PRE-OPERATIVE ANEMIA AS A PREDICTIVE MORBIDITY OUTCOME — A RETROSPECTIVE ANALYSIS OF A VASCULAR SURGERY DEPARTMENT

  • Carolina Semião MD
  • Clara Nogueira Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
  • Jacinta Campos Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Unidade de Angiologia e Cirurgia Vascular da Faculdade de Medicina da Universidade do Porto, Porto, Portugal
  • Andreia Coelho Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Unidade de Angiologia e Cirurgia Vascular da Faculdade de Medicina da Universidade do Porto, Porto, Portugal
  • Rita Augusto Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Unidade de Angiologia e Cirurgia Vascular da Faculdade de Medicina da Universidade do Porto, Porto, Portugal
  • Nuno Coelho Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Unidade de Angiologia e Cirurgia Vascular da Faculdade de Medicina da Universidade do Porto, Porto, Portugal
  • Evelise Pinto Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
  • João Ribeiro Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
  • João Peixoto Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
  • Alexandra Canedo Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Unidade de Angiologia e Cirurgia Vascular da Faculdade de Medicina da Universidade do Porto, Porto, Portugal
Keywords: Pre-operative anemia, Iron supplementation, Patient Blood Management, Vascular surgery

Abstract

Introduction: Anemia is associated with increased adverse outcomes during the early postoperative period because of high physiologic stress and increased cardiac demand. The aim of this study was to assess the relationship between pre-operative anemia and morbi-mortality outcomes in patients undergoing elective carotid endarterectomy (CEA), open aortic repair (OAR) or endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) and infrainguinal bypass surgery in chronic limb-threatening ischemia. 

Methods: Retrospective analysis of all elective patients between 2016-2018, who underwent: CEA, OAR, EVAR and infrainguinal bypass surgery in chronic limb-threatening ischemia. Emergency procedures and transfusion of more than 4 units of red blood cells (RBC) were excluded. Hemoglobin levels were categorized according to the WHO definition for anemia: severe (< 8 g/dL), moderate (8-10.9 g/dL), mild (11-11.9 g/dL in women and 11-12.9 g/dL in men) and no anemia (≥12 g/dL in women and ≥13 g/dL in men). 

Results: Our study population comprised 257 patients, of which 74 (28%) underwent EVAR, 26 (10.1%) OAR, 67 (26.1%) CEA and 90 (35%) infrainguinal bypass. Pre-operative anemia was identified in 37.4% (n = 96) of the patients. Of those, 67.7% (n = 65) had mild anemia and 32.3% (n = 31) had moderate-severe anemia. Anemic patients have longer length of stay when compared with non-anemic patients (16.61±16.5; 7.68±4.92, respectively) (p = 0.022) and also longer stay in the post-operative care unite in comparison with patients with hemoglobin within the normal range (average 2.08 days ± 1.12; 1.77 days ± 1.01, respectively) (p<0.001). Pre-operative anemia was associated with the need of peri-operative transfusions (p < 0.001), as expected. In-hospital adverse events were influenced by the presence of anemia (p<0.001), namely surgical site infection (p = 0.002) and re-intervention (p<0.007). Patients who received blood transfusion peri-operatively were more prone to adverse outcomes (p<0.001), such as renal disfunction (p = 0.006), respiratory infections (p =0.015), surgical site infection (p = 0.001) and re-intervention (p = 0.001). 

Conclusion: Pre-operative anemia evaluation should be incorporated into the preoperative risk assessment. Iron deficiency anemia is the most frequent type of anemia. In these cases, oral or IV iron supplementation pre-operatively is the preferential treatment, and might decrease the need of blood transfusions. Patients with iron deficiency without anemia also have indication to take oral iron supplementation. This situation urges the application of a well-structured protocol to optimize pre-operative hemoglobin, reduce intra-operative blood loss and improve anemic patients’ status in an effort to reach better outcomes. 

Downloads

Download data is not yet available.

References

1. Simmons, J.D., et al., Elevated levels of plasma mitochondrial DNA DAMPs are linked to clinical outcome in severely injured human subjects. Ann Surg, 2013. 258(4): p. 591-6; discussion 596-8.

2. McMillan, M.T., et al., Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy: A Model for Performance Evaluation. Ann Surg, 2016. 264(2): p. 344-52.

3. DeMatteo, R.P., et al., Long-term results of adjuvant imatinib mesylate in localized, high-risk, primary gastrointestinal stromal tumor: ACOSOG Z9000 (Alliance) intergroup phase 2 trial. Ann Surg, 2013. 258(3): p. 422-9.

4. Dakour-Aridi, H., et al., Anemia and postoperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms. J Vasc Surg, 2019. 69(3): p. 738-751 e2.

5. Cotton, B.A., et al., A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg, 2013. 258(4): p. 527-32; discussion 532-3.

6. Nutritional anaemias. Report of a WHO scientific group. World Health Organ Tech Rep Ser, 1968. 405: p. 5-37.

7. Obi, A.T., et al., The association of perioperative transfusion with 30-day morbidity and mortality in patients undergoing major vascular surgery. J Vasc Surg, 2015. 61(4): p. 1000-9 e1.

8. Leahy, M.F., et al., A pragmatic approach to embedding patient blood management in a tertiary hospital. Transfusion, 2014. 54(4): p. 1133-45.

9. Gupta, P.K., et al., Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations. Ann Surg, 2013. 258(6): p. 1096-102.

10. Trentino, K.M., et al., Associations of nadir haemoglobin level and red blood cell transfusion with mortality and length of stay in surgical specialties: a retrospective cohort study. Anaesthesia, 2019. 74(6): p. 726-734.

11. Bernard, A.C., et al., 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. J Am Coll Surg, 2009. 208(5): p. 931-7, 937 e1-2; discussion 938-9.

12. O'Keeffe, S.D., et al., Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization. J Vasc Surg, 2010. 51(3): p. 616-21, 621 e1-3.

13. Spahn, D.R., Patient Blood Management: Success and Potential in the Future. Ann Surg, 2016. 264(2): p. 212-3.

14. Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic, S., et al., 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth, 2018. 32(1): p. 88-120.
Published
2020-12-13
Section
Original Article

Most read articles by the same author(s)