Effect of postoperative anemia and baseline cardiac risk on serious adverse outcomes after major vascular interventions

Kougias, Panos; Sharath, Sherene; Barshes, Neal R.; Chen, Millie; Mills, Joseph L.

doi:10.1016/j.jvs.2017.05.113

Cited by 26 publications

(10 citation statements)

References 25 publications

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“…26 We found that nadir Hb below 9.0 g/dL was associated with a higher risk of composite adverse events, even after stratifying patients by whether or not they received transfusions, what type of operation they had, or other confounders. This result suggests that above 9.0 g/dL may be the optimal Hb level for this population of patients, consistent with a previous report 27 that the inflection point in the incidence of composite outcomes lay around nadir Hb 9.0 g/dL for patients undergoing major vascular operation.…”

Section: Commentsupporting

confidence: 91%

Postoperative Nadir Hemoglobin and Adverse Outcomes in Patients Undergoing On-Pump Cardiac Operation

Zhou

Liu

Yan

et al. 2021

The Annals of Thoracic Surgery

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BACKGROUND Patients undergoing cardiac operation are susceptible to anemia. Low hemoglobin concentration is a risk factor for composite adverse events and death after cardiac operation. Here we investigated the association of postoperative nadir hemoglobin with adverse outcomes in patients undergoing on-pump cardiac operation.METHODS Adult patients in 2 medical centers were retrospectively analyzed. The primary outcome was postoperative composite adverse events. The secondary outcome was all-cause death in the hospital. RESULTSOf the 8206 patients analyzed, 1628 (19.8%) experienced composite adverse events after operation and 109(1.3%) died. Patients receiving on-pump cardiac operation with nadir hemoglobin of 9.0 to 9.9 g/L showed a low incidence of composite adverse events (175 of 1423 [12.3%]) and death (5 of 1423 [0.4%]). Compared with nadir hemoglobin at 9.0 to 9.9 g/dL, the relative risk (RR) of composite adverse events increased stepwise as nadir hemoglobin fell below 9.0 g/dL: adjusted RR was 1.44 (95% confidence interval [CI], 1.14-1.83) for 8.5 to 8.9 g/dL, 1.56 (95% CI, 1.23-1.99) for 8.0 to 8.4 g/dL, 1.66 (95% CI, 1.31-2.11) for 7.5 to 7.9 g/dL, 2.22 (95% CI, 1.75-2.83) for 7.0 to 7.4 g/dL, and 4.00 (95% CI, 3.18-5.04) for less than 7 .0 g/dL. Furthermore, the risk of death was significantly higher when nadir hemoglobin was below 7.0 g/dL than when it was 9.0 to 9.9 g/dL (RR, 5.36; 95% CI,).CONCLUSIONS Compared with the risks when nadir hemoglobin is 9.0 to 9.9 g/dL, the risk of composite adverse events increases when postoperative nadir hemoglobin is below 9.0 g/dL, whereas risk of death increases when nadir hemoglobin is below 7.0 g/dL.

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Section: Commentsupporting

confidence: 91%

Postoperative Nadir Hemoglobin and Adverse Outcomes in Patients Undergoing On-Pump Cardiac Operation

Zhou

Liu

Yan

et al. 2021

The Annals of Thoracic Surgery

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“…Fluid resuscitation with red blood cells (RBCs) plays a fundamental role in maintaining tissue oxygenation during blood loss. This is particularly relevant for the vascular surgical patient because of frequent preoperative anemia 1,2 and surgical hemorrhage exceeding 500 mL, [3][4][5] both of which are associated with improved survival if RBC transfusion is initiated during surgery compared with no transfusion. 6 Furthermore, as these patients often present with cardiac disease, [7][8][9] they may be particularly vulnerable to a hemoglobin (Hb) level below 10 g/dL.…”

Section: Introductionmentioning

confidence: 99%

“…6 Furthermore, as these patients often present with cardiac disease, [7][8][9] they may be particularly vulnerable to a hemoglobin (Hb) level below 10 g/dL. 2,10 However, as allogeneic RBC transfusions are also associated with mortality and cardiovascular morbidity, [11][12][13] and are an expensive and limited resource, randomized trials are warranted to balance risks and benefits of transfusion strategies in vascular surgery. 14 In other surgical specialties, it has been demonstrated that withholding transfusion until reaching a Hb level of 7.0 to 8.0 g/dL is safe, [15][16][17][18][19] but the majority of the evidence is based on postoperative stable patients.…”

Section: Introductionmentioning

confidence: 99%

Low vs high hemoglobin trigger for transfusion in vascular surgery: a randomized clinical feasibility trial

Møller

Nielsen²,

Wetterslev

et al. 2019

Blood

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Current guidelines advocate to limit red blood cell (RBC) transfusion during surgery, but the feasibility and safety of such a strategy remain unclear, as the majority of evidence is based on postoperatively stable patients. We assessed the effects of a protocol aiming to restrict RBC transfusion throughout hospitalization for vascular surgery. Fifty-eight patients scheduled for lower limb bypass or open abdominal aortic aneurysm repair were randomly assigned, on hemoglobin drop below 9.7 g/dL, to either a low-trigger (hemoglobin < 8.0 g/dL) or a high-trigger (hemoglobin < 9.7 g/dL) group for RBC transfusion. Near-infrared spectroscopy assessed intraoperative oxygen desaturation in brain and muscle. Explorative outcomes included nationwide registry data on death and major vascular complications. The primary outcome, mean hemoglobin within 15 days of surgery, was significantly lower in the low-trigger group, at 9.46 vs 10.33 g/dL in the high-trigger group (mean difference, −0.87 g/dL; P = .022), as were units of RBCs transfused (median [interquartile range (IQR)], 1 [0-2] vs 3 [2-6]; P = .0015). Although the duration and magnitude of cerebral oxygen desaturation increased in the low-trigger group (median [IQR], 421 [42-888] vs 127 [11-331] minutes × %; P = .0036), muscle oxygenation was unaffected. The low-trigger group associated to a higher rate of death or major vascular complications (19/29 vs 8/29; hazard ratio, 3.20; P = .006) and fewer days alive outside the hospital within 90 days (median [IQR], 76 [67-82] vs 82 [76-84] days; P = .049). In conclusion, a perioperative protocol restricting RBC transfusion successfully separated hemoglobin levels and RBC units transfused. Exploratory outcomes suggested potential harm with the low-trigger group and warrant further trials before such a strategy is universally adopted. This trial was registered at www.clinicaltrials.gov as #NCT02465125.

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“…La población que padece aneurismas aórticos generalmente está constituida por individuos de edad avanzada con comorbilidad, y durante estos complejos procedimientos pueden ocurrir hemorragias transoperatorias que requieran transfusiones sanguíneas [23][24][25][26] .Esta práctica ha sido estudiada en el escenario de intervenciones de revascularización de miembros inferiores por O'Keeffe, et al 27 ,quienes concluyen que los pacientes sometidos a derivaciones en los miembros pélvicos que recibieron al menos tres paquetes globulares tenían una razón de momios de 2.48 (intervalo de confianza del 95%: 1.55-3.98) mayor para desarrollar complicaciones posoperatorias que aquellos que no requirieron transfusiones. En 2017, Kougias, et al 28 analizaron 2508 procedimientos vasculares en 2106 pacientes durante un periodo de 8 años, y concluyeron que la anemia posoperatoria era un factor que incrementaba la mortalidad temprana y los eventos isquémicos, en particular en los pacientes con riesgo cardiovascular. Estos autores hacen énfasis en la necesidad de realizar ensayos clínicos controlados que aborden este dilema clínico, favoreciendo la restricción de transfusiones en los pacientes que se someten a cirugía vascular mayor.…”

Section: Figura 3 Gráfica Del Análisis De Kaplan-meier Para Comparar La Supervivencia De Los Pacientes Sometidos a Reconstrucción Aórticaunclassified

Factores que impactan la función renal durante la reconstrucción abierta y endovascular de aneurismas aórticos

Hinojosa¹,

Anaya‐Ayala²,

Carrera-Ramirez³

et al. 2019

CIRU

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Analizar qué factores influyen en el deterioro de la función renal en pacientes sometidos a reconstrucción aórtica abierta o endovascular, y su impacto en la supervivencia. Método: Estudio retrospectivo. Se analizaron variables demográficas, de laboratorio, transoperatorias y posoperatorias. Se determinó la función renal y se utilizó la prueba exacta de Fisher en la búsqueda de asociaciones, y el análisis de Kaplan-Meier para estimar la supervivencia. resultados: De 2007 a 2017, 80 pacientes (media de edad: 70 años) fueron sometidos a procedimientos de reconstrucción aórtica. Cincuenta y ocho (73%) eran de sexo masculino. Doce (15%) tuvieron elevación de creatinina en el posoperatorio y sangrado mayor de 1500 ml con necesidad de transfusión que se asoció a insuficiencia renal aguda (p = 0.005). Durante el periodo de seguimiento de 60 meses, 8 (10%) pacientes desarrollaron insuficiencia renal crónica, 2 (2.5%) requirieron hemodiálisis y 18 (22%) fallecieron. La edad, el sexo, la comorbilidad y las características anatómicas del aneurisma, así como el tipo de intervención o el nivel de pinzamiento aórtico, no impactaron la función renal posoperatoria. Conclusiones: La reparación de los aneurismas aórticos complejos continúa siendo un reto. Un sangrado superior a 1500 ml, con necesidad de transfusión, se asoció a deterioro de la función renal posoperatoria e impactó en la supervivencia a 5 años.

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Effect of postoperative anemia and baseline cardiac risk on serious adverse outcomes after major vascular interventions

Cited by 26 publications

References 25 publications

Postoperative Nadir Hemoglobin and Adverse Outcomes in Patients Undergoing On-Pump Cardiac Operation

Postoperative Nadir Hemoglobin and Adverse Outcomes in Patients Undergoing On-Pump Cardiac Operation

Low vs high hemoglobin trigger for transfusion in vascular surgery: a randomized clinical feasibility trial

Factores que impactan la función renal durante la reconstrucción abierta y endovascular de aneurismas aórticos

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