Does blood transfusion increase the risk of infection after hip fracture?

Is perioperative blood transfusion a risk factor for mortality or infection after hip fracture?

OBJECTIVES

To assess whether allogeneic blood transfusion in the perioperative period is associated with changes in mortality or complication rates in patients undergoing surgical treatment for hip fracture (proximal femoral fracture).

DESIGN

Retrospective case-control series, all patients followed up for 1 year or until death.

SETTING

District General Hospital in Peterborough, UK. PATIENTS PARTICIPANTS: Three thousand six hundred twenty-five consecutive patients admitted and operated for hip fracture (proximal femoral fracture) during July 1989 to January 2002 (151 months); 1068 (29.9%) received a perioperative allogeneic blood transfusion.

MAIN OUTCOME MEASURES

Thirty- 120-, and 365-day mortality, deep and superficial wound infection rates.

RESULTS

Overall mortality for all patients at 1 year post fracture was 28.2% (1007 patients). Transfusion was associated with a statistically significant increase in mortality from 120 days onward after hip fracture. However, when this was adjusted with a statistical regression model for baseline characteristics and confounding variables, this difference became statistically insignificant (P = 0.17). Infection rates in the transfusion group were 2.0% for superficial infection and 0.9% for deep infection compared with 1.9% and 0.6%, respectively, in the nontransfusion group. These figures were not statistically significantly different. Other complications of deep venous thrombosis, chest infection, and congestive cardiac failure showed no statistically significant increase in those patients who received transfusion.

CONCLUSIONS

Our data suggest that transfusion is not associated with a change in mortality or infection rates in the hip-fracture patient.

Surgical-site infections within 60 days of coronary artery by-pass graft surgery

Surgical wound infections (SWIs) after coronary artery by-pass graft (CABG) within 30 and 60 days of operation were registered. Already known risk factors and possible risk factors for wound infection were studied. SWIs of sternal and/or leg wounds have been reported to occur in 2-20% of patients after CABG. Deep sternal infection, mediastinitis, occurs after 0.5-5% of CABG procedures. The duration and methods of follow-up, as well as definitions of SWI, vary in different studies. Previously known and possible new risk factors were registered for 374 patients. Patients were contacted by telephone 30 and 60 days after surgery and interviewed in accordance with a questionnaire about symptoms and signs of wound infections. Our definition of SWI was based on the Centers for Disease Control and Prevention (CDC) definition. SWIs were diagnosed in 114 of 374 (30.5%) of the patients. In total SWI were diagnosed in 120 surgical-site incisions. Almost all SWIs of the sternum (93.3%) were diagnosed within 30 days of surgery. Most of the SWIs of the leg (73%) were diagnosed within 30 days of surgery and 27% were diagnosed within 31 to 60 days of surgery. Being female was the most important risk factor for SWI of the leg. Low preoperative haemoglobin concentrations were the most important risk factor for superficial SWI on the sternum. Patients with mediastinitis had higher BMI and had more often received erythrocyte transfusions on postoperative day two or later than those without infections.

Blood Transfusion is Associated with Infection and Increased Resource Utilization in Combat Casualties

Combat casualty care has made significant advances in recent years, including administration of blood products in far-forward locations. However, recent studies have shown blood transfusion to be a significant risk factor for infection and increased resource utilization in critically injured patients. We therefore sought to investigate the incidence of blood transfusion and its association with infection and resource utilization in combat casualties. Prospective data were collected and retrospectively reviewed on 210 critically injured patients admitted to the USNS Comfort over a 7-week period during the 2003 assault phase of Operation Iraqi Freedom. Patients were stratified by age, gender, and injury severity score (ISS). Multivariate regression analyses were used to assess blood transfusion and hematocrit (HCT) as independent risk factors for infection and intensive care unit (ICU) admission controlling for age, gender, and ISS. The study cohort had a mean age of 30 ± 2 years, a mean ISS of 14 ± 3, 84 per cent were male, and 88 per cent sustained penetrating trauma. Blood transfusion was required in 44 per cent (n = 93) of the study cohort. Transfused patients had a higher ISS (18 ± 4 vs. 10 ± 3, P < 0.01), a higher pulse rate (105 ± 4 vs. 93 ± 3, P < 0.0001), and a lower admission HCT (27 ± 1 vs. 33 ± 2, P < 0.0001) compared with patients not transfused. Patients receiving blood transfusion had an increased infection rate (69% vs. 18%, P < 0.0001), ICU admission rate (52% vs. 21%, P < 0.0001), and ICU length of stay (6.7 ± 2.1 days vs. 1.4 ± 0.5 days, P < 0.0001) compared with nontransfused patients. However, there was no significant difference in mortality between transfused and nontransfused patients. Multivariate binomial regression analysis identified blood transfusion and HCT as independent risk factors for infection (P < 0.01) and blood transfusion as an independent risk factor for ICU admission (P < 0.05). Combat casualties have a high incidence of blood transfusion. Blood transfusion is an independent risk factor for infection and increased resource utilization. Therefore, consideration should be given to the use of alternative blood substitutes and recombinant human erythropoietin in the treatment and management of combat casualties.

Transfusion increases the risk of postoperative infection after cardiovascular surgery

BACKGROUND

Because of the immunomodulatory effects of transfusion, we attempted to identify factors associated with blood product use and determine the association of transfusion quantity with postoperative infection.

STUDY DESIGN

We studied total perioperative transfusion of blood products for 15,592 cardiovascular operations performed from July 1998 to May 2003. Infection end points were septicemia/bacteremia (n=351, 2.2%) and superficial (n=353, 2.3%) and deep (n=212, 1.4%) sternal wound infections. Factors associated with blood product administration were used to form balancing scores to adjust for differences in patient characteristics among those receiving and not receiving blood products.

RESULTS

Fifty-five percent of patients received packed red blood cells (RBC), 21% received platelets, 13% got fresh frozen plasma (FFP), and 3% got cryoprecipitate. Factors associated with RBC use included older age, female gender, higher New York Heart Association class, lower hematocrit, reoperation, and longer cardiopulmonary bypass time--all indicative of higher-risk patients. The more RBC units transfused, the higher was the occurrence of septicemia/bacteremia (p < 0.0001) and superficial (p=0.0007) and deep (p < 0.0001) sternal wound infection. Use of FFP (septicemia/bacteremia) and platelets (septicemia/bacteremia and deep sternal wound infection) mitigated against this association only slightly.

CONCLUSIONS

Blood products tended to be used in the sickest patients. But after accounting for this, risk of infection increased incrementally with each unit of blood transfused. Although cause and effect cannot be established, results suggested that blood product transfusion is an independent risk factor for postoperative infection in cardiac surgical patients, blood products are more likely to be used in the sickest patients, and no amount of blood loss treated by transfusion is innocuous.

The Frequency and Factors Linked to a Urinary Tract Infection Coding in Patients Undergoing Hip Fracture Surgery

OBJECTIVE

To study the frequency and factors linked to having an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis of urinary tract infection (UTI) in patients undergoing hip fracture surgery.

METHODS

A retrospective observational study of a cohort of all patients admitted to a university teaching hospital with a principal ICD-9 diagnosis of a hip fracture during 3 consecutive calendar years.

RESULTS

A total of 138 subjects (67% were 65 years or older) underwent hip fracture surgery during the study period. Twelve percent of subjects had an ICD-9 UTI diagnosis during the hospitalization period. The incidence of UTI diagnosis was greater in subjects who were 65 years or older compared with younger subjects (16% vs 4%, P < .05), females compared with males (18% vs 5%, P < .05), subjects admitted to a medical floor compared with subjects admitted to a surgical floor (45% vs 10%, P < .001), and in subjects with biochemical evidence of dehydration on admission compared with those without such evidence (20% vs 7%, P < .05). The incidence of an ICD-9 UTI diagnosis correlated positively with the number of days subjects received nothing per mouth (NPO) after surgery (P < .0001). Subjects who had a UTI diagnosis scored higher on the Goldman Cardiac Risk index (P < .05) indicating they were sicker. Using logistic regression analysis, only the number of days a patient was kept NPO after surgery was an independent predictor of having a UTI diagnosis (B = -1.34, P = .043). Presence of biochemical evidence of dehydration on admission was another possible predictor with a P value approaching significance (B = 0.3, P = .07). Subjects with a UTI diagnosis had longer mean (+/- SD) length of hospital stay (8.7 +/- 8 vs 5.4 +/- 3 days, P < .05) and greater incidence of delirium (35% vs 8%, P < .0001) compared with subjects without a UTI diagnosis.

CONCLUSIONS

Urinary tract infection ICD-9 diagnosis is frequent among patients undergoing hip fracture surgery and is linked to prolonged length of hospital stay and to increased incidence of delirium. Number of days patients were kept off oral intake after surgery was an independent factor associated with a UTI diagnosis during the hospitalization period in this patient population.

Universal Leukocyte Reduction

This article discusses the evidence for the generally accepted uses of leukocyte-reduced blood and the controversy over leukocyte reduction and transfusion-related immunomodulation. A perspective is provided on the continued need for leukocyte reduction on the part of all patients in the United States.

Role of parenteral iron in the management of anaemia in the elderly patient undergoing displaced subcapital hip fracture repair: preliminary data

INTRODUCTION

An important percentage of patients affected by hip fracture require the administration of allogenic blood transfusion (ABT) to avoid the risks of perioperative acute anaemia. However, concerns about ABT risks have led to the search for alternatives, especially in elective orthopaedic surgery.

MATERIALS AND METHODS

We have prospectively investigated the effect of preoperative intravenous 200-300 mg (group 2; n=20) iron sucrose on ABT requirements and postoperative morbid-mortality in patients undergoing surgery for displaced subcapital hip fracture (DSHF) repair. A previous series of 57 DSHF patients served as the control group (group 1). All patients were older than 65 years, were operated on the 3rd day after admission to the hospital, by the same medical team, and using the same implant. Age, gender, ASA classification, surgical procedure, perioperative haemoglobin, requirements for ABT, postoperative infection, length of hospital stay (LOS) and 30-day mortality rate were examined.

RESULTS

No adverse reactions to the iron administration were observed. The iron group had a lower transfusion rate (15% vs 36.8%), lower transfusion index (0.26 vs 0.77 units per patient), lower 30d mortality rate (0 vs 19.3%), shorter LOS (11.9 vs 14.1 days), as well as a trend to a lower postoperative infection rate (15% vs 33%).

CONCLUSION

Preoperative parenteral iron administration could be a safe and effective way to reduce the ABT requirements in DSHF patients. This reduction in the ABT requirements is accompanied by a reduction in the morbid-mortality rate and LOS. A large, randomised, controlled trial to confirm these results is warranted.

Emerging risks and outcomes of blood transfusion in surgery

Prior to 1900, blood transfusions were fraught with danger and often caused more complications than the underlying disease. Discovery of the ABO compatibility system in the early twentieth century opened the modern era of blood transfusion, yet ABO incompatibility-as a result of clerical error-remains a significant threat to the recipient today. The risk of disease transmission now includes new and emerging agents, such as Trepanosoma cruzii and West Nile Virus (WNV), as well as other existing pathogens. Transfusion-related immunomodulation (TRIM) presents a further risk to recipient patients. Confounding these problems are shortages of safe blood and the accelerated rise in the cost of blood due to increased testing. Outcome data on transfusion therapy have not always been favorable, particularly in the areas of postoperative infection, systemic inflammatory response syndrome (SIRS), multiple organ failure (MOF), and mortality. Such data have generated extensive efforts to determine association versus underlying cause of post-transfusion complications. In addition, unprecedented global initiatives to minimize the use of allogeneic blood are on the way. Options may include, but are not limited to, the use of "blood substitutes," although validation of such products is still required. In the meantime, blood product conservation techniques should become part of routine transfusion medicine.

Seguridad y eficacia del hierro intravenoso en la anemia aguda por fractura trocantérea de cadera en el anciano

BACKGROUND AND OBJECTIVE

An important percentage of patients with hip fracture need allogeneic transfusion to resolve their perioperative anemia. Our goal was to determine the safety profile and usefulness of parenteral iron in order to avoid allogeneic transfusions in trochanteric hip fracture (THF).

PATIENTS AND METHOD

A pseudo-experimental study was performed comparing a historic THF group (n = 104) with another group (n = 23) treated with parenteral iron (Venofer) (doses of 100 mg). Patients who had primary blood diseases or were receiving anticoagulation therapy were excluded. Age, gender, elapsed time, type of THF (international AO classification), surgical procedure, transfusion procedure and quantity, hemoglobin and hematocrit at days 0 and +2 (if a surgical procedure was not performed) and postoperatively were examined. We also analyzed the morbidity (post-surgical infection) and hospital stay and mortality rate at the first month.

RESULTS

We have not observed any adverse reactions upon iron administration. The iron group was transfused less times (39.1% vs. 56.7%) and had lower morbidity (infection) (20.3% vs. 35.4%) (p = 0.04), lower mortality (13% vs. 16.3%), less blood consumption (0.87 vs. 1.31 units) and less stay (13.7 vs. 14.3 days).

CONCLUSIONS

Parenteral administration of iron could be a safe and effective way to avoid or reduce allogeneic blood transfusions in THF patients. The reduction in the transfusional rate in the iron treated group is also accompanied by a reduction in the morbidity, infection rate, mortality rate and hospital stay.

Age, Blood Transfusion, and Survival after Trauma

Blood transfusion affects outcomes after trauma, but whether elderly patients are disproportionately affected remains unknown. To determine the possible interaction between age, packed cell transfusion volume (PCTV), and mortality after injury, we designed a 6-year retrospective review (January 1995 through December 2000) of patients ≥16 years of age who received blood transfusion within the first 24 hours after injury. One thousand three hundred twelve patients ≥16 years of age admitted to our trauma center received packed red blood cells in the initial 24 hours after admission. Of the 1312 patients, 1028 (78%) were ≤55 years and 284 (22%) were >55 years of age, and overall mortality was 21.2 per cent. Age, Injury Severity Score (ISS) Glasbow Coma Scale (GCS), and PCTV emerged as independent predictors of mortality. PCTV for elderly survivors (4.6 units) was significantly less than that of younger survivors (6.7 units). Furthermore, mean PCTV for all survivors decreased progressively with advancing age. No patient >75 years with a PCTV > 12 units survived. Age and PCTV act independently, yet synergistically to increase mortality following injury.

Transfusion in surgery and trauma

The role of transfusion in surgery and trauma continues to evolve with our greater understanding of the true indications for and effects of transfusion. The potential adverse immune consequences and end-organ effects of blood transfusion must be weighed against the need for replacement of blood volume and oxygen-carrying capacity. The techniques to conserve blood and avoid transfusion play an important role in caring for the bleeding surgical patient. The future holds great promise for the possibility of redefining the art of blood transfusion and perhaps one day replacing it entirely.

Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis

BACKGROUND

Immunosuppression is a consequence of allogeneic (homologous) blood transfusion (ABT) in humans and is associated with an increased risk in cancer recurrence rates after potentially curative surgery as well as an increase in the frequency of postoperative bacterial infections. Although a meta-analysis has been reported demonstrating the relationship between ABT and colon cancer recurrence, no meta-analysis has been reported demonstrating the relationship of ABT to postoperative bacterial infection.

METHODS

Twenty peer-reviewed articles published from 1986 to 2000 were included in a meta-analysis. Criteria for inclusion included a clearly defined control group (nontransfused) compared with a treated (transfused) group and statistical analysis of accumulated data that included stepwise multivariate logistic regression analysis. In addition, a subgroup of publications that included only the traumatically injured patient was included in a separate meta-analysis. A fixed effects analysis was conducted with odds ratios obtained by using the conditional maximum likelihood method and 95% confidence intervals on the obtained odds ratios were determined using the mid-p technique.

RESULTS

The total number of subjects included in this meta-analysis was 13,152 (5,215 in the transfused group and 7,937 in the nontransfused group). The common odds ratio for all articles included in this meta-analysis evaluating the association of ABT to the incidence of postoperative bacterial infection was 3.45 (range, 1.43-15.15), with 17 of the 20 studies demonstrating a value of p < or = 0.05. These results provide overwhelming evidence that ABT is associated with a significantly increased risk of postoperative bacterial infection in the surgical patient. The common odds ratio of the subgroup of trauma patients was 5.263 (range, 5.03-5.43), with all studies showing a value of p < 0.05 (0.005-0.0001). These results demonstrate that ABT is associated with a greater risk of postoperative bacterial infection in the trauma patient when compared with those patients receiving ABT during or after elective surgery.

CONCLUSION

These results demonstrate that ABT is an associated and apparently significant and frequently overlooked risk factor for the development of postoperative bacterial infection in the surgical patient. Allogeneic blood transfusion is a greater risk factor in the traumatically injured patient when compared with the elective surgical patient for the development of postoperative bacterial infection.

[Predictive factors for transfusion requirements in patients over 65 years old with subcapital hip fracture]

BACKGROUND AND OBJECTIVE

Our goal was to know the patient's clinical and hematologic characteristics that could influence the use of blood in subcapital hip fracture (SCHF).

PATIENTS AND METHOD

A prospective study of all patients affected by SCHF having surgery during 1998. Patients younger than 65 years, with primary blood diseases or under anticoagulation therapy were excluded. Age, gender, elapsed time, type of SCHF (international AO classification), surgical procedure (nail vs. hip arthroplasty), transfusional procedure and total used; hemoglobin (Hb) and hematocrit (Hct) levels at days 0 and + 2 (if surgical procedure was not performed) and after surgery were studied. Also we analyzed different hematimetric parameters: VCM, HCM, and RDW, transfusional act and blood consume. Statistical univariant analysis included T-Student test for numeric variables and Pearson X2 test for string variables. Statistical significance differences were considered when p < 0.05. A multivariate stepwise logistic regression model was carried out.

RESULTS

75 patients with SCHF were studied: 18 B1, 8 B2 and 49 B3 according to AO classification. Male/female: 12/63; age 81(SD: 8) years (range 65-99). At the admission day, the Hb level was 128 (SD: 23) g/L; Hct 0.39 L/L (SD: 0.06) (range 13-52), HCM 30.3 pg, VCM 91.4 fL and RDW 14.3%. The elapsed time was 5 (SD: 2.8) days. 22 patients (29.3%) had anemia on admission. Surgery consisted of: nails in 23 (31%) and hip arthroplasty in 52 (69%) patients. At day + 2 (n: 36) Hb was 119 g/L (SD: 12) and Hct 0.36 L/L (SD: 0.04). 34 (45%) patients were not transfused. On the statitiscal univariant study, Hb and Hct levels at admission and after surgery, RDW (anisocytosis), type of fracture and the surgical act were all associated with a transfusional procedure. In the transfused patients the Hb level (119.9 g/L) was lower than in non-transfused ones (138 g/L) (p < 0.01). 71% hip arthroplasty patients were transfused vs 17% nail patients (p < 0.01). On the logistic regression only the preoperative Hb level (p < 0.01) was identified as an independent predictor of transfusion.

CONCLUSIONS

These results invite us to improve the hematological parameters in this elderly population and to promote earlier and less aggressive surgical procedures (nails) and to promote the use of alternatives methods to reduce the use of allogenic blood.

Pharmacotherapeutic considerations in anesthesia

This article focuses on new findings leading to improved understanding of the pathophysiology and mechanisms of potential drug interactions between anesthetic drugs or techniques and cardiovascular medications in patients scheduled for surgery. Only the most frequently used drugs are reviewed. Elective surgery provides the luxury to consider these risks and alter therapy accordingly. Under urgent circumstances, however, the increased risks associated with these agents should be anticipated with the goal to minimize adverse effects while maintaining optimal cardiovascular function in the perioperative period.

Signs and symptoms associated with the transfusion of WBC-reduced RBCs and non-WBC-reduced RBCs in patients with anemia and HIV infection: results from the Viral Activation Transfusion Study

BACKGROUND

RBC transfusion is associated with fever and other reactions in some patients. The Viral Activation Transfusion Study randomly assigned patients to receive either unmodified or WBC-reduced RBCs and thus offered an opportunity to assess the effect of WBC-reduced RBCs on the incidence of transfusion reactions prospectively.

STUDY DESIGN AND METHODS

This prospective, randomized, double-blind, multicenter study compared prestorage WBC-reduced RBCs to unmodified RBCs in HIV-infected, CMV-seropositive, and transfusion-naive persons who required transfusions for anemia. Primary endpoints were survival and change in the plasma HIV RNA level at 7 days after transfusion. The incidence of transfusion reactions was prospectively evaluated.

RESULTS

The two groups had similar baseline characteristics and study endpoints; 3864 RBC units (median storage age, 9 days) were administered to 531 patients during 1745 transfusions. The most frequent signs reported were elevated temperature and hypotension. Subjects who reported fever within the week prior to transfusion were more likely to have an elevation in temperature associated with transfusion. The administration of RBCs that were less than 10 days old was associated with a marginal increase in the incidence of transfusion-associated temperature elevation among recipients of unmodified RBCs, but not among recipients of WBC-reduced RBCs. Caregivers reported fewer instances of both elevated temperature and hypotension than were identified by review of transfusion records.

CONCLUSIONS

The incidence of elevated temperature and hypotension associated with transfusion in this population was unexpectedly high. Use of WBC-reduced RBCs had no effect on the overall rates of elevated temperature or hypotension associated with transfusion of RBCs. The occurrence of a pre-existing fever was associated with a higher frequency of transfusion-associated elevated temperature.

Perioperative anemia: an independent risk factor for infection, mortality, and resource utilization in surgery

BACKGROUND

Previous studies on patients with hip fractures and in patients with colorectal cancer have documented that perioperative transfusion is associated with a significant increase in postoperative infection rate. Therefore, we sought to investigate the incidence of preoperative and postoperative anemia in noncardiac surgical patients and to determine if transfusion is an independent risk factor for infection and adverse outcome postoperatively.

METHODS

Prospective data from the National Veterans Administration Surgical Quality Improvement Program (NSQIP) was collected on 6301 noncardiac surgical patients at the Veterans Affairs Maryland Healthcare System from 1995 to 2000.

RESULTS

The mean age of the study cohort was 61 +/- 13. Descriptive data revealed 95% were male, 44% used tobacco, 19% were diabetic, 9% had COPD, 9% used alcohol, 3% used steroids, 1.7% had a diagnosis of cancer, and 1.2% had ascites. Preoperative anemia (hematocrit less than 36) was found in 33.9% and postoperative anemia was found in 84.1% of the study cohort. In the postoperative period, 32.5% of patients had a hematocrit of 26-30, and 26.5% had a hematocrit of 21-25. Mean units of blood transfused in the perioperative period ranged from 0.1 +/- 0.9 in patients without anemia to 2.7 +/- 2.9 in those with anemia. Incidence of pneumonia increased from 2.6 to 5% with increasing degree of anemia. Multiple logistic regression analysis documented that low preoperative hematocrit, low postoperative hematocrit, and increased blood transfusion rates were associated with increased mortality (P < 0.01), increased postoperative pneumonia (P < or = 0.05), and increased hospital length of stay (P < 0.05).

CONCLUSION

There is a high incidence of preoperative and postoperative anemia in surgical patients, with a coincident increase in blood utilization. These factors are associated with increased risk for perioperative infection and adverse outcome (mortality) in surgical patients. Consideration should be given to preoperative diagnosis and correction of anemia with iron, vitamin B12, folate supplementation, or administration of recombinant human erythropoietin.

Anemia in the critically ill: the role of erythropoietin

Anemia is a common clinical problem in critically ill patients and is associated with substantial red blood cell (RBC) transfusion requirements. However, RBC transfusion has significant risks, including adverse effects on the immune system. Although a low hemoglobin concentration may be tolerable, it may not be optimal for the critically ill patient. Thus, alternative therapies that can increase hemoglobin and avoid complications of RBC transfusion are desirable. Critically ill patients appear to have anemia identical to the anemia of chronic inflammatory disease with blunted erythropoietin production. Results of a recent randomized controlled trial in critically ill patients demonstrated that recombinant human erythropoietin (r-HuEPO, epoetin alfa) significantly reduced (by approximately 50%) the number of RBC units transfused (P <.002) and significantly increased hematocrit (P <.01) compared with placebo. There was no increase in mortality or adverse clinical events with therapy. Epoetin alfa may be an effective therapeutic approach to anemia in critically ill patients, decreasing the need for transfusion and achieving higher hemoglobin concentrations than generally attained with transfusion.

Pathophysiology of surgical site infection in total hip arthroplasty

This article is a case report of a 69-year-old man who underwent a right total hip replacement procedure and developed a surgical site infection. Areas of concern in prevention and treatment of hip arthroplasty infection are presented, focusing on the pathophysiologic process involved. A review of the patient risk factors and the pathophysiologic action potentiating risk for infection include host immunity, nutritional status, diabetes, age, use of steroids or immunosuppressive drugs, rheumatoid arthritis, and urinary tract or other infections. The case report identifies the patient's age, multiple instrumentation of the bladder resulting in bacteriuria and the reinfusion of 400 cc of autologous shed blood via cell saver, a controversial risk subject, as the primary risk factors for surgical site infection in this patient. Readmission to the hospital on day 16 after the operation was completed on identification of 2 pathogenic organisms, methicillin-resistant Staphylococcus aureus and Acinetobacter calcoaceticus bio anitratus. The infection was successfully treated with oral ciprofloxacin and intravenous administration of tobramycin, preventing progression from superficial to deep infection and preserving the prosthesis.

Morbidity and mortality in elderly trauma patients

BACKGROUND

Despite an increasing incidence, relatively few studies have examined the factors that predict morbidity and mortality in older patients and several reports have found standard predictors such as the Injury Severity Score to be less useful in this patient population. Similarly, the effect of skeletal injury has not been examined with regard to complications and mortality. The purpose of this study was to review a large multicenter experience with elderly trauma patients to isolate factors that might predict morbidity and mortality. The potential effect of skeletal long-bone injury was of particular interest.

METHODS

The charts of all patients older than 60 years who were admitted to one of four Level I trauma centers after sustaining blunt trauma were reviewed. Mechanisms of injury included in the study were motor vehicle crash, pedestrian struck, fall from a height, and crush injury. Slip-and-fall injuries were excluded. A total of 326 patients met inclusion criteria. Variables studied included age, sex, mechanism of injury, Injury Severity Score (ISS), Revised Trauma Score, Glasgow Coma Scale (GCS) score, blood transfusion, fluid resuscitation, surgery performed (laparotomy, long-bone fracture stabilization, both), and timing of surgery. Outcome variables measured included incidence of adult respiratory distress syndrome, pneumonia, sepsis, myocardial infarction, deep venous thromboembolism, gastrointestinal complications, and death. chi2, logistic regression, t test, and nonparametric analyses were done as appropriate for the type of variable.

RESULTS

The average age of the patients was 72.2+/-8 years. Overall, 59 patients (18.1%) died, of whom 52 of 59 survived at least 24 hours. Statistical significance for continuous variables (p < 0.05) using univariate analysis was reached for the following factors for the patients who died: higher ISS (33.1 vs. 16.4), lower GCS score (11.5 vs. 13.9), greater transfusion requirement (10.9 vs. 2.9 U), and more fluid infused (12.4 vs. 4.9 L). Logistic regression analysis was performed to determine the factors that predicted mortality. They included (odds ratios and p values in parentheses) transfusion (1.11, p = 0.01), ISS (1.04, p = 0.008), GCS score (0.87, p = 0.007), and fluid requirement (1.06, p = 0.06). Regarding surgery, orthopedic surgery alone had an odds ratio of 0.53, indicating that orthopedic patients was less likely to die than patients who did not undergo any surgery. Patients who underwent only a general surgical procedure were 2.5 times more likely to die (p = 0.03) and patients who underwent both general and orthopedic procedures were 1.5 times more likely to die (p = 0.32) than patients who did not require surgery. Early (< or =24 hours) versus late (>24 hours) surgery for bony stabilization did not have a statistical effect on mortality (11% early vs. 18% late). Two patients in need of bony stabilization, however, died before these procedures were performed. With regard to complications, regression analysis revealed that ISS predicted adult respiratory distress syndrome, pneumonia, sepsis, and gastrointestinal complications; fluid transfusion predicted myocardial infusion; and need for surgery and transfusion requirements predicted sepsis. These complications, in turn, were significant risk factors for mortality. This large series of elderly patients demonstrates that mortality correlates closely with ISS and is influenced by blood and fluid requirements and by GCS score. The institution-specific mortality was the same when adjusted for ISS. The need for orthopedic surgery and the timing of the surgery was not a risk factor for systemic complications or mortality in this series.

CONCLUSION

Mortality is predicted by ISS and by complications in older patients. Seventy-seven percent of the orthopedic injuries were stabilized early, but the timing of surgery did not have any statistical effect on the incidence of complications or mortality. (ABSTRACT TRUNCA

Developments in blood management: the potential therapeutic role for epoetin alfa in orthopedic trauma

Orthopedic trauma is a major source of morbidity and mortality in the United States and other countries. Major orthopedic trauma often results in significant blood loss, which is the most common cause of shock in the trauma setting. Transfusion of allogeneic blood and blood products may be used to maintain blood pressure but may not be the most effective therapy for the acute anemia that results from trauma-induced hemorrhage. Because acute anemia can interfere with successful and timely rehabilitation of these patients, it is important to be aggressive in treating anemia. One approach is to administer Epoetin alfa to stimulate erythropoiesis. A pilot study is currently in progress to test the efficacy of this approach in major trauma patients.

Blood conservation in hip trauma

Patients with hip or pelvic fractures experience significant blood loss as a result of the fracture and from the surgery that subsequently is performed. The emergent and unplanned nature of fracture surgery precludes the use of preoperative blood donation and the optimization of chronic medical problems. Blood transfusion frequently is required to maintain adequate tissue O2 delivery in these injured patients. However, the administration of allogeneic blood causes other problems, including a well documented increase in the risk of infectious complications. Perioperative measures to minimize blood loss such as hypotensive anesthesia and red blood cell salvage are important, but often are inadequate to prevent the need for blood transfusion. Recently, erythropoietin therapy has been shown to stimulate hematopoiesis in patients with hip fractures. The authors discuss their experience with blood loss management in these patients with hip injuries, including aggressive Fe replacement therapy and the use of recombinant human erythropoietin.