The effects of preoperative moderate to severe anaemia on length of hospital stay: A propensity score-matched analysis in non-cardiac surgery patients

Preoperative risk factors for extended hospital stay: A prospective study in a South African clinic

BACKGROUND

 Preoperative assessment clinics play a critical role in identifying, evaluating and mitigating perioperative risks. Despite global data highlighting the importance of preoperative risk factors on surgical outcomes, there remains limited information on their impact on post-operative length of stay (LOS) in South African contexts.

AIM

 This study aimed to describe the demographic and clinical profiles of patients referred to a preoperative clinic as well as factors associated with post-operative extended LOS.

SETTING

 The preoperative clinic is based in the city of Johannesburg in South Africa.

METHODS

 This was a prospective cohort study conducted between 2021 and 2022 at a private clinic in patients undergoing non-cardiac surgery. Data on demographics, co-morbidities, surgical procedures and clinical outcomes were collected. Statistical analysis was performed to assess relationships between preoperative risk factors, including ASA grading, Revised Cardiac Risk Index (RCRI), estimated glomerular filtration rate, diabetes mellitus, age, obesity and LOS.

RESULTS

 A total of 214 patients were assessed, of which 75.7% were female, with a median age of 62.5 years. Common co-morbidities included hypertension (59.3%) and obesity (55%). The median LOS was 3.5 days, with 47.2% of patients staying more than 3 days post-operatively. Knee (33.2%) and hip surgeries (21%) were the most common procedures. A significant association was found between longer LOS and RCRI score ≥ 1 (p = 0.007), renal dysfunction in knee surgery patients (p = 0.027) and age in patients undergoing hip surgery (p = 0.049).

CONCLUSION

 Findings note the need for targeted intereventions in preoperative care to reduce LOS, particularly for high-risk patients.Contribution: This study highlights the fact that preoperative information may play a significant role in patient's outcomes post surgery. Further research is needed to validate these results across broader healthcare settings.

Preoperative ANemiA among elderly undergoing Major Abdominal surgery (PANAMA) is associated with early postoperative morbidity and worse quality of life outcomes

Preoperative anemia is associated with poor outcomes, but less is known about its impact on quality of life (QoL). This study investigates the association between preoperative anemia and QoL in elderly undergoing major abdominal surgery. This prospective observational study was conducted from 2017 to 2021 in a tertiary hospital's preoperative anesthesia clinic. QoL outcomes were assessed using the EuroQol 5-Dimension 3-Level (EQ-5D-3L) and the EuroQol-Visual Analogue Scale (EQ-VAS). Data was collected at baseline, 1-, 3-, and 6-month postoperatively. Patients were included if they were 65 years or older, could provide written informed consent and were planned for elective major abdominal surgery. Patients were excluded if they were going for organ transplant surgery. A total of 469 patients were analyzed, of which 176 (38%) had anemia. There was no significant difference across varying anemia severity in EQ-5D-3L dimensions of mobility, self-care, usual activities, and pain/discomfort. Moderate-to-severe anemic patients generally have more issues across EQ-5D-3L dimensions. At baseline, these patients exhibited more issues with self-care (3%), pain/discomfort (13%), and anxiety/depression (19%), along with a lower mean EQ-VAS score of 77. However, there was a significant improvement in mobility, usual activities, and pain/discomfort over time. EQ-VAS score significantly improved for all groups of patients over time. The dimensions of EQ-5D-3L and EQ-VAS scores improved as the severity of anemia decreased. Preoperative anemia is associated with a significant decrease in QoL based on EQ-VAS. Recognizing and managing preoperative anemia may improve the recovery of elderly patients undergoing major abdominal surgery.

Preoperative anemia in older individuals undergoing major abdominal surgery is associated with early postoperative morbidity: a prospective observational study

PURPOSE

Preoperative anemia is associated with poor postoperative outcomes. Older patients have limited physiologic reserves, which renders them vulnerable to the stress of major abdominal surgery. We aimed to determine if the severity of preoperative anemia is associated with early postoperative morbidity among older patients undergoing major abdominal surgery.

METHODS

Ethics approval was obtained from SingHealth Centralized Institutional Review Board. This is a prospective observational study conducted in the preoperative anesthesia clinic of a tertiary Singapore hospital from 2017 to 2021. Patient demographic data, comorbidities, and intraoperative details were collected. Outcome measures included blood transfusions, complications according to the Postoperative Morbidity Survey, days alive and out of hospital (DaOH), length of hospital stay, and mortality.

RESULTS

A total of 469 patients were analyzed, 37.5% of whom had preoperative anemia (serum hemoglobin of < 13 g·dL-1 in males and < 12 g·dL-1 in females). Anemia was significantly associated with older age, a higher age-adjusted Comprehensive Complication Index score, a higher incidence of diabetes mellitus, and a higher proportion of patients with an American Society of Anesthesiologists Physical Status of III or IV. The severity of anemia was associated with the presence of early postoperative morbidity at day 5, increased blood transfusions, longer length of hospital stay, and fewer DaOH at 30 days and six months.

CONCLUSION

Anemia is significantly associated with poorer postoperative outcomes in the older population. The impact of anemia on postoperative outcomes could be further evaluated with quality of life indicators, patient-reported outcome measures, and health economic tools.

Association between preoperative hemoglobin with length of hospital stay among non-cardiac and non-obstetric surgery patients: a secondary analysis of a retrospective cohort study

BACKGROUND

Previous studies concerning the association between preoperative Hemoglobin (HB) level and the Length Of hospital Stay (LOS) in patients with non-cardiac surgery and non-obstetric surgery remain inconclusive. Herein, the objective of this study was to analyze whether and to what extent the preoperative HB level was connected with the LOS in non-cardiac and non-obstetric surgery patients.

METHODS

This retrospective cohort study was performed at a single institution, involving patients who underwent elective non-cardiac, non-obstetric surgery from April 2007 to September 2013. Clinical characteristics of patients such as demographics, comorbidities, preoperative HB level, LOS, mortality, procedure length, and pulmonary hypertension (PHTN) Severity Class data were collected. A univariate analysis was used to determine the association between clinical characteristics and LOS. Multivariate regression analysis was conducted to investigate the relationship between preoperative HB level and LOS.

RESULTS AND DISCUSSION

In this study, 311 patients were included. We observed that compared with the LOS > 7 days group, the average HB level of patients in the LOS ≤ 7 days group was higher (12.04 ± 2.20 g/dl vs. 10.92 ± 2.22 g/dl, p < 0.001). In addition, there were fewer patients with moderate-to-severe anemia in LOS ≤ 7 days group than the LOS > 7 days group (32.74% vs 58.82%, p < 0.001). In addition, we found that patients with LOS ≤ 7 days were accompanied with lower mortality (0.44% vs. 7.06%, p < 0.001) and lower mean combined pulmonary artery systolic pressure (PASP) and right ventricular systolic pressure (RVSP) than that in patients with LOS > 7 days (42.56 ± 11.97 vs. 46.00 ± 12.37, p < 0.05). After controlling for relevant confounders, we discovered a nonlinear association between preoperative HB level and LOS as well as a threshold effect based on LOS. Specifically, when preoperative HB level was less than 11.9 g/dL, LOS decreased by 2 days for each 1 g/dL increase in HB level. However, LOS did not alter substantially with the rise of preoperative HB level when it was higher than 11.9 g/dL.

CONCLUSION

Our study showed a close non-linear association between preoperative HB level and LOS in patients with non-cardiac surgery and non-obstetric surgery. In particular, for patients with preoperative HB less than 11.9 g/dL, increasing the preoperative HB level can help shorten the LOS after operation.

Allogeneic Blood Transfusion and Risk of Postoperative Complications in Patients with Mild and Moderate Anemia of Any Cause? A Retrospective Cohort Study in Total Revision Hip Surgery

Introduction

Patients undergoing revision total hip surgery (RTHS) have a high prevalence of mild and moderate preoperative anemia, associated with adverse outcomes. The aim of this study was to investigate the association of perioperative allogeneic blood transfusions (ABT) and postoperative complications in preoperatively mild compared to moderate anemic patients undergoing RTHS who did not receive a diagnostic anemia workup and treatment before surgery.

Methods

We included 1,765 patients between 2007 and 2019 at a university hospital. Patients were categorized according to their severity of anemia using the WHO criteria of mild, moderate, and severe anemia in the first Hb level of the case. Patients were grouped as having received no ABT, 1-2 units of ABT, or more than 2 units of ABT. Need for intraoperative ABT was assessed in accordance with institutional standards. Primary endpoint was the compound incidence of postoperative complications. Secondary outcomes included major/minor complications and length of hospital and ICU stay.

Results

Of the 1,765 patients, 31.0% were anemic of any cause before surgery. Transfusion rates were 81% in anemic patients and 41.2% in nonanemic patients. The adjusted risks for compound postoperative complication were significantly higher in patients with moderate anemia (OR 4.88, 95% CI: 1.54-13.15, p = 0.003) but not for patients with mild anemia (OR 1.93, 95% CI: 0.85-3.94, p < 0.090). Perioperative ABT was associated with significantly higher risks for complications in nonanemic patients and showed an increased risk for complications in all anemic patients. In RTHS, perioperative ABT as a treatment for moderate preoperative anemia of any cause was associated with a negative compound effect on postoperative complications, compared to anemia or ABT alone.

Discussion

ABT is associated with adverse outcomes of patients with moderate preoperative anemia before RTHS. For this reason, medical treatment of moderate preoperative anemia may be considered.

Identification of myocardial injury using perioperative troponin surveillance in major noncardiac surgery and net benefit over the Revised Cardiac Risk Index

BACKGROUND

Patients with perioperative myocardial injury are at risk of death and major adverse cardiovascular and cerebrovascular events (MACCE). The primary aim of this study was to determine optimal thresholds of preoperative and perioperative changes in high-sensitivity cardiac troponin T (hs-cTnT) to predict MACCE and mortality.

METHODS

Prospective, observational, cohort study in patients ≥50 yr of age undergoing elective major noncardiac surgery at seven hospitals in Sweden. The exposures were hs-cTnT measured before and days 0-3 after surgery. Two previously published thresholds for myocardial injury and two thresholds identified using receiver operating characteristic analyses were evaluated using multivariable logistic regression models and externally validated. The weighted comparison net benefit method was applied to determine the additional value of hs-cTnT thresholds when compared with the Revised Cardiac Risk Index (RCRI). The primary outcome was a composite of 30-day all-cause mortality and MACCE.

RESULTS

We included 1291 patients between April 2017 and December 2020. The primary outcome occurred in 124 patients (9.6%). Perioperative increase in hs-cTnT ≥14 ng L^-1 above preoperative values provided statistically optimal model performance and was associated with the highest risk for the primary outcome (adjusted odds ratio 2.9, 95% confidence interval 1.8-4.7). Validation in an independent, external cohort confirmed these findings. A net benefit over RCRI was demonstrated across a range of clinical thresholds.

CONCLUSIONS

Perioperative increases in hsTnT ≥14 ng L^-1 above baseline values identifies acute perioperative myocardial injury and provides a net prognostic benefit when added to RCRI for the identification of patients at high risk of death and MACCE.

CLINICAL TRIAL REGISTRATION

NCT03436238.