Does blood transfusion increase the risk of infection after hip fracture?

Early surgery within 48 h was associated with reduced perioperative blood loss and red blood cell transfusion requirements in older patients with hip fracture: a retrospective study

PURPOSE

The aim of this study was to analyze the relationship between the timing of surgery and perioperative blood loss, red blood cell (RBC) transfusion rate, and RBC transfusion volume in older patients with hip fracture.

METHODS

From January 2020 to August 2022, this retrospective study enrolled older patients with hip fracture who underwent surgery in our hospital. The demographics, fracture type, type of surgery, time from injury to hospital, timing of surgery, medical history (hypertension, diabetes), duration of surgery, intraoperative blood loss, laboratory tests, and preoperative, postoperative and perioperative RBC transfusion requirements were recorded and analyzed. According to the surgical treatment within 48 h or after 48 h after admission, the patients were divided into early surgery group (ES) and delayed surgery group (DS).

RESULTS

A total of 243 older patients with hip fracture were finally included in the study. Among these, 96 patients (39.51%) underwent surgery within 48 h of admission and 147 (60.49%) underwent surgery after this time. Total blood loss (TBL) in the ES group was lower than that in the DS group (576.03 ± 265.57 ml vs 699.26 ± 380.58 ml, P = 0.003). Preoperative RBC transfusion rate, and preoperative and perioperative RBC transfusion volume in the ES group were significantly lower than those in the DS group (15.63% vs 26.53%, P = 0.046; 50.00 ± 128.15 ml vs 117.01 ± 225.85 ml, P = 0.004; 80.21 ± 196.63 ml vs 144.90 ± 253.52 ml, P = 0.027).

CONCLUSION

Timing of surgery within 48 h of admission for older patients with hip fracture was associated with reduced the total blood loss and RBC transfusion requirements during the perioperative period.

Development of a prediction model for postoperative complications and economic burden analysis in older patients with hip fractures

Purpose

The high rates of disability and mortality due to postoperative complications of hip fractures in the elderly, especially the oldest-old individuals, have become an increasingly serious global public health concern. This study aimed to establish a nomogram prediction model and analyze the economic burden to guide clinical decision-making and improve patient prognosis.

Methods

Data of 514 patients aged over 80 years with hip fractures who received surgical treatment were retrospectively collected, and the patients were divided into training and validation cohorts. Independent risk factors for postoperative complications were identified based on logistic regression analysis, and a nomogram was constructed. The model was evaluated for its discrimination and consistency using receiver operating characteristic (ROC) curves and calibration curves, and for its clinical benefit using decision curve analysis (DCA). The economic burden was analyzed using propensity score matching (PSM).

Results

The American Society of Anesthesiologists (ASA) classification ≥Ⅲ, anemia, male sex, diabetes mellitus, and the number of comorbidities were found to be independent risk factors for postoperative complications in oldest-old patients with hip fracture (all P < 0.05). The areas under the curve (AUC) of the nomogram prediction model for the training and validation cohorts were 0.743 and 0.767, respectively, indicating reliable discrimination. The calibration curves and DCA showed that the model has good consistency and high benefits. The direct economic burden of postoperative complications for the patients was US$1045.10.

Conclusions

The nomogram model can accurately quantify the risk of postoperative complications among oldest-old patients with hip fractures and guide clinical professionals to implement early and targeted preventive treatment for high-risk patients.

Perioperative allogenic blood transfusions are associated with increased fracture related infection rates, but not nonunion in operatively treated distal femur fractures

INTRODUCTION

Distal femur fractures are common injuries that remain difficult for orthopedic surgeons to treat. High complication rates, including nonunion rates as high as 24% and infection rates of 8%, can lead to increased morbidity for these patients. Allogenic blood transfusions have previously been identified as risk factors for infection in total joint arthroplasty and spinal fusion surgeries. No studies have explored the relationship between blood transfusions and fracture related infection (FRI) or nonunion in distal femur fractures.

METHODS

418 patients with operatively treated distal femur fractures at two level I trauma centers were retrospectively reviewed. Patient demographics were collected including age, gender, BMI, medical comorbidities, and smoking. Injury and treatment information was also collected including open fracture, polytrauma status, implant, perioperative transfusions, FRI, and nonunion. Patients with less than three months of follow up were excluded.

RESULTS

366 patients were included in final analysis. One hundred thirty-nine (38%) patients received a perioperative blood transfusion. Forty-seven (13%) nonunions and 30 (8%) FRI were identified. Allogenic blood transfusion was not associated with nonunion (13% vs 12%, P = 0.87), but was associated with FRI (15% vs 4%, P<0.001). Binary logistic regression analysis identified a dose dependent relationship between number of perioperative blood transfusions and FRI: total transfusion ≥2 U PRBC RR= 3.47(1.29, 8.10, P = 0.02), ≥3 RR= 6.99 (3.01, 12.40, P<0.001), and ≥4 RR= 8.94 (4.03, 14.42, P<0.001).

DISCUSSION

In patients undergoing operative treatment of distal femur fractures, perioperative blood transfusions are associated with increased risk of fracture related infection, but not the development of a nonunion. This risk association increases in a dose-dependent relationship with increasing total blood transfusions received.

Effect of a Patient Blood Management Program on the Appropriateness of Red Blood Cell Transfusion and Clinical Outcomes in Elderly Patients Undergoing Hip Fracture Surgery

BACKGROUND

Elderly patients with hip fractures frequently receive perioperative transfusions, which are associated with increased morbidity and mortality. This study aimed to evaluate the impact of a patient blood management (PBM) program on the appropriateness of red blood cell (RBC) transfusion and clinical outcomes in geriatric patients undergoing hip fracture surgery.

METHODS

In 2018, the revised PBM program was implemented at the Korea University Anam Hospital, Seoul, Republic of Korea. Elderly patients aged ≥ 65 years who underwent hip fracture surgery from 2017 to 2020 were evaluated. Clinical characteristics and outcomes were analyzed according to the timing of PBM implementation (pre-PBM, early-PBM, and late-PBM). Multiveriate regression analysis was used to evaluate the risk factors of the adverse outcomes, such as in-hospital mortality or 30-day readmission.

RESULTS

A total of 884 elderly patients were included in this study. The proportion of patients who received perioperative RBC transfusions decreased significantly (43.5%, 40.1%, and 33.2% for pre-PBM, early-PBM, and late-PBM, respectively; P = 0.013). However, the appropriateness of RBC transfusion significantly increased (54.0%, 60.1%, and 94.7%, respectively; P < 0.001). The duration of in-hospital stay and 30-day readmission rates significantly decreased. Multivariable regression analysis revealed that RBC transfusion (odds ratio, 1.815; 95% confidence interval, 1.137-2.899; P = 0.013) was significantly associated with adverse outcomes.

CONCLUSION

Implementing the PBM program increased the appropriateness of RBC transfusion without compromising transfusion quality and clinical outcomes. Therefore, adopting the PBM program may improve the clinical management of elderly patients following hip fracture surgery.

Correlation of the severity of anemia in patients undergoing total joint arthroplasty with preoperative deep vein thrombosis: a retrospective cohort study

BACKGROUND

To explore the correlation of the severity of preoperative anemia with deep vein thrombosis (DVT) in patients undergoing total joint arthroplasty (TJA).

METHODS

A total of 2461 TJA patients were classified into anemia and non-anemia groups or DVT and non-DVT groups. A logistic regression model was established using propensity score matching (PSM) analysis with preoperative anemia of TJA patients as a dependent variable and DVT-related variables as covariates. The caliper value was set as 0.01, and the anemia and non-anemia groups were matched based on the ratio of 1:1 (835 pairs). Finally, data of all patients were analyzed by binary logistic regression.

RESULTS

Preoperative anemia was observed in 872 cases (35.43%) and DVT in 170 cases (6.91%). Binary logistic regression after PSM revealed that the DVT risk of patients with preoperative, moderate and severe anemia increased by 1.82 [P = 0.00, 95% confidence interval (95% CI) (1.32-2.48)], 2.77 [P = 0.00, 95% CI (1.72-4.45)], and 8.26 [P = 0.00, 95% CI (3.22-21.16)] times, respectively. The risks of blood transfusion in the perioperative period in patients with anemia, mild anemia, moderate anemia, and severe anemia increased by 3.52 times [P = 0.00, 95% CI (2.78-4.47)], 2.13 [P = 0.00, 95% CI (1.63-2.79)], 7.22 [P = 0.00, 95% CI (5.30-9.83)], and 61.37 [P = 0.00, 95% CI (14.21-265.04)] times, respectively.

CONCLUSION

Preoperative anemia is an independent risk factor for preoperative DVT and blood transfusion in the perioperative period for TJA patients. The more severe the preoperative anemia, the greater the risk of preoperative DVT and perioperative blood transfusion in TJA patients. Therefore, patients with preoperative anemia, especially with moderate and severe anemia, should be screened for DVT formation before undergoing TJA. Trial registration ChiCRT2100054844.

Factors affecting the need of postoperative blood transfusion in elderly patients with intertrochanteric hip fracture

INTRODUCTION

We investigated the risk factors that increased the frequency of blood transfusions in elderly patients with intertrochanteric hip fractures to determine blood transfusion risk before surgery and to take selective precautionary measures in the group at high risk for transfusion to ensure safe surgery.

MATERIALS AND METHODS

We retrospectively reviewed the electronic medical records of 203 patients who underwent surgical fixation of intertrochanteric hip fractures from January 2015 to December 2020. We hypothesized that patient sex, age, body mass index, preoperative hemoglobin, preoperative platelet count, glomerular filtration rate (GFR), preoperative albumin level, American Society of Anesthesiologist score, intraoperative blood loss, duration of surgery, method of anesthesia, and time from injury to surgery would affect the need for blood transfusion. Student's t-test, Chi-squared test, and the one-way analysis of variance test were used to determine whether differences between variables in the transfusion and non-transfusion groups were significant.

RESULTS

Unstable fractures (P = 0.002), general anesthesia (P = 0.028), lower preoperative hemoglobin levels (P < 0.001), and lower GFRs (P < 0.001) were identified as related to blood transfusions in univariate analysis. In multivariate logistic analysis, the need for allogeneic blood transfusion in unstable fractures was approximately 2.949 times higher than in stable fractures (P = 0.009). The risk in general anesthesia patients was about 2.953 times higher than in spinal anesthesia patients (P = 0.007). In addition, the need for allogeneic blood transfusion increased by about 1.293 times as preoperative hemoglobin levels decreased by 1 g/dL (P = 0.017) and increased by about 1.017 times as the GFR decreased by 1 mL/min/1.7m2 (P = 0.006).

CONCLUSION

Low preoperative hemoglobin levels, low GFRs, general anesthesia, and unstable fractures in elderly patients with intertrochanteric hip fractures increased the risk of blood transfusion.

Extracorporeal measurement of femoral nail length in the treatment of trochanteric hip fractures: the "box" technique

Intramedullary nails, long and short, are widely used for fixation of trochanteric femur fractures. In theory, long nails may be able to protect the entire length of the femur from a future periprosthetic fracture, providing that the nail spans the length of the entire femoral canal. The described technique for long nail insertion calls for the use of an intramedullary guidewire and depth gauge for premeasurement of the length of the canal, as well as the use of a reamer. However, compared with short nails, this technique may add cost, operating time, and blood loss. We describe a safe technique for long nail measurement that reliably spans the length of the femur while potentially reducing surgical cost, time, and blood loss. We also describe 21 cases in which the technique was applied.

Perioperative Transfusion Associated With Increased Morbidity and Mortality in Geriatric Patients Undergoing Hip Fracture Surgery

Introduction:

Both conservative and liberal transfusion thresholds, in regard to hematocrit and hemoglobin levels, have been widely studied with varying outcomes. The aim of this study was to evaluate if transfusion administered peri- (anytime during the admission), pre-, intra-, or postoperatively an its association with morbidity and mortality in the geriatric population undergoing hip surgery.

Methods:

This study was an institutional review board approved retrospective analysis of data collected from 841 patients at a single urban institution who underwent surgical repairs for hip fractures from 2008 to 2010.

Results:

Our analysis included data from 841 surgical patients. Mean patient age was 83, 74% were female, 48% received spinal anesthesia while 52% underwent general anesthesia. Out of 841 patients, 425 were transfused during the perioperative period. Most transfusions occurred postoperatively. Perioperative, intraoperative and postoperative transfusion was associated with an increase in post-operative AKI. Intraoperative blood transfusion was associated with an increase in morbidity (11.6% increased to 22.2%) by 1.9 fold, AKI (3.9% increased to 11.1%) by 2.8 fold, as well as an increase in mortality (5.2 increased to 15.6%) within 60 days by 3 fold.

Conclusions:

This may suggest that patients transfused prior to surgery, despite having met a specific trigger hemoglobin level earlier, may have been treated before deteriorating to a point that would cause future systemic implications.

Blood transfusion rates and predictors following geriatric hip fracture surgery

BACKGROUND

Postoperative blood product transfusions in elderly hip fracture patients cause concern for morbidity and mortality. The purpose of this study was to identify predictors and short-term sequelae of postoperative transfusion following geriatric hip fracture surgery.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify geriatric (⩾65 years) patients who sustained operative femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to determine risk-adjusted odds ratios (OR) of associated perioperative risk factors and sequelae of postoperative transfusion.

RESULTS

In total, 8416 geriatric hip fracture patients were identified of whom 28.3% had documented postoperative transfusion. In multivariate analysis, age (OR 1.03 [1.02-1.04], p < 0.001), preoperative anaemia (OR 4.69 [3.99-5.52], p = 0.001), female sex (OR 1.61 [1.39-1.87], p < 0.001), lower BMI (OR 0.97 [0.96-0.98], p < 0.001), American Society of Anesthesiologists (ASA) classification (OR 1.14 [1.01-1.27], p = 0.031), COPD (OR 1.30 [1.06-1.59], p = 0.011), hypertension (OR 1.17 [1.01-1.35], p = 0.038), increased OR time (OR 1.02 [1.01-1.03], p < 0.001), and intertrochanteric (OR 2.99 [2.57-3.49], p < 0.001) and subtrochanteric femur fractures (OR 5.07 [3.84-6.69], p < 0.001) were independent risk factors for receiving postoperative blood transfusion. Patients with postoperative transfusion had a significantly higher risk-adjusted 30-day mortality (8.4% vs. 6.4%, OR 1.29 [1.02-1.64], p = 0.035), hospital readmission rate (9.4% vs. 7.7%, OR 1.27 [1.04-1.55], p = 0.018), and total hospital LOS (7.3 vs. 6.3 days, p < 0.001).

CONCLUSIONS

Postoperative transfusion is a common occurrence in geriatric fragility hip fractures with multiple risk factors. Careful preoperative planning and multidisciplinary management efforts are warranted to reduce use of postoperative transfusions.

The Correlation Between Timing of Surgery and the Need for RBC Transfusions in the Geriatric Intertrochanteric Fracture Population

Objective:

To identify whether the timing of surgery affects red blood cell (RBC) transfusion requirements in the elderly with intertrochanteric fractures.

Methods:

We retrospectively studied all patients undergoing surgical fixation of their intertrochanteric fractures in our hospital between January 2009 and December 2018 and analyzed the relationship between the timing of surgery and RBC transfusion.

Results:

A total of 679 patients were included in this study. The need for RBC transfusion was lower in the patients who underwent surgery within 12 h after admission (timing of surgery <12 h, <12 h group) than those who underwent surgery over 12 h after admission (timing of surgery >12 h, >12 h group) (P = 0.046); lower in the the patients who underwent surgery within 24 h after admission (timing of surgery <24 h, <24 h group) than in those who underwent surgery over 24 h after admission (timing of surgery >24 h, >24 h group) (P = 0.008), and lower in the <24 h group compared to the patients who underwent surgery within 48 h after admission (timing of surgery <48 h, <48 h group) (P = 0.035). Moreover, the need for RBC transfusion was lower in the <24 h group (in the first 24 h from admission to surgery) than in the 24-48 h group (in the second 24 h from admission to surgery) (P = 0.016), and also lower in the <24 h group compared to the 48-72 h group (in the third 24 h from admission to surgery) (P = 0.047). However, there were no differences between the <12 h group and 12-24 h group, between the <12 h group and <24 h group, and between the 12-24 h group and <24 h group, respectively.

Conclusion:

Timing of surgery within 24 h contributes to the reduction of RBC transfusion in the elderly with intertrochanteric fractures.

The prevalence of pre-operative anaemia and an examination of its effect on transfusion practice between sexes: A multicentre retrospective study

Pre-operative anaemia affects one third of patients presenting for surgery and is associated with increased peri-operative morbidity and mortality. Most studies on this subject make a distinction in acceptable haemoglobin level between sexes. We analysed data for patients undergoing major elective surgery, with pre-operative anaemia defined as haemoglobin <13 g/dL. Data was collected for 1074 patients, of whom 411 (38.3%) had pre-operative anaemia. The odds of red cell transfusion were significantly higher in patients with pre-operative anaemia, OR = 4.35 [95%CI OR: 3.0- 6.2]. Additional binary logistic regression results identified haemoglobin level, male gender and increasing age as independent predictors for red cell transfusion. The length of post-operative stay was also significantly higher in anaemic patients, those with lower haemoglobin, males and older patients. Women were twice as likely to have a haemoglobin < 13 g/dl as men. Women were also 3.55 times more likely not to be transfused despite being anaemic. This suggests differences in clinician's attitudes to transfusion limits in women, despite Blaudszun et al. 2018 showing that women with borderline anaemia (Hb 12-12.9 g/dL) are: more likely to be transfused; to be transfused more units of red cells; and to have longer lengths of hospital stay than non- anaemic women. A change in attitude to acceptable haemoglobin in women is needed. Increased clinician awareness of the associated morbidity of even a mild reduction in haemoglobin in women is required to result in more pro-active anaemia management pre-operatively and less allogenic red cell transfusion, shorter lengths of hospital stay and overall decreased morbidity.

Association between Hemiarthroplasty vs Total Hip Arthroplasty and Major Surgical Complications among Patients with Femoral Neck Fracture

Previous studies have shown better clinical outcomes after total hip arthroplasty (THA) compared to hemiarthroplasty (HA) for displaced femoral neck fracture. However, few studies have focused on the surgical risks of the two procedures. Therefore, we investigated the perioperative complications of HA and THA in femoral neck fracture, using a large nationwide inpatient database. A total of 286,269 patients (281,140 patients with HA and 5129 with THA) with a mean age of 81.7 were enrolled and HA and THA patients were matched by a propensity score to adjust for patient and hospital characteristics. Patients in a matched cohort were analyzed to compare complications and mortality. The systemic complication rate was not significantly different after a propensity score matching of 4967 pairs of patients. However, the incidence of both hip dislocation and revision surgery was more frequent in the THA group (Risk difference (RD), 2.74; 95% Confidence interval (CI), 2.21–3.27; p < 0.001; RD, 2.82; 95% CI, 2.27–3.37; p < 0.001, respectively). There was no significant difference in 30 day in-hospital mortality among the two groups. The risk of dislocation and reoperation was higher for THA than for HA in elderly patients with a femoral neck fracture in this retrospective study using a nationwide database.

Reamed Versus Unreamed Intertrochanteric Femur Fractures, Is It Time?

OBJECTIVES

This study compares the intraoperative and postoperative outcomes of the traditional technique of femoral canal reaming to placement of an unreamed 10-mm nail.

DESIGN

Retrospective cohort study.

SETTING

Academic Level I Trauma Center, Southeastern US.

PATIENTS/PARTICIPANTS

Intertrochanteric femur fractures treated with a CMN (January 2016-December 2018) were retrospectively identified. Inclusion criteria were as follows: low-energy mechanism, at least 60 years of age, and long CMN. Exclusion criteria were as follows: short CMN, polytrauma, and subtrochanteric fractures.

OUTCOME MEASUREMENTS

Records were reviewed for demographics, hematologic markers, transfusion rates, operative times, and postoperative complications. Variables were assessed with a χ or Student T-test. Significance was set at 0.05.

RESULTS

Sixty-five patients were included (37 reamed and 28 unreamed), with a mean age of 76.2 years and mean body mass index of 25.1. Between the reamed and unreamed groups, respectively, mean nail size was 11.0 (SD 1.1) and 10.0 (SD 0.0), P < 0.001; mean blood loss was 209.1 mL (SD 177.5) and 195.7 mL (SD 151.5), P = 0.220; 55% (21/38), and 43% (12/28) were transfused, P = 0.319; operative time was 98.2 (SD 47.3) and 81.5 minutes (SD 40.7); P = 0.035. Changes in hemoglobin/hematocrit were not significant between the study groups. Two patients from the reamed group experienced implant failure due to femoral head screw cut out and returned to the operating room. Two patients from the unreamed group returned to operating room for proximal incision infection, without implant removal. One reamed patient and 2 unreamed patients died before 6-month follow-up.

CONCLUSIONS

Unreamed CMNs for geriatric intertrochanteric femur fractures provide shorter operative times with no difference in perioperative complications. Both reamed and unreamed techniques are safe and effective measures for fixation of these fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Utilization, effectiveness, and safety of tranexamic acid use in hip fracture surgery: A population-based study

Objective

To assess the effect of tranexamic acid (TXA) use in hip fracture surgery.

Methods

A retrospective cohort study was performed using the Premier Healthcare database. A propensity score matching approach was applied to assess associations between TXA use and blood transfusion, perioperative complications, length of stay (LOS), and hospitalization cost.

Results

In 153,169 patients, TXA use was associated with a 17% decrease in odds of blood transfusion, no increase in the risk of perioperative complications, 16% shorter LOS, and minimal effects on hospitalization cost.

Conclusion

Our results are in support of a wider use of TXA in hip fracture surgery.

Level of evidence

Level III.

Prevention and detection of prosthetic temporomandibular joint infections-update

Prosthetic joint infections are not only distressing complications for patients and surgeons, but also have an enormous financial impact on healthcare systems. The reported incidence of prosthetic joint infection is likely underestimated due to difficulties in their diagnosis. This unfortunate complication has challenged joint replacement surgeons for years, despite all the advances made in this surgical discipline. Since eradication of these infections can be very difficult, prevention remains the primary objective. Identifying recipient risk factors, adopting a proper surgical technique, appropriate wound care, optimizing the operating room environment, and appropriate postoperative care have become some of the core elements that can help to minimize the overall incidence of this complication. The purpose of this article is to provide the temporomandibular joint replacement surgeon with an update on the prevention and detection of prosthetic joint infections based on a review of the most recent information published in the orthopedic and surgical literature.

The Influence of Patient Gender on Morbidity Following Total Hip or Total Knee Arthroplasty

BACKGROUND

Little research has focused on the influence of gender on postoperative morbidity following total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study aimed to compare operative time, length of stay, 30-day complications, and readmissions based on patient gender.

METHODS

The prospectively collected National Surgical Quality Improvement Program registry from 2005 to 2014 was queried to identify primary elective THA and TKA patients. Multivariate regression was used to compare the rates of 30-day adverse events, rates of readmission, operative time, and postoperative length of stay between men and women. Multivariate analyses were controlled for baseline patient characteristics and procedure type.

RESULTS

A total of 173,777 patients were included (63.5% TKA and 36.5% THA). Male gender increased the risk of multiple adverse events, including death (relative risk [RR] 1.1, P < .001), surgical site infection (RR 1.2, P < .001), sepsis (RR 1.4, P < .001), cardiac arrest (RR 1.8, P < .001), and return to the operating room (RR 1.3, P < .001). Men had decreased overall adverse events (RR 0.8, P < .001) secondary to a lower risk of urinary tract infection (RR 0.5, P < .001) and blood transfusion (RR 0.7, P < .001), which were prevalent adverse events. Men had an increased risk of 30-day readmission (RR 1.2, P < .001), slightly increased operative time (+6 minutes, P < .001), and slightly decreased length of stay (-0.2 days, P < .001).

CONCLUSION

Men had increased risk of multiple individual adverse events including death, surgical site infection, cardiac arrest, return to the operating room, and readmission. Conversely, women had increased risk of urinary tract infection and blood transfusion.

Intraoperative Topical Antibiotics for Infection Prophylaxis in Pelvic and Acetabular Surgery

OBJECTIVES

To determine if topical vancomycin and tobramycin powder reduces the incidence of surgical site infection after pelvic ring and acetabulum fracture surgery.

DESIGN

Retrospective cohort study.

SETTING

University of Alabama at Birmingham, Academic Level I Trauma Center.

PATIENTS/PARTICIPANTS

Two hundred nineteen patients (140 meeting inclusion criteria) with pelvic and acetabular fractures who underwent open reduction and internal fixation from March 2012 to November 2013.

INTERVENTION

One gram vancomycin and 1.2 g tobramycin powder applied deep in the surgical wound of the treatment group.

MAIN OUTCOME MEASUREMENTS

Postoperative infection rate.

RESULTS

One hundred forty patients were included. Control group (n = 69) and treatment group (n = 71) were similar for sex, age, ethnicity, and body mass index. There was no difference between groups with regards to renal function postoperative day 2 (P = 0.24). The risk of infection was 14.5% and 4.2% (P = 0.04) for the control and treatment groups, respectively. No significant effect of antibiotic treatment was observed overall after adjusting for EBL (odds ratio 0.20, 95% confidence interval, 0.02-1.06). Of note, a nonsignificant 71% increase was observed among those with ≥1 L EBL (odds ratio 1.71, 95% confidence interval, 0.02-147.02).

CONCLUSIONS

Topical antibiotics possibly reduce the incidence of surgical site infection after open pelvic and acetabulum fixation without increasing risk of renal impairment. The protective effect of topical antibiotics may be limited to patients with minimal intraoperative blood loss.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is This Autograft Worth It?: The Blood Loss and Transfusion Rates Associated With Reamer Irrigator Aspirator Bone Graft Harvest

OBJECTIVES

To investigate the blood loss and transfusion rate associated with the use of reamer irrigator aspirator (RIA).

DESIGN

Retrospective review.

SETTING

Academic Level-I trauma hospital.

PATIENTS

One hundred eight patients requiring bone graft harvest for surgical reconstruction of nonunion or failed arthrodesis.

INTERVENTION

Bone graft harvest preformed via RIA or iliac crest bone graft (ICBG).

MAIN OUTCOME MEASURE

Blood loss as measured by a change in preoperative and postoperative hematocrit (Hct). In addition, postoperative transfusion reported intraoperative blood loss, volume of graft harvested, and major complications.

RESULTS

The average Hct drop was found to be 13.7 (4.1-27.4) in the RIA cohort of 61 patients and 7.36 (1.2-14.5) in the ICBG cohort of 47 patients (P = 0.013). Operative reports documented an average estimated blood loss of 674 mL (100-2000 mL) in the RIA cohort compared with 255 mL (50-1000 mL) in the ICBG cohort (P < 0.001). Twenty-seven patients (44%) required blood transfusion after RIA, whereas 10 patients (21%) required blood transfusion after ICBG (odds ratio 5.32, 95% confidence interval 2.2-6.3, P < 0.001). RIA procedures collected an average 53 mL (20-100 mL) of bone graft compared with 27 mL (15-50 mL) with ICBG. There was no significant difference between groups regarding age, sex, medical comorbidities, or postoperative major complications.

CONCLUSIONS

This series demonstrated that 44% of patients undergoing RIA bone graft harvest required transfusion, with a mean Hct drop of 13.7 across all subjects, which is significantly greater than that associated with ICBG.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

An Evaluation of Intra- and Post-operative Blood Loss in Total Hip Arthroplasty at the National Orthopaedic Hospital, Lagos

Background:

Severe hip pain with associated significant functional limitation is the major indication for total hip replacement, a rewarding and gratifying procedure. However, significant blood loss can occur in the intra- and post-operative periods, posing a major challenge and necessitating prompt restoration of circulating blood volume to minimize morbidity and mortality. The aim of this study was to evaluate blood loss after primary total hip replacement, and to determine the effect of surgical time on blood loss.

Patients and Methods:

A prospective study of blood loss after total hip arthroplasty in 41 patients. All cases were primary total hip arthroplasty done by one surgeon. Intra- and post-operative blood losses were recorded in two groups of patients (surgical time <2 h and surgical time >2 h), and the effect of these on blood loss was evaluated.

Results:

The mean intra- and post-operative blood losses were 1222.7 ml and 574.3 ml, respectively. These showed a strong positive correlation with total blood loss (r = 0.790, P < 0.001 and r = 0.517, P < 0.001). Higher intra- and post-operative blood losses were recorded in patients with surgical time >2 h, with a significant difference on postoperative days 2 and 3 (P = 0.003 and P = 0.014, respectively).

Conclusion:

Blood loss in total hip replacement is an important factor and may be influenced by a shorter surgical time.

Outcome and 2-Year Survival Rate in Elderly Patients With Lateral Compression Fractures of the Pelvis

Introduction:

Osteoporotic pelvic ring fractures are a rising problem for surgeons in industrialized countries. There is no evidence-based treatment strategy especially for lateral compression (LC) fractures involving the sacrum. The aim of this study was to evaluate and compare outcome and survival rate of nonoperative and operative treatment strategies for lateral compression fractures.

Patients and Methods:

In a retrospective study, 128 patients (aged ≥65 years) with an Orthopedic Trauma Association (OTA) types B2.1 and B3.3 fracture were included and analyzed regarding demographic and treatment data and adverse events. After a follow-up period of at least 2-year survival rate, quality of life and pain were evaluated using the EuroQol-5D and Short Form–12 questionnaires and the visual analog scale.

Results:

Fifty patients (78.3 ± 7.6 years) obtained operative treatment and 77 patients (82.7 ± 7.9 years) obtained nonoperative treatment. One died within 24 hours after admission. High rates of complications occurred in both groups (operative group: 18% and nonoperative group: 8%). Eighteen percent (14 of the 77) of conservatively treated patients needed operative treatment after discharge due to worsening pain and mobilization. The 2-year follow-up showed a high overall mortality (30%), with a significant higher survival rate for operatively treated patients (2-year survival: operatively treated 82% vs conservative 61%). No difference was found in pain and quality of life.

Discussion:

Elderly patients display a high rate and variety of complications and mortality in the aftermath of lateral compression fractures of the pelvis. Although a significantly higher 2-year survival rate for operatively treated patients was found, this study cannot give proof of superior position for operative treatment. Due to lacking data for alternative treatment algorithms especially for fracture-related immobilized patients, we recommended operative treatment with the aim to reduce complications related to prolonged bed rest and ensure early mobilization.

Gender Role in Total Knee Arthroplasty: A Retrospective Analysis of Perioperative Outcomes in US Patients

BACKGROUND

Women present later than men for total knee arthroplasty (TKA) with more severe osteoarthritic disease but achieve comparable functional improvement and implant survival and also lower rates of revision. Despite these findings, there is significant underutilization of the procedure for women compared to men.

METHODS

We conducted a retrospective study to address the lack of information in the literature concerning the immediate and short-term perioperative outcomes between genders. The National Hospital Discharge Survey was evaluated between 2001 and 2010 for men and women undergoing primary TKA in the United States. Differences in gender, patient demographics, comorbidities, complications, length of stay, and discharge disposition were analyzed and identified.

RESULTS

The growth in TKA was 145% for men and 131% for women over the 10-year period. Women presented with significantly higher rates of obesity, morbid obesity, postoperative transfusion rate, and length of stay. In contrast, men showed a greater proportion of diabetes, postoperative wound infections, and increased mortality rates. Males were also more likely to be discharged to home, whereas females were more likely to be discharged to rehabilitation facilities.

CONCLUSION

Our findings provide important insight into the perioperative outcomes that may be influencing gender disparity in TKA.

Major Complications and Transfusion Rates After Hemiarthroplasty and Total Hip Arthroplasty for Femoral Neck Fractures

BACKGROUND

Postoperative complications and perioperative transfusions are common after hemiarthroplasty or total hip arthroplasty (THA) and can lead to increased morbidity and mortality.

METHODS

The National Surgical Quality Improvement Program Database was queried to compare 30-day major complications and perioperative transfusions after femoral neck fractures.

RESULTS

A total of 4058 patients were included in the study: 3192 were treated with hemiarthroplasty and 866 with THA. Multivariable logistic regression analysis revealed that having a THA was not an independent risk factor for major complications (odds ratio = 0.8, P = .18) but was an independent risk factor for requiring transfusions (odds ratio = 1.68, P < .001).

CONCLUSION

The risk of major complications is influenced by patient factors rather than the choice of procedure. However, THA was a risk factor for transfusions after controlling for all other variables.

Post-operative Blood Salvage and Retransfusion in Total Hip and Knee Arthroplasty

This retrospective study evaluated the safety and efficacy of post-operative blood salvage and retransfusion in 430 patients undergoing total hip arthroplasty and 530 patients undergoing total knee arthroplasty. Volumes of autologous blood retransfused (mean ± SD) were 525 ± 75 and 660 ± 95 ml in the hip and knee replacement groups, respectively. Overall, 230 patients (24%) also required allogeneic blood transfusion. In a subgroup of 150 randomly selected patients, the values of free haemoglobin in the allogeneic, autologous and patients' blood at the time of surgery were 0.568 ± 0.112, 0.272 ± 0.067 and 0.032 ± 0.011 g/l, respectively. On the first and third post-operative days, the levels in patients' blood were 0.092 ± 0.039 and 0.057 ± 0.028 g/l, respectively. There were no major complications; transient chills and fever were reported in 99 (10.3%) and 115 patients (12.0%), respectively. In conclusion, post-operative blood salvage and retransfusion is a safe way to reduce the need for allogeneic blood transfusion in patients undergoing elective orthopaedic surgery.

Minimising the risk of infection: a peri-operative checklist

The purpose of this article is to provide the reader with a seven-step checklist that could help in minimising the risk of PJI. The check list includes strategies that can be implemented pre-operatively such as medical optimisation, and reduction of the bioburden by effective skin preparation or actions taking during surgery such as administration of timely and appropriate antibiotics or blood conservation, and finally implementation of post-operative protocols such as efforts to minimise wound drainage and haematoma formation.

A restrictive policy for red blood cell transfusion in older hip fracture patients: experiences from a patient register

Background

Allogeneic red blood cell transfusions (ABT) are common in older hip fracture patients. Recent research supports a restrictive transfusion policy. The aim was to study variation in hemoglobin (Hb) concentration, and clinical outcomes in these patients.

Results

Cross-sectional study with one-year follow-up in an orthogeriatric unit. Data were obtained from a quality register with demographic and medical information collected by an interdisciplinary team. 106 (22 %) of the 491 patients admitted from September 2011 throughout September 2012 (76 % women, mean age 85 years) received ABT. When given ABT, 80 % had Hb <80 g/l and mean Hb was 78 g/l. Mean Hb, regardless ABT, showed variation from 125 g/l (±16) on admission to 106 g/l (±17), 101 g/l (±16) and 102 g/l (±14) on 1st, 3rd and 5th postoperative day respectively. Patients with per-/subtrochanteric fractures more often received ABT than those with femur neck fractures (p < 0.001), 70 % of the patients receiving ABT had a per-/subtrochanteric fracture. Patients who received ABT were older, had more chronic diseases and lower mean Hb throughout the hospital stay. Length of stay was longer (median 7 vs. 6 days, p = 0.01), and medical complications more common. In-hospital and 30-day mortalities were similar in patients given ABT and in those who were not, but 1-year mortality was higher among patients who were given ABT (p = 0.008).

Conclusions

Hb had a tendency to fall during the three first days after surgery and seemed to be stabilized on day 5. Patients who received ABT had poorer health, but not significantly higher short-term mortality. This study demonstrates a restrictive transfusion policy.

Red Cell Transfusion Triggers and Postoperative Outcomes After Major Surgery

BACKGROUND

The effect of packed red blood cell (PRBC) transfusion on postoperative outcomes of patients undergoing major surgery remains unclear. We sought to determine the impact of blood utilization, as well as transfusion practices, on perioperative outcomes of patients undergoing cardiothoracic-vascular (CT-V) and gastrointestinal (GI) procedures.

METHODS

Patients who underwent major surgical procedures at Johns Hopkins Hospital between 2009 and 2014 were identified. Data on perioperative hemoglobin (Hb) and blood utilization were obtained; transfusion strategy was categorized as liberal (Hb trigger ≥7 g/dL) vs. restrictive (Hb trigger <7 g/dL). Risk-adjusted logistic regression models and propensity score matching were used to assess the association between transfusion triggers and perioperative morbidity.

RESULTS

Among 10,163 patients undergoing either CT-V (50.9 %) or GI (49.1 %) surgery, 4401 (43.3 %) patients received PRBCs. Of the 4401 patients transfused, 71.2 % were transfused using a liberal trigger (≥7 g/dL hemoglobin), while 28.8 % had a restrictive trigger (<7 g/dL). The median number of PRBCs transfused was 3 (restrictive 5 vs. liberal 2 units). While ischemic adverse events were more common among patients undergoing CT-V surgery (17.3 %), infection was the more common complication among patients undergoing GI surgery (11.9 %). American Society of Anesthesiologist (ASA) class 3-4, Charlson score ≥3, and total units of transfused PRBCs were independently associated with overall complications (all P < 0.05). Patients in the restrictive transfusion group did not have increased risk of complications compared with the liberal transfusion group on multivariable analysis (odds ratio (OR) 1.16, 95 % confidence interval (CI) 0.98-1.38; P = 0.08) or after propensity score matching (OR 1.04, 95 % CI 0.88-1.22; P = 0.65).

CONCLUSIONS

Liberal transfusion triggers after major surgery were more common than restrictive practice. Patients with restrictive transfusion trigger did not have increased risk for complications compared with patients transfused with a liberal trigger.

The efficacy of tranexamic acid in hip hemiarthroplasty surgery: an observational cohort study

Tranexamic acid (TXA) has been shown to reduce perioperative blood loss in elective lower limb arthroplasty surgery. There are potentially even greater physiological benefits in minimising blood loss in hip fracture surgery, however limited evidence exists for TXA use in hemiarthroplasty surgery. This study investigates the effect of TXA use on postoperative transfusion rates and haemoglobin (Hb) levels specifically following hemiarthroplasty surgery for hip fractures. A retrospective cohort study was conducted for consecutive hip hemiarthroplasties for fractures between June 2013 and October 2014 comparing patients with or without prophylactic TXA before incision. During the study, 305 hemiarthroplasties were performed with 271 cases eligible. TXA was given in 84 (31%) cases, and both patient groups were matched for known confounding factors. Patients given TXA had a lower transfusion rate (6% vs. 19%. p=0.005) and less blood loss (Hb drop>20g/L) on day 1 post surgery (26% vs. 42%; p=0.014). One transfusion was prevented with every 8 patients given prophylactic TXA. There were no differences in the 30 and 90-day mortality rates with TXA use. Tranexamic acid is safe, cost-effective and reduces the need for blood transfusion and should be considered in all patients undergoing hip hemiarthroplasty for fractures.

A systematic review of pre-operative anaemia and blood transfusion in patients with fractured hips

We systematically reviewed the observational associations of anaemia with outcomes and the effects of interventions to increase haemoglobin concentrations following hip fracture in older people. Anaemia on hospital admission was associated with increased mortality, relative risk 1.64 (95% CI 1.47-1.82), p < 0.0001. After adjustment for co-morbidities, the association of anaemia with increased mortality remained in four of eight observational studies. There was no association of postoperative transfusion with mortality after adjusting for covariates. Transfusion at 80 g.l(-1) vs 100 g.l(-1) increased acute myocardial infarction, relative risk 1.67 (95% CI 1.01-2.77), p = 0.05. Transfusion threshold was not associated with differences in other outcomes. There were insufficient high-quality studies to inform pre-operative blood transfusion or the use of peri-operative iron or erythropoietin. Studies for most interventions recruited too few participants to determine effects on infections, mortality or function.

Topical versus intravenous tranexamic acid in total knee arthroplasty

The objective of this study is to compare the effectiveness of intravenous versus topical application of tranexamic acid in patients undergoing knee arthroplasty. All patients who underwent primary knee arthroplasty at our total joint center over a 12-month period were included in the study. One surgeon utilized 1 g of IV TXA at time of incision in all patients (n=373) except those with a documented history of venous thromboembolism (VTE). Two surgeons utilized a topical application of TXA for all patients without exception (n=198) in which the joint was injected after capsular closure with 3 g TXA/100 mL saline. The transfusion rate was 0% in the topical group vs. 2.4% in the IV group and this was statistically significant (P<0.05).

Factors affecting transfusion requirement after hip fracture: can we reduce the need for blood?

BACKGROUND

Hip fractures are common injuries that result in blood loss and frequently require the transfusion of blood products. We sought to identify risk factors leading to increased blood transfusion in patients presenting with hip fractures, especially those factors that are modifiable.

METHODS

We retrospectively reviewed the cases of all patients who had fixation of their hip fractures between October 2005 and February 2010. The need for transfusion was correlated with potential risk factors, including age, sex, preoperative hemoglobin, fracture type, fixation method and more.

RESULTS

A total of 835 patients had fixation of their hip fractures during the study period; 631 met the inclusion criteria and 249 of them (39.5%) were transfused. We found an association between need for blood transfusion and female sex (p = 0.018), lower preoperative hemoglobin (p < 0.001), fracture type (p < 0.001) and fixation method (p < 0.001). Compared with femoral neck fractures, there was a 2.37 times greater risk of blood transfusion in patients with intertrochanteric fractures (p < 0.001) and a 4.03 times greater risk in those with subtrochanteric fractures (p < 0.001). Dynamic hip screw (DHS) fixation decreased the risk of transfusion by about half compared with intramedullary nail or hemiarthroplasty. We found no association with age, delay to operation (p = 0.17) or duration of surgery (p = 0.30).

CONCLUSION

The only modifiable risk factor identified was fixation method. When considering blood transfusion requirements in isolation, we suggest a potential benefit in using a DHS for intertrochanteric and femoral neck fractures amenable to DHS fixation.

Association of perioperative blood transfusion and adverse events after operative treatment of proximal humerus fractures

BACKGROUND

The purpose of this study was to assess the relationship between perioperative blood transfusion for proximal humerus fracture and inpatient mortality, adverse events, prolonged hospital stay, and nonroutine disposition.

METHODS

Among the >55,000 patients with an operatively treated proximal humerus fracture identified in the Nationwide Inpatient Sample between 2008 and 2011, 17% received a perioperative blood transfusion. Multivariable logistic regression analyses addressed the association of blood transfusion with inpatient mortality, adverse events, hospital stay, and nonroutine discharge, accounting for comorbidities and other known confounders.

RESULTS

Perioperative blood transfusion for fracture of the proximal humerus was not associated with inhospital death, but it was independently associated with inpatient adverse events (odds ratio (OR) 4.4, 95% confidence interval (CI) 4.2-4.6), prolonged hospital stay (OR 2.8, 95% CI 2.7-2.9), and increased nonroutine discharge (OR 1.8, 95% CI 1.7-1.9).

CONCLUSIONS

Inpatients with fracture of the proximal humerus who receive transfusion are not more likely to die in hospital, but they do stay longer, experience more adverse events, and are less likely to be discharged home. Additional study is merited to determine if the judicious use of blood transfusion in the perioperative period can decrease inpatient morbidity and health-care resource utilisation.

LEVEL OF EVIDENCE

Level II, Retrospective Design, Prognosis Study.

Predicting the need for blood transfusions in elderly patients with pertrochanteric femoral fractures

OBJECTIVE

The need exists for perioperative blood management measures aimed at improving patient outcomes and reducing the risks of allogeneic blood transfusion (ABT). Our study aim is to discuss an algorithm to predict the need for perioperative blood transfusion in old patients with pertrochanteric femoral fractures.

METHODS

We retrospectively analysed the data from 220 elderly patients with pertrochanteric femoral fractures with regard to the probability of receiving an ABT within 72h after surgery. The patients were divided into ABT and non-ABT groups. A univariate analysis was used to compare between-group differences with regard to 13 variables. A logistic regression analysis and a probability algorithm to predict the need for an ABT based on independent predictors were used.

RESULTS

The non-ABT group included 131 patients (55 males and 76 females), with an average age of 77.2±6.8 years; the ABT group included 89 patients (29 males and 60 females), with an average age of 79.7±6.6 years. The total volume of transfused blood was 276 Units; the actual average blood transfusion was 3.1±1.47 Units. Significant between-group differences (P<0.05) were observed with regard to age, duration of operation, haemoglobin (Hb) at admission, intra-operative blood loss, type of fracture and type of anaesthesia. The mean volume of transfused blood in the proximal femoral nail anti-rotation (PFNA) and Gamma3 group was larger than that of the dynamic hip screw (DHS) group (P<0.05). A logistic regression analysis revealed that patients with pertrochanteric femoral fractures who were elderly (>81 years), had lower Hb levels at admission (≤124g/L), longer duration of operations (t>85min), underwent intramedullary fixation (Gamma3 and PFNA) and had more intra-operative blood loss were more likely to need an ABT. This regression model predicted 74.1% of the transfused cases.

CONCLUSIONS

An algorithm was devised to predict and manage the need for an ABT within 72h after surgery in patients with pertrochanteric femoral fractures. A reasonable transfusion program might reduce the complications caused by anaemia and effectively avoid the risks associated with ABTs.

Strategies for the prevention of periprosthetic joint infection

Periprosthetic joint infection (PJI) is a devastating complication which can follow a total joint arthroplasty (TJA). Although rare, this ongoing threat undermines the success of TJA, a historically reputable procedure. It has haunted the orthopedic community for decades and several ongoing studies have provided insights and new approaches to effectively battle this multilayered problem.

Blood utilization: fostering an effective hospital transfusion culture

An effective hospital transfusion culture should encourage clinicians to consider the possibility of transfusion in their patients well before the need actually arises, and to plan ahead in an attempt to use blood products most efficiently. Strategies for improved blood utilization include timely and adequate preoperative assessment of risk, optimization of baseline hemoglobin, anticipation of potential transfusion problems, intraoperative techniques to minimize blood loss, blood conservation technologies, transfusion guidelines and targeted therapy, point of care testing, and massive transfusion protocols. Attention to these elements promotes a safe and cost-effective transfusion culture.

The risks of red cell transfusion for hip fracture surgery in the elderly

BACKGROUND AND OBJECTIVES

The benefits and indications for blood transfusion among surgical patients are controversial. There is evidence which suggests that blood transfusion is associated with poor clinical outcomes and risks of infection, but there are few data in the elderly population.

MATERIALS AND METHODS

Data were collected on haemoglobin concentrations and transfusions in 919 patients undergoing hip fracture repair at a university hospital over a 2-year period. 28-day and 180-day mortality were specified as primary outcomes. A composite infection outcome (chest infections, urinary tract infections and wound infections) was the main secondary outcome. Preoperative, operative and/or postoperative transfusions were the main exposure variable. Regression analyses were used to explore the associations between transfusion and outcomes, adjusting for pre-defined preoperative variables.

RESULTS

300 patients (32·6%) were transfused at least once during their admission. There was no evidence of a significant difference in either 28-day survival or 180-day survival between transfused and non-transfused hip fracture patients. The transfused group had higher adjusted composite infection rate (HR, 1·91; 95% CI, 1·41-2·59, P < 0·001) and prolonged length of stay in hospital than the non-transfused group (HR, 1·15; 95% CI, 1·07, 1·23, P < 0·001). Anaemia at the time of admission, extra capsular fracture and using walking aids in an indoor setting were preoperative variables, which predicted the need for transfusion.

CONCLUSION

Among an elderly population with hip fracture, blood transfusion was not associated with changes in mortality, but was associated with an increased rate of postoperative infection. These data add to the wider literature about adverse clinical outcomes in patients receiving blood transfusions and emphasises the need for prospective trials to evaluate the role of transfusion in the elderly.

Survivorship of the native hip joint after percutaneous repair of acetabular fractures in the elderly

Our purpose was to examine survivorship of the native hip joint in patients ages 60 and over who underwent percutaneous reduction and fixation of acetabular fractures. A retrospective review at a University Level I Trauma Center was performed. Our institutional trauma database was reviewed. Patients aged 60 or older treated with percutaneous reduction and fixation of acetabular fractures between 1994 and 2007 were selected. 79 consecutive patients with 80 fractures were identified. Rate of conversion to total hip arthroplasty were used to construct a Kaplan-Meier curve showing survivorship of the native hip joint after treatment. 75 fractures had adequate clinical follow-up with a mean of 3.9 years (range 0.5-11.9 years). Average blood loss was 69 cc and there were no postoperative infections. 19/75 (25%) were converted to total hip arthroplasty at a mean time of 1.4 years after the index procedure. Survivorship analysis demonstrated a cumulative survival of 65% at 11.9 years of follow-up. There were no conversions to arthroplasty beyond 4.7 years postoperatively. There were no statistically significant associations between conversion to arthroplasty and age, sex, closed vs. limited open reduction, and simple vs. complex fracture pattern. Percutaneous fixation is a viable treatment option for patients age 60 or greater with acetabular fractures. Rates of conversion to total hip arthroplasty are comparable to open treatment methods and if conversion is required, soft tissues are preserved for future surgery.

The association of preoperative anemia and perioperative allogeneic blood transfusion with the risk of surgical site infection

BACKGROUND

The purpose of the study was to investigate allogeneic blood transfusion (ABT) and preoperative anemia as risk factors for surgical site infection (SSI).

STUDY DESIGN AND METHODS

A prospective, observational cohort of 5873 consecutive general surgical procedures at Basel University Hospital was analyzed to determine the relationship between perioperative ABT and preoperative anemia and the incidence of SSI. ABT was defined as transfusion of leukoreduced red blood cells during surgery and anemia as hemoglobin concentration of less than 120 g/L before surgery. Surgical wounds and resulting infections were assessed to Centers for Disease Control standards.

RESULTS

The overall SSI rate was 4.8% (284 of 5873). In univariable logistic regression analyses, perioperative ABT (crude odds ratio [OR], 2.93; 95% confidence interval [CI], 2.1 to 4.0; p < 0.001) and preoperative anemia (crude OR, 1.32; 95% CI, 1.0 to 1.7; p = 0.037) were significantly associated with an increased odds of SSI. After adjusting for 13 characteristics of the patient and the procedure in multivariable analyses, associations were substantially reduced for ABT (OR, 1.25; 95% CI, 0.8 to 1.9; p = 0.310; OR, 1.07; 95% CI, 0.6 to 2.0; p = 0.817 for 1-2 blood units and >or=3 blood units, respectively) and anemia (OR, 0.91; 95% CI, 0.7 to 1.2; p = 0.530). Duration of surgery was the main confounding variable.

CONCLUSION

Our findings point to important confounding factors and strengthen existing doubts on leukoreduced ABT during general surgery and preoperative anemia as risk factors for SSIs.

Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med. 2008;36:2667-2674. [PMID: 18679112 DOI: 10.1097/ccm.0b013e3181844677]

BACKGROUND

Red blood cell (RBC) transfusions are common in intensive care unit, trauma, and surgical patients. However, the hematocrit that should be maintained in any particular patient because the risks of further transfusion of RBC outweigh the benefits remains unclear.

OBJECTIVE

A systematic review of the literature to determine the association between red blood cell transfusion, and morbidity and mortality in high-risk hospitalized patients.

DATA SOURCES

MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles.

STUDY SELECTION

Cohort studies that assessed the independent effect of RBC transfusion on patient outcomes. From 571 articles screened, 45 met inclusion criteria and were included for data extraction.

DATA EXTRACTION

Forty-five studies including 272,596 were identified (the outcomes from one study were reported in four separate publications). The outcome measures were mortality, infections, multiorgan dysfunction syndrome, and acute respiratory distress syndrome. The overall risks vs. benefits of RBC transfusion on patient outcome in each study was classified as (i) risks outweigh benefits, (ii) neutral risk, and (iii) benefits outweigh risks. The odds ratio and 95% confidence interval for each outcome measure was recorded if available. The pooled odds ratios were determined using meta-analytic techniques.

DATA SYNTHESIS

Forty-five observational studies with a median of 687 patients/study (range, 63-78,974) were analyzed. In 42 of the 45 studies the risks of RBC transfusion outweighed the benefits; the risk was neutral in two studies with the benefits outweighing the risks in a subgroup of a single study (elderly patients with an acute myocardial infarction and a hematocrit <30%). Seventeen of 18 studies, demonstrated that RBC transfusions were an independent predictor of death; the pooled odds ratio (12 studies) was 1.7 (95% confidence interval, 1.4-1.9). Twenty-two studies examined the association between RBC transfusion and nosocomial infection; in all these studies blood transfusion was an independent risk factor for infection. The pooled odds ratio (nine studies) for developing an infectious complication was 1.8 (95% confidence interval, 1.5-2.2). RBC transfusions similarly increased the risk of developing multi-organ dysfunction syndrome (three studies) and acute respiratory distress syndrome (six studies). The pooled odds ratio for developing acute respiratory distress syndrome was 2.5 (95% confidence interval, 1.6-3.3).

CONCLUSIONS

Despite the inherent limitations in the analysis of cohort studies, our analysis suggests that in adult, intensive care unit, trauma, and surgical patients, RBC transfusions are associated with increased morbidity and mortality and therefore, current transfusion practices may require reevaluation. The risks and benefits of RBC transfusion should be assessed in every patient before transfusion.

Red blood cell transfusions and the risk of acute respiratory distress syndrome among the critically ill: a cohort study

INTRODUCTION

Recent data indicate that transfusion of packed red blood cells (pRBCs) may increase the risk for the development of acute respiratory distress syndrome (ARDS) in critically ill patients. Uncertainty remains regarding the strength of this relationship.

METHODS

To quantify the association between transfusions and intensive care unit (ICU)-onset ARDS, we performed a cohort study within Crit, a multicenter, prospective, observational study of transfusion practice in the ICU which enrolled 4,892 critically ill patients in 284 ICUs in the United States. Diagnostic criteria for ARDS were prospectively defined, and we focused on subjects without ARDS at admission. The development of ARDS in the ICU served as the primary endpoint.

RESULTS

Among the 4,730 patients without ARDS at admission, 246 (5.2%) developed ARDS in the ICU. At baseline, ARDS cases were younger, more likely to be in a surgical ICU, and more likely to be admitted with pneumonia or sepsis than controls without ARDS. Cases also were more likely to have a serum creatinine of greater than 2.0 mg/dl (23% versus 18%) and a serum albumin of less than or equal to 2.3 g/dl (54% versus 30%) and were more severely ill upon ICU admission as measured by either the APACHE II (Acute Physiology and Chronic Health Evaluation II) or SOFA (Sequential Organ Failure Assessment) score (p < 0.05 for all). Sixty-seven percent and 42% of cases and controls, respectively, had exposure to pRBC transfusions (p < 0.05), and the unadjusted odds ratio (OR) of developing ARDS in transfused patients was 2.74 (95% confidence interval [CI], 2.09 to 3.59; p < 0.0001) compared to those never transfused. After age, baseline severity of illness, admitting diagnosis, and process-of-care factors were adjusted for, the independent relationship between pRBC transfusions and ICU-onset ARDS remained significant (adjusted OR, 2.80; 95% CI, 1.90 to 4.12; p < 0.0001).

CONCLUSION

Development of ARDS after ICU admission is common, occurring in approximately 5% of critically ill patients. Transfusion of pRBCs is independently associated with the development of ARDS in the ICU.

Effect of a restrictive transfusion strategy on transfusion-attributable severe acute complications and costs in the US ICUs: a model simulation

Background

Nearly half of all patients in the Intensive Care Unit (ICU) receive red blood cell (pRBC) transfusions (TFs), despite their associated complications. Restrictive transfusion strategy (Hemoglobin [Hb] < 7 g/dL) has been shown to reduce TF exposure. We estimated the potential annual reduction in transfusion-attributable severe acute complications (TSACs) and costs across the US ICUs with the adoption of restrictive strategy.

Methods

A model, utilizing inputs from published studies, was constructed. Step 1 calculated potential number of patients appropriate for this strategy. In step 2, total number of pRBC units avoided with the restrictive trigger was extrapolated to the annual TFs in the US ICUs. Step 3 quantified excess acute complications and the number of pRBC units TF/1 TSAC in the TRICC trial. Step 4 transformed restrictive strategy-related avoidance of pRBC units to a reduction in TSACs, and step 5 quantified the associated cost savings.

Results

Of the 4.4 million annual ICU admissions, 1,020,800 comprised the at-risk population. The total of 1,295,126 units of pRBC ($643/unit) could be saved with the restrictive strategy. Based on the data from the TRICC trial, dividing the 49 excess complications in the liberal group into the calculated excess of pRBCs transfused (1,624 units) yielded the rate of 33 pRBC units per one complication. Thus, dividing 1,295,126 units saved by 33 units/1 TSAC, the base-case analysis showed that 39,246 TSACs could potentially be avoided annually in the US ICUs, with the cost savings of $821,109,826.

Conclusion

This model demonstrates that a restrictive transfusion strategy in appropriate at risk ICU patients is dominant and could result in improved quality of care and cost savings. Given the potential savings of 40,000 TSACs and nearly $1 billion, it is incumbent upon the intensivist community to promote more ubiquitous adoption of a clinically appropriate restrictive transfusion strategy in the ICU.