A survey of perioperative management of sickle cell disease in North America

Preoperative Transfusion and Surgical Outcomes for Children with Sickle Cell Disease

BACKGROUND

Current guidelines recommending preoperative transfusion to a hemoglobin level of 9 to 10 g/dL for patients with sickle cell disease (SCD) are based on imperfect evidence. The benefit of preoperative transfusion in children specifically is not known. This study aimed to evaluate whether preoperative RBC transfusion is associated with different rates of sickle cell crisis and surgical complications, compared with no preoperative transfusion, among children with SCD undergoing common abdominal operations.

STUDY DESIGN

The NSQIP-Pediatrics database (2013 to 2019) was queried. Patients who underwent cholecystectomy, splenectomy, or appendectomy with a preoperative Hct level of less than 30% were included. The primary outcome was 30-day readmission for sickle cell crisis. Secondary outcomes were 30-day surgical complications and hospital length of stay. Propensity score matching methods were used to obtain two statistically similar cohorts of patients comprised of those who were preoperatively transfused and those who were not.

RESULTS

Among 357 SCD patients, 200 (56%) received preoperative transfusion. In the matched cohort of 278 patients (139 per group), there was no statistically significant difference in 30-day readmission for sickle cell crisis in the transfused and non-transfused groups (5.8% vs 7.2%, p = 0.80). The rate of 30-day surgical complications did not differ between matched groups (10.8% vs 9.4%, p = 0.84). Subgroups defined by presenting Hct levels of 27.3% or greater or less than 27.3%, American Society of Anesthesiologists classification, wound class, and index operation were not associated with an altered risk of sickle cell crisis or surgical complications after preoperative transfusion compared with no transfusion.

CONCLUSIONS

Preoperative transfusion for children with SCD undergoing semi-elective abdominal operations was not associated with improved outcomes. Prospective investigation is warranted to strengthen guidelines and minimize unnecessary perioperative transfusions in this population.

Risk factors for complications after abdominal surgery in children with sickle cell disease

BACKGROUND

Abdominal surgery in children with sickle cell disease (SCD) carries an increased risk of postoperative complications. Preoperative transfusions are frequently given to decrease the risk of vasoocclusive events. However, risk factors for postoperative complications are not well-defined in the pediatric population.

METHODS

Pediatric patients with SCD undergoing common abdominal operations were identified from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012 to 2018. Outcomes of interest were the incidence rates of 1) any complication or readmission, and 2) serious SCD-related complications (stroke, new onset seizure, ventilator support >24 h postoperatively, or readmission with SCD crisis within 30 days of surgery). Patients were categorized by transfusion approach (transfusion within 48 h before surgery vs. no transfusion) and preoperative hematocrit (<21.0, 21.0-23.9, 24.0-26.9, 27.0-29.9, ≥30.0). Stratified bivariate analyses and multivariable logistic regression were used to identify independent risk factors for complications.

RESULTS

A total of 813 patients met inclusion criteria. There were 470 cholecystectomy, 251 splenectomy, 39 appendectomy, and 53 combination procedures; 13% of cases were urgent or emergent. Preoperative hematocrit levels were <21.0 in 3%, 21.0-23.9 in 10%, 24.0-26.9 in 17%, 27.0-29.9in 30%, and ≥30.0 in 41% of patients; 52% received perioperative transfusion. The 30-day incidences of any complication/readmission and SCD-related complications were 12% and 4%, respectively. On bivariate analyses, urgent/emergent case status was the only significant predictor of complications, carrying risk of 20% and 8% for overall and SCD-related complications, respectively; this finding persisted on multivariable logistic regression (OR 1.83, 95% CI 1.0.2-3.29, p = 0.04). Neither preoperative transfusion nor preoperative hematocrit level was associated with complication risk, although there was a trend toward higher SCD-related complications in patients with preoperative hematocrit <21.0 (p = 0.07).

CONCLUSION

In this large cohort of pediatric SCD patients undergoing abdominal surgery, there was no clear association between postoperative complications and the transfusion approach or the preoperative hematocrit level within the range above 21.0. Urgent/emergent surgical procedures carried a nearly two-fold higher complication risk compared to elective procedures. Future studies should prospectively evaluate preoperative transfusion approaches and compare immediate and delayed operative management to nonoperative management in this population.

LEVEL OF EVIDENCE

III Retrospective review.

Quality and Impact of Survey Research Among Anesthesiologists: A Systematic Review

New technology has facilitated survey research of anesthesia professional society members. We evaluated prevailing metrics of quality and impact of published research studies based on surveys of anesthesiologists. We hypothesized that adherence to recommended practices (such as use of reminders) would be associated with increased survey response rates, and that higher response rates would be associated with higher article impact. Using the MEDLINE database, we identified 45 English-language research articles published in 2010-2017 reporting original data from surveys of anesthesiologists. The median response rate was 37% (IQR: 25-46%). Recommended survey practices, including the use of reminders (p = 0.861) and validated questionnaires (p = 0.719), were not correlated with response rates. In turn, survey response rates were not associated with measures of article impact (p = 0.528). The impact of published research based on surveys of anesthesiologists, as measured by citation scores (p = 0.493) and Altmetrics (p = 0.826), may be driven primarily by the novel data or questions raised using survey methodology, but does not appear to be associated with response rates. Improving reporting of survey methodology and understanding possible sources of non-response bias are important for future studies in this area.

Preoperative transfusion versus no transfusion policy in sickle cell disease patients: a randomized trial

BACKGROUND

Many children with sickle cell disease (SCD) indicated for adenotonsillectomy receive pre-operative transfusion therapy, either simple or exchange transfusion, in order to reduce surgical and sickle cell disease-related complications.

SUBJECTS AND METHODS

This is a prospective randomized controlled clinical trial aiming to compare between preoperative simple transfusion and no transfusion in pediatric patients with sickle SCD admitted in Sultan Qaboos University Hospital, Muscat, Oman for adenotonsillectomy during the period from January 2014 through June 2018. They were randomly assigned into two arms (simple transfusion and no transfusion).

RESULTS

Postoperative SCD-related complications have been encountered in 6 out of 138 patients (4.3%). There was no statistically significant difference between the two studied groups as regards the development of surgical or SCD-related complications (p = 0.6 and 0.8 respectively). The length of postoperative hospital stay was comparable in the two groups. (p = 0.607). SCD-related complications occurred exclusively in cases with homozygous sickle anemia (4 out of 81 = 4.9%).

CONCLUSION

Sickle cell disease patients with a hemoglobin level above 7.5 g/dL do not need PRBCs transfusion prior to adenotonsillectomy. This approach did not increase the risk of postoperative surgical or SCD-related complications.

Perioperative care of children with sickle cell disease: A systematic review and clinical recommendations

Children with sickle cell disease (SCD) require specific perioperative care, and clinical practice in this area remains poorly defined. We aimed to conduct a systematic, PRISMA-based review of the literature, available clinical guidelines and practice recommendations. We also aimed to extract any valuable information for the "best of available-evidence"-based prevention of perioperative adverse events in children with SCD, and highlight the most urgent priorities in clinical research. As data sources, US National Library of Medicine, Medline, National Guideline Clearinghouse, International Guideline Network, TRIP databases were searched for any content until January 2019. We also included institutional, consortia and expert group guidelines. Included were reports/guidelines in English, French, German, and Italian. Excluded were reports on obstetrical and fetal management. We identified 202 reports/guidelines fulfilling the criteria outlined above. A majority focused on visceral, cardiovascular and orthopedic surgery procedures, and only five were multicenter randomized controlled trials and two prospective randomized studies. After grading of the quality of the evidence, the extracted data was summarized into clinical recommendations for daily practice. Additionally, we designed a risk-grading algorithm to identify contexts likely to be associated with adverse outcomes. In conclusion, we provide a systematic PRISMA-based review of the existing literature and ancillary practice and delineate a set of clinical recommendations and priorities for research.

Essentials of Pulmonology

Pulmonary complications are a major cause of perioperative morbidity in the pediatric population. Although preexisting pulmonary pathologic processes in children can present significant challenges to anesthetic delivery, a thorough assessment of the problem combined with meticulous anesthetic management allows most children to undergo surgical interventions without long-term adverse sequelae. Asthma, cystic fibrosis and sickle cell disease continue to pose challenges during anesthesiology. Consultation with a pediatric pulmonologist is indicated when appropriate for specific problems as outlined in this chapter; a team approach may markedly improve operative and postoperative outcomes.

Orthopaedic Manifestations of Sickle Cell Disease

Sickle cell disease (SCD) is an autosomal recessive disorder that results in hemolytic anemia related to abnormal hemoglobin and erythrocyte levels. SCD is characterized by vascular occlusive episodes, visceral sequestration, and aplastic or hemolytic crises. These crises most commonly occur in bone. The orthopaedic manifestations of SCD comprise much of the morbidity associated with this disorder. Osteonecrosis and osteomyelitis are among the most disabling and serious musculoskeletal complications in patients with SCD. Effective management of the bone and joint sequelae requires an accurate diagnosis, an understanding of the pathophysiology of the disease, and knowledge of available medical and surgical treatment alternatives. The major orthopaedic manifestations of SCD are osteonecrosis, osteomyelitis, septic arthritis, and bone infarction. Patients with SCD require close monitoring in the perioperative period because of the risk for vasoocclusive crisis.

Variation in intraoperative and postoperative red blood cell transfusion in pediatric surgery

BACKGROUND

Intraoperative and postoperative red blood cell (RBC) transfusions are relatively frequent events tracked in the American College of Surgeons' National Surgical Quality Improvement Program-Pediatric (ACS-NSQIP-P). This study sought to quantify variation in RBC transfusion practices among hospitals.

STUDY DESIGN AND METHODS

This is an observational study of children older than 28 days who underwent a general, neurologic, urologic, otolaryngologic, plastic, or orthopedic operation at 50 hospitals in participating in the ACS-NSQIP-P during 2011 to 2012. The primary outcome was whether or not a RBC transfusion was administered from incision time to 72 hours postoperatively. Transfusions of fresh-frozen plasma, cryoprecipitate, and platelets were excluded from data abstraction due the rarity of their administration. A multivariate hierarchical risk-adjustment model estimated the risk-adjusted hospital RBC transfusion odds ratio (OR) and designated hospitals by transfusion practice.

RESULTS

The mean RBC transfusion rate was 1.5%. Five preoperative variables were associated with greater than threefold increased odds of having an intraoperative or postoperative RBC transfusion; young age; 29 days to 1 year (OR, 5.9; p < 0.001) and 1 to 2 years (OR, 3.4; p < 0.001); American Society of Anesthesiologists Class IV (OR, 3.2; p < 0.001); procedure linear risk (OR, 3.1; p < 0.001); preoperative septic shock (OR, 14.5; p < 0.001); and preoperative cardiopulmonary resuscitation (OR, 8.1; p < 0.001). Twenty-five hospitals had RBC transfusion practices significantly different than risk-adjusted mean (17 higher and eight lower).

CONCLUSION

Intraoperative and postoperative RBC transfusion practices vary widely among hospitals after controlling for patient and procedural characteristics.

Surgical procedures and outcomes among children with sickle cell disease

BACKGROUND

Although children with sickle cell disease often undergo surgery, there are limited current epidemiological data for this pediatric population. We performed a database analysis to estimate population characteristics, surgical procedures, and perioperative outcomes in this population.

METHODS

We queried the Nationwide Inpatient Sample Database from 2000 to 2010 for discharges pertaining to patients <18 years of age having a diagnosis of sickle cell disease who underwent 1 or more surgical procedures during that admission. We abstracted surgical procedures using the Clinical Classifications Software procedure codes and the ICD-9-CM procedure codes. We described characteristics of patients undergoing the 6 most common procedures.

RESULTS

During 2000 to 2010, 3.6 % (SE 0.12) of individual hospital discharges were of children with sickle cell disease who had undergone surgical procedures. The most frequent surgical procedures were cholecystectomy (1.47% [0.08]), tonsillectomy/adenoidectomy (0.81% [0.06]), splenectomy (0.62% [0.06]), repair of umbilical hernia (0.19% [0.02]), and appendectomy (0.17% [0.02]). Acute chest syndrome was recorded among 3.08% (0.60) of patients undergoing elective surgery. The incidence of stroke was 0.20% (0.11); death was reported in <11 patients (<0.20%).

CONCLUSION

Surgical procedures such as cholecystectomy, tonsillectomy, splenectomy, hernia repair, and appendectomy account for a small but significant proportion of hospital admissions in children with sickle cell disease. Acute chest syndrome is among the most common complications of elective surgery, while stroke and death are rare.

The Transfusion Alternatives Preoperatively in Sickle Cell Disease (TAPS) study: a randomised, controlled, multicentre clinical trial

BACKGROUND

No consensus exists on whether preoperative blood transfusions are beneficial in patients with sickle-cell disease. We assessed whether perioperative complication rates would be altered by preoperative transfusion.

METHODS

We did a multicentre, randomised trial. Eligible patients were aged at least 1 year, had haemoglobin SS or Sβ(0)thalassaemia sickle-cell-disease subtypes, and were scheduled for low-risk or medium-risk operations. Patients were randomly assigned no transfusion or transfusion no more than 10 days before surgery. The primary outcome was the proportion of clinically important complications between randomisation and 30 days after surgery. Analysis was by intention to treat.

FINDINGS

67 (96%) of 70 enrolled patients-33 no preoperative transfusion and 34 preoperative transfusion-were assessed. 65 (97%) of 67 patients had the haemoglobin SS subtype and 54 (81%) were scheduled to undergo medium-risk surgery. 13 (39%) of 33 patients in the no-preoperative-transfusion group had clinically important complications, compared with five (15%) in the preoperative-transfusion group (p=0.023). Of these, 10 (30%) and one (3%), respectively, had serious adverse events. The unadjusted odds ratio of clinically important complications was 3.8 (95% CI 1.2-12.2, p=0.027). 10 (91%) of 11 serious adverse events were acute chest syndrome (nine in the no-preoperative-transfusion group and one in the preoperative-transfusion group). Duration of hospital stay and readmission rates did not differ between study groups.

INTERPRETATION

Preoperative transfusion was associated with decreased perioperative complications in patients with sickle-cell disease in this trial. This approach could, therefore, be beneficial for patients with the haemoglobin SS subtype who are scheduled to undergo low-risk and medium-risk surgeries.

FUNDING

NHS Blood and Transplant.

Transfusion practices in the management of sickle cell disease: a survey of Florida hematologists/oncologists

The purpose of this study was to characterize transfusion practices in the management of sickle cell disease and to identify factors attributing to differences in prescribing practices among Florida hematologists/oncologists. A cross-sectional study was performed in 2005-2006 utilizing a mail survey. The survey instrument addressed practice characteristics, sickle cell patient populations, transfusion settings, indications and techniques, red blood cell phenotype specifications/modifications, use of practice guidelines, and educational resource utilization. One hundred fifty two physicians (75% adult-oriented, 25% pediatric) completed the survey. Non-academic practice settings (78 %) were the primary location. Pediatric practices had a larger percentage of patients with overt strokes, and receiving hydroxyurea therapy than adult-oriented practices. The majority of survey respondents did not request limited phenotypically matched red blood cells on a routine basis. The majority of pediatric practices (60%) had individually defined transfusion practice guidelines in contrast to 8% of adult-oriented practices. There were statistically significant differences for pediatric and adult-oriented practices in managing certain acute and chronic transfusion indications. Analysis of clinical vignette data revealed variation among hematologists/oncologists in the transfusion management of common clinical scenarios. The study underscores the need for the development and dissemination of comprehensive sickle cell transfusion guidelines and protocols.