Age and blood transfusion: relationship and prognostic implications in cardiac surgery

Optimizing the transfusion strategy in surgical patients in a Lebanese university hospital

BACKGROUND AND PURPOSE

Our aim was to analyze factors that influence transfusion requirements in surgical patients in order to achieve a transfusion-saving strategy.

METHODS

Data was collected from patient's files at the Notre Dame de Secours-Jbeil University Hospital Center between January 2017 and June 2019. Selection was made for 400 patients who had undergone surgery and required transfusion. The studied variables were age, sex, and type of surgery whether planned or urgent with its expected level of bleeding. The presence of chronic anemia, coronary artery disease, values of hemoglobin and hematocrit before and after transfusion, iron status preoperatively, and post-operation complications were also noted.

RESULTS

The analysis of 400 transfused surgical patients showed that the mean age was 62 ± 18 years with 52.5% women and 47.5% men. In 82.3% of patients, surgical bleeding was expected, 77.8% of surgeries were scheduled, and 22.3% were urgent. Fifty-two percent of patients were known to have coronary artery disease. Orthopedic (35%) and cardiothoracic (29.5%) surgeries had the highest transfusion rate. Among all patients, only 106 patients (26.5%) underwent a preoperative iron workup. The pre-transfusion levels of hemoglobin were 9.9 ± 0.6 and hematocrit of 29.7 ± 1.9. 26.3% of patients had a post-transfusion complication. On the other hand, 19.5% of women and 20% of men were already anemic when admitted to the hospital. Anemic women required 7.6 times more transfusions than non-anemic, while anemic men required 12.38 times more transfusions than non-anemic men. Age, presence of coronary artery disease, and chronic anemia have been found to be factors increasing the risk of post-transfusion complications. Finally, urgent and unplanned surgeries are 2.9 times more likely to cause post-transfusion complications.

CONCLUSION

This study therefore confirms that anemic patients are more likely to receive perioperative blood transfusions. Consequently, in order to reduce blood transfusion and its complications, it would be beneficial primarily to diagnose and treat anemia preoperatively. Other transfusion-saving strategies could also be useful in the setting of surgical bleeding, such as the use of tranexamic acid and different autologous transfusion methods like the cell saver.

Acute kidney injury after cardiac surgery

PURPOSE OF REVIEW

Patients undergoing cardiac surgery are at high risk to develop cardiac surgery-associated acute kidney injury (CS-AKI) postoperatively. CS-AKI is associated with an increased risk for persistent renal dysfunction, morbidity and mortality. This review summarizes the epidemiology and pathophysiology of CS-AKI, as well as current treatment and prevention strategies.

RECENT FINDINGS

As AKI is a syndrome with complex pathophysiology, no causative treatment strategies exist. Recent advances in the field of AKI biomarkers offer new perspectives on the issue and the implementation of biomarker-guided preventive strategies may reduce rates of CS-AKI. Finally, nephroprotective treatments and angiotensin II as a novel vasopressor may offer new opportunities for high-risk patients undergoing cardiac surgery.

SUMMARY

Based on the described novel approaches for early detection, prevention and management of CS-AKI, a precision-medicine approach should be implemented in order to prevent the development of AKI in patients undergoing cardiac surgery.

Investigating preoperative myoglobin level as predictive factor for acute kidney injury following cardiac surgery with cardiopulmonary bypass: a retrospective observational study

BACKGROUND

Early identification of patients at risk of AKI after cardiac surgery is of critical importance for optimizing perioperative management and improving outcomes. This study aimed to identify the association between preoperative myoglobin levels and postoperative acute kidney injury (AKI) in patients undergoing valve surgery or coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass.

METHODS

This retrospective study included 293 patients aged over 17 years who underwent valve surgery or CABG with cardiopulmonary bypass. We excluded 87 patients as they met the exclusion criteria. Therefore, 206 patients were included in the final analysis. The patients... demographics as well as intraoperative and postoperative data were collected from electronic medical records. AKI was defined according to the Acute Kidney Injury Network classification system.

RESULTS

Of the 206 patients included in this study, 77 developed AKI. The patients who developed AKI were older, had a history of hypertension, underwent valve surgery with concomitant CABG, had lower preoperative hemoglobin levels, and experienced prolonged extracorporeal circulation (ECC) times. Multivariate logistic regression analysis revealed that preoperative myoglobin levels and ECC time were correlated with the development of AKI. A higher preoperative myoglobin level was an independent risk factor for the development of cardiac surgery-associated AKI.

CONCLUSIONS

Higher preoperative myoglobin levels may enable physicians to identify patients at risk of developing AKI and optimize management accordingly.

Examining participant representation by sex, race, ethnicity and age in United States blood donation and blood transfusion clinical trials

Significant inequities based on sex, race, ethnicity, and age exist among participants in clinical trials dedicated to investigating medical disease states. While general demographic data regarding blood donors and blood transfusion recipients have been studied extensively, the demographics of participants involved in blood donation and blood transfusion clinical trials are unknown. We performed a cross-sectional analysis of United States (U.S.) -based interventional blood donation and blood transfusion clinical trials registered with Clinicaltrials.gov to ascertain the composition of participants' sex, race, ethnicity, and age, as well as diagnostic conditions and geographic trial locations.Eligible trials were undertaken between July 2003 and August 2020. Thirty-eight of the one hundred and fifty-two blood donation and blood transfusion clinical trials met inclusion criteria (seven blood donation and thirty-one blood transfusion trials). While the participant dataset from trial reports were incomplete, 100 % of blood donation trials reported sex and age, 71.4 % reported race, and 42.3 % reported ethnicity. 96.8 % of blood transfusion trials reported sex, 51.6 % reported race, 38.7 % reported ethnicity, and 100 % reported age. Among 2720 participants enrolled in the seven blood donation trials, females were underrepresented (28.5 %) compared to U.S. Census data. Conversely, female (50.8 %) and male participants (49.2 %) were equally represented in blood transfusion trials (9255 participants). White participants were overrepresented in blood donation trials (73.4 %), while Hispanic or Latinos were underrepresented in both blood donation (7.7 %) and blood transfusion (8.2 %) trials compared to 2019 U.S.Census data. Only 8.3 % of blood transfusion clinical trials open to adults reported including older adults (i.e., ≥ 65yo). Despite mandatory reporting requirements and an already established framework, researchers frequently failed to report complete demographics of blood donation and blood transfusion clinical trial participants. Furthermore, various demographic groups were underrepresented in blood donation and/or blood transfusion clinical trials, including females, Hispanic or Latino individuals, and older adults. These findings demonstrate the need for implementation of strategies to ensure equitable representation of individuals in blood donation and transfusion clinical trials.

Association between acute kidney injury and prognoses of cardiac surgery patients: Analysis of the MIMIC-III database

Background

Acute kidney injury (AKI) is the most common major complication of cardiac surgery field. The purpose of this study is to investigate the association between acute kidney injury and the prognoses of cardiac surgery patients in the Medical Information Mart for Intensive Care III (MIMIC-III) database.

Methods

Clinical data were extracted from the MIMIC-III database. Adult (≥18 years) cardiac surgery patients in the database were enrolled. Multivariable logistic regression analyses were employed to assess the associations between acute kidney injury (AKI) comorbidity and 30-day mortality, 90-day mortality and hospital mortality. Different adjusting models were used to adjust for potential confounders.

Results

A total of 6,002 patients were involved, among which 485 patients (8.08%) had comorbid AKI. Patients with AKI were at higher risks of prolonged ICU stay, hospital mortality, 90-day mortality (all P < 0.001), and 30-day mortality (P = 0.008). AKI was a risk factor for hospital mortality [Model 1, OR (95% CI) = 2.50 (1.45-4.33); Model 2, OR (95% CI) = 2.44 (1.48-4.02)], 30-day mortality [Model 1, OR (95% CI) = 1.84 (1.05-3.24); Model 2, OR (95% CI) = 1.96 (1.13-3.22)] and 90-day mortality [Model 1, OR (95% CI) = 2.05 (1.37-3.01); Model 2, OR (95% CI) = 2.76 (1.93-3.94)]. Higher hospital mortality, 30-day mortality and 90-day mortality was observed in higher KDIGO grade for cardiac surgery patients with AKI (all P < 0.05).

Conclusion

Comorbid AKI increased the risk of hospital mortality, 30-day mortality, and 90-day mortality of cardiac surgery patients in the MIMIC-III database.

Development and validation of a model for predicting acute kidney injury after cardiac surgery in patients of advanced age

Objective

To develop a clinical model for predicting postoperative acute kidney injury (AKI) in patients of advanced age undergoing cardiac surgery.

Methods

A total of 848 patients (aged ≥ 60 years) undergoing cardiac surgery were consecutively enrolled. Among them, 597 were randomly selected for the development set and the remaining 251 for the validation set. AKI was the primary outcome. To develop a model for predicting AKI, visualized as a nomogram, we performed logistic regression with variables selected by Lasso regression analysis. The discrimination, calibration, and clinical usefulness of the new model were assessed and compared with those of Cleveland Clinic score and Simplified Renal Index (SRI) score in the validation set.

Results

The incidence of AKI was 61.8% in the development set. The new model included seven variables including preoperative serum creatinine, hypertension, preoperative uric acid, New York Heart Association classification ≥ 3, cardiopulmonary bypass time > 120 min, intraoperative red blood cell transfusion, and postoperative prolonged mechanical ventilation. In the validation set, the areas under the receiver operating characteristic curves for assessing discrimination of the new model, Cleveland Clinic score, and SRI score were 0.801, 0.670, and 0.627, respectively. Compared with the other two scores, the new model presented excellent calibration according to the calibration curves. Decision curve analysis presented the new model was more clinically useful than the other two scores.

Conclusions

We developed and validated a new model for predicting AKI after cardiac surgery in patients of advanced age, which may help clinicians assess patients' risk for AKI.

Topical rifampicin for prevention of deep sternal wound infections in patients undergoing coronary artery bypass grafting

Deep sternal wound infections (DSWI), although an infrequent complication, significantly impair postoperative outcomes after coronary artery bypass grafting (CABG) surgery. Among several preventive strategies, topical antibiotic therapy immediately before sternal closure has been strongly advocated. In this retrospective analysis, the incidence of DSWI in 517 patients undergoing isolated CABG and receiving rifampicin irrigation of mediastinum, sternum and suprasternal tissues was compared to an historical consecutive cohort of 448 patients. To account for the inherent selection bias, a 1:1 propensity matched analysis was performed. Patients receiving topical rifampicin experienced significantly less occurrence of postoperative DSWI (0.2% vs 2.5%, p = 0.0016 in the unmatched analysis; 0.3% vs 2.1%, p = 0.0391 in the matched analysis). Intensive care unit stay, hospital stay, and operative mortality were similar between groups. This study shows that topical rifampicin in combination with commonly prescribed preventative strategies significantly reduces the incidence of DSWI to less than 0.3% in unselected patients undergoing a full median sternotomy for CABG. Further studies, including a larger number of patients and with a randomization design, would establish the potential preventative role of topical rifampicin in reducing the occurrence of DSWI.

Determinants of blood transfusion for elective surgical procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, 2017

BACKGROUND

Till date 80% of the world's population has access to only 20% of the world's safe blood that is properly collected and tested. Paradoxically, despite a severely inadequate supply, blood is often transfused unnecessarily and it will expose patients to complications. Despite lots of publication and investigation on the efficiency of blood usage, there is no clear demarcation which patients really need blood transfusion.

OBJECTIVES

To determine factors associated with blood transfusion in elective surgical procedures in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, 2017 G.C.

METHODS

Hospital based cross sectional study was conducted from February 1, 2017 to September 30, 2017 G.C at Tikur Anbessa specialized Hospital. Data was collected by using convenient sampling technique and structured checklist. Multivariate logistic regression analysis was conducted to identify significant predictors of transfusion based on p-value less than 0.05 with 95% confidence level.

RESULTS

Among all 387 elective surgical patients 88 (22.7%) of patients were transfused with prepared blood. The independent predictors of perioperative blood transfusion were neurosurgery (craniotomy) (p = 0.017), hemoglobin level < 11.0 g/dl (p < 0.001) and intraoperative blood loss ≥ 15% (P < 0 0.001).

CONCLUSION

neurosurgery, hemoglobin <11.0 g/dl and intraoperative blood loss ≥15% were the major determinants of blood transfusion.

Reverse shoulder arthroplasty has higher perioperative implant complications and transfusion rates than total shoulder arthroplasty

Background

Indications for reverse total shoulder arthroplasty (RTSA) have expanded. The purpose of this retrospective cohort study was to evaluate national trends in shoulder arthroplasty utilization and to compare national perioperative complication rates for hemiarthroplasty (HA), total shoulder arthroplasty (TSA), and RTSA in a matched cohort.

Methods

The National Inpatient Sample was queried from 2011-2013 to identify patients who underwent HA, TSA, or RTSA. Age, sex, race, insurance type, Elixhauser comorbidity index, and perioperative complications were identified. A coarsened exact matching algorithm was used to match RTSA patients with TSA and HA patients to compare medical and implant-related perioperative in-hospital complications. Multivariable logistic regression analysis was performed on unmatched data to identify risk factors for development of perioperative complications.

Results

Overall, 42,832 shoulder arthroplasties were identified (44% TSAs, 34% RTSAs, 19% HAs). After matching, RTSAs had 6.2 times the odds of a perioperative implant-related complication (P < .001) and 2 times the odds of a red blood cell transfusion compared with TSAs (P < .001). The logistic regression model showed that prior shoulder arthroplasty (odds ratio [OR], 15.1; P < .001), younger age (OR, 0.98; P = .006), earlier year of index surgery (OR, 0.83; P = .002), history of illicit drug use (OR, 6.2; P = .008), and depression (OR, 2.3; P = .003) were risk factors for development of in-hospital implant-related complications after RTSA.

Conclusion

The perioperative implant-related complication rate and postoperative transfusion rate of RTSAs were significantly higher than those of TSAs. In addition, prior shoulder surgery, younger age, earlier year of index surgery, history of illicit drug use, and depression were risk factors for implant-related complications after RTSA. However, the perioperative RTSA implant-related complications did decline each year, suggesting a growing national proficiency with performing RTSA.

Acute Kidney Injury after Cardiac Surgery in Patients Without Chronic Kidney Disease

Introduction

Among patients undergoing cardiac surgery, the occurrence of acute renal injury appears to be associated with worse prognosis and increased mortality. The objective of this study was to evaluate risk factors and the impact this complication on mortality and survival after cardiac surgery among patients without chronic kidney disease.

Methods

In this retrospective study, we reviewed the medical records of 142 patients who underwent elective coronary artery bypass grafting, valve replacement (single or multiple), or both (simultaneously) at a tertiary care hospital.

Results

Among the 142 patients evaluated, the mean age was 58.28±13.87 years and 80 (56.33%) were female. The postoperative incidence of acute renal injury was 43.66%. Univariate analysis between the groups with and without acute renal injury revealed no significant differences, whereas multivariate analysis showed that risk factors for acute renal injury included valve replacement (OR=4.7, P=0.002, 95% CI=1.76-12.62, age (OR=1.044, P=0.012, 95% CI=1.01-1.07), previous cardiac surgery (OR=36.1, P=0.015, 95% CI=1.99-653.85), postoperative use of the vasoactive drug norepinephrine (OR=3.32, P=0.013, 95% CI=1.29-8.58) and dobutamine (OR=5.3, P=0.019, 95% CI=1.32-21.64). In our sample, there were 30 deaths, of which 25 had acute kidney injury. Survival was also lower among the patients with this complication, especially those who had required hemodialysis (OR=2.60, P<0.001, 95% CI=1.01-6.70) or had previously undergone cardiac surgery (OR=3.68, P<0.001, 95% CI=1.09-12.37).

Conclusion

Our findings underscore the importance of identifying risk factors for developing acute renal injury after cardiac surgery, which can further the development of effective renoprotective strategies.

Gender and intraoperative blood transfusion: analysis of 54,122 non-reoperative coronary revascularization procedures

Background:

Previous studies have shown that women undergoing isolated coronary artery bypass graft (CABG) surgery have an increased risk for postoperative morbidity and mortality when compared to men. Additionally, recent evidence suggests that blood transfusions are independently associated with an increased risk of adverse outcome.

Methods:

We evaluated gender differences in the risk of intraoperative red blood cell (RBC) transfusion during CABG surgery. Consecutive, non-reoperative CABG procedures performed across 196 institutions between April 2012 and May 2015 were retrospectively reviewed. Gender differences for intraoperative transfusion were evaluated with a multi-variable binary logistic regression model, adjusting for age, blood volume (Nadler formula to normalize for height and weight), body mass index, procedure acuity, net extracorporeal circuit prime volume, use of autologous priming, first hematocrit (Hct) in the operating room (OR), nadir Hct on cardiopulmonary bypass (CPB), volume added on CPB, ultrafiltration volume, urine output on CPB and procedure duration.

Results:

Among 54,122 patients (25.3% female), 21.6% (n = 11,701) received a RBC transfusion. Compared to men, female patients were older (66 years vs. 64 years, p<0.001), had lower blood volumes (4.3L vs. 5.6L, p<0.001) and a lower preoperative Hct (32.9% vs. 37.2%, p<0.001). Transfusion rates were three-fold higher in women versus men (45.1% vs. 13.7%, p<0.001). After adjustment for independent predictors of intraoperative transfusion, women remained at increased risk versus men (OR = 1.30, 95%CI = 1.19−1.43).

Conclusions:

Women have an increased risk of intraoperative RBC transfusion versus men. After adjusting for height and weight, much of this risk is due to gender differences in preoperative Hct and blood volume; however, a residual significant risk remained after adjustment. Perfusion strategies aimed at gender differences may minimize unnecessary transfusions. Future study on the impact of gender on transfusion practice in cardiac surgery is warranted.