Preoperative hematocrit levels and postoperative mortality in patients undergoing craniotomy for brain tumors

Background

Abnormal hematocrit values, including anemia and polycythemia, are common in patients undergoing craniotomy, but the extent to which preoperative anemia or polycythemia independently increases the risk of mortality is unclear. This retrospective cohort study aimed to examine the association between preoperative anemia and polycythemia and postoperative mortality in patients who underwent craniotomy for brain tumor resection.

Methods

We retrospectively analyzed data from 12,170 patients diagnosed with a brain tumor who underwent cranial surgery at West China Hospital between January 2011 and March 2021. The preoperative hematocrit value was defined as the last hematocrit value within 7 days before the operation, and patients were grouped according to the severity of their anemia or polycythemia. We assessed the primary outcome of 30-day postoperative mortality using logistic regression analysis adjusted for potential confounding factors.

Results

Multivariable logistic regression analysis reported that the 30-day mortality risk was raised with increasing severity of both anemia and polycythemia. Odds ratios for mild, moderate, and severe anemia were 1.12 (95% CI: 0.79-1.60), 1.66 (95% CI: 1.06-2.58), and 2.24 (95% CI: 0.99-5.06), respectively. Odds ratios for mild, moderate, and severe polycythemia were 1.40 (95% CI: 0.95-2.07), 2.81 (95% CI: 1.32-5.99), and 14.32 (95% CI: 3.84-53.44), respectively.

Conclusions

This study demonstrated that moderate to severe anemia and polycythemia are independently associated with increased postoperative mortality in patients undergoing craniotomy for brain tumor resection. These findings underscore the importance of identifying and managing abnormal hematocrit values before craniotomy surgery.

Cefazolin-Induced Thrombocytopenia in a Patient with Polycythemia Vera Following Coronary Artery Bypass

Cefazolin is an antibiotic that is commonly administered perioperatively to reduce the risk of surgical site infections. Cephalosporins have a well-established safety profile, but have been associated with thrombocytopenia and neutropenia due to their myelosuppressive effects. While this effect may be benign in healthy patients undergoing minor surgery, it can be detrimental in patients with underlying hematologic disorders presenting for open-heart surgery. Herein, we discuss the first case in the literature of cefazolin-induced thrombocytopenia and severe coagulopathy in a patient with polycythemia vera (PCV) during a coronary artery bypass-grafting surgery.

Polycythaemia Vera and Coronary Artery Bypass Graft Surgery: A Systematic Review of the Literature

OBJECTIVES

Polycythaemia vera (PV) is a condition that may potentially put patients undergoing cardiac surgery at an increased risk of bleeding and thrombosis; however, there is currently a paucity of literature regarding the management of these patients. We aim to examine the literature in this systematic review to indicate the interventions that may be considered to minimise complications.

METHODS

We conducted a literature search using keywords and MeSH terms to identify articles discussing PV and cardiac surgery. The studies were identified and qualitatively analysed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol.

RESULTS

In total, 10 case reports representing 11 patients were identified for this systematic review and were included in qualitative analysis. 63.6% of patients had preoperative intermittent phlebotomy, and the majority of patients received postoperative therapy that involved one antiplatelet and one anticoagulant. Generous perioperative fluid management, phlebotomy, preservation of core body temperature, early extubation, monitoring of myocardial ischaemia, infarction and vascular events, intense chest physiotherapy and patient mobilisation are important to consider to reduce the risk of complications arising from surgery.

CONCLUSION

These considerations should be systematically discussed in a multidisciplinary team, where the acute surgical need can be balanced appropriately against the risk of haemorrhage and thrombosis.

Thrombosis of Coronary Arteries in a Patient With Polycythemia Vera During the Myocardial Revascularization: A Case Report

Introduction

Coronary artery bypass grafting in a patient suffering from polycythemia vera is clinically rare and extremely challenging. There is no established protocol regarding the management of these patients because the number of patients in this circumstance is very small. Expressed thrombotic risk in patients suffering from polycythemia vera is highly emphasized in patients with coronary artery disease. Only a few cases have been reported of performing coronary artery bypass grafting, and in those cases a successful outcome seems to be an exception.

Case presentation

We report a case of a 73-year-old male caucasian patient suffering from frequent daily chest pain and unstable angina with a 75% stenosis of the left main coronary artery and a subocclusion of proximal right coronary artery undergoing coronary artery bypass grafting, where despite following all the management algorithms and hematologic and cardiologic guidelines properly during the preoperative workup, the patient had a complex postoperative recovery with thrombosis of native coronary vessels—the left anterior descending artery and right coronary artery.

Conclusion

Further investigation is needed regarding the effect of deciding between strategies in the domain of cardiac surgery as well as in the hematologic domain on the final outcome. It would be absolutely necessary to conduct a global trial to investigate the preferred cardiosurgical procedure (OPCAB or on-pump CABG).

Laparoscopic hepatectomy in a patient with uncontrolled polycythaemia vera

This case report describes the peri-operative course of a patient with uncontrolled polycythaemia vera who underwent a laparoscopic hepatectomy for intrahepatic cholangiocarcinoma. Polycythaemia vera is a chronic condition that results in erythrocytosis and puts patients at risk of peri-operative complications including thrombotic events and paradoxical haemorrhage. Little evidence exists on the ideal peri-operative management of uncontrolled polycythaemia vera when the proposed procedure carries a high risk of haemorrhage. Our patient presented with a pre-operative haemoglobin of 197 g.l^-1 (haematocrit 65%) and was not phlebotomised pre-operatively. Intra-operatively he lost 2700 ml of blood, reducing his haematocrit to 48%, and then suffered fatal thrombotic complications postoperatively. The patient did not receive any blood product transfusions during his peri-operative course. We review the available evidence to guide the peri-operative management of patients with polycythaemia vera. The inherent risks of thrombosis and haemorrhage associated with polycythaemia vera need to be weighed against the specific surgical and transfusion-related risks. Phlebotomy to achieve a pre-operative haematocrit under 45% is recommended and intra-operative phlebotomy shows promise for reducing blood loss during hepatectomies. Management of postoperative erythrocytosis may be an important and underappreciated aspect of reducing the peri-operative risk of thrombosis in patients with polycythaemia vera.

Red Blood Cell Disorders: Perioperative Considerations for Patients Undergoing Cardiac Surgery

Disorders affecting red blood cells (RBCs) are uncommon yet have many important physiologic considerations for patients undergoing cardiac surgery. RBC disorders can be categorized by those that are congenital or acquired, and further by disorders affecting the RBC membrane, hemoglobin, intracellular enzymes, or excessive RBC production. A foundational understanding of the physiologic derangement for these disorders is critical when considering perioperative implications and optimization, strategies for cardiopulmonary bypass, and the rapid recognition and treatment if complications occur. This review systematically outlines the RBC disorders of frequency and relevance with an emphasis on how the disorder affects normal physiologic processes, a review of the literature related to the disorder, and the implications and recommendations for patients undergoing cardiac surgery.