchung, ob sich das perioperative Outcome und operationsspezifische Prozessgrößen bei Patienten mit Hüftgelenksersatz signifikant verschlechtern, wenn die Operation durch einen unerfahrenen Operateur, assistiert durch einen erfahrenen Operateur, im Kontext eines zertifizierten Endoprothesenzentrums durchgeführt wird.

Material und Methoden

Es wurden 1480 Patienten eingeschlossen, die zwischen 2013 und 2016 bei primärer Koxarthrose mit einer primären zementfreien Hüfttotalendoprothese (HTEP) versorgt wurden. Die relevanten Daten wurden retrospektiv aus dem Krankenhausinformationssystem, dem Entlassungsbrief und aus dem EndoCert-Bogen dokumentiert. Die Operateure wurden nach ihrer Qualifikation in erfahrene (Senior, > 50 HTEP pro Jahr) und unerfahrene Operateure (Junior, < 50 HTEP pro Jahr) unterteilt. Anschließend erfolgte der Vergleich der erhobenen Daten anhand dieser Unterteilung.

Resultate

Es zeigte sich bei unerfahrenen Operateuren eine signifikante Verlängerung der Operationsdauer um 20,7 min (Senior 62,6 ± 20,4 min; Junior 83,3 ± 19,5 min; p ≤ 0,001), der Krankenhausverweildauer um 0,25 Tage (Senior 8,8 ± 0,9 d; Junior 9,0 ± 0,9 d; p ≤ 0,001) und eine Erhöhung der Transfusionshäufigkeit von Erythrozytenkonzentraten (Senior 0,6 ± 1,1 Stk.; Junior 0,9 ± 1,4 Stk.; p ≤ 0,001). Dagegen zeigte sich kein Unterschied bei perioperativen Komplikationen (p = 0,682) und beim perioperativen Blutverlust (Senior 1,3 ± 0,5 l; Junior 1,3 ± 0,5 l; p = 0,097). Zwischen Operationsdauer und Blutverlust bestand allerdings eine positive Korrelation (Senior r = 0,183; Junior r = 0,214; jeweils p ≤ 0,01).

Schlussfolgerung

Die Ausbildung von unerfahrenen Operateuren an einem zertifizierten Endoprothesenzentrum führt bei Assistenz durch erfahrene Operateure nicht zur Reduktion der Patientensicherheit mit vermehrten Komplikationen. Aufgrund der Operationszeitverlängerung kommt es allerdings zu einer Mehrbelastung der Kliniken im Wettbewerb mit nichtausbildenden Kliniken, die nicht im DRG-System abgebildet ist.

Sex differences in complications and readmission rates following shoulder arthroplasty in the United States

Introduction

Shoulder arthroplasty (SA) procedures are increasingly performed in the United States. However, there is a lack of data evaluating how patient sex may affect perioperative complications. The purpose of this study was to evaluate sex-based differences in 30-day postoperative complication and readmission rates after SA.

Methods

Total SA and reverse SA cases between 2012-2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. The 30-day complication rate, readmission rate, operation time, length of stay, and mortality were compared between women and men. Multivariable logistic regression analysis was performed to identify independent perioperative complications associated with patient sex.

Results

Of 12,530 SA cases, 6949 (55.4%) were female and 5499 (44.5%) were male. Compared with women, on average men were significantly younger, had lower body mass index, and were less likely to be functionally dependent, and less likely to have an American Society of Anesthesiologists score of 3+ (P < .001). Although overall complications and readmission rates between women and men were similar (3.4% vs. 3.7%, P = .489; 3.0% vs. 2.8%, P = .497), men were significantly less likely to develop urinary tract infections (UTIs; odds ratio [OR] 0.58, P = .032) and require transfusions (OR 0.49, P < .001) and had shorter lengths of stay (P < .001). However, men were significantly more likely to have a superficial surgical site infection (OR 2.63, P = .035) and 6.8 minute longer operating time (P < .001) compared with women.

Conclusion

Though the overall complication risk is similar between the sexes, their risk profiles are distinct. Men had decreased risk of UTI, blood transfusions, and shorter length of stay but increased risk of surgical site and longer operating time compared with women. This disparity should be discussed when counseling and risk-stratifying patients for SA.

Preoperative Dehydration does not Increase the Risk of Complications Following Elective Lumbar Surgery

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to evaluate the effect of preoperative dehydration on hospital length of stay (LOS), rates of 30-day postoperative complications, related reoperations, and readmissions.

SUMMARY OF BACKGROUND DATA

Preoperative dehydration has long been associated with postoperative infection, deep vein thrombosis (DVT), acute renal failure, and an increased hospital LOS. To our knowledge, the effect of preoperative dehydration on complication rates for patients undergoing elective lumbar spine surgery has not been well described.

METHODS

An analysis of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data from 2006 to 2013 was performed. Patients undergoing elective lumbar procedures were identified and exclusion criteria eliminated patients who underwent any emergency procedures, infections, tumor cases, or revision surgeries. Patient dehydration was defined as preoperative blood urea nitrogen/creatinine (BUN/Cr) ratio greater than 20.

RESULTS

Patients (4698; 34.5%) with preoperative dehydration based on BUN/Cr ratio were identified. Univariate analysis was suggestive of an association between preoperative dehydration and an increased risk of DVT (1.1% compared with 0.6%; P = 0.002), urinary tract infection (2.5% compared with 1.6%; P < 0.001), and need for transfusion postoperatively (17.6% compared with 14.4%; P < 0.001). However, on the basis of multivariate regression, no significant association between dehydration and increased odds of aforementioned outcomes was identified.

CONCLUSION

Preoperative dehydration does not appear to negatively affect perioperative outcomes or readmission in patients undergoing elective lumbar spine surgery.

LEVEL OF EVIDENCE

3.

The incidence and risk factors for allogenic blood transfusion in total knee and hip arthroplasty

Background

Excessive blood loss in total joint arthroplasty (TJA) usually leads to an allogenic blood transfusion, which may cause adverse outcomes, prolonged length of hospitalization, and increased costs. The purpose of this study was to determine the incidence and risk factors for intraoperative and postoperative allogenic transfusion in patients undergoing primary unilateral total knee and hip arthroplasty (TKA and THA).

Methods

We conducted a retrospective study and enrolled consecutive patients undergoing primary unilateral TKA and THA at our institution between January 2010 and July 2014 (n = 1534). Information about allogenic transfusion was collected from medical records to determine the incidence. We performed univariate analysis and multivariate logistic regression analysis to identify the independent risk factors.

Results

Total, intraoperative, and postoperative transfusion rates were 17.9%, 7.9%, and 11.3%, respectively. The preoperative lower level of hemoglobin (Hb) (P < 0.001) and increased amount of intraoperative blood loss (P < 0.001) were independently associated with transfusion in TKA. The independent risk factors for transfusion in THA were female (P = 0.023), preoperative lower Hb level (P < 0.001), prolonged operation time (P < 0.001), and increased intraoperative blood loss (P < 0.001).

Conclusions

Given the high prevalence and potential risk of transfusion in TJA, interventions for identified risk factors should be used during the perioperative period.

The incidence of transfusion and associated risk factors in pelvic reconstructive surgery

BACKGROUND

Almost 400,000 female pelvic reconstructive operations were performed in 2010 for urinary incontinence and pelvic organ prolapse in the United States, and it is likely that this will continue to increase each year. There is a lack of population-based data evaluating the risk of blood transfusion after urogynecologic procedures.

OBJECTIVE

We sought to assess the incidence of blood transfusion related to pelvic reconstructive surgery in a large national surgical quality database and to identify transfusion-associated risk factors.

STUDY DESIGN

This retrospective cohort study was performed using the National Surgical Quality Improvement Program database from the years 2010 through 2014. All women undergoing surgery for pelvic floor disorders were identified by Current Procedural Terminology code. Demographic and clinical variables were abstracted. The incidence of blood transfusion was determined. A multivariate logistic regression analysis was performed to identify clinical factors independently associated with blood transfusion.

RESULTS

A total of 54,387 women underwent pelvic reconstructive surgery from 2010 through 2014 in the National Surgical Quality Improvement Program database. Of these subjects, 686 (1.26%) received a blood transfusion. The median age was 57 (range 28-89) years. Of the population, 0.81% was underweight (body mass index <18.5), 27.0% was normal weight (body mass index 18.5-24.9), 35.6% was overweight (body mass index 25-29.9), and 36.7% was obese (body mass index ≥30). The majority of subjects in the study cohort were Caucasian (91.4%) followed by African Americans (4.6%); the remainder included Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander. Hispanic ethnicity was reported in 9.3% of the population. American Society of Anesthesiologists class 1 and 2 represented a majority of the sample (76.5%). Concomitant hysterectomy was performed in 20,735 (38.1%) of the population. In the multivariate analysis, preoperative hematocrit <30% (odds ratio, 13.68; 95% confidence interval, 10.65-17.59), history of coagulopathy (odds ratio, 3.74; 95% confidence interval, 2.50-5.60), and concomitant hysterectomy (odds ratio, 1.77; 95% confidence interval, 1.49-2.12) were factors independently associated with receiving blood transfusion (all P < .05). When compared to American Society of Anesthesiologists class 1, patients who were class 3 (odds ratio, 2.82, P < .01; 95% confidence interval, 2.02-3.93) or class 4 (odds ratio, 6.56, P < .01; 95% confidence interval, 3.65-11.78) were more likely to require a transfusion. When compared to Caucasians, African Americans (odds ratio, 1.73, P < .01; 95% confidence interval, 1.27-2.36) and Hispanics (odds ratio, 1.92, P < .01; 95% confidence interval, 1.54-2.40) were more likely to require a transfusion. In this cohort, overweight (odds ratio, 0.75; 95% confidence interval, 0.62-0.93) and obese (odds ratio, 0.61; 95% confidence interval, 0.49-0.75) subjects were less likely to receive a transfusion. When compared to a vaginal approach, patients who had a minimally invasive approach (odds ratio, 0.63; 95% confidence interval, 0.49-0.83) were less likely to receive a transfusion, while those with an open approach were more likely to receive a transfusion (odds ratio, 5.43; 95% confidence interval, 4.49-6.56). Age was not a risk factor for transfusion.

CONCLUSION

Transfusion after pelvic reconstructive surgery is uncommon. The variables associated with transfusion are preoperative hematocrit <30%, American Society of Anesthesiologists class, bleeding disorders, nonwhite race, Hispanic ethnicity, and concomitant hysterectomy. Recognition of these factors can help guide preoperative counseling regarding transfusion risk after pelvic reconstructive surgery and individualize preoperative preparation.

Risk Factors for 30-Day Postoperative Complications Following Open Reduction Internal Fixation of Proximal Ulna Fractures

PURPOSE

Fractures of the proximal ulna are common injuries in the elderly population. These fractures can be managed nonsurgically or with open reduction internal fixation (ORIF). Whereas nonsurgical management may lead to a relative loss of elbow extension and to nonunion, ORIF carries a risk of complications. Although complications specific to the orthopedic intervention have been reported, few studies have identified postoperative systemic complications in this higher-risk group. The purposes of this study were to determine the rate of systemic complications in patients undergoing surgical fixation of proximal ulna fractures and to determine risk factors for complications.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database for all cases of proximal ulna fracture ORIF between 2005 and 2013. Demographic, historical, and preoperative laboratory data and 30-day postoperative complications were recorded. Univariate and multivariable analyses were performed to identify independent risk factors for complications.

RESULTS

A total of 650 patients met inclusion criteria. Within the 30-day postoperative period, 61 complications occurred in 45 patients (6.9%). Return to the operating room, which occurred in 19 patients (2.9%), was the most common major morbidity. American Society of Anesthesiologists class III or IV and dialysis dependence were independent risk factors for any complication.

CONCLUSIONS

Proximal ulna fracture ORIF has a low rate of systemic complications. The most common morbidities are return to the operating room, blood transfusion, and urinary tract infections. Dialysis and American Society of Anesthesiologists class III or IV are independent risk factors for complications. These complications may be nonspecific and related more to the patient population than procedure. We believe that the relatively low risk of short-term complications makes operative treatment a suitable option even in elderly patients with multiple morbidities.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.