The association of perioperative transfusion with 30-day morbidity and mortality in patients undergoing major vascular surgery

Obi, Andrea; Park, Yeo Jung; Bove, P; Cuff, Robert; Kazmers, Andris; Gurm, Hitinder S.; Grossman, Paul; Henke, Peter K.

doi:10.1016/j.jvs.2014.10.106

Cited by 88 publications

(50 citation statements)

References 42 publications

(44 reference statements)

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“…14–16,32 The large number of CLTI patients with anemia highlights the need for clinical practice guidelines, yet recommendations from vascular societies currently do not exist. Our observations reflect the lack of a uniform standard to guide the appropriateness of blood product usage, as hematocrit values that triggered transfusions varied greatly.…”

Section: Discussionmentioning

confidence: 99%

“…14,15 As such, blood transfusions are likely to act as an intermediate variable between the independent variable (preoperative anemia) and the dependent variable (adverse outcome). Due to this relationship, postoperative blood transfusion was not included as a covariate in the initial multivariable models which allowed more comprehensive assessment of the direct effect of anemia on outcomes.…”

Section: Methodsmentioning

confidence: 99%

“…Despite the widespread use of blood transfusions in patients with anemia, several studies have failed to demonstrate a benefit and, in fact, blood transfusions have shown to be harmful in many clinical settings. 14–18 Some suggest that it is not the practice of treatment of anemia with blood transfusions that is associated with adverse events, but rather the anemia itself that increases the patients’ risk of postoperative complications. 4 Interestingly, few reports have evaluated the combined effect of preoperative anemia and blood transfusions, although this is a relevant clinical question for physicians.…”

Section: Introductionmentioning

confidence: 99%

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Preoperative anemia associated with adverse outcomes after infrainguinal bypass surgery in patients with chronic limb-threatening ischemia

Bodewes

Pothof

Darling

et al. 2017

Journal of Vascular Surgery

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Objective Preoperative anemia in elderly patients undergoing surgery is prevalent and associated with adverse events; however, the interaction with other risk factors in patients with chronic limb-threatening ischemia (CLTI) is not well described. The purpose of this study was to assess the association between lower hematocrit (HCT) on admission and postoperative outcomes after infrainguinal bypass surgery. Methods Patients with CLTI undergoing non-emergent infrainguinal bypass were identified in the targeted vascular NSQIP 2011–2014. Thirty-day outcomes were compared across preoperative HCT levels: severe (HCT ≤29%), moderate (HCT 29.1–34%), mild (HCT 34.1–39%), or no anemia (HCT >39%), with no anemia serving as the reference group for all analyses. Independent associations between levels of anemia and postoperative outcomes were established using multivariable logistic regression. A sensitivity analysis was performed to assess interactions between preoperative anemia and blood transfusions. Results We identified 5,081 patients undergoing bypass, of which 741 (15%) had severe, 1,317 (26%) moderate, 1,516 (30%) mild, and 1,507 (30%) no anemia. Anemic patients were older and more commonly suffered from tissue loss and comorbidities (e.g. hypertension, diabetes, and renal insufficiency) (all P<.001). After adjustment for baseline conditions, mortality was higher in those with severe (3.1%, OR: 2.8, [95% CI: 1.3–6.3]) and moderate anemia (3.0%, OR: 2.6 [1.2–5.5]) compared to those without anemia (0.7%). Severe anemia was independently associated with major amputation (6.9% vs. 3.3%, OR: 1.6 [1.01–2.6]) compared to no anemia. Anemia on admission was additionally associated with several other adverse outcomes, such as major adverse cardiovascular event (MACE) (severe: OR: 1.9 [1.1–3.0]; moderate: OR: 1.9 [1.3–2.9]; mild: OR: 1.6 [1.1–2.4]) and unplanned return to the operating room (severe: OR: 1.6 [1.2–2.1]; moderate: OR: 1.5 [1.2–1.8]; mild: OR: 1.3 [1.03–1.6]). Moreover, mortality associated with preoperative anemia was not different in patients receiving postoperative blood transfusions compared to those who did not, while MACE was significantly higher in patients with preoperative anemia and blood transfusions (interaction; P < .001) Conclusions Mortality and major adverse events in CLTI patients undergoing infrainguinal bypass are inversely associated with preoperative hematocrit levels, with the highest event rates in the most severely anemic patients. The correlation between anemia and MACE – but not mortality – was stronger in those patients receiving postoperative blood transfusions. Further research is needed to define an appropriate transfusion threshold and attention should be focused on how to best optimize anemic CLTI patients prior to intervention.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Preoperative anemia associated with adverse outcomes after infrainguinal bypass surgery in patients with chronic limb-threatening ischemia

Bodewes

Pothof

Darling

et al. 2017

Journal of Vascular Surgery

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“…18,19 This increase in mortality may occur up to 1 year after CABG. 20 Even transfusion of 1 to 2 units seems to carry a significant risk of increased mortality.…”

Section: Discussionmentioning

confidence: 99%

Major transfusions remain frequent despite the generalized use of tranexamic acid: an audit of 3322 patients undergoing cardiac surgery

et al. 2016

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“…Nonetheless, our finding of increased complications in those receiving preoperative transfusion is consistent with observations reported by other authors. 4,8,9,18,19 …”

Section: Discussionmentioning

confidence: 99%

Preoperative blood transfusion is a predictor of worse short-term postoperative outcomes after colectomy

Papageorge

Kennedy

Carchman

2017

Surgery

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Background Both anemia and blood transfusion are associated with poor outcomes. The aim of this study was to evaluate the effect of preoperative blood transfusion on postoperative outcomes after colectomy, stratified by severity of anemia. Methods Patients undergoing colectomy from 2012–2014 were selected from the National Surgical Quality Improvement Program targeted colectomy database. Patients were divided into 2 groups based on receipt of preoperative transfusion and then stratified by hematocrit. Univariate and multivariate analyses were used to compare 30-day outcomes between the 2 groups. Results A total of 60,785 patients were included in the study, with an overall preoperative transfusion rate of 3.4% (n = 2,073). On univariate analysis, transfusion was associated with significantly greater rates of postoperative morbidity. The risk-adjusted, multivariate model confirmed increased risk of complications with preoperative transfusion (odds ratio 1.32, 95% confidence interval, 1.18–1.48). Furthermore, transfusion did not improve outcomes even in the setting of moderate anemia (odds ratio 1.35, 95% confidence interval, 1.14–1.60) or severe anemia (odds ratio 0.97, 95% confidence interval, 0.66–1.41). Conclusions Preoperative transfusion is an independent predictor of complications in patients with mild and moderate anemia. Furthermore, these retrospective data suggest that even severely anemic patients do not benefit from preoperative transfusion and empiric transfusion therefore should be avoided. Alternatives to preoperative optimization of this high-risk surgical population should be sought. (Surgery 2017;161:1067-75.)

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The association of perioperative transfusion with 30-day morbidity and mortality in patients undergoing major vascular surgery

Abstract: Perioperative transfusion in vascular surgical patients is independently associated with increased 30-day morbidity and mortality. Given indeterminate causation, these data suggest the need for a prospective transfusion threshold study in vascular surgical patients.

Cited by 88 publications

References 42 publications

Preoperative anemia associated with adverse outcomes after infrainguinal bypass surgery in patients with chronic limb-threatening ischemia

Preoperative anemia associated with adverse outcomes after infrainguinal bypass surgery in patients with chronic limb-threatening ischemia

Major transfusions remain frequent despite the generalized use of tranexamic acid: an audit of 3322 patients undergoing cardiac surgery

Preoperative blood transfusion is a predictor of worse short-term postoperative outcomes after colectomy

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