1
|
Zhao BC, Xie YS, Luo WC, Lei SH, Liu JM, Yang X, Dong YH, Liu WF, Liu KX. Postoperative haemoglobin and anaemia-associated ischaemic events after major noncardiac surgery: A sex-stratified cohort study. J Clin Anesth 2024; 95:111439. [PMID: 38471194 DOI: 10.1016/j.jclinane.2024.111439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 01/01/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024]
Abstract
STUDY OBJECTIVE To determine the sex-specific associations between postoperative haemoglobin and mortality or complications reflecting ischaemia or inadequate oxygen supply after major noncardiac surgery. DESIGN A retrospective cohort study with prospective validation. SETTING A large university hospital health system in China. PATIENTS Men and women undergoing elective major noncardiac surgery. INTERVENTIONS AND MEASUREMENTS The primary exposure was nadir haemoglobin within 48 h after surgery. The outcome of interest was a composite of postoperative mortality or ischaemic events including myocardial injury, acute kidney injury and stroke within hospitalisation. MAIN RESULTS The study included 26,049 patients (15,757 men and 10,292 women). Low postoperative haemoglobin was a strong predictor of the composite outcome in both sexes, with the risk progressively increasing as the nadir haemoglobin concentration dropped below 130 g l-1 in men and 120 g l-1 in women (adjusted odds ratio [OR] 1.43, 95% CI 1.37-1.50 in men, and OR 1.45, 95% CI 1.35-1.55 in women, per 10 g l-1 decrease in postoperative nadir haemoglobin). Above these sex-specific thresholds, the change of nadir haemoglobin was no longer associated with odds of the composite outcome in either men or women. There was no significant interaction between patient sex and the association between postoperative haemoglobin and the composite outcome (Pinteraction = 0.673). Validation in an external prospective cohort (n = 2120) with systematic postoperative troponin and creatinine measurement confirmed our findings. CONCLUSIONS Postoperative haemoglobin levels following major noncardiac surgery were nonlinearly associated with ischaemic complications or mortality, without any clinically important interaction with patient sex.
Collapse
Affiliation(s)
- Bing-Cheng Zhao
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yi-Shan Xie
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wen-Chi Luo
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shao-Hui Lei
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jia-Ming Liu
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiao Yang
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ye-Hong Dong
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei-Feng Liu
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Ke-Xuan Liu
- Department of Anaesthesiology, Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| |
Collapse
|
2
|
Park LJ, Moloo H, Ramsay T, Thavorn K, Presseau J, Zwiep T, Martel G, Devereaux PJ, Talarico R, McIsaac DI. Associations of preoperative anaemia with healthcare resource use and outcomes after colorectal surgery: a population-based cohort study. Br J Anaesth 2024; 133:58-66. [PMID: 38644160 PMCID: PMC11213985 DOI: 10.1016/j.bja.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Preoperative anaemia is common in patient undergoing colorectal surgery. Understanding the population-level costs of preoperative anaemia will inform development and evaluation of anaemia management at health system levels. METHODS This was a population-based cohort study using linked, routinely collected data, including residents from Ontario, Canada, aged ≥18 yr who underwent an elective colorectal resection between 2012 and 2022. Primary exposure was preoperative anaemia (haemoglobin <130 g L-1 in males; <120 g L-1 in females). Primary outcome was 30-day costs in 2022 Canadian dollars (CAD), from the perspective of a publicly funded healthcare system. Secondary outcomes included red blood cell transfusion, major adverse events (MAEs), length of stay (LOS), days alive at home (DAH), and readmissions. RESULTS We included 54,286 patients, with mean 65.3 (range 18-102) years of age and 49.0% females, among which 21 264 (39.2%) had preoperative anaemia. There was an absolute adjusted cost increase of $2671 per person at 30 days after surgery attributable to preoperative anaemia (ratio of means [RoM] 1.05, 95% confidence interval [CI] 1.04-1.06). Compared with the control group, 30-day risks of transfusion (odds ratio [OR] 4.34, 95% CI 4.04-4.66), MAEs (OR 1.14, 95% CI 1.03-1.27), LOS (RoM 1.08, 95% CI 1.07-1.10), and readmissions (OR 1.16, 95% CI 1.08-1.24) were higher in the anaemia group, with reduced DAH (RoM 0.95, 95% CI 0.95-0.96). CONCLUSIONS Approximately $2671 CAD per person in 30-day health system costs are attributable to preoperative anaemia after colorectal surgery in Ontario, Canada.
Collapse
Affiliation(s)
- Lily J Park
- Population Health Research Institute, Hamilton, ON, Canada; Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada; Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Husein Moloo
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada; Department of Surgery, Division of Colorectal Surgery, Ottawa, ON, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; ICES, Toronto, ON, Canada
| | - Justin Presseau
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
| | - Terry Zwiep
- Department of Surgery, Division of General Surgery, University of Western Ontario, London, ON, Canada
| | - Guillaume Martel
- Department of Surgery, Division of Hepatobiliary Surgery, University of Ottawa, Ottawa, ON, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada; Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Cardiology, McMaster University, Hamilton, ON, Canada
| | | | - Daniel I McIsaac
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada; ICES, Toronto, ON, Canada; Departments of Anesthesiology and Pain Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, ON, Canada.
| |
Collapse
|
3
|
Moral V, Abad Motos A, Jericó C, Antelo Caamaño ML, Ripollés Melchor J, Bisbe Vives E, García Erce JA. Management of peri-surgical anemia in elective surgery. Conclusions and recommendations according to Delphi-UCLA methodology. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:454-465. [PMID: 38670490 DOI: 10.1016/j.redare.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/22/2023] [Accepted: 11/25/2023] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Preoperative anemia affects approximately one third of surgical patients. It increases the risk of blood transfusion and influences short- and medium-term functional outcomes, increases comorbidities, complications and costs. The "Patient Blood Management" (PBM) programs, for integrated and multidisciplinary management of patients, are considered as paradigms of quality care and have as one of the fundamental objectives to correct perioperative anemia. PBM has been incorporated into the schemes for intensified recovery of surgical patients: the recent Enhanced Recovery After Surgery 2021 pathway (in Spanish RICA 2021) includes almost 30 indirect recommendations for PBM. OBJECTIVE To make a consensus document with RAND/UCLA Delphi methodology to increase the penetration and priority of the RICA 2021 recommendations on PBM in daily clinical practice. MATERIAL AND METHODS A coordinating group composed of 6 specialists from Hematology-Hemotherapy, Anesthesiology and Internal Medicine with expertise in anemia and PBM was formed. A survey was elaborated using Delphi RAND/UCLA methodology to reach a consensus on the key areas and priority professional actions to be developed at the present time to improve the management of perioperative anemia. The survey questions were extracted from the PBM recommendations contained in the RICA 2021 pathway. The development of the electronic survey (Google Platform) and the management of the responses was the responsibility of an expert in quality of care and clinical safety. Participants were selected by invitation from speakers at AWGE-GIEMSA scientific meetings and national representatives of PBM-related working groups (Seville Document, SEDAR HTF section and RICA 2021 pathway participants). In the first round of the survey, the anonymized online questionnaire had 28 questions: 20 of them were about PBM concepts included in ERAS guidelines (2 about general PBM organization, 10 on diagnosis and treatment of preoperative anemia, 3 on management of postoperative anemia, 5 on transfusion criteria) and 8 on pending aspects of research. Responses were organized according to a 10-point Likter scale (0: strongly disagree to 10: strongly agree). Any additional contributions that the participants considered appropriate were allowed. They were considered consensual because all the questions obtained an average score of more than 9 points, except one (question 14). The second round of the survey consisted of 37 questions, resulting from the reformulation of the questions of the first round and the incorporation of the participants' comments. It consisted of 2 questions about general organization of PBM programme, 15 questions on the diagnosis and treatment of preoperative anemia; 3 on the management of postoperative anemia, 6 on transfusional criteria and finally 11 questions on aspects pending od future investigations. Statistical treatment: tabulation of mean, median and interquartiles 25-75 of the value of each survey question (Tables 1, 2 and 3). RESULTS Except for one, all the recommendations were accepted. Except for three, all above 8, and most with an average score of 9 or higher. They are grouped into: 1.- "It is important and necessary to detect and etiologically diagnose any preoperative anemia state in ALL patients who are candidates for surgical procedures with potential bleeding risk, including pregnant patients". 2.- "The preoperative treatment of anemia should be initiated sufficiently in advance and with all the necessary hematinic contributions to correct this condition". 3.- "There is NO justification for transfusing any unit of packed red blood cells preoperatively in stable patients with moderate anemia Hb 8-10g/dL who are candidates for potentially bleeding surgery that cannot be delayed." 4.- "It is recommended to universalize restrictive criteria for red blood cell transfusion in surgical and obstetric patients." 5.- "Postoperative anemia should be treated to improve postoperative results and accelerate postoperative recovery in the short and medium term". CONCLUSIONS There was a large consensus, with maximum acceptance,strong level of evidence and high recommendation in most of the questions asked. Our work helps to identify initiatives and performances who can be suitables for the implementation of PBM programs at each hospital and for all patients.
Collapse
Affiliation(s)
- V Moral
- Department of Anaesthesia. Hospital Universitario Sant Pau and Universidad Autónoma de Barcelona, Barcelona, Spain
| | - A Abad Motos
- Department of Anaesthesiology, Hospital Universitario Donostia, San Sebastián, Spain; Spanish Perioperative Audit and Research Network (ReDGERM), Zaragoza, Spain; Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR).
| | - C Jericó
- Servicio de Medicina Interna, Complex Hospitalari Moisès Broggi, Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Spain; Grupo Multidisciplinar para el Estudio y Manejo de la Anemia del Paciente Quirúrgico (Anemia Working Group España, www.awge.org); Grupo Español de Rehabilitación Multimodal (GERM, www.grupogerm.es); Grupo de Investigación Gestión en el Paciente Sangrante-PBM, Instituto de Investigación Sanitaria, Hospital Universitaria La Paz (IdiPAZ), Madrid, Spain
| | - M L Antelo Caamaño
- Banco de Sangre y Tejidos de Navarra, Servicio Navarro de Salud, Osasunbidea, Pamplona, Spain
| | - J Ripollés Melchor
- Spanish Perioperative Audit and Research Network (ReDGERM), Zaragoza, Spain; Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR); Department of Anesthesiology, and Critical Care, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - E Bisbe Vives
- Grupo Multidisciplinar para el Estudio y Manejo de la Anemia del Paciente Quirúrgico (Anemia Working Group España, www.awge.org); Department of Anaesthesiology, Parc de Salut Mar, Barcelona, Spain
| | - J A García Erce
- Grupo Multidisciplinar para el Estudio y Manejo de la Anemia del Paciente Quirúrgico (Anemia Working Group España, www.awge.org); Grupo Español de Rehabilitación Multimodal (GERM, www.grupogerm.es); Grupo de Investigación Gestión en el Paciente Sangrante-PBM, Instituto de Investigación Sanitaria, Hospital Universitaria La Paz (IdiPAZ), Madrid, Spain; Banco de Sangre y Tejidos de Navarra, Servicio Navarro de Salud, Osasunbidea, Pamplona, Spain.
| |
Collapse
|
4
|
Netz A, Hof L, Rumpf F, Blum LV, Neef V, Kerner A, Zacharowski K, Meybohm P, Choorapoikayil S. Adjusting Current Hemoglobin Thresholds: A Way to Improve Outcome in Women Undergoing Major Surgery. J Womens Health (Larchmt) 2024; 33:678-684. [PMID: 38530069 DOI: 10.1089/jwh.2023.0665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
Background/Objective: In the perioperative setting, a suboptimal total hemoglobin (Hb) mass puts women and men at an unreasonable disadvantage. Anemia is an independent risk factor for transfusion, postoperative complications, and mortality. The Hb cut-off value for women was set at <12.0 g/dL by the World Health Organization (WHO) and has been rigorously debated for decades. The aim of this study was to elucidate the risk for postoperative complications in female patients with Hb levels < 12.0, 12.0-12.9, and ≥13.0 g/dL. Material and Methods: Single-center retrospective analysis of female patients undergoing major surgery. Results: In total, 6,516 patients ≥18 years of age had major surgery between 2018 and 2019 and 2,446 female patients were included in analysis. Mean age was 67.4 ± 16.6, 66.4 ± 15.6, and 64.5 ± 15.5 years in female patients with preoperative Hb levels <12.0, 12.0-12.9 and ≥13.0 g/dL, respectively. The transfusion rate of red blood cells (RBCs) was significantly higher in female patients with Hb <12.0 g/dL (53%) and with Hb 12.0-12.9 g/dL (31%) compared to female patients ≥13.0 g/dL (22%). Rates of pneumonia, acute kidney injury, and sepsis were significantly higher in patients with Hb <12.0 and 12.0-12.9 g/dL compared to patients with Hb ≥13.0 g/dL. Total length of hospital stay was significantly longer in female patients with Hb <12.0 g/dL than patients with Hb 12.0-12.9 g/dL and Hb ≥13.0 g/dL (10 days vs. 8 days). Conclusion: Taken together, our data show that Hb values below 12.9 g/dL are associated with increased probability of RBC transfusions and increased risk of postoperative complications. In addition, our results indicate that postoperative outcomes for women might be optimized by increasing cut-off values for anemia. The call to revise the anemia threshold for women by the WHO can no longer be disregarded.
Collapse
Affiliation(s)
- Alina Netz
- Goethe University Frankfurt, University Hospital Frankfurt, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Lotta Hof
- Goethe University Frankfurt, University Hospital Frankfurt, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Florian Rumpf
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Lea Valeska Blum
- Goethe University Frankfurt, University Hospital Frankfurt, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Vanessa Neef
- Goethe University Frankfurt, University Hospital Frankfurt, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Anja Kerner
- Goethe University Frankfurt, University Hospital, Institute of Medical Informatics (IMI), Frankfurt am Main, Germany
- University Hospital, Department of Information and Communication Technology (DICT), Data Integration Center (DIC), Frankfurt am Main, Germany
| | - Kai Zacharowski
- Goethe University Frankfurt, University Hospital Frankfurt, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Patrick Meybohm
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Suma Choorapoikayil
- Goethe University Frankfurt, University Hospital Frankfurt, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| |
Collapse
|
5
|
Bolliger D, Gebhard CE. Unravelling the Impact of Gender Disparities in Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:1084-1087. [PMID: 38443204 DOI: 10.1053/j.jvca.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Caroline E Gebhard
- Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| |
Collapse
|
6
|
Hosseini M, Griffeth EM, Schaff HV, Klompas AM, Warner MA, Stulak JM, Dearani JA, Lee AT, Lahr BD, Crestanello JA. Analysis of Anemia, Transfusions, and CABG Outcomes in The Society of Thoracic Surgeons National Database. Ann Thorac Surg 2024; 117:1053-1060. [PMID: 38286201 DOI: 10.1016/j.athoracsur.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND This study characterized the association of preoperative anemia and intraoperative red blood cell (RBC) transfusion on outcomes of elective coronary artery bypass grafting (CABG). METHODS Data from 53,856 patients who underwent CABG included in The Society of Thoracic Surgeons (STS) Adult Cardiac Database in 2019 were used. The primary outcome was operative mortality. Secondary outcomes were postoperative complications. The association of anemia with outcomes was analyzed with multivariable regression models. The influence of intraoperative RBC transfusion on the effect of preoperative anemia on outcomes was studied using mediation analysis. RESULTS Anemia was present in 25% of patients. Anemic patients had a higher STS Predicted Risk of Operative Mortality (1.2% vs 0.7%; P < .001). Anemia was associated with operative mortality (odds ratio [OR], 1.27; 99.5% CI, 1.00-1.61; P = .047), postoperative RBC transfusion (OR, 2.28; 99.5% CI, 2.12-2.44; P < .001), dialysis (OR, 1.58; 99.5% CI, 1.19-2.11; P < .001), and prolonged intensive care unit and hospital length of stay. Intraoperative RBC transfusion largely mediated the effects of anemia on mortality (76%), intensive care unit stay (99%), and hospital stay, but it only partially mediated the association with dialysis (34.9%). CONCLUSIONS Preoperative anemia is common in patients who undergo CABG and is associated with increased postoperative risks of mortality, complications, and RBC transfusion. However, most of the effect of anemia on mortality is mediated through intraoperative RBC transfusion.
Collapse
Affiliation(s)
- Motahar Hosseini
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Elaine M Griffeth
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alexander T Lee
- Department of Quantitative Health Sciences; Mayo Clinic, Rochester, Minnesota
| | - Brian D Lahr
- Department of Quantitative Health Sciences; Mayo Clinic, Rochester, Minnesota
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
7
|
Ozawa S, Ozawa-Morriello J, Rock R, Sromoski M, Walbolt S, Hall T, Pearse BL. Patient Blood Management as an Emerging Concept in Quality: The Role of Nurses. J Nurs Care Qual 2024; 39:129-135. [PMID: 37350618 DOI: 10.1097/ncq.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Transfusion of blood components has long been considered lifesaving therapy. While blood transfusion may be clinically indicated as a treatment option for some patients, the benefits of transfusion in asymptomatic, hemodynamically stable patients are questionable. PROBLEM Blood component transfusion is routinely used as a default therapy when not clinically indicated, increasing the risk of poor patient outcomes, adverse events, pressures on blood supply and availability, and increased health care costs. APPROACH Nurses have the responsibility to advocate for patients and reduce/avoid unnecessary blood transfusion through the implementation of patient blood management (PBM). The PBM paradigm includes treatment of anemia, minimizing blood loss and bleeding, optimization of coagulation, and employing true patient-centered decision making. CONCLUSIONS PBM should become the standard of care with the goal of improving health care quality and patient outcomes while using the multidisciplinary team for its implementation. As advocates for their patients, nurses can play a major role in the development, implementation, and promotion of PBM.
Collapse
Affiliation(s)
- Sherri Ozawa
- Author Affiliations: Deparment of Patient Blood Management (Mss Ozawa and Hall), Accumen Incorporated, Phoenix, Arizona; Department of Clinical Training and Evaluation Center, The University of Western Australia, Perth, Western Australia (Ms Ozawa); Department of Bloodless Medicine and Patient Blood Management, Englewood Health, Englewood, New Jersey (Ms Ozawa and Mr Ozawa-Morriello); Society for the Advancement of Patient Blood Management (SABM), Mt Royal, New Jersey (Ms Ozawa, Rock, Sromoski, Walbolt, and Hall and Mr Ozawa-Morriello); Department of Patient Blood Management and Center for Bloodless Medicine, Geisinger Health System, Danville, Pennsylvania (Mr Ozawa-Morriello and Ms Sromoski); Departments of Bloodless Medicine and Surgery, and Cardiac Surgery Services, Hackensack University Medical Center, Hackensack, New Jersey (Mr Ozawa-Morriello); Department of Patient Blood Management, Alberta Health Services, Calgary, Alberta, Canada (Ms Rock); Association for the Advancement of Blood & Biotherapies (AABB), Bethesda, Maryland (Ms Sromoski); ProMedica Health System, Toledo, Ohio (Ms Walbolt); Department of Patient Blood Management The Prince Charles Hospital, Brisbane, Queensland, Australia (Dr Pearse); and Department of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia (Dr Pearse)
| | | | | | | | | | | | | |
Collapse
|
8
|
Warner MA, Hanson AC, Schulte PJ, Sanz JR, Smith MM, Kauss ML, Crestanello JA, Kor DJ. Preoperative Anemia and Postoperative Outcomes in Cardiac Surgery: A Mediation Analysis Evaluating Intraoperative Transfusion Exposures. Anesth Analg 2024; 138:728-737. [PMID: 38335136 PMCID: PMC10949062 DOI: 10.1213/ane.0000000000006765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND Preoperative anemia is associated with adverse outcomes in cardiac surgery, yet it remains unclear what proportion of this association is mediated through red blood cell (RBC) transfusions. METHODS This is a historical observational cohort study of adults undergoing coronary artery bypass grafting or valve surgery on cardiopulmonary bypass at an academic medical center between May 1, 2008, and May 1, 2018. A mediation analysis framework was used to evaluate the associations between preoperative anemia and postoperative outcomes, including a primary outcome of acute kidney injury (AKI). Intraoperative RBC transfusions were evaluated as mediators of preoperative anemia and outcome relationships. The estimated total effect, average direct effect of preoperative anemia, and percent of the total effect mediated through transfusions are presented with 95% confidence intervals and P -values. RESULTS A total of 4117 patients were included, including 1234 (30%) with preoperative anemia. Overall, 437 of 4117 (11%) patients went on to develop AKI, with a greater proportion of patients having preoperative anemia (219 of 1234 [18%] vs 218 of 2883 [8%]). In multivariable analyses, the presence of preoperative anemia was associated with increased postoperative AKI (6.4% [4.2%-8.7%] absolute difference in percent with AKI, P < .001), with incremental decreases in preoperative hemoglobin concentrations displaying greater AKI risk (eg, 11.9% [6.9%-17.5%] absolute increase in probability of AKI for preoperative hemoglobin of 9 g/dL compared to a reference of 14 g/dL, P < .001). The association between preoperative anemia and postoperative AKI was primarily due to direct effects of preoperative anemia (5.9% [3.6%-8.3%] absolute difference, P < .001) rather than mediated through intraoperative RBC transfusions (7.5% [-4.3% to 21.1%] of the total effect mediated by transfusions, P = .220). Preoperative anemia was also associated with longer hospital durations (1.07 [1.05-1.10] ratio of geometric mean length of stay, P < .001). Of this total effect, 38% (22%, 62%; P < .001) was estimated to be mediated through subsequent intraoperative RBC transfusion. Preoperative anemia was not associated with reoperation or vascular complications. CONCLUSIONS Preoperative anemia was associated with higher odds of AKI and longer hospitalizations in cardiac surgery. The attributable effects of anemia and transfusion on postoperative complications are likely to differ across outcomes. Future studies are necessary to further evaluate mechanisms of anemia-associated postoperative organ injury and treatment strategies.
Collapse
Affiliation(s)
- Matthew A Warner
- From the Departments of Anesthesiology and Perioperative Medicine
| | | | | | - Juan Ripoll Sanz
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Mark M Smith
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Marissa L Kauss
- From the Departments of Anesthesiology and Perioperative Medicine
| | | | - Daryl J Kor
- From the Departments of Anesthesiology and Perioperative Medicine
| |
Collapse
|
9
|
Li MM, Miles S, Callum J, Lin Y, Karkouti K, Bartoszko J. Postoperative anemia in cardiac surgery patients: a narrative review. Can J Anaesth 2024; 71:408-421. [PMID: 38017198 DOI: 10.1007/s12630-023-02650-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/25/2023] [Accepted: 08/08/2023] [Indexed: 11/30/2023] Open
Abstract
PURPOSE Anemia reduces the blood's ability to carry and deliver oxygen. Following cardiac surgery, anemia is very common and affects up to 90% of patients. Nevertheless, there is a paucity of data examining the prognostic value of postoperative anemia. In this narrative review, we present findings from the relevant literature on postoperative anemia in cardiac surgery patients, focusing on the incidence, risk factors, and prognostic value of postoperative anemia. We also explore the potential utility of postoperative anemia as a therapeutic target to improve clinical outcomes. SOURCE We conducted a targeted search of MEDLINE, Embase, and the Cochrane Database of Systematic Reviews up to September 2022, using a combination of search terms including postoperative (post-operative), perioperative (peri-operative), anemia (anaemia), and cardiac surgery. PRINCIPAL FINDINGS The reported incidence of postoperative anemia varied from 29% to 94% across the studies, likely because of variations in patient inclusion criteria and classification of postoperative anemia. Nonetheless, the weight of the evidence suggests that postoperative anemia is common and is an independent risk factor for adverse postoperative outcomes such as acute kidney injury, stroke, mortality, and functional outcomes. CONCLUSIONS In cardiac surgery patients, postoperative anemia is a common and prognostically important risk factor for postoperative morbidity and mortality. Nevertheless, there is a lack of data on whether active management of postoperative anemia is feasible or effective in improving patient outcomes.
Collapse
Affiliation(s)
- Michelle M Li
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Sarah Miles
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Jeannie Callum
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, ON, Canada
| | - Yulia Lin
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada.
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
10
|
Almonacid-Cardenas F, Rivas E, Auron M, Hu L, Wang D, Liu L, Tolich D, Mascha EJ, Ruetzler K, Kurz A, Turan A. Association between preoperative anemia optimization and major complications after non-cardiac surgery: a retrospective analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744474. [PMID: 38043700 DOI: 10.1016/j.bjane.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Anemia is common in the preoperative setting and associated with increased postoperative complications and mortality. However, it is unclear if preoperative anemia optimization reduces postoperative complications. We aimed to assess the association between preoperative anemia optimization and a composite endpoint of major cardiovascular, renal, and pulmonary complications and all-cause mortality within 30 days after noncardiac surgery in adult patients. METHODS In this retrospective analysis preoperative anemia was defined as hemoglobin concentration below 12.0 g.dl-1 in women and 13.0 g.dl-1 in men within 6 months before surgery. A propensity score-based generalized estimating equation analysis was used to determine the association between preoperative anemia optimization and the primary outcome. Moreover, mediation analysis was conducted to investigate whether intraoperative red blood cell transfusion or duration of intraoperative hypotension were mediators of the relation between anemia optimization and the primary outcome. RESULTS Fifty-seven hundred anemia optimized, and 8721 non-optimized patients met study criteria. The proportion of patients having any component of the composite of major complications and all-cause mortality was 21.5% in the anemia-optimized versus 18.0% in the non-optimized, with confounder-adjusted odds ratio estimate of 0.99 (95% CI 0.86‒1.15) for anemia optimization versus non-optimization, p = 0.90. Intraoperative red blood cell transfusion had a minor mediation effect on the relationship between preoperative anemia optimization and the primary outcome, whereas duration of intraoperative hypotension was not found to be a mediator. CONCLUSION Preoperative anemia optimization did not appear to be associated with a composite outcome of major in-hospital postoperative cardiovascular, renal, and pulmonary complications and all-cause in-hospital mortality.
Collapse
Affiliation(s)
| | - Eva Rivas
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Universidad de Barcelona, Hospital Clinic of Barcelona, IDIBAPS, Department of Anesthesia, Barcelona, Spain
| | - Moises Auron
- Cleveland Clinic, Department of Blood Management, Cleveland, USA
| | - Lucille Hu
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA
| | - Dong Wang
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Liu Liu
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Deborah Tolich
- Cleveland Clinic, Department of Blood Management, Cleveland, USA
| | - Edward J Mascha
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Kurt Ruetzler
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA
| | - Andrea Kurz
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA
| | - Alparslan Turan
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA.
| |
Collapse
|
11
|
Lau MPXL, Low CJW, Ling RR, Liu NSH, Tan CS, Ti LK, Kofidis T, MacLaren G, Ramanathan K. Preoperative anemia and anemia treatment in cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2024; 71:127-142. [PMID: 37932652 DOI: 10.1007/s12630-023-02620-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/07/2023] [Accepted: 07/23/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE We aimed to conduct a systematic review and meta-analysis to assess the effects of anemia and anemia severity on patient outcomes in cardiac surgery and determine whether preoperative treatments confer postoperative benefit. SOURCE We searched four international databases for observational and randomized studies published until 1 October 2022. Study quality was assessed via Newcastle-Ottawa scores and the Cochrane Risk-of-Bias 2 tool and certainty of evidence was rated with the Grading of Recommendations, Assessment, Development and Evaluations approach. We conducted random-effects meta-analyses for our primary outcome of mortality, for secondary outcomes including length of stay (LOS) in the hospital and intensive care unit, and for postsurgical complications. As part of a secondary analysis, we analyzed short-term preoperative anemia treatments and conducted trial sequential analysis of randomized trials to assess the efficacy of these treatment programs. PRINCIPAL FINDINGS We included 35 studies (159,025 patients) in our primary meta-analysis. Preoperative anemia was associated with increased mortality (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.2 to 2.9; P < 0.001, high certainty). Study-level meta-regression revealed lower hemoglobin levels and studies with lower proportions of male patients to be associated with increased risk of mortality. Preoperative anemia was also associated with an increase in LOS and postsurgical complications. Our secondary analysis (seven studies, 1,012 patients) revealed short-term preoperative anemia treatments did not significantly reduce mortality (OR, 1.1; 95% CI, 0.65 to 1.9; P = 0.69). Trial sequential analysis suggested that there was insufficient evidence to conclude if treatment programs yield any benefit or harm. CONCLUSIONS Preoperative anemia is associated with mortality and morbidity after cardiac surgery. More research is warranted to test the efficacy of current anemia treatment programs. STUDY REGISTRATION PROSPERO (CRD42022319431); first submitted 17 April 2023.
Collapse
Affiliation(s)
- Michele P X L Lau
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Christopher J W Low
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Nigel S H Liu
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Chuen Seng Tan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Lian Kah Ti
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore, Singapore
| | - Theo Kofidis
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, National University Hospital, National University Health System, Singapore, Singapore
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore, Singapore.
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| |
Collapse
|
12
|
Räsänen J, Ellam S, Hartikainen J, Juutilainen A, Halonen J. Sex Differences in Red Blood Cell Transfusions and 30-Day Mortality in Cardiac Surgery: A Single Center Observational Study. J Clin Med 2023; 12:7674. [PMID: 38137742 PMCID: PMC10743830 DOI: 10.3390/jcm12247674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/30/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
In cardiac surgery, women have higher short-term mortality and a higher risk of receiving red blood cell (RBC) transfusions than men. This study's aim was to evaluate possible sex differences in RBC transfusions in cardiac surgery and their association with preoperative hemoglobin levels, body mass index, and 30-day mortality. A single-center retrospective study was conducted with 1583 patients (1181 men and 402 women) undergoing cardiac surgery. A total of 64.4% of the women and 33.0% of the men received an RBC transfusion. In a multivariable analysis, female sex was an independent predictor of RBC transfusion (OR 3.88, 95% CI 2.95-5.11, p < 0.001). Other independent predictors of RBC transfusion were age, preoperative hemoglobin level, and body mass index. The women were more likely to receive RBC transfusions than the men, regardless of the type of cardiac surgery. Decreased transfusion risk was found in all higher-than-normal weight categories in the women, but only in the severe obesity category in the men. Preoperative hemoglobin was similarly associated with RBC transfusion in the men and women. The crude 30-day mortality rate was higher in the women than in the men (2.5% vs. 0.9%, p = 0.018). In both sexes, RBC transfusion was associated with an increased probability of death within 30 days.
Collapse
Affiliation(s)
- Jenni Räsänen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland; (J.H.); (A.J.)
- Heart Center, Kuopio University Hospital, 70029 Kuopio, Finland
| | - Sten Ellam
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, 70029 Kuopio, Finland;
| | - Juha Hartikainen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland; (J.H.); (A.J.)
- Heart Center, Kuopio University Hospital, 70029 Kuopio, Finland
| | - Auni Juutilainen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland; (J.H.); (A.J.)
| | - Jari Halonen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland; (J.H.); (A.J.)
- Heart Center, Kuopio University Hospital, 70029 Kuopio, Finland
| |
Collapse
|
13
|
Guinn N, Tanaka K, Erdoes G, Kwak J, Henderson R, Mazzeffi M, Fabbro M, Raphael J. The Year in Coagulation and Transfusion: Selected Highlights from 2022. J Cardiothorac Vasc Anesth 2023; 37:2435-2449. [PMID: 37690951 DOI: 10.1053/j.jvca.2023.08.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023]
Abstract
This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.
Collapse
Affiliation(s)
- Nicole Guinn
- Chief of Neuroanesthesiology, Otolaryngology and Offsite Anesthesia Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Jenny Kwak
- Division of Cardiac Anesthesia, Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL
| | - Reney Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Medical Center, Charlottesville, VA
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miami, FL
| | - Jacob Raphael
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA.
| |
Collapse
|
14
|
Zhao BC, Lei SH, Liu JM, Qiu SD, Yao ZW, Liu J, Deng F, Li ZH, Liu KX. Sex-Specific Associations Between Preoperative Hemoglobin and Outcomes After Major Noncardiac Surgery: A Retrospective Cohort Study. Anesth Analg 2023; 137:1019-1028. [PMID: 37713328 DOI: 10.1213/ane.0000000000006661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
BACKGROUND Preoperative anemia is an established risk factor for morbidity and mortality after surgery. Men and women have different hemoglobin concentrations and are at different risks of postoperative complications. However, sex-stratified analysis on the association between preoperative hemoglobin and outcomes after noncardiac surgery has been limited in previous studies. METHODS This was a retrospective cohort study of adult patients undergoing elective major noncardiac surgery in a large academic hospital. The primary outcome was a collapsed composite of postoperative mortality or cardiovascular, renal, pulmonary, and infectious complications during hospitalization. Sex-specific univariable associations between preoperative hemoglobin and the composite outcome were visualized using moving-average and cubic-spline smoothing plots. Multivariable regression models adjusting for patient demographics, comorbidities, medication uses, laboratory tests, and anesthesia/surgery features were used to estimate confounder-adjusted associations. Restricted cubic spline and piecewise linear functions were used to assess the possible nonlinear relationships between preoperative hemoglobin and the outcomes. The interaction between patient sex and hemoglobin on outcomes was assessed using a likelihood-ratio test. RESULTS We included 22,550 patients, with 6.7% (622 of 9268) of women and 9.7% (1293 of 13,282) of men developing the primary outcome. Lower preoperative hemoglobin was associated with a higher incidence of the primary composite outcome in both men and women. Nonlinearity for the association was not statistically significant in either women ( P = .539) or men ( P = .165). The multivariable-adjusted odds ratios per 1 g/dL increase in hemoglobin were 0.93 (95% confidence interval [CI], 0.87-0.98; P = .013) for women and 0.94 (95% CI, 0.90-0.97; P < .001) for men, with no interaction by sex ( Pinteraction = .923). No hemoglobin thresholds were confirmed at which the associations with the primary outcome changed significantly. CONCLUSIONS Low preoperative hemoglobin was associated with a higher risk of complications or mortality after elective noncardiac surgery in both men and women. No differences in the strength of associations between sexes were found. Further studies are needed to assess whether these associations are linear or there are sex-specific thresholds of preoperative hemoglobin concentrations below which postoperative risks begin to increase.
Collapse
Affiliation(s)
- Bing-Cheng Zhao
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shao-Hui Lei
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jia-Ming Liu
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shi-Da Qiu
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi-Wen Yao
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jian Liu
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fan Deng
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi-Hao Li
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, China
| | - Ke-Xuan Liu
- From the Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| |
Collapse
|
15
|
Samuelson Bannow B, Cushman M. Sex Matters: Policy on Reporting Sex as a Biological Variable at Research and Practice in Thrombosis and Hemostasis. Res Pract Thromb Haemost 2023; 7:102256. [PMID: 38053984 PMCID: PMC10694598 DOI: 10.1016/j.rpth.2023.102256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Affiliation(s)
| | - Mary Cushman
- Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| |
Collapse
|
16
|
Hensley NB, Holmes SD, Cho BC, Salenger R, Alejo D, Fonner CE, Ad N. Unexpected impact of preoperative anemia in low-risk isolated coronary artery bypass grafting or single-valve surgical patients: Do not overlook these patients in anemia management! J Thorac Cardiovasc Surg 2023:S0022-5223(23)00969-8. [PMID: 37839659 DOI: 10.1016/j.jtcvs.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/27/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE Preoperative anemia is prevalent in cardiac surgery and independently associated with increased risk for short-term and long-term mortality. The purpose of this study was to examine the effect of preoperative hematocrit (Hct) on outcomes in cardiac surgical patients and whether the effect is comparable across levels of Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM). METHODS The study consisted of adult, isolated coronary artery bypass grafting (CABG) or single-valve surgical patients in a statewide registry from 2011 to 2022 (N = 29,828). Regressions were used to assess effect of preoperative Hct on STS-defined major morbidity/mortality including the interaction of Hct and STS PROM as continuous variables. RESULTS Median age was 66 years (58-73 years), STS PROM was 1.02% (0.58%-1.99%), and preoperative Hct was 39.5% (35.8%-42.8%). The sample consisted of 78% isolated CABG (n = 23,261), 10% isolated mitral valve repair/replacement (n = 3119), 12% isolated aortic valve replacement (n = 3448), and 29% were female (n = 8646). Multivariable analyses found that greater Hct was associated with reduced risk of STS-defined morbidity/mortality (odds ratio, 0.96; P < .001). These effects for Hct persisted even after adjustment for intraoperative blood transfusion. The interaction of Hct and STS PROM was significant for morbidity/mortality (odds ratio, 1.01; P < .001). There was a stronger association between Hct levels and morbidity/mortality risk in the patients with the lowest STS risk compared with patients with the greatest STS risk. CONCLUSIONS Patients with lower risk had a greater association between preoperative Hct and major morbidity and mortality compared with patients with greater risk. Preoperative anemia management is essential across all risk groups for improved outcomes.
Collapse
Affiliation(s)
- Nadia B Hensley
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Sari D Holmes
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Brian C Cho
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Rawn Salenger
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, and St Joseph's Medical Center, Baltimore, Md
| | - Diane Alejo
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Niv Ad
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| |
Collapse
|
17
|
Deng Y, Weng M, Zhang J. Preoperative anemia and long-term survival in patients undergoing colorectal cancer surgery: a retrospective cohort study. World J Surg Oncol 2023; 21:122. [PMID: 37013545 PMCID: PMC10071685 DOI: 10.1186/s12957-023-03005-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 03/25/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND The impact of preoperative anemia on a survival outcome and the importance of correcting preoperative anemia in patients with colorectal cancer (CRC) remain controversial. This study aimed to explore how preoperative anemia affects the long-term survival of patients undergoing colorectal cancer surgery. METHODS This was a retrospective cohort study in which adult patients underwent surgical resection for colorectal cancer between January 1, 2008, and December 31, 2014, at a large tertiary cancer center. A total of 7436 patients were enrolled in this study. Anemia was defined according to the diagnostic criteria of China (hemoglobin level < 110 g/L for women and < 120 g/L for men). The median follow-up time was 120.5 months (10.0 years). Inverse probability of treatment weighting (IPTW) using the propensity score was used to reduce selection bias. Overall survival (OS) and disease-free survival (DFS) were compared between patients with and without preoperative anemia using the Kaplan-Meier estimator and the weighted log-rank test based on IPTW. Univariate and multivariate Cox proportional hazards models were used to assess factors associated with OS and DFS. Multivariable Cox regression was also used to assess red blood cell (RBC) transfusion associations between preoperative anemia and outcomes. RESULTS After IPTW adjustment, clinical profiles were similar, except that tumor location and TNM stage remained imbalanced between the preoperative anemia and preoperative non-anemia groups (p < 0.001). IPTW analysis showed that the 5-year OS rate (71.3 vs. 78.6%, p < 0.001) and the 5-year DFS rate (63.9 vs. 70.9%, p < 0.001) were significantly lower in the preoperative anemia group. Multivariate analysis showed that preoperative anemia was associated with poorer OS and DFS, while RBC transfusion may improve OS (hazard ratio [HR] 0.54, p = 0.054) and DFS (HR 0.50, p = 0.020) in CRC patients with preoperative anemia. CONCLUSIONS Preoperative anemia is an independent risk factor for survival in patients undergoing colorectal surgery. Strategies to reduce preoperative anemia in patients with CRC should be considered.
Collapse
Affiliation(s)
- Yixu Deng
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No. 270 Dongan Road, Xuhui District, Shanghai, 200032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
| | - Meilin Weng
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, People's Republic of China.
| | - Jun Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No. 270 Dongan Road, Xuhui District, Shanghai, 200032, People's Republic of China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China.
| |
Collapse
|
18
|
Shander A, Corwin HL, Meier J, Auerbach M, Bisbe E, Blitz J, Erhard J, Faraoni D, Farmer SL, Frank SM, Girelli D, Hall T, Hardy JF, Hofmann A, Lee CK, Leung TW, Ozawa S, Sathar J, Spahn DR, Torres R, Warner MA, Muñoz M. Recommendations From the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS). Ann Surg 2023; 277:581-590. [PMID: 36134567 PMCID: PMC9994846 DOI: 10.1097/sla.0000000000005721] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Perioperative anemia has been associated with increased risk of red blood cell transfusion and increased morbidity and mortality after surgery. The optimal approach to the diagnosis and management of perioperative anemia is not fully established. OBJECTIVE To develop consensus recommendations for anemia management in surgical patients. METHODS An international expert panel reviewed the current evidence and developed recommendations using modified RAND Delphi methodology. RESULTS The panel recommends that all patients except those undergoing minor procedures be screened for anemia before surgery. Appropriate therapy for anemia should be guided by an accurate diagnosis of the etiology. The need to proceed with surgery in some patients with anemia is expected to persist. However, early identification and effective treatment of anemia has the potential to reduce the risks associated with surgery and improve clinical outcomes. As with preoperative anemia, postoperative anemia should be treated in the perioperative period. CONCLUSIONS Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients.
Collapse
Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology, Critical Care Medicine, Hyperbaric Medicine and Pain Management, Englewood Hospital and Medical Center, Englewood, NJ
- Society for the Advancement of Blood Management (SABM), Englewood, NJ
| | | | - Jens Meier
- Clinic of Anaesthesiology and Intensive Care Medicine, Kepler University Hospital, Linz, Austria
- Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Brussels, Belgium
| | - Michael Auerbach
- School of Medicine, Georgetown University, Washington, DC
- Auerbach Hematology and Oncology, Baltimore, MD
| | - Elvira Bisbe
- Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Brussels, Belgium
- Department of Anaesthesiology, Perioperative Medicine Research Group, Hospital del Mar Medical Research Institute, IMIM, Barcelona, Spain
| | - Jeanna Blitz
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Jochen Erhard
- Department of Surgery, Evangelisches Klinikum Niederrhein, Duisburg, Germany
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Shannon L. Farmer
- Discipline of Surgery, Medical School, The University of Western Australia, Perth, Australia
- Department of Haematology, Royal Perth Hospital, Perth, Australia
| | - Steven M. Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Domenico Girelli
- Department of Medicine, University of Verona and Integrated University Hospital of Verona, Verona, Italy
| | | | - Jean-François Hardy
- Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Brussels, Belgium
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Axel Hofmann
- Discipline of Surgery, Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - Cheuk-Kwong Lee
- Hong Kong Red Cross Blood Transfusion Service, Hong Kong SAR, China
| | - Tsin W. Leung
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong SAR, China
| | - Sherri Ozawa
- Patient Blood Management, Accumen Inc., San Diego, CA
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Ampang, Malaysia
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Rosalio Torres
- Section of Hematology, Department of Internal Medicine, Makati Medical Center, Makati City, Philippines
| | - Matthew A. Warner
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Manuel Muñoz
- Department of Surgical Specialties, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
| |
Collapse
|
19
|
Kloeser R, Buser A, Bolliger D. Treatment Strategies in Anemic Patients Before Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:266-275. [PMID: 36328926 DOI: 10.1053/j.jvca.2022.09.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 01/14/2023]
Abstract
Both preoperative anemia and the transfusion of red blood cells have been associated with increased morbidity and mortality after cardiac surgery. To reduce the need for blood transfusion during surgery and improve patient outcomes, patient blood management programs have been developed. A primary focus of patient blood management in the preoperative period is the identification, diagnosis, and treatment of preoperative anemia, as anemia is associated with an increased risk of preoperative blood transfusion. In this narrative review, the authors focus on the laboratory screening of anemia before surgery and the evidence and limitations of different treatment strategies in anemic patients scheduled for cardiac surgery. To accurately correct preoperative anemia, the timely detection and definition of the etiology of anemia before elective cardiac surgery are crucial. Multiple randomized studies have been performed using preoperative iron supplementation and/or administration of erythropoiesis-stimulating agents in patients undergoing cardiac surgery. Although preoperative iron substitution in patients with iron deficiency is recommended, the evidence of its effectiveness is limited. In patients with nonpure iron deficiency anemia, combined therapy with erythropoiesis-stimulating agents and intravenous iron is recommended. Combined therapy might effectively reduce the need for red blood cell transfusion, even if applied shortly before cardiac surgery. The therapeutic effect on morbidity and mortality remains unclear. Nonetheless, the timely preoperative assessment of anemia and determination of iron status, eventually leading to targeted therapy, should become a standard of care and might potentially improve patient outcomes.
Collapse
Affiliation(s)
- Raphael Kloeser
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, and Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
| |
Collapse
|
20
|
Fabbro M, Patel PA, Henderson RA, Bolliger D, Tanaka KA, Mazzeffi MA. Coagulation and Transfusion Updates From 2021. J Cardiothorac Vasc Anesth 2022; 36:3447-3458. [PMID: 35750604 PMCID: PMC8986228 DOI: 10.1053/j.jvca.2022.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/02/2022]
Abstract
2021 and the COVID 19 pandemic have brought unprecedented blood shortages worldwide. These deficits have propelled national efforts to reduce blood usage, including limiting elective services and accelerating Patient Blood Management (PBM) initiatives. A host of research dedicated to blood usage and management within cardiac surgery has continued to emerge. The intent of this review is to highlight this past year's research pertaining to PBM and COVID-19-related coagulation changes.
Collapse
|
21
|
Kattou F, Montandrau O, Rekik M, Delentdecker P, Brini K, Zannis K, Beaussier M. Critical Preoperative Hemoglobin Value to Predict Anemia-Related Complications After Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:1901-1907. [PMID: 35148943 DOI: 10.1053/j.jvca.2022.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Preoperative anemia is frequent in patients undergoing cardiac surgery and is associated with increased postoperative complications. The purpose of this observational study was to estimate the critical preoperative hemoglobin threshold associated with the occurrence of complications after cardiac surgery. DESIGN A retrospective observational cohort study. SETTING A tertiary-care medical center from January 2019 to April 2020. PARTICIPANTS A total of 1,004 patients undergoing elective cardiac surgery were included. INTERVENTIONS None (observational study). MEASUREMENTS AND MAIN RESULTS The primary study endpoint was to define the hemoglobin threshold that predicted the occurrence of postoperative major complications after elective cardiac surgery. Postoperative complications were a composite criterion, including transient ischemic attack or stroke, myocardial infarction, acute kidney injury, respiratory failure, mediastinitis, or mesenteric ischemia. A discrimination threshold was determined by using receiver operating characteristic curves. The discrimination threshold for hemoglobin concentration with the best sensitivity/specificity ratio for the occurrence of postoperative complications was 13 g/dL for male patients and 11.8 g/dL for female patients. The incidence of postoperative complications was 17.2% in the total population. Independent risks were preoperative hemoglobin concentration, red blood cell transfusion, European System for Cardiac Operative Risk Evaluation II, and the type of surgery. CONCLUSIONS The critical preoperative hemoglobin thresholds associated with the occurrence of postoperative complications with the best sensitivity/specificity ratio were 13 g/dL for men and 11.8 g/dL for women, which were very similar to the World Health Organization criteria defining anemia.
Collapse
Affiliation(s)
- Fehmi Kattou
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Olivier Montandrau
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France.
| | - Mohamed Rekik
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Philippe Delentdecker
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Kais Brini
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Konstantinos Zannis
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Marc Beaussier
- Department of Anesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| |
Collapse
|