The Effect of Perioperative Blood Transfusions on Microvascular Anastomoses

Transfusion Rates in Free Flap Breast Reconstruction Patients: A Single-Centre Experience

Background Previous studies have demonstrated low transfusion rates in breast reconstruction with deep inferior epigastric perforator (DIEP) flaps. We often employ the transverse upper gracilis (TUG) flap; however, perioperative transfusion rates have not previously been studied in this group. Due to the different dissection and exposure required, transfusion rates may vary. We aim to ensure that perioperative resource use is appropriate and efficient, particularly group and save (G&S) sampling preoperatively. The objective of this study is to quantify transfusion rates in all patients undergoing free flap-based breast reconstruction and to determine the necessity of preoperative G&S sampling. Methods We retrospectively reviewed the electronic patient records, the electronic transfusion system, operation notes, and prescription records of all patients undergoing breast reconstruction using free-flap tissue transfer over one year. We identified transfusion of red blood cells and the current practice of perioperative G&S sampling in this patient group. These data were analysed using descriptive statistics. Results Of the 124 patients undergoing breast reconstruction with a free flap, a DIEP-based flap was deployed in 105, and a TUG flap in 14; in the remaining five, a selection of other flaps were utilised. Three patients required transfusion of blood products during their admission (2.4%), all after DIEP flap-based reconstructions. All received two units of packed red blood cells, with one transfusion on each of days one to three postoperatively. The indication for all three was slow but ongoing bleeding with low haemoglobin (less than 80 g/L) on routine full blood count. All recovered well following this. We found a low rate of transfusion in patients undergoing free flap breast reconstruction, with only three of 124 requiring transfusion (2.4%), all DIEP flaps. In addition to the published literature regarding DIEP flaps, we also include several TUG flaps in this cohort and several other flap types. None of the three transfusions were emergent in nature; all were completed with fully cross-matched blood according to local protocols. Conclusion We recommend that preoperative G&S sampling is not routinely necessary for patients undergoing free flap breast reconstruction. Preoperative G&S should be considered for those with a risk of atypical anti-red cell antibodies (for example, if previously transfused or pregnant), as cross-matched blood may take several days to be made available. We expect this judicious use of G&S sampling to significantly reduce costs and laboratory resource use without a significant effect on the use of emergency red cell units.

Novel Challenges and Opportunities for Anesthesia and Perioperative Care in Microvascular Flap Surgery: A Narrative Review

Complex microvascular techniques and in-depth knowledge of blood rheology and microanastomosis function are required for success in microvascular flap surgery. Substantial progress has been achieved in preventing complications, but the rate of flap loss is still significant and can have significant adverse effects on the patient. Flap thrombosis, flap hematoma, and flap loss are the most frequent and severe major surgical complications. Advances in understanding the pathophysiology of different flap complications, the use of preoperative risk assessment and new treatment concepts could improve the perioperative care of microvascular flap surgery patients. Our aim was to outline novel avenues for best practice and provide an outlook for further research of anesthesia and perioperative care concepts in microvascular flap surgery.

The Hidden Risks of Perioperative Transfusions in Traumatic Lower Extremity Free Flap Reconstruction

BACKGROUND

 Blood transfusions have been associated with surgical complications; however, these studies are not specific to lower extremity (LE) reconstruction. We evaluated the effect of perioperative packed red blood cell (PRBC) transfusions on LE free flap outcomes in trauma patients.

METHODS

 Patients undergoing LE free flap reconstruction following acute injuries from 2016 to 2021 were retrospectively analyzed. The perioperative period for transfusions was defined as ± 3 days from the procedure. Parameters included demographics, perioperative characteristics, and outcomes. Major complications were complications requiring reoperation. Univariate and multivariate analyses were performed to identify associations.

RESULTS

 Of the 205 patients, 48% received PRBCs perioperatively. There was a trend toward higher major complications rate in the transfusion group (19 vs. 10%, p = 0.09). Wound size, injury severity score (ISS), and intraoperative estimated blood loss were greater in the transfusion group (p < 0.01). Preoperative hemoglobin/hematocrit were lower in the transfusion group (p < 0.001). Units of PRBCs transfused were independently associated with major complications on multivariate analysis (odds ratio [OR] = 1.34, confidence interval [CI]: 1.06-1.70, p = 0.015) and length of hospital stay (LOS; OR = 1.05, CI: 1.02-1.08, p = 0.002). Infection, wound size, ISS, and preoperative hemoglobin/hematocrit were independently associated with increased LOS (p < 0.05) but not with major complications.

CONCLUSION

 The number of units of PRBCs given perioperatively was the only variable independently associated with major complications on multivariate analysis and was one of many variables associated with increased LOS. These findings suggest the usage of restrictive transfusion protocols in trauma patients requiring LE reconstruction.

Hemoglobin-Albumin-Lymphocyte-Platelet (HALP) Score as a Predictive Model for the Success of Reconstruction of Head and Neck Defects with Free Microvascular Flaps

Significant advances in reconstructive head and neck surgery with free microvascular flaps have had a positive impact on esthetic outcomes and quality of life. However, complications still occur in some patients. This study investigated the influence of the Hemoglobin, Albumin, Lymphocyte, and Platelet Score (HALP score), an immunonutritive marker, on complications and flap success. The retrospective analysis included 194 patients who underwent reconstruction of head and neck defects with free microvascular flaps. The HALP score correlated strongly with overall complications, including flap necrosis, infection, fistula, and hematoma. Hemoglobin, albumin, lymphocytes, and platelets individually showed associations with specific complications. HALP score was an extremely strong predictor of complications (AUC = 0.85). HALP score may be valuable for assessing patient status and predicting complications in microvascular free-flap reconstruction to allow timely interventions and improve outcomes. Further research is needed to investigate additional predictors and improve postoperative care.

Plasma and Platelet Transfusion Strategies in Critically Ill Children Following Noncardiac Surgery and Critically Ill Children Undergoing Invasive Procedures Outside the Operating Room: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present consensus statements and supporting literature for plasma and platelet transfusions in critically ill children following noncardiac surgery and critically ill children undergoing invasive procedures outside the operating room from the Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill children undergoing invasive procedures outside of the operating room or noncardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill children following noncardiac surgery or undergoing invasive procedures outside of the operating room. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed eight expert consensus statements focused on the critically ill child following noncardiac surgery and 10 expert consensus statements on the critically ill child undergoing invasive procedures outside the operating room.

CONCLUSIONS

Evidence regarding plasma and platelet transfusion in critically ill children in this area is very limited. The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding Consensus Conference developed 18 pediatric specific consensus statements regarding plasma and platelet transfusion management in these critically ill pediatric populations.

Research Priorities for Plasma and Platelet Transfusion Strategies in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present a list of high-priority research initiatives for the study of plasma and platelet transfusions in critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of 13 experts developed research priorities for the study of plasma and platelet transfusions in critically ill children which were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. The specific priorities focused on the following subpopulations: severe trauma, traumatic brain injury, intracranial hemorrhage, cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, oncologic diagnosis or stem cell transplantation, acute liver failure and/or liver transplantation, noncardiac surgery, invasive procedures outside of the operating room, and sepsis and/or disseminated intravascular coagulation. In addition, tests to guide plasma and platelet transfusion, as well as component selection and processing, were addressed. We developed four general overarching themes and 14 specific research priorities using modified Research and Development/University of California, Los Angeles methodology.

CONCLUSIONS

Studies are needed to focus on the efficacy/harm, dosing, timing, and outcomes of critically ill children who receive plasma and/or platelet transfusions. The completion of these studies will facilitate the development of evidence-based recommendations.