Neurosurgical Review

, Volume 40, Issue 4, pp 633–642 | Cite as

Risk associated with perioperative red blood cell transfusion in cranial surgery

  • Jonathan A. Cohen
  • Nima Alan
  • Andreea Seicean
  • Robert J. Weil
Original Article


We assessed the impact of intra- and postoperative RBC transfusion on postoperative morbidity and mortality in cranial surgery. A total of 8924 adult patients who underwent cranial surgery were identified in the 2006–2011 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Patients undergoing a biopsy, radiosurgery, or outpatient surgery were excluded. Propensity scores were calculated according to demographic variables, comorbidities, and preoperative laboratory values. Patients who had received RBC transfusion were matched to those who did not, by propensity score, preoperative hematocrit level, and by length of surgery, as an indirect measure of potential intraoperative blood loss. Logistic regression was used to predict adverse postoperative outcomes. A total of 625 (7%) patients were transfused with one or more units of packed RBCs. Upon matching, preoperative hematocrit, length of surgery, and emergency status were no longer different between transfused and non-transfused patients. RBC transfusion was associated with prolonged length of hospitalization (OR 1.6, 95% CI 1.2–2.2), postoperative complications (OR 2.8, 95% CI 2.0–3.8), 30-day return to operation room (OR 2.0, 95% CI 1.3–3.2), and 30-day mortality (OR 4.3, 95% CI 2.4–7.6). RBC transfusion is associated with substantive postoperative morbidity and mortality in patients undergoing both elective and emergency cranial surgery. These results suggest judicious use of transfusion in cranial surgery, consideration of alternative means of blood conservation, or pre-operative restorative strategies in patients undergoing elective surgery, when possible.


Transfusion Perioperative Cranial Surgery 


Compliance with ethical standards

Conflicts of interests

The authors declare that they have no conflicts of interest.

Ethical approval

This article does not contain any studies with animals performed by any of the authors.

Informed consent

For this type of study, formal consent is not required.


  1. 1.
    American College of Surgeons National Surgical Quality Improvement Project (2012) User guide for the 2011 participant use data file. American College of Surgeons, ChicagoGoogle Scholar
  2. 2.
    Andrews NB (2009) Neurosurgical procedures in Jehovah’s witnesses: the Tema experience. West Afr J Med 28(3):148–150PubMedGoogle Scholar
  3. 3.
    Bergstralh E, Kosanke J (1995) Computerized matching of cases to controls. Technical report serial no. 56. Mayo Clinic Section of Biostatistics, MinnesotaGoogle Scholar
  4. 4.
    Beris P, Muñoz M, García-Erce JA, Thomas D, Maniatis A, Van der Linden P (2008) Perioperative anaemia management: consensus statement on the role of intravenous iron. Br J Anaesth 100(5):599–604CrossRefPubMedGoogle Scholar
  5. 5.
    Carlson AP, Schermer CR, Lu SW (2006) Retrospective evaluation of anemia and transfusion in traumatic brain injury. J Trauma 61(3):567–571CrossRefPubMedGoogle Scholar
  6. 6.
    Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG et al (2011) FOCUS investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 365(26):2453–2462CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Dhar R, Zazulia AR, Videen TO, Zipfel GJ, Derdeyn CP, Diringer MN (2009) Red blood cell transfusion increases cerebral oxygen delivery in anemic patients with subarachnoid hemorrhage. Stroke 40(9):3039–3044CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Engoren MC, Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ (2002) Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg 74(4):1180–1186CrossRefPubMedGoogle Scholar
  9. 9.
    Feagan BG, Wong CJ, Kirkley A, Johnston DW, Smith FC, Whitsitt P et al (2000) Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial. Ann Intern Med 133(11):845–854CrossRefPubMedGoogle Scholar
  10. 10.
    George ME, Skarda DE, Watts CR, Pham HD, Beilman GJ (2008) Aggressive red blood cell transfusion: no association with improved outcomes for victims of isolated traumatic brain injury. Neurocrit Care 8(3):337–343CrossRefPubMedGoogle Scholar
  11. 11.
    Glance LG, Dick AW, Mukamel DB, Fleming FJ, Zollo RA, Wissler R et al (2011) Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 114(2):283–292CrossRefPubMedGoogle Scholar
  12. 12.
    Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G et al (1999) A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in critical care investigators, Canadian critical care trials group. N Engl J Med 340(6):409–417CrossRefPubMedGoogle Scholar
  13. 13.
    Heddle NM, Cook RJ, Arnodl DM, Lui Y, Barty R, Crowther MA et al (2016) Effect of short-term vs. long-term blood storage on mortality after transfusion. N Engl J Med 375(20):1937–1945CrossRefPubMedGoogle Scholar
  14. 14.
    Hendrickson JE, Hillyer CD (2009) Noninfectious serious hazards of transfusion. Anesth Analg 108(3):759–769CrossRefPubMedGoogle Scholar
  15. 15.
    Hu SS (2004) Blood loss in adult spinal surgery. Eur Spine J 13(Suppl 1):S3–S5CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Koch CG, Khandwala F, Li L, Estafanous FG, Loop FD, Blackstone EH (2006) Persistent effect of red cell transfusion on health-related quality of life after cardiac surgery. Ann Thorac Surg 82(1):13–20CrossRefPubMedGoogle Scholar
  17. 17.
    Koch CG, Li L, Duncan AI, Mihaljevic T, Cosgrove DM, Loop FD et al (2006) Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med 34(6):1608–1616CrossRefPubMedGoogle Scholar
  18. 18.
    Koch CG, Li L, Sessler DI, Figueroa P, Hoeltge GA, Mihaljevic T, Blackstone EH (2008) Duration of red-cell storage and complications after cardiac surgery. N Engl J Med 358(12):1229–1239CrossRefPubMedGoogle Scholar
  19. 19.
    Khuri SF, Henderson WG, Daley J, Jonasson O, Jones RS, Campbell DA et al (2007) The patient safety in surgery study: background, study design, and patient populations. J Am Coll Surg 204:1089–1102CrossRefPubMedGoogle Scholar
  20. 20.
    Kramer AH, Le Roux P (2012) Red blood cell transfusion and transfusion alternatives in traumatic brain injury. Curr Treat Options Neurol. doi: 10.1007/s11940-012-0167-8 PubMedGoogle Scholar
  21. 21.
    Kumar A (2009) Perioperative management of anemia: limits of blood transfusion and alternatives to it. Cleve Clin J Med 76(Suppl 4):S112–S118CrossRefPubMedGoogle Scholar
  22. 22.
    Kumar MA, Boland TA, Baiou M, Moussouttas M, Herman JH, Bell RD et al (2013) Red blood cell transfusion increases the risk of thrombotic events in patients with subarachnoid hemorrhage. Neurocrit Care 20(1):84–90CrossRefGoogle Scholar
  23. 23.
    Naidech AM, Shaibani A, Garg RK, Duran IM, Liebling SM, Bassin SL et al (2010) Prospective, randomized trial of higher goal hemoglobin after subarachnoid hemorrhage. Neurocrit Care 13(3):313–320CrossRefPubMedGoogle Scholar
  24. 24.
    Okuyama M, Ikeda K, Shibata T, Tsukahara Y, Kitada M, Shimano T (2005) Preoperative iron supplementation and intraoperative transfusion during colorectal cancer surgery. Surg Today 35(1):36–40CrossRefPubMedGoogle Scholar
  25. 25.
    Rosenbaum PR, Rubin D (1983) The central role of the propensity score in observational studies for causal effects. Biometrika 70:41–55CrossRefGoogle Scholar
  26. 26.
    Seicean A, Seicean S, Alan N, Schiltz NK, Rosenbaum BP, Jones PK et al (2013) Pre-operative anemia and peri-operative outcomes in patients who undergo elective spine surgery. Spine 38(15):1331–1341CrossRefPubMedGoogle Scholar
  27. 27.
    Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR (2010) Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion 50(4):753–765CrossRefPubMedGoogle Scholar
  28. 28.
    Smith MJ, Le Roux PD, Elliott JP, Winn HR (2004) Blood transfusion and increased risk for vasospasm and poor outcome after subarachnoid hemorrhage. J Neurosurg 101(1):1–7CrossRefPubMedGoogle Scholar
  29. 29.
    Suess S, Suess O, Brock M (2001) Neurosurgical procedures in Jehovah's witnesses: an increased risk? Neurosurgery 49(2):266–272PubMedGoogle Scholar
  30. 30.
    Theusinger OM, Leyvraz PF, Schanz U, Seifert B, Spahn DR (2007) Treatment of iron deficiency anemia in orthopedic surgery with intravenous iron: efficacy and limits: a prospective study. Anesthesiology 107(6):923–927CrossRefPubMedGoogle Scholar
  31. 31.
    Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C et al (2013) Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 368(1):11–21CrossRefPubMedGoogle Scholar
  32. 32.
    Warner MA, O'Keeffe T, Bhavsar P, Shringer R, Moore C, Harper C et al (2010) Transfusions and long-term functional outcomes in traumatic brain injury. J Neurosurg 113(3):539–546CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Jonathan A. Cohen
    • 1
  • Nima Alan
    • 2
    • 3
  • Andreea Seicean
    • 2
    • 4
    • 5
  • Robert J. Weil
    • 6
    • 7
  1. 1.Department of Neurological SurgeryUniversity of Pittsburgh Medical CenterPittsburghUSA
  2. 2.Case Western Reserve University School of MedicineClevelandUSA
  3. 3.Department of Neurological SurgeryUniversity of Pittsburgh Medical CenterPittsburghUSA
  4. 4.Department of Epidemiology and BiostatisticsCase Western Reserve UniversityClevelandUSA
  5. 5.Department of PsychiatryUniversity of Illinois at ChicagoChicagoUSA
  6. 6.The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, and Department of Neurosurgery, The Neurological InstituteCleveland ClinicClevelandUSA
  7. 7.Neurosurgery DepartmentGeisinger Health SystemDanvilleUSA

Personalised recommendations