Impact of Preoperative Anaemia and Blood Transfusion on Postoperative Outcomes in Gynaecological Surgery

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Abstract

Objective

To evaluate the effect of preoperative anaemia and blood transfusion on 30-day postoperative morbidity and mortality in patients undergoing gynecological surgery.

Study Design

Data were analyzed from 12,836 women undergoing operation in the American College of Surgeons National Surgical Quality Improvement Program. Outcomes measured were; 30-day postoperative mortality, composite and specific morbidities (cardiac, respiratory, central nervous system, renal, wound, sepsis, venous thrombosis, or major bleeding). Multivariate logistic regression models were performed using adjusted odds ratios (OR _adj) to assess the independent effects of preoperative anaemia (hematocrit <36.0%) on outcomes, effect estimates were performed before and after adjustment for perioperative transfusion requirement.

Results

The prevalence of preoperative anaemia was 23.9% (95%CI: 23.2–24.7). Adjusted for confounders by multivariate logistic regression; preoperative anaemia was independently and significantly associated with increased odds of 30-day mortality (OR: 2.40, 95%CI: 1.06–5.44) and composite morbidity (OR: 1.80, 95%CI: 1.45–2.24). This was reflected by significantly higher adjusted odds of almost all specific morbidities including; respiratory, central nervous system, renal, wound, sepsis, and venous thrombosis. Blood Transfusion increased the effect of preoperative anaemia on outcomes (61% of the effect on mortality and 16% of the composite morbidity).

Conclusions

Preoperative anaemia is associated with adverse post-operative outcomes in women undergoing gynecological surgery. This risk associated with preoperative anaemia did not appear to be corrected by use of perioperative transfusion.

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Most cited references 21

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Effect of anaemia and cardiovascular disease on surgical mortality and morbidity.

J L Carson, A Duff, R M Poses … (1996)

Guidelines have been offered on haemoglobin thresholds for blood transfusion in surgical patients. However, good evidence is lacking on the haemoglobin concentrations at which the risk of death or serious morbidity begins to rise and at which transfusion is indicated. A retrospective cohort study was performed in 1958 patients, 18 years and older, who underwent surgery and declined blood transfusion for religious reasons. The primary outcome was 30-day mortality and the secondary outcome was 30-day mortality or in-hospital 30-day morbidity. Cardiovascular disease was defined as a history of angina, myocardial infarction, congestive heart failure, or peripheral vascular disease. The 30-day mortality was 3.2% (95% CI 2.4-4.0). The mortality was 1.3% (0.8-2.0) in patients with preoperative haemoglobin 12 g/dL or greater and 33.3% (18.6-51.0) in patients with preoperative haemoglobin less than 6 g/dL. The increase in risk of death associated with low preoperative haemoglobin was more pronounced in patients with cardiovascular disease than in patients without (interaction p < 0.03). The effect of blood loss on mortality was larger in patients with low preoperative haemoglobin than in those with a higher preoperative haemoglobin (interaction p < 0.001). The results were similar in analyses of postoperative haemoglobin and 30-day mortality or in-hospital morbidity. A low preoperative haemoglobin or a substantial operative blood loss increases the risk of death or serious morbidity more in patients with cardiovascular disease than in those without. Decisions about transfusion should take account of cardiovascular status and operative blood loss as well as the haemoglobin concentration.

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Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients.

Andrew C Bernard, Daniel L. Davenport, Phillip K. Chang … (2009)

Transfusion of packed red blood cells (PRBCs) increases morbidity and mortality in select surgical specialty patients. The impact of low-volume, leukoreduced RBC transfusion on general surgery patients is less well understood. The American College of Surgeons National Surgical Quality Improvement Program participant use file was queried for general surgery patients recorded in 2005 to 2006 (n = 125,223). Thirty-day morbidity (21 uniformly defined complications) and mortality, demographic, preoperative, and intraoperative risk variables were obtained. Infectious complications and composite morbidity and mortality were stratified across intraoperative PRBCs units received. Multivariable logistic regression was used to assess influence of transfusion on outcomes, while adjusting for transfusion propensity, procedure type, wound class, operative duration, and 30+ patient risk factors. After adjustment for transfusion propensity, procedure group, wound class, operative duration, and all other important risk variables, 1 U PRBCs significantly (p < 0.05) increased risk of 30-day mortality (odds ratio [OR] = 1.32), composite morbidity (OR = 1.23), pneumonia (OR = 1.24), and sepsis/shock (OR = 1.29). Transfusion of 2 U additionally increased risk for these outcomes (OR = 1.38, 1.40, 1.25, 1.53, respectively; p

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Surgical outcomes and transfusion of minimal amounts of blood in the operating room.

Victor A. Ferraris (2012)

To examine outcomes in patients who receive small amounts of intraoperative blood transfusion. Longitudinal, uncontrolled observational study evaluating results of intraoperative transfusion in patients entered into the American College of Surgeons National Surgical Quality Improvement Program database. We made propensity-matched comparisons between patients who received and did not receive intraoperative transfusion to minimize confounding when estimating the effect of intraoperative transfusion on postoperative outcomes. We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients undergoing operations between January 1, 2005, and December 31, 2009. A large sample of surgical patients from 173 hospitals throughout the United States. Operative mortality and serious perioperative morbidity (≥1 of 20 complications). After exclusions, 941,496 operations were analyzed in patients from 173 hospitals. Most patients (893,205 patients [94.9%]) did not receive intraoperative transfusions. Patients who received intraoperative infusion of 1 unit of packed red blood cells (15,186 patients [1.6%]) had higher unadjusted rates of mortality and more serious morbidity. These rates further increased with intraoperative transfusion of more than 1 unit of packed red blood cells in a dose-dependent manner. After propensity matching to adjust for multiple preoperative risks, transfusion of a single unit of packed red blood cells increased the multivariate risk of mortality, wound problems, pulmonary complications, postoperative renal dysfunction, systemic sepsis, composite morbidity, and postoperative length of stay compared with propensity-matched patients who did not receive intraoperative transfusion. There is a dose-dependent adverse effect of intraoperative blood transfusion. It is likely that a small, possibly discretionary amount of intraoperative transfusion leads to increased mortality, morbidity, and resource use, suggesting that caution should be used with intraoperative transfusions for mildly hypovolemic or anemic patients.

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Author and article information

Contributors

Halvard Bönig: Role: Academic Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 6 July 2015

Publication date Collection: 2015

Volume: 10

Issue: 7

Electronic Location Identifier: e0130861

Affiliations

[1 ]Division of Surgery and Interventional Science, University College London Hospital, London, United Kingdom

[2 ]Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon

[3 ]Department of Obstetrics and Gynaecology, American University of Beirut Medical Centre, Beirut, Lebanon

[4 ]Department of Surgery, American University of Beirut Medical Centre, Beirut, Lebanon

German Red Cross Blood Service Frankfurt, GERMANY

Author notes

Competing Interests: UCL and the research program led by TR has received research funding from a variety of sources (19) including government, charity and industry sources for research into anaemia, blood transfusion and iron therapy including, NIHR HTA, Health Foundation, Gideon Richter, Vifor Pharma Ltd, Pharmocosmos. TR has also been the invited speaker at over 50 conferences on anaemia, blood transfusion and iron therapy in the last 5 years. KMM received consultancy fees and travel support from Vifor Pharma Ltd. ES received honoraria from Gideon Richter and Ethicon for provision of training to healthcare professionals. FRJ received research funding from Vifor Pharma Ltd. The remaining authors have no conflicts of interest to disclose. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Conceived and designed the experiments: TR KMM FRJ. Performed the experiments: JN GG MS. Analyzed the data: TR KMM FRJ. Contributed reagents/materials/analysis tools: JN GG MS. Wrote the paper: TR KMM KG FRJ. Approved final manuscript: TR KMM JN GG MS KG FRJ.

* E-mail: fj03@ 123456aub.edu.lb

Article

Publisher ID: PONE-D-15-00176

DOI: 10.1371/journal.pone.0130861

PMC ID: 4492675

PubMed ID: 26147954

SO-VID: 2b1410b9-2553-4fe4-bf97-c69dbbdf2b85

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

History

Date received : 24 January 2015

Date accepted : 26 May 2015

Page count

Figures: 2, Tables: 3, Pages: 12

Funding

The authors received no specific funding for this work.

Custom metadata

Data Availability All relevant data are within the paper and its Supporting Information files.

Impact of Preoperative Anaemia and Blood Transfusion on Postoperative Outcomes in Gynaecological Surgery

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Abstract

Objective

Study Design

Results

Conclusions

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PLOS Global Public Health

Most cited references 21

Effect of anaemia and cardiovascular disease on surgical mortality and morbidity.

Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients.

Surgical outcomes and transfusion of minimal amounts of blood in the operating room.

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Funding

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