Preoperative anaemia and red blood cell transfusion in patients with aneurysmal subarachnoid and intracerebral haemorrhage – A multicentre subanalysis of the German PBM Network Registry

Purpose Anaemia is common in patients presenting with aneurysmal subarachnoid (aSAH) and intracerebral haemorrhage (ICH). In surgical patients, anaemia was identified as an idenpendent risk factor for postoperative mortality, prolonged hospital length of stay (LOS) and increased risk of red blood cell (RBC) transfusion. This multicentre cohort observation study describes the incidence and effects of preoperative anaemia in this critical patient collective for a 10-year period. Methods This multicentre observational study included adult in-hospital surgical patients diagnosed with aSAH or ICH of 21 German hospitals (discharged from 1 January 2010 until 30 September 2020). Descriptive, univariate and multivariate analyses were performed to investigate the incidence and association of preoperative anaemia with RBC transfusion, in-hospital mortality and postoperative complications in patients with aSAH and ICH. Results A total of n = 9,081 patients were analysed (aSAH n = 5,008; ICH n = 4,073). Preoperative anaemia was present at 28.3% in aSAH and 40.9% in ICH. RBC transfusion rates were 29.9% in aSAH and 29.3% in ICH. Multivariate analysis revealed that preoperative anaemia is associated with a higher risk for RBC transfusion (OR= 3.25 in aSAH, OR = 4.16 in ICH, p < 0.001), for in-hospital mortality (OR= 1.48 in aSAH, OR= 1.53 in ICH, p < 0.001) and for several postoperative complications. Conclusions Preoperative anaemia is associated with increased RBC transfusion rates, in-hospital mortality and postoperative complications in patients with aSAH and ICH. Trial registration: ClinicalTrials.gov, NCT02147795, https://clinicaltrials.gov/ct2/show/NCT02147795

An Observational Study of Paediatric Preoperative Transfusion Practice in a Resource-Limited Setting

Background Paediatric anaemia is highly prevalent in low–middle-income countries and can negatively impact postoperative outcomes. Currently, there are no guidelines for the management of paediatric preoperative anaemia. To ensure optimal care in resource-limited settings: balancing the risks of anaemia and using resources such as blood transfusion, we first need to understand current practices. To address this, a joint UK–Bangladesh team conducted an observational study at a paediatric surgical centre in Bangladesh. Methods A total of 464 patients ≤16 years who underwent elective and emergency surgery were categorised into major (351/464), moderate (92/464) and minor (21/464) surgery groups according to anticipated blood loss. Preoperative anaemia testing and transfusion was assessed retrospectively through patient notes. Results Median age was 4 years and 73% were male. 32.5% (151/464) patients had preoperative blood testing for anaemia. 17.5% (81/464) children were transfused preoperatively. Of those children transfused, 40.7% (33/81) underwent transfusion solely based on visible signs of anaemia on clinical examination. Seventy-five percentage (36/48) of children who underwent transfusion after blood testing had haemoglobin ≥80 g/L. Major surgery category had the highest proportion of children who were transfused and tested for anaemia. Conclusion A liberal transfusion approach is evident here. Discussion with local clinicians revealed that this was due to limitations in obtaining timely blood results and reduction in laboratory costs incurred by families when clinical suspicion of anaemia was high. Further research is needed to analyse the potential of using bedside haemoglobin testers in conjunction with patient blood management strategies to limit blood transfusions and its associated risks.

Do Preoperative Transfusions Impact Prognosis in Moderate to Severe Anaemic Surgical Patients with Colon Cancer?

(1) Background: Anaemia is a common finding in patients with colon cancer and is commonly corrected by blood transfusion prior to surgery. However, the prognostic role of perioperative transfusions is still debated. The aim of the present study was to investigate the role of preoperative anaemia and preoperative blood transfusion in influencing the prognosis in colon cancer. (2) Patients and Methods: Patients undergoing elective surgery for colon cancer at a tertiary referral university hospital between January 2010 and December 2018 were included in a retrospective review of a prospectively collected database. Univariate and regression analyses were performed to identify the prognostic role of preoperative anaemia and preoperative transfusions in this homogeneous cohort of patients. (3) Results: A total of 780 patients were included in the final analysis. The estimated five-year overall survival rate was significantly worse in the anaemic group (83.8% in non-anaemic patients, 60.6% in mild anaemic patients, 61.3% in moderate anaemic patients and 58.4% in severe anaemic patients; log-rank < 0.001 vs. non-anaemic patients). Anaemic status was found to be an independent adverse prognostic factor (hazard ratio (HR): 1.46; 95% confidence interval (CI): 1.02–2.07) during multivariate analysis. Among moderate to severe anaemic patients, no significant association was found between preoperative transfusions and the risk of mortality or recurrence. (4) Conclusions: Preoperative anaemia, regardless of its severity, and not preoperative blood transfusion, was independently associated with a worse prognosis after surgery in patients with colonic cancer.

The Influence of Preoperative Hematocrit Levels on Early Outcomes in Patients undergoing Cardiac Surgery

Background: Anemia is a common risk factor for cardiovascular disease. The impact of preoperative anaemia is unclear in cardiac surgery. Preoperative anaemia affects early findings in patients undergoing cardiac surgery. Aim and Objective: The main objective of current research was to investigate the impact of preoperative anaemia on early outcomes in heart surgery patients. Material and Methods: A prospective randomized clinical research was undertaken after obtaining written informed consent from patients for cardiac surgery at the PIC, Lahore between Apr 2020 and Feb 2021. A total of 120 individuals between the ages of 20 and 60 were chosen for the research. Preoperative anaemia was described as Hb levels of <13 g/dl for males and <12 g/dl in female patients undergoing cardiac surgery. Results: Total 120 patients were enrolled and stratified into two groups (60 patients each) with average age 5 ± 5.75 years. Early outcomes after surgery such as postoperative stroke (6.67 % versus 1.6 %), AF (37 % versus32 %), and duration of hospital stay > 7 days (50 % vs 41.67 %) were found to be different between anaemic and normal Hb groups. Conclusion: Preoperative anaemia can be increased risk of morbidity and mortality in patients after surgery. Low preoperative Hb found as advanced risk factor for death, renal impairment, stroke, AF and long hospital stay in our research. Keywords: Anemia, CABG, AF, MI, IABP, CPB

The Impact of Preoperative Anaemia on Early Outcomes after Off-pump Coronary Artery Bypass Grafting

Introduction: In cardiac surgery, anaemia itself or combined with other risk factors has been found to be a major predictor for adverse outcome both preoperatively and postoperatively and even during extracorporeal circulation, but data about the specific tolerance of Coronary Artery Bypass Graft (CABG) patients for anaemia are conflicting and may in part be confounded by the effects of bypass surgery. Objectives: This study was performed in the National Institute of Cardiovascular Diseases (NICVD) to observe whether the early outcomes of Off-Pump CABG (OPCAB)were affected by pre-operative haematocrit levels. Methods: A total of 200 patients who underwent isolated OPCAB between January 2015 and December 2020 were retrospectively selected and purposively allocated into two groups: a)100 patients having preoperative anaemia and b) 100 patients without preoperative anaemia. Preoperative, per-operative and early post-operative variables were recorded, compiled and compared. Results: Preoperative characteristics were homogenously distributed between two groups other than haemoglobin level. Female patients had lower haemoglobin in each group. More patients of anaemic group required intraoperative and postoperative blood transfusion. The amount of blood loss and transfused blood products was also higher in anaemic patients. The ventilation time, length of ICU and post-operative hospital stay were significantly higher among anaemic patients. Among the post-operative complications, only the incidence of renal dysfunction was significantly higher among anaemic patients. Conclusion:This study has showed that anaemic patients undergoing OPCAB had an increased risk of postoperative adverse events. Importantly, the extent of preexisting comorbidities substantially affected perioperative anaemia tolerance. Therefore, preoperative risk assessment, optimization and subsequent therapeutic strategies, such as blood transfusion, should take into account both the individual level of preoperative haemoglobin and the extent of concomitant risk factors. Bangladesh Heart Journal 2021; 36(1) : 47-54

1037 Early Detection and Management of Preoperative Anaemia in An Elective Vascular Surgery Cohort

Introduction Iron deficiency anaemia is the most common cause of anaemia in the surgical population. Patients receiving transfusions during major surgery encounter more adverse outcomes compared to those that do not, indicating the early management of pre-operative anemia is likely to reduce major surgical patient morbidity and mortality. Previous studies have demonstrated that 33% of patients undergoing major vascular surgery operations are anaemic (haemaglobin, Hb, &lt;130g/L). Aim We aim to reduce the proportion of anaemic patients undergoing major vascular surgery by 50%. Method A point-of-care HemoCue machine was used to measure Hb in patients who were referred for elective major surgery in 11 vascular clinics. Patients with Hb &lt; 130g/L were prescribed a 1-month course of Ferrous Sulfate (200mg TDS), and a letter was sent to their GP requesting iron function tests. Post-intervention Hb levels were rechecked following the preoperative anaesthetics review. Results 11 patients were referred for major surgery, of which 4 were identified as anaemic (36%). The mean Hb concentration was 121.3g/L, which increased to 137.3g/L following oral iron therapy. The mean duration of follow up was 36 days (range 0-94 days). Conclusions The implementation of a HemoCue machine to identify and manage preoperative anaemia was successful in our pilot study. Further work should include full integration of our pathway into current vascular clinics without student support. This will enable evaluation of the impact of our intervention on a wider scale.

Preoperative Anemia Is A Predictor of Cacoethic Postoperative Outcomes Following Open Pancreatoduodenectomy – A Propensity Score-Based Analysis

Background: Preoperative anaemia is a common clinical situation that was proved to be associated with severe outcomes in major surgery but not pancreatic surgery alone. We aimed to study the impact of preoperative anaemia on morbidity and mortality in patients undergoing open pancreaticoduodenectomy by using propensity score matching (PSM) to balance the basal data and reduce bias. Methods: Consecutive patients undergoing open pancreaticoduodenectomy with complete record of preoperative haemoglobin at two pancreatic centers in China between 2015 to 2019 were analysed. Haemoglobin less than 12g/dl for male and 11g/dl for female were defined as anaemia in Chinese population. Clinical and economic outcomes were compared before and after propensity score matching (PSM). Logistic regression analysis was used to assess correlation between variables and anaemia. Results: The unmatched initial cohort consist of 517 patients. 148 cases (28.6%) were diagnosed as anaemia at admission, and no case received preoperative blood transfusion or anti-anaemia therapy. After PSM, 126 cases were in each group. The rate of severe postoperative complications was significantly higher in anaemia group than in normal group (43.7% versus 27.0%, P=0.006), among which prevalence of clinically relevant postoperative pancreatic fistula (31.0% versus 15.9%, P=0.005) and cardiac and cerebrovascular events (4.0% versus 0.0%, P=0.024) were most significant. It costed more in the anaemia group (26958.2±21671.9 versus 20987.7±10237.9 USD, P=0.013). Among all patients, multivariate analysis showed that preoperative obstructive jaundice [OR 1.813, 95%CI (1.206-2.725), P=0.004] and pancreatic ductal adenocarcinoma [OR 1.861, 95%CI (1.178-2.939), P=0.008] were predictors of anaemia. Among paired patients, preoperative anaemia [OR 2.593, 95%CI (1.481-5.541), P=0.001] and malignant pathology [OR 4.266, 95%CI (1.597-11.395), P=0.004] were predictors of postoperative severe complications.Conclusions: Preoperative anaemia is a predictor of cacoethic postoperative outcomes following open pancreatoduodenectomy and needs identified and treated.

Independent Risk Factors for RBC Transfusion in Children Undergoing Surgery. Analysis of 14,248 Cases at a German University Hospital

Background: paediatric patients are vulnerable to blood loss and even a small loss of blood can be associated with severe shock. In emergency situations, a red blood cell (RBC) transfusion may become unavoidable, although it is associated with various risks. The aim of this trial was to identify independent risk factors for perioperative RBC transfusion in children undergoing surgery. Methods: to identify independent risk factors for perioperative RBC transfusion in children undergoing surgery and to access RBC transfusion rates and in-hospital outcomes (e.g., length of stay, mortality, and typical postoperative complication rates), a monocentric, retrospective, and observational study was conducted. Descriptive, univariate, and multivariate analyses were performed. Results: between 1 January 2010 and 31 December 2019, data from n = 14,248 cases were identified at the centre. Analysis revealed an RBC transfusion rate of 10.1% (n = 1439) in the entire cohort. The independent predictors of RBC transfusion were the presence of preoperative anaemia (p < 0.001; OR = 15.10 with preoperative anaemia and OR = 2.40 without preoperative anaemia), younger age (p < 0.001; ORs between 0.14 and 0.28 for children older than 0 years), female gender (p = 0.036; OR = 1.19 compared to male gender), certain types of surgery (e.g., neuro surgery (p < 0.001; OR = 10.14), vascular surgery (p < 0.001; OR = 9.93), cardiac surgery (p < 0.001; OR = 4.79), gynaecology (p = 0.014; OR = 3.64), visceral surgery (p < 0.001; OR = 2.48), and the presence of postoperative complications (e.g., sepsis (p < 0.001; OR = 10.16), respiratory dysfunction (p < 0.001; OR = 7.56), cardiovascular dysfunction (p < 0.001; OR = 4.68), neurological dysfunction (p = 0.029; OR = 1.77), and renal dysfunction (p < 0.001; OR = 16.17)). Conclusion: preoperative anaemia, younger age, female gender, certain types of surgery, and postoperative complications are independent predictors for RBC transfusion in children undergoing surgery. Future prospective studies are urgently required to identify, in detail, the potential risk factors and impact of RBC transfusion in children.

Clinical Outcome and Risk Factors of Red Blood Cell Transfusion in Patients Undergoing Elective Primary Meningioma Resection

Transfusion of red blood cells (RBC) in patients undergoing major elective cranial surgery is associated with increased morbidity, mortality and prolonged hospital length of stay (LOS). This retrospective single center study aims to identify the clinical outcome of RBC transfusions on skull base and non-skull base meningioma patients including the identification of risk factors for RBC transfusion. Between October 2009 and October 2016, 423 patients underwent primary meningioma resection. Of these, 68 (16.1%) received RBC transfusion and 355 (83.9%) did not receive RBC units. Preoperative anaemia rate was significantly higher in transfused patients (17.7%) compared to patients without RBC transfusion (6.2%; p = 0.0015). In transfused patients, postoperative complications as well as hospital LOS was significantly higher (p < 0.0001) compared to non-transfused patients. After multivariate analyses, risk factors for RBC transfusion were preoperative American Society of Anaesthesiologists (ASA) physical status score (p = 0.0247), tumor size (p = 0.0006), surgical time (p = 0.0018) and intraoperative blood loss (p < 0.0001). Kaplan-Meier curves revealed significant influence on overall survival by preoperative anaemia, RBC transfusion, smoking, cardiovascular disease, preoperative KPS ≤ 60% and age (elderly ≥ 75 years). We concluded that blood loss due to large tumors or localization near large vessels are the main triggers for RBC transfusion in meningioma patients paired with a potential preselection that masks the effect of preoperative anaemia in multivariate analysis. Further studies evaluating the impact of preoperative anaemia management for reduction of RBC transfusion are needed to improve the clinical outcome of meningioma patients.