Transfusion needs during intraoperative and immediate postoperative periods in arthroplasty of the hip and knee

OBJECTIVES: To determine the factors associated with immediate perioperative transfusion requirements of hip or knee arthroplasty patients who have not been enrolled in a blood salvage program. PATIENTS AND METHODS: This prospective study collected demographic (age, sex, weight, height, etc.), physiological (hemoglobin levels, coagulation times, preoperative platelet counts, etc.), clinical history and anesthetic and surgical data (type of anesthesia, surgical diagnosis, duration of procedure) in 112 patients undergoing orthopedic surgery: 19 cases of primary knee arthroplasty, 77 cases of hip arthroplasty and 16 replacements of hip arthroplasty. Logistic regression analysis of the aforementioned variables was performed to search for factors related to transfusional needs during and after hip arthroplasty or after knee arthroplasty, which was performed with a tourniquet applied to render intraoperative transfusion unnecessary. RESULTS: The variables that increased the risk of transfusion during surgery were duration of procedure exceeding 120 min (OR 15.24; p = 0.01) and loss of over 500 ml of blood during surgery (OR 11.4; p = 0.02). The variables associated with perioperative transfusion were loss of over 500 ml in the postanesthetic recovery room (OR 12.6; p < 0.0001), hypotensive episodes during recovery (OR 11.7; p = 0.0001), prosthetic replacement (OR 6.33; p = 0.005), height < 160 cm (OR 5.03; p = 0.02), preoperative hemoglobin level < 13.5 g/dl (OR 4.97; p = 0.02), and surgery for reasons other than osteoarthritis (arthritis, pathological fractures, etc.) (OR 4.60; p = 0.04). Variables associated with transfusion of over two units of packed red cells were a history of neoplastic disease unrelated to arthroplasty (OR 378.67; p = 0.005), prosthetic replacement (OR 49.71; p = 0.009), diabetes (OR 36.49; p = 0.02) and a hypotensive event while in the postanesthetic recovery room (OR 29.12; p = 0.02). CONCLUSION: These results suggest that certain modifiable factors increase the risk of blood transfusion in knee and hip arthroplasty. Specifically, they are duration of surgery, intra- and postoperative bleeding, preoperative hemoglobin level and instances of perioperative hypotension. Other factors outside our control are height or patient clinical history.     

Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths

OBJECTIVE: The authors report on the surgical techniques and protocol for perioperative care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hepatectomy results are analyzed with the aim of further reducing the postoperative morbidity rate. SUMMARY BACKGROUND DATA: In recent years, hepatectomy has been performed with a mortality rate of <10% in patients with HCC, but a zero hospital mortality rate in a large patient series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC have evolved yearly into a final standardized protocol that reduced the hospital mortality rate from 28% in 1989 to 0% in 1996 and 1997. METHODS: Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion, and ischemic injury to the liver remnant in hepatectomy. Postoperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutritional support that consisted of branched-chain amino acid-enriched solution, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed each year to assess the influence of the evolving surgical techniques and perioperative care on outcome. RESULTS: Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and chronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectively. There were no significant changes in the patient characteristics throughout the 9-year period, but there were significant reductions in intraoperative blood loss and blood transfusion requirements. From 1994 to 1997, the median blood transfusion requirement was 0 ml, and 64% of the patients did not require a blood transfusion. The postoperative morbidity rate remained the same throughout the study period. Complications in the patients operated on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, biliary leakage, and hepatic coma, were absent. By univariate analysis, the volume of blood loss, volume of blood transfusions, and operation time were correlated positively with postoperative morbidity rates in 1996 and 1997. Stepwise logistic regression analysis revealed that the operation time was the only parameter that correlated significantly with the postoperative morbidity rate. CONCLUSION: With appropriate surgical techniques and perioperative management to preserve function of the liver remnant, hepatectomy for HCC can be performed without hospital deaths. To improve surgical outcome further, strategies to reduce the operation time are being investigated.     

Surgical complications of graft nephrectomy in the modern transplant era

PURPOSE: Transplant nephrectomy has been considered a hazardous procedure throughout transplantation history. Better surgical techniques and clinical treatment of patients have improved the results of this surgery in the last decades. We report the surgical complications of nephrectomy of early and late failed kidneys performed at a referral center. MATERIALS AND METHODS: The charts of 70 consecutive patients who underwent graft nephrectomy between May 1994 and April 2002 were reviewed regarding surgical complications. Patients were divided into 2 groups according to the timing of graft removal. Early nephrectomy group 1 included 23 procedures performed in the first 60 days after transplantation and late nephrectomy group 2 included 47 performed after that interval. Groups were compared concerning outcome, blood loss and amount of blood transfused in the perioperative period, and the incidence of surgical complications according to the surgical technique, immunosuppressive regimen and timing of surgery. RESULTS: Mean blood loss was 434 ml (range 20 to 3,000) in group 1 and 546 (range 60 to 2,200) in group 2 (p = 0.02). Nine group 1 patients (39.1%) and 22 in group 2 (46.8%) received blood transfusion in the perioperative period (p = 0.62). The mean amount of blood transfused was 516.7 ml in group 1 and 436.3 ml in group 2 (p = 0.36). Four and 2 minor surgical complications occurred in groups 1 and 2 (17.4% and 4.3%, respectively, p = 0.09). Seven major complications were noted in group 2 (14.9%), while there were none in group 1 (p = 0.05). Three complications (25%) occurred in patients who received antirejection globulins or methylprednisolone and 1 (9.1%) developed when these agents were not administered (p = 0.33). The incidence of surgical complications after intracapsular and extracapsular nephrectomy was 20% and 17.6%, respectively (p = 0.58). Mean blood loss and the mean amount of blood transfused was 638 and 525 ml for intracapsular nephrectomy and 383 and 350 ml for extracapsular nephrectomy, respectively, respectively. Surgical complications occurred in 3 patients who received mycophenolate mofetil (23.1%) and in 6 (17.6%) who did not received this drug (p = 0.48). CONCLUSIONS: Blood loss and surgical complication rates were higher in late failed graft nephrectomies. Surgical complications in intracapsular vs extracapsular nephrectomies were similar but blood loss and transfusions were higher for intracapsular nephrectomy. Acute rejection treatment, or prophylaxis with methylprednisolone or globulins increased the incidence of surgical complications.     

Comparison of early oncologic results of laparoscopic radical prostatectomy by extraperitoneal versus transperitoneal approach

PURPOSE: Compare the early oncological results of laparoscopic radical prostatectomy performed by either an extraperitoneal or a transperitoneal approach. METHODS: 330 consecutive men underwent laparoscopic radical prostatectomy for localized prostate cancer, the first 165 by transperitoneal approach, and the last 165 by extraperitoneal approach. Clinical stage, serum PSA, Gleason score of biopsy were recorded, as well as operating time, surgical and medical complications, blood loss, length of hospital stay and catheterization time. The weight of the specimen, pathological stage (1997 TNM classification) and status of the surgical margins were noted. The Fisher test as well as the chi2-test were used for statistical analysis. Differences were considered significant when p < 0.05. RESULTS: There were no significant differences between the two groups in terms of preoperative characteristics except for Gleason score of the biopsies which was higher in the extraperitoneal group (p < 0.0001). The operating time was longer with the transperitoneal approach (248.5 min vs. 220.0 min, p < 0.0001). There was no difference in transfusion rate (1.2% vs. 5.4%, transperitoneal vs. extraperitoneal, respectively, p = 0.6). There was no difference in hospital stay, medical and surgical complications. Respectively, in the transperitoneal and extraperitoneal groups, there were 108 and 88 pT2 tumors. There were no differences in terms of positive surgical margins between the two groups, 23% and 29.7% (p = 0.21) overall, 13.0% and 17.0% (p = 0.42) in pT2 tumors and 43.6% and 44.7% (p = 0.99) in pT3 tumors. CONCLUSIONS: Extraperitoneal approach offers the same early oncological results as transperitoneal approach with a shorter operative time.     

Factors affecting blood loss during percutaneous nephrolithotomy: prospective study

BACKGROUND AND PURPOSE: Bleeding is a major concern during percutaneous nephrolithotomy (PCNL), especially with the use of multiple tracts. This prospective study aimed to identify factors affecting blood loss during PCNL. PATIENTS AND METHODS: Data were collected prospectively from 236 patients undergoing 301 PCNL procedures at our institute since June 2002. Blood loss was estimated by the postoperative drop in hemoglobin factored by the quantity of any blood transfusion. Various patient-related and intraoperative factors were assessed for association with total blood loss or blood transfusion requirement using stepwise multivariate regression analysis. RESULTS: The average hemoglobin drop was 1.68 +/- 1.23 g/dL. Stepwise multivariate regression analysis showed that the occurrence of operative complications (P < 0.0001), mature nephrostomy tract (P < 0.0001), operative time (P < 0.0001), method of access guidance (fluoroscopy v ultrasound) (P = 0.0001), method of tract dilatation (P = 0.0001), multiple (> or =2) tracts (P = 0.003), size of the tract (P = 0.001), renal parenchymal thickness (P = 0.05), and diabetes (P = 0.05) were significant predictors of blood loss. The overall blood transfusion rate for all patients was 7.9%. Preoperative hemoglobin, multiple tracts, stone size, and total blood loss were significant in predicting perioperative blood transfusion requirement. Factors such as age, hypertension, renal insufficiency, urinary infection, the degree of hydronephrosis, stone bulk, and the function of the ipsilateral renal unit did not have any effect on the blood loss. Technical factors such as the operating surgeon and the calix of entry also did not affect the blood loss. CONCLUSIONS: Diabetes, multiple-tract procedures, prolonged operative time, and the occurrence of intraoperative complications are associated with significantly increased blood loss. Atrophic parenchyma and past ipsilateral intervention are associated with reduced blood loss. On the basis of this evidence, maneuvers that may reduce blood loss and transfusion rate include ultrasound-guided access, use of Amplatz or balloon dilatation systems, reducing the operative time, and staging the procedure in cases of a large stone burden or intraoperative complications. Reducing the tract size in pediatric cases, nonhydronephrotic systems and those with a narrow infundibulum, and secondary tracts in a multiple-tract procedure may also reduce blood loss during PCNL.     

Early neurological complications after coronary artery bypass grafting and valve surgery in octogenarians.

OBJECTIVE: To determine the incidence and risk factors for neurological events complicating cardiac surgery, and the implications for operative outcome in octogenarians. METHODS: Of 6791 who underwent primary on-pump CABG and/or valve surgery from 1998 through 2006, 383 were aged > or =80 years. Neurological complications, classified as reversible or permanent, were investigated by head CT scan in patients who did not recover soon after an event. RESULTS: There were more females (47% vs 26%, p<0.0001) among octogenarians (n=383, median age 82 years) than among younger patients (n=6408, median age 66 years). Controlled heart failure, NYHA class III/IV and chronic obstructive pulmonary disease were more prevalent in octogenarians while preoperative myocardial infarction was predominant in younger patients. Octogenarians were at higher operative risk (median EuroScore 6 vs 2, p<0.0001). Operative procedures differed between octogenarians and younger patients (p<0.0001); respective frequencies were 45% vs 77% for CABG, 26% vs 10% for AVR, and 23% vs 6% for AVR+CABG. Mortality was higher for octogenarians (8.9% vs 2.1, p<0.0001). Early neurological complications observed in 3.9% of the entire study population were mostly reversible (3.2%). Age > or =80 years (odds ratio [OR] 2.82, 95% confidence interval [CI] 1.89-4.21, p<0.0001), prior cerebrovascular disease (OR 2.23, 95% CI 1.56-3.18, p<0.0001), AVR+CABG (OR 2.92, 95% CI 1.60-5.33, p<0.0001) and MVR+CABG (OR 4.77, 95% CI 2.10-10.85, p<0.0001) were predictive of neurological complications. More octogenarians experienced neurological events (p<0.0001): overall 12.8% vs 3.4%, reversible 11.5% vs 2.8%, permanent 1.3% vs 0.6%. Among octogenarians, neurological complication was associated with elevated operative mortality (18% vs 8% for those without neurological complication, p=0.03), and prolonged ventilation, intensive care stay and hospitalisation. Predictors of neurological complications in octogenarians were blood and/or blood product transfusion (OR 3.60, 95% CI 1.56-8.32, p=0.003) and NYHA class III/IV (OR 7.6, 95% CI 1.47-39.70, p=0.02). CONCLUSION: Octogenarians undergoing on-pump CABG and/or valve repair/replacement are at higher risk of neurological dysfunction, from which the majority recover fully. The adverse implications for operative mortality and morbidity, however, are profound. Blood product transfusion which has a powerful correlation with neurological complication should be reduced by rigorous haemostasis with parsimonious use of sealants when appropriate.     

Allogenic blood transfusion in the first 24 hours after trauma is associated with increased systemic inflammatory response syndrome (SIRS) and death

BACKGROUND: Previous studies have documented that blood transfusion incites a substantial inflammatory response with the systemic release of cytokines. Furthermore, blood transfusion is a significant independent predictor of multiple organ failure in trauma. The objective of this study was to assess the risk of systemic inflammatory response syndrome (SIRS) and intensive care unit (ICU) admission, length of stay (LOS), and mortality in trauma patients who require blood transfusion. METHODS: Prospective data were collected on 9,539 trauma patients admitted to the R. Adams Cowley Shock Trauma Center over a 30-month period from January, 1997 to July, 1999. Complete SIRS data were available on 7,602 patients. Patients were stratified by age, gender, race, Glasgow coma scale (GCS), and injury severity score (ISS). A systemic inflammatory response to a wide variety of severe clinical insults (SIRS) was defined as a SIRS score of > or =2, as calculated on admission. Blood transfusion was assessed as an independent predictor of SIRS, ICU admission and length of stay, and mortality. RESULTS: The mean age of the study cohort was 37 +/- 17 years; the mean ISS was 9 +/- 9 points. Seventy-one percent of the patients were male, and 85% sustained blunt trauma. Blood transfusion within the first 24 h was administered to 954 patients, comprising 10% of the study cohort. Transfused patients were significantly older (43 +/- 20 vs. 36 +/- 16 years, p < 0.00001), had higher ISS (22 +/- 12 vs. 8 +/- 7 points, p < 0.00001), and lower GCS (12 +/- 4 vs. 14 +/- 2 points, p < 0.00001) than non-transfused patients. Blood transfusion and increased total volume of blood transfusion was associated with SIRS. Blood transfusion was also a significant independent predictor of SIRS, ICU admission, and mortality in trauma patients by multinomial logistic regression analysis. Trauma patients who received blood transfusion had a two- to nearly sixfold increase in SIRS (p < 0.0001) and more than a fourfold increase in ICU admission (OR 4.62, 95% CI 3.84-5.55, p < 0.0001) and mortality (OR 4.23, 95% CI 3.07-5.84, p < 0.0001) compared to those that were not transfused. Linear regression analysis revealed that transfusion was an independent predictor of ICU LOS (Coef. 5.20, SE 0.43, p < 0.0001). Transfused patients had significantly longer ICU LOS (16.8 +/- 14.9 vs. 9.9 +/- 10.6 days, p < 0.00001) and hospital LOS (14.5 +/- 15.5 vs. 2.5 +/- 5.3 days, p < 0.00001) compared to non-transfused patients. CONCLUSIONS: Blood transfusion within the first 24 h was an independent predictor of mortality, SIRS, ICU admission, and ICU LOS in trauma patients. The use of blood substitutes and alternative agents to increase serum hemoglobin concentration in the post-injury period warrants further investigation.     

Liver resection for hepatocellular carcinoma in patients with cirrhosis

BACKGROUND: Although liver resection is now a safe procedure, its role for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial. METHODS: This study compared the results of liver resection for HCC in patients with cirrhosis over two time intervals. One hundred and sixty-one patients had resection during period 1 (1991-1996) and 265 in period 2 (1997-2002). Early and long-term results after liver resection in the two periods were compared, and clinicopathological characteristics that influenced survival were identified. RESULTS: Tumour size was smaller, indocyanine green retention rate was higher, patients were older and a greater proportion of patients were asymptomatic in period 2 than period 1. Operative blood loss, need for blood transfusion, operative mortality rate, postoperative hospital stay and total hospital costs were significantly reduced in period 2. The 5-year disease-free survival rates were 28.2 and 33.9 per cent in periods 1 and 2 respectively (P = 0.042), and 5-year overall survival rates were 45.9 and 61.2 per cent (P < 0.001). Multivariate analysis identified serum alpha-fetoprotein level, need for blood transfusion and Union Internacional Contra la Cancrum tumour node metastasis stage as independent determinants of disease-free and overall survival. CONCLUSION: The results of liver resection for HCC in patients with cirrhosis improved over time. Liver resection remains a good treatment option in selected patients with HCC arising from a cirrhotic liver.     

Decreasing blood loss in patients treated with radical cystectomy: a prospective randomizes trial using a new stapling device

PURPOSE: Radical cystectomy has been associated with significant blood loss and the need for heterologous transfusion. We investigated the potential decrease in blood loss and/or in transfusion requirement using a new stapling device compared with the traditional suture ligation technique. MATERIALS AND METHODS: We prospectively examined 70 patients with urothelial carcinoma who were scheduled for radical cystectomy. Each patient was randomized to traditional suture ligation or the Compact Flex Articulating Linear Cutter (Ethicon Endo-Surgery, Cincinnati, Ohio) stapling device. The 2 groups were prospectively compared with respect to estimated blood loss, transfusion requirement, operative time and complications. RESULTS: The groups were equivalent in terms of demographic and clinical variables, indicating that randomization produced 2 comparable groups. The stapler group had significantly lower estimated blood loss during cystectomy (p = 0.007) and during the whole procedure (p = 0.02). This group also required fewer transfusions (p = 0.006) and fewer mean units transfused (p = 0.003). The overall transfusion rate was 20% (14 of 70 cases). All patients in the stapler group had lower estimated blood loss and transfusion requirements. There was no statistical difference in time needed for bladder removal (p = 0.91) or total operative time (p = 0.17). No complications were attributable to the stapler device. CONCLUSIONS: In this prospective randomized study the stapling device significantly decreased blood loss and the transfusion requirement during radical cystectomy. These significant advantages combined with its relative safety make it an attractive surgical option and argue in favor of continued strategic attempts to decrease blood loss during radical cystectomy.     

Effect of Pleurotomy on Blood Loss During Coronary Artery Bypass Grafting

Abstract   Background: We conducted a retrospective study to compare two different techniques of internal mammarian artery (IMA) preparation concerning pleurotomy upon the effects of blood loss and pulmonary functions. Methods: Between January 1998 and November 2006, 1357 consecutive patients undergoing coronary artery bypass grafting (CABG) using the left IMA, either alone or in combination with saphenous vein graft, were included in this study. The patients were divided into two groups according to the pleural opening: Group I (n = 1046) patients underwent IMA harvesting with pleurotomy and Group 2 (n = 311) patients with intact pleura. Results: During the study, 27 hospital deaths (1.9%) occurred. The amount of postoperative blood loss and blood transfusion requirements were significantly higher in Group 1 than in Group 2 (p = 0.029 and p = 0.0001). The mechanical ventilation stay was significantly higher in Group 1 than in Group 2 (p = 0.0001). The incidence of left pleural effusion and atelectasis was significantly higher in Group 1 than in Group 2 on day 1 and day 3 after operation. Conclusions: These results demonstrate that preserving pleural integrity has beneficial effects on the postoperative blood loss. Postoperative blood loss and transfusion requirements were higher in patients with pleurotomy. Left pleural effusion, atelectasis, and mechanical ventilatory stay were significantly reduced in patients with preserved pleural integrity.     

A clinical calculator for predicting intraoperative blood loss and transfusion risk in spine tumor patients

BACKGROUND CONTEXTSurgery for vertebral column tumors is commonly associated with intraoperative blood loss (IOBL) exceeding 2 liters and the need for transfusion of allogeneic blood products. Transfusion of allogeneic blood, while necessary, is not benign, and has been associated with increased rates of wound complication, venous thromboembolism, delirium, and death.PURPOSETo develop a prediction tool capable of predicting IOBL and risk of requiring allogeneic transfusion in patients undergoing surgery for vertebral column tumors.STUDY DESIGN/SETTINGRetrospective, single-center study.PATIENT SAMPLEConsecutive series of 274 patients undergoing 350 unique operations for primary or metastatic spinal column tumors over a 46-month period at a comprehensive cancer centerOUTCOME MEASURESIOBL (in mL), use of intraoperative blood products, and intraoperative blood products transfused.METHODSWe identified IOBL and transfusions, along with demographic data, preoperative laboratory data, and surgical procedures performed. Independent predictors of IOBL and transfusion risk were identified using multivariable regression.RESULTSMean age at surgery was 57.0±13.6 years, 53.1% were male, and 67.1% were treated for metastatic lesions. Independent predictors of IOBL included en bloc resection (p<.001), surgical invasiveness (β=25.43 per point; p<0.001), and preoperative albumin (β=?244.86 per g/dL; p=0.011). Predictors of transfusion risk included preoperative hematocrit (odds ratio [OR]=0.88 per %; 95% confidence interval [CI, 0.84, 0.93]; p<0.001), preoperative MCHgb (OR=0.88 per pg; 95% CI [0.78, 1.00]; p=0.048), preoperative red cell distribution width (OR=1.32 per %; 95% CI [1.13, 1.55]; p<0.001), en bloc resection (OR=3.17; 95%CI [1.33, 7.54]; p=0.009), and surgical invasiveness (OR=1.08 per point; [1.06; 1.11]; p<0.001). The transfusion model showed a good fit of the data with an optimism-corrected area under the curve of 0.819. A freely available, web-based calculator was developed for the transfusion risk model (https://jhuspine3.shinyapps.io/TRUST/).CONCLUSIONSHere we present the first clinical calculator for intraoperative blood loss and transfusion risk in patients being treated for primary or metastatic vertebral column tumors. Surgical invasiveness and preoperative microcytic anemia most strongly predict transfusion risk. The resultant calculators may prove clinically useful for surgeons counseling patients about their individual risk of requiring allogeneic transfusion.     

Hepatic resection for large hepatocellular carcinoma.

BACKGROUND: Long-term survival and prognostic factors after hepatic resection for large hepatocellular carcinoma (HCC) remain to be proved. METHODS: The surgical outcome in 133 consecutive patients with HCC in diameter of > or = 5 cm (large HCC; L group) undergoing hepatic resection was retrospectively clarified and compared with that of 253 patients with HCC in diameter of < 5 cm (small HCC; S group). Postresection prognostic factors were evaluated by univariate and multivariate analysis using Cox's proportional hazards model. RESULTS: The disease-free 3- and 5-year survival rates between L group and S group were 26% versus 42% and 20% versus 25%, respectively (P = 0.0032). The overall 3- and 5-year survival rates between L group and S group were 38% versus 67% and 28% versus 47%, respectively (P < 0.0001). Multivariate analysis revealed that large amount of intraoperative blood transfusion was an independently significant factor of poor disease-free and overall survivals. CONCLUSIONS: Long-term survival in patients with large HCC remains unsatisfactory compared with that in patients with non-large HCC. Restriction of intraoperative blood transfusion may play an important role in the improvement of survival and recurrence in such patients.     

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.     

Intraoperative Iatrogenic Rupture of Hepatocellular Carcinoma

Intraoperative iatrogenic rupture of hepatocellular carcinoma (HCC), which can occur during hepatic resection when large tumors are being mobilized, may adversely affect the operative outcome. Little information is available in the literature on this serious intraoperative complication. The aim of the present study is to document iatrogenic rupture of HCC as a serious complication during hepatic resection and its effects on the operative and long-term outcomes of patients with this complication. A retrospective study was performed on all patients with intraoperative iatrogenic rupture of HCC during hepatic resection from 1989 to 1997, and the operative and long-term survival outcomes were compared with those of patients without the complication. Among 194 patients who underwent hepatic resection for a large HCC (> or =5 cm) during the study period, 8 (4.1%) had intraoperative iatrogenic rupture of the tumor. When compared with 186 patients with similar clinical parameters but without intraoperative rupture, patients with intraoperative rupture had significantly more intraoperative blood loss (median 5.7 vs. 2.0 L;p = 0.01) and blood transfusion requirement (median 3.1 vs 0.9 L; p = 0.02). On follow-up, patients in the intraoperative rupture group had a significantly higher intraperitoneal extrahepatic recurrence rate (33.3% vs. 2.9%; p =0.02) and significantly shorter survival (median 11.5 vs. 37.9 months,p = 0.04) when compared with patients without the complication. Intraoperative iatrogenic rupture is a serious complication of hepatic resection for HCC because it is associated with increased intraoperative blood loss, increased incidence of intraperitoneal extrahepatic recurrence, and short survival. Extreme care should be taken during mobilization of the tumor, and an alternative operative approach in the presence of a difficult hepatic resection of a large HCC may be required to avoid the complication.     

Analysis of early complications after radical cystectomy: results of a collaborative care pathway

PURPOSE: We examined our recent series of patients who underwent radical cystectomy to determine and analyze the early perioperative morbidity of the procedure in a contemporary series treated with the guidance of a clinical pathway. MATERIALS AND METHODS: We reviewed the records of 304 consecutive patients who underwent radical cystectomy from December 1995 to July 2000. We specifically evaluated complications that developed within 30 days of the procedure. Potential variables predictive of early morbidity were analyzed, including patient age, gender, race, American Society of Anesthesiologists score, type of urinary diversion, smoking history, estimated blood loss, transfusion requirement, pathological stage and operative time. RESULTS: The overall minor complication rate was 30.9% (94 of 304 patients). Postoperative ileus was the most common minor complication, affecting 54 patients (18%). Increased blood loss and major complications predicted a significantly higher likelihood of ileus on multivariate analysis (p = 0.02 and 0.001, respectively). Major complications in 15 patients (4.9%) correlated with higher American Society of Anesthesiologists score, surgical intensive care unit admission and transfusion requirement (p = 0.01, <0.001 and 0.001, respectively). The early mortality rate was 0.3% (1 patient). CONCLUSIONS: Within the framework of a clinical pathway, radical cystectomy can be performed safely with an acceptable rate of early minor and major complications. Delay in the return of bowel function is the most common minor complication. Increased estimated blood loss, transfusion requirement and a major complication predicted a higher likelihood of postoperative ileus. The acceptable rate of early morbidity in this series in a 5-year period validates its use in patients undergoing radical cystectomy.     

Role of anemia in traumatic brain injury

BACKGROUND: Few studies have investigated the effects of anemia in patients with traumatic brain injury (TBI). The objective of this study was to examine the role of anemia and blood transfusion on outcomes in TBI patients. STUDY DESIGN: We performed a retrospective review of all blunt trauma patients with TBI admitted to the ICU from July 1998 to December 2005. Admission and daily ICU blood hemoglobin (hemoglobin) levels and blood transfusions during the first week of hospitalization were measured. Anemia was defined as a hemoglobin<9 g/dL occurring on 3 consecutive blood draws. The role of anemia and blood transfusion was investigated using logistic regression adjusting for factors, with p<0.2 from the bivariate analysis. RESULTS: During the study period, 1,150 TBI patients were admitted to the ICU. When both anemia and blood transfusion were included in the full model, blood transfusion was significantly associated with higher mortality (adjusted odds ratio [AOR], 2.19 [95% CI, 1.27, 3.75]; p=0.0044) and more complications (AOR, 3.67 [95% CI, 2.18, 6.17]; p<0.0001), but anemia was not. But when transfusion was not included in the full model, anemia was a significant risk factor for mortality (AOR, 1.59 (95% CI, 1.13, 2.24); p=0.007) and for complications (AOR, 1.95 [95% CI, 1.42, 2.70]; p<0.0001). CONCLUSIONS: Blood transfusion is associated with significantly worse outcomes in traumatic brain injured patients. In addition, blood transfusion is a major contributing factor to worse outcomes in TBI patients who are anemic. We caution against the liberal use of blood in TBI patients.     

Transfusion increases the risk of postoperative infection after cardiovascular surgery

BACKGROUND: Because of the immunomodulatory effects of transfusion, we attempted to identify factors associated with blood product use and determine the association of transfusion quantity with postoperative infection. STUDY DESIGN: We studied total perioperative transfusion of blood products for 15,592 cardiovascular operations performed from July 1998 to May 2003. Infection end points were septicemia/bacteremia (n=351, 2.2%) and superficial (n=353, 2.3%) and deep (n=212, 1.4%) sternal wound infections. Factors associated with blood product administration were used to form balancing scores to adjust for differences in patient characteristics among those receiving and not receiving blood products. RESULTS: Fifty-five percent of patients received packed red blood cells (RBC), 21% received platelets, 13% got fresh frozen plasma (FFP), and 3% got cryoprecipitate. Factors associated with RBC use included older age, female gender, higher New York Heart Association class, lower hematocrit, reoperation, and longer cardiopulmonary bypass time--all indicative of higher-risk patients. The more RBC units transfused, the higher was the occurrence of septicemia/bacteremia (p < 0.0001) and superficial (p=0.0007) and deep (p < 0.0001) sternal wound infection. Use of FFP (septicemia/bacteremia) and platelets (septicemia/bacteremia and deep sternal wound infection) mitigated against this association only slightly. CONCLUSIONS: Blood products tended to be used in the sickest patients. But after accounting for this, risk of infection increased incrementally with each unit of blood transfused. Although cause and effect cannot be established, results suggested that blood product transfusion is an independent risk factor for postoperative infection in cardiac surgical patients, blood products are more likely to be used in the sickest patients, and no amount of blood loss treated by transfusion is innocuous.     

Is perioperative blood transfusion a risk factor for mortality or infection after hip fracture?

OBJECTIVES: To assess whether allogeneic blood transfusion in the perioperative period is associated with changes in mortality or complication rates in patients undergoing surgical treatment for hip fracture (proximal femoral fracture). DESIGN: Retrospective case-control series, all patients followed up for 1 year or until death. SETTING: District General Hospital in Peterborough, UK. PATIENTS PARTICIPANTS: Three thousand six hundred twenty-five consecutive patients admitted and operated for hip fracture (proximal femoral fracture) during July 1989 to January 2002 (151 months); 1068 (29.9%) received a perioperative allogeneic blood transfusion. MAIN OUTCOME MEASURES: Thirty- 120-, and 365-day mortality, deep and superficial wound infection rates. RESULTS: Overall mortality for all patients at 1 year post fracture was 28.2% (1007 patients). Transfusion was associated with a statistically significant increase in mortality from 120 days onward after hip fracture. However, when this was adjusted with a statistical regression model for baseline characteristics and confounding variables, this difference became statistically insignificant (P = 0.17). Infection rates in the transfusion group were 2.0% for superficial infection and 0.9% for deep infection compared with 1.9% and 0.6%, respectively, in the nontransfusion group. These figures were not statistically significantly different. Other complications of deep venous thrombosis, chest infection, and congestive cardiac failure showed no statistically significant increase in those patients who received transfusion. CONCLUSIONS: Our data suggest that transfusion is not associated with a change in mortality or infection rates in the hip-fracture patient.     

Blood transfusion is an independent predictor of increased mortality in nonoperatively managed blunt hepatic and splenic injuries

BACKGROUND: Management strategies for blunt solid viscus injuries often include blood transfusion. However, transfusion has previously been identified as an independent predictor of mortality in unselected trauma admissions. We hypothesized that transfusion would adversely affect mortality and outcome in patients presenting with blunt hepatic and splenic injuries after controlling for injury severity and degree of shock. METHODS: We retrospectively reviewed records from all adults with blunt hepatic and/or splenic injuries admitted to a Level I trauma center over a 4-year period. Demographics, physiologic variables, injury severity, and amount of blood transfused were analyzed. Univariate and multivariate analysis with logistic and linear regression were used to identify predictors of mortality and outcome. RESULTS: One hundred forty-three (45%) of 316 patients presenting with blunt hepatic and/or splenic injuries received blood transfusion within the first 24 hours. Two hundred thirty patients (72.8%) were selected for nonoperative management, of whom 75 (33%) required transfusion in the first 24 hours. Transfusion was an independent predictor of mortality in all patients (odds ratio [OR], 4.75; 95% confidence interval [CI], 1.37-16.4; p = 0.014) and in those managed nonoperatively (OR, 8.45; 95% CI, 1.95-36.53; p = 0.0043) after controlling for indices of shock and injury severity. The risk of death increased with each unit of packed red blood cells transfused (OR per unit, 1.16; 95% CI, 1.10-1.24; p < 0.0001). Blood transfusion was also an independent predictor of increased hospital length of stay (coefficient, 5.45; 95% CI, 1.64-9.25; p = 0.005). CONCLUSION: Blood transfusion is a strong independent predictor of mortality and hospital length of stay in patients with blunt liver and spleen injuries after controlling for indices of shock and injury severity. Transfusion-associated mortality risk was highest in the subset of patients managed nonoperatively. Prospective examination of transfusion practices in treatment algorithms of blunt hepatic and splenic injuries is warranted.     

Systematic Review and Meta-analysis of Perioperative Outcomes and Complications After Robot-assisted Radical Prostatectomy

Context

Perioperative complications are a major surgical outcome for radical prostatectomy (RP).

Objective

Evaluate complication rates following robot-assisted RP (RARP), risk factors for complications after RARP, and surgical techniques to improve complication rates after RARP. We also performed a cumulative analysis of all studies comparing RARP with retropubic RP (RRP) or laparoscopic RP (LRP) in terms of perioperative complications.

Evidence acquisition

A systematic review of the literature was performed in August 2011, searching Medline, Embase, and Web of Science databases. A free-text protocol using the term radical prostatectomy was applied. The following limits were used: humans; gender (male); and publications dating from January 1, 2008. A cumulative analysis was conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK).

Evidence synthesis

We retrieved 110 papers evaluating oncologic outcomes following RARP. Overall mean operative time is 152 min; mean blood loss is 166 ml; mean transfusion rate is 2%; mean catheterization time is 6.3 d; and mean in-hospital stay is 1.9 d. The mean complication rate was 9%, with most of the complications being of low grade. Lymphocele/lymphorrea (3.1%), urine leak (1.8%), and reoperation (1.6%) are the most prevalent surgical complications. Blood loss (weighted mean difference: 582.77; p < 0.00001) and transfusion rate (odds ratio [OR]: 7.55; p < 0.00001) were lower in RARP than in RRP, whereas only transfusion rate (OR: 2.56; p = 0.005) was lower in RARP than in LRP. All the other analyzed parameters were similar, regardless of the surgical approach.

Conclusions

RARP can be performed routinely with a relatively small risk of complications. Surgical experience, clinical patient characteristics, and cancer characteristics may affect the risk of complications. Cumulative analyses demonstrated that blood loss and transfusion rates were significantly lower with RARP than with RRP, and transfusion rates were lower with RARP than with LRP, although all other features were similar regardless of the surgical approach.