Abstract
Background
Major emergency abdominal surgery is associated with excess mortality. Transfusion is known to be associated with increased morbidity and emergency surgery is an independent risk factor for perioperative transfusion. The primary objectives of this study were to identify risk factors for transfusion, and secondarily to investigate the influence of transfusion on clinical outcomes after major emergency abdominal surgery.
Study design and methods
This study combined retrospective observational data including intraoperative, postoperative, and transfusion data in patients undergoing major emergency abdominal surgery from January 2010 to October 2016 at a Danish university hospital. The primary outcome was a transfusion of any kind from initiation of surgery to postoperative day 7. Secondary outcomes included 7-, 30-, 90-day and long-term mortality (median follow-up = 34.6 months, IQR = 13.0–58.3), lengths of stay, and surgical complication rate (Clavien–Dindo score ≥ 3a).
Results
A total of 1288 patients were included and 391 (30%) received a transfusion of any kind. Multivariate logistic regression identified age, hepatic comorbidity, cardiac comorbidity, post-surgical anemia, ADP-receptor inhibitors, acetylsalicylic acid, anticoagulants, and operation type as risk factors for postoperative transfusion. 60.1% of the transfused patients experienced a serious surgical complication within 30 days of surgery compared with 28.1% of the non-transfused patients (p < 0.001). Among patients receiving a postoperative transfusion, unadjusted long-term mortality was increased with a hazard ratio of 3.8 (95% CI 2.9–5.0), p < 0.01. Transfused patients had significantly higher mortality at 7-, 30-, 90- and long-term, as well as a longer hospital stay but in the multivariate analyses, transfusion was not associated with mortality.
Conclusion
Peri- and postoperative transfusion in relation to major emergency abdominal surgery was associated with an increased risk of postoperative complications. The potential benefits and harms of blood transfusion and clinical significance of pre- and postoperative anemia after major emergency abdominal surgery should be further studied in clinical prospective studies.
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References
Ingraham AM, Cohen ME, Raval MV, Ko CY, Nathens AB. Comparison of hospital performance in emergency versus elective general surgery operations at 198 hospitals. J Am Coll Surg. 2011;212:20–8.
Ingraham AM, Haas B, Cohen ME, Ko CY, Nathens AB. Comparison of hospital performance in trauma vs emergency and elective general surgery: implications for acute care surgery quality improvement. Arch Surg. 2012;147:591–8.
Sørensen LT, et al. Risk factors for mortality and postoperative complications after gastrointestinal surgery. J Gastrointest Surg. 2007. https://doi.org/10.1007/s11605-007-0165-4.
Symons NRA, et al. Mortality in high-risk emergency general surgical admissions. Br J Surg. 2013;100:1318–25.
Alazawi W, Pirmadjid N, Lahiri R, Bhattacharya S. Inflammatory and immune responses to surgery and their clinical impact. Ann Surg. 2016;264:73–80.
Johansson PI, Stensballe J, Ostrowski SR. Shock induced endotheliopathy (SHINE) in acute critical illness—a unifying pathophysiologic mechanism. Crit Care. 2017;21(1):187.
Havens JM, et al. Explaining the excess morbidity of emergency general surgery: packed red blood cell and fresh frozen plasma transfusion practices are associated with major complications in nonmassively transfused patients. Am J Surg. 2016;211:656-663.e4.
Matsuyama T, et al. Risk factors for postoperative mortality and morbidities in emergency surgeries. J Anesth. 2013;27:838–43.
Glance LG, et al. Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology. 2011. https://doi.org/10.1097/ALN.0b013e3182054d06.
Havens JM, et al. The excess morbidity and mortality of emergency general surgery. J Trauma Acute Care Surg. 2015;78:306–11.
Halabi WJ, et al. Blood transfusions in colorectal cancer surgery: incidence, outcomes, and predictive factors: an American College of Surgeons National Surgical Quality Improvement Program analysis. Am J Surg. 2013;206:1024–32.
Spiegelman J, et al. Risk factors for blood transfusion in patients undergoing high-order Cesarean delivery. Transfusion. 2017;57:2752–7.
Venkat R, Guerrero MA. Risk factors and outcomes of blood transfusions in adrenalectomy. J Surg Res. 2015. https://doi.org/10.1016/j.jss.2015.06.042.
Hart A, et al. Blood transfusion in primary total hip and knee arthroplasty. Incidence, risk factors, and thirty-day complication rates. J Bone Jt Surg Am. 2014. https://doi.org/10.2106/JBJS.N.00077.
Lam SK, et al. Patient-, procedure-, and hospital-related risk factors of allogeneic and autologous blood transfusion in pediatric spinal fusion surgery in the United States. Spine (Phila Pa 1976). 2015. https://doi.org/10.1097/BRS.0000000000000816.
Benchimol EI, et al. The REporting of studies conducted using observational routinely-collected health Data (RECORD) Statement. PLoS Med. 2015;12:e1001885.
Sundararajan V, et al. New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality. J Clin Epidemiol. 2004;57:1288–94.
Clavien PA, et al. The Clavien-Dindo classification of surgical complications. Ann Surg. 2009;250:187–96.
Kristensen, J. S. on behalf of the national working group (2014) National clinical guidline on transfusion of blood products. The Danish national board of health. Sundhedsstyrelsen. https://www.sst.dk/-/media/Udgivelser/2018/NKR-blod-og-blodkomponenter/298771-Quick-Guide-NKR-transfusion-med-blodkomponenter_EN.ashx?la=da%26hash=FA7E863A0A911FF83108CA61ABAB610683F64A1C
Pedersen CB, Gøtzsche H, Møller JØ, Mortensen PB. The Danish civil registration system A cohort of eight million persons. Dan Med Bull. 2006;53:441–9.
Elhenawy AM, Meyer SR, Bagshaw SM, MacArthur RG, Carroll LJ. Role of preoperative intravenous iron therapy to correct anemia before major surgery: study protocol for systematic review and meta-analysis. Syst Rev. 2015;4:29.
Hallward G, Balani N, McCorkell S, Roxburgh J, Cornelius V. The relationship between preoperative hemoglobin concentration, use of hospital resources, and outcomes in cardiac surgery. J Cardiothorac Vasc Anesth. 2016;30:901–8.
Ostrowski SR, Johansson PI. Rethinking platelet function: Thrombocytopenia induced immunodeficiency in critical illness. Med Hypotheses. 2011;77:798–802.
Schack A, Berkfors AA, Ekeloef S, Gögenur I, Burcharth J. The effect of perioperative iron therapy in acute major non-cardiac surgery on allogenic blood transfusion and postoperative haemoglobin levels: a systematic review and meta-analysis. World J Surg. 2019;43:1677–91.
McEvoy MT, Shander A. Anemia, bleeding, and blood transfusion in the intensive care unit: causes, risks, costs, and new strategies. Am J Crit Care. 2013. https://doi.org/10.4037/ajcc2013729.
Karkouti K, Wijeysundera DN, Beattie WS. Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study. Circulation. 2008. https://doi.org/10.1161/CIRCULATIONAHA.107.718353.
Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med. 2008. https://doi.org/10.1097/CCM.0b013e3181844677.
Hébert PC, et al. Clinical outcomes following institution of the canadian universal leukoreduction program for red blood cell transfusions. J Am Med Assoc. 2003. https://doi.org/10.1001/jama.289.15.1941.
Garraud O, et al. Transfusion as an inflammation hit: knowns and unknowns. Front Immunol. 2016;7:1–10.
Mazer CD, et al. Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J Med. 2017. https://doi.org/10.1056/NEJMoa1711818.
Simon GI, Craswell A, Thom O, Fung YL. Outcomes of restrictive versus liberal transfusion strategies in older adults from nine randomised controlled trials: a systematic review and meta-analysis. Lancet Haematol. 2017. https://doi.org/10.1016/S2352-3026(17)30141-2.
Welsby IJ, et al. ABO blood group and bleeding after coronary artery bypass graft surgery. Blood Coagul Fibrinolysis. 2007;18:781–5.
Tran HA, et al. An update of consensus guidelines for warfarin reversal. Med J Aust. 2013. https://doi.org/10.5694/mja12.10614.
Columbo JA, et al. A meta-analysis of the impact of aspirin, clopidogrel, and dual antiplatelet therapy on bleeding complications in noncardiac surgery. Ann Surg. 2018. https://doi.org/10.1097/SLA.0000000000002279.
Zalpuri S, et al. Association vs causality in transfusion medicine: Understanding multivariable analysis in prediction vs etiologic research. Transfus Med Rev. 2013;27:74–81.
Middelburg RA, Van De Watering LMG, Van Der Bom JG. Blood transfusions: good or bad?: Confounding by indication, an underestimated problem in clinical transfusion research. Transfusion. 2010;50:1181–3.
Aden N, Massimiano P, Burton N, Halpin L, Pritchard G, Shuman D, Holmes S. Effect of patient age on blood product transfusion after cardiac surgery. J Thorac Cardiovasc Surg. 2015;150(1):209–14.
Zampieri FG, Iwashyna TJ, Viglianti EM, Taniguchi LU, Viana WN, Costa R, Corrêa TD, Moreira CEN, Maia MO, Moralez GM, Lisboa T, Ferez MA, Freitas CEF, de Carvalho CB, Mazza BF, Lima MFA, Ramos GV, Silva AR, Bozza FA, Salluh JIF, Soares M, ORCHESTRA Study Investigators. Association of frailty with short-term outcomes, organ support and resource use in critically ill patients. Intens Care Med. 2018;44(9):1512–20. https://doi.org/10.1007/s00134-018-5342-2.
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AS: This author helped by study design, data collection, data analysis, data interpretation, drafting of manuscript, critical revision. SE: This author helped by study design, data interpretation, and critical revision. SRO: This author helped by data interpretation, and critical revision. IG: This author helped by study design, data interpretation, and critical revision. JB: This author helped by study design, data analysis, data interpretation, and critical revision. All authors have seen and approved the final version of the manuscript.
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Schack, A., Ekeloef, S., Ostrowski, S.R. et al. Blood transfusion in major emergency abdominal surgery. Eur J Trauma Emerg Surg 48, 121–131 (2022). https://doi.org/10.1007/s00068-020-01562-3
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DOI: https://doi.org/10.1007/s00068-020-01562-3