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Choi UE, Nicholson RC, Frank SM, Cha S, Cho BC, Lawton JS, Lester LC, Hensley NB. Use of preoperative erythropoietin-stimulating agents is associated with decreased thrombotic adverse events compared to red blood cell transfusion in surgical patients with anaemia. Vox Sang 2024. [PMID: 39168487 DOI: 10.1111/vox.13729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 07/26/2024] [Accepted: 08/04/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND AND OBJECTIVES Preoperative red blood cell (RBC) transfusions increase post-operative venous thromboembolic (VTE) events. Erythropoietin-stimulating agents (ESAs) increase VTE risk in cancer patients; we aimed to assess ESA versus RBC-associated VTE risks in a broad population of surgical patients. MATERIALS AND METHODS We queried TriNetX Diamond Network from 2006 to 2023, comparing patients with anaemia within 3 months preoperatively who received preoperative ESAs with or without intravenous (IV) iron to patients who received preoperative RBCs. Sub-analyses included (1) all surgeries and (2) cardiovascular surgeries. We propensity score matched for demographics, comorbidities, medical services, post-treatment haemoglobin (g/dL) and, for all-surgery comparisons, surgery type. Outcomes included 30-day post-operative mortality, VTE, pulmonary embolism (PE), disseminated intravascular coagulation (DIC) and haemoglobin. RESULTS In our 19,548-patient cohorts, compared with preoperative RBC transfusion, ESAs without IV iron were associated with lower mortality (relative risk [RR] = 0.51 [95% confidence interval (CI), 0.45-0.59]), VTE (RR = 0.57 [0.50-0.65]) and PE (RR = 0.67 [0.54-0.84]). Post-operative haemoglobin was higher in the ESA without IV iron cohort compared with the transfusion cohort (10.0 ± 1.4 vs. 9.4 ± 1.8 g/dL, p = 0.002). Cardiac surgical patients receiving ESAs with or without IV iron had lower risk for post-operative mortality, VTE and PE (p < 0.001) than those receiving RBCs. Post-operative haemoglobin differed between patients receiving ESAs with IV iron versus RBCs (10.1 ± 1.5 vs. 9.4 ± 1.9 g/dL, p = 0.0009). CONCLUSION Compared with surgical patients who were transfused RBCs, ESA recipients had reduced 30-day post-operative risk of mortality, VTE, PE and DIC and increased haemoglobin levels. IV iron given with ESAs improved mortality.
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Affiliation(s)
- Una E Choi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan C Nicholson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephanie Cha
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brian C Cho
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer S Lawton
- Cardiac Surgery Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laeben C Lester
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nadia B Hensley
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Gauthier CW, Bakaes YC, Kern EM, Kung JE, Hopkins JS, Hamilton CA, Bishop BC, March KA, Jackson JB. Total Joint Arthroplasty Outcomes in Eligible Patients Versus Patients Who Failed to Meet at Least 1 Eligibility Criterion: A Single-Center Retrospective Analysis. J Arthroplasty 2024; 39:1974-1981.e2. [PMID: 38403078 DOI: 10.1016/j.arth.2024.02.056] [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: 08/29/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND This study looks to investigate how not meeting eligibility criteria affects postoperative outcomes following total joint arthroplasty surgery. METHODS A retrospective review was conducted of total joint arthroplasty patients at a single academic institution. Demographics, laboratory values, and complications were recorded. Continuous and categorical variables were compared using the Student's T-test and the Chi-Square test, respectively. Multivariable analysis was used to control for confounding variables. RESULTS Our study included 915 total hip and 1,579 total knee arthroplasty patients. For total hip and total knee arthroplasty, there were no significant differences in complications (P = .11 and .87), readmissions (P = .83 and .2), or revision surgeries (P = .3 and 1) when comparing those who met all criteria to those who did not. Total hip arthroplasty patients who did not meet two criteria had 16.1 higher odds (P = .02) of suffering a complication. There were no differences in complications (P = .34 and .41), readmissions (P = 1 and .55), or revision surgeries (P = 1 and .36) between ineligible patients treated by total joint arthroplasty surgeons and those who were not. Multivariable analysis demonstrated no eligibility factors were associated with outcomes for both total hip and knee arthroplasty. CONCLUSIONS There was no significant difference in outcomes between those who met all eligibility criteria and those who did not. Not meeting two criteria conferred significantly higher odds of suffering a complication for total hip arthroplasty patients. Total joint arthroplasty surgeons had similar outcomes to non-total joint surgeons, although their patient population was more complex. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Chase W Gauthier
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Yianni C Bakaes
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Elizabeth M Kern
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Justin E Kung
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Jeffrey S Hopkins
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Corey A Hamilton
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Braxton C Bishop
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Kyle A March
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - J Benjamin Jackson
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
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Smyke NA, Sedlak CA. Blood Management for the Orthopaedic Surgical Patient. Orthop Nurs 2023; 42:363-373. [PMID: 37989156 DOI: 10.1097/nor.0000000000000986] [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] [Indexed: 11/23/2023] Open
Abstract
Prevention and management of anemia and blood loss in the orthopaedic patient undergoing surgery is a major concern for healthcare providers and patients. Although transfusion technology can be lifesaving, there are risks to blood products that have led to increased awareness of blood management and development of hospital patient blood management programs. Use of patient blood management can be effective in addressing preoperative anemia, a major modifiable risk factor in patients undergoing surgery. In this informational article, evidence-based practice guidelines for perioperative blood management are addressed. A case scenario is introduced focusing on a patient whose religious preference is Jehovah's Witness having "no blood wishes" undergoing elective orthopaedic surgery. Orthopaedic nurses can facilitate optimal patient blood management through multidisciplinary collaboration.
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Affiliation(s)
- Norman A Smyke
- Norman A. Smyke, Jr., MD, Medical Director Center for Blood Conservation at Grant, Medical Director Otterbein/Grant Nurse Anesthesia Program, OhioHealth Grant Medical Center, Grant Anesthesia Services, Columbus
- Carol A. Sedlak, PhD, RN, FAAN, Professor Emeritus, Kent State University, College of Nursing, Kent, OH
| | - Carol A Sedlak
- Norman A. Smyke, Jr., MD, Medical Director Center for Blood Conservation at Grant, Medical Director Otterbein/Grant Nurse Anesthesia Program, OhioHealth Grant Medical Center, Grant Anesthesia Services, Columbus
- Carol A. Sedlak, PhD, RN, FAAN, Professor Emeritus, Kent State University, College of Nursing, Kent, OH
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Gonzalez CA, O'Mara A, Cruz JP, Roth D, Van Rysselberghe NL, Gardner MJ. Postoperative sepsis and septic shock after hip fracture surgery. Injury 2023:110833. [PMID: 37365091 DOI: 10.1016/j.injury.2023.05.064] [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: 01/26/2023] [Revised: 04/09/2023] [Accepted: 05/15/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION There is a paucity of research in the rates for sepsis and septic shock in the hip fracture population specifically, despite marked clinical and prognostic differences between these conditions. The purpose of this study was to determine the incidence, risk factors, and mortality rates for sepsis and septic shock as well as evaluate potential infectious causes in the surgical hip fracture population. METHODS The ACS-NSQIP (2015-2019) was queried for patients who underwent hip fracture surgery. A backward elimination multivariate regression model was used to identify risk factors for sepsis and septic shock. Multivariate regression that controlled for preoperative variables and comorbidities was used to calculate the odds of 30-day mortality. RESULTS Of 86,438 patients included, 871 (1.0%) developed sepsis and 490 (0.6%) developed septic shock. Risk factors for both postoperative sepsis and septic shock were male gender, DM, COPD, dependent functional status, ASA class ≥3, anemia, and hypoalbuminemia. Unique risk factors for septic shock were CHF and ventilator dependence. The 30-day mortality rate was 4.8% in aseptic patients, 16.2% in patients with sepsis, and 40.8% in patients who developed septic shock (p < 0.001). Patients with sepsis (OR 2.87 [95% CI 2.37-3.48], p < 0.001) and septic shock (OR 11.27 [95% CI 9.26-13.72], p < 0.001) had increased odds of 30-day mortality compared to patients without postoperative septicemia. Infections that preceded a diagnosis of sepsis or septic shock included urinary tract infections (24.7%, 16.5%), pneumonia (17.6%, 30.8%), and surgical site infections (8.5%, 4.1%). CONCLUSIONS The incidence of sepsis and septic shock after hip fracture surgery was 1.0% and 0.6%, respectively. The 30-day mortality rate was 16.2% in patients with sepsis and 40.8% in patients with septic shock. Potentially modifiable risk factors for both sepsis and septic shock were anemia and hypoalbuminemia. Urinary tract infections, pneumonia, and surgical site infections preceded the majority of cases of sepsis and septic shock. Prevention, early identification, and successful treatment of sepsis and septic shock are paramount to lowering mortality after hip fracture surgery.
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Affiliation(s)
| | - Alana O'Mara
- Stanford University School of Medicine, Stanford, CA, USA
| | - Jacquelyn P Cruz
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Dylan Roth
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
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Peterson DF, McKibben NS, Hutchison CE, Lancaster K, Yang CJ, Dekeyser GJ, Friess DM, Schreiber MA, Willett NJ, Shatzel JJ, Aslan JE, Working ZM. Role of single-dose intravenous iron therapy for the treatment of anaemia after orthopaedic trauma: protocol for a pilot randomised controlled trial. BMJ Open 2023; 13:e069070. [PMID: 36944463 PMCID: PMC10032390 DOI: 10.1136/bmjopen-2022-069070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Orthopaedic trauma and fracture care commonly cause perioperative anaemia and associated functional iron deficiency due to a systemic inflammatory state. Modern, strict transfusion thresholds leave many patients anaemic; managing this perioperative anaemia is an opportunity to impact outcomes in orthopaedic trauma surgery. The primary outcome of this pilot study is feasibility for a large randomised controlled trial (RCT) to evaluate intravenous iron therapy (IVIT) to improve patient well-being following orthopaedic injury. Measurements will include rate of participant enrolment, screening failure, follow-up, missing data, adverse events and protocol deviation. METHODS AND ANALYSIS This single-centre, pilot, double-blind RCT investigates the use of IVIT for acute blood loss anaemia in traumatically injured orthopaedic patients. Patients are randomised to receive either a single dose infusion of low-molecular weight iron dextran (1000 mg) or placebo (normal saline) postoperatively during their hospital stay for trauma management. Eligible subjects include adult patients admitted for lower extremity or pelvis operative fracture care with a haemoglobin of 7-11 g/dL within 7 days postoperatively during inpatient care. Exclusion criteria include history of intolerance to intravenous iron supplementation, active haemorrhage requiring ongoing blood product resuscitation, multiple planned procedures, pre-existing haematologic disorders or chronic inflammatory states, iron overload on screening or vulnerable populations. We follow patients for 3 months to measure the effect of iron supplementation on clinical outcomes (resolution of anaemia and functional iron deficiency), patient-reported outcomes (fatigue, physical function, depression and quality of life) and translational measures of immune cell function. ETHICS AND DISSEMINATION This study has ethics approval (Oregon Health & Science University Institutional Review Board, STUDY00022441). We will disseminate the findings through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT05292001; ClinicalTrials.gov.
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Affiliation(s)
- Danielle F Peterson
- Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - Natasha S McKibben
- Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - Catherine E Hutchison
- Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - Karalynn Lancaster
- Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - Chih Jen Yang
- Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Graham J Dekeyser
- Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - Darin M Friess
- Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - Martin A Schreiber
- Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Nick J Willett
- Bioengineering, University of Oregon, Eugene, Oregon, USA
| | - Joseph J Shatzel
- Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph E Aslan
- Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Zachary M Working
- Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
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Chouairi F, Mercier MR, Alperovich M, Clune J, Prsic A. Preoperative Deficiency Anemia in Digital Replantation: A Marker of Disparities, Increased Length of Stay, and Hospital Cost. J Hand Microsurg 2022; 14:147-152. [PMID: 35983290 PMCID: PMC9381176 DOI: 10.1055/s-0040-1714152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Introduction The effects of preoperative anemia have been shown to be an independent risk factor associated with poor outcomes in both cardiac and noncardiac surgery. Socioeconomic status and race have also been linked to poor outcomes in a variety of conditions. This study was designed to study iron deficiency anemia as a marker of health disparities, length of stay and hospital cost in digital replantation. Materials and Methods Digit replantations performed between 2008 and 2014 were reviewed from the National Inpatient Sample (NIS) database using the ICD-9-CM procedure codes 84.21 and 84.22. Patients with more than one code or with an upper arm (83.24) or hand replantation (84.23) code were excluded. Extracted variables included age, race, comorbidities, hospital type, hospital region, insurance payer type, and median household income quartile. Digit replantations were separated into patients with and without deficiency anemia. Demographics, comorbidities, and access to care were compared between cohorts by chi-squared and t -tests. Multivariate regressions were utilized to assess the effects of anemia on total cost and length of stay. The regression controlled for demographics, region, income, insurance, hospital type, and comorbidities. Beta coefficient was calculated for length of stay and hospital cost. The regression controlled for significant age, race, region, and comorbidities in addition to the above variables. Results In the studied patient population of those without anemia, 59.5% were Caucasian, and in patients with anemia, 46.7% were Caucasian ( p < 0.001). Whereas in the in the studied patient population of those without anemia, 6.7% were Black, and in patients with anemia, 15.7% were Black ( p < 0.001). Median household income, payer information, length of stay and total cost of hospitalization had statistically significant differences. Using regression and β-coefficient, the effect of anemia on length of stay and cost was also significant ( p < 0.001). Regression controlled for age, race, region and comorbidities, with the β-coefficient for effect on cost 37327.18 and on length of stay 3.96. Conclusion These data show that deficiency anemias are associated with a significant increase in length and total cost of stay in patients undergoing digital replantation. Additionally, a larger percentage of patients undergoing digital replantations and who have deficiency anemia belong to the lowest income quartile. Our findings present an important finding for public health prevention and resource allocation. Future studies could focus on clinical intervention with iron supplementation at the time of digital replantation.
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Affiliation(s)
- Fouad Chouairi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, United States
- Yale University School of Medicine, New Haven, Connecticut, United States
| | - Michael R. Mercier
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, United States
- Yale University School of Medicine, New Haven, Connecticut, United States
| | - Michael Alperovich
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, United States
- Yale University School of Medicine, New Haven, Connecticut, United States
| | - James Clune
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, United States
- Yale University School of Medicine, New Haven, Connecticut, United States
| | - Adnan Prsic
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, United States
- Yale University School of Medicine, New Haven, Connecticut, United States
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