Incidence of and risk factors for perioperative blood transfusion in infants undergoing index pediatric surgery procedures

BackgroundThere is a paucity of data on the frequency of transfusion during pediatric surgery index cases and guidelines for pretransfusion testing, defined as type and screen and crossmatch testing, prior to operation are not standardized. This study aimed to determine the incidence of perioperative blood transfusions during index neonatal operations and identify risk factors associated with perioperative blood transfusion to determine which patients benefit from pretransfusion testing.MethodsA retrospective review of infants who underwent index neonatal cases between 2013 and 2019 was performed. Data were collected for patients who underwent operations for Hirschsprung's disease, esophageal atresia/tracheoesophageal fistula (EA/TEF), biliary atresia, anorectal malformation, omphalocele, gastroschisis, duodenal atresia, congenital diaphragmatic hernia (non-ECMO) or pulmonary lobectomy. Infants under 6 months were included except in the case of lobectomy where infants up to 12 months were included.ResultsAnalysis was performed on 420 patients. Twenty-five (6.0%) patients received perioperative blood transfusion. Patients who received perioperative transfusion most commonly underwent EA/TEF repair. Patients who received perioperative transfusion had higher rates of structural heart disease (52.0% vs 17.7%, p<0.001), preoperative transfusion (48.0% vs 8.9%, p<0.001), and prematurity (52.0% vs 25.6%, p = 0.005). Presence of all three risk factors resulted in a 48% probability of requiring perioperative transfusion.ConclusionsBlood transfusion during the perioperative period of neonatal index operations is rare. Factors associated with increased risk of perioperative transfusion include prematurity, structural heart disease, and history of previous blood transfusion.Level of EvidenceIII     

Laparoscopic renal-adrenal surgery in patients on oral anticoagulant therapy

PURPOSE: Patients requiring chronic anticoagulation are theoretically at increased risk for hemorrhage or thromboembolism perioperatively. Experience with laparoscopic renal/adrenal surgery in patients on chronic warfarin is limited. We assessed hemorrhagic/thromboembolic complications in this group of patients. MATERIALS AND METHODS: The records of 787 patients undergoing laparoscopic renal/adrenal surgery were retrospectively reviewed. A total of 25 patients on chronic oral anticoagulation with warfarin were identified. The indications for warfarin therapy as well as perioperative management were reviewed. Clinical parameters, including operative time, estimated blood loss, hemorrhagic/thromboembolic complications and transfusions, were documented and compared with those in patients not receiving chronic anticoagulation. RESULTS: Atrial fibrillation (56% of cases) and a prosthetic mitral valve (28%) were the most frequent indications for chronic anticoagulation. Bridging anticoagulation with unfractionated heparin was the most frequent management method (68% of cases). Patients with anticoagulation were older (p <0.001) and hospitalized longer (<0.001) than those without anticoagulation. Operative time, estimated blood loss and the conversion rate were not significantly different between the groups. However patients on chronic warfarin significantly more often required transfusion (24% vs 5.2%, p <0.005) and had more postoperative bleeding episodes (8% vs 0.9%, p <0.05) than patients not on chronic anticoagulation. No thromboembolic events occurred in the anticoagulated group, while 3 occurred in the nonanticoagulated group (p = 1). CONCLUSIONS: Laparoscopic renal/adrenal surgery in patients requiring chronic anticoagulation therapy can be performed safely. The risk of intraoperative bleeding is not increased, although the incidence of postoperative bleeding as well as transfusions is higher.     

Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases

OBJECTIVE: To determine if transfusion affected perioperative and long-term outcome in patients undergoing liver resection for metastatic colorectal cancer. SUMMARY BACKGROUND DATA: Blood transfusion produces host immunosuppression and has been postulated to result in adverse outcome for patients undergoing surgical resection of malignancies. METHODS: Blood transfusion records and clinical outcomes for 1,351 patients undergoing liver resection at a tertiary cancer referral center were analyzed. RESULTS: Blood transfusion was associated with adverse outcome after liver resection. The greatest effect was in the perioperative course, where transfusion was an independent predictor of operative mortality, complications, major complications, and length of hospital stay. This effect was dose-related. Patients receiving one or two units or more than two units had an operative mortality of 2.5% and 11.1%, respectively, compared to 1.2% for patients not requiring transfusions. Transfusion was also associated with adverse long-term survival by univariate analysis, but this factor was not significant on multivariate analysis. Even patients receiving only one or two units had a more adverse outcome. CONCLUSIONS: Perioperative blood transfusion is a risk factor for poor outcome after liver resection. Blood conservation methods should be used to avoid transfusion, especially in patents currently requiring limited amounts of transfused blood products.     

Heparin-induced thrombocytopenia following cardiac surgery is associated with poor outcome

OBJECTIVE: The outcome of cardiac surgical patients with clinically diagnosed heparin-induced thrombocytopenia (HIT) was studied. DESIGN: Retrospective, observational study. SETTING: University hospital. PARTICIPANTS: All cardiac surgical patients with diagnosed HIT after cardiac surgery between January 2002 and December 2004, and concurrently, consecutive patients without HIT. INTERVENTIONS: None Measurements and Main Results: 3465 patients were treated postoperatively in the cardiac surgical intensive care unit during the study period. Clinical suspicion of HIT arose when platelet count markedly fell several days after surgery and HIT was proven by a positive enzyme immunoassay in 20 patients. Thrombocytopenia (35.5 [22] x 10(9)/L, median [interquartile range]) developed within 7 (6) days. HIT patients received significantly more platelet transfusions perioperatively than controls (p < 0.001). Thromboembolic complications occurred in 70% of HIT patients, but in none of non-HIT patients (14/20 v 0/20, p = 0.001). Intensive care unit stay was longer in HIT patients than in controls (16.5 [11.0] v 1.0 [3.0] days, p < 0.001). Nine HIT patients died (45%), while all control patients survived. Mortality was related to thrombotic complications in seven HIT patients (35%). CONCLUSIONS: The incidence of HIT in association with low-molecular-weight heparin use after cardiac surgery was low. HIT was associated with perioperative platelet transfusions and carried a remarkably high risk of thromboembolic complications and death. In order to reduce morbidity and mortality, early recognition of heparin-associated antiplatelet antibodies and alternative anticoagulation strategies need to be implemented.     

Effect of blood transfusion on long-term survival after cardiac operation

BACKGROUND: Blood transfusions have been linked to increased morbidity and mortality. Bleeding during and after cardiac operations and the hemodilution effects of cardiopulmonary bypass commonly result in blood transfusions. Because we could not find any studies evaluating the effects of transfusion on long-term survival after cardiac operation, we sought to determine these effects. METHODS: We studied 1,915 patients who underwent first-time isolated coronary artery bypass operations between July 6, 1994 and December 31, 1997 at our institution. Patients with transfusions were compared with those who had not been transfused. Long-term survival data were obtained from the United States Social Security Death Index. Groups were compared by Cox proportional hazard models, Kaplan-Meier survival plots, and hazard functions. RESULTS: Six hundred forty-nine of 1,915 study patients (34%) received a transfusion during their hospitalization. Transfused patients were older, smaller, and more likely to be female, and had more comorbidity. Transfused patients also had twice the 5-year mortality (15% vs 7%) of nontransfused patients. After correction for comorbidities and other factors, transfusion was still associated with a 70% increase in mortality (risk ratio = 1.7; 95% confidence interval = 1.4 to 2.0; p = 0.001). By multivariate analysis, transfusion, peripheral vascular disease, chronic obstructive pulmonary disease, New York Heart Association functional class IV, and age were significant predictors of long-term mortality. CONCLUSIONS: We found that blood transfusions during or after coronary artery bypass operations were associated with increased long-term mortality.     

Large volume acute normovolemic hemodilution in patients undergoing cardiac surgery with intermediate-high risk of transfusion: A randomized controlled trial

Study Objective: To investigate whether large volume acute normovolemic hemodilution (L-ANH), compared with moderate acute normovolemic hemodilution (M-ANH), can reduce perioperative allogeneic blood transfusion in patients with intermediate-high risk of transfusion during cardiac surgery with cardiopulmonary bypass (CPB).Design: Prospective randomized controlled trial.Setting: University hospital.Patients: Patients with transfusion risk understanding scoring tool (“TRUST”) ≥2 points undergoing cardiac surgery with CPB in the Second Affiliated Hospital of Zhejiang University from May 2020 to January 2021 were included.Interventions: The patients were randomly assigned with a 1:1 ratio to M-ANH (5 to 8 mL/kg) or L-ANH (12 to 15 mL/kg).Measurements: The primary outcome was perioperative red blood cell (RBC) transfusion units. The composite outcome included new-onset atrial fibrillation, pulmonary infection, cardiac surgery associated acute kidney injury (CSA-AKI) class ≥2, surgical incision infection, postoperative excessive bleeding, and resternotomy. Main results: Total 159 patients were screened and 110 (55 L-ANH and 55 M-ANH) were included for final analysis. Removed blood volume of L-ANH is significantly higher than M-ANH (886 ± 152 vs. 395 ± 86 mL, P < 0.001). Perioperative RBC transfusion was median 0 unit ([25th, 75th] percentiles: 0–4.4) in M-ANH group vs. 0 unit ([25th, 75th] percentiles: 0–2.0) in L-ANH group (P = 0.012) and L-ANH was associated with lower incidence of transfusion (23.6% vs. 41.8%, P = 0.042, rate difference: 0.182, 95% confidence interval [0.007–0.343]). The incidence of postoperative excessive bleeding was significantly lower in L-ANH vs. M-ANH (3.6% vs. 18.2%, P = 0.029, rate difference: 0.146, 95% confidence interval [0.027–0.270]) without significant difference for other second outcomes. The volume of ANH was inversely related to perioperative RBC transfusion units (Spearman r = −0.483, 95% confidence interval [−0.708 to −0.168], P = 0.003), and L-ANH in cardiac surgery was associated with a significantly reduced risk of perioperative RBC transfusion (odds ratio: 0.43, 95% confidence interval: 0.19–0.98, P = 0.044).Conclusions: Compared with M-ANH, L-ANH during cardiac surgery inclined to be associated with reduced perioperative RBC transfusion and the volume of RBC transfusion was inversely proportional to the volume of ANH. In addition, LANH during cardiac surgery was associated with a lower incidence of postoperative excessive bleeding.     

Perioperative blood transfusion in anemic patients undergoing elective endovascular abdominal aneurysm repair

ObjectiveAlthough blood transfusion can be lifesaving in active hemorrhage or severe anemia, it is also associated with increased morbidity and mortality. Several trials have established this risk and therefore defined a restrictive standard for transfusion, but this threshold and the risk of transfusions have not been specifically examined in vascular surgery patients. We therefore sought to assess transfusion practices and outcomes of anemic patients undergoing elective endovascular aneurysm repair (EVAR).MethodsThe Vascular Quality Initiative database was queried for patients undergoing EVAR between the years 2008 and 2017. Anemic patients were included in the study and were further stratified into mild anemia, defined by a hemoglobin level of 10 to 13 g/dL in men or 10 to 12 g/dL in women, and moderate to severe anemia, defined by a hemoglobin level <10 g/dL. The primary study outcomes were in-hospital mortality and complications.ResultsAmong 27,777 EVAR patients, one-third (n = 9232) were anemic and included in the study. One-fifth (n = 1866) of anemic patients received a perioperative transfusion. Transfused patients were more likely to have a history of cardiovascular disease. In-hospital mortality was significantly higher for anemic patients who received transfusions, both in mild anemia (mortality, 3.6% vs 0.4% in no transfusion; P < .001) and in moderate to severe anemia (4.5% vs 1.3%; P < .01). Morbidity was also significantly higher, with anemic patients who received a transfusion having higher rates of myocardial infarction, congestive heart failure, dysrhythmias, renal complications, leg ischemia, respiratory complications, and reoperation compared with anemic patients who did not receive any transfusion. The 30-day mortality was also higher in transfused patients (P < .001). After adjustment for patients' demographics, comorbidities, and operative factors, transfusion in anemic patients was associated with a nearly 4.4-fold increased odds of in-hospital mortality (odds ratio [OR], 4.38; 95% confidence interval [CI], 2.72-7.05; P < .001) and 4.3-fold higher odds of any in-hospital complication (OR, 4.31; 95% CI, 3.47-5.34; P < .001). This was more pronounced among patients with mild anemia, with 5.7 times (OR, 5.7; 95% CI, 1.78-18.0) and 4.3 times (OR, 4.3; 95% CI, 3.46-5.29) the odds of in-hospital mortality and complications, respectively.ConclusionsAmong anemic patients undergoing elective EVAR, transfusion is associated with an increased risk of death and in-hospital complications, even after controlling for patients' comorbidities and operative factors. These data suggest that the restrictive use of blood transfusions might be safer in vascular surgery EVAR patients. Medical management of anemia may be warranted in these patients to reduce morbidity and mortality; however, further studies are needed to evaluate effectiveness.     

Perioperative clopidogrel is associated with increased bleeding and blood transfusion at the time of lower extremity bypass

Objective

Controversy persists surrounding the perceived bleeding risk associated with perioperative clopidogrel use in patients undergoing lower extremity bypass (LEB). The purpose of this study was to examine the LEB bleeding risk and clinical sequelae associated with clopidogrel.

Impact of preoperative locoregional chemotherapy with fluorodeoxyuridine on the outcome of liver resection

The aim of the study was to evaluate the effects of preoperative intra-arterial hepatic chemotherapy (IAHC) on the outcome of liver resections for hepatic metastases from colorectal cancer. Twelve patients (IAHC group) treated by IAHC with fluorodeoxyuridine (FUdR) and subsequent liver resection and 40 patients who underwent liver resection without preliminary IAHC (non-IAHC group) were analysed comparatively in terms of age, gender, concomitant diseases, previous abdominal surgery, type of hepatic resection, use of portal clamping, and associated surgical procedures. For the purposes of the study, length of operation, intraoperative blood losses, perioperative transfusions, length of hospitalisation, complications and mortality were also recorded. The two groups were comparable (p = n.s.) for those variables affecting the perioperative course. As regards the end points of the study, no significant differences were recorded in length of operation, intraoperative blood losses, perioperative transfusions [except for more postoperative plasma transfusions in the IAHC group (16.7% vs 5.0%, p = 0.009)] and postoperative complications (9.1% vs 17.5%, p = 0.415). Postoperative mortality consisted in one patient in the IAHC group. Postoperative hospitalization was significantly longer in the non-IAHC group (median: 8 vs 10, range: 6-13 vs 5-33 days; p = 0.004). IAHC does not negatively affect the outcome of subsequent liver resection.     

The Effects of Frailty in Patients Undergoing Elective Cardiac Surgery

Background

The Society of Thoracic Surgeons (STS) recommends using gait speed as a marker of frailty to identify cardiac surgery patients at risk for adverse outcomes. However, a single marker of frailty may not provide consistently reliable risk information. We evaluated the impact of frailty and gait speed on patient outcomes after elective cardiac surgery.

Methods

This was a prospective study of 167 older (≥65 years) coronary artery bypass grafting (CABG) and/or valve surgery patients. Patients were assessed using Cardiovascular Health Study (CHS) Frailty Index criteria: weight loss, exhaustion, physical activity, gait speed, and grip strength.

Results

Frailty was identified in 39 patients (23%) using CHS criteria. Frail patients had longer median intensive care unit stays (54 vs. 28 h, p = 0.003), longer median length of stay (8 vs. 5 days, p < 0.001), and greater likelihood of STS‐defined complications (54% vs. 32%, p = 0.011) and discharge to an intermediate‐care facility (45% vs. 12%, p < 0.001) but were not different from nonfrail patients on major outcome, operative mortality, or readmissions. After multivariate adjustment, frail and nonfrail patients were similar on perioperative outcomes. Absolute gait speed and slow gait speed using a cutoff were not related to incidence of STS‐defined complications or major outcome in multivariate analyses. However, higher body mass index was correlated with slower gait speed (r_s = 0.30, p < 0.001).

Conclusions

The CHS index did not identify “frail” patients at increased risk for adverse outcomes. No relationship was found between gait speed and outcome. There is a need for alternative multidimensional measures to assess frailty in cardiac surgical patients. doi: 10.1111/jocs.12699 (J Card Surg 2016;31:187–194)     

Urgent carotid endarterectomy is safe in patients with few comorbid medical conditions

Recent reports from single institutions have confirmed the efficacy of carotid endarterectomy (CEA) performed in the urgent or emergent setting, although with higher perioperative mortality and morbidity. We determined the results of urgently performed CEA in academic and community hospitals and whether patient or hospital factors affected outcome. The records of patients undergoing CEA in all nonfederal hospitals in the state of Connecticut between 1992 and 2002 were reviewed, and symptomatic patients who presented in an urgent or emergent fashion were compared to patients treated electively. Multivariable logistic regression was used to determine the effect of patient risk factors on perioperative mortality, stroke, and cardiac complications. Patients undergoing urgent CEA (n = 764, 6.3%) had higher perioperative mortality (2.0% vs. 0.3%, p < 0.0001) and stroke (2.9% vs. 1.1%, p < 0.0001) but not cardiac complications (3.0% vs. 2.2%, p = 0.14) compared to patients undergoing elective CEA (n = 11,312). Patients undergoing urgent CEA and with high rates of associated comorbidity had a higher risk of perioperative mortality (7.8% vs. 0.4, p = 0.001), stroke (10.9% vs. 0.8%, p = 0.0002), and cardiac complications (14.1% vs. 0.8%, p < 0.0001) compared to patients presenting urgently but with little comorbidity. Perioperative mortality was associated with performance of the procedure in hospitals with low bed capacity (odds ratio [OR] = 4.6, p = 0.01). Perioperative stroke was associated with renal insufficiency (OR = 5.3, p = 0.04). Perioperative cardiac complications were associated with diabetes (OR = 2.6, p = 0.03) and performance in hospitals with low bed capacity (OR = 5.0, p < 0.01). Urgent admission was associated with age >/=80 (OR = 1.2, p = 0.04), renal disease (OR = 1.8, p = 0.05), and cardiac disease (OR = 1.3, p < 0.01). Urgently performed CEA has higher perioperative mortality and stroke compared with electively performed cases. However, the subset of patients with low rates of associated comorbid medical conditions but urgently needing CEA is associated with low rates of perioperative complications. Patients with severe associated comorbid medical conditions who present urgently for CEA may form a high-risk group of patients to be considered for referral to large treatment centers or possibly alternative therapy.     

Autotransfusion with cell saver for off-pump coronary artery bypass surgery: a randomized trial

OBJECTIVES: Off-pump coronary surgery reduces transfusions, however, many patients still receive blood. This trial aims to clarify the effect of using a cell saver intraoperatively. DESIGN: In 60 patients shed blood was collected in the cell saver reservoir intraoperatively; randomization and processing or discharge were performed immediately after surgery. Primary outcome measures: proportion of patients receiving allogeneic blood, and average number of units per patient. Secondary outcome measures: blood loss, hemoglobin levels, complications, and costs. RESULTS: Cell saver group versus control group; received transfusions: 17/30 vs. 14/29 (p = 0.28), allogeneic units: median 1 (interquartile range 0 - 2) vs. 2 (IQR 0 - 7) (p = 0.06), intraoperative net blood loss: median 300 ml (IQR 193 - 403) vs. 610 ml (IQR 450 - 928) (p < 0.001). Control group patients had more complications leading to transfusion. Hemoglobin levels and costs were comparable between groups. CONCLUSIONS: Use of cell saver reduced intraoperative net blood loss and seemed to reduce transfusions by 1 unit per patient, however, this was probably attributable to more complications leading to transfusion in the control group. In the future larger trials are necessary.     

Autotransfusion with cell saver for off-pump coronary artery bypass surgery: a randomized trial

Objectives. Off-pump coronary surgery reduces transfusions, however, many patients still receive blood. This trial aims to clarify the effect of using a cell saver intraoperatively. Design. In 60 patients shed blood was collected in the cell saver reservoir intraoperatively; randomization and processing or discharge were performed immediately after surgery. Primary outcome measures: proportion of patients receiving allogeneic blood, and average number of units per patient. Secondary outcome measures: blood loss, hemoglobin levels, complications, and costs. Results. Cell saver group versus control group; received transfusions: 17/30 vs. 14/29 (p?=?0.28), allogeneic units: median 1 (interquartile range 0 – 2) vs. 2 (IQR 0 – 7) (p?=?0.06), intraoperative net blood loss: median 300 ml (IQR 193 – 403) vs. 610 ml (IQR 450 – 928) (p?<?0.001). Control group patients had more complications leading to transfusion. Hemoglobin levels and costs were comparable between groups. Conclusions. Use of cell saver reduced intraoperative net blood loss and seemed to reduce transfusions by 1 unit per patient, however, this was probably attributable to more complications leading to transfusion in the control group. In the future larger trials are necessary.     

Anaemia in cardiac surgery – a retrospective review of a centre's experience with a pre-operative intravenous iron clinic

Pre-operative anaemia is associated with higher rates of transfusion and worse outcomes, including prolonged hospital stay, morbidity and mortality. Iron deficiency is associated with significantly lower haemoglobin levels throughout the peri-operative period and more frequent blood transfusion. Correction of iron stores before surgery forms part of the first pillar of patient blood management. We established a pre-operative anaemia clinic to aid identification and treatment of patients with iron deficiency anaemia scheduled for elective cardiac surgery. We present a retrospective observational review of our experience from January 2017 to December 2019. One-hundred and ninety patients received treatment with intravenous iron, a median of 21 days before cardiac surgery. Of these, 179 had a formal laboratory haemoglobin level measured before surgery, demonstrating a median rise in haemoglobin of 8.0 g.l^-1. Patients treated with i.v. iron demonstrated a significantly higher incidence of transfusion (60%) compared with the non-anaemic cohort (22%) during the same time period, p < 0.001. Significantly higher rates of new requirement for renal replacement therapy (6.7% vs. 0.6%, p < 0.001) and of stroke (3.7% vs. 1.2%, p = 0.010) were also seen in this group compared with those without anaemia, although there was no significant difference in in-hospital mortality (1.6% vs. 0.8%, p = 0.230). In patients where the presenting haemoglobin was less than 130 g.l^-1, but there was no intervention or treatment, there was no difference in rates of transfusion or of complications compared with the anaemic group treated with iron. In patients with proven iron deficiency anaemia, supplementation with intravenous iron showed only a modest effect on haemoglobin and this group still had a significantly higher transfusion requirement than the non-anaemic cohort. Supplementation with intravenous iron did not improve outcomes compared with patients with anaemia who did not receive intravenous iron and did not reduce peri-operative risk to non-anaemic levels. Questions remain regarding identification of patients who will receive most benefit, the use of concomitant treatment with other agents, and the optimum time frames for treatment in order to produce benefit in the real-world setting.     

Impact of allogeneic blood transfusions on clinical outcomes in severely burned patients

BackgroundAllogeneic blood transfusions are common in the treatment of severely burned patients as surgery may lead to major blood loss. However, transfusions are associated with a number of adverse events. Therefore, the purpose of our study was to investigate the impact of allogeneic blood transfusions on clinical outcomes in severely burned patients.MethodsThis retrospective study included all adult patients admitted to the burn center of the University Hospital Zurich between January 2004 and December 2014, with burn injuries greater than 10% of total body surface area and receiving both surgical and intensive care treatment. Primary Endpoints were infectious or thromboembolic complications and mortality and secondary endpoints were length of hospital and ICU stay. Simple and multivariable logistic and linear regression models, adjusted for injury severity and confounders, were applied.Results413 patients met inclusion criteria of which 212 patients (51%) received allogenic blood products. After adjustment for injury severity and confounders, red blood cell transfusion was independently associated with wound infection (OR 13.5, 95% CI 1.7–107, p = 0.014), sepsis (OR 8.3, 4.2–16.3; p < 0.001), pneumonia (OR 4.7, 2.2–10.0; p < 0.001), thrombosis (OR 3.0, 1.2–7.4; p = 0.015), central line infection (OR 34.7, 4.6–260; p = 0.001) and a longer ICU and hospital stay (difference 17.7, CI 12.1–23.4, p < 0.001 and 22.0, 15.8–28.2, p < 0.001, respectively). Fresh frozen plasma transfusion was independently associated with a longer ICU and hospital stay (difference 13.7, 95% CI 5.5–21.8, p = 0.001 and 13.5, 4.6–22.5, p = 0.003, respectively). Platelet transfusion was independently associated with systemic inflammatory response syndrome (OR 4.5, 1.3–15.5; p = 0.018) and mortality (OR 5.8, 2.1–16.0; p = 0.001).ConclusionTransfusion of allogeneic blood products is associated with an increased infection rate and thromboembolic morbidity and a longer hospital stay in severely burned patients.     

Allogeneic Blood Transfusion Does Not Affect Outcome After Curative Resection for Advanced Cholangiocarcinoma

Purpose

To assess the impact of perioperative blood transfusion on overall and disease-free survival in patients undergoing curative resection for cholangiocarcinoma.

Methods

In a single-center study, 128 patients undergoing curative resection for cholangiocarcinoma between 2001 and 2010 were assessed. The median follow-up period was 19 months. Transfused and nontransfused patients were compared by Cox regression and propensity score analyses.

Results

Overall, 38 patients (29.7 %) received blood transfusions. The patient characteristics were highly biased with respect to receiving transfusions (propensity score 0.69 ± 0.22 vs. 0.11 ± 0.16, p < 0.001). In the unadjusted analysis, blood transfusion was associated with a 105 % increased risk of mortality [hazard ratio (HR) 2.05, 95 % CI 1.19–3.51, p = 0.010]. In the multivariate (HR 1.14, 95 % CI 0.52–2.48, p = 0.745) and the propensity score-adjusted Cox regression (HR 1.02, 95 % CI 0.39–2.62, p = 0.974), blood transfusion had no influence on overall survival. Similarly, in the propensity score-adjusted Cox regression (HR 0.62, 95 % CI 0.24–1.58, p = 0.295), no relevant effect of blood transfusion on disease-free survival was observed.

Conclusions

To our knowledge, this is the first propensity score-based analysis providing compelling evidence that the worse oncological outcome after curative resection for advanced cholangiocarcinoma in patients receiving perioperative blood transfusions is caused by the clinical circumstances requiring the transfusions, not by the blood transfusions themselves.     

Trends in the indications for and short-term outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

BackgroundCytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an increasingly utilized strategy for patients with peritoneal surface malignancies (PSM).MethodsThe US HIPEC Collaborative was retrospectively reviewed to compare the indications and perioperative outcomes of patients who underwent CRS ± HIPEC between 2000 and 2012 (P1) versus 2013–2017 (P2).ResultsAmong 2,364 patients, 39% were from P1 and 61% from P2. The most common primary site was appendiceal (64%) while the median PCI was 13 and most patients had CCR 0 (60%) or 1 (25%). Over time, median estimated blood loss, need for transfusion, and length of hospital stay decreased. While the incidence of any (55% vs. 57%; p = 0.426) and Clavien III/IV complications did not change over time, there was a decrease in 90-day mortality (5% vs. 3%; p = 0.045).ConclusionCRS-HIPEC is increasingly performed for PSM at high-volume centers. Despite improvements in some perioperative outcomes and a reduction in postoperative mortality, morbidity rates remain high.     

Thromboelastography-Based Transfusion Algorithm Reduces Blood Product Use after Elective CABG: A Prospective Randomized Study

Abstract   Objective: Bleeding and allogeneic transfusion remain constant problems in cardiac surgical procedures. In this study, we aimed to test the role of a routine thromboelastography (TEG)-based algorithm on bleeding and transfusions in patients undergoing elective coronary artery bypass grafting (CABG). Methods: Patients (n = 224) undergoing elective CABG with cardiopulmonary bypass were prospectively randomized into two groups according to transfusion strategy: in group 1 (clinician-directed transfusion, n = 110) need for blood transfusion was based on clinician's discretion and standard coagulation tests and in group 2 (TEG algorithm group, n = 114) kaolin-activated (k) TEG-based algorithm-guided perioperative transfusion management. Transfusion, blood loss, and outcome data were recorded.  Results: There were no differences in consumption of packed cell units, blood loss, re-exploration for bleeding, and early clinical outcome between the groups. Patients in the TEG group had significantly lower median units of fresh frozen plasma and platelets compared with the other group (p = 0.001). The median number of total allogeneic units transfused (packed cells and blood products) was significantly reduced in the TEG group compared with the other group (median 2, range 1–3 units vs. median 3, range 2–4 units, respectively, p = 0.001). The need for tranexamic acid was significantly diminished in the TEG group compared with the other group (10.3% vs. 19%, respectively, p = 0.007). Conclusion: Our results show that routine use of a kTEG-guided algorithm reduces the consumption of blood products in patients undergoing elective CABG. Adopting such an algorithm into routine management of these patients may help to improve clinical outcome and reduce the potential risks of transfusion-related complications and total costs after CABG.     

Clinical outcomes in cardiac surgery: conventional surgery versus bloodless surgery

Bleeding during and after cardiac operations and the effects of cardiopulmonary bypass hemodilution commonly result in blood transfusions. Excessive microvascular bleeding can result in re-exploration and prolonged hospitalization. Nearly 20% of all blood transfusions in the United States are associated with cardiac surgery. The risks associated with the use of allogeneic blood product transfusion include mistransfusion, immunologic complications, and transmission of infectious diseases. The large demand for blood products places significant pressure on the national blood supply, resulting in frequent shortages. The variability in transfusion practice of cardiac surgery patients suggests that sound blood management and a conservative approach to this population can result in reduced transfusions without increasing morbidity or mortality and avoiding complications associated with allogeneic blood transfusion.     

Considerations regarding major bleeding after cardiac transplantation

Postoperative bleeding is one of the most frequent complications after cardiac surgery, leading to longer stays in the intensive care unit (ICU) and the hospital as well as increased morbidity and mortality. We designed an observational prospective study to evaluate early complications after cardiac transplantation, focusing on major bleeding and transfusion requirements. We also evaluated whether massive transfusion was related to increased morbidity and mortality. In patients who received ≥6 blood units, we observed significant differences regarding the need for continuous renal replacement techniques (50% vs 12.5%; P=.01) and ICU mortality (33.3% vs 4%; P=.01). This difference in mortality was also observed when comparing plasma transfusion requirements (35.3% vs 9.4%; P=.04). The overall mortality rate was 24.50%, showing significant differences in patients with massive transfusion (83.3% vs 37.8%; P=.008). In conclusion, perioperative bleeding and massive transfusion were associated with increased morbidity and mortality in this group of patients, which may prompt a review of surgical procedures and the introduction of new techniques, such as thromboelastography.