Conditions that increase the risk of cesarean-related blood transfusions: a single-center cohort study

Objective This study aimed to define the conditions that increase the possibility of receiving a blood transfusion in patients who had a cesarean section. Methods This study was conducted between January 2016 – May 2020 in a university hospital located in Konya, Turkey. Pregnant women undergoing cesarean section were included. Of 4303 eligible patients, 188 women were the transfused group and 4115 women were the non-transfused group. Logistic regression analysis was performed for potential confounding factors. Results A total of 4303 eligible patients were evaluated in this study. There were 4115 patients (95.6%) in the non-transfused group. The transfused group consisted of 188 patients (4.4%). The probability of transfusion was higher in pregnant women with placenta previa, placenta accreta spectrum, thrombocytopenia, preoperative anemia, macrosomia above 4500 g, and multiple gestations [adjusted OR values (95% CI); 10.58 (range 4.75–23.57), 7.75 (range 3.22–18.61), 7.85 (range 3.46–17.79), 5.71 (range 4.21–7.74), 4.22 (range 1.21-14.67) and 2.10 (range 1.18-3.72), respectively]. There was no increase in the possibility of transfusion in 4000–4500 gram macrosomia, uterine fibroids, preeclampsia, premature rupture of membranes, previous cesarean sections and gestational diabetes mellitus. Conclusion Placenta previa, placenta accreta spectrum, thrombocytopenia, preoperative anemia, macrosomia above 4500 g and multiple gestations increase the possibility of transfusion. Perioperative blood preparation is vital in such patients. Prevention of anemia during pregnancy is critical in reducing transfusions.

Impact of anemia on outcomes in on-pump coronary artery bypass surgery patients

Aim To study the contribution of preoperative anemia to the prognosis of adverse clinical events (mortality, complications, transfusion) in patients with ischemic heart disease (IHD) after myocardial revascularization in the conditions of artificial circulation.Material and methods This retrospective cohort study included 1 133 patients with IHD who had undergone isolated myocardial revascularization in the conditions of artificial circulation in 2019. The primary endpoints were mortality and a composite endpoint that included, in addition to mortality, cases of acute coronary syndrome, heart, respiratory and renal failure, neurological deficit, and infectious complications. The secondary endpoints were duration of artificial ventilation of more than 12 h, duration of stay in the resuscitation and intensive care unit (RICU) of more than one day, and duration of postoperative inpatient treatment of more than 7 days. Results Preoperative anemia was found in 196 (17.3 %) patients. The anemia was not associated with mortality but increased the risk of the composite endpoint, prolonged artificial ventilation, stay in RICU for more than one day, and red blood cell transfusion. Despite the absence of a relationship between red blood cell transfusion and mortality, the use of transfusion was associated with increased risks of the composite endpoint and prolonged stay in the RICU and hospital.Conclusion Preoperative anemia is a risk factor for adverse outcomes of myocardial revascularization in the conditions of artificial circulation. Timely treatment of preoperative anemia may improve outcomes of the treatment.

Efficacy of Ninjin’yoeito for Preoperative Anemia, Fatigue, and Anxiety in Patients with Gynecological Disease: an Open-Label, Single-Center, Randomized Phase-II Trial.

Background: Preoperative anemia affects perioperative outcomes and often causes fatigue and psychological disorders. Therefore, anemia should be treated before a patient undergoes surgery. Ninjin’yoeito (NYT), a Japanese Kampo medicine composed of ginseng and Japanese angelica root with the other 10 herbs, is administered for anemia, fatigue and anxiety; however, there are a few reports that have prospectively examined the effects of NYT before surgery for gynecological diseases. Hence, we tended to investigate its efficacy and safety.Methods: In this open-label randomized trial, women with gynecological diseases accompanied by preoperative anemia (defined as <11.0 g/dL Hemoglobin [Hb]) were randomly assigned (1:1) into the iron supplementation and NYT groups. Patients of the iron supplementation group and the NYT group received 100 mg/day iron supplementation with and without NYT (7.5 g/day) for at least 10 days before surgery. The primary endpoint was improvement in Hb levels before and after treatment, and Cancer Fatigue Scale (CFS) and Visual Analogue Scale for Anxiety (VAS-A) scores between groups. Statistical analyses were performed with Wilcoxon signed rank test, Wilcoxon rank sum test, and Fisher’s exact test as appropriate.Results: 40 patients were enrolled of whom 30 patients were finally analyzed after allocating 15 to each group. There was no difference in the characteristics between both groups. Hb significantly increased in both groups (iron supplementation group, 9.9 ± 0.8 g/dL vs. 11.9 ± 1.6 g/dL; NYT group, 9.8 ± 1.0 g/dL vs. 12.0 ± 1.0 g/dL); the difference in the elevations in Hb between both groups was statistically insignificant (P = 0.72). Contrarily, CFS (17.9 ± 10.2 vs. 8.1 ± 5.2) and VAS-A (56 mm (50–70) vs. 23 mm (6–48)) scores were significantly decreased only in the NYT group and these changes were greater in the NYT group (∆CFS, P = 0.015; ∆VAS-A, P = 0.014). Liver dysfunction occurred in one patient of the NYT group.Conclusions: For treating preoperative anemia in women with gynecological conditions, NYT administration along with iron supplementation safely and efficiently improved the preoperative anemia, fatigue and anxiety.Trial registration: jRCT1051190012 (28/April/2019, retrospectively registered).

Evaluation of anemia as a postoperative risk factor in the evolution of patients with gastric resection for malignancies

Introduction. Gastric cancer remains among the top three digestive diseases with the highest mortality rates in the world. Treatment of gastric cancer is multidisciplinary, gastric resection being essential for the best result. Anemia is one of the most common comorbidities present in patients diagnosed with gastric cancer. Materials and Methods. This is a retrospective analytical study over a period of 6 years (2014-2019). It is based on 114 consecutive gastric resections for cancer performed by a single team using exclusively resection and reconstruction stapling methods. The study aims to investigate a correlation between the presence of preoperative anemia and the incidence of postoperative morbidity and mortality. Results. Preoperative anemia was found in 70% of patients, with about half of these patients presenting with mild anemia. Most postoperative complications were grade I and II according to the Clavien Dindo scale. Anemia was correlated with an increase in infectious complications, anastomotic leaks and secondary peritoneal abscesses, pancreatic complications after multivisceral resection and length of hospital stay. Conclusions. Preoperative anemia is a risk factor that exposes the cancer patient to an increased incidence of life-threatening postoperative complications. In addition, it also extends the length of hospital stay and costs. Therefore, special attention should be paid to the identification and reduction of anemia before extensive gastric surgery in order to obtain the best possible therapeutic result.

Preoperative Hemoglobin Optimization in Jehovah's Witness Cardiovascular Surgery Patients with Anemia and Barriers to Care

Cardiac surgery has a risk for extensive blood loss which poses a particular challenge in individuals refusing blood transfusions. Additionally, preoperative anemia with a hemoglobin (Hb) below 13 g/dL in men and 12 g/dL in women is associated with increased short and long-term complications and mortality and increases the need for blood transfusion support. The current guidelines for perioperative anemia management recommend optimizing hemoglobin levels prior to surgery and utilizing blood conservation techniques during the procedure. At present red blood cell (RBC) transfusions during cardiac surgery are usually recommended when Hb levels are below 7-8 g/dL a restrictive transfusion strategy to reduce complications. However, the use of any RBC transfusions is associated with worse outcomes in cardiac surgery compared with those who do not receive transfusions. We have found that JW seek out quality health care and accept the vast majority of medical treatments once they are educated. The Transfusion Free Medicine Coordinator's role in the Anemia Clinic is to endorse clinical strategies for managing hemorrhage and anemia without blood transfusion. They educate and counsel the patients so they can decide as to what blood fractions and cell salvage techniques they will accept. We have found that some Health Care Providers are unaware that ESAs also contain albumin so JW patients may be given this product without that knowledge. The vast majority of patients will accept the use of ESAs but find the cost prohibitive. Jehovah's Witness patients have provided a natural case study for examining how well adjuvant therapies can improve preoperative anemia without transfusions and continue with good outcomes. Hb optimization is achieved through the use of intravenous iron and, if needed, erythropoiesis stimulating agents (ESAs). In Table 1 we highlight our single center data in which all cardiovascular surgeries were performed by a surgeon experienced in blood-conservation strategies. Our thirty-day re-admission rates for all patients was zero percent, compared to state-specific data, which estimates about an 11.7% rate of re-admission. The data illustrate the need to have a target Hb 13 or above to allow for the decline that may occur during the hospital stay. Of note no thromboembolic events have occurred with the use of an ESA in this group. Although ESAs are approved to optimize Hb in orthopedic surgery, they are not covered for cardiac surgery which has presented a significant challenge to patients who can not safely proceed to surgery until a target Hb between 13 to 15 g/dL is achieved. These data highlight the utility and safety associated with the use of ESAs for patients who do not accept blood products at an experienced Center for Transfusion-Free Medicine, such as ours. At this time, since insurance companies do not cover the cost of ESAs for patients needing life-saving cardiovascular operations, cost is a prohibitive barrier for patients. Unfortunately, it is not uncommon for patients to have to borrow money from others or set up payment plans. We hope that analyses like ours will help drive changes in reimbursement policies, particularly for patients who based on religious convictions, cannot receive blood products, and thus for whom pre-operative hemoglobin optimization is of utmost importance. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Erythropoiesis-stimulating agent (ESA) are indicated for the treatment of anemia due to Chronic Kidney Disease in patients on dialysis and not on dialysis, Zidovudine in patients with HIV-infection, anemia due to myelosuppressive chemotherapy and reduction of allogeneic RBC transfusions in patients undergoing elective, noncardiac, nonvascular surgery

Perioperative Anemia Management in Women Undergoing Gynecologic Procedures: A 10 Year Multisite Study

Background Preoperative anemia is a known risk factor for adverse patient outcomes. In women undergoing gynecologic surgery, preoperative anemia is independently associated with increased 30-day mortality, surgical complications, and hospital re-admission. Women with abnormal uterine bleeding and women undergoing gynecologic surgery remain under-studied and over-transfused. Patient blood management (PBM) initiatives are emerging from growing awareness of adverse outcomes associated with preoperative anemia. PBM efforts involve optimizing red cell mass and limiting unnecessary red blood cell (RBC) transfusions, with the goal of improving outcomes. Iron deficiency is a common cause of anemia in women with gynecologic sources of blood loss, and early identification and repletion of iron stores is an important component of PBM. Our research evaluated perioperative RBC utilization and intravenous (IV) iron use in women undergoing gynecologic procedures at three large academic hospitals. Methods This retrospective cohort study used data from the Transfusion Registry for Utilization Surveillance and Tracking database, a multihospital database network in Ontario, Canada. Canadian Classification of Health Interventions codes were used to identify women aged 15 and older who underwent gynecologic surgery with a hospital admission between January 1, 2010 and December 31, 2019 at three academic hospitals. Patients undergoing gynecologic surgery with malignant and non-malignant conditions were included. Patients who were pregnant and immediately postpartum were excluded. Collected data included patient demographics, laboratory investigations, RBC utilization, IV iron use, hospital length of admission, intensive care unit (ICU) admission, and in-hospital mortality. Data was collected from 90 days prior to gynecologic surgery to 30 days post gynecologic surgery. Only the first gynecologic surgery per patient was included in the analysis. Patients with an underlying malignancy were analyzed separately from patients without a malignancy diagnosis. Results A total of 4,822 patients with a gynecologic surgery were identified during the study period, with 4,842 hospital admissions. 3,687 patients had a malignancy diagnosis. We identified that 27.3% of all gynecologic surgery patients were anemic (hemoglobin (Hb) &lt;120 g/L) on preoperative bloodwork. In the malignancy group, 798 patients (21.6%) received at least 1 unit RBC in the perioperative period, with 2.9% transfused in the 90 days prior to surgery, 12.6% transfused on the day of surgery, and 13.0% transfused within 30 days post-surgery. Of the non-malignancy patients, 58 patients (5.1%) had at least 1 unit RBC in the perioperative period, with 0.8% transfused in the 90 days prior to surgery, 1.9% transfused on the day of surgery, and 3.4% transfused within 30 days post-surgery (Table 1). Only 0.6% of patients in the malignancy group and 0.4% of patients in the non-malignancy group received IV iron in the perioperative period. Patients with a preoperative Hb&lt; 120 g/L had an increased rate of ICU admission and longer hospital admission compared to patients with a preoperative Hb &gt; 120 g/L; adverse outcomes were higher in patients with Hb&lt; 80 g/L (Table 2). A logistic regression model adjusting for baseline characteristics demonstrated an association between preoperative anemia and ICU admission compared to non-anemic patients: for Hb 80-120 g/L, odds ratio (OR) 1.53, 95% CI 1.27-1.85, P &lt;.0001; for Hb&lt;80 g/L, OR 2.81, 95% CI 1.45-5.46, P=.0022. There was no significant change in transfusion rates from 2010 to 2019 (Figure 1). Conclusion Our retrospective cohort study of women undergoing gynecologic surgery is consistent with the findings of previous studies demonstrating that preoperative anemia is associated with adverse clinical outcomes in this population. IV iron was under-utilized in our study cohort; increased use of IV iron may have reduced unnecessary perioperative transfusions. 1 in 6 women in our study were transfused in the perioperative period. The appropriateness of these transfusions and the potential for preventing RBC transfusion in this patient population warrant further investigation. In contrast to other surgical specialties, transfusion rates in the gynecologic surgery population have been static over the past decade, suggesting a need for further PBM initiatives in this group. Figure 1 Figure 1. Disclosures Zeller: Canadian Blood Services: Consultancy, Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Canadian Insitutes of Health Research: Research Funding; American Society of Hematology: Honoraria.