Anaemia in the older surgical patient: a review of prevalence, causes, implications and management

The association between preoperative anemia and postoperative mortality among non-cardiac surgical patients in Northwest Ethiopia: a prospective cohort study

INTRODUCTION

In a low-income country, the impact of preoperative anemia on postoperative mortality among noncardiac surgery patients is little understood. As a result, we aim to investigate the association between preoperative anemia and postoperative mortality in noncardiac surgery patients in Northwest Ethiopia.

METHODS

This is a prospective follow-up study of 3506 noncardiac surgery patients who were included in the final analysis between June 1, 2019, and July 1, 2021. We used a propensity score-match analysis to group anemic and non-anemic patients. The propensity score match analysis took into account age, gender, comorbidities, American Society of Anesthesiologists physical status, urgency of surgery, and trauma. Patients with and without preoperative anemia were divided into a 1:1 ratio in a propensity score balance. The association between preoperative anemia and postoperative mortality was determined using adjusted odds ratios and 95% confidence interval.

RESULTS

This study included 3506 noncardiac surgery patients, of which 1532 (43.7%) had preoperative anemia. The propensity score-matching results reveal that one-to-one nearest neighbour propensity score matching without replacement was successful for 1351 pairs of surgical patients. The postoperative 28-day mortality rate for anemic patients was 53 (3.9%), with (OR:1.63; 95% CI: 1.05-2.54).

CONCLUSION

The study found that patients undergoing noncardiac surgery in Northwest Ethiopia had a higher rate of preoperative anemia than those in high-income countries. Preoperative anemia had a significant association with 28-day mortality after surgery.

Propensity score matching analysis of early vs. delayed surgery for intertrochanteric fracture in older patients: a retrospective multicenter cohort study of 7414 patients with a mean 4-year follow up

BACKGROUND

The widespread acceptance of early surgery as a treatment for acute intertrochanteric fracture (ITF) has been accompanied by ongoing controversy due to conflicting conclusions presented in previous studies. This study aims to compare the occurrence of perioperative complications and mortality, as well as functional outcomes in older patients with ITF who underwent either early or delayed surgery.

METHODS

A retrospective multicenter cohort study involving 7414 patients with ITF between Jan. 2017 and Dec. 2021 was conducted. After predefined participants selection inclusion and exclusion criteria, 2323 surgically treated ITF patients were included and analyzed utilizing propensity score matching (PSM) method. Their demographics, injury-related data, surgery-related data, and perioperative adverse outcomes during hospitalization were collected and compared between the early or delayed surgery groups by PSM with a 1:4 ratio. All participants received a minimum of two-year follow-up and perioperative outcomes, functional outcomes, and survival analyses were conducted and compared.

RESULTS

After adjustment for potential confounders, there were no significant difference in surgery duration, intraoperative blood loss, transfusion rate, mortality rates, functional outcomes, and perioperative complications rates including severe complications, cardiac complications, pulmonary complications, and neurological complications regardless of whether the patient was treated with early or delayed surgery (all P > 0.05). Although length of hospital stay (mean, 11.5 versus 14.4 days, P < 0.001), total hospital costs (mean, 39305 versus 42048 yuan, P < 0.001), and minor complications rates including hematological complications (31.7% versus 41.2%, P = 0.007) and nutritional/metabolic complications (59.3% versus 66.4%, P = 0.039) were lower in the early surgery group, our result indicated patients with early surgery were more inclined to receive more blood transfusion (mean, 2.8 versus 2.2 units, P = 0.004).

CONCLUSIONS

Our findings suggest that a 48-hour delay in surgical intervention for older patients with an ITF does not result in a higher mortality rate, worse functional outcomes, and increased incidence of major perioperative complications when compared to early surgery. While expedited surgery is undoubtedly necessary for suitable patients, a reasonable preoperative delay of 48 h may be justified and safe for those with severe conditions, rather than strictly adhering to the current guidelines.

Development and validation of models for predicting mortality in intertrochanteric fracture surgery patients with perioperative blood transfusion: a prospective multicenter cohort study

BACKGROUND

The association between allogenic blood transfusions and all-cause mortality in surgically treated hip fracture patients with perioperative transfusion (STHFPT) remained unknown. The authors aim to introduce transfusion-related factors, new variables to develop, and validate models to predict mortality in these patients.

METHODS

A prospective multicenter cohort study was conducted with STHFPT hospitalized during January 2018 and June 2021. The database was divided into training cohort and validation cohort in a ratio of 70-30% using the randomization method. All participants received a minimum of 2-year follow-up and all participants' overall and eight time-specific survival status were recorded. Prediction models were developed using multivariate logistic regression and Cox regression for variable selection. Model performance was measured by determining discrimination, calibration, overall model performance or precision, and utility. Sensitivity analyses were performed to test robustness of the results.

RESULTS

A total of 7074 consecutive patients were prospectively screened and assessed for eligibility to participate. Finally, 2490 patients met our inclusion and exclusion criteria and 1743 (70%) patients were randomized to the training cohort and 747 (30%) to the validation cohort. The median duration of follow-up was 38.4 months (IQR 28.0-62.0). Our novel models highlight that preoperative transfusion is of significance for short-term mortality while mid-term outcomes are predominantly determined by severe complications, pulmonary complications, and advanced age. Our models showed high discriminative power, good calibration, and precision for mortality prediction in both training and validation cohorts, especially in short-term mortality prediction.

CONCLUSIONS

The authors introduce transfusion-related factors, new variables to develop, and validate models to predict mortality with STHFPT. The models can be further tested and updated with the ultimate goal of assisting in optimizing individual transfusion strategy.

Preoperative factors predict prolonged length of stay, serious adverse complications, and readmission following operative intervention of proximal humerus fractures: a machine learning analysis of a national database

Background

Proximal humerus fractures are a common injury, predominantly affecting older adults. This study aimed to develop risk-prediction models for prolonged length of hospital stay (LOS), serious adverse complications, and readmission within 30 days of surgically treated proximal humerus fractures using machine learning (ML) techniques.

Methods

Adult patients (age >18) who underwent open reduction internal fixation (ORIF), hemiarthroplasty, or total shoulder arthroplasty for proximal humerus fracture between 2016 and 2021 were included. Preoperative demographic and clinical variables were collected for all patients and used to establish ML-based algorithms. The model with optimal performance was selected according to area under the curve (AUC) on the receiver operating curve (ROC) curve and overall accuracy, and the specific predictive features most important to model derivation were identified.

Results

A total of 7473 patients were included (72.1% male, mean age 66.2 ± 13.7 years). Models produced via gradient boosting performed best for predicting prolonged LOS and complications. The model predicting prolonged LOS demonstrated good discrimination and performance, as indicated by (Mean: 0.700, SE: 0.017), recall (Mean: 0.551, SE: 0.017), accuracy (Mean: 0.717, SE: 0.010), F1-score (Mean: 0.616, SE: 0.014), AUC (Mean: 0.779, SE: 0.010), and Brier score (Mean: 0.283, SE: 0.010) Preoperative hematocrit, preoperative platelet count, and patient age were considered the strongest predictive features. The model predicting serious adverse complications exhibited comparable discrimination [precision (Mean: 0.226, SE: 0.024), recall (Mean: 0.697, SE: 0.048), accuracy (Mean: 0.811, SE: 0.010), F1-score (Mean: 0.341, SE: 0.031)] and superior performance relative to the LOS model [AUC (Mean: 0.806, SE: 0.024), Brier score (Mean: 0.189, SE: 0.010), noting preoperative hematocrit, operative time, and patient age to be most influential. However, the 30-day readmission model achieved the weakest relative performance, displaying low measures of precision (Mean: 0.070, SE: 0.012) and recall (Mean: 0.389, SE: 0.053), despite good accuracy (Mean: 0.791, SE: 0.009).

Conclusion

Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. Modifiable preoperative factors such as hematocrit and platelet count were identified as significant predictive features, suggesting that clinicians could address these factors during preoperative patient optimization to enhance outcomes. Overall, these findings highlight the potential for ML techniques to enhance preoperative management, facilitate shared decision-making, and enable more effective and personalized orthopedic care by exploring alternative approaches to risk stratification.

Fatigue, fear of being mobilized and residual limb pain limit independent basic mobility and physiotherapy for patients early after major dysvascular lower extremity amputation: A prospective cohort study

AIM

Early mobilization of patients with a major lower extremity amputation (LEA) is often a challenge because of lack of compliance. Therefore, we investigated factors limiting independent mobility and physiotherapy on the first day with physiotherapy (PTDay1) and the following 2 days after LEA.

METHODS

A total of 60 consecutive patients, mean age 73.7 years (SD 12.1 years), undergoing LEA were included over a period of 7 months. The Basic Amputee Mobility Score was used to assess basic mobility. Predefined limitations for not achieving independent mobility or not completing physiotherapy were residual limb pain, pain elsewhere, fear of being mobilized, fatigue, nausea/vomiting, acute cognitive dysfunction or "other" factors reported on PTDay1 and the following 2 days after LEA.

RESULTS

Fatigue and fear of being mobilized were the most frequent limitations for not achieving independent mobility on PTDay1 and the following 2 days after LEA. Patients (n = 55) who were not independent in the Basic Amputee Mobility Score activity transferring from bed to chair on PTDay1 were limited by fatigue (44%) and fear of being mobilized (33%). A total of 21 patients did not complete planned physiotherapy on PTDay1, and were limited by fatigue (38%), residual limb pain (24%) and "other" factors (24%).

CONCLUSION

Fatigue and fear of being mobilized were the most frequent factors that limited independent mobility early after LEA. Fatigue, residual limb pain and "other" factors limited completion of physiotherapy. Geriatr Gerontol Int 2024; 24: 470-476.

Incidence, risk factors and impact of anemia after elective neurosurgery: A retrospective cohort study

Objectives

Anemia after surgery is common and is associated with adverse clinical outcomes. Understanding the incidence and risk factors for postoperative anemia is important to reduce anemia-related complications and blood transfusion. There is lack of data regarding postoperative anemia and its contributing factors in neurosurgery. This study evaluates the incidence and risk factors of postoperative anemia, and its impact on clinical outcomes.

Methods

This was a single centre, retrospective study of patients who underwent elective neurosurgery over seven months. Data regarding age, gender, body mass index, American Society of Anesthesiologists (ASA) physical status, diagnosis, surgery, preoperative hemoglobin, surgery duration, intraoperative blood loss and red blood cell (RBC) transfusion, dose of tranexamic acid, intraoperative fluid balance, years of surgeon's experience, postoperative hemoglobin, postoperative RBC transfusion, Glasgow Coma Scale (GCS) score at hospital discharge, and duration of postoperative intensive care unit and hospital stay were collected. Logistic regression was used to identify predictors of postoperative anemia.

Results

The incidence of postoperative anemia was 11.3% (116/1025). On univariate analysis; age, preoperative hemoglobin, surgery duration, gender, ASA grade, surgery type, and surgeon's experience were associated with postoperative anemia. Lower preoperative hemoglobin (p<0.001) and non-tumor surgery (p<0.001) were predictive of postoperative anemia on multivariate analysis. Postoperative anemia resulted in increased RBC transfusion (p<0.001) and lower GCS score at discharge (p=0.012).

Conclusions

Atleast one in ten patients undergoing elective neurosurgery develop postoperative anemia. Lower preoperative hemoglobin and non-tumor surgery predict anemia. Anemia results in increased RBC transfusion and lower discharge GCS score.

Endovascular Repair in Blunt Thoracic Aortic Injury: A 10-Year Single Center Experience

BACKGROUND

Life-threatening blunt thoracic aortic injury (BTAI) typically occurs alongside multiple other traumatic injuries. Symptoms of BTAI can range from being asymptomatic in the case of intimal tears to becoming catastrophic in the case of uncontained aortic ruptures. The aim of this research was to examine the clinical outcomes for those who underwent thoracic endovascular aortic repair (TEVAR) in hospital settings.  Methods: A cross-sectional retrospective study was conducted using patient data that were extracted from Al-Noor Specialist Hospital, Makkah, Saudi Arabia, for the duration between January 2011 and December 2021. This study included data from all patients aged 18 and up who had been diagnosed with BTAI and had undergone TEVAR. The BTAI diagnoses were confirmed using CT scans. Logistic regression was utilized to identify predictors of patients' health status improvement and length of stay.

RESULTS

A total of 80 patients were involved. Around 50.0% (n=40) of the patients had grade 3 thoracic aortic injuries. The median duration of stay was 14.00 days (Interquartile range 21.00). Only one patient developed post-procedure complications (1.3%). Almost one-third (31.3%; n=25) of the patients required subclavian coverage. One patient developed intraoperative endoleak (1.3%). One patient developed an access site complication (1.3%). The mortality rate within 30 days of the operation was 1.3%. The vast majority of the patients (92.5%; n=74) showed improvement upon discharge from the hospital. The baseline patient characteristics and length of hospitalization had no effect on the improvement of patient status upon discharge or their length of stay (p>0.05).

CONCLUSION

Patients with BTAI have shown an excellent success rate with TEVAR and a low complication rate. Predictors of procedure success and length of stay need to be identified; however, this can't be done without larger-scale investigations. This can aid in the development of preventative measures that improve clinical outcomes for the patients.

Risk factors for short-term mortality in elderly hip fracture patients with complicated heart failure in the ICU: A MIMIC-IV database analysis using nomogram

BACKGROUND

Hip fracture is a prevalent and hazardous injury among the elderly population that often results in intensive care unit (ICU) admission due to various complications, despite advanced medical science. One common complication experienced in the ICU by elderly hip fracture patients is heart failure, which significantly impacts short-term survival rates. Currently, there is a deficit of adequate predictive models to forecast the short-term risk of death following heart failure for elderly hip fracture patients in the ICU. This study aims to identify independent risk factors for all-cause mortality within 30 days for elderly patients with hip fractures and heart failure while in the ICU in order to develop a predictive model.

METHOD

A total of 641 elderly patients with hip fractures combined with heart failure were recruited from the Medical Information Mart for Intensive Care IV dataset and randomized to the training and validation sets. The primary outcome was all-cause mortality within 30 days. The least absolute shrinkage and selection operator regression was used to reduce data dimensionality and select features. Multivariate logistic regression was used to build predictive models. Consistency index (C-index), receiver operating characteristic curve, and decision curve analysis (DCA) were used to measure the predictive performance of the nomogram.

RESULT

Our results showed that these variables including MCH, MCV, INR, monocyte percentage, neutrophils percentage, creatinine, and combined sepsis were independent factors for death within 30 days in elderly patients with hip fracture combined with heart failure in the ICU. The C-index was 0.869 (95% CI 0.823-0.916) and 0.824 (95% CI 0.749-0.900) for the training and validation sets, respectively. The results of the area under the curve and decision curve analysis (DCA) confirmed that the nomogram performed well in predicting elderly patients with hip fractures combined with heart failure in the ICU.

CONCLUSION

We developed a new nomogram model for predicting 30-day all-cause mortality in elderly patients with hip fractures combined with heart failure in the ICU, which could be a valid and useful clinical tool for clinicians for targeted treatment and prognosis prediction.

Redefining Multimorbidity in Older Surgical Patients

BACKGROUND

Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations.

STUDY DESIGN

We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general = 230,410 patients, orthopaedic = 778,131 patients, vascular = 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching.

RESULTS

Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general = 85.0% (conventional) vs 55.9% (new) (p < 0.0001); orthopaedic = 66.6% vs 40.2% (p < 0.0001); and vascular = 96.2% vs 52.7% (p < 0.0001). Thirty-day mortality was higher by the new definitions: general = 3.96% (conventional) vs 5.64% (new) (p < 0.0001); orthopaedic = 0.13% vs 1.68% (p < 0.0001); and vascular = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference = -0.94% [-1.36%, -0.52%], p < 0.0001; orthopaedic = -0.20% [-0.34%, -0.05%], p = 0.0087; and vascular = -0.12% [-0.69%, 0.45%], p = 0.6795).

CONCLUSIONS

Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.

A retrospective cohort study of the effect of intravenous tranexamic acid infusion on geriatric hip fractures patients undergoing proximal femoral nail antirotation

Background: Tranexamic acid (TXA) has been used in the management of bleeding. We are conducting a retrospective cohort study to analyse the effect of intravenous TXA infusion on the surgical outcomes of geriatric hip fracture cases which undergoes proximal femoral nail antirotation.  Methods: In this study, 364 patients who had undergone proximal femoral nail antirotation between January 2018 and December 2019 in United Christian Hospital have been recruited. Two-hundred thirteen patients were recruited in controlled group and 151 patients were recruited in TXA group. One gram of TXA acid was injected intravenously on induction of anaesthesia and before surgical incision. Outcomes including length of stay, operation time, intraoperative blood loss, haemoglobin and haematocrit drop and post-operative blood transfusion have been measured. Results: There was a reduction in operative time, intraoperative blood loss, post-operative haemoglobin and haematocrit drop and post-operative blood transfusion in TXA group, with a reduction in the intraoperative blood loss (Controlled group: 97.8 ±  67.7 ml, TXA group: 76.0 ± 71.4, Difference −22.3%, p-value: 0.0036) and post-operative haematocrit drop (Controlled group: 0.04 ± 0.03, TXA group: 0.03 ± 0.03, Difference −25%, p-value: 0.05) being statistically significant. The length of stay is not statistically significant between the two groups. TXA is an antifibrinolytic agent which acts by binding to plasminogen which inhibits plasma formation. It has a potential reduction in blood loss in major operations.  Conclusion: Intravenous TXA infusion helps to reduce blood loss in a patient undergoing proximal femoral nail antirotation. It is safe to use in the geriatric group of patients. We would recommend the usage of TXA infusion to improve the surgical outcome.

The importance of perioperative optimisation to facilitate safe regional anaesthesia and their improved outcomes in fracture neck of femur patients

BACKGROUND

Hip fractures are common presentations to orthopaedic departments, and their surgical management often results in blood transfusions. Compared with general anaesthesia, regional anaesthesia reduces the need for transfusions and mortality in the wider surgical population.

AIMS

In hip fracture patients, our primary outcome measure was to examine any relationship between anaesthetic modality and transfusion rates. The secondary outcome measure was to assess the relationship between anaesthetic modality and one-year mortality.

METHODS

A retrospective cohort study of 280 patients was carried out in 2017 and 2018. Data were collected from patient records, local transfusion laboratory and the national hip fracture database.

RESULTS

A total of 59.6% had regional and 40.4% general anaesthesia. Regional anaesthesia patients were younger with fewer comorbidities (p < .05). About 19.8% regional and 34.5% general anaesthesia patients received transfusions (odds ratio (OR) = 0.47, p < .05); 13.6% were taking anticoagulants and were less likely to receive a regional anaesthetic (31.6% versus 64%, OR = 0.26, p < .05). One-year mortality was 27% for regional and 37% for general anaesthetic patients (OR = 0.64, p = .09).

CONCLUSION

Regional anaesthesia halved the risk of blood transfusion. Anticoagulated patients were 74% less likely to receive regional anaesthetics, but had no additional transfusion risk. With optimisation, a larger proportion of patients could have regional anaesthesia.

Effect of a Patient Blood Management Program on the Appropriateness of Red Blood Cell Transfusion and Clinical Outcomes in Elderly Patients Undergoing Hip Fracture Surgery

BACKGROUND

Elderly patients with hip fractures frequently receive perioperative transfusions, which are associated with increased morbidity and mortality. This study aimed to evaluate the impact of a patient blood management (PBM) program on the appropriateness of red blood cell (RBC) transfusion and clinical outcomes in geriatric patients undergoing hip fracture surgery.

METHODS

In 2018, the revised PBM program was implemented at the Korea University Anam Hospital, Seoul, Republic of Korea. Elderly patients aged ≥ 65 years who underwent hip fracture surgery from 2017 to 2020 were evaluated. Clinical characteristics and outcomes were analyzed according to the timing of PBM implementation (pre-PBM, early-PBM, and late-PBM). Multiveriate regression analysis was used to evaluate the risk factors of the adverse outcomes, such as in-hospital mortality or 30-day readmission.

RESULTS

A total of 884 elderly patients were included in this study. The proportion of patients who received perioperative RBC transfusions decreased significantly (43.5%, 40.1%, and 33.2% for pre-PBM, early-PBM, and late-PBM, respectively; P = 0.013). However, the appropriateness of RBC transfusion significantly increased (54.0%, 60.1%, and 94.7%, respectively; P < 0.001). The duration of in-hospital stay and 30-day readmission rates significantly decreased. Multivariable regression analysis revealed that RBC transfusion (odds ratio, 1.815; 95% confidence interval, 1.137-2.899; P = 0.013) was significantly associated with adverse outcomes.

CONCLUSION

Implementing the PBM program increased the appropriateness of RBC transfusion without compromising transfusion quality and clinical outcomes. Therefore, adopting the PBM program may improve the clinical management of elderly patients following hip fracture surgery.

Preoperative Risk Factor Analysis and Dynamic Online Nomogram Development for Early Infections Following Primary Hip Arthroplasty in Geriatric Patients with Hip Fracture

Background

Hip arthroplasty is in increasing demand with the aging of the world population, and early infections, such as pneumonia, surgical site infection (SSI), and urinary tract infection (UTI), are uncommon but fatal complications following hip arthroplasty. This study aimed to identify preoperative risk factors independently associated with early infections following primary arthroplasty in geriatric hip fracture patients, and to develop a prediction nomogram.

Methods

Univariate and multivariate logistical analyses were performed to identify the independent risk factors for early infections, which were combined and transformed into a nomogram model. The prediction model was evaluated by using the area under the receiver operating characteristic curve (AUC), Hosmer-Lemeshow test, concordance index (C-index), 1000 bootstrap replications, decision curve analysis (DCA), and calibration curve.

Results

One thousand eighty-four eligible patients got included and 7 preoperative variables were identified to be independently associated with early infections, including heart disease (odds ratio (OR): 2.17; P: 0.026), cerebrovascular disease (OR: 2.25; P: 0.019), liver disease (OR: 8.99; P: <0.001), time to surgery (OR: 1.10; P: 0.012), hematocrit (<lower limit; OR: 3.72; P: 0.015), the platelet-to-mean platelet volume ratio (PMR; >44.52; OR: 2.73; P: 0.047), and high-sensitivity C-reactive protein (HCRP; >78.64mg/L; OR: 3.71; P: <0.001). For the nomogram model, AUC was 0.807 (95% confidence interval (CI): 0.742-0.873), the Hosmer-Lemeshow test demonstrated no overfitting (P = 0.522), and C-index was 0.807 (95% CI: 0.742-0.872) with corrected value of 0.784 after 1000 bootstrapping validations. Moreover, the calibration curve and DCA exhibited the tools' good prediction consistency and clinical practicability.

Conclusion

Heart disease, cerebrovascular disease, liver disease, time to surgery, hematocrit, PMR, and HCRP were significant preoperative predictors for early infections following primary arthroplasty in elderly hip fracture patients, and the converted nomogram model had strong discriminatory ability and translatability to clinical application.

Perioperative Management and Outcomes of Hip Fracture Patients with Advanced Chronic Kidney Disease

Aims

To explore clinical characteristics, perioperative management and outcomes of Hip Fracture patients with advanced Chronic Kidney Disease (HF-aCKD) compared to the general Hip Fracture population without aCKD (HF-G) within a large volume tertiary hospital in Western Australia.

Methods

Retrospective chart review of patients admitted with hip fracture (HF) to a single large volume tertiary hospital registered on Australian and New Zealand Hip Fracture Registry (ANZHFR). We compared baseline demographic and clinical frailty scale (CFS) of HF-aCKD (n = 74), defined as eGFR < 30 mls/min/1.73 m2, with HF-G (n = 452) and determined their outcomes at 120 days.

Results

We identified 74 (6.97%) HF patients with aCKD. General demographics were similar in HF-aCKD and HF-G populations. 120-days mortality for HF-aCKD was double that of HF-G population (34% vs 17%, P = .001). For dialysis patients, 120-days mortality was triple that of HF-G population (57%). Except for the fit category of HF-aCKD group, higher CFS was associated with higher 120-days mortality in both groups. Of all HF-aCKD patients, 96% had operative intervention and 48% received blood transfusion. There were no new starts to dialysis peri-operatively. Each point reduction in eGFR below 12 mL/min/1.73 m2 was associated with 3% increased probability of death in hospital.

Conclusions

120-days mortality was double in HF-aCKD and triple in HF-dialysis that of the HF-G within our institution. Clinical frailty scale can be useful in predicting mortality after HF in frail aCKD patients. High rate of blood transfusions was observed in HF-aCKD group. Further studies with larger HF-aCKD numbers are required to explore these associations in detail.

A nationwide study of blood transfusion in hip fracture patients

Aims

The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients.

Methods

A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes.

Results

A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001), intramedullary fixation (OR 7.15 (95% CI 6.50 to 7.86); p < 0.001), and sliding hip screw constructs (OR 2.34 (95% CI 2.19 to 2.50); p < 0.001). Blood transfusion during admission was significantly associated with higher rates of 30-day mortality (OR 1.35 (95% CI 1.19 to 1.53); p < 0.001) and 60-day mortality (OR 1.54 (95% CI 1.43 to 1.67); p < 0.001), as well as delays to postoperative mobilization, higher likelihood of not returning to their home, and longer length of stay.

Conclusion

Blood transfusion after hip fracture was common, although practice varied nationally. RBCT is associated with adverse outcomes, which is most likely a reflection of perioperative anaemia, rather than any causal effect. Use of RBCT does not appear to reverse this effect, highlighting the importance of perioperative blood loss reduction. Cite this article: Bone Joint J 2022;104-B(11):1266–1272.

Intertrochanteric Fracture Surgery Patients with Diabetes Mellitus are Prone to Suffer Perioperative Neurological and Endocrine/Metabolic Complications: A Propensity-Score Matched Analysis

Background

In older adults, the recovery after hip fracture surgery is not always to be well expected due to high risks of adverse outcomes including perioperative complications and mortality. We aimed to evaluate the intertrochanteric fracture (IF) patients with diabetes mellitus (DM) and receiving surgical fixation with intramedullary nail on the perioperative complications, total hospital costs (THC), length of hospital stay (LOS), and mortality.

Methods

In this retrospective cohort study, among 487 consecutive intertrochanteric fracture patients with age over 65 years and treated surgically by using intramedullary nail between Jan. 2015 and Mar. 2020, 353 patients were included, including 81 with DM and 272 without DM. After using propensity-score matched (PSM) analysis, 80 patients remained in each group. The perioperative complications, 30-day, 90-day, 1-year, and 2-year survival rates, THC, and LOS were observed and compared between two groups. Overall survival was compared by Kaplan–Meier method.

Results

No significant between-group differences were found in 30-day, 90-day, 1-year, and 2-year mortality rates, THC, LOS, and other perioperative complications after PSM and McNemar’s tests (all p>0.05), except for neurological complications (p<0.004) and endocrine/metabolic complications (p<0.001). At a mean follow-up time of 36.2 months, there were no statistically significant differences between the groups based on the Kaplan–Meier survival curve (p=0.171, log-rank).

Conclusion

IF surgery patients with DM are more prone to suffer perioperative neurological and endocrine/metabolic complications and they should be managed individually while being aware of these risks henceforth. Further high evidence clinical trials are needed to expand in DM patients with IF.

Using tranexamic acid for an additional 24 hours postoperatively in hip and knee arthroplasty saves money: a cost analysis from the TRAC-24 randomized control trial

Aims

Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT.

Methods

TRAC-24 was a prospective RCT on patients undergoing TKA and THA. Three groups were included: Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour postoperative oral regime, Group 2 received only the perioperative dose, and Group 3 did not receive TXA. Cost analysis was performed out to day 90.

Results

Group 1 was associated with the lowest mean total costs, followed by Group 2 and then Group 3. The differences between Groups 1 and 3 (-£797.77 (95% confidence interval -1,478.22 to -117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in Groups 1 and 2 resulted from reduced length of stay, readmission rates, emergency department attendances, and blood transfusions.

Conclusion

This study demonstrated significant cost savings when using TXA in primary THA or TKA. Extended oral dosing reduced costs further in THA but not TKA.

Cite this article: Bone Jt Open 2022;3(7):536–542.

Incidence and risk factors associated with surgical site infection after surgically treated hip fractures in older adults: a retrospective cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common complications in the traumatic orthopedics field, but remains not adequately studied after hip fractures.

AIMS

This study aims to investigate the incidence and risk factors associated with SSI after surgically treated hip fractures in older adults.

METHODS

A retrospective cohort study including 2932 older adult patients (1416 with femoral neck fracture and 1516 with intertrochanteric fracture) surgically treated from Jan 2015 to Dec 2019 due to hip fractures was performed. Their data on demographics, injury-related data, surgery-related data, and preoperative laboratory test results were collected from hospitalization medical records. Univariate analyses were used to compare between the patients with and without SSI, and multivariate logistic regression analyses were used to identify the risk factors.

RESULTS

A total of 89 patients developed SSI, with an accumulated incidence rate of 3.04% (95%CI 2.41-3.66). Staphylococcus aureus was the most common source of infection. In univariate analysis, 11 items were found to be significant in femoral neck fractures and 5 items were found to be significant in intertrochanteric fracture. In the multivariable logistic regression model, cerebrovascular disease (OR 2.17, 95%CI 1.14-4.15) and hematocrit (HCT) (< Lower limit) (OR 3.46, 95%CI 1.13-10.56) were independent risk factors for SSI in femoral neck fracture. Heart disease (OR 2.13, 95%CI 1.18-3.85) was a risk factor for SSI, while LDH (> 250 U/L) (OR 0.44, 95%CI 0.20-0.95) was a protective factor for SSI in intertrochanteric fracture.

DISCUSSION

We observed 89 cases (3.04%) of SSI in 2932 older adult patients with hip fractures in this study. Cerebrovascular disease and lower HCT were two independent risk factors for SSI in femoral neck fracture, whereas heart disease was a risk factor and LDH was a protective factor for SSI in intertrochanteric fracture.

CONCLUSIONS

Targeted preoperative management, such as predicting the probability of SSI and taking appropriate measures accordingly is essential and highly regarded. Future multicentric studies with more patients evaluated are expected to better address the risk factors for SSI in older hip fracture patients.

Non-erythropoiesis-stimulating agent, non-iron therapies for the management of anaemia: protocol for a scoping review

INTRODUCTION

Preoperative anaemia is associated with poor postoperative outcomes and is the strongest predictor of allogenic blood transfusion, which contributes further to patient morbidity. Emphasis has been placed on correcting anaemia prior to surgery to mitigate these outcomes. Conflicting evidence exists regarding the benefit of currently recommended interventions. With greater understanding of iron haemostasis and erythropoiesis, novel therapies have been identified. These are at varying stages of development with some demonstrating promising results in patients with chronic kidney disease. It is not known how these agents have been studied outside this population, particularly in the perioperative context. To address this, we will conduct a scoping review of the published literature to chart the evidence.

METHODS AND ANALYSIS

The scoping review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews framework. The electronic database search will include Scopus, MEDLINE (Ovid) and Excerpta Medica database (Ovid), with no language restrictions, and will include all publications since 1 January 2010. This review will have three objectives: (1) to describe the mechanisms of action for novel agents, (2) to describe the level of evidence and stage of development of novel agents in a perioperative setting, and (3) to determine the potential agents suitable for prospective controlled trials in a preoperative or postoperative patient cohort and aiming to improve patient-centred outcomes. The review process will involve two reviewers with a third reviewer resolving disagreements. Data will be extracted and organised with subsequent analysis.

ETHICS AND DISSEMINATION

This scoping review does not require research ethics approval. The results will be published in a peer-reviewed journal and inform the development of future prospective trials based on established evidence from potential therapeutic agents.

TRIAL REGISTRATION NUMBER

This protocol has been registered prospectively on the Open Science Framework registry (DOI:10.17605/OSF.IO/SM3UH, https://osf.io/sm3uh/?view_only=39876ccf7a4348dfbd566535b957a7db).Cite Now.

Blood transfusions and hip fracture mortality - A retrospective cohort study

BACKGROUND

Hip fractures are associated with serious morbidity and mortality. Low haemoglobin at presentation has been shown to be associated with increased mortality in hip fracture patients. This comorbid patient group commonly receives packed red cell blood transfusions during their hospital admission, the impact of which is less clear.

AIMS AND OBJECTIVES

We aim to assess the rate, appropriateness and impact of blood transfusions on one-year mortality in hip fracture patients. We also aim to assess the impact of patients taking anticoagulant medications at presentation on the rates of blood transfusions in this patient group.

METHODS

A retrospective cohort study of 324 consecutive hip fracture patients. Data was collected from the national hip fracture database, electronic patient records and PACS.

RESULTS

75 patients received a blood transfusion. Receiving a blood transfusion increased absolute risk of one-year mortality by 2.466 (p < 0.05). Adjusted for age, sex, comorbidities, residence prior to admission and time from presentation to surgery increased the risk of one-year mortality was 2.790 (p < 0.05).28% of patients who went on to receive a transfusion had a haemoglobin of less than 100 g/L at presentation. 94.6% of transfused patients had a pre-transfusion haemoglobin of less than 90 g/L. There was no increased risk of requiring a blood transfusion if anticoagulant medication was being taken at presentation.

CONCLUSION

Receiving a blood transfusion during an admission for hip fracture carried an increased risk of one-year mortality of almost two and a half times. With appropriate preoperative optimisation, taking an anticoagulant medication at presentation did not increase the risk of requiring a transfusion. Most blood transfusions were administered appropriately using thresholds. Just over a quarter of patients who received a transfusion had an admission haemoglobin of less than 100 g/L, showing it as a poor predictor of blood transfusion requirement during admission.

Using Fracture Patterns and Planned Operative Modality to Identify Fractured Neck of Femur Patients at High Risk of Blood Transfusion

Background Fractured neck of femurs is common, serious injuries usually requiring operative management. Red blood cell transfusions are often required to treat perioperative anaemia, but these are not without adverse effects. Aims and objectives The aim of this study is to identify subgroups of fractured neck of femur patients more likely to require red blood cell transfusions. We try to identify targeted strategies to reduce blood transfusion-associated adverse effects and thus improve outcomes. Design and methods A retrospective cohort study of 324 patients. Patients were divided into cohorts based on radiological fracture patterns and operations performed. Data were collected from patient records, picture archiving and communication systems, the local transfusion laboratory, and the national hip fracture database. The primary outcome was blood transfusion rates in different fracture patterns in fractured necks of femur patients. The secondary outcome was blood transfusion rates in different operation types for fractured neck of femur patients. Chi-squared tests for independence were performed. Results 14.9%, 34.7% and 33.3% of patients with intracapsular, intertrochanteric and subtrochanteric fractures, respectively, received blood transfusions. There was a significant relationship between fracture pattern and blood transfusion (X 2 (2, N = 324) = 17.1687, p = 0.000187). 47% of patients receiving long intramedullary nails, 45% of short intramedullary nails, 27% of open reduction internal fixations, 18% of hemiarthroplasties and 9% of total hip arthroplasties resulted in blood transfusions. There was a significant relationship between operative modality and blood transfusion (X 2 (4, N = 302) = 22.0184, p = 0.000199). Conclusion In patients who have sustained a fractured neck of the femur, the fracture pattern and operative modality are both independently associated with the rates of red blood cell transfusion. In these identified groups, we propose that increased vigilance and awareness regarding transfusion avoiding strategies are utilised with the goal of improving patient outcomes.

Intramedullary Fixation Does Not Cause a Large Amount of Hidden Blood Loss in Elderly Patients with Intertrochanteric Fractures

Purpose

Controversy remains around intramedullary fixation of intertrochanteric fractures in elderly patients when considering hidden blood loss (HBL). However, whether treating the fractures with intramedullary fixation causes a large amount of HBL is not known.

Patients and Methods

In this retrospective cohort study, 1,017 consecutive patients aged ≥65 years with acute intertrochanteric fractures were included and assigned to three groups (non-operative group, delayed surgery group, and acute surgery group) between July 2013 and January 2018. The data of patients’ demographics, injury-related data, operation-related data, comorbidities, perioperative hemoglobin values, transfusion data and serial of HBL calculated during hospitalization were collected and compared among three groups. All independent variables were further analyzed by multiple linear regression to evaluate the influential factors of HBL. A long-term follow-up was conducted and survival analysis was performed for all individuals.

Results

Our results showed that fixation by proximal femoral nail anti-rotation for intertrochanteric fracture has been estimated to contribute 11–34% of the increase of HBL during hospitalization and it does not increase the allogeneic transfusion rate. For HBL, male patients, unstable fracture, and blood transfusion may have strong influences. Surgical delay was associated with longer time from injury to hospital admission, higher ASA-grade, and comorbidities such as diabetes and coronary heart disease. Survival analysis revealed that mortality increased in patients with conservative treatment, where a rapid decline was found in the first year, especially in the 90 days after injury. A higher mortality rate was also obtained in patients with surgery delay than acute surgery patients.

Conclusion

In conclusion, HBL is the main component of total blood loss and it is more likely to result from the initial trauma rather than the surgery. Intertrochanteric fracture treated by intramedullary fixation does not cause a large amount of HBL.

Early Outcomes After Surgical Management of Geriatric Patella Fractures

Objectives:

To report the incidence and risk factors for prolonged hospitalization, discharge to a facility, and postoperative complications in geriatric patients who underwent surgery for patella fracture.

Design:

Retrospective database review.

Setting:

The American College of Surgeons—National Surgical Quality Improvement Program (NSQIP) collects data from 600 hospitals across the United States.

Patients/Participants:

NSQIP patients over 65 years of age with patella fractures.

Intervention:

Surgical fixation of patella fracture including extensor mechanism repair.

Main Outcome Measurements:

Prolonged hospitalization, discharge to a facility, and 30-day post-operative complications.

Results:

1721 patients were included in the study. The average age was 74.9 years. 358 (20.8%) patients were male. 122 (7.1%) patients had a length of stay greater than 7 days. Factors associated with prolonged length of stay include pre-existing renal failure, need for emergent surgery, and time to surgery greater than 24 hours from admission. 640 patients (37.2%) of patients were discharged to a facility after surgery. Discharge to facility was associated with age >77 years, obesity, anemia, thrombocytopenia, pre-operative SIRS, and CCI > 0.5. Admission from home decreased the odds of discharge to a facility. The most common postoperative complications in this population were unplanned readmission (3.4%), unplanned reoperation (2.7%), surgical site infection (1.1%), mortality (1.0%), venous thromboembolism (0.8%), and wound dehiscence (0.2%). Complication rates increased with anemia and ASA class IV-V.

Conclusions:

Geriatric patients undergoing operative intervention for patella fractures are at high risk for prolonged hospitalization, discharge to facility, unplanned readmission or reoperation, and surgical site complications in the first 30 days following surgery. This study highlights modifiable and non-modifiable risk factors associated with adverse events. Early recognition of these factors can allow for close monitoring and multidisciplinary intervention in the perioperative period to improve outcomes.

Level of Evidence:

Prognostic level III.

Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.

Euthyroid sick syndrome in hip fractures: Evaluation of postoperative anemia

INTRODUCTION

Incidence of hip fractures is increasing with upward estimates representing one of the most current health problems. According to some authors this condition is associated with an early mortality rate ranging between 20% and 35% and low outcomes. One of the predictive factors of poor outcome after hip fracture is anaemia. In fragile patients, hormonal changes due to fracture and surgical trauma, may occur in the hypophyseal hypothalamus axis which may lead to the Euthyroid Sick Syndrome (ESS). This pathological condition is characterized by a reduction in the concentration of triiodothyronine (T3) with normal or slightly reduced thyrotropin (TSH) values and with or without a reduction (cancellata) ​​of thyroxine (T4). ESS has been associated to an increased mortality in elderly patients.

MATERIALS AND METHODS

Inclusion criteria were: age > 65y, X-ray diagnosis of proximal femoral fracture classified as AO 31A or 31B requiring surgical treatment, admittance to the emergency room within 72 hours from trauma. Exclusion criteria were: any thyroid-related pathology, concomitant acute coronary syndrome, active pneumonia, concomitant neoplastic disease, assumption of medications able to affect thyroid function, refusal to undergo surgical treatment. All patients underwent routine blood testing and a complete thyroid-hormone profile dosage before surgical operation. The same blood tests performed before surgical operation were repeated on the first and third post-operative days.

RESULTS

Thirtytwo patients met the inclusion criteria and were enrolled after they accepted to participate to the study. Sixteen patients presented with ESS on admission and 16 patients did not. The mean age was 82,5 yo. There was no statistically significant difference in bleeding risk factors among the two groups. In the ESS group there was a number of blood transfusions of 1.06 units higher than the control group (p=0.01).

CONCLUSIONS

We have demonstrated that patients with ESS have a higher need of red blood cells  transfusion compared to patients without ESS and, thus they have a higher risk to develop anemia in the peri-operative period. We believe it would be useful to diagnose ESS in fragile patients at their arrival to the emergency room and apply a peri-operative therapeutic protocol to prevent anemia.

Super elderly patients with intertrochanteric fractures do not predict worse outcomes and higher mortality than elderly patients: a propensity score matched analysis

We aimed to investigate whether super elderly patients aged over 90 years had significantly worse functional outcomes, perioperative complications, and survival rates. Among 3560 patients aged over 65 years presenting with intertrochanteric fractures and treated surgically between Jan 2014 and Jan 2019, 2242 patients were included, including 206 in super elderly group and 2036 in elderly group. After using propensity score matching to minimize the effects of possible confounding variables, 192 remained in each group. No significant difference was observed in functional outcomes, perioperative complications, or 30-day, 90-day, and 1-year mortality after propensity score matching and McNemar’s tests (p>0.05). After an average follow-up of 37 months, the Kaplan-Meier survival curve showed no significant difference between the two groups in terms of cumulative survival rate (p=0.081, log-rank). Our data demonstrated progressive increases in mortality and poor outcomes with increasing Elixhauser comorbidity scores, which represented the severity index of patients preoperatively. Our study also found that there were weak correlations between five characteristics and the patient age. These results all suggested that it is not the advanced age itself but other concomitant factors, that appear to be responsible for the adverse functional outcomes, perioperative complications, and mortality in super elderly patients.

Delay in detection and treatment of perioperative anemia in hip fracture surgery and its impact on postoperative outcomes

BACKGROUND

Elderly patients with hip fractures are at high risk for perioperative anemia as a result of fracture- and surgery-related blood loss. The detection of anemia is dependent on intermittent blood samples and therefore might be delayed, potentially leading to a significant delay in transfusion. This study aimed to investigate the possible delay in perioperative anemia detection, accumulated perioperative anemia-associated burden, peripheral perfusion, and their association with patient outcomes in elderly patients with hip fracture.

METHODS

Elderly patients with acute hip fracture scheduled for surgery were enrolled in this prospective study from August 2016 to December 2016. All patients were monitored continuously for hemoglobin concentration (SpHb) and perfusion index (PI) with the Radical-7® Pulse CO-Oximeter® and Rainbow® R1 Adhesive Multi-parameter Sensors (Masimo Corp., Irvine, CA, US) from 12 h presurgery to 24 h postsurgery.

RESULTS

Fifty-one patients were enrolled, and 41 were included in the final analyses. Mean delay in the detection of low Hb (<10 g/dL) using intermittent blood samples, when compared with SpHb, was 1.07 h (standard deviation, ±2.84 h). Median perioperative cumulated time with low SpHb (<10 g/dL for at least one min) was 25 min (interquartile range [IQR]: 21-690). There was a significant association between perioperative time with low SpHb and the occurrence of postoperative delirium (median cumulated time with low SpHb: 162 min in patients with delirium vs 22 min in patients without delirium, P = 0.034) and a nonsignificant trend for an association between perioperative time with low SpHb and 90-day mortality or medical complications (median cumulated time with low SpHb: 119 min for patients with mortality or severe complication vs 22 min for patients without mortality or severe complication, P = 0.104). PI values during the perioperative period were not significantly associated with patient outcomes. Cumulated time with low PI (<0.5) preoperatively (but not perioperatively) was significantly associated with the occurrence of postoperative delirium (P = 0.047).

CONCLUSIONS

This study showed a delay in transfusion threshold detection, and the presence of significant associations between low SpHb or time with low SpHb and postoperative outcomes.

Blood management in hip fractures; are we leaving it too late? A retrospective observational study

BACKGROUND

Anaemia in hip fracture patients has been associated with increased risk of allogenic blood transfusion (ABT), poorer functional outcomes and increased mortality. Few studies have reported the prevalence of anaemia on admission or its progression prior to surgery in this cohort. We aimed to measure the prevalence of anaemia on admission in older persons who sustain a hip fracture, identify if anaemia develops or progresses prior to surgery, and to report associations with outcome.

METHODS

A retrospective, observational study was undertaken in a regional hospital. All patients aged 60 and over, admitted with a primary hip fracture resulting from a simple fall, in the 12 months of 2014 were included. The World Health Organization (WHO) definition of anaemia was used. Pathology databases and clinical records were reviewed to collect data. Repeated measures ANOVA's were used to quantify the progression of anaemia prior to surgery, and Chi square test were used to report associations with outcome variables.

RESULTS

Two hundred sixty-one patients were identified, median age was 81 years. There were twice as many females as males and just over half the sample had extracapsular fractures. Anaemia was present on admission in 45% (n = 117), highest incidence of anaemia occurred in males 52.0% (n = 39), extracapsular fractures 41.9% (n = 78) and those aged over 80 years 49.7% (n = 91). Progression of anaemia prior to surgery was significant in all groups (p < 0.05), with the greatest reduction seen in extracapsular fractures. Pre-surgery reduction in Hb was recorded in 82.3% of patients between admission and day 1, and in 71.4% between admission and day 2. There was significant association between anaemia on admission and PRBC transfusion (p < 0.05), in hospital mortality (p < 0.05) however no association with the use of antiplatelet or anticoagulant medication, nor LOS.

CONCLUSIONS

The findings demonstrate that pre-surgical anaemia in older hip fracture patients is associated with a PRBC transfusion and increased hospital mortality. Importantly, it also identified that patients continue to bleed after admission, leading to the development of or worsening anaemia. Thus, identification anaemia in the pre-surgical period provides an opportunity for treatment to avoid transfusions and improve patient outcomes.

Clinical standards for patient blood management and perioperative hemostasis and coagulation management. Position Paper of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new "standard of care" so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period.

Surgical and Clinical Results of Minimally Invasive Spinal Fusion Surgery in an Unselected Patient Cohort of a Spinal Care Unit

OBJECTIVES

To review the surgical results and to identify possible parameters influencing the clinical outcomes in an unselected patient collective undergoing minimally invasive lumbar interbody fusion in a spinal care unit.

METHODS

A total of 229 adult patients who underwent minimally invasive lumbar spinal fusion between 2008 and 2016 were included in this retrospective analysis. Lumbar fusion was performed using transforaminal interbody fusion (TLIF) devices and posterolateral fusion. To eliminate confounding parameters, in all patients interbody fusion was indicated by lumbar degenerative pathologies, and surgery was performed using the same fusion device. Treatment efficacy was evaluated using scores describing pain (visual analogue scale [VAS]) and health impairment (EQ-5D, Oswestry Disability Index [ODI]). The influence of patient age, obesity, active smoking status, and co-morbidities on clinical outcome and perioperative complications was analyzed.

RESULTS

The patient population reviewed had improved VAS (P_{(leg pain)} ≤ 0.0001, P_{(back pain)} ≤ 0.0001), ODI (P ≤ 0.0001), EQ-VAS (P ≤ 0.0001), and EQ-5D subscales "mobility", "self-care", "pain", and "anxiety" (P_(mobility) ≤ 0.0001, P_(self-care)  = 0.41, P_(pain) ≤ 0.0001, P_(anxiety)  = 0.011) postoperatively. Neither advanced patient age, nor increased body mass index (BMI), hypertension, or active smoking status had a significantly limiting influence on the success of minimally invasive spinal surgeries (MIS). Duration of surgery strongly correlated with the number of spinal levels treated and with intraoperative blood loss (r = 0.774, P ≤ 0.0001, n = 208). Weak positive correlations were found between patient age and duration of surgery (r = 0.184, P = 0.005, n = 229), intraoperative blood loss (r = 0.165, P = 0.012, n = 229), and duration of hospitalization (r = 0.270, P ≤ 0.0001, n = 228), respectively. When compared to non-smokers, smokers were younger (P ≤ 0.0001), and had a significantly lower BMI (P = 0.001), shorter durations of surgery (P ≤ 0.0001), decreased intraoperative blood loss (P = 0.022), and shorter hospital stays (P = 0.006), respectively. Complications occurred in 17 patients (7%) and were not affected by patient age, BMI, hypertension, or active smoking status.

CONCLUSION

Minimally invasive spinal surgery is a safe and effective treatment option and may be superior to open surgery in subpopulations with significant co-morbidities and risk factors, such as elderly and obese patients as well as patients with an active smoking status.

What is the effect of perioperative intravenous iron therapy in patients undergoing non-elective surgery? A systematic review with meta-analysis and trial sequential analysis

Background

Guidelines to treat anaemia with intravenous (IV) iron have focused on elective surgical patients with little attention paid to those undergoing non-elective/emergency surgery. Whilst these patients may experience poor outcomes because of their presenting illness, observational data suggests that untreated anaemia may also be a contributing factor to poor outcomes. We conducted a systematic review to investigate the safety and efficacy of IV iron in patients undergoing non-elective surgery.

Methods

We followed a pre-defined review protocol and included randomised controlled trials (RCTs) in patients undergoing non-elective surgery who received IV iron. Primary outcomes were all-cause infection and mean difference in haemoglobin (Hb) at follow-up. Secondary outcomes included transfusion requirements, hospital length of stay (LOS), health-related quality of life (HRQoL), mortality and adverse events.

Results

Three RCTs (605 participants) were included in this systematic review of which two, in both hip fracture (HF) patients, provided data for meta-analysis. Both of these RCTs were at low risk of bias. We found no evidence of a difference in the risk of infection (RR 0.99, 95% CI 0.55 to 1.80, I ² = 9%) or in the Hb concentration at 'short-term' (≤ 7 days) follow-up (mean difference - 0.32 g/L, 95% CI - 3.28 to 2.64, I ² = 37%). IV iron did not reduce the risk of requiring a blood transfusion (RR 0.90, 95% CI 0.73 to 1.11, p = 0.46, I ² = 0%), and we observed no difference in mortality, LOS or adverse events. One RCT reported on HRQoL and found no difference between treatment arms.

Conclusion

We found no conclusive evidence of an effect of IV iron on clinically important outcomes in patients undergoing non-elective surgery. Further adequately powered trials to evaluate its benefit in emergency surgical specialties with a high burden of anaemia are warranted.

Trial registration

This systematic review was registered on PROSPERO (CRD42018096288).

A practical risk scale for predicting morbidity and mortality in the emergency general surgical setting: A prospective multi-center study

BACKGROUND

Low albumin is a prognostic factor associated with poor surgical outcomes. We aimed to examine the predicative ability of easily obtainable point-of-care variables in combination, to derive a practical risk scale for predicting older adults at risk of poor outcomes on admission to the emergency general surgical setting.

METHODS

This is an international multi-center prospective cohort study conducted as part of the Older Persons Surgical Outcomes Collaboration (www.OPSOC.eu). The effect of having hypoalbuminemia (defined as albumin ≤3.5 g/dL) on selected outcomes was examined using fully adjusted multivariable models. In a subgroup of patients with hypoalbuminemia, we observed four risk characteristics (Male, Anemia, Low albumin, Eighty-five and over [MALE]). Subsequently, the impact of incremental increase in MALE score (each characteristic scoring 1 point (maximum score 4) on measured outcomes was assessed.

RESULTS

The cohort consisted of 1406 older patients with median (IQR) age of 76 (70-83) years. In fully adjusted models, hypoalbuminemia was significantly associated with undergoing emergency surgery (1.32 (95%CI 1.03-1.70); p = 0.03), 30-day mortality (4.23 (2.22-8.08); p < 0.001), 90-day mortality (3.36 (2.14-5.28); p < 0.001) (primary outcome), and increased hospital length of stay, irrespective of whether a patient received emergency surgical intervention. Every point increase in MALE score was associated with higher odds of mortality, with a MALE score of 4 being associated with 30-day mortality (adjusted OR(95% CI) = 33.38 (3.86-288.7); p = 0.001) and 90-day mortality (11.37 (3.85-33.59); p < 0.001) compared to the reference category of those with MALE score 0.

CONCLUSIONS

The easy to use and practical MALE risk score calculated at point of care identifies older adults at a greater risk of poor outcomes, thereby allowing clinicians to prioritize patients who may benefit from early comprehensive geriatric assessment in the emergency general surgical setting.

Preoperative anemia: a common finding that predicts worse outcomes in patients undergoing primary hiatal hernia repair

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.

Implementation of a patient blood management program in an Australian private hospital orthopedic unit

Background

Preoperative anemia in surgical patients has been linked to increased rates of allogeneic blood transfusion (ABT) and associated adverse patient outcomes such as prolonged ventilation in intensive care, increased length of hospital stay, and infections. We conducted a multifaceted implementation for orthopedic surgeons to improve preoperative patient assessment of anemia and iron deficiency to reduce perioperative blood transfusions.

Materials and methods

Using a before-and-after study design of independent samples, we recruited a convenience sample of surgeons who performed primary total hip arthroplasty at 1 Australian private hospital. Our implementation intervention consisted of: executive support, interactive education, and peer-to-peer support to encourage adherence to the National Blood Authority’s Patient Blood Management Program (PBMP) guidelines. We also used monthly reminders, e-learning access, and posters. Pre and post medical record audits evaluated preoperative blood tests, preoperative anemia, and number of blood units transfused between day of surgery until discharge. The primary outcome was an increase in the proportion of patients with preoperative blood tests undertaken prior to total hip arthroplasty surgery as recommended by the PBMP guidelines.

Results

Audits from 239 pre- and 263 postimplementation patients from 3 surgeons were conducted. Our primary outcome showed a significantly increased proportion of patients who had all the required preoperative tests postimplementation (0% to 94.6%; P<0.0001). Administration of ABT significantly decreased (pre: 9.2%, n=22; post: 2.3%, n=6; P=0.001) as well as the standard 2 blood units transfused (pre: 73%, n=16; post: 17%, n=1; P=0.022). The time between preoperative tests and day of surgery increased from 16 to 20 days (P<0.0001), allowing more time for physician’s review of test results.

Conclusion

Our results demonstrated successful implementation of a targeted PBMP to improve preoperative assessment to diagnose and treat anemia and/or iron deficiency prior to orthopedic surgery. This avoided unnecessary ABT and therefore mitigated potential risk to the patient.

Induction of the pneumococcal vncRS operon by lactoferrin is essential for pneumonia

Streptococcus pneumoniae (pneumococcus), the major pathogen for pneumonia, commonly colonizes the lung, but the mechanism underlying the coordination of virulence factors during invasion via the host protein remains poorly understood. Bacterial lysis releases the components of the cell wall, and triggers innate immunity and the subsequent secretion of pro-inflammatory cytokines. Previously, the virulence of the pep27 mutant was shown to be attenuated as a feasible candidate for vaccine development. However, the role of pep27 gene, belonging to the vancomycin-resistance locus (vncRS operon), in virulence, is largely unknown. This study demonstrates that transferrin in the host serum reduces the survival of the host during S. pneumoniae infections in mice. The exposure of the pneumococcal D39 strain to lactoferrin induced the vncRS operon, lysis, and subsequent in vivo cytokine production, resulting in lung inflammation. However, these responses were significantly attenuated in pneumococci harboring a mutation in pep27. Mechanistically, the VncS ligand, identified as lactoferrin, induced the vncRS operon and increased the in vivo mortality rates. Thus, serum-induced activation of vncRS plays an essential role in inducing pneumonia.

Effect of Pre-operative Anaemia on Post-operative Complications in Low-Resource Settings

BACKGROUND

In high-resource settings, even mild anaemia is associated with an increased risk of post-operative complications. Whether this is true in low-resource settings is unclear. We aimed to evaluate the effect of anaemia on surgical outcomes in the Republic of Congo and Madagascar.

METHOD

It is a retrospective chart review of 2064 non-pregnant patients undergoing elective surgery with Mercy Ships. Logistic regression was used to determine the association between pre-operative anaemia and pre-defined surgical complications, adjusted for age, gender, surgical specialty, and country.

RESULTS

The average age of patients was 27.2 years; 56.7% were male. Sixty-two percent of patients were not anaemic, and 22.7, 13.9 and 1.4% met sex-related criteria for mild, moderate and severe anaemia, respectively. In adjusted analyses, the severe anaemia group had an 8.58 [3.65, 19.49] higher odds of experiencing any surgical complication (p < 0.001) compared to non-anaemic patients. Analysis of each complication showed a 33.13 [9.57, 110.39] higher odds of unexpected ICU admission (p < 0.001); a 7.29 [1.98, 21.45] higher odds of surgical site infection (p < 0.001); and 7.48 [1.79, 25.78] higher odds of requiring hospital readmission (p < 0.001). Evaluating other anaemia categories, only those with moderate anaemia had a higher risk of requiring ICU admission (odds ratio 2.75 [1.00, 7.04], p = 0.04) compared to those without anaemia.

CONCLUSION

Our results indicate that in low-income settings, severe anaemia is associated with an increased risk of post-operative complications including unexpected ICU admission, surgical site infection and hospital readmission, whereas mild anaemia was not associated with increased post-operative complications.

The physician's role in perioperative management of older patients undergoing surgery

Life-sustaining and life-improving surgical interventions are increasingly available to older, frailer patients, many of whom have multimorbidity. Physicians can help support perioperative multidisciplinary teams with assessment and preoperative optimisation of physiological reserve, comorbidities and associated geriatric syndromes. Similar structured support can be useful in the postoperative period where older patients are at increased risk of delirium, medical complications, increased functional dependency and where discharge planning can prove more difficult than in younger cohorts. Comprehensive geriatric assessment has been shown to improve outcomes and is now embedded in most UK-based services for traumatic hip fracture. Perioperative comprehensive geriatric assessment has been explored in other surgical disciplines and procedures and, where evaluated, has been associated with improved outcomes. The need to support older patients with frailty undergoing surgery exceeds the capacity of specialist geriatricians. Other groups of healthcare professionals need to nurture the core competencies to support this group perioperatively.

Preoperative Anemia in Hindfoot and Ankle Arthrodesis

This is a retrospective study (n = 39) evaluating the postoperative outcomes of patients with mild to moderate preoperative anemia who underwent a hindfoot and/or ankle arthrodesis. In the study, 32 patients did not have preoperative anemia, and 7 had preoperative anemia. Mortality, length of hospital stay, blood transfusions, deep-vein thrombosis, infection, time to union, malunion, delayed union, nonunion, and ulceration were of particular interest. Comparative analyses between patients with preoperative anemia and those without were performed utilizing the independent samples t-test or by the nonparametric Mann-Whitney U-test. The Fisher exact test was used to analyze categorical data. The Shapiro-Wilk test was utilized to check normality. Statistical significance was defined at a 2-sided level of P <.05. Delayed union, nonunion, and malunion were all significantly increased in patients with preoperative anemia (P = .032, P = .004, and P = .028, respectively). Accordingly, the median total number of noninfectious complications (delayed union + nonunion + malunion) in patients with preoperative anemia (0.86 ± 0.38) was significantly higher than in patients without preoperative anemia (0.063 ± 0.25; P < .001). Patients with preoperative anemia had a significantly longer length of hospital stay in days (4.14 ± 2.61). Total infection was also significantly associated with preoperative anemia (P = .001). This study clearly demonstrated that infectious complications, noninfectious complications, and length of hospital stay in hindfoot and/or ankle arthrodesis was significantly affected by preoperative anemia. Thus, consideration should be given to addressing preoperative anemia prior to hindfoot and/or ankle arthrodesis.

LEVELS OF EVIDENCE

Level II Study.

Perioperative Surgical Home. Meeting tomorrow's challenges

New healthcare models pose a variety of changes for anesthesiologists, ranging from the need to improve quality and to cost containment: as such, the concept of Perioperative Surgical Home (PSH) has been developed. Modelled after the UK's Enhanced Recovery After Surgery (ERAS), PSH takes a step further by coordinating care starting from the time a surgical decision is made for the patient to as many as 30 days postoperatively, taking a logical evidenced-based approach to judicious preoperative testing. Perioperative surgical home also relies heavily on engineering imported strategies such as the use of Lean Six Sigma methodologies, and involves active participation of all stakeholders. By comparison, ERAS is a series of well-defined clinical protocols that do not extend beyond the episode of surgical care. As an added aspect of its benefits, PSH also helps to control costs by decreasing unnecessary testing and cancellations, and allowing for more OR access by inpatients.

Does Surgical Approach Affect Patient-reported Function After Primary THA?

BACKGROUND

Total hip arthroplasty (THA) relieves pain and improves physical function in patients with hip osteoarthritis, but requires a year or more for full postoperative recovery. Proponents of intermuscular surgical approaches believe that the direct-anterior approach may restore physical function more quickly than transgluteal approaches, perhaps because of diminished muscle trauma. To evaluate this, we compared patient-reported physical function and other outcome metrics during the first year after surgery between groups of patients who underwent primary THA either through the direct-anterior approach or posterior approach.

QUESTIONS/PURPOSES

We asked: (1) Is a primary THA using a direct-anterior approach associated with better patient-reported physical function at early postoperative times (1 and 3 months) compared with a THA performed through the posterior approach? (2) Is the direct-anterior approach THA associated with shorter operative times and higher rates of noninstitutional discharge than a posterior approach THA?

METHODS

Between October 2008 and February 2010, an arthroplasty fellowship-trained surgeon performed 135 THAs. All 135 were performed using the posterior approach. During that period, we used this approach when patients had any moderate to severe degenerative joint disease of the hip attributable to any type of arthritis refractory to nonoperative treatment measures. Of the patients who were treated with this approach, 21 (17%; 23 hips) were lost to followup, whereas 109 (83%; 112 hips) were available for followup at 1 year. Between February and September 2011, the same surgeon performed 86 THAs. All 86 were performed using the direct-anterior approach. During that period, we used this approach when patients with all types of moderate to severe degenerative joint disease had nonoperative treatment measures fail. Of the patients who were treated with this approach, 35 (41%; 35 hips) were lost to followup, whereas 51 (59%; 51 hips) were available for followup at 1 year. THAs during the surgeon's direct-anterior approach learning period (February 2010 through January 2011) were excluded because both approaches were being used selectively depending on patient characteristics. Clinical outcomes included operative blood loss; allogeneic transfusion; adverse events; patient-reported Veterans RAND-12 Physical (PCS) and Mental Component Summary (MCS) scores, and University of California Los Angeles (UCLA) activity scores at 1 month, 3 months, and 1 year after surgery. Resource utilization outcomes included operative time, length of stay, and discharge disposition (home versus institution). Outcomes were compared using logistic and linear regression techniques.

RESULTS

After controlling for relevant confounding variables including age, sex, and BMI, the direct-anterior approach was associated with worse adjusted MCS changes 1 and 3 months after surgery (1-month score change, -9; 95% CI, -13 to -5; standard error, 2), compared with the posterior approach (3-month score change, -9; 95% CI, -14 to -3; standard error, 3) (both p < 0.001), while the direct-anterior approach was associated with greater PCS improvement at 3 months compared with the posterior approach (score change, 6; 95% CI, 2-10; standard error, 2; p = 0.008). There were no differences in adjusted PCS at either 1 month or 12 months, and no clinically important differences in UCLA scores. Although the PCS score differences are greater than the minimum clinically important difference of 5 points for this endpoint, the clinical importance of such a small effect is questionable. At 1 year after THA, there were no intergroup differences in self-reported physical function, although both groups had significant loss-to-followup at that time. Operative time (skin incision to skin closure) between the two groups did not differ (81 versus 79 minutes; p = 0.411). Mean surgical blood loss (403 versus 293 mL; p < 0.001; adjusted, 119 more mL; 95% CI, 79-160; p < 0.001) and in-hospital transfusion rates (direct-anterior approach, 20% [17/86] versus posterior approach, 10% [14/135], p = 0.050; adjusted odds ratio, 3.6; 95% CI, 1.3-10.1; p = 0.016) were higher in the direct-anterior approach group. With the numbers available, there was no difference in the frequency of adverse events between groups when comparing intraoperative complications, perioperative Technical Expert Panel complications, and other non-Technical Expert Panel complications within 1 year of surgery, although this study was not adequately powered to detect differences in rare adverse events.

CONCLUSIONS

With suitable experience, the direct-anterior approach can be performed with expected results similar to those of the posterior approach. There may be transient and small benefits to the direct-anterior approach, including improved physical function at 3 months after surgery. However, the greater operative blood loss and greater likelihood of blood transfusions, even when the surgeon is experienced, may be a disadvantage. Given some of the kinds of bias present that we found, including loss to followup, the conclusions we present should be considered preliminary, but it appears that any benefits that accrue to the patients who had the direct-anterior approach would be transient and modest. Prospective randomized studies on the topic are needed to address the differences between surgical approaches more definitively.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Prevalence of multimorbidity and its association with outcomes in older emergency general surgical patients: an observational study

OBJECTIVES

Multimorbidity is the presence of 2 or more medical conditions. This increasingly used assessment has not been assessed in a surgical population. The objectives of this study were to assess the prevalence of multimorbidity and its association with common outcome measures.

DESIGN

A cross-sectional observational study.

SETTING

A UK-based multicentre study, included participants between July and October 2014.

PARTICIPANTS

Consecutive emergency (non-elective) general surgical patients admitted to hospital, aged over 65 years.

OUTCOME MEASURES

The outcome measures were (1) the prevalence of multimorbidity and (2) the association between multimorbidity and frailty; the rate and severity of surgery; length of hospital stay; readmission to hospital within 30 days of discharge; and death at 30 and 90 days.

RESULTS

Data were collected on 413 participants aged 65-98 years (median 77 years, (IQR (70-84)). 51.6% (212/413) participants were women. Multimorbidity was present in 74% (95% CI 69.7% to 78.2%) of the population and increased with age (p<0.0001). Multimorbidity was associated with increasing frailty (p for trend <0.0001). People with multimorbidity underwent surgery as often as those without multimorbidity, including major surgery (p=0.03). When comparing multimorbid people with those without multimorbidity, we found no association between length of hospital stay (median 5 days, IQR (1-54), vs 6 days (1-47), (p=0.66)), readmission to hospital (64 (21.1%) vs 18 (16.8%) (p=0.35)), death at 30 days (14 (4.6%) vs 6 (5.6%) (p=0.68)) or 90-day mortality (28 (9.2%) vs 8 (7.6%) (p=0.60)).

CONCLUSIONS AND IMPLICATIONS

Multimorbidity is common. Nearly three-quarters of this older emergency general surgical population had 2 or more chronic medical conditions. It was strongly associated with age and frailty, and was not a barrier to surgical intervention. Multimorbidity showed no associations across a range of outcome measures, as it is currently defined. Multimorbidity should not be relied on as a useful clinical tool in guidelines or policies for older emergency surgical patients.

An evidence-based approach to red blood cell transfusions in asymptomatically anaemic patients

INTRODUCTION

Surgeons and physicians encounter blood transfusions on a daily basis but a robust evidence-based strategy on indications and timing of transfusion in asymptomatic anaemic patients is yet to be determined. For judicious use of blood products, the risks inherent to packed red blood cells, the patient's co-morbidities and haemoglobin (Hb)/haematocrit levels should be considered. This review critiques and summarises the latest available evidence on the indications for transfusions in healthy and cardiac disease patients as well as the timing of transfusions relative to surgery.

METHODS

An electronic literature search of the MEDLINE(®), Google Scholar™ and Trip databases was conducted for articles published in English between January 2006 and January 2015. Studies discussing timing and indications of transfusion in medical and surgical patients were retrieved. Bibliographies of studies were checked for other pertinent articles that were missed by the initial search.

FINDINGS

Six level 1 studies (randomised controlled trials or systematic reviews) and six professional society guidelines were included in this review. In healthy patients without cardiac disease, a restrictive transfusion trigger of Hb 70-80g/l is safe and appropriate whereas in cardiac patients, the trigger is Hb 80-100g/l. The literature on timing of transfusions relative to surgery is limited. For the studies available, preoperative transfusions were associated with a decreased incidence of subsequent transfusions and timing of transfusions did not affect the rates of colorectal cancer recurrence.

Pre-operative anaemia

Pre-operative anaemia is a relatively common finding, affecting a third of patients undergoing elective surgery. Traditionally associated with chronic disease, management has historically focused on the use of blood transfusion as a solution for anaemia in the peri-operative period. Data from large series now suggest that anaemia is an independent risk associated with poor outcome in both cardiac and non-cardiac surgery. Furthermore, blood transfusion does not appear to ameliorate this risk, and in fact may increase the risk of postoperative complications and hospital length of stay. Consequently, there is a need to identify, diagnose and manage pre-operative anaemia to reduce surgical risk. Discoveries in the pathways of iron metabolism have found that chronic disease can cause a state of functional iron deficiency leading to anaemia. The key iron regulatory protein hepcidin, activated in response to inflammation, inhibits absorption of iron from the gastrointestinal tract and further reduces bioavailability of iron stores for red cell production. Consequently, although iron stores (predominantly ferritin) may be normal, the transport of iron either from the gastrointestinal tract or iron stores to the bone marrow is inhibited, leading to a state of 'functional' iron deficiency and subsequent anaemia. Since absorption from the gastrointestinal tract is blocked, increasing oral iron intake is ineffective, and studies are now looking at the role of intravenous iron to treat anaemia in the surgical setting. In this article, we review the incidence and impact of anaemia on the pre-operative patient. We explain how anaemia may be caused by functional iron deficiency, and how iron deficiency anaemia may be diagnosed and treated.