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1.
Minerva Med ; 111(3): 203-212, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32525293

RESUMO

BACKGROUND: The optimal antithrombotic therapy after transcatheter aortic valve implantation (TAVI) is unsettled. Short and longer-term thromboembolic and bleeding risk post TAVI remain high. Non-vitamin K oral anticoagulant drugs (NOAC) may be attractive after TAVI but the implications of prolonged NOAC in this setting require further research. The aim of this study was to assess the HAS-BLED bleeding risk in a contemporary TAVI population and explore its correlation with the effective bleeding complications with or without (N)OAC. METHODS: This study included 986 consecutive successful TAVI patients from 2 tertiary care facilities. Statistical analysis consisted of Cox regression. Bleedings were classified according to VARC-2 criteria. RESULTS: Mean age was 80.5 years, mean STS was 4.7 and 54% were males. A total of 483 patients (49.2%) had AF and 42.1% were on (N)OAC. The median HAS-BLED score was 2, 42.6% had a HAS-BLED≥3. Overall 216 patients (21.9%) experienced at least 1 bleeding, 166 (16.9%) occurred early after TAVI. HAS-BLED≥3 was an independent predictor of overall and pre-discharge bleeding (respectively HR 1.347 CI 1.029-1.763, P=0.03: HR 1.403 CI 1.032-1.905, P=0.05). The incidence of bleeding was similar in patient on (N)OAC vs. patients not on (N)OAC, both in the low and high HAS-BLED cohorts (P=0.93, P=0.42 respectively). Cardiovascular mortality was significantly higher in the high HAS-BLED cohort (37.5% vs. 24%, P=0.04) and HAS-BLED≥3 was an independent predictor of late mortality (HR 1.452 CI 1.028-2.053, P=0.03). CONCLUSIONS: In our series, contemporary TAVI patients had an elevated HAS-BLED score. The HAS-BLED score correlated with early bleedings and mortality after TAVI. Use of (N)OAC was not associated with more bleedings after TAVI.


Assuntos
Anticoagulantes/efeitos adversos , Estenose da Valva Aórtica/cirurgia , Hemorragia Pós-Operatória/etiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Fibrilação Atrial/epidemiologia , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/mortalidade , Intervalo Livre de Progressão , Análise de Regressão , Tromboembolia/etiologia , Substituição da Valva Aórtica Transcateter/mortalidade
2.
JACC Cardiovasc Interv ; 13(9): 1058-1068, 2020 05 11.
Artigo em Inglês | MEDLINE | ID: mdl-32381184

RESUMO

OBJECTIVES: The aim of this study was to examine the value of frailty to predict in-hospital major bleeding and determine its impact on mid-term mortality following transcatheter (TAVR) or surgical (SAVR) aortic valve replacement. BACKGROUND: Bleeding complications are harbingers of mortality and major morbidity in patients undergoing TAVR or SAVR. Despite the high prevalence of frailty in this population, little is known about its effects on bleeding risk. METHODS: A post hoc analysis was performed of the multinational FRAILTY-AVR (Frailty Aortic Valve Replacement) cohort study, which prospectively enrolled older adults ≥70 years of age undergoing TAVR or SAVR. Trained researchers assessed frailty using a questionnaire and physical performance battery pre-procedure and ascertained clinical data from the electronic health record. The primary endpoint was major or life-threatening bleeding during the index hospitalization, and the secondary endpoint was units of packed red blood cells transfused. RESULTS: The cohort consisted of 1,195 patients with a mean age of 81.3 ± 6.0 years. The incidence of life-threatening bleeding, major bleeding with a clinically apparent source, and major bleeding without a clinically apparent source was, respectively, 3%, 6%, and 9% in the TAVR group and 8%, 10%, and 31% in the SAVR group. Frailty measured using the Essential Frailty Toolset was an independent predictor of major bleeding and packed red blood cell transfusions in both groups. Major bleeding was associated with a 3-fold increase in 1-year mortality following TAVR (odds ratio: 3.40; 95% confidence interval: 2.22 to 5.21) and SAVR (odds ratio: 2.79; 95% confidence interval: 1.25 to 6.21). CONCLUSIONS: Frailty is associated with post-procedural major bleeding in older adults undergoing TAVR and SAVR, which is in turn associated with a higher risk for mid-term mortality.


Assuntos
Estenose da Valva Aórtica/cirurgia , Idoso Fragilizado , Fragilidade/complicações , Implante de Prótese de Valva Cardíaca/efeitos adversos , Hemorragia Pós-Operatória/etiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Canadá , Transfusão de Eritrócitos , Feminino , Fragilidade/diagnóstico , Fragilidade/mortalidade , França , Avaliação Geriátrica , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Hemorragia Pós-Operatória/mortalidade , Hemorragia Pós-Operatória/terapia , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Estados Unidos
3.
Br J Radiol ; 93(1110): 20190413, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32142365

RESUMO

OBJECTIVE: Iatrogenic hemorrhages occur in 0.5-16% of medical procedures. A retrospective study was conducted to analyze technical and clinical outcome of transarterial embolization (TAE) used for acute iatrogenic hemorrhage and to identify factors predicting outcome. METHODS: All patients undergoing TAE for acute iatrogenic bleeding from 2006 to 2013 were retrospectively analyzed. Primary end points were technical and clinical success or failure and 30 day mortality. RESULTS: A total of 153 patients underwent 182 TAEs. Factors associated with clinical failure were lower blood hemoglobin concentration, use of higher number of units of red blood cell concentrate, TAE performed at night or weekend, embolization of more than one vessel, shock state before digital subtraction angiography (DSA), and intensive care before TAE. In multivariate analysis, independent factors for clinical success were hemoglobin concentration, number of units of red blood cell concentrate, and TAE of more than one vessel. Technical failure was associated with female gender, failure to detect signs of bleeding in DSA, TAE of more than one vessel, and shock state before DSA. Bleeding related to anticoagulation medication resulted in a significantly higher mortality rate compared with bleeding due to the remaining causes (30% vs 15%, p < 0.05). CONCLUSION: Despite excellent technical success, the mortality rate was significant. The only factors affecting clinical success were bleeding intensity and extent of injury. Bleeding attributed to anticoagulation is related to high mortality and therefore requires special attention. ADVANCES IN KNOWLEDGE: This study gives insights into morbidity and mortality of iatrogenic bleedings and the technical and clinical success rates of TAE in a large study population.


Assuntos
Embolização Terapêutica/métodos , Hemorragia Pós-Operatória/terapia , Doença Aguda , Idoso , Angiografia Digital , Anticoagulantes/efeitos adversos , Causas de Morte , Cuidados Críticos , Embolização Terapêutica/mortalidade , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Hemoglobina A/análise , Humanos , Doença Iatrogênica , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/mortalidade , Estudos Retrospectivos , Resultado do Tratamento
4.
Am J Cardiol ; 125(8): 1142-1147, 2020 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-32087994

RESUMO

Bleeding risk stratification is an unresolved issue in older adults. Anemia may reflect subclinical blood losses that can be exacerbated after percutaneous coronary intervention . We sought to prospectively determine the contribution of anemia to the risk of bleeding in 448 consecutive patients aged 75 or more years, treated by percutaneous coronary interventions without concomitant indication for oral anticoagulation. We evaluated the effect of WHO-defined anemia on the incidence of 1-year nonaccess site-related major bleeding. The prevalence of anemia was 39%, and 13.1% of anemic and 5.2% of nonanemic patients suffered a bleeding event (hazard ratio 2.75, 95% confidence interval 1.37 to 5.54, p = 0.004). Neither PRECISE-DAPT nor CRUSADE scores were superior to hemoglobin for the prediction of bleeding. In conclusion, anemia is a powerful predictor of bleeding with potential utility for simplifying tailoring therapies.


Assuntos
Síndrome Coronariana Aguda/cirurgia , Anemia/epidemiologia , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Hemorragia Pós-Operatória/epidemiologia , Síndrome Coronariana Aguda/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angina Instável/epidemiologia , Angina Instável/cirurgia , Anticoagulantes/uso terapêutico , Antitrombinas/uso terapêutico , Aspirina/uso terapêutico , Causas de Morte , Clopidogrel/uso terapêutico , Comorbidade , Doença da Artéria Coronariana/epidemiologia , Stents Farmacológicos , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/mortalidade , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/mortalidade , Heparina/uso terapêutico , Hirudinas , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/mortalidade , Estimativa de Kaplan-Meier , Masculino , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/cirurgia , Fragmentos de Peptídeos/uso terapêutico , Cuidados Pós-Operatórios , Hemorragia Pós-Operatória/induzido quimicamente , Hemorragia Pós-Operatória/mortalidade , Cloridrato de Prasugrel/uso terapêutico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Proteínas Recombinantes/uso terapêutico , Medição de Risco , Stents , Ticagrelor/uso terapêutico , Doenças Urológicas/induzido quimicamente , Doenças Urológicas/epidemiologia , Doenças Urológicas/mortalidade
5.
Arch Cardiovasc Dis ; 113(4): 263-275, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32057662

RESUMO

Transcatheter aortic valve replacement (TAVR) has emerged as the treatment of choice for patients with severe aortic stenosis deemed at high or intermediate risk for cardiac surgery. In light of the latest literature advances, TAVR will undoubtedly concern a growing number of patients because of the progressive extension of its indications. Whereas significant efforts have been made to reduce the burden of periprocedural complications, TAVR still exposes patients to a sizeable number of adverse outcomes, including thrombotic and bleeding events. Although contradictory, these two phenomena are closely related to pathophysiological processes inherent to flow disturbances induced by aortic stenosis itself, but also to a complex interaction between bioprosthetic valves and native tissues in frail patients clustering various co-morbidities. Reinforcing this paradigm, multiple TAVR studies have emphasized the view that both thrombosis and bleeding events have a deleterious effect on patient outcomes. Therefore, we sought to perform a comprehensive translational review of the current literature addressing the pathophysiological mechanisms leading to thrombosis and bleeding after TAVR, and underline innovative strategies aimed at reducing these complications.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Hemorragia Pós-Operatória/etiologia , Trombose/etiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Animais , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Estenose da Valva Aórtica/mortalidade , Tomada de Decisão Clínica , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Próteses Valvulares Cardíacas , Humanos , Hemorragia Pós-Operatória/mortalidade , Hemorragia Pós-Operatória/prevenção & controle , Medição de Risco , Fatores de Risco , Trombose/mortalidade , Trombose/prevenção & controle , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/mortalidade , Pesquisa Médica Translacional , Resultado do Tratamento
6.
BMC Cardiovasc Disord ; 20(1): 3, 2020 01 10.
Artigo em Inglês | MEDLINE | ID: mdl-31924163

RESUMO

BACKGROUND: Perioperative bleeding during cardiac surgery are known to make patients susceptible to adverse outcomes and several bleeding classifications have been developed to stratify the severity of bleeding events. Further validation of different classifications was needed. The aim of present study was to validate and explore the prognostic value of different bleeding classifications in patients undergoing off-pump coronary artery bypass grafting (OPCAB). METHODS: Data on baseline and operative characteristics of 3988 patients who underwent OPCAB in Beijing Anzhen Hospital from February 2008 to December 2014 were available. The primary endpoint was a composite of in-hospital death and nonfatal postoperative myocardial infarction (MI). The secondary endpoint was postoperative acute kidney injury (AKI). We explored the association of major bleeding defined by the European registry of Coronary Artery Bypass Grafting (E-CABG), Universal Definition of Perioperative Bleeding (UDPB), Bleeding Academic Research Consortium (BARC) classification and Study of Platelet Inhibition and Patient Outcomes (PLATO) with primary endpoints by multivariable logistic regression analysis and investigated their significance of adverse event prediction using goodness-of-fit tests of - 2 log likelihood. RESULTS: In-hospital mortality was 1.23% (n = 49) and postoperative MI was observed in 4.76% (n = 190) of patients, AKI in 24.69% (n = 985). The incidence of the primary outcome was 5.99% (n = 239). Multivariable logistic regression analysis showed that BARC type 4 (OR = 2.64, 95% CI: 1.66-4.19, P < 0.001), UDPB class 4 (OR = 3.52, 95% CI: 2.05-6.02, P < 0.001) and E-CABG class 2-3 (class 2: OR = 2.24, 95% CI: 1.36-3.70, P = 0.001; class 3: OR = 12.65, 95% CI: 2.74-18.43, P = 0.002) bleeding but not PLATO bleeding were associated with an increased risk of in-hospital death and postoperative MI. Major bleeding defined by all the four classifications mentioned above was an independent risk factor of AKI after surgery. Inclusion of major bleeding defined by these four classifications improved the predictive performance of the multivariable model with baseline characteristics. CONCLUSIONS: Bleeding assessed by BARC, E-CABG and UDPB classifications were significantly associated with poorer immediate outcomes. These classifications seemed to be valuable tool in the assessment of prognostic effect of perioperative bleeding.


Assuntos
Perda Sanguínea Cirúrgica , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Hemorragia Pós-Operatória/diagnóstico , Terminologia como Assunto , Lesão Renal Aguda/etiologia , Idoso , Pequim , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Hemorragia Pós-Operatória/classificação , Hemorragia Pós-Operatória/mortalidade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
7.
J Cardiovasc Surg (Torino) ; 61(2): 234-242, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31937080

RESUMO

BACKGROUND: Cardiac surgery is associated with perioperative bleeding and carries high risk of allogeneic blood transfusion. Recently new scores for prediction of severe bleeding have been developed. This study aims to compare the WILL-BLEED, CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting major bleeding after CABG in patients with low estimated operative risk. METHODS: A multicenter observational study included 1391 patients who underwent isolated CABG from July 2015 to January 2018. We tested the hypothesis that the WILL-BLEED score, specifically designed for CABG, would perform at least as well as the CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting postoperative major bleeding in low operative risk patients. The primary endpoint was the performance of known bleeding risk scores after CABG. The secondary endpoint was the evaluation of in-hospital mortality. RESULTS: Mean age was 68.2±9.4 years and median Euroscore II value was 1.69% (IQR 1.15-2.81%). Mean blood losses in the first 12 postoperative hours was 339.75 mL. Seventy-three (5.2%) subjects underwent administration of blood products. The rate of severe-massive bleeding according to UDPB grades 3-4 was 1.5%. WILL-BLEED, TRUST, TRACK and ACTION scores were significantly associated with severe postoperative bleeding. WILL-BLEED presented the best c-index (AUC: 0.658; 95% CI: 0.600,0.716). Reclassification analysis showed a worsening in sensitivity and significant negative reclassification of CRUSADE, PAPWORTH, TRACK and ACTION scores when compared with WILL-BEED. The combination of WILL-BLEED and TRUST scores improved the prediction ability (AUC: 0.673; 95% CI: 0.615-0.732). Overall in-hospital mortality was 1.65%. Early mortality in patients with severe versus no-severe bleeding was found to be 11.8% vs. 1.0% Severe bleeding (OR: 13.26; P value<0.001) was found to be significantly associated with early mortality. CONCLUSIONS: Severe bleeding after CABG is a harmful event associated with adverse outcomes. WILL-BLEED Score has the better performance in predicting severe-massive bleeding after CABG. The TRUST Score, although suboptimal, represents a valuable alternative in this setting.


Assuntos
Transfusão de Sangue/métodos , Ponte de Artéria Coronária/efeitos adversos , Mortalidade Hospitalar/tendências , Hemorragia Pós-Operatória/diagnóstico , Hemorragia Pós-Operatória/mortalidade , Idoso , Área Sob a Curva , Causas de Morte , Intervalos de Confiança , Angiografia Coronária/métodos , Ponte de Artéria Coronária/métodos , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Estenose Coronária/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/terapia , Prognóstico , Medição de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Resultado do Tratamento
8.
Circ Cardiovasc Interv ; 13(1): e008227, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31937138

RESUMO

BACKGROUND: Vascular and bleeding complications were commonly reported in transcatheter aortic valve replacement clinical trials. Little is known about complication rates in contemporary US clinical practice or clinical outcomes associated with these complications. METHODS: In the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, we evaluated patients undergoing transcatheter aortic valve replacement from November 1, 2011 to June 30, 2016. The primary outcomes were in-hospital vascular complications and bleeding events. Secondary outcomes included all-cause mortality, stroke, and rehospitalization at 1 year. P values for trends were calculated for rates over time, and multivariable logistic regression was used to determine the association between vascular/bleeding complications and in-hospital clinical outcomes. RESULTS: Overall, 34 893 patients undergoing transcatheter aortic valve replacement at 445 hospitals were analyzed. Of these, 9.3% (n=3257) experienced a vascular complication while 7.6% (n=2651) had an in-hospital bleeding event. Rates of both vascular complications and bleeding events decreased over time (P value for trend test <0.0001); however, there was significant variation in rates across hospital sites (adjusted median rate, 11.4%; IQR, 8.9-14.5). Vascular complications were independently associated with 30-day death (adjusted HR, 2.23 [95% CI, 1.80-2.77]) and death (adjusted HR, 1.17 [95% CI, 1.05-1.30]) and rehospitalization (adjusted HR, 1.14 [95% CI, 1.07-1.22]) at 1 year. Bleeding events were also associated with 30-day death (adjusted HR, 3.71 [95% CI, 2.94-4.69]), and with death (adjusted HR, 1.39 [95% CI, 1.23-1.56]) and hospital readmission (adjusted HR, 1.19 [95% CI, 1.11-1.27]) at 1 year. CONCLUSIONS: In patients undergoing transcatheter aortic valve replacement in the US, vascular complications and in-hospital bleeding events were common, but rates have declined over time with significant variation in complication rates across hospital sites. Vascular and bleeding complications are both associated with worse short- and long-term clinical outcomes including all-cause mortality. Further innovation to reduce sheath sizes and optimize antithrombotic therapy is necessary to reduce the incidence of these detrimental complications.


Assuntos
Cateterismo Periférico/tendências , Artéria Femoral , Hemorragia Pós-Operatória/epidemiologia , Substituição da Valva Aórtica Transcateter/tendências , Doenças Vasculares/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/mortalidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Readmissão do Paciente/tendências , Hemorragia Pós-Operatória/mortalidade , Sistema de Registros , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologia , Doenças Vasculares/mortalidade
9.
Ann Vasc Surg ; 63: 53-62, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31626929

RESUMO

BACKGROUND: Perioperative allogenic blood transfusions, specifically packed red bloods cells (pRBC), after vascular surgery procedures are modifiable risk factors that are associated with increased cardiovascular events and 30-day mortality. The aim of this study is to evaluate the effect of transfusion timing (intraoperative vs. postoperative) on the rate of postoperative myocardial infarction (POMI) and death. METHODS: Six surgical and endovascular modules within the Vascular Quality Initiative (VQI) from 2013 to 2017 were reviewed at a single institution. Transfusion data on elective and urgent cases were abstracted and all patients who underwent inpatient procedures had routine postoperative troponin/ECG testing. The primary endpoint was POMI utilizing the American Heart Association's third universal definition for myocardial infarction. These criteria include the detection of a rise/and or fall of cTnT with at least one value above the 99th percentile and with at least one of the following 1) symptoms of acute myocardial ischemia, 2) new ischemic ECG changes, 3) development of pathological Q waves, 4) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with ischemic etiology. The secondary endpoint was 30-day all-cause mortality. Multivariable logistic regression analysis was utilized to evaluate the risk of transfusions on POMI and death. RESULTS: We identified 1,154 cases for analysis (299 abdominal aortic aneurysm [EVAR], 117 infrainguinal bypasses, 127 open abdominal aortic aneurysm [AAA], 41 suprainguinal bypasses, 168 thoracic endovascular aortic repair [TEVAR], and 402 peripheral vascular interventions). Overall, the POMI rate was 2% and mortality 1%. Rates of POMI differed by procedure type (P = 0.04), where infrainguinal bypass had the highest rate of POMI at 4%. Death rates did not vary by type of procedure (P = 0.89). Mean number of intraoperative pRBC and postoperative pRBC transfusion was higher for patients with POMI (intraop: 1.3 vs. 0.3, postop: 1.8 vs. 0.4, both P < 0.01) and death (intraop: 1.4 vs. 0.3, postop: 2.5 vs. 0.4, both P < 0.01). In addition, older age and coronary artery disease (CAD) were associated with POMI on univariate analysis. On multivariable analysis for POMI, CAD (odds ratio [OR] = 5.15, 95% confidence interval [CI] [2.00-13.24], P < 0.001), receiving both an intraoperative and postoperative transfusion (OR = 6.20, 95% CI [1.78-21.55], P < 0.01) as well as a postoperative transfusion only (OR = 5.70, 95% CI [1.81-17.94], P < 0.01) compared to no transfusion were associated with higher odds of POMI; however intraoperative transfusion only was not (OR = 3.42, 95% CI [0.88-13.31], P = 0.08). On multivariable analysis, increasing age of the patient was associated with higher odds of death (OR = 1.08, 95% CI [1.01-1.15], P = 0.02) and statin use was highly protective (OR = 0.27, 95% CI [0.10-0.74], P = 0.01), but any intraoperative or postoperative transfusion compared to no transfusion was not associated with death after adjustment. CONCLUSIONS: In our series with routine postoperative troponin screening in the inpatient setting, the use of an isolated postoperative transfusion as well as cases requiring both an intraoperative and postoperative transfusion was associated with POMI. However, isolated intraoperative transfusion was not associated with POMI, and we did not identify an association of transfusion with 30-day mortality. These data suggest that the perioperative setting of transfusions is important in its impact on postoperative outcomes and needs to be accounted for when evaluating transfusion outcomes and indications.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Eritrócitos/efeitos adversos , Infarto do Miocárdio/etiologia , Hemorragia Pós-Operatória/terapia , Tempo para o Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Perda Sanguínea Cirúrgica/mortalidade , Tomada de Decisão Clínica , Transfusão de Eritrócitos/mortalidade , Feminino , Humanos , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Seleção de Pacientes , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Troponina/sangue , Procedimentos Cirúrgicos Vasculares/mortalidade
10.
Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi ; 54(11): 837-842, 2019 Nov 07.
Artigo em Chinês | MEDLINE | ID: mdl-31795545

RESUMO

Objective: To investigate the potential risk factors for the death of patients underwent gastric pull-up reconstruction following total pharyngoesophagectomy during perioperative periods. Methods: A total of 71 patients, including 64 males and 7 females, aged from 35 to 72 years old, with hypopharyngeal or cervical esophageal carcinoma, who underwent gastric pull-up reconstruction after pharyngoesophagectomy between October 2008 and October 2017, were reviewed retrospectively. Seventeen factors which may have potential influence on the mortality of patients during perioperative periods were evaluated by single factor Logistic regression analysis, and then those factors with obvious difference in statistics were further analyzed by multi-factor Logistic regression. Results: The rate of perioperative mortality was 9.9% (7/71). Single factor Logistic regression analysis indicated that the age of patients, abnormal electrocardiogram, TNM stages, alanine aminotransferase and D-Dimer changes, postoperative bleeding were risk factors for the death of patients(P values were 0.023, 0.004, 0.026, 0.021, 0.015 and 0.002, respectively). Multi-factor Logistic regression showed that postoperative bleeding and D-Dimer changes were 2 independent risk factors for perioperative death(P=0.021 and 0.047, respectively). Conclusions: Many potential factors may affect the perioperative mortality of patients underwent gastric pull-up reconstruction following total pharyngoesophagectomy. Postoperative bleeding and significantly elevated D-Dimer level were independent risk factors for the death of patients, indicating poor prognosis.


Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia/mortalidade , Esôfago/cirurgia , Faringectomia/mortalidade , Faringe/cirurgia , Estômago/cirurgia , Adulto , Idoso , Anastomose Cirúrgica/mortalidade , Neoplasias Esofágicas/sangue , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/mortalidade , Procedimentos Cirúrgicos Reconstrutivos/mortalidade , Estudos Retrospectivos , Fatores de Risco
11.
Surg Obes Relat Dis ; 15(10): 1675-1681, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31590999

RESUMO

BACKGROUND: Bleeding after laparoscopic sleeve gastrectomy (LSG) is an important complication associated with significant morbidity and a drastic increase in healthcare resources. Multiple strategies have been developed to minimize bleeding, including varying bougie size, line reinforcement, and intra-operative tranexamic acid. These techniques, however, have been implemented without a clear understanding of the pre-, intra-, and postoperative predictors of bleeding in patients undergoing SG. OBJECTIVES: The purpose of this study was to examine predictors and outcomes associated with postoperative bleeding in patients undergoing LSG. SETTING: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry. METHODS: We identified Metabolic and Bariatric Surgery Accreditation and Quality Improvement patients who underwent LSG in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of bleeding in LSG patients. Our secondary outcomes of interest include characterizing overall complication rates in LSG patients. Univariate analysis of pre-, intra-, and postoperative variables was performed using Χ2 tests for categorical data and independent sample t test for continuous data. A nonparsimonious multivariable logistic regression model was then developed to determine predictive factors for development of postoperative bleed. RESULTS: A total of 175,353 patients underwent LSG from 2015 to 2016. The majority of patients were female (79.0%), with a mean age of 44.4 ± 12.0 years and a mean body mass index of 45.2 kg/m2 ± standard deviation of 7.9 kg/m2. A total of 1116 (.6%) patients had a postoperative bleed. Bleeding was associated with a mortality of 1.0% versus .1% among patients without bleeding. The mean operative time was 74.0 ± 36.6 minutes with a mean bougie size of 36.9 ± 2.9 Fr, and a mean pylorus distance of 4.80 ± 1.1 cm. Staple-line reinforcement was used in 67.8% of patients while 22.4% were oversewn. Bleeds were associated with a statistically significant increase in all complications, readmission, reoperation, and mortality rates at 30 days. The following statistically significant independent predictors of bleed after LSG were identified using multivariable logistic regression analysis: bougie size, age, prior cardiac procedure, hypertension, renal insufficiency, therapeutic anticoagulation, diabetes, obstructive sleep apnea, and operative length. Staple-line reinforcement, staple-line oversewing, and higher body mass index were found to be protective for bleed after adjusting for confounders and interactions. An increase in pylorus distance did show a signal toward a protective effect; however, this was not statistically significant. CONCLUSION: Bleeding after LSG is associated with increased complications, readmission and reoperation rates, and mortality at 30 days. Staple-line reinforcement techniques independently predict a lower risk of postoperative bleeding after LSG. Adoption of these techniques may therefore have an important role in reducing morbidity and mortality for patients who undergo LSG.


Assuntos
Cirurgia Bariátrica , Gastrectomia , Obesidade Mórbida , Hemorragia Pós-Operatória , Adolescente , Adulto , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/mortalidade , Feminino , Gastrectomia/efeitos adversos , Gastrectomia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/mortalidade , Obesidade Mórbida/cirurgia , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/mortalidade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
12.
Am Surg ; 85(10): 1184-1188, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657321

RESUMO

Guidelines suggest targeting a preoperative international normalized ratio (INR) < 1.5. We examined and compared the predictive value of INR relative to the Model for End-Stage Liver Disease (MELD). We reviewed the American College of Surgeons NSQIP from 2005 to 2016 for adult patients undergoing open or laparoscopic cholecystectomy. Patients with a preoperative INR were stratified into groups: ≤1, >1 to ≤1.5, >1.5 to ≤2, and >2. Thirty day postoperative mortality was the primary outcome. Multivariable logistic regressions controlled for baseline differences. Of 58,177 cholecystectomy patients, 15.2 per cent had INR ≤ 1, 80.4 per cent had INR > 1 to ≤1.5, 3.7 per cent had INR > 1.5 to ≤2, and 0.7 per cent had INR > 2. Patients with INR > 2 were older and more likely to have diabetes and hypertension (P < 0.001). Multivariable regression demonstrated a stepwise increase in mortality for INR > 1 to ≤1.5 (odds ratio (OR) = 1.50 [1.10-2.05]), INR > 1.5 to ≤2 (OR = 2.96 [1.97-4.45]), and INR > 2 (OR = 3.21 [1.64-6.31]) relative to INR ≤ 1. C-statistic for INR (0.910) and MELD (0.906) models indicated a similar value in predicting mortality. INR groups also faced an incremental, increased risk of bleeding. Although unable to track preoperative correction of INR, this analysis identifies that INR remains an excellent predictor of postoperative mortality and bleeding after both open and laparoscopic cholecystectomies and is comparable to MELD.


Assuntos
Colecistectomia/mortalidade , Doença Hepática Terminal/sangue , Doença Hepática Terminal/mortalidade , Coeficiente Internacional Normatizado/mortalidade , Adulto , Fatores Etários , Análise de Variância , Colecistectomia Laparoscópica/mortalidade , Diabetes Mellitus/tratamento farmacológico , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Hipertensão/tratamento farmacológico , Coeficiente Internacional Normatizado/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/mortalidade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco
13.
Urology ; 134: 62-65, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31536740

RESUMO

OBJECTIVE: To evaluate feasibility of percutaneous nephrolithotomy (PCNL) for complex nephrolithiasis in patients 80 years of age and older compared to younger individuals. METHODS: From an institutional IRB-approved database, 1,647 patients were identified who underwent PCNL from 1999 to 2019. Patients were stratified by age: group 1 (20-59), group 2 (60-79), and group 3 (>80). Statistics were performed using chi-square and ANOVA to compare outcomes. RESULTS: Of the 1,647 patients, median age was 46, 66, and 83, respectively (P <0.0001). Three patients within group 3 were 90 or older. Females made up 54%, 46%, 56% of patients (P = 0.02). Average stone size with SD was 2.6 ± 2.2, 2.5 ± 2.3, 2.2± 1.9 cm for each group (P = 0.06). Mean preoperative hemoglobin (Hgb) was significantly lower in the 80+ group (13.8, 13.4, 13.1 g/dL, P <.0001). Change in Hgb was not significantly different. There were more Clavien II-IV complications (10.4, 14.4, 28.8%; P = 0.02) and transfusions (2.3, 4.7, 10.2%; P <0.001) in the elderly. The most common complications in the 80+ group were bleeding related (10.1%). No difference in readmission rates or ICU admissions was noted. CONCLUSION: PCNL is feasible in the extremely elderly; however with a higher rate of complications and longer hospitalizations. No long-term sequelae or deaths in the 80 and older cohort were seen. This study allows us to appropriately counsel older patients on a realistic postoperative course and supports use of PCNL as the best means of long-term survival.


Assuntos
Cálculos Renais , Nefrolitotomia Percutânea , Hemorragia Pós-Operatória , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Hemoglobinas/análise , Humanos , Cálculos Renais/sangue , Cálculos Renais/epidemiologia , Cálculos Renais/cirurgia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Nefrolitotomia Percutânea/efeitos adversos , Nefrolitotomia Percutânea/métodos , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/mortalidade , Hemorragia Pós-Operatória/terapia , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Estados Unidos/epidemiologia
14.
Am Heart J ; 217: 64-71, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31514076

RESUMO

BACKGROUND: Prior registry data suggest that 4%-20% of patients require noncardiac surgery (NCS) within 2 years of percutaneous coronary intervention (PCI). Contemporary data on NCS after PCI in the United States among women and men are limited. We determined the rate of early hospital readmission for NCS and associated outcomes in a large cohort of patients who underwent PCI in the United States. METHODS: Adults undergoing PCI between January 1 and June 30, 2014, were identified from the Nationwide Readmission Database. Patients readmitted for NCS within 6 months of PCI were identified. Outcomes of interest were in-hospital death, myocardial infarction (MI), and bleeding defined by International Classification of Diseases, Ninth Revision, codes. RESULTS: Among 221,379 patients who underwent PCI and survived to hospital discharge, 3.5% (n = 7,696) were readmitted for NCS within 6 months post-PCI, and 41% of these hospitalizations were elective. Early NCS was complicated by MI in 4.7% of cases, and 21% of perioperative MIs were fatal. Bleeding was recorded in 32.0% of patients. All-cause mortality occurred in 4.4% of patients (n = 339) readmitted for surgery. The risk of death or MI was greatest when NCS was performed within the first month after PCI. CONCLUSIONS: Despite clear guidelines to avoid surgery early after PCI, NCS was performed in 1 of every 29 patients with recent PCI, corresponding to as many as ~30,000 patients each year nationwide. Surgical mortality and perioperative MI were high in this setting. Strategies to minimize perioperative thrombotic and bleeding risks during readmission for NCS after PCI are necessary.


Assuntos
Stents Farmacológicos/estatística & dados numéricos , Infarto do Miocárdio/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Hemorragia Pós-Operatória/epidemiologia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Bases de Dados Factuais/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Razão de Chances , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/mortalidade , Risco , Fatores Sexuais , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/mortalidade , Fatores de Tempo , Estados Unidos
15.
Updates Surg ; 71(4): 659-667, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31376077

RESUMO

Precise risk factors for bleeding after pancreatoduodenectomy (PD) need to be further explored. We aimed to identify which variables were associated with the risk of post-pancreatectomy hemorrhage (PPH) and benchmark the PPH rate and related outcome in our intermediate-volume center with the current literature. We retrospectively analyzed 183 PD records. We investigated the association between PPH and a number of pre-surgical (age, body mass index, bilirubin plasma level, gender, American Society of Anesthesiologists classification (ASA) and smoking status, vascular hypertension), surgical (technique, additional organ resection, occlusion of the stump) and post-surgical (pancreatic fistula, bile leak and abscess development) risk factors with multivariable regression models. PPH episodes were classified and graded according to the International Study Group of Pancreatic Surgery. The overall PPH risk was 19.6%. Specific PPH mortality was 16.6%. Occurrence of PPH was increased in male patients (RR = 2.4, p = 0.001), with ASA ≥ 3 (RR = 2.1, p = 0.009) and hypertension (RR = 1.8, p = 0.04). Active smoking was protective (RR = 0.26, p = 0.001). Among postoperative factors, only pancreatic fistula increased the risk (RR = 1.6, p = 0.034). Early PPH was associated with the type of surgical reconstruction (RR 4.02, 95% CI 1.41-11.44, p = 0.009) and late PPH with pancreatic fistula (RR 2.88, 95% CI 1.06-7.83, p = 0.038). For grade C PPH, the impact of pancreatic fistula was greater (RR = 2.8, p = 0.04). Pancreatic fistula plays a crucial role in the pathogenesis of PPH. In addition, male gender, ASA ≥ 3 and hypertension increase the risk of PPH, while smoking appears protective. The PPH risk and subsequent consequences are at an acceptable rate in an intermediate-volume center.


Assuntos
Pancreaticoduodenectomia/efeitos adversos , Hemorragia Pós-Operatória/epidemiologia , Idoso , Bases de Dados Factuais , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Incidência , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Fístula Pancreática/epidemiologia , Hemorragia Pós-Operatória/mortalidade , Estudos Retrospectivos , Fatores de Risco
16.
Heart Surg Forum ; 22(4): E294-E297, 2019 07 25.
Artigo em Inglês | MEDLINE | ID: mdl-31398095

RESUMO

BACKGROUND: The aim of this study is to evaluate the negative effect of malnutrition in patients with coronary artery disease who are undergoing coronary artery bypass graft surgery. METHODS: In this study, we analyzed 149 patients, who underwent coronary artery bypass surgery. Nutritional status of the patients was classified using controlling nutritional status score (CONUT) and prognostic nutritional index (PNI). Statistical correlation between malnutrition and complication following operation was evaluated with the chi-square test. Statistical alpha significant level was accepted P < 0.05. RESULTS: There were various complications in 38 patients. Renal failure was the predominant problem in 18 of them. There was statistical significance between malnutrition and complication (P < .001). There were more complications in the controlling nutritional status score and prognostic nutritional index groups. Renal complication (P < .001), hemorrhage (P < .05), and mortality (P < .05) were high in the severe controlling nutritional status score and prognostic nutritional index groups. CONCLUSION: There are manifest correlations between the severe controlling nutritional status score and prognostic nutritional index groups and morbidity and mortality after coronary artery bypass graft surgery. We found that renal complications, hemorrhage, and mortality rate.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Desnutrição/complicações , Avaliação Nutricional , Estado Nutricional , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Distribuição de Qui-Quadrado , Ponte de Artéria Coronária/mortalidade , Feminino , Humanos , Masculino , Desnutrição/mortalidade , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/mortalidade , Insuficiência Renal/etiologia , Insuficiência Renal/mortalidade , Adulto Jovem
18.
CMAJ ; 191(30): E830-E837, 2019 07 29.
Artigo em Inglês | MEDLINE | ID: mdl-31358597

RESUMO

BACKGROUND: Among adults undergoing contemporary noncardiac surgery, little is known about the frequency and timing of death and the associations between perioperative complications and mortality. We aimed to establish the frequency and timing of death and its association with perioperative complications. METHODS: We conducted a prospective cohort study of patients aged 45 years and older who underwent inpatient noncardiac surgery at 28 centres in 14 countries. We monitored patients for complications until 30 days after surgery and determined the relation between these complications and 30-day mortality using a Cox proportional hazards model. RESULTS: We included 40 004 patients. Of those, 715 patients (1.8%) died within 30 days of surgery. Five deaths (0.7%) occurred in the operating room, 500 deaths (69.9%) occurred after surgery during the index admission to hospital and 210 deaths (29.4%) occurred after discharge from the hospital. Eight complications were independently associated with 30-day mortality. The 3 complications with the largest attributable fractions (AF; i.e., potential proportion of deaths attributable to these complications) were major bleeding (6238 patients, 15.6%; adjusted hazard ratio [HR] 2.6, 95% confidence interval [CI] 2.2-3.1; AF 17.0%); myocardial injury after noncardiac surgery [MINS] (5191 patients, 13.0%; adjusted HR 2.2, 95% CI 1.9-2.6; AF 15.9%); and sepsis (1783 patients, 4.5%; adjusted HR 5.6, 95% CI 4.6-6.8; AF 12.0%). INTERPRETATION: Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality. Study registration: ClinicalTrials.gov, no. NCT00512109.


Assuntos
Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/mortalidade , Estudos Prospectivos , Sepse/mortalidade
19.
Circ J ; 83(8): 1674-1681, 2019 07 25.
Artigo em Inglês | MEDLINE | ID: mdl-31257312

RESUMO

BACKGROUND: Although minimally invasive mitral valve surgery via a right minithoracotomy (MICS-mitral) is widely performed, no tool to evaluate its risk has been reported. We sought to establish MICS-mitral risk calculators using a national clinical database for selection of appropriate patients.Methods and Results:Between 2008 and 2015, 3,240 patients (mean age 59±14 years, males 1,950) underwent a MICS-mitral procedure in Japan and were registered in a national clinical database. We examined mortality and composite outcome (operative mortality, stroke, reoperation for bleeding) using multivariate analysis, then developed a risk calculator for each using stepwise analysis. Operative mortality was 1.1% and the composite outcome rate was 5%. In multivariate analysis, risk factors for operative mortality were shown to be age, respiratory dysfunction, thoracic aortic disease, myocardial infarction, body mass index >30, NYHA class IV, moderate or severe aortic regurgitation, mitral valve replacement, multiple valve surgery, and annual cases <10. ROC curve analysis of our prediction formulas for mortality and composite outcome revealed an area under the curve for operative mortality of 0.877 (95% confidence interval: 0.82-0.94, P<0.01) and for composite outcome of 0.665 (95% confidence interval: 0.62-0.71, P<0.01). CONCLUSIONS: We developed risk calculator formulas using risk factors associated with both operative mortality and composite outcome. The present risk calculator formula is useful for patient selection and may influence future applications for this procedure.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Tomada de Decisão Clínica , Técnicas de Apoio para a Decisão , Doenças das Valvas Cardíacas/cirurgia , Valva Mitral/cirurgia , Seleção de Pacientes , Toracotomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Bases de Dados Factuais , Feminino , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/fisiopatologia , Hemodinâmica , Mortalidade Hospitalar , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Hemorragia Pós-Operatória/mortalidade , Hemorragia Pós-Operatória/cirurgia , Valor Preditivo dos Testes , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Toracotomia/efeitos adversos , Toracotomia/mortalidade , Fatores de Tempo , Resultado do Tratamento
20.
Transfusion ; 59(9): 2812-2819, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31259421

RESUMO

BACKGROUND: Recent research has questioned restrictive transfusion policies in vulnerable elderly populations. Our audit assesses the prevalence and postoperative outcomes of extremely elderly patients undergoing the stress of surgery with perioperative hemoglobin (Hb) less than 9 g/dL. STUDY DESIGN AND METHODS: This retrospective analysis of prospectively collected data addressed patients aged 85+ undergoing elective surgery. Demographic data and baseline characteristics were recorded, as well as Hb and transfused red blood cell (RBC) units. The main endpoint was the prevalence of perioperative Hb less than 9 g/dL, that is, patients with baseline Hb <9 g/dL without preoperative transfusions (defined as Group A). Patients with perioperative Hb of 9 g/dL or greater (with or without transfusion) were designated as Group B. Secondary outcomes included morbidity, length of hospital stay, and mortality 30 days and 6 months after surgery. A bivariate analysis was performed followed by logistic regression to determine whether undergoing the stress of surgery with perioperative Hb less than 9 g/dL was an independent risk factor for postoperative outcomes. RESULTS: A total of 148 patients were included. The prevalence of perioperative Hb less than 9 g/dL was 25%. It was associated with increased morbidity and mortality -both 30 days and 6 months after surgery- and a prolonged length of hospital stay. Anemia-associated complications were higher among patients from Group A, whereas transfusion-associated ones were evenly distributed. In all the regression models, perioperative Hb less than 9 g/dL was an independent risk factor for worse postoperative outcomes. CONCLUSION: Perioperative Hb less than 9 g/dL was common among patients aged 85+, and it was associated with increased risk of adverse postoperative outcomes. The tolerance to anemia might decrease perioperatively when Hb is less than 9 g/dL. Thus, less restrictive thresholds deserve further evaluation.


Assuntos
Envelhecimento/fisiologia , Transfusão de Sangue/normas , Fatores Etários , Idoso de 80 Anos ou mais , Envelhecimento/sangue , Transfusão de Sangue/métodos , Transfusão de Sangue/estatística & dados numéricos , Calibragem , Auditoria Clínica , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/mortalidade , Procedimentos Cirúrgicos Eletivos/normas , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Transfusão de Eritrócitos/efeitos adversos , Feminino , Humanos , Tempo de Internação , Masculino , Morbidade , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/mortalidade , Hemorragia Pós-Operatória/terapia , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Reação Transfusional/epidemiologia , Reação Transfusional/mortalidade , Reação Transfusional/prevenção & controle , Populações Vulneráveis
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