Use of preoperative erythropoietin-stimulating agents is associated with decreased thrombotic adverse events compared to red blood cell transfusion in surgical patients with anaemia.

BACKGROUND AND OBJECTIVES: Preoperative red blood cell (RBC) transfusions increase post-operative venous thromboembolic (VTE) events. Erythropoietin-stimulating agents (ESAs) increase VTE risk in cancer patients; we aimed to assess ESA versus RBC-associated VTE risks in a broad population of surgical patients. MATERIALS AND METHODS: We queried TriNetX Diamond Network from 2006 to 2023, comparing patients with anaemia within 3 months preoperatively who received preoperative ESAs with or without intravenous (IV) iron to patients who received preoperative RBCs. Sub-analyses included (1) all surgeries and (2) cardiovascular surgeries. We propensity score matched for demographics, comorbidities, medical services, post-treatment haemoglobin (g/dL) and, for all-surgery comparisons, surgery type. Outcomes included 30-day post-operative mortality, VTE, pulmonary embolism (PE), disseminated intravascular coagulation (DIC) and haemoglobin. RESULTS: In our 19,548-patient cohorts, compared with preoperative RBC transfusion, ESAs without IV iron were associated with lower mortality (relative risk [RR] = 0.51 [95% confidence interval (CI), 0.45-0.59]), VTE (RR = 0.57 [0.50-0.65]) and PE (RR = 0.67 [0.54-0.84]). Post-operative haemoglobin was higher in the ESA without IV iron cohort compared with the transfusion cohort (10.0 ± 1.4 vs. 9.4 ± 1.8 g/dL, p = 0.002). Cardiac surgical patients receiving ESAs with or without IV iron had lower risk for post-operative mortality, VTE and PE (p < 0.001) than those receiving RBCs. Post-operative haemoglobin differed between patients receiving ESAs with IV iron versus RBCs (10.1 ± 1.5 vs. 9.4 ± 1.9 g/dL, p = 0.0009). CONCLUSION: Compared with surgical patients who were transfused RBCs, ESA recipients had reduced 30-day post-operative risk of mortality, VTE, PE and DIC and increased haemoglobin levels. IV iron given with ESAs improved mortality.

A Propensity-Matched Cohort Study of Intravenous Iron versus Red Cell Transfusions for Preoperative Iron-Deficiency Anemia.

BACKGROUND: While preoperative anemia is associated with adverse perioperative outcomes, the benefits of treatment with iron replacement versus red blood cell (RBC) transfusion remain uncertain. We used a national database to establish trends in preoperative iron-deficiency anemia (IDA) treatment and to test the hypothesis that treatment with preoperative iron may be superior to RBC transfusion. METHODS: This study is a propensity-matched retrospective cohort analysis from 2003 to 2023 using TriNetX Research Network, which included surgical patients diagnosed with IDA within 3 months preoperatively. After matching for surgery type and comorbidities, we compared a cohort of patients with preoperative IDA who were treated with preoperative intravenous (IV) iron but not RBCs (n = 77,179), with a cohort receiving preoperative RBCs but not IV iron (n = 77,179). Propensity-score matching was performed for age, ethnicity, race, sex, overweight and obesity, type 2 diabetes, hyperlipidemia, essential hypertension, heart failure, chronic ischemic heart disease, neoplasms, hypothyroidism, chronic kidney disease, nicotine dependence, surgery type, and lab values from the day of surgery including ferritin, transferrin, and hemoglobin split into low (<7 g/dL), medium (7-<12 g/dL), and high (≥12 g/dL) to account for anemia severity. The primary outcome was 30-day postoperative mortality with the secondary outcomes being 30-day morbidity, postoperative hemoglobin level, and 30-day postoperative RBC transfusion. RESULTS: Compared with RBC transfusion, preoperative IV iron was associated with lower risk of postoperative mortality (n = 2550/77,179 [3.3%] vs n = 4042/77,179 [5.2%]; relative risk [RR], 0.63, 95% confidence interval [CI], 0.60-0.66), and a lower risk of postoperative composite morbidity (n = 14,174/77,179 [18.4%] vs n = 18,632/77,179 [24.1%]; RR, 0.76, 95% CI, 0.75-0.78) (both P = .001 after Bonferroni adjustment). Compared with RBC transfusion, IV iron was also associated with a higher hemoglobin in the 30-day postoperative period (10.1 ± 1.8 g/dL vs 9.4 ± 1.7 g/dL, P = .001 after Bonferroni adjustment) and a reduced incidence of postoperative RBC transfusion (n = 3773/77,179 [4.9%] vs n = 12,629/77,179 [16.4%]; RR, 0.30, 95% CI, 0.29-0.31). CONCLUSIONS: In a risk-adjusted analysis, preoperative IDA treatment with IV iron compared to RBC transfusion was associated with a reduction in 30-day postoperative mortality and morbidity, a higher 30-day postoperative hemoglobin level, and reduced postoperative RBC transfusion. This evidence represents a promising opportunity to improve patient outcomes and reduce blood transfusions and their associated risk and costs.

Perioperative Plasma in Addition to Red Blood Cell Transfusions Is Associated With Increased Venous Thromboembolism Risk Postoperatively.

BACKGROUND: Perioperative red blood cell (RBC) transfusions increase venous thromboembolic (VTE) events. Although a previous study found that plasma resuscitation after trauma was associated with increased VTE, the risk associated with additional perioperative plasma is unknown. METHODS: A US claims and EHR database (TriNetX Diamond Network) was queried. We compared surgical patients who received perioperative plasma and RBC to patients who received perioperative RBC but not plasma. Subanalyses included (1) all surgeries (n = 48,580) and (2) cardiovascular surgeries (n = 38,918). Propensity score matching was performed for age at surgery, ethnicity, race, sex, overweight and obesity, type 2 diabetes, disorders of lipoprotein metabolism, essential hypertension, neoplasms, nicotine dependence, coagulopathies, sepsis, chronic kidney disease, liver disease, nonsteroidal anti-inflammatory analgesics, platelet aggregation inhibitors, anticoagulants, hemoglobin level, outpatient service utilization, and inpatient services; surgery type was included for "all surgeries" analyses. Outcomes included 30-day mortality, postoperative VTE, pulmonary embolism (PE), and disseminated intravascular coagulation (DIC). RESULTS: After matching the surgical cohorts, compared to only RBC, plasma + RBC was associated with higher risk of postoperative mortality (4.52% vs 3.32%, risk ratio [RR]: 1.36 [95% confidence interval, 1.24-1.49]), VTE (3.92% vs 2.70%, RR: 1.36 [1.24-1.49]), PE (1.94% vs 1.33%, RR: 1.46 [1.26-1.68]), and DIC (0.96% vs 0.35%, RR: 2.75 [2.15-3.53]). Among perioperative cardiovascular patients, adding plasma to RBC transfusion was associated with similar increased risk. CONCLUSIONS: When compared with perioperative RBC transfusion, adding plasma was associated with increased 30-day postoperative mortality, VTE, PE, and DIC risk among surgical and cardiovascular surgical patients. Reducing unnecessary plasma transfusion should be a focus of patient blood management to improve overall value in health care.

Examining cefazolin utilization and perioperative anaphylaxis in patients with and without a penicillin allergy label: A cross-sectional study.

STUDY OBJECTIVE: To compare the occurrence of cefazolin perioperative anaphylaxis (POA) in patients with and without a penicillin allergy label (PAL) to determine whether the prevalence of cefazolin POA differs based on the presence of a PAL. DESIGN: Cross-sectional study. SETTING: A large U.S. healthcare system in the Baltimore-D.C. region, July 2017 to July 2020. PATIENTS: 112,817 surgical encounters across inpatient and outpatient settings in various specialties, involving 90,089 patients. Of these, 4876 (4.3%) encounters had a PAL. INTERVENTIONS: Perioperative cefazolin administration within 4 h before surgery to 4 h after the procedure began. MEASUREMENTS: The primary outcome was cefazolin POA in patients with and without PALs. Potential POA cases were identified based on tryptase orders or diphenhydramine administrations within the initial cefazolin administration to 6 h postoperatively. Verification included two validation steps. The first checked for hypersensitivity reaction (HSR) documentation, and the second, led by Allergy specialists, identified POA and the probable culprit. The secondary outcome looked at cefazolin use trends in patients with a PAL, stratified by setting and specialty. MAIN RESULTS: Of 112,817 encounters, 1421 (1.3%) had possible cefazolin HSRs. Of these, 22 (1.5%) had POA, resulting in a 0.02% prevalence. Of these, 13 (59.1%) were linked to cefazolin and 9 (40.9%) attributed to other drugs. Only one cefazolin POA case had a PAL, indicating no significant difference in cefazolin POA prevalence between patients with and without PALs (p = 0.437). Perioperative cefazolin use in patients with PALs steadily increased from 2.6% to 6.0% between 2017 and 2020, specifically in academic settings. CONCLUSIONS: The prevalence of cefazolin POA does not exhibit significant differences between patients with and without PALs, and notably, the incidence remains remarkably low. Based on these findings, it is advisable to view cefazolin as an acceptable choice for prophylaxis in patients carrying a PAL.

Development and Publication of Clinical Practice Parameters, Reviews, and Meta-analyses: A Report From the Society of Cardiovascular Anesthesiologists Presidential Task Force.

The Society of Cardiovascular Anesthesiologists (SCA) is committed to improving the quality, safety, and value that cardiothoracic anesthesiologists bring to patient care. To fulfill this mission, the SCA supports the creation of peer-reviewed manuscripts that establish standards, produce guidelines, critically analyze the literature, interpret preexisting guidelines, and allow experts to engage in consensus opinion. The aim of this report, commissioned by the SCA President, is to summarize the distinctions among these publications and describe a novel SCA-supported framework that provides guidance to SCA members for the creation of these publications. The ultimate goal is that through a standardized and transparent process, the SCA will facilitate up-to-date education and implementation of best practices by cardiovascular and thoracic anesthesiologists to improve patient safety, quality of care, and outcomes.

Team Dynamics in the Operating Room: How Is Team Performance Optimized?

Health care requires the effort of a team, and nowhere is this more evident than in the care of the surgical patient. No single clinician can perform all aspects of the continuum of surgical care. The basic operating room (OR) team consists of nurses, technicians, surgeons, and anesthesiologists with unique and well-defined roles and expertise in perioperative care. The modern OR team continues to grow and evolve in size, diversity, and complexity to meet the needs of growing patient and procedural complexity. This growing complexity makes achieving optimal team performance paramount and challenging.

Unexpected impact of preoperative anemia in low-risk isolated coronary artery bypass grafting or single-valve surgical patients: Do not overlook these patients in anemia management!

OBJECTIVE: Preoperative anemia is prevalent in cardiac surgery and independently associated with increased risk for short-term and long-term mortality. The purpose of this study was to examine the effect of preoperative hematocrit (Hct) on outcomes in cardiac surgical patients and whether the effect is comparable across levels of Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM). METHODS: The study consisted of adult, isolated coronary artery bypass grafting (CABG) or single-valve surgical patients in a statewide registry from 2011 to 2022 (N = 29,828). Regressions were used to assess effect of preoperative Hct on STS-defined major morbidity/mortality including the interaction of Hct and STS PROM as continuous variables. RESULTS: Median age was 66 years (58-73 years), STS PROM was 1.02% (0.58%-1.99%), and preoperative Hct was 39.5% (35.8%-42.8%). The sample consisted of 78% isolated CABG (n = 23,261), 10% isolated mitral valve repair/replacement (n = 3119), 12% isolated aortic valve replacement (n = 3448), and 29% were female (n = 8646). Multivariable analyses found that greater Hct was associated with reduced risk of STS-defined morbidity/mortality (odds ratio, 0.96; P < .001). These effects for Hct persisted even after adjustment for intraoperative blood transfusion. The interaction of Hct and STS PROM was significant for morbidity/mortality (odds ratio, 1.01; P < .001). There was a stronger association between Hct levels and morbidity/mortality risk in the patients with the lowest STS risk compared with patients with the greatest STS risk. CONCLUSIONS: Patients with lower risk had a greater association between preoperative Hct and major morbidity and mortality compared with patients with greater risk. Preoperative anemia management is essential across all risk groups for improved outcomes.

Institutional Variability in Red Blood Cell Transfusion With Coronary Bypass in a Statewide Database.

BACKGROUND: The decision to perform transfusion is common but varies among centers and surgeons. This study looked at variables associated with red blood cell (RBC) transfusion in a statewide database. The study aimed to understand discrepancies in transfusion rates among hospitals and to establish whether the hospital itself was a significant variable in transfusion, independent of variables known to affect transfusion in patients undergoing cardiac surgical procedures. METHODS: The Maryland Cardiac Surgery Quality Initiative is a consortium of centers in the state. Patients undergoing isolated coronary artery bypass grafting from January 2018 to June 2020 from 10 centers in Maryland were included. Multivariable logistic regression was used to determine probability of RBC transfusion with covariates, including age, preoperative hemoglobin value, The Society of Thoracic Surgeons predicted risk of mortality, emergency status, preoperative adenosine diphosphate receptor blocker use, sex, body mass index, and off-pump status. RESULTS: A total of 5343 patients were included and had an overall RBC transfusion rate of 30.3% (range, 11.3%-55.8%). There was significant variability in the incidence of RBC transfusion among hospitals (χ2 = 604.7; P < .001). After covariate adjustment, a significant effect of hospital on transfusion remained (Wald = 547.3; P < .001). Hospital variation in RBC transfusion was not correlated with hospital variation in median age (P = .467), hemoglobin (P 0 855), The Society of Thoracic Surgeons predicted risk of mortality (P = .855), or sex (P = .726). CONCLUSIONS: In a statewide analysis, wide variability in transfusion rates was observed, with hospital-specific management strongly associated with RBC transfusion. This study suggests that RBC transfusion may be affected by the culture and practices of an institution independent of clinical and demographic variables.

Ultrafiltration in cardiac surgery: Results of a systematic review and meta-analysis.

Background: Ultrafiltration is used with cardiopulmonary bypass to reduce the effects of hemodilution and restore electrolyte balance. We performed a systematic review and meta-analysis to analyze the effect of conventional and modified ultrafiltration on intraoperative blood transfusion.Methods: Utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, we systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane Library to perform a meta-analysis of studies of randomized controlled trials (RCTs) and observational studies evaluating conventional ultrafiltration (CUF) and modified ultrafiltration (MUF) on the primary outcome of intraoperative red cell transfusions.Results: A total of 7 RCTs (n = 928) were included, comparing modified ultrafiltration (n = 473 patients) to controls (n = 455 patients) and 2 observational studies (n = 47,007), comparing conventional ultrafiltration (n = 21,748) to controls (n = 25,427). Overall, MUF was associated with transfusion of fewer intraoperative red cell units per patient (n = 7); MD -0.73 units; 95% CI -1.12 to -0.35 p = 0.04; p for heterogeneity = 0.0001, I2 = 55%) compared to controls. CUF was no difference in intraoperative red cell transfusions compared to controls (n = 2); OR 3.09; 95% CI 0.26-36.59; p = 0.37; p for heterogeneity = 0.94, I2 = 0%. Review of the included observational studies revealed an association between larger volumes (>2.2 L in a 70 kg patient) of CUF and risk of acute kidney injury (AKI).Conclusion: The results of this systematic review and meta-analysis suggest that MUF is associated with fewer intraoperative red cell transfusions. Based on limited studies, CUF does not appear to be associated with a difference in intraoperative red cell transfusion.

Implementing change in the care of the complex cardiac patient.

PURPOSE OF REVIEW: Development of advanced and minimally invasive surgical procedures is providing treatment opportunities to older and higher risk patients. This has also led to highly specialized physicians and a need for better communication and planning with the patients and within the care team. RECENT FINDINGS: In the field of cardiac surgery, the heart team model has been advocated and implemented as a vehicle to optimize decision making prior to procedure, care during the procedure and in the recovery process. The goal is to provide a treatment path that prioritizes the patient's goals and to anticipate and minimize complications. SUMMARY: In this review, we discuss the concepts of shared decision making (SDM) and implementation science in the context of the complex cardiac patient. We also review the most recent evidence for their use in cardiac surgery. We argue that a team model not only bridges knowledge gaps but provides a multidisciplinary environment for the practice of SDM and implementation of evidence-based practices. Be believe this will provide patients with a better experience as they navigate their care and improve their medical outcomes as well.

Dose-dependent effects of red blood cell transfusion and case mix index on venous thromboembolic events in spine surgery.

BACKGROUND AND OBJECTIVES: Venous thromboembolic (VTE) events represent a major source of morbidity and mortality in spine surgery. Our goal was to assess whether a dose-response relationship exists between red blood cell (RBC) transfusion and postoperative VTE events among spine surgery patients. MATERIALS AND METHODS: A total of 786 spine surgery patients at a single institution who received at least 1 RBC unit perioperatively were included (2016-2019). Patients were stratified based on RBC transfusion volume: 1-2 units (39.3%), 3-4 units (29.4%), 5-6 units (15.9%) and ≥7 units (15.4%). Subgroup analyses were performed after stratification by case mix index, a standardized surrogate for patients' disease severity and comorbidities. Multivariable regression was used to assess risk factors for the development of postoperative VTE events. RESULTS: The overall VTE event rate was 2.4% (n = 19). A dose-response relationship was seen between RBC transfusion volume and VTE events (1-2 units: 0.97%, 3-4 units: 1.30%, 5-6 units: 3.20%, ≥7 units: 7.44%; p < 0.01). Similar dose-response relationships were seen between case mix index and VTE events (1.00-3.99: 0.52%, 4.00-6.99: 2.68%, ≥7.00: 9.00%; p < 0.01). On multivariable regression, larger RBC transfusion volumes (adjusted odds ratio [OR] 1.18 per RBC unit, 95% confidence interval [CI] 1.07-1.29; p < 0.01) and higher case mix index scores (adjusted OR 1.39 per unit increase, 95% CI 1.14-1.69; p < 0.01) were associated with an increased risk of thrombosis. CONCLUSION: Larger RBC transfusion volumes and higher case mix index scores were associated with an increased risk of VTE events. Physicians should be aware of how these dose-response relationships can influence a patient's risk of developing thrombotic complications postoperatively.

Patient Blood Management in Vascular Surgery.

Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.

Selected Transesophageal Echocardiographic Parameters of Left Ventricular Diastolic Function Predict Length of Stay Following Coronary Artery Bypass Graft-A Prospective Observational Study.

(1) Importance: Abnormal left ventricular (LV) diastolic function, with or without a diagnosis of heart failure, is a common finding that can be easily diagnosed by intra-operative transesophageal echocardiography (TEE). The association of diastolic function with duration of hospital stay after coronary artery bypass (CAB) is unknown. (2) Objective: To determine if selected TEE parameters of diastolic dysfunction are associated with length of hospital stay after coronary artery bypass surgery (CAB). (3) Design: Prospective observational study. (4) Setting: A single tertiary academic medical center. (5) Participants: Patients with normal systolic function undergoing isolated CAB from September 2017 through June 2018. (6) Exposures: LV function during diastole, as assessed by intra-operative TEE prior to coronary revascularization. (7) Main Outcomes and Measures: The primary outcome was duration of postoperative hospital stay. Secondary intermediate outcomes included common postoperative cardiac, respiratory, and renal complications. (8) Results: The study included 176 participants (mean age 65.2 ± 9.2 years, 73% male); 105 (60.2%) had LV diastolic dysfunction based on selected TEE parameters. Median time to hospital discharge was significantly longer for subjects with selected parameters of diastolic dysfunction (9.1/IQR 6.6−13.5 days) than those with normal LV diastolic function (6.5/IAR 5.3−9.7 days) (p < 0.001). The probability of hospital discharge was 34% lower (HR 0.66/95% CI 0.47−0.93) for subjects with diastolic dysfunction based on selected TEE parameters, independent of potential confounders, including a baseline diagnosis of heart failure. There was a dose−response relation between severity of diastolic dysfunction and probability of discharge. LV diastolic dysfunction based on those selected TEE parameters was also associated with postoperative cardio-respiratory complications; however, these complications did not fully account for the relation between LV diastolic dysfunction and prolonged length of hospital stay. (9) Conclusions and Relevance: In patients with normal systolic function undergoing CAB, diastolic dysfunction based on selected TEE parameters is associated with prolonged duration of postoperative hospital stay. This association cannot be explained by baseline comorbidities or common post-operative complications. The diagnosis of diastolic dysfunction can be made by TEE.