Smoking is Associated with Increased Blood Loss and Transfusion Use After Lumbar Spinal Surgery

Abstract

Background Little is known about the association between smoking and intraoperative blood loss and perioperative transfusion use in patients undergoing spinal surgery. However, we found that although many of the common complications and deleterious effects of smoking on surgical patients had been well documented, the aspect of blood loss seemingly had been overlooked despite data reported in nonorthopaedic sources to suggest a possible connection. Questions/Purposes We asked: (1) Is smoking associated with increased estimated blood loss during surgery in patients undergoing lumbar spine surgery? (2) Is smoking associated with increased perioperative transfusion usage?Methods Between 2005 and 2009, 581 lumbar decompression procedures (with or without fusion) were performed at one academic spine center. Of those, 559 (96%) had sufficient chart documentation to categorize patients by smoking status, necessary intra-and postoperative data to allow analysis with respect to bleeding and transfusion-related endpoints, and who did not meet exclusion criteria. Exclusion criteria included: patients whose smoking status did not fit in our two categories, patients with underlying coagulopathy, patients receiving anticoagulants (including aspirin and platelet inhibitors), history of hepatic disease, history of platelet disorder or other blood dyscrasias, and patient or family history of any other known bleeding disorder. Smoking history in packs per day was obtained for all subjects. We defined someone as a smoker if the patient reported smoking up until the day of their surgical procedure; nonsmokers were patients who quit smoking at least 6 weeks before surgery or had no history of smoking. We used a binomial grouping for whether patients did or did not receive a transfusion perioperatively. Age, sex, number of levels of discectomies, number of levels decompressed, number of levels fused, and use of instrumentation were recorded. The same approaches were used for transfusions in all patients regardless of smoking history; decisions were made in consultation between the surgeon and the anesthesia team. Absolute indications for transfusion postoperatively were: a hemoglobin less than 7 g/dL, continued symptoms of dizziness, tachycardia, decreased exertional tolerance, or hypotension that failed to respond to fluid resuscitation. Multiple linear regression analyses correcting for the above variables were performed to determine associations with intraoperative blood loss, while logistic regression was used to analyze perioperative transfusion use.

Surgical and Clinical Results of Minimally Invasive Spinal Fusion Surgery in an Unselected Patient Cohort of a Spinal Care Unit

“…Our results further showed reduced intraoperative blood loss among active smokers, which is in contrast to the findings of previous studies: McCunniff et al . report a linear correlation between packs smoked per day and estimated intraoperative blood loss, with an additional blood loss of 330 mL per pack smoked. It is unclear whether the significantly younger age of our smoking patients had a confounding influence on these results.…”

“…Whereas complex multi‐level spinal surgeries or open surgeries were observed to carry higher complication risks in elderly patients, this did not hold true among elderly patients undergoing MIS. In view of these findings, it is reasonable to assume that MIS provides a promising and innovative alternative for elderly patients, but also for patients with significant co‐morbidities, and other risk factors, such as obesity and active smoking status. The number of obese patients is increasing due to changed lifestyles, and body mass index impacts surgical outcomes.…”

Does the severity of pain correlate with severity of functional disability? Factors influencing ‘patient reported outcome measures’ in spinal patients

“…The subgroup analysis of the microdiscectomy and decompression patient cohort demonstrated a significantly greater mean ODI score in those that currently smoke. Recent literature has demonstrated increased complication rates in smokers [ 15 ], so this adds further evidence to the importance of counselling smokers with regard to cessation prior to their procedure as this could also impact the long-term outcomes after their operation.…”

Risk Factors for Blood Transfusion in Revision Total Hip Arthroplasty for Mechanical Failure

“…38,39 Conversely, Grosflam et al found no association between smoking and blood transfusion requirements in primary THA, while McCunniff et al found that smoking increased the risk of transfusion after lumbar spine surgery. 40,41 These conflicting findings are likely explained by the fact that while smokers tend to have higher baseline hemoglobin levels, 42 they may also have an increased risk of bleeding through impairment of platelet membrane function and alterations in the clotting cascade. [43][44][45][46] Irrespective of the effect of smoking on anemia, surgeons should counsel their patients on smoking cessation prior to elective rTHA to minimize risks of infection and wound complications.…”