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Abdelkarim A, Straus SL, Moghaddam M, Nakhaei P, Clary B, Malas MB. POSTOPERATIVE OUTCOMES IN ANEMIC PATIENTS UNDERGOING CAROTID REVASCULARIZATION. J Vasc Surg 2024:S0741-5214(24)01777-4. [PMID: 39179005 DOI: 10.1016/j.jvs.2024.08.027] [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: 06/28/2024] [Revised: 08/08/2024] [Accepted: 08/11/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Preoperative anemia is associated with worse postoperative morbidity and mortality following major vascular procedures. Limited research has examined the optimal method of carotid revascularization in anemic patients. Therefore, we aim to compare the postoperative outcomes following carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) among anemic patients. STUDY DESIGN This is a retrospective review of anemic patients undergoing CEA, TFCAS, and TCAR in the Vascular Quality Initiative database between 2016-2023. We defined anemia as a preoperative hemoglobin level of <13 g/dL in men and <12 g/dL in women. The primary outcomes were 30-day mortality and in-hospital major adverse cardiac events (MACE). Logistic regression models were used for multivariate analyses. RESULTS Our study included 40,383 (59.3%) CEA, 9,159 (13.5%) TFCAS, and 18,555 (27.3%) TCAR cases in anemic patients. TCAR patients were older and had more medical comorbidities than CEA and TFCAS patients. TCAR was associated with decreased 30-day mortality (aOR=0.45,95%CI:0.37-0.59],P<0.001), in-hospital MACE (aOR=0.58,95%CI:0.46-0.75,P<0.001) compared to TFCAS. Additionally, TCAR was associated with 20% reduction in the risk of 30-day mortality (aOR=0.80,95%CI:0.65-0.98,P=0.03), and similar risk of in-hospital MACE (aOR=0.86,95%CI:0.77-1.01, P=0.07) compared to CEA. Furthermore, TFCAS was associated with an increased risk of 30-day mortality (aOR= 2,95%CI: 1.5-2.68,P<0.001), in-hospital MACE (aOR=1.7,95% CI:1.4-2,P<0.001) compared to CEA. CONCLUSIONS In this multi-institutional national retrospective analysis of a prospectively collected database, TFCAS is associated with a high risk of 30-day mortality and in-hospital MACE compared to CEA and TCAR in anemic patients. TCAR was associated with lower risk of 30-day mortality compared to CEA. These findings suggest TCAR as the optimal minimally invasive procedure for carotid revascularization in anemic patients.
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Affiliation(s)
- Ahmed Abdelkarim
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, California
| | - Sabrina L Straus
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, California
| | - Marjan Moghaddam
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, California
| | - Pooria Nakhaei
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, California
| | - Bryan Clary
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, California
| | - Mahmoud B Malas
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, California.
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Li R, Sidawy A, Nguyen BN. Preoperative anemia is a risk factor for worse 30-day outcomes in both open and endovascular repair of non-ruptured infrarenal abdominal aortic aneurysm. Vascular 2024:17085381241273141. [PMID: 39121867 DOI: 10.1177/17085381241273141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
BACKGROUND Anemia is a highly prevalent condition potentially linked to chronic inflammation. Preoperative anemia is an independent risk factor across many surgical fields. However, the relationship between anemia and abdominal aortic aneurysm (AAA) repair outcomes remains unclear. This study aimed to examine the effects of preoperative anemia on 30-day outcomes of non-ruptured infrarenal AAA repair. METHODS Patients who underwent open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infrarenal AAA were identified in National Surgical Quality Improvement Program (NSQIP) targeted databases from 2012 to 2021. Anemia was defined as preoperative hematocrit less than 39% in males and 36% in females. Multivariable logistic regression was used to compare 30-day perioperative outcomes between anemic and non-anemic patients, adjusting for demographics, comorbidities, indications, aneurysm extents, operation time, and surgical approaches. RESULTS There were 408 (22.13%) anemic and 1436 (77.88%) non-anemic patients who underwent OSR for non-ruptured AAA, while 3586 (25.20%) patients with and 10,644 (74.80%) without anemia underwent EVAR. In both OSR and EVAR, anemic patients had higher risks of bleeding requiring transfusion (OSR, aOR = 2.446, p < .01; EVAR, aOR = 3.691, p < .01), discharge not to home (OSR, aOR = 1.385, p = .04; EVAR, aOR = 1.27, p < .01), and 30-day readmission (OSR, aOR = 1.99, p < .01; EVAR, aOR = 1.367, p < .01). Also, anemic patients undergoing OSR had higher pulmonary events (aOR = 2.192, p < .01), sepsis (aOR = 2.352, p < .01), and venous thromboembolism (aOR = 2.913, p = .01), while in EVAR, anemic patients had higher mortality (aOR = 1.646, p = .01), cardiac complications (aOR = 1.39, p = .04), renal dysfunction (aOR = 1.658, p = .02), and unplanned reoperation (aOR = 1.322, p = .01). Moreover, in both OSR and EVAR, anemic patients had longer hospital length of stay (p < .01). CONCLUSION In OSR and EVAR, preoperative anemia was independently associated with worse 30-day outcomes. Preoperative anemia could be a useful marker for risk stratification for patients undergoing infrarenal AAA repair.
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Affiliation(s)
- Renxi Li
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Anton Sidawy
- Department of Surgery, The George Washington UniversityHospital, Washington, DC, USA
| | - Bao-Ngoc Nguyen
- Department of Surgery, The George Washington UniversityHospital, Washington, DC, USA
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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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Aksu H, Manduz B, Armagan M, Satoglu İS, Hanci V. Early complications in scoliosis surgery and relation to preoperative factors: A single-center retrospective study. Medicine (Baltimore) 2024; 103:e37529. [PMID: 38552046 PMCID: PMC10977596 DOI: 10.1097/md.0000000000037529] [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: 01/08/2024] [Accepted: 02/15/2024] [Indexed: 04/02/2024] Open
Abstract
In this study, we aimed to investigate the perioperative complications of the patients who underwent scoliosis surgery in our hospital and the factors that may affect the outcome. Between 2014 and 2018, scoliosis patients recorded data was examined retrospectively. Age, gender, height, body weight, comorbidity, Cobb index, scoliosis etiology, operation time, preoperative and postoperative hemoglobin, hematocrit, leukocyte, blood urea nitrogen, creatinine, coagulation value, operation time, level of instrumentation, intraoperative and postoperative blood loss, blood transfusion, intraoperative fluid administration, preoperative pulmonary function test values, blood gas values, urine outputs, hospital (LOS) and post anesthesia care unit stays, complications and mortality rates were examined. The files of 77 patients (48 female, 29 male) were retrospectively analyzed. The average age was 19.54 ± 16.32 years and 98.7% were elective surgery. The mean of LOS was 13.55 ± 9.13 days. As the preoperative hematocrit value decreases, LOS increases significantly. In patients with chronic obstructive pulmonary disease, smokers and high ASA scores, LOS is prolonged in patients with previous operations. As intraoperative colloid administration increased, crystalloid and blood products increased, it was also observed that the amount of crystalloid increased LOS. As the amount of intraoperative colloid or red blood cell administration increases, the duration of surgery and anesthesia increases, also increases the duration of post anesthesia care unit. Compared to patients with complications (n = 29) to the patients without complications (n = 47), it was found that they had longer anesthesia, and surgery times, also longer LOS times (P < .05). Our study showed that chronic obstructive pulmonary disease in the preoperative period, smoking, high ASA score, excessive use of colloid, prolonged duration of surgery and anesthesia, and long intubation durations increase the length of hospital stay. Preoperative comorbidity is directly related to postoperative complications and causes longer hospitalization after reconstructive scoliosis surgery.
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Affiliation(s)
- Hale Aksu
- Department of Anesthesiology and Reanimation, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Busra Manduz
- Department of Anesthesiology and Reanimation, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Mustafa Armagan
- Orthopedics and traumatology, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - İsmail Safa Satoglu
- Department of Anesthesiology and Reanimation, School of Medicine, Dokuz Eylul University, Izmir, Turkey
- Orthopedics and traumatology, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Volkan Hanci
- Department of Anesthesiology and Reanimation, School of Medicine, Dokuz Eylul University, Izmir, Turkey
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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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Meister R, Puelacher C, Glarner N, Gualandro DM, Andersson HA, Pargger M, Huré G, Virant G, Bolliger D, Lampart A, Steiner L, Hidvegi R, Lurati Buse G, Kindler C, Gürke L, Mujagic E, Schaeren S, Clauss M, Lardinois D, Hammerer-Lercher A, Chew M, Mueller C. Prediction of perioperative myocardial infarction/injury in high-risk patients after noncardiac surgery. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:729-739. [PMID: 37548292 PMCID: PMC10655147 DOI: 10.1093/ehjacc/zuad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
AIMS Perioperative myocardial infarction/injury (PMI) is a surprisingly common yet difficult-to-predict cardiac complication in patients undergoing noncardiac surgery. We aimed to assess the incremental value of preoperative cardiac troponin (cTn) concentration in the prediction of PMI. METHODS AND RESULTS Among prospectively recruited patients at high cardiovascular risk (age ≥65 years or ≥45 years with preexisting cardiovascular disease), PMI was defined as an absolute increase in high-sensitivity cTnT (hs-cTnT) concentration of ≥14 ng/L (the 99th percentile) above the preoperative concentration. Perioperative myocardial infarction/injury was centrally adjudicated by two independent cardiologists using serial measurements of hs-cTnT. Using logistic regression, three models were derived: Model 1 including patient- and procedure-related information, Model 2 adding routinely available laboratory values, and Model 3 further adding preoperative hs-cTnT concentration. Models were also compared vs. preoperative hs-cTnT alone. The findings were validated in two independent cohorts. Among 6944 patients, PMI occurred in 1058 patients (15.2%). The predictive accuracy as quantified by the area under the receiver operating characteristic curve was 0.73 [95% confidence interval (CI) 0.71-0.74] for Model 1, 0.75 (95% CI 0.74-0.77) for Model 2, 0.79 (95% CI 0.77-0.80) for Model 3, and 0.74 for hs-cTnT alone. Model 3 included 10 preoperative variables: age, body mass index, known coronary artery disease, metabolic equivalent >4, risk of surgery, emergency surgery, planned duration of surgery, haemoglobin, platelet count, and hs-cTnT. These findings were confirmed in both independent validation cohorts (n = 722 and n = 966). CONCLUSION Preoperative cTn adds incremental value above patient- and procedure-related variables as well as routine laboratory variables in the prediction of PMI.
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Affiliation(s)
- Rebecca Meister
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Danielle Menosi Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Enéas Carvalho de Aguiar, 44, Cerqueira César, 05403-900 São Paulo, Brazil
| | - Henrik A Andersson
- Department of Anaesthesiology and Intensive Care Medicine, Linköping University Hospital, SE-581 83 Linköping, Sweden
| | - Mirjam Pargger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Georgiana Virant
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Andreas Lampart
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Luzius Steiner
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
- Department of Clinical Research, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Reka Hidvegi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Department of Anaesthesiology, Cantonal Hospital St. Gallen, Rorschacher Str. 95/Haus 03, 9007 St. Gallen, Switzerland
| | - Giovanna Lurati Buse
- Department of Anaesthesiology, University Hospital Dusseldorf, Moorenstr. 5 40225 Düsseldorf, NRW, Germany
| | - Christoph Kindler
- Department of Anaesthesiology, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Aargau, Switzerland
| | - Lorenz Gürke
- Department of Vascular Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Stefan Schaeren
- Department of Spinal Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Martin Clauss
- Department of Orthopedics and Center of Musculoskeletal Infections, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Didier Lardinois
- Department of Thoracic Surgery, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Angelika Hammerer-Lercher
- Department of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Aargau, Switzerland
| | - Michelle Chew
- Department of Anaesthesiology and Intensive Care Medicine, Linköping University Hospital, SE-581 83 Linköping, Sweden
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
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Xiao Y, Cheng X, Jia L, Tian Y, He J, He M, Chen L, Hao P, Li T, Chong W, Hai Y, You C, Peng L, Fang F, Zhang Y. Preoperative hematocrit levels and postoperative mortality in patients undergoing craniotomy for brain tumors. Front Oncol 2023; 13:1246220. [PMID: 37916178 PMCID: PMC10616849 DOI: 10.3389/fonc.2023.1246220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023] Open
Abstract
Background Abnormal hematocrit values, including anemia and polycythemia, are common in patients undergoing craniotomy, but the extent to which preoperative anemia or polycythemia independently increases the risk of mortality is unclear. This retrospective cohort study aimed to examine the association between preoperative anemia and polycythemia and postoperative mortality in patients who underwent craniotomy for brain tumor resection. Methods We retrospectively analyzed data from 12,170 patients diagnosed with a brain tumor who underwent cranial surgery at West China Hospital between January 2011 and March 2021. The preoperative hematocrit value was defined as the last hematocrit value within 7 days before the operation, and patients were grouped according to the severity of their anemia or polycythemia. We assessed the primary outcome of 30-day postoperative mortality using logistic regression analysis adjusted for potential confounding factors. Results Multivariable logistic regression analysis reported that the 30-day mortality risk was raised with increasing severity of both anemia and polycythemia. Odds ratios for mild, moderate, and severe anemia were 1.12 (95% CI: 0.79-1.60), 1.66 (95% CI: 1.06-2.58), and 2.24 (95% CI: 0.99-5.06), respectively. Odds ratios for mild, moderate, and severe polycythemia were 1.40 (95% CI: 0.95-2.07), 2.81 (95% CI: 1.32-5.99), and 14.32 (95% CI: 3.84-53.44), respectively. Conclusions This study demonstrated that moderate to severe anemia and polycythemia are independently associated with increased postoperative mortality in patients undergoing craniotomy for brain tumor resection. These findings underscore the importance of identifying and managing abnormal hematocrit values before craniotomy surgery.
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Affiliation(s)
- Yangchun Xiao
- Department of Neurosurgery, Clinical Medical College and Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Xin Cheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Jia
- Department of Neurosurgery, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China
| | - Yixin Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jialing He
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Miao He
- Department of Anesthesia, Clinical Medical College and Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Lvlin Chen
- Department of Critical Care Medicine, Clinical Medical College and Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Pengfei Hao
- Department of Neurosurgery, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China
| | - Tiangui Li
- Department of Neurosurgery, Longquan Hospital, Chengdu, Sichuan, China
| | - Weelic Chong
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Yang Hai
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Liyuan Peng
- Department of Critical Care Medicine, Clinical Medical College and Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Fang Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Zhang
- Center for Evidence Based Medical, Clinical Medical College and Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
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Carmichael ED, Apple CG, Kannan KB, Gardener A, Anton S, Efron PA, Moldawer LL, Moore FA, Brakenridge SC, Mohr AM. Chronic Critical Illness in Patients With Sepsis is Associated With Persistent Anemia, Inflammation, and Impaired Functional Outcomes. Am Surg 2023; 89:2563-2571. [PMID: 35593749 PMCID: PMC9675873 DOI: 10.1177/00031348221104252] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Survivors of sepsis will progress towards rapid recovery (RAP) or enter a state of persistent organ dysfunction and chronic critical illness (CCI). Independently, anemia is known to be a significant factor in functional recovery of hospitalized patients. This study aims to analyze long-term hemoglobin levels and functional outcomes following RAP and CCI. METHODS A prospective, cohort study was performed in septic patients who were stratified into RAP (N = 54) with ICU length of stay < 14 days or CCI (N = 63) with ICU length of stay > 14 days. CBC and plasma inflammatory markers were measured on the day of enrollment, weekly until day 42, then at 3 and 6 months. Functional outcomes using Zubrod scale, gait speed test, and total short physical performance battery (SPPB) were assessed at 3, 6, and 12 months. RESULTS Mean age was 59 years (range: 20-83) and 62% were male. Hemoglobin was significantly decreased at 3 and 6 months in CCI compared to RAP (8.9* and 9.2* vs 10.4 and 11.1 g/dL), despite receiving significantly more red blood cell transfusions. CCI patients had persistent elevation of CRP, IL-6 and TNF-α. CCI patients had worse functional outcome with a significantly higher Zubrod score, and lower SPPB, and gait speed score at 3, 6, and 12 months. CONCLUSION Despite receiving more pRBC transfusions, CCI patients had a persistent anemia that was associated with chronic systemic inflammation and poor functional outcomes six months following sepsis. Alleviating prolonged inflammation could improve persistent anemia and functional outcomes in CCI patients.
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Affiliation(s)
- Ethan D Carmichael
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Camille G Apple
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Kolenkode B Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Anna Gardener
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Stephen Anton
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Philip A Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Lyle L Moldawer
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Frederick A Moore
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Scott C Brakenridge
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Alicia M Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
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9
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The Effect of Hematocrit on All-Cause Mortality in Geriatric Patients with Hip Fractures: A Prospective Cohort Study. J Clin Med 2023; 12:jcm12052010. [PMID: 36902799 PMCID: PMC10004393 DOI: 10.3390/jcm12052010] [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: 02/06/2023] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
OBJECTIVE The present study aimed to evaluate the association between hematocrit (HCT) levels and all-cause mortality in geriatric hip fractures. METHODS Older adult patients with hip fractures were screened between January 2015 and September 2019. The demographic and clinical characteristics of these patients were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between HCT levels and mortality. Analyses were performed using EmpowerStats and the R software. RESULTS A total of 2589 patients were included in this study. The mean follow-up period was 38.94 months. Eight hundred and seventy-five (33.8%) patients died due to all-cause mortality. Linear multivariate Cox regression models showed that HCT level was associated with mortality (hazard ratio [HR] = 0.97, 95% confidence interval [CI]: 0.96-0.99, p = 0.0002) after adjusting for confounding factors. However, the linear association was unstable and nonlinearity was identified. A HCT level of 28% was the inflection point for prediction. A HCT level of <28% was associated with mortality (HR = 0.91, 95% CI: 0.87-0.95, p < 0.0001), whereas a HCT level > 28% was not a risk factor for mortality (HR = 0.99, 95% CI: 0.97-1.01, p = 0.3792). We found that the nonlinear association was very stable in the propensity score-matching sensitivity analysis. CONCLUSIONS The HCT level was nonlinearly associated with mortality in geriatric hip fracture patients and could be considered a predictor of mortality in these patients. REGISTRATION ChiCTR2200057323.
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10
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Yin K, Willie-Permor D, Zarrintan S, Dakour-Aridi H, Ramirez JL, Iannuzzi JC, Naazie I, Malas MB. Anemia is associated with higher mortality and morbidity after thoracic endovascular aortic repair. J Vasc Surg 2023; 77:357-365.e1. [PMID: 36087831 DOI: 10.1016/j.jvs.2022.08.037] [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: 09/17/2021] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND It is uncertain whether preoperative anemia is independently associated with thoracic endovascular aortic repair (TEVAR) outcomes. Using a national vascular surgery database, we evaluated the associations between preoperative anemia and 30-day mortality, postoperative complications, and 1-year survival for patients undergoing TEVAR. METHODS We retrospectively analyzed all patients in the Vascular Quality Initiative who had undergone TEVAR for aortic dissection, aortic aneurysm, penetrating aortic ulcer, hematoma, or thrombus between January 2011 and December 2019. We excluded patients with a ruptured aneurysm, traumatic dissection, emergent repair, treated aorta distal to zone 5, polycythemia, transfusion of >4 U of packed red blood cells intraoperatively or postoperatively, and missing data on hemoglobin level or surgical indications. The final study cohort was dichotomized into two groups: normal/mild anemia (women, ≥10 g/dL; men, ≥12 g/dL) and moderate/severe anemia (women, <10 g/dL; male, <12 g/dL). Propensity scores by stratification were used to control for confounding in the analysis of the association between the outcomes of 30-day mortality, postoperative complications, and 1-year survival and a binary indicator variable of moderate/severe anemia vs normal/mild anemia. Kaplan-Meier analysis and log-rank tests were used to compare the 1-year survival between the two groups. A Cox regression model was fitted to assess the associations between anemia and survival outcomes. RESULTS A total of 3391 patients were analyzed, 958 (28.3%) of whom had had moderate/severe anemia. After adjustment for multiple clinical factors using propensity score stratification, moderate/severe anemia was associated with a 141% increased odds of 30-day mortality (adjusted odds ratio [aOR], 2.41; 95% confidence interval [CI], 1.15-5.05; P = .019), 58% increased odds of any in-hospital complication (aOR, 1.58; 95% CI, 1.17-2.13; P = .003), 281% increased odds of intraoperative transfusion (aOR, 3.81; 95% CI, 2.68-5.53; P < .001). In addition, moderate/severe anemia was associated with significantly worse survival within the first year after TEVAR (log-rank P < .001; 1-year survival rate using Kaplan-Meier estimates, 86.4% ± 1.3% standard error vs 92.5% ± 0.6% standard error) and with an increased risk of mortality in the first postoperative year (adjusted hazard ratio, 1.81; 95% CI, 1.16-2.82; P = .009). CONCLUSIONS We found that moderate or severe anemia is associated with significantly increased odds of mortality, postoperative complications, and worse 1-year survival after TEVAR. Future studies are needed to evaluate the effect of anemia correction on the outcomes of TEVAR.
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Affiliation(s)
- Kanhua Yin
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Daniel Willie-Permor
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Sina Zarrintan
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA.
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11
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Natour AK, Shepard AD, Nypaver TJ, Rteil A, Corcoran P, Tang X, Kabbani L. Impact of Preoperative Anemia on Hospitalization, Death, and Overall Survival in Patients With Peripheral Artery Disease Undergoing Endovascular Therapy: A Retrospective Cohort Study in the United States and Canada. J Endovasc Ther 2023:15266028221149926. [PMID: 36680405 DOI: 10.1177/15266028221149926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE Preoperative anemia is associated with adverse outcomes after cardiac and noncardiac surgeries, but outcomes after an endovascular peripheral vascular intervention (PVI) are not well established. We aimed to assess the association of preoperative anemia with 30 day death, hospital length of stay (LOS), and overall (long term) survival in patients undergoing an endovascular PVI for peripheral artery disease. MATERIALS AND METHODS In this retrospective, cohort study in the United States and Canada, we queried the national Vascular Quality Initiative database for all endovascular PVIs performed between 2010 and 2019, and outcomes were correlated with patients' hemoglobin (Hb) levels. Anemia was classified as mild (Hb=10-13 g/dL for men and 10-12 g/dL for women), moderate (Hb=8-9.9 g/dL), and severe (Hb<8 g/dL). RESULTS A total of 79 707 adult patients who met study criteria underwent endovascular PVI. The mean age was 68 years, and 59% of patients were male. Anemia was documented in 38 543 patients (48%) and was mild in 27 435 (71%), moderate in 9783 (25%), and severe in 1325 (4%). The median follow-up duration was 4 years (range, 1.25-5.78 years). On univariate analysis, 30 day mortality, total LOS, and overall survival were significantly associated with the level of preoperative anemia. These associations persisted in the multivariate models. Kaplan-Meier survival analysis demonstrated an association of death with degree of anemia (p<0.001). CONCLUSION The presence and degree of preoperative anemia were independently associated with increased 30 day mortality and LOS and decreased overall survival for patients with peripheral artery disease who had undergone endovascular PVI. CLINICAL IMPACT The findings from this study have many implications for how to approach vascular surgery in patients with variable hemoglobin levels. Our findings will strengthen our ability to conduct accurate preoperative risk stratification for patients undergoing peripheral vascular interventions. This may also mitigate healthcare expenditures if findings are applied in a way that can lower patient length of postoperative stay while also maintaining quality of care and patient safety. Our results will also serve as guidance for clinical trials, and future prospective trials should evaluate the effect of preoperative optimization of hemoglobin as a potentially modifiable risk factor for outcomes.
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Affiliation(s)
| | | | | | - Ali Rteil
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Paul Corcoran
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Xiaoqin Tang
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Loay Kabbani
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
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12
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Bindra A, Bharadwaj S, Mishra N, Masapu D, Bhargava S, Luthra A, Marda M, Hrishi AP, Bhagat H, Bidkar PU, Vanamoorthy P, Ali Z, Khan MA. Preanesthetic Evaluation and Preparation for Neurosurgical Procedures: An Indian Perspective. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1749649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Abstract
Background A questionnaire-based survey was conducted to determine the preanesthetic evaluation (PAE) practices among the members of the Indian Society of Neuroanesthesiology and Critical Care (ISNACC). The survey aimed to assess the current clinical practice of PAE and optimization of neurosurgical patients in India.
Methods An online questionnaire was designed by the working group of ISNACC and circulated among its active members. Response to individual questions was considered significant if 50% or more respondents concurred. The survey questions to which less than 50% of respondents concurred were identified as inconclusive results.
Results Out of 438 active ISNACC members, 218 responded. Responses were obtained from various parts of the country. The majority of participants were practicing neuroanesthesiology. Questions asked were regarding clinical assessment, preoperative optimization, prognostication, and airway management in neurosurgery. More than 50% of practitioners acceded to most of the questions; however, the percentage of responses varied across different questions (50–100%). The questions related to preoperative duplex scanning in chronically immobilized patients, preoperative cognitive testing, and risk stratification during neurosurgical procedures received an inconclusive response (< 50%).
Conclusion The survey highlights the variable PAE practices perused by ISNACC members across the country. A guideline for uniform PAE practices may help to enhance research and improve perioperative care.
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Affiliation(s)
- Ashish Bindra
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Suparna Bharadwaj
- Department of Neuroanesthesiology and Neurocritical Care, National Institute of Mental Health and Neuro-Sciences, Bengaluru, Karnataka, India
| | - Nitasha Mishra
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
| | - Dheeraj Masapu
- Department of Neuroanesthesia, Sakra World Hospital, Bangalore, Karnataka, India
| | - Saurabh Bhargava
- Department of Emergency Medicine, National Institute of Medical Sciences Medical College, Jaipur, Rajasthan, India
| | - Ankur Luthra
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Marda
- Department of Neuroanaesthesia and Critical Care, Max Super-Specialty Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India
| | - Ajay P. Hrishi
- Department of Neuroanaesthesia, Sree Chitra Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prasanna U. Bidkar
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ponniah Vanamoorthy
- Department of Neurocritical Care and Neuroanaesthesiology, MGM Healthcare PVT. LTD., Chennai, Tamil Nadu, India
| | - Zulfiqar Ali
- Division of Neuroanesthesiology and Critical Care, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Maroof A. Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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13
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Hematopoiesis, Inflammation and Aging-The Biological Background and Clinical Impact of Anemia and Increased C-Reactive Protein Levels on Elderly Individuals. J Clin Med 2022; 11:jcm11030706. [PMID: 35160156 PMCID: PMC8836692 DOI: 10.3390/jcm11030706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 01/27/2023] Open
Abstract
Anemia and systemic signs of inflammation are common in elderly individuals and are associated with decreased survival. The common biological context for these two states is then the hallmarks of aging, i.e., genomic instability, telomere shortening, epigenetic alterations, loss of proteostasis, deregulated nutrient sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion and altered intercellular communication. Such aging-associated alterations of hematopoietic stem cells are probably caused by complex mechanisms and depend on both the aging of hematopoietic (stem) cells and on the supporting stromal cells. The function of inflammatory or immunocompetent cells is also altered by aging. The intracellular signaling initiated by soluble proinflammatory mediators (e.g., IL1, IL6 and TNFα) is altered during aging and contributes to the development of both the inhibition of erythropoiesis with anemia as well as to the development of the acute-phase reaction as a systemic sign of inflammation with increased CRP levels. Both anemia and increased CRP levels are associated with decreased overall survival and increased cardiovascular mortality. The handling of elderly patients with inflammation and/or anemia should in our opinion be individualized; all of them should have a limited evaluation with regard to the cause of the abnormalities, but the extent of additional and especially invasive diagnostic evaluation should be based on an overall clinical evaluation and the possible therapeutic consequences.
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14
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Nakamori E, Shigematsu K, Higashi M, Yamaura K. Postoperative Noninvasive Hemoglobin Monitoring Is Useful to Prevent Unnoticed Postoperative Anemia and Inappropriate Blood Transfusion in Patients Undergoing Total Hip or Knee Arthroplasty: A Randomized Controlled Trial. Geriatr Orthop Surg Rehabil 2021; 12:21514593211060575. [PMID: 34820147 PMCID: PMC8606913 DOI: 10.1177/21514593211060575] [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: 07/28/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 01/28/2023] Open
Abstract
Introduction Postoperative nadir hemoglobin (Hb) is related to a longer length of stay for geriatric patients undergoing orthopedic surgery. We investigated whether postoperative pulse Hb (SpHb) measurement is useful for avoiding anemia and inappropriate blood transfusion after total hip arthroplasty and total knee arthroplasty. Material and Methods This prospective randomized controlled study included 150 patients randomly assigned to receive blood transfusion, either guided by SpHb monitoring (SpHb group) or based on the surgeons’ experience (control group). The target laboratory Hb value was set to >8 g/dL at postoperative day 1 (POD1). The primary endpoints were the product of total time and degree of SpHb <8 g/dL (area under SpHb 8 g/dL) during the period up to POD1 and the incidence of laboratory Hb <8 g/dL at POD1. The secondary endpoints were the amount of blood transfusion and inappropriate blood transfusion, which was defined as allogeneic blood transfusion unnecessary in a case of SpHb >12 g/dL or delayed transfusion in a case of SpHb <8 g/dL. Results The area under SpHb 8 g/dL was 37.6 ± 44.1 g/dL-min (5 patients) in the control group and none in the SpHb group (P = .0281). There was 1 patient with Hb <8 g/dL at POD1 in the control group. There was no difference in laboratory Hb levels and the amount of blood transfusion. Forty-one patients (19 in the control group and 22 in the SpHb group) received an allogeneic blood transfusion. Among these patients, 7 in the control group and none in the SpHb group received inappropriate blood transfusion (P = .0022). Discussion The SpHb monitoring could reduce unnoticed anemia, which may prevent complications and be useful in avoiding unnecessary and excessive blood transfusion. Conclusion Postoperative SpHb monitoring decreased the incidence of transient, unnoticed anemia during the period up to POD1 and inappropriate blood transfusion.
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Affiliation(s)
- Erisa Nakamori
- Department of Anesthesiology, Fukuoka University Hospital, Fukuoka, Japan
| | - Kenji Shigematsu
- Department of Anesthesiology, Fukuoka University Hospital, Fukuoka, Japan
| | - Midoriko Higashi
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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15
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Esteban C, Hernández-Rodríguez I. Peripheral arterial disease and anaemia. A review. Med Clin (Barc) 2021; 158:221-228. [PMID: 34602211 DOI: 10.1016/j.medcli.2021.07.010] [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: 03/24/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 12/24/2022]
Abstract
Iron deficiency anaemia is highly prevalent worldwide. In the surgical patient, anaemia of any cause implies higher morbidity and mortality in the post-operative period. This is especially important in patients with peripheral artery disease, as they have very high rates of anaemia due to iron deficiency or other causes. In intermittent claudication, anaemia is a predictor of death in the medium term. Patients with critical ischaemia have higher prevalence of anaemia and it is an indicator of amputation and death in the medium term. Specific protocols need to be developed for these patients since the natural history of their disease does not allow for the correction of anaemia before surgery.
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Affiliation(s)
- Carlos Esteban
- Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Inés Hernández-Rodríguez
- Servicio de Hematología, ICO-Hospital Universitari Germans Trias i Pujol, Institute de Investigación contra la Leucemia Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Barcelona, España.
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16
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Thin TN, Tan BPY, Sim EY, Shum KL, Chan HSP, Abdullah HR. Preoperative Single-Dose Intravenous Iron Formulation to Reduce Postsurgical Complications in Patients Undergoing Major Abdominal Surgery: A Randomized Control Trial Feasibility Study (PIRCAS Trial Pilot). Cureus 2021; 13:e17357. [PMID: 34567897 PMCID: PMC8452824 DOI: 10.7759/cureus.17357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 12/01/2022] Open
Abstract
Background Preoperative anemia is associated with an increased need for blood transfusion, complications, and prolonged hospital stay. Iron deficiency anemia (IDA) may be treated with oral or intravenous (IV) iron. IV iron repletes iron stores more rapidly. Its impact on perioperative blood transfusion, postoperative complications, patients’ recovery, and long-term quality of life is unclear. Newer agents, such as ferric carboxymaltose (FCM), are costly but have higher maximum approved doses and a very low incidence of anaphylactic-type reactions. This study aims to explore the feasibility of a randomized control trial to compare the preoperative treatment of IDA with IV FCM versus oral ferrous fumarate, in patients undergoing elective major abdominal surgery. Experimental design This is an open-label pilot randomized controlled trial. A total of 30 adults with IDA scheduled for elective major abdominal surgery were recruited for the study. They were randomized into two groups to receive either oral iron or IV FCM. Primary outcomes are defined as the time from enrollment to study drug administration, recruitment rate, and follow-up rate up to three months. Secondary outcomes are hemoglobin rise from recruitment to surgery, perioperative blood transfusion, postoperative complications, EQ-5D-3L scores at baseline, and three months and adverse events related to IV FCM therapy. Results All patients received study drugs within five days of enrollment; 30 patients were recruited within four months, 15 patients in each group. Two in each group were withdrawn for surgery postponement. All patients were followed up for three months and there was no crossover of patients. Per protocol, analysis was performed. No severe adverse events related to IV FCM therapy occurred. Both groups had similar baseline characteristics, similar hemoglobin rise from enrollment to the day of surgery [0.2 (+1.6) g/dL in the FCM group and 0.8 (+0.7) g/dL in the Oral Iron group, p=0.3] and similar mean units of perioperative blood transfused (recruitment to discharge) per patient [1.3 (+ 2.1) in the FCM group and 0.9 (+1.3) in the Oral Iron group, p=0.6]. Postoperatively, there was a similar hospital length of stay [11.5 (+13.6 days) in the FCM group and 9.0 (+9.8 days) in the Oral Iron group, p=0.6]; there were similar postoperative complications as reflected by the average Comprehensive Complication Index [12.8 (+19.6) in the FCM group and 22.6 (+30.7) in the Oral Iron group, p=0.3]; similar postoperative health-related quality of life as reflected by mean EQ-5D-3L scores at one month [70.4 (+21.8) in the FCM group and 84.5 (+12.1) in the Oral Iron group] and three months [80.0 (+18.4) in the FCM group and 85.9 (+10.7) in the Oral Iron group]. Conclusions A full-scale randomized controlled trial to evaluate the effectiveness of preoperative IV FCM compared to oral iron in patients with IDA undergoing major abdominal surgery is feasible.
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Affiliation(s)
- Thiri Naing Thin
- Department of Anesthesiology, Singapore General Hospital, Singapore, SGP
| | - Brenda Pei Yi Tan
- Department of Anesthesiology, Singapore General Hospital, Singapore, SGP
| | - Eileen Y Sim
- Department of Anesthesiology, Singapore General Hospital, Singapore, SGP
| | - Koin Lon Shum
- Department of Internal Medicine, Singapore General Hospital, Singapore, SGP
| | - Hazel Su Pin Chan
- Department of Anesthesiology, Singapore General Hospital, Singapore, SGP
| | - Hairil Rizal Abdullah
- Department of Anesthesiology, Singapore General Hospital, Singapore, SGP.,Anesthesiology, Duke-National University of Singapore (NUS) Medical School, Singapore, SGP
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Sarkadi H, Csőre J, Veres DS, Szegedi N, Molnár L, Gellér L, Bérczi V, Dósa E. Incidence of and predisposing factors for pseudoaneurysm formation in a high-volume cardiovascular center. PLoS One 2021; 16:e0256317. [PMID: 34428222 PMCID: PMC8384184 DOI: 10.1371/journal.pone.0256317] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/03/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose To evaluate factors associated with pseudoaneurysm (PSA) development. Methods Between January 2016 and May 2020, 30,196 patients had invasive vascular radiological or cardiac endovascular procedures that required arterial puncture. All patients with PSA were identified. A matched (age, gender, and type of the procedure) control group of 134 patients was created to reveal predictors of PSA formation. Results Single PSAs were found in 134 patients. Fifty-three PSAs developed after radiological procedures (53/6555 [0.8%]), 31 after coronary artery procedures (31/18038 [0.2%]), 25 after non-coronary artery cardiac procedures (25/5603 [0.4%]), and 25 due to procedures in which the arterial puncture was unintended. Thirty-four PSAs (25.4%) were localized to the upper extremity arteries (vascular closure device [VCD], N = 0), while 100 (74.6%) arose from the lower extremity arteries (VCD, N = 37). The PSA prevalence was 0.05% (10/20478) in the radial artery, 0.1% (2/1818) in the ulnar artery, 1.2% (22/1897) in the brachial artery, and 0.4% (99/22202) in the femoral artery. Treatments for upper and lower limb PSAs were as follows: bandage replacement (32.4% and 14%, respectively), ultrasound-guided compression (11.8% and 1%, respectively), ultrasound-guided thrombin injection (38.2% and 78%, respectively), and open surgery (17.6% and 12%, respectively). Reintervention was necessary in 19 patients (14.2%). The prevalence of PSA for the punctured artery with and without VCD use was 37/3555 (1%) and 97/27204 (0.4%), respectively (OR, 2.94; 95% CI, 1.95–4.34; P<0.001). The effect of red blood cell (RBC) count (P<0.001), hematocrit value (P<0.001), hemoglobin value (P<0.001), international normalized ratio (INR; P<0.001), RBC count—INR interaction (P = 0.003), and RBC count—VCD use interaction (P = 0.036) on PSA formation was significant. Conclusion Patients in whom the puncture site is closed with a VCD require increased observation. Preprocedural laboratory findings are useful for the identification of patients at high risk of PSA formation.
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Affiliation(s)
- Hunor Sarkadi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Judit Csőre
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Dániel Sándor Veres
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Nándor Szegedi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Levente Molnár
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Viktor Bérczi
- Medical Imaging Center, Semmelweis University, Budapest, Hungary
| | - Edit Dósa
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Hungarian Vascular Radiology Research Group, Semmelweis University, Budapest, Hungary
- * E-mail:
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18
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Bulte CS, Boer C, Hemmes SN, Neto AS, Binnekade JM, Hedenstierna G, Jaber S, Hiesmayr M, Hollmann MW, Mills GH, Melo MFV, Pearse RM, Putensen C, Schmid W, Severgnini P, Wrigge H, de Abreu MG, Pelosi P, Schultz MJ. The effects of preoperative moderate to severe anaemia on length of hospital stay: A propensity score-matched analysis in non-cardiac surgery patients. Eur J Anaesthesiol 2021; 38:571-581. [PMID: 33399375 PMCID: PMC9867571 DOI: 10.1097/eja.0000000000001412] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Anaemia is frequently recorded during preoperative screening and has been suggested to affect outcomes after surgery negatively. OBJECTIVES The objectives were to assess the frequency of moderate to severe anaemia and its association with length of hospital stay. DESIGN Post hoc analysis of the international observational prospective 'Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study. PATIENTS AND SETTING The current analysis included adult patients requiring general anaesthesia for non-cardiac surgery. Preoperative anaemia was defined as a haemoglobin concentration of 11 g dl-1 or lower, thus including moderate and severe anaemia according to World Health Organisation criteria. MAIN OUTCOME MEASURES The primary outcome was length of hospital stay. Secondary outcomes included hospital mortality, intra-operative adverse events and postoperative pulmonary complications (PPCs). RESULTS Haemoglobin concentrations were available for 8264 of 9864 patients. Preoperative moderate to severe anaemia was present in 7.7% of patients. Multivariable analysis showed that preoperative moderate to severe anaemia was associated with an increased length of hospital stay with a mean difference of 1.3 ((95% CI 0.8 to 1.8) days; P < .001). In the propensity-matched analysis, this association remained present, median 4.0 [IQR 1.0 to 5.0] vs. 2.0 [IQR 0.0 to 5.0] days, P = .001. Multivariable analysis showed an increased in-hospital mortality (OR 2.9 (95% CI 1.1 to 7.5); P = .029), and higher incidences of intra-operative hypotension (36.3 vs. 25.3%; P < .001) and PPCs (17.1 vs. 10.5%; P = .001) in moderately to severely anaemic patients. However, this was not confirmed in the propensity score-matched analysis. CONCLUSIONS In this international cohort of non-cardiac surgical patients, preoperative moderate to severe anaemia was associated with a longer duration of hospital stay but not increased intra-operative complications, PPCs or in-hospital mortality. TRIAL REGISTRATION The LAS VEGAS study was registered at Clinicaltrials.gov, NCT01601223.
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Affiliation(s)
- Carolien S.E. Bulte
- Department of Anaesthesiology, Amsterdam UMC, VU University Amsterdam, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University Amsterdam, Amsterdam, The Netherlands
| | - Sabrine N.T. Hemmes
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paolo, Brazil
| | - Jan M. Binnekade
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Goran Hedenstierna
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Samir Jaber
- Montpellier University Hospital, Saint Eloi Intensive Care Unit and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Michael Hiesmayr
- Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Markus W. Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gary H. Mills
- Operating Services, Critical Care and Anaesthesia, Sheffield Teaching Hospitals, Sheffield and University of Sheffield, Sheffield, UK
| | - Marcos F. Vidal Melo
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Bostan, MA, USA
| | | | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Schmid
- Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Paolo Severgnini
- Department of Biotechnology and Sciences of Life, ASST Sette Laghi Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Hermann Wrigge
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Universitá degli Studi di Genova, Genova, Italy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marcus J. Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Mahidol Oxford Tropical Medicine Research Unit (MORU), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands, Mahidol University, Bangkok, Thailand, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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19
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Rosario L, Jotwani R, Chen J, White RS, Aaronson JA. The economic cost of gender disparities in perioperative medicine. J Comp Eff Res 2021; 10:339-342. [PMID: 33706535 DOI: 10.2217/cer-2020-0237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Lauren Rosario
- Department of Anesthesiology, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY 10021, USA
| | - Rohan Jotwani
- Department of Anesthesiology, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY 10021, USA
| | - Jaclynn Chen
- Department of Nursing, Weill Cornell Medicine/NewYork-Presbyterian Alexandra Cohen Hospital for Women & Newborns, New York, NY 10021, USA
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Jaime A Aaronson
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
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20
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Woo SH, Marhefka GD, Cowan SW, Ackermann L. Development and Validation of a Prediction Model for Stroke, Cardiac, and Mortality Risk After Non-Cardiac Surgery. J Am Heart Assoc 2021; 10:e018013. [PMID: 33522252 PMCID: PMC7955339 DOI: 10.1161/jaha.120.018013] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Commonly used cardiovascular risk calculators do not provide risk estimation of stroke, a major postoperative complication with high morbidity and mortality. We developed and validated an accurate cardiovascular risk prediction tool for stroke, major cardiac complications (myocardial infarction or cardiac arrest), and mortality after non-cardiac surgery. Methods and Results This retrospective cohort study included 1 165 750 surgical patients over a 4-year period (2007-2010) from the American College of Surgeons National Surgical Quality Improvement Program Database. A predictive model was developed with the following preoperative conditions: age, history of coronary artery disease, history of stroke, emergency surgery, preoperative serum sodium (≤130 mEq/L, >146 mEq/L), creatinine >1.8 mg/dL, hematocrit ≤27%, American Society of Anesthesiologists physical status class, and type of surgery. The model was trained using American College of Surgeons National Surgical Quality Improvement Program data from 2007 to 2009 (n=809 880) and tested using data from 2010 (n=355 870). Risk models were developed using multivariate logistic regression. The outcomes were postoperative 30-day stroke, major cardiovascular events (myocardial infarction, cardiac arrest, or stroke), and 30-day mortality. Major cardiac complications occurred in 0.66% (n=5332) of patients (myocardial infarction, 0.28%; cardiac arrest, 0.41%), postoperative stroke in 0.25% (n=2005); 30-day mortality was 1.66% (n=13 484). The risk prediction model had high predictive accuracy with area under the receiver operating characteristic curve for stroke (training cohort=0.869, validation cohort=0.876), major cardiovascular events (training cohort=0.871, validation cohort=0.868), and 30-day mortality (training cohort=0.922, validation cohort=0.925). Surgery types, history of stroke, and coronary artery disease are significant risk factors for stroke and major cardiac complications. Conclusions Postoperative stroke, major cardiac complications, and 30-day mortality can be predicted with high accuracy using this web-based predictive model.
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Affiliation(s)
- Sang H Woo
- Division of Hospital Medicine Department of Medicine Thomas Jefferson University Philadelphia PA
| | - Gregary D Marhefka
- Division of Cardiology Department of Medicine Thomas Jefferson University Philadelphia PA
| | - Scott W Cowan
- Department of Surgery Thomas Jefferson University Philadelphia PA
| | - Lily Ackermann
- Division of Hospital Medicine Department of Medicine Thomas Jefferson University Philadelphia PA
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21
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Abdullah HR, Thamnachit T, Hao Y, Lim WY, Teo LM, Sim YE. Real-world results of the implementation of preoperative anaemia clinic with intravenous iron therapy for treating iron-deficiency anaemia: a propensity-matched case-control study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:6. [PMID: 33553299 PMCID: PMC7859766 DOI: 10.21037/atm-20-4942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Preoperative anaemia is associated with blood transfusion and longer hospital length of stay. Preoperative iron deficiency anaemia (IDA) can be treated with oral or intravenous (IV) iron. IV iron can raise haemoglobin faster compared with oral iron. However, its ability to reduce blood transfusion and length of stay in clinical trials is inconclusive. This study aims to compare blood transfusion and hospital length of stay between anemic patients who received preoperative IV iron versus standard care, after implementation of a protocol in 2017 to screen patients for preoperative IDA, and its treatment with IV iron. Methods Retrospective before-after cohort study comparing 89 patients who received IV iron preoperatively in 2017, with historic patients who received oral iron therapy (selected by propensity score matching (PSM) from historic cohort of 7,542 patients who underwent surgery in 2016). Propensity score was calculated using ASA status, age, gender, surgical discipline, surgical risk and preoperative haemoglobin concentration. Both 1:1 and 1:2 matching were performed as sensitivity analysis. Results After PSM, there was no statistically significant difference in distribution of preoperative clinical variables. There was no significant difference in proportion of cases requiring transfusion nor a difference in average units transfused per patient. IV iron cohort stayed in hospital on average 8.0 days compared to non-IV iron cohort 14.1–15.1 days (P=0.006, P=0.013 respectively). Average time from IV iron therapy to surgery was 10.5 days. Conclusions Preoperative IV iron therapy for patients with IDA undergoing elective surgery may not reduce perioperative blood transfusion, but this could be due to the short time between therapy and surgery. Implementation of IV iron therapy may reduce hospital length of stay compared to standard care for anemic patients, although this may be enhanced by concomitant improvement in perioperative care.
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Affiliation(s)
- Hairil R Abdullah
- Department of Anaesthesiology, Singapore General Hospital, 169608, Singapore
| | - Tanakorn Thamnachit
- Department of Anaesthesiology, Singapore General Hospital, 169608, Singapore
| | - Ying Hao
- Health Services Research Centre (HSRC), Singapore Health Services, 169608, Singapore
| | - Wan Yen Lim
- Department of Anaesthesiology, Singapore General Hospital, 169608, Singapore
| | - Li Ming Teo
- Department of Anaesthesiology, Singapore General Hospital, 169608, Singapore
| | - Yilin Eileen Sim
- Department of Anaesthesiology, Singapore General Hospital, 169608, Singapore
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22
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Ionescu A, Sharma A, Kundnani NR, Mihăilescu A, David VL, Bedreag O, Săndesc D, Dinu AR, Săndesc MA, Albulescu N, Drăgoi RG. Intravenous iron infusion as an alternative to minimize blood transfusion in peri-operative patients. Sci Rep 2020; 10:18403. [PMID: 33110237 PMCID: PMC7591902 DOI: 10.1038/s41598-020-75535-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 10/14/2020] [Indexed: 01/07/2023] Open
Abstract
Despite the reported benefits of intravenous iron therapy (IVIT) for correcting iron deficiency anemia (IDA) before any major surgery and the evidence thereof, perioperative allogenic blood transfusion (ABT) practice is still considered as the only viable option by some clinicians worldwide. As ABT increases the likelihood of infections, cardiac complications, longer hospital stays and mortality among the patients, the practice of ABT should only be reserved for critical cases (Hb level < 7 g/dl). Timely iron studies and iron replenishment (oral/IV) of prospective surgical patients could help decrease the ABT practice, and prove beneficial from both the clinical and economic standpoint. Evidence based patient blood management guidelines should be developed and standardized for use by clinicians worldwide. These guidelines should include specific instructions on timely assessment of surgical patients for correction of their IDA by either oral iron supplementation, if time permits, or by using IVIT such as ferric carboxymaltose (FCM) in emergency surgeries and in patients with functional ID. This study was conducted to explore the clinical benefits of the timely administration of IV-FCM in iron-deficient preoperative patients during 2017-2018 and compare the results thereof with that of the ABT. Based on the IDA treatment plan of 2953 patients, 11.14% cases were administered IV FCM (Group 1), 11.58% cases received ABT (Group 2), while the remaining 77.27% of anemic cases received neither ABT nor IV FCM (Group 3). The results indicate that the IV FCM administration reduces the need for ABT and thus minimizes its associated side effects. The findings of our study concur with the favorable outcomes reported by the other similar studies.
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Affiliation(s)
- Alin Ionescu
- Department of Family Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Abhinav Sharma
- Department of Cardio-Vascular Rehabilitation & Family Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Nilima Rajpal Kundnani
- Department of Physiology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania.
| | - Alexandra Mihăilescu
- Department of Genetics, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Vlad Laurențiu David
- Department of Pediatric Surgery and Orthopedics, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Ovidiu Bedreag
- Department of Anesthesia and Intensive Care, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Dorel Săndesc
- Department of Anesthesia and Intensive Care, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Anca Raluca Dinu
- Department of Physical Medicine and Balneology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Mihai Alexandru Săndesc
- Department of Orthopedics and Traumatology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Nicolae Albulescu
- "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Răzvan Gabriel Drăgoi
- Department of Rehabilitation Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
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23
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Janssen TL, Steyerberg EW, van Gammeren AJ, Ho GH, Gobardhan PD, van der Laan L. Intravenous Iron in a Prehabilitation Program for Older Surgical Patients: Prospective Cohort Study. J Surg Res 2020; 257:32-41. [PMID: 32818782 DOI: 10.1016/j.jss.2020.07.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/14/2020] [Accepted: 07/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Older patients often have iron deficiency anemia before surgery, which can be effectively treated with intravenous iron supplementation (IVIS). Anemia and blood transfusions are associated with an increased risk of delirium. The aim of this research was to assess the effectiveness and safety of using IVIS in a prehabilitation program. MATERIAL AND METHODS Patients ≥70 y who underwent abdominal surgery between November 2015 and June 2018 were included in this single-center prospective cohort study. All patients were prehabilitated; however, only anemic patients received a single dose of 1000 mg intravenous iron (ferric carboxymaltose) to increase preoperative hemoglobin levels (IVIS group). Nonanemic patients received standard care (SC). The hemoglobin levels (primary outcome) were assessed at the outpatient clinic visit, at admission, and at discharge. Secondary outcomes were postoperative delirium, postoperative anemia, blood transfusion, complications other than delirium, and length of hospital stay. All outcomes were compared between the IVIS group and SC group. RESULTS Of all patients (n = 248), 97 anemic patients received IVIS (39%). Of the anemic patients, 50 patients (52%) had iron deficiency. Initial differences in hemoglobin concentrations between the IVIS group and SC group at T1 and T2 (7.2 versus 8.8; P < 0.001 and 7.4 versus 8.6; P = 0.023, respectively) were no longer present at discharge (6.6 versus 7.2; P = 0.35). No statistically significant differences were observed for all secondary outcomes between the IVIS group and the SC group. No infusion-related adverse events occurred. CONCLUSIONS Adding IVIS to prehabilitation programs is safe and diminishes differences in these concentrations between preoperatively anemic and nonanemic patients. IVIS may be worthwhile as an additional component of prehabilitation programs. Results merit further investigation.
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Affiliation(s)
- Ties L Janssen
- Department of Surgery, Amphia Hospital, Breda, the Netherlands.
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Adriaan J van Gammeren
- Department of Clinical Chemistry and Haematology, Amphia Hospital, Breda, the Netherlands
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | | | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, Breda, the Netherlands; Department of Cardiovascular Science, University Hospital Leuven, Belgium
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Acheampong DO, Paul P, Boateng P, Leitman IM. Predictors and Outcomes of Cardiac Events following Thoracic Endovascular Aortic Repair in Descending Thoracic Aortic Aneurysm and Dissection. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:6-13. [PMID: 32599627 PMCID: PMC7324254 DOI: 10.1055/s-0040-1701606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac events following thoracic endovascular aortic repair (TEVAR) have been associated with significant morbidity and mortality. However, predictors of post-TEVAR cardiac events in descending thoracic aortic aneurysm or dissection are poorly understood. METHODS A retrospective analysis of completed TEVAR procedures performed from 2010 to 2016 was conducted using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) participant user file database. Adult patients (≥18 years) who underwent TEVAR for descending thoracic aortic aneurysm or dissection were identified and 30-day outcomes were examined. An initial univariate analysis was performed to determine associations between all patient variables and cardiac events, defined as myocardial infarction or cardiac arrest that occurred ≤30 days of surgery. Multivariate logistic regression was subsequently performed to identify independent risk factors for cardiac events following TEVAR. RESULTS The study identified 150 out of 2,905 (5.2%) patients who underwent TEVAR for descending thoracic aortic aneurysm or dissection who developed cardiac events. No significant difference in incidence of cardiac events was noted among patients presenting with aortic aneurysm or dissection (p = 0.339). The overall 30-day mortality rate for all patients was 9.1%. Independent preoperative predictors of post-TEVAR cardiac events included emergency procedure (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.9-4.1, p < 0.01); American Society of Anesthesiologists score >3 (OR 1.71, 95% CI 1.1-2.6, p = 0.01), ventilator dependence (OR 2.33, 95% CI 1.3-4.2, p < 0.01), renal failure (OR 2.53, 95% CI 1.50-4.3, p < 0.01), blood transfusion (OR 1.84, 95% CI 1.1-3.2, p = 0.03), and preoperative leukocytosis (OR 2.45, 1.6-3.8, p < 0.01). After TEVAR, unplanned reintubation (OR 5.52, 95% CI 3.5-8.8, p < 0.01), prolonged mechanical ventilation (OR 1.94, 95% CI 1.2-3.2, p = 0.011), and postoperative blood transfusion (OR 4.02, 95% CI 2.70-6.0, p < 0.01) were independent predictors of cardiac events. Cardiac events greatly increased mortality (60.7 vs. 5.5%), total length of hospital stay (13.2 ± 14.7 days vs. 8.3 ± 9.3 days), and readmission rates (19.3 vs. 8.2%, p < 0.01). CONCLUSIONS Cardiac events following TEVAR are associated with significant mortality. Patients with these risk factors should be appropriately monitored to improve outcomes.
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Affiliation(s)
- Derrick O Acheampong
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Philip Paul
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Percy Boateng
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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25
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Luo X, Li F, Hu H, Liu B, Zheng S, Yang L, Gao R, Li Y, Xi R, He J. Anemia and perioperative mortality in non-cardiac surgery patients: a secondary analysis based on a single-center retrospective study. BMC Anesthesiol 2020; 20:112. [PMID: 32393181 PMCID: PMC7212669 DOI: 10.1186/s12871-020-01024-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 04/26/2020] [Indexed: 12/26/2022] Open
Abstract
Background Evidence regarding the relationship between anemia and perioperative prognosis is controversial. The study was conducted to highlight the specific relationship between anemia and perioperative mortality in non-cardiac surgery patients over 18 years of age. Methods This study was a retrospective analysis of the electronic medical records of 90,784 patients at the Singapore General Hospital from January 1, 2012 to October 31, 2016. Multivariate regression, propensity score analysis, doubly robust estimation, and an inverse probability-weighting model was used to ensure the robustness of our findings. Results We identified 85,989 patients, of whom75, 163 had none or mild anemia (Hemoglobin>90g/L) and 10,826 had moderate or severe anemia (Hemoglobin≤90g/L). 8,857 patients in each study exposure group had similar propensity scores and were included in the analyses. In the doubly robust model, postoperative 30-day mortality rate was increased by 0.51% (n = 219) in moderate or severe anemia group (Odds Ratio, 1.510; 95% Confidence Interval (CI), 1.049 to 2.174) compared with none or mild anemia group (2.47% vs.1.22%, P<0.001). Moderate or severe anemia was also associated with increased postoperative blood transfusion rates (OR, 5.608; 95% CI, 4.026 to 7.811, P < 0.001). There was no statistical difference in Intensive Care Unit (ICU) admission rate among different anemia groups within 30 days after surgery (P=0.104). Discussion In patients undergoing non-cardiac surgery over 18 years old, moderate or severe preoperative anemia would increase the occurrence of postoperative blood transfusion and the risk of death, rather than ICU admission within 30 days after surgery.
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Affiliation(s)
- Xueying Luo
- Department of Plastic and reconstructive, Shenzhen People's Hospital, No. 1017, Dongmen North Road, Luohu District, Shenzhen, ,518000, Guangdong, China
| | - Feng Li
- Department of Breast thyroid surgery, Shenzhen Breast Cancer Research and Treatment Research Center, Peking University Shenzhen Hospital, Shenzhen, China
| | - Haofei Hu
- Department of Breast thyroid surgery, Shenzhen Breast Cancer Research and Treatment Research Center, Peking University Shenzhen Hospital, Shenzhen, China
| | - Baoer Liu
- Department of Breast thyroid surgery, Shenzhen University, No. 3688 Nanhai Avenue, Nanshan District, Shenzhen, 518000, Guangdong, China
| | - Sujing Zheng
- Department of Thyroid and Breast surgery, Shenzhen Second People's Hospital, No. 3002, Sungang West Road, Futian District, Shenzhen, Shenzhen, 518000, Guangdong, China
| | - Liping Yang
- Department of Breast thyroid surgery, Shenzhen University, No. 3688 Nanhai Avenue, Nanshan District, Shenzhen, 518000, Guangdong, China
| | - Rui Gao
- Department of Breast thyroid surgery, Shenzhen Breast Cancer Research and Treatment Research Center, Peking University Shenzhen Hospital, Shenzhen, China
| | - Ya Li
- Department of General Medicine, Shenzhen University, No. 3002, Sungang West Road, Futian District, Shenzhen, 518000, Guangdong, China
| | - Rao Xi
- Department of Radiation Oncology, Faculty of Medicine, Universitatsklinikum Freiburg, Freiburg, Germany
| | - Jinsong He
- Department of Breast thyroid surgery, Shenzhen Breast Cancer Research and Treatment Research Center, Peking University Shenzhen Hospital, 1120 Lianhua Road, Futian District, Shenzhen, 518000, Guangdong, China.
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Rubinger DA, Cahill C, Ngo A, Gloff M, Refaai MA. Preoperative Anemia Management: What’s New in 2020? CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00385-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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27
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Anemia as an independent predictor of adverse outcomes after carotid revascularization. J Vasc Surg 2020; 72:1711-1719.e2. [PMID: 32249047 DOI: 10.1016/j.jvs.2020.01.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 01/31/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Anemia has been identified as a risk factor for postoperative morbidity and mortality after major vascular procedures. Carotid revascularization carries less cardiac morbidity and physiologic stress compared with other vascular interventions. This study evaluated the association between preoperative anemia and major adverse events after carotid revascularization. METHODS Patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) between January 2012 and June 2018 in the Vascular Quality Initiative database were identified. Anemia was defined as a preoperative hemoglobin level of <12 g/dL in women and <13 g/dL in men. Multivariable logistic analysis and 1:1 coarsened exact matching were used to study the association between preoperative anemia and in-hospital major adverse cardiac events (MACEs), defined as a composite of stroke, death, and myocardial infarction, and between anemia and 30-day mortality after CEA and CAS. RESULTS Of 102,719 patients included in the analysis, 34.8% were anemic (CEA, 34.1%; CAS, 37.8%; P < .001). Anemic patients were older and had more medical comorbidities compared with nonanemic patients. In-hospital MACEs (2.8% vs 1.9%; P < .001) and 30-day mortality (0.9% vs 0.4%; P < .001) were higher among anemic patients. On multivariable analysis, anemia was associated with 18% higher odds of in-hospital MACEs (odds ratio, 1.18; 95% confidence interval, 1.07-1.31, P = .001) and 74% higher odds of 30-day mortality (odds ratio, 1.74; 95% confidence interval, 1.40-2.17, P < .001). Coarsened exact matching showed similar results. The association between preoperative anemia and adverse outcomes was similar in both CAS and CEA and in symptomatic and asymptomatic patients (P interaction > .05). CONCLUSIONS Anemia is associated with increased odds of adverse events after CEA and CAS. It should be factored into the preoperative risk assessment of patients undergoing carotid revascularization. Prospective studies are needed to study the effectiveness of correcting low preoperative hemoglobin levels in these patients and the association between anemia and long-term outcomes after CEA and CAS.
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Grandone E, Colaizzo D, Mastroianno M, Petruzzelli F, di Mauro L, Carella M, Tiscia GL, Ostuni A. Pulmonary embolism associated with transfusion after severe post-partum haemorrhage: is less more? BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:13-19. [PMID: 31657705 PMCID: PMC7053526 DOI: 10.2450/2019.0060-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 08/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transfusion of red blood cells is associated with superficial vein thrombosis (SVT) and venous thromboembolism (deep vein thrombosis and/or pulmonary embolism, VTE). The present study investigated the prevalence of SVT and VTE in women transfused in the peri-partum period. MATERIALS AND METHODS We carried out an observational study in a tertiary level obstetrics department in the Apulia Region of Southern Italy to investigate VTE in women transfused during or after labour. The study included all women who delivered between January 1st and November 30th, 2018. A thrombotic event was defined as an admission with an ICD-9 code of SVT and VTE as a primary or secondary diagnosis. Maternal "near-miss" rate, as defined by the World Health Organization, was calculated and outcome of transfused women was recorded. RESULTS From January 1st to November 30th, a total of 1,028 women delivered, 39% of them by caesarean section (CS). One-hundred and thirty-two women (12.8%) had been classified with one or more complication codes. Most complications occurred in women who underwent CS with an odds ratio (OR) of 7.0 (95% CI: 4.0-12.5; p=0.000). Twelve women (1.2%) were transfused in the peri-partum period, 7 of them had delivered by CS. The only thrombotic events recorded in the entire cohort of 1,028 patients were isolated pulmonary embolisms observed in 2 out of 12 transfused women. Overall, patients had received a mean of 7.5 units of packed red blood cells (1 patient also received 7 plasma units, while 1 patient also received 1 platelet unit). Consequently, the near-miss rate was 2.0/1,000 deliveries, which is not significantly different from that expected in Italy and in high-income countries. CONCLUSIONS Pulmonary embolism is a life-threatening complication, which can be associated with transfusion in the peri-partum period.
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Affiliation(s)
- Elvira Grandone
- Thrombosis and Haemostasis Research Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza”, S. Giovanni Rotondo (FG), Italy
- Ob/Gyn Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Donatella Colaizzo
- Thrombosis and Haemostasis Research Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza”, S. Giovanni Rotondo (FG), Italy
| | - Mario Mastroianno
- ICT, Innovation and Research Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza”, S. Giovanni Rotondo (FG), Italy
| | - Francesco Petruzzelli
- Ob/Gyn Department, Fondazione IRCCS “Casa Sollievo della Sofferenza”, S. Giovanni Rotondo (FG), Italy
| | - Lazzaro di Mauro
- Immunohaematology and Transfusion Medicine Service, Fondazione IRCCS “Casa Sollievo della Sofferenza”, S. Giovanni Rotondo (FG), Italy
| | - Massimo Carella
- ICT, Innovation and Research Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza”, S. Giovanni Rotondo (FG), Italy
| | - Giovanni L. Tiscia
- ICT, Innovation and Research Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza”, S. Giovanni Rotondo (FG), Italy
| | - Angelo Ostuni
- Immunohaematology and Transfusion Medicine Service, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Italy
- S.R.C. Apulia Region, Bari, Italy
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Ng O, Keeler BD, Mishra A, Simpson JA, Neal K, Al‐Hassi HO, Brookes MJ, Acheson AG. Iron therapy for preoperative anaemia. Cochrane Database Syst Rev 2019; 12:CD011588. [PMID: 31811820 PMCID: PMC6899074 DOI: 10.1002/14651858.cd011588.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Preoperative anaemia is common and occurs in 5% to 76% of patients preoperatively. It is associated with an increased risk of perioperative allogeneic blood transfusion, longer hospital stay, and increased morbidity and mortality. Iron deficiency is one of the most common causes of anaemia. Oral and intravenous iron therapy can be used to treat anaemia. Parenteral iron preparations have been shown to be more effective in conditions such as inflammatory bowel disease, chronic heart failure and postpartum haemorrhage due to rapid correction of iron stores. A limited number of studies has investigated iron therapy for the treatment of preoperative anaemia. The aim of this Cochrane Review is to summarise the evidence for iron supplementation, both enteral and parenteral, for the management of preoperative anaemia. OBJECTIVES To evaluate the effects of preoperative iron therapy (enteral or parenteral) in reducing the need for allogeneic blood transfusions in anaemic patients undergoing surgery. SEARCH METHODS We ran the search on 30 July 2018. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic and Embase (Ovid), CINAHL Plus (EBSCO), PubMed, and clinical trials registries, and we screened reference lists. We ran a top-up search on 28 November 2019; one study is now awaiting classification. SELECTION CRITERIA We included all randomised controlled trials (RCTs) that compared preoperative iron monotherapy to placebo, no treatment, standard care or another form of iron therapy for anaemic adults undergoing surgery. We defined anaemia as haemoglobin values less than 13 g/dL for males and 12 g/dL for non-pregnant females. DATA COLLECTION AND ANALYSIS Two review authors collected data and a third review author checked all collected data. Data were collected on the proportion of patients who receive a blood transfusion, the amount of blood transfused per patient (units), quality of life, ferritin levels and haemoglobin levels, measured as continuous variables at the following predetermined time points: pretreatment (baseline), preoperatively but postintervention, and postoperatively. We performed statistical analysis using the Cochrane software, Review Manager 5. We summarised outcome data in tables and forest plots. We used the GRADE approach to describe the quality of the body of evidence. MAIN RESULTS Six RCTs, with a total of 372 participants, evaluated preoperative iron therapy to correct anaemia before planned surgery. Four studies compared iron therapy (either oral (one study) or intravenous (three studies)) with no treatment, placebo or usual care, and two studies compared intravenous iron therapy with oral iron therapy. Iron therapy was delivered over a range of periods that varied from 48 hours to three weeks prior to surgery. The 372 participants in our analysis fall far short of the 819 required - as calculated by our information size calculation - to detect a 30% reduction in blood transfusions. Five trials, involving 310 people, reported the proportion of participants who received allogeneic blood transfusions. Meta-analysis of iron therapy versus placebo or standard care showed no difference in the proportion of participants who received a blood transfusion (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.87 to 1.70; 4 studies, 200 participants; moderate-quality evidence). Only one study that compared oral versus intravenous iron therapy measured this outcome, and reported no difference in risk of transfusion between groups. There was no difference between the iron therapy and placebo/standard care groups for haemoglobin level preoperatively at the end of the intervention (mean difference (MD) 0.63 g/dL, 95% CI -0.07 to 1.34; 2 studies, 83 participants; low-quality evidence). However, intravenous iron therapy produced an increase in preoperative postintervention haemoglobin levels compared with oral iron (MD 1.23 g/dL, 95% CI 0.80 to 1.65; 2 studies, 172 participants; low-quality evidence). Ferritin levels were increased by intravenous iron, both when compared to standard care ((MD 149.00, 95% CI 25.84 to 272.16; 1 study, 63 participants; low-quality evidence) or to oral iron (MD 395.03 ng/mL, 95% CI 227.72 to 562.35; 2 studies, 151 participants; low-quality evidence). Not all studies measured quality of life, short-term mortality or postoperative morbidity. Some measured the outcomes, but did not report the data, and the studies which did report the data were underpowered. Therefore, uncertainty remains regarding these outcomes. The inclusion of new research in the future is very likely to change these results. AUTHORS' CONCLUSIONS The use of iron therapy for preoperative anaemia does not show a clinically significant reduction in the proportion of trial participants who received an allogeneic blood transfusion compared to no iron therapy. Results for intravenous iron are consistent with a greater increase in haemoglobin and ferritin when compared to oral iron, but do not provide reliable evidence. These conclusions are drawn from six studies, three of which included very small numbers of participants. Further, well-designed, adequately powered, RCTs are required to determine the true effectiveness of iron therapy for preoperative anaemia. Two studies are currently in progress, and will include 1500 randomised participants.
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Affiliation(s)
- Oliver Ng
- University of NottinghamNottingham Digestive Diseases Centre and Biomedical Research UnitDerby RdNottinghamUKNG7 2UH
| | - Barrie D Keeler
- University of NottinghamNottingham Digestive Diseases Centre and Biomedical Research UnitDerby RdNottinghamUKNG7 2UH
| | - Amitabh Mishra
- University of NottinghamNottingham Digestive Diseases Centre and Biomedical Research UnitDerby RdNottinghamUKNG7 2UH
| | - J A Simpson
- University of NottinghamNottingham Digestive Diseases Centre and Biomedical Research UnitDerby RdNottinghamUKNG7 2UH
| | - Keith Neal
- University of NottinghamDepartment of Epidemiology and Public Health188 Alfreton RoadLittle EatonDerbyUKDE21 5AB
| | - Hafid Omar Al‐Hassi
- University of WolverhamptonOffice (MA112b), Wulfruna StreetWolverhamptonUKWV1 1LY
| | | | - Austin G Acheson
- University of NottinghamNottingham Digestive Diseases Centre and Biomedical Research UnitDerby RdNottinghamUKNG7 2UH
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Miles LF, Larsen T, Bailey MJ, Burbury KL, Story DA, Bellomo R. Borderline anaemia and postoperative outcome in women undergoing major abdominal surgery: a retrospective cohort study. Anaesthesia 2019; 75:210-217. [DOI: 10.1111/anae.14870] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2019] [Indexed: 12/30/2022]
Affiliation(s)
- L. F. Miles
- Centre for Integrated Critical Care Melbourne Medical School Vic. Australia
| | - T. Larsen
- Data Analytics Research and Evaluation (DARE) Centre Austin Health Melbourne Vic. Australia
| | - M. J. Bailey
- Australian and New Zealand Intensive Care Research Centre Monash University Melbourne Vic. Australia
| | - K. L. Burbury
- Sir Peter MacCallum Department of Oncology The University of Melbourne Vic. Australia
| | - D. A. Story
- Centre for Integrated Critical Care Melbourne Medical School Vic. Australia
| | - R. Bellomo
- Centre for Integrated Critical Care Melbourne Medical School Vic. Australia
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Tyan P, Taher A, Carey E, Sparks A, Radwan A, Amdur R, Tamim H, Gu A, Robinson H, Moawad GN. The effect of anemia severity on postoperative morbidity among patients undergoing laparoscopic hysterectomy for benign indications. Acta Obstet Gynecol Scand 2019; 99:112-118. [PMID: 31449328 DOI: 10.1111/aogs.13718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/03/2019] [Accepted: 08/05/2019] [Indexed: 01/02/2023]
Abstract
INTRODUCTION One-third of non-pregnant women worldwide are anemic.1 Anemia is a known independent risk factor for postoperative morbidity.2 Given that the vast majority of hysterectomies are not performed in the emergency setting, we designed this study to evaluate the effect of preoperative anemia on postoperative morbidity following laparoscopic hysterectomy performed for benign indications. Our main goal is to encourage surgeons to use anemia-corrective measures before surgery when feasible. MATERIAL AND METHODS Retrospective cohort study of 98 813 patients who underwent a laparoscopic hysterectomy between 2005 and 2016 for benign indications identified through the American College of Surgeons National Surgical Quality Improvement Program. Anemia was examined as a function of hematocrit and was analyzed as an ordinal variable stratified by anemia severity as mild, moderate or severe. Associations between preoperative anemia and patient demographics, preoperative comorbidities and postoperative outcomes were evaluated using univariate analyses. Multivariable logistic regression models were used to identify independent associations between hematocrit level and postoperative outcomes after adjusting for confounding covariates. At the multivariable logistic regression level, anemia severity was analyzed using hematocrit as a continuous variable to assess the independent association between each 5% decrease in hematocrit level and several postoperative morbidities. RESULTS Of the 98 813 patients who met our inclusion and exclusion criteria, 19.5% were anemic. A lower preoperative hematocrit was associated with higher body mass index, younger age, Black or African American race, longer operative times, and multiple other medical comorbidities. After appropriate regression modeling, anemia was identified as an independent risk factor for extended length of stay, readmission and composite morbidity after surgery. CONCLUSIONS Preoperative anemia is common among patients undergoing laparoscopic hysterectomy. Preoperative anemia increases patients' risk for multiple postoperative comorbidities. Given that most hysterectomies are performed in the elective setting, gynecologic surgeons should consider the use of anemia-corrective measures to minimize postoperative morbidity.
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Affiliation(s)
- Paul Tyan
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Ali Taher
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Erin Carey
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Andrew Sparks
- Department of Surgery, School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
| | - Amr Radwan
- Department of Internal Medicine, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Richard Amdur
- Department of Surgery, School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Alex Gu
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Hannah Robinson
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Gaby N Moawad
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, The George Washington University, Washington, DC, USA
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Ulug P, Powell JT, Warschkow R, von Allmen RS. Editor's Choice – Sex Specific Differences in the Management of Descending Thoracic Aortic Aneurysms: Systematic Review with Meta-Analysis. Eur J Vasc Endovasc Surg 2019; 58:503-511. [DOI: 10.1016/j.ejvs.2019.04.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/15/2019] [Accepted: 04/23/2019] [Indexed: 11/28/2022]
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Accuracy and trending ability of hemoglobin measurement by the Pulse CO-Oximeter during vascular surgery. J Clin Monit Comput 2019; 34:501-508. [DOI: 10.1007/s10877-019-00337-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/06/2019] [Indexed: 12/19/2022]
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Reis P, Lopes AI, Leite D, Moreira J, Mendes L, Ferraz S, Amaral T, Abelha F. Predicting mortality in patients admitted to the intensive care unit after open vascular surgery. Surg Today 2019; 49:836-842. [DOI: 10.1007/s00595-019-01805-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 03/23/2019] [Indexed: 01/22/2023]
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Postoperative Medical Complications and Intermediate Care Unit/Intensive Care Unit Admission in Joint Replacement Surgery: A Prospective Risk Model. J Arthroplasty 2019; 34:717-722. [PMID: 30718172 DOI: 10.1016/j.arth.2018.12.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 12/09/2018] [Accepted: 12/27/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Postoperative complications are the main consumers of technical, medical, and human resources. Especially in the field of elective joint replacement surgery, a specialized, easy-to-obtain, and cost-efficient preoperative stratification and risk-estimation model is missing. METHODS With preoperatively surveyed patient parameters, we identified the most relevant parameters to predict postoperative medical complications. We devised a prospective risk model, measuring the individual probability for intermediate care unit (IMC) or intensive care unit (ICU) admission. The study includes all patients (n = 649) treated with primary or revision total knee arthroplasty in our clinic from 2008 to 2012. RESULTS The association between general comorbidity scores and mortality risk is well known. Among different comorbidity scores, the Charlson Comorbidity Index is not only relevant for overall postoperative complications (odds ratios [OR] = 2.20) but also predictive of specific complications such as the postoperative need for blood transfusion (OR = 1.94) and unexpected adverse events (OR = 1.74). Considering adverse events, c-reactive protein and leukocyte levels are also highly relevant. Upon predicting a necessary postoperative transfer to an IMC or ICU, the preoperative hemoglobin level, the Charlson Comorbidity Index, and the Index of Coexistent Disease stood out. The latter indicates an increased rate for an IMC/ICU stay by 341% per point. Condensing the most influential predictors, the probability for postoperative IMC/ICU transfer can be calculated for each individual patient. Using the routinely assessed patient's variables, no steadier prediction is possible. CONCLUSION The introduced risk-estimation model offers a specialized preoperative resource-stratification method in knee joint replacement surgery. It condenses the most influential, individual risk factors to avoid clinical test redundancy and improve resource efficiency and presurgical care planning. A prospective follow-up study could help validating the risk model in clinical routine.
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Mueller MM, Van Remoortel H, Meybohm P, Aranko K, Aubron C, Burger R, Carson JL, Cichutek K, De Buck E, Devine D, Fergusson D, Folléa G, French C, Frey KP, Gammon R, Levy JH, Murphy MF, Ozier Y, Pavenski K, So-Osman C, Tiberghien P, Volmink J, Waters JH, Wood EM, Seifried E. Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference. JAMA 2019; 321:983-997. [PMID: 30860564 DOI: 10.1001/jama.2019.0554] [Citation(s) in RCA: 358] [Impact Index Per Article: 71.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs. OBJECTIVE To develop a set of evidence-based recommendations for patient blood management (PBM) and for research. EVIDENCE REVIEW The scientific committee developed 17 Population/Intervention/Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018. FINDINGS From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization. CONCLUSIONS AND RELEVANCE The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.
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Affiliation(s)
- Markus M Mueller
- German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Kari Aranko
- European Blood Alliance (EBA), Amsterdam, the Netherlands
| | - Cécile Aubron
- Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
| | | | - Jeffrey L Carson
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | | | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
- Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Dana Devine
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Departments of Medicine, Surgery, Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Gilles Folléa
- Société Française de Transfusion Sanguine (SFTS), Paris, France
| | - Craig French
- Intensive Care, Western Health, Melbourne, Australia
| | | | | | - Jerrold H Levy
- Department of Cardiothoracic Intensive Care Medicine, Duke University Medical Centre, Durham, North Carolina
| | - Michael F Murphy
- National Health Service Blood and Transplant and University of Oxford, Oxford, United Kingdom
| | - Yves Ozier
- Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
| | | | - Cynthia So-Osman
- Sanquin Blood Bank, Leiden and Department of Haematology, Groene Hart Hospital, Gouda, the Netherlands
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
| | | | - Jimmy Volmink
- Department of Clinical Epidemiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jonathan H Waters
- Departments of Anesthesiology and Bioengineering, University of Pittsburgh Medical Centre, Pittsburgh, Pennsylvania
| | - Erica M Wood
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Erhard Seifried
- German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
- European Blood Alliance (EBA), Amsterdam, the Netherlands
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
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Dakour-Aridi H, Nejim B, Locham S, Alshwaily W, Malas MB. Anemia and postoperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms. J Vasc Surg 2019; 69:738-751.e2. [DOI: 10.1016/j.jvs.2018.05.233] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/31/2018] [Indexed: 02/01/2023]
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Esteban C, Rodríguez P, Escudero JR, Clarà A, Fernández A, Fernández S, Agúndez I. Anaemia in patients who underwent vascular surgery: a significant predictor of amputation and death. Med Clin (Barc) 2019; 152:6-12. [PMID: 29650265 DOI: 10.1016/j.medcli.2018.01.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/04/2018] [Accepted: 01/11/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND OBJECTIVE In patients with peripheral artery disease requiring surgery, anaemia has been found to independently predict short and medium term higher morbidity and mortality. PATIENTS AND METHODS We retrospectively studied all patients undergoing surgery, consecutively during 2months in 12 vascular surgery units. We analysed cardiovascular risk factors and preoperative haemoglobin. Statistical analysis was done with Kaplan-Meier for survival and logistic regression modelling to identify predictors of mortality. RESULTS 518 patients were consecutively operated on in our vascular units, the mortality rate was 21% the first year and 34% for cardiovascular events. Preoperative anaemia was present in 63% of the ischemic patients and in 23% of the patients requiring aneurysm repair, one year after surgery it increased to 68% and 50% respectively. When preoperative anaemia was superior to 10mg/dl, one year survival increased (96% vs. 90%), fewer cardiovascular events occurred and there were fewer amputations (24% vs. 68%). CONCLUSIONS On multivariable analysis: age, renal failure, chronic lung disease, coronary artery disease, postoperative complications and previous cardiovascular events were associated with an increased risk mortality rate. Preoperative haemoglobin influenced proportionally such that for every 1mg /dl increase, the probability of mortality decreases by 0.81. Preoperative anaemia, especially when haemoglobin is inferior to 10mg/dl, is associated with an increased risk of death and amputation.
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Affiliation(s)
- Carlos Esteban
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, España.
| | - Patricia Rodríguez
- Servicio de Angiología y Cirugía Vascular, Hospital Josep Trueta, Gerona, España
| | - José Román Escudero
- Servicio de Angiología y Cirugía Vascular, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Albert Clarà
- Servicio de Angiología y Cirugía Vascular, Hospital del Mar, Barcelona, España
| | - Alvaro Fernández
- Servicio de Angiología y Cirugía Vascular, Hospital La Paz, Madrid, España
| | - Sebastián Fernández
- Servicio de Angiología y Cirugía Vascular, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
| | - Ignacio Agúndez
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Burgos, Burgos, España
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Latchana N, Hirpara DH, Hallet J, Karanicolas PJ. Red blood cell transfusion in liver resection. Langenbecks Arch Surg 2019; 404:1-9. [PMID: 30607533 DOI: 10.1007/s00423-018-1746-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes. PURPOSE Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion. RESULTS Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods. CONCLUSION Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.
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Affiliation(s)
- Nicholas Latchana
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dhruvin H Hirpara
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul J Karanicolas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
- Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
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Burton BN, A'Court AM, Brovman EY, Scott MJ, Urman RD, Gabriel RA. Optimizing Preoperative Anemia to Improve Patient Outcomes. Anesthesiol Clin 2018; 36:701-713. [PMID: 30390789 DOI: 10.1016/j.anclin.2018.07.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Anemia is a decrease in red blood cell mass, which hinders oxygen delivery to tissues. Preoperative anemia has been shown to be associated with mortality and morbidity following major surgery. The preoperative care clinic is an ideal place to start screening for anemia and discussing potential interventions in order to optimize patients for surgery. This article (1) reviews the relevant literature and highlights consequences of preoperative anemia in the surgical setting, and (2) suggests strategies for screening and optimizing anemia in the preoperative setting.
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Affiliation(s)
- Brittany N Burton
- School of Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Alison M A'Court
- Department of Anesthesiology, Preoperative Care Clinic, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Ethan Y Brovman
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiothoracic Anesthesia, Harvard Medical School, Brigham & Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University Health System, 1200 East Broad Street, PO Box 980695, Richmond, VA 23298, USA; Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Rodney A Gabriel
- Division of Regional Anesthesia and Acute Pain, Department of Anesthesiology, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA.
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Desai N, Schofield N, Richards T. Perioperative Patient Blood Management to Improve Outcomes. Anesth Analg 2018; 127:1211-1220. [DOI: 10.1213/ane.0000000000002549] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Preoperative anemia: a common finding that predicts worse outcomes in patients undergoing primary hiatal hernia repair. Surg Endosc 2018; 33:535-542. [PMID: 29998393 DOI: 10.1007/s00464-018-6328-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/06/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND The increased incidence of anemia in patients with hiatal hernias (HH) and resolution of anemia after HH repair (HHR) have been clearly demonstrated. However, the implications of preoperative anemia on postoperative outcomes have not been well described. In this study, we aimed to identify the incidence of preoperative anemia in patients undergoing primary HHR at our institution and sought to determine whether preoperative anemia had an impact on postoperative outcomes. METHODS Using our IRB-approved institutional HH database, we retrospectively identified patients undergoing primary HHR between January 2011 and April 2017 at our institution. We identified patients with anemia, defined as serum hemoglobin levels less than 13 mg/dL in men and 12 mg/dL in women, measured within two weeks prior to surgery, and compared this group to a cohort of patients with normal preoperative hemoglobin. Perioperative outcomes analyzed included estimated blood loss (EBL), operative time, perioperative blood transfusions, failed postoperative extubation, intensive care unit (ICU) admission, postoperative complications, length of stay (LOS), and 30-day readmission. Outcomes were compared by univariable and multivariable analyses, with significance set at p < 0.05. RESULTS We identified 263 patients undergoing HHR. The median age was 66 years and most patients were female (78%, n = 206). Seventy patients (27%) were anemic. In unadjusted analyses, anemia was significantly associated with failed postoperative extubation (7 vs. 2%, p = 0.03), ICU admission (13 vs. 5%, p = 0.03), postoperative blood transfusions (9 vs. 0%, p < 0.01), and postoperative complications (41 vs. 18%, p < 0.01). On adjusted multivariable analysis, anemia was associated with 2.6-fold greater odds of postoperative complications (OR 2.57; 95% CI 1.36-4.86; p < 0.01). CONCLUSIONS In this study, anemia had a prevalence of 27% in patients undergoing primary HHR. Anemic patients had 2.6-fold greater odds of developing postoperative complications. Anemia is common in patients undergoing primary HHR and warrants consideration for treatment prior to elective repair.
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Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of the study was to determine readmission rates and predictors of readmission after posterior cervical fusion (PCF). SUMMARY OF BACKGROUND DATA PCFs are common spinal operations for a variety of spinal disorders including cervical myelopathy, unstable fractures, cervical deformity, and tumors. Data elaborating on risk factors for 30-day readmission are limited. METHODS Data were collected from the 2006 to 2013 American College of Surgeons National Surgical Quality Improvement Program database. Predictors of 30-day readmission comprising patient demographics, comorbidities, operative features, and postoperative complications were identified through logistic multivariable regression. RESULTS A total of 3401 patients met study criteria. Rate of 30-day readmission was 6.20%. Multilevel fusion was performed in 69.16% of patients. Postoperative infection was the most reason, accounting for 17.06% of all readmissions. Age older than 70 years (odds ratio [OR] = 1.61, P = 0.012), renal failure requiring dialysis (OR = 3.69, P = 0.011), anemia (OR = 1.57, P = 0.006), multilevel fusion (OR = 1.61, P = 0.012), surgical site infections (OR = 20.4, P < 0.001), wound dehiscence (OR = 19.08, P < 0.001), postoperative pneumonia (OR = 2.75, P = 0.01), pulmonary embolism (OR = 15.39, P < 0.001), and progressing renal insufficiency (OR = 10.13, P = 0.061) were significant predictors of hospital readmission. CONCLUSION The identified predictors of readmission after PCF can improve patient counseling, identification of high-risk patients, and guide changes in healthcare delivery pathways. Patients with modifiable risk factors such as anemia and kidney failure may benefit from preoperative optimization. In addition, postoperative complications represent a key target for intervention. LEVEL OF EVIDENCE 3.
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Bovonratwet P, Malpani R, Ottesen TD, Tyagi V, Ondeck NT, Rubin LE, Grauer JN. Aseptic revision total hip arthroplasty in the elderly. Bone Joint J 2018; 100-B:143-151. [DOI: 10.1302/0301-620x.100b2.bjj-2017-0895.r1] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to compare the rate of perioperative complications following aseptic revision total hip arthroplasty (THA) in patients aged ≥ 80 years with that in those aged < 80 years, and to identify risk factors for the incidence of serious adverse events in those aged ≥ 80 years using a large validated national database. Patients and Methods Patients who underwent aseptic revision THA were identified in the 2005 to 2015 National Surgical Quality Improvement Program (NSQIP) database and stratified into two age groups: those aged < 80 years and those aged ≥ 80 years. Preoperative and procedural characteristics were compared. Multivariate regression analysis was used to compare the risk of postoperative complications and readmission. Risk factors for the development of a serious adverse event in those aged ≥ 80 years were characterized. Results The study included 7569 patients aged < 80 years and 1419 were aged ≥ 80 years. Multivariate analysis showed a higher risk of perioperative mortality, pneumonia, urinary tract infection and the requirement for a blood transfusion and an extended length of stay in those aged ≥ 80 years compared with those aged < 80 years. Independent risk factors for the development of a serious adverse event in those aged ≥ 80 years include an American Society of Anesthesiologists score of ≥ 3 and procedures performed under general anaesthesia. Conclusion Even after controlling for patient and procedural characteristics, aseptic revision THA is associated with greater risks in patients aged ≥ 80 years compared with younger patients. This is important for counselling and highlights the need for medical optimization in these vulnerable patients. Cite this article: Bone Joint J 2018;100-B:143–51.
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Affiliation(s)
- P. Bovonratwet
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - R. Malpani
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - T. D. Ottesen
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - V. Tyagi
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - N. T. Ondeck
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - L. E. Rubin
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - J. N. Grauer
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
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45
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Mistry N, Mazer CD, Sled JG, Lazarus AH, Cahill LS, Solish M, Zhou YQ, Romanova N, Hare AGM, Doctor A, Fisher JA, Brunt KR, Simpson JA, Hare GMT. Red blood cell antibody-induced anemia causes differential degrees of tissue hypoxia in kidney and brain. Am J Physiol Regul Integr Comp Physiol 2018; 314:R611-R622. [PMID: 29351418 DOI: 10.1152/ajpregu.00182.2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Moderate anemia is associated with increased mortality and morbidity, including acute kidney injury (AKI), in surgical patients. A red blood cell (RBC)-specific antibody model was utilized to determine whether moderate subacute anemia could result in tissue hypoxia as a potential mechanism of injury. Cardiovascular and hypoxic cellular responses were measured in transgenic mice capable of expressing hypoxia-inducible factor-1α (HIF-1α)/luciferase activity in vivo. Antibody-mediated anemia was associated with mild intravascular hemolysis (6 h) and splenic RBC sequestration ( day 4), resulting in a nadir hemoglobin concentration of 89 ± 13 g/l on day 4. At this time point, renal tissue oxygen tension (PtO2) was decreased in anemic mice relative to controls (13.1 ± 4.3 vs. 20.8 ± 3.7 mmHg, P < 0.001). Renal tissue hypoxia was associated with an increase in HIF/luciferase expression in vivo ( P = 0.04) and a 20-fold relative increase in renal erythropoietin mRNA transcription ( P < 0.001) but no increase in renal blood flow ( P = 0.67). By contrast, brain PtO2 was maintained in anemic mice relative to controls (22.7 ± 5.2 vs. 23.4 ± 9.8 mmHg, P = 0.59) in part because of an increase in internal carotid artery blood flow (80%, P < 0.001) and preserved cerebrovascular reactivity. Despite these adaptive changes, an increase in brain HIF-dependent mRNA levels was observed (erythropoietin: P < 0.001; heme oxygenase-1: P = 0.01), providing evidence for subtle cerebral tissue hypoxia in anemic mice. These data demonstrate that moderate subacute anemia causes significant renal tissue hypoxia, whereas adaptive cerebrovascular responses limit the degree of cerebral tissue hypoxia. Further studies are required to assess whether hypoxia is a mechanism for acute kidney injury associated with anemia.
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Affiliation(s)
- Nikhil Mistry
- Department of Anesthesia, St. Michael's Hospital, University of Toronto , Toronto, Ontario , Canada.,Department of Physiology, University of Toronto , Toronto, Ontario , Canada
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto , Toronto, Ontario , Canada.,Department of Physiology, University of Toronto , Toronto, Ontario , Canada.,Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada
| | - John G Sled
- Mouse Imaging Centre, The Hospital for Sick Children , Toronto, Ontario , Canada.,Department of Medical Biophysics, University of Toronto , Toronto, Ontario , Canada
| | - Alan H Lazarus
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada.,Canadian Blood Services Centre for Innovation , Ottawa, Ontario , Canada
| | - Lindsay S Cahill
- Mouse Imaging Centre, The Hospital for Sick Children , Toronto, Ontario , Canada
| | - Max Solish
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada
| | - Yu-Qing Zhou
- Mouse Imaging Centre, The Hospital for Sick Children , Toronto, Ontario , Canada
| | - Nadya Romanova
- Department of Human Health and Nutritional Sciences and Cardiovascular Research Group, University of Guelph , Guelph, Ontario , Canada
| | - Alexander G M Hare
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada
| | - Allan Doctor
- Department of Pediatrics, Department of Biochemistry and Molecular Biophysics, Washington University in St. Louis , St. Louis, Missouri
| | - Joseph A Fisher
- Department of Physiology, University of Toronto , Toronto, Ontario , Canada.,Department of Anesthesia, Toronto General Hospital, University of Toronto , Toronto, Ontario , Canada
| | - Keith R Brunt
- Department of Pharmacology, Dalhousie University , Saint John, New Brunswick , Canada
| | - Jeremy A Simpson
- Department of Human Health and Nutritional Sciences and Cardiovascular Research Group, University of Guelph , Guelph, Ontario , Canada
| | - Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, University of Toronto , Toronto, Ontario , Canada.,Department of Physiology, University of Toronto , Toronto, Ontario , Canada.,Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada.,St. Michael's Hospital Center of Excellence in Patient Blood Management, University of Toronto, Toronto, Ontario, Canada
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46
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Preoperative Anemia in Cardiac Operation: Does Hemoglobin Tell the Whole Story? Ann Thorac Surg 2018; 105:100-107. [DOI: 10.1016/j.athoracsur.2017.06.074] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 06/05/2017] [Accepted: 06/28/2017] [Indexed: 01/26/2023]
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47
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Bovonratwet P, Tyagi V, Ottesen TD, Ondeck NT, Rubin LE, Grauer JN. Revision Total Knee Arthroplasty in Octogenarians: An Analysis of 957 Cases. J Arthroplasty 2018; 33:178-184. [PMID: 28844628 DOI: 10.1016/j.arth.2017.07.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 07/15/2017] [Accepted: 07/20/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The number of octogenarians undergoing revision total knee arthroplasty (TKA) is increasing. However, there has been a lack of studies investigating the perioperative course and safety of revision TKA performed in this potentially vulnerable population in a large patient population. The purpose of this study is to compare complications following revision TKA between octogenarians and 2 younger patient populations (<70 and 70-79 year olds). METHODS Patients who underwent revision TKA were identified in the 2005-2015 National Surgical Quality Improvement Program database and stratified into 3 age groups: <70, 70-79, and ≥80 years. Baseline preoperative and intraoperative characteristics were compared between the 3 groups. Propensity score matched comparisons were then performed for 30-day perioperative complications, length of hospital stay, and readmissions. RESULTS This study included 6523 (<70 years), 2509 (70-79 years), and 957 octogenarian patients who underwent revision TKA. After propensity matching, statistical analysis revealed only higher rates of blood transfusion and slightly longer length of stay in octogenarians compared to <70 year olds. Similarly, octogenarians had only higher rates of blood transfusion and slightly longer length of stay compared to 70-79 year olds. Notably, there were no differences in mortality or readmission between octogenarians compared to younger populations. CONCLUSION These data suggest that revision TKA can safely be considered for octogenarians with the observation of higher rates of blood transfusion and slightly longer length of stay compared to younger populations. Octogenarian patients need not be discouraged from revision TKA solely based on their advanced age.
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Affiliation(s)
- Patawut Bovonratwet
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Vineet Tyagi
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Nathaniel T Ondeck
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Lee E Rubin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
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Gualandro DM, Puelacher C, LuratiBuse G, Llobet GB, Yu PC, Cardozo FA, Glarner N, Zimmerli A, Espinola J, Corbière S, Calderaro D, Marques AC, Casella IB, de Luccia N, Oliveira MT, Lampart A, Bolliger D, Steiner L, Seeberger M, Kindler C, Osswald S, Gürke L, Caramelli B, Mueller C. Prediction of major cardiac events after vascular surgery. J Vasc Surg 2017; 66:1826-1835.e1. [DOI: 10.1016/j.jvs.2017.05.100] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/06/2017] [Indexed: 12/20/2022]
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49
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Lim J, Miles L, Litton E. Intravenous Iron Therapy in Patients Undergoing Cardiovascular Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2017; 32:1439-1451. [PMID: 29246691 DOI: 10.1053/j.jvca.2017.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Jolene Lim
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Lachlan Miles
- Department of Anaesthesia, Austin Health, Melbourne, Australia; Anaesthesia, Perioperative and Pain Medicine Unit, School of Medicine, University of Melbourne, Parkville, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia; Australia.
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50
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Pothof AB, Bodewes TCF, O'Donnell TFX, Deery SE, Shean K, Soden PA, de Borst GJ, Schermerhorn ML. Preoperative anemia is associated with mortality after carotid endarterectomy in symptomatic patients. J Vasc Surg 2017; 67:183-190.e1. [PMID: 28822658 DOI: 10.1016/j.jvs.2017.05.114] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 05/15/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Preoperative anemia and blood transfusions are associated with worse outcomes after surgery. However, the impact of preoperative anemia and transfusions on outcomes after carotid endarterectomy (CEA) is unknown. METHODS CEA patients from 2011 to 2015 in the American College of Surgeons National Surgical Quality Improvement Program Targeted Vascular module were compared by the presence of preoperative anemia (hematocrit <36%) after stratification by symptom status. Multivariable analysis accounted for differences in baseline characteristics. We included an interaction term in our multivariable model to assess whether the effect of anemia differed significantly between patients who received a perioperative transfusion and those who did not, with 30-day mortality as our primary outcome. RESULTS Of 16,068 patients, 6734 (42%) were symptomatic, of whom 1500 (22%) had anemia. Of the 9334 asymptomatic patients, 1935 (21%) had anemia. Both symptomatic and asymptomatic anemic patients were more likely to be transfused perioperatively compared with nonanemic patients, with 7.0% vs 0.4%, and 5.8% vs 0.7% (both P < .001). Among symptomatic patients, those with anemia compared with those without had a higher rate of 30-day mortality (2.5% vs 0.7%; P < .001). After adjustment, anemic symptomatic patients had a higher 30-day mortality risk (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.9-5.0; P < .001) compared with nonanemic symptomatic patients. In addition, in symptomatic patients, we found a significant interaction between anemia and perioperative transfusion on the outcome of 30-day mortality (P = .004), with a higher risk in perioperatively transfused symptomatic patients with anemia (OR, 7.8; 95% CI, 3.4-18.0; P < .001) than in symptomatic patients with anemia who did not receive a perioperative transfusion (OR, 2.3; 95% CI, 1.4-3.9; P = .002). In asymptomatic patients, anemic and nonanemic patients had comparable 30-day mortality rates (0.9% vs 0.6%; P = .2). After adjustment, anemia was not associated with 30-day mortality in asymptomatic patients (OR, 1.0; 95% CI, 0.5-2.0; P = .9), nor did we identify an interaction between anemia and perioperative transfusion in asymptomatic patients (P = .1). Patients who received a preoperative transfusion had a higher 30-day mortality rate than anemic patients not receiving preoperative transfusion in both symptomatic (n = 31, 9.7% vs 2.5%; P = .04) and asymptomatic patients (n = 21, 9.5% vs 0.9%; P = .02). CONCLUSIONS Preoperative anemia is a risk factor for 30-day mortality after CEA in symptomatic patients but not in asymptomatic patients. These results should be factored into the selection of symptomatic patients for CEA and dissuade treatment of asymptomatic patients scheduled for CEA who need a preoperative transfusion.
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Affiliation(s)
- Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Thomas C F Bodewes
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Katie Shean
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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