Association Between Intraoperative Blood Transfusion and Mortality and Morbidity in Patients Undergoing Noncardiac Surgery

Abstract

T here is a strong association between a reduced estimated glomerular filtration rate (eGFR) and an increase in cardiovascular disease and all-cause mortality. Associations with morbidity in elective moderate-risk noncardiac surgery have not been examined. It was hypothesized that chronic kidney disease (CKD) would be associated with excess morbidity after elective, moderate-risk orthopedic surgery. Because they represent a large proportion of global surgical procedures and are characterized by highly homogeneous anesthetic and surgical practice, patients undergoing elective orthopedic joint replacement procedures were studied. Calculation of eGFR was done based on routine creatinine measurements using the Modification of Diet in Renal Disease equation. Chronic kidney disease was defined as eGFR G60 mL/min per 1.73 m 2 . Cardiac risk (Revised Cardiac Risk Index) and evidence-based preoperative factors associated with perioperative morbidity, such as operative time, blood loss, and perioperative temperature, were prospectively recorded using the postoperative morbidity survey. Differences in morbidity were analyzed between patients with CKD and normal preoperative renal function (W 2 test for trend) and presented as a hazard ratio (HR) or odds ratio (OR) with 95% confidence intervals (95% CIs). Secondary end points were time to hospital discharge and freedom from morbidities (analyzed by the log-rank test), both between and within CKD patients compared with those with normal renal function. Multiple regression analysis was performed to assess the association of CKD and perioperative factors with morbidity and length of hospital stay. A morbidity survey was conducted postoperatively in 526 patients undergoing elective orthopedic surgery. Chronic kidney disease patients (n = 142; 27%) sustained excess morbidity on postoperative day 5 (OR, 2.1 [95% CI, 1.2Y3.7]). It took longer (HR, 1.6 [95% CI, 1.2Y1.9]) for CKD patients to become free of morbidities (log-rank test). Time to hospital discharge was delayed by 4 days in CKD patients (HR, 1.4 [95% CI, 1.2Y1.7], log-rank test). Such patients sustained more pulmonary (OR, 2.2 [95% CI, 1.3Y3.6]), infectious (OR, 1.7 [95% CI, 1.1Y2.7]), cardiovascular (OR, 2.4 [95% CI, 1.2Y4.8]), renal (OR, 2.3 [95% CI, 1.5Y3.5]), neurological (OR, 4.3 [95% CI, 1.3Y17.7]), and pain (OR, 1.8 [95% CI, 1.03Y3.1]) morbidities.Additional stratification of CKD patients showed a preoperative eGFR of 50 mL/min per 1.73 m 2 or less to be associated with more frequent morbidity and a longer hospital stay, independent of age. Multiple regression analysis revealed CKD and congestive cardiac failure to be preoperative factors associated with a prolonged hospital stay. A sizable minority of CKD patients undergoing elective orthopedic procedures are at greater risk of prolonged morbidity and a longer hospital stay. Preoperative eGFR may enhance perioperative risk stratification beyond traditional risk factors. COMMENTIn recent years, the cardiovascular literature has focused on the relationship between C...

Variation in Transfusion Practices and the Effect on Outcomes After Noncardiac Surgery

“…[2][3][4][5][6] PRBC transfusions are thought to offset this oxygen debt and correct the physiologic imbalance, thereby ameliorating the negative effects of postoperative anemia. [8][9][10][11] Several trials have demonstrated that a restrictive transfusion strategy is at least as efficacious and probably superior to a liberal transfusion strategy in critically ill patients, 12 those with septic shock, 13 and in high-risk cardiac patients undergoing hip replacement. [8][9][10][11] Several trials have demonstrated that a restrictive transfusion strategy is at least as efficacious and probably superior to a liberal transfusion strategy in critically ill patients, 12 those with septic shock, 13 and in high-risk cardiac patients undergoing hip replacement.…”

“…In one large observational study, Bennett-Guerrero and colleagues 18 demonstrate a wide hospital-level variation in the use of perioperative PRBC transfusions among patients undergoing cardiac surgery in the United States, independent of case-mix and hospital characteristics, a finding that had been persistently present for more than 20 years. 8,11,24 In this context, we assessed the hospital-level variation in PRBC transfusion practices and the patient-level effects on outcomes after noncardiac general or vascular surgery, using population-based prospectively collected data. It is also difficult to gauge the effectiveness of PRBC transfusions in noncardiac surgical patients.…”

Risks associated with preoperative anemia and perioperative blood transfusion in open surgery for intracranial aneurysms

“…Similarly, patients who receive a transfusion have a more severe medical condition. 17 Thus, the association between anemia or transfusion and adverse outcomes in the general cohorts may be, at least in part, reflective of overall poor health of these patients. However, this association persists after matching on propensity scores, which allow us to balance the burden of comorbidities between anemia and no anemia and transfused and nontransfused patients.…”

Goal-directed hemostatic therapy using the rotational thromboelastometry in patients requiring emergent cardiovascular surgery

“…Vivacqua et al showed that morbidity and mortality were lowest in patients who received no blood transfusion, higher for patients receiving blood transfusion but had no reoperation, higher still for those requiring reoperation but no blood transfusion, and highest among those who received blood transfusion and also a reoperation. [1] To avoid indiscriminate use of allogeneic blood transfusion during severe perioperative bleeding, European Society of Anaesthesiology (ESA) guidelines [2] strongly recommend the application of transfusion algorithms incorporating predefined intervention triggers to guide hemostatic intervention.…”

“…[1] Surgical skills, extent of vascular injury and integrity of the hemostatic system all influence the volume of blood loss while the severity of anemia and the amount of blood transfusion are major determinants of postoperative outcome. [2][3][4][5] Impaired hemostasis may develop in surgical patients, owing to dilution of coagulation factors, hypothermia, low hematocrit and hypoperfusion associated with metabolic with transfusion requirements. [8] Given the lack of a consensus in transfusion decision-making, there is a wide variability in transfusion practices among different countries, hospitals and even health care providers within the same institution.…”