Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery

Red blood cell transfusion in the neurological ICU

Red blood cell transfusion (RBCT) is a common therapy used in the intensive care unit to treat anemia. However, due to deleterious side effects and questionable efficacy, the clinical benefit of RBCT in patients who are not actively bleeding is unclear. The results of randomized controlled trials suggest there is no benefit to a liberal transfusion practice in general critical care populations. Whether the results of these trials are applicable to brain injured patients is unknown, as patients with primary neurological injury were excluded. This article reviews the efficacy and complications of RBCT, as well as the relationship between RBCT and its outcome in both the general intensive care unit and neurologically critically ill populations.

Developing performance measures for patient blood management

In 2005, The Joint Commission set about assessing the need for performance measures associated with the provision of blood products. Through a rigorous process, seven patient blood management performance measures were created. These measures incorporated a measure requiring transfusion consent; three measures requiring the combination of a laboratory value and a rationale for transfusion of plasma, platelets, or red blood cells; a measure requiring standard documentation about a transfusion; a measure evaluating preoperative anemia screening; and a measure of preoperative type screening and antibody testing before the start of major blood loss surgery. This article describes the process of this measure development and summarizes the final measures and some of the evidence supporting the measures.

Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study

BACKGROUND

Preoperative anaemia is associated with adverse outcomes after cardiac surgery but outcomes after non-cardiac surgery are not well established. We aimed to assess the effect of preoperative anaemia on 30-day postoperative morbidity and mortality in patients undergoing major non-cardiac surgery.

METHODS

We analysed data for patients undergoing major non-cardiac surgery in 2008 from The American College of Surgeons' National Surgical Quality Improvement Program database (a prospective validated outcomes registry from 211 hospitals worldwide in 2008). We obtained anonymised data for 30-day mortality and morbidity (cardiac, respiratory, CNS, urinary tract, wound, sepsis, and venous thromboembolism outcomes), demographics, and preoperative and perioperative risk factors. We used multivariate logistic regression to assess the adjusted and modified (nine predefined risk factor subgroups) effect of anaemia, which was defined as mild (haematocrit concentration >29-<39% in men and >29-<36% in women) or moderate-to-severe (≤29% in men and women) on postoperative outcomes.

FINDINGS

We obtained data for 227,425 patients, of whom 69,229 (30·44%) had preoperative anaemia. After adjustment, postoperative mortality at 30 days was higher in patients with anaemia than in those without anaemia (odds ratio [OR] 1·42, 95% CI 1·31-1·54); this difference was consistent in mild anaemia (1·41, 1·30-1·53) and moderate-to-severe anaemia (1·44, 1·29-1·60). Composite postoperative morbidity at 30 days was also higher in patients with anaemia than in those without anaemia (adjusted OR 1·35, 1·30-1·40), again consistent in patients with mild anaemia (1·31, 1·26-1·36) and moderate-to-severe anaemia (1·56, 1·47-1·66). When compared with patients without anaemia or a defined risk factor, patients with anaemia and most risk factors had a higher adjusted OR for 30-day mortality and morbidity than did patients with either anaemia or the risk factor alone.

INTERPRETATION

Preoperative anaemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery.

FUNDING

Vifor Pharma.

The relationship between perioperative blood transfusion and overall mortality in patients undergoing radical cystectomy for bladder cancer

OBJECTIVES

The relationship between perioperative blood transfusion (PBT) and oncologic outcomes is controversial. In patients undergoing surgery for colon cancer and several other solid malignancies, PBT has been associated with an increased risk of mortality. Yet, the urologic literature has a paucity of data addressing this topic. We sought to evaluate whether PBT affects overall survival following radical cystectomy (RC) for patients with bladder cancer.

METHODS

The medical records of 777 consecutive patients undergoing RC for urothelial carcinoma of the bladder were reviewed. PBT was defined as transfusion of red blood cells during RC or within the postoperative hospitalization. The primary outcome was overall survival. Clinical and pathologic variables were compared using χ(2) tests, and Cox multivariate survival analyses were performed.

RESULTS

A total of 323 patients (41.6%) underwent PBT. In the univariate analysis, PBT was associated with increased overall mortality (HR 1.40, 95% CI 1.11-1.78). Additionally, an independent association was demonstrated in a non-transformed Cox regression model (HR, 95% CI 1.01-1.36) but not in a model utilizing restricted cubic splines (HR 1.03, 95% CI 0.77-1.38). The c-index was 0.78 for the first model and 0.79 for the second.

CONCLUSIONS

In a traditional multivariate model, mirroring those that have been applied to this question in the general surgery literature, we demonstrated an association between PBT and overall mortality after RC. However, this relationship is not observed in a second statistical model. Given the complex nature of adequately controlling for confounding factors in studies of PBT, a prospective study will be necessary to fully elucidate the independent risks associated with PBT.