Perioperative Allogeneic Red Blood Cell Research Articles

High Cell Saver Autotransfusion is Associated With Perioperative Medical Complications in Adult Spinal Deformity Patients.

A retrospective, propensity-matched observational study. To assess the impact of cell saver (CS) homologous transfusion on perioperative medical complications in adult patients undergoing spinal deformity surgery. Despite many endorsing its use, many analyses still refute the efficacy of CS on decreasing total perioperative allogenic red blood cell transfusions, cost efficiency, and its effect on perioperative complications. Adult patients who underwent spinal deformity surgery at a single center between 2015 and 2021 were retrospectively reviewed. Patient-specific, operative, radiographic, and 30-day complications/readmission data were collected for further analysis. Two methods were utilized to test our hypothesis: (1) absolute threshold model: two cohorts created among patients who received ≥550mL of CS intraoperatively and those who received less; (2) adjusted ratio model: two cohorts created dependent on the ratio of CS to estimated blood loss (EBL). Propensity-score matching and various statistical tests were utilized to test the association between CS and perioperative medical complications. Two hundred seventy-eight patients were included in this analysis with a mean age of 61.3±15.7yrs and 67.6% being female. Using the first method, 73 patients received ≥550mL of CS, and 205 received less. Propensity-score matching resulted in 28 pairs of patients. 39.3% of patients with ≥550mL CS required readmission within 30 days compared with 3.57% of patients in the <550mL cohort ( P =0.016), despite a nearly identical proportion of patients requiring intraoperative blood transfusions ( P >0.9999). Using the second method, 155 patients had CS/EBL<0.33 and 123 with CS/EBL ≥0.33. 5.16% and 21.9% among patients with CS/EBL<0.33 and CS/EBL≥0.33, respectively, were readmitted by the 30-day marker ( P <0.0001). Our findings indicate that greater CS volumes transfused are associated with higher rates of 30-day readmissions. Thus, surgeons should consider limiting CS volume intraoperatively to 550mL and when greater volumes are required or preferred, ensuring that the ratio of CS:EBL remains under 0.33.

Clinical efficacy of intraoperative Cell Saver autologous blood salvage in emergency surgery for massive hemothorax.

The objective of this study was to investigate the efficacy of intraoperative Cell Saver blood salvage during emergency surgery for massive hemothorax on minimizing perioperative allogeneic red blood cell (RBC) transfusion. Fourteen consecutive patients of massive hemothorax with more than 800cc of intrathoracic bleeding estimated by chest X-ray and/or chest computed tomography (CT) scan at presentation between 2009 and 2021 were retrospectively reviewed. Intraoperative Cell Saver blood salvage was performed in 11 patients (Cell Saver group) with a median volume of 820cc (range, 421-1700cc). The amount of perioperative allogeneic RBC transfusion in the Cell Saver group (median, 4 units) was significantly smaller than that in the non-Cell Saver group (median, 10 units) (P = 0.009). The volume of Cell Saver autologous transfusion in 6 patients without preoperative chest tube drainage (median, 1114cc) was significantly larger than that in 5 patients who had preoperative drainage (median, 660cc) (P = 0.0173). In conclusion, the utilization of intraoperative blood salvage in emergency surgery for massive hemothorax along with limiting the amount of preoperative chest tube drainage is an efficient strategy to minimize perioperative allogeneic RBC transfusion.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Association of Perioperative Allogeneic Red Blood Cell Transfusion with Postoperative Infections

Allogeneic red blood cell transfusion can induce transfusion-related immunomodulation while correcting anemia and improving oxygenation,and thus may be associated with the increased risk of postoperative infections.However,the available studies have conflicting conclusions.Preclinical studies demonstrate transfusion-related immunomodulation is associated with transfusion amounts.Stored red blood cells can cause more significant immunosuppression than fresh blood products,while leukoreduction alleviates the negative effect on immune system.However,clinical studies do not reach agreements on these issues.Recently,accumulating multi-center,large-sample-size,real-world studies have reported significant associations of all ogeneic red blood cell transfusion in cardiac,orthopedic,hepatic,pancreatic,gastrointestinal,and vesical surgeries with postoperative infections.Considering the limitations of previous studies,future research should focus on multiple operations,prolong the time interval between transfusion and surgery,include different infections into outcomes,and define the postoperative infections accurately in the premise of adequate samples.High-quality clinical evidence could help to optimize the utilization of blood products and improve the postoperative outcomes.

Association between perioperative allogeneic red blood cell transfusion and infection after clean-contaminated surgery: a retrospective cohort study

BackgroundAllogeneic red blood cell (RBC) transfusion can induce immunosuppression, which can then increase the susceptibility to postoperative infection. However, studies in different types of surgery show conflicting results regarding this effect. MethodsIn this retrospective cohort study conducted in a tertiary referral centre, we included adult patients undergoing clean-contaminated surgery from 2014 to 2018. Patients who received allogeneic RBC transfusion from preoperative Day 30 to postoperative Day 30 were included into the transfusion group. The control group was matched for the type of surgery in a 1:1 ratio. The primary outcome was infection within 30 days after surgery, which was defined by healthcare-associated infection, and identified mainly based on antibiotic regimens, microbiology tests, and medical notes. ResultsAmong the 8098 included patients, 1525 (18.8%) developed 1904 episodes of postoperative infection. Perioperative RBC transfusion was associated with an increased risk of postoperative infection after controlling for 27 confounders by multivariable regression analysis (odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.39–1.84; P<0.001) and propensity score weighing (OR: 1.64; 95% CI: 1.45–1.85; P<0.001) and matching (OR: 1.70; 95% CI: 1.43–2.01; P<0.001), and a dose–response relationship was observed. The transfusion group also showed higher risks of surgical site infection, pneumonia, bloodstream infection, multiple infections, intensive care admission, unplanned reoperation, prolonged postoperative length of hospital stay, and all-cause death. ConclusionsPerioperative allogeneic RBC transfusion is associated with an increased risk of infection after clean-contaminated surgery in a dose–response manner. Close monitoring of infections and enhanced prophylactic strategies should be considered after transfusion.

The Effect of Perioperative Blood Transfusion on Long-Term Survival Outcomes After Surgery for Pancreatic Ductal Adenocarcinoma: A Systematic Review.

To evaluate survival outcomes associated with perioperative allogeneic red blood cell transfusion (RBCT) in patients with pancreatic ductal adenocarcinoma undergoing surgery. PubMed, Embase, Cochrane, and Web of Science Core Collection were queried for English-language articles until May 28, 2020. Studies evaluating long-term outcomes of RBCT compared with no transfusion in adults with pancreatic ductal adenocarcinoma undergoing pancreatectomy were included. E-value sensitivity analysis assessed the potential for unmeasured confounders to overcome these findings. Of 4379 citations, 5 retrospective cohort studies were included. Three studies reported shorter recurrence-free survival by 1 to 5 months with RBCT. Two studies found shorter disease-specific survival by 5 to 13 months with RBCT. Overall survival was reduced by 5 to 7 months with RBCT in 3 studies. All multivariable findings associated with RBCT could be readily overcome unmeasured confounding on sensitivity analysis. Confounding in baseline characteristics resulted in high risk of bias. Imprecision, unmeasured confounding, small effect sizes, and overall low quality of the available literature result in uncertainty regarding the effect of transfusion on recurrence-free survival, disease-specific survival, and overall survival in patients undergoing surgery for pancreatic cancer. Randomized trials are needed to determine if there is a causal relationship between transfusion and survival after pancreatic resection.

Significant Variation in Blood Transfusion Practice Persists Following Adolescent Idiopathic Scoliosis Surgery.

Retrospective case control study. To review current transfusion practise following Adolescent Idiopathic Scoliosis (AIS) surgery and assess risks of complication from transfusion in this cohort. No study to date has investigated variation in blood transfusion practices across surgeons and hospitals following AIS surgery. Data were extracted from the Statewide Planning and Research Cooperative System. Using International Classification of Diseases (ICD-9) all patients with (ICD-9) code for AIS (737.30) ("idiopathic scoliosis") and underwent spinal fusion between 2000 and 2015 were included. Bivariate and mixed-effects logistic regression analyses were performed to assess patient, surgeon, and hospital factors associated with perioperative allogeneic red blood cell transfusion. Additional multivariable analyses examined the association between transfusion and infectious complications. Of the 7689 patients who underwent AIS surgery, 21.1% received a perioperative blood transfusion. After controlling for patient factors, wide variation in risk-adjusted transfusion rates was present with a 10-fold difference in transfusion rates observed across surgeons (4.4%-46.1%) and hospitals (5.1%-50%). Patient factors did not explain any of the surgeon or hospital variation. Use of autologous blood transfusion, higher surgeon procedure volume, and greater surgeon years in practice were independently associated with lower odds of allogeneic blood transfusion (P < 0.001), and surgeon and hospital characteristics explained 45% of surgeon variation but only 2.4% of hospital variation. Allogeneic blood transfusion was independently associated with postoperative wound infection (OR = 1.87, 95% CI = 1.20-2.93), pneumonia (OR = 1.68, 95% CI = 1.26-2.44), and sepsis (OR = 2.42, 95% CI = 1.11-5.83). Significant variation exists across both surgeons and hospitals in perioperative blood transfusion utilization following AIS surgery. Use of autologous blood transfusion and implementing institutional transfusion protocols may reduce unwarranted variation and potentially decrease infectious complication rates.Level of Evidence: 3.

Red blood cell transfusions and the survival in patients with cancer undergoing curative surgery: a systematic review and meta-analysis.

Allogenic red blood cell transfusions exert a potential detrimental effect on the survival when delivered to cancer patients undergoing surgery with curative intent. We performed a systematic review and meta-analysis to assess the association between perioperative allogenic red blood cell transfusions and risk of death as well as relapse after surgery for localized solid tumors. PubMed, the Cochrane Library, and EMBASE were searched from inception to March 2019 for studies reporting the outcome of patients receiving transfusions during radical surgery for non-metastatic cancer. Risk of death and relapse were pooled to provide an adjusted hazard ratio with a 95% confidence interval [hazard ratio (HR) (95% confidence interval {CI})]. Mortality and relapse associated with perioperative transfusion due to cancer surgery were evaluated among participants (n = 123 studies). Overall, RBC transfusions were associated with an increased risk of death [HR = 1.50 (95% CI 1.42-1.57), p < 0.01] and relapse [HR = 1.36 (95% CI 1.26-1.46), p < 0.01]. The survival was reduced even in cancer at early stages [HR = 1.45 (1.36-1.55), p < 0.01]. In cancer patients undergoing surgery, red blood cell transfusions reduced the survival and increased the risk of relapse. Transfusions based on patients' blood management policy should be performed by applying a more restrictive policy, and the planned preoperative administration of iron, if necessary, should be pursued.

Risk factors of allogeneic red blood transfusion following enhanced recovery hip and knee arthroplasty

Objective: To Explore the current status and risk factors of perioperative allogenic red blood cell transfusion following enhanced recovery hip and knee joint arthroplasty. Methods: Patients who have taken their primary unilateral total hip and knee arthroplasty (THA, TKA) or simultaneous primary THA were retrospectively included from January, 2019 to December, 2019 in West China Hospital. The baseline characteristics were compared between patients with allogeneic transfusion and those without. And logistic regression were used to analyze the risk factors of perioperative allogeneic red blood cell transfusion. Results: A total of 2 034 patients (2072 arthroplasties) were included, 705 males and 1 329 females, aged (60±24) years. Of all, 1 137 patients received primary THA (38 simultaneous THA), 897 patients received primary unilateral TKA. Eleven (0.54%) patients received allogeneic red blood cell transfusion, and the mean volume was (2.6±1.2) U. Deep venous thrombosis occurred in 2 patients (0.09%) undergoing primary TKA. The transfusion rate in primary THA patients was 0.79% (9/1 137), and 0.22% (2/897) in TKA. Lower preoperative hemoglobin level (P=0.041) and more hematological comorbidities (P=0.005) were detected in transfused patients. And logistic analysis further revealed that preoperative substandard hemoglobin level was the most important risk factor for transfusion (OR=5.663, P=0.018). Conclusions: Under the intervention of enhanced recovery after surgery concept and modern blood management strategies, the transfusion requirement has been significantly reduced following primary joint arthroplasty. Pre-operative hemoglobin level should be an important threshold for perioperative blood management.

Perioperative Allogeneic Red Blood Cell Transfusion and Wound Infections: An Observational Study.

It remains unclear whether the benefits of performing perioperative allogeneic red blood cell (RBC) transfusion outweigh the risks of postoperative wound infection. The aim of this study was to assess the impact of perioperative RBC transfusion as well as dose-response relationship on wound infections in surgical patients in a large cohort. As a retrospective observational study, the national Hospital Quality Monitoring System database was used to retrieve information about in-hospital surgical patients without limitations on surgical types in the People's Republic of China between 2013 and 2018. Patients were divided into the perioperative RBC transfusion and non-RBC transfusion groups, and wound infection rates (the primary end point) were compared. Secondary end points included in-hospital mortality, nosocomial infections, and length of hospital stay. Furthermore, patients who underwent RBC transfusion were subdivided into 6 groups based on the volume of transfused RBCs to investigate the dose-response relationship between RBC transfusions and wound infections. The association between RBC transfusion and patient outcomes were analyzed using multivariable logistic regression models adjusted for potential confounders. A total of 1,896,584 patients from 29 provinces were included, among whom 76,078 (4.0%) underwent RBC transfusions; the overall wound infection rate was 0.7%. After adjusting for confounding factors, perioperative RBC transfusion was associated with higher odds of wound infection (odds ratio [OR] = 2.24, 95% confidence interval [CI], 2.09-2.40; P < .001). As the volume of transfused RBCs increased, so did the odds of wound infection with a clear dose-response relationship (OR of >0 and ≤1 U, >1 and ≤2 U, >2 and ≤4 U, >4 and ≤8 U, >8 U transfusion compared with no RBC transfusion were 1.20, 95% CI, 0.76-1.91; 1.27, 95% CI, 1.10-1.47; 1.70, 95% CI, 1.49-1.93; 2.12, 95% CI, 1.83-2.45 and 3.65, 95% CI, 3.13-4.25, respectively). RBC transfusion was also found to be associated with higher odds of in-hospital mortality, nosocomial infection, and longer hospital stay. RBC transfusion was associated with an increased odd of postoperative wound infection in surgical patients, and a significant dose-related relationship was also observed. While there are still essential confounders not adjusted for and the results do not necessarily indicate a causal relationship, we still recommend to lessen perioperative blood loss and optimize blood conservation strategies.

Erythropoietin plus iron versus control treatment including placebo or iron for preoperative anaemic adults undergoing non-cardiac surgery.

Erythropoietin plus iron versus control treatment including placebo or iron for preoperative anaemic adults undergoing non-cardiac surgery.

Implications of perioperative allogeneic red blood cell transfusion on the immune-inflammatory response.

BackgroundThe allogeneic transfusion-related immunomodulation (TRIM) may be responsible for an increase in survival of renal transplants but in contrast it could increase the rate of bacterial infections or the recurrence rate of tumors post-operatively.ObjectiveThis review focuses in the implications of perioperative allogeneic transfusions on the immune-inflammatory response of surgical transfused patients.ResultsABTs modify immune functions in recipients including decrease of the number of lymphocytes; decrease the CD4 cells; decrease the CD4/CD8 T-cell ratio; decrease NK cells; and decrease the lymphocyte response to mitogens. TRIM effects may be mediated by allogeneic white cells present in blood products; soluble peptides present in transfused plasma; and/or biologic mediators released into the supernatant of blood units. A recent systematic review and meta-analysis including 36 clinical observational studies (n = 174,036) concluded that perioperative ABTs not only decreased overall survival and reduced colorectal cancer-specific survival. Furthermore ABTs increased the rate of infectious, cardiac, pulmonary and anastomotic complications in colorectal cancer patients undergoing surgery.ConclusionsIt has been demonstrated by laboratory tests that TRIM is associated with transfusion recipient immune alterations but its influence in colorectal cancer recurrence after resection remains controversial though may exist. Surgical techniques reducing intraoperative blood loss have limited the number of ABTs perioperatively, however increase in mortality continues to be reported in literature after ABT in colorectal cancer surgery. Poor survival associated to TRIM in colorectal cancer might be due to higher number of allogeneic transfused units and/or prolonged length of blood storage.

An audit and evaluation of appropriateness of perioperative allogenic red blood cell transfusion in liver surgery

Presenter: Laura Baker MD | University of Ottawa Background: Red blood cell (RBC) transfusion in liver surgery is common and associated with post-operative morbidity. Knowledge of appropriateness of administered transfusions in this patient population is lacking. The objective of this study is to (1) evaluate the appropriateness of perioperative transfusions, (2) identify prescriber-associated characteristics associated with inappropriate transfusions, and (3) determine if patients deemed inappropriately transfused are at increased risk of post-operative adverse events in comparison to patients not transfused. Methods: A retrospective review of patients undergoing hepatectomy at a tertiary care liver surgery unit from March 2011 to April 2018 was preformed. Patient demographics, operative details, clinical variables surrounding transfusion events, and information pertaining to patients post-operative course were collected. Appropriateness of RBC transfusions was determined via application of three distinct tools, independently, in duplicate. Results: A cohort of 489 patients underwent liver resection during the study period, of which 19% (n=91) received a total of 241 RBC transfusions in the perioperative period. Forty-one percent of patients underwent a major liver resection. Ninety percent of cases were preformed open. The primary indication for hepatectomy was colorectal liver metastases (52%); 22% of patients underwent resection for primary liver malignancy. Median preoperative hemoglobin was 132g/L; 19% of patients were anemic at the time of surgery. Between 22% to 63% of transfusions administered during the intraoperative period were considered inappropriate based on the three different appropriateness tools. Thirty-eight to 67% of transfusions administered during the post-operative period were considered inappropriate. Patients were at increased risk of being inappropriately transfused in the immediate postoperative period while in the post-operative recovery unit while their care was being overseen by anesthesiologist, compared to later in the postoperative period (OR18.6; 95% CI 2.3-151.5). Prescriber experience (junior versus senior resident versus attending physician), time of transfusion (evenings and weekends versus business hours) and method through which transfusion order was delivered (written versus verbal order) did not influence appropriateness of the transfusion. Patients considered to have been inappropriately transfused during the intraoperative period were at increased risk of developing a major post-operative adverse event (Clavien-Dindo≥grade 3) compared to those who did not receive a transfusion (OR 4.2; 95% CI 1.1-15.6). Conclusion: Despite trends towards reductions in perioperative transfusions in patients undergoing hepatectomy, this work highlights that a significant proportion of patients are being exposed to unnecessary transfusion. There is substantial variability in the estimates provided by the three appropriateness tools, with the incidence of inappropriate RBC transfusion ranging between 22-67%. This study identified the immediate post-operative period as a particularly vulnerable period for patients being transfused unnecessarily. Furthermore, the association identified between development of major post-operative adverse events in patients identified as inappropriately transfused compared to those not transfused further supports the described deleterious effects of blood transfusions in surgical patients. Further work in this area is warranted to minimize the administration of unnecessary, and potentially harmful RBC transfusions.

Outcome impact of different tranexamic acid regimens in cardiac surgery with cardiopulmonary bypass (OPTIMAL): Rationale, design, and study protocol of a multicenter randomized controlled trial

Tranexamic acid (TxA) reduces perioperative blood transfusion in cardiac surgery; however, the optimal dose of TxA remains unknown. METHODS AND RESULTS: This large-scale, double-blind, randomized controlled trial with a 1-year follow-up enrolls patients undergoing elective cardiac surgery with cardiopulmonary bypass. Patients are randomly assigned 1:1 into either the high-dose TxA group (intravenous bolus [30 mg/kg] after anesthesia followed by intravenous maintenance [16 mg/kg/h] throughout the operation, and a pump prime dose of 2 mg/kg) or the low-dose TxA group (intravenous bolus and maintenance are 10 mg/kg and 2 mg/kg/h, respectively, and a pump prime dose of 1 mg/kg). The primary efficacy end point is the rate of perioperative allogeneic red blood cell (RBC) transfusion defined as the number (%) of patients who will receive at least 1 RBC unit from operation day to discharge. The primary safety end point is the 30-day rate of the composite of perioperative seizures, renal dysfunction, myocardial infarction, ischemic stroke, deep vein thrombosis, pulmonary embolism, and all-cause mortality. The secondary end points are perioperative allogeneic RBC transfusion volume, the non-RBC blood transfusion rate, postoperative bleeding, reoperation rate, mechanical ventilation duration, intensive care unit stay, hospital length of stay, total hospitalization cost, each component of composite primary safety end point, and the 6-month/1-year follow-up mortality and morbidity. We estimated a sample size of 3,008 participants. CONCLUSIONS: The study is designed to identify a TxA dose with maximal efficacy and minimal complications. We hypothesize that the high dose has superior efficacy and noninferior safety to the low dose.

Effect of perioperative allogeneic red blood cell infusion on T cell subsets and natural killer cells in peripheral blood of patients with gastric cancer

Objective To investigate the effect of allogeneic red blood cell transfusion on T lymphocyte subsets and natural killer (NK) cells in peripheral blood of patients with gastric cancer during perioperative period. Methods 50 patients with gastric cancer in our hospital from January 2017 to December 2017 were randomly divided into control group (n=25) and observation group (n=25). Perioperative allogeneic erythrocyte transfusion was performed in the observation group, while no allogeneic erythrocyte transfusion was performed in the control group. Blood samples were taken from two groups before and after operation 3 d, and serum T lymphocyte subsets (CD3+, CD4+, CD8+, CD4+ /CD8+ ) and NK cell levels were measured. T cell subsets and NK cell levels of patients in observation group, control group and observation group at different clinical stages before and after operation were counted. According to blood transfusion volume, the patients in the observation group were divided into <4 U group and <4 U group. T cell subsets and NK cell levels before and after operation were compared between the two groups. Results There was no significant difference in CD3+, CD4+, CD8+, CD4+ /CD8+, NK cells between the two groups before operation (P>0.05). The levels of CD3+, CD4+, CD4+ /CD8+, NK cells in the two groups after operation were lower than those before operation and CD8+ levels were higher than those before operation. The levels of CD3+, CD4+, CD4+ /CD8+, NK cells in the observation group were lower than those in the control group, and the levels of CD8+ in the observation group were higher than those in the control group (P 0.05). After operation, the levels of CD3+, CD4+, CD4+ /CD8+, NK cells in the two groups were lower and CD8+ levels were higher than those before operation. The levels of CD3+, CD4+, CD4+ /CD8+, NK cells in stage Ⅰ-Ⅱ patients were higher than those in stage Ⅲ-Ⅳ patients, and CD8+ levels were lower than those in stage Ⅲ-Ⅳ patients (P 0.05). After operation, the levels of CD8+ in the two groups were higher than those before operation, while the levels of CD3+, CD4+, CD4+ /CD8+, NK cells were lower than those before operation; The levels of CD3+, CD4+, CD4+ /CD8+, NK cells in the 4 U group, and CD8+ levels were lower than those in >4 U group (P<0.05). Conclusions Perioperative allogeneic red blood cell transfusion can affect T cell subsets and NK cell content in peripheral blood of patients with gastric cancer, and there are some differences in the effects of different clinical stages of gastric cancer patients, which can cause the suppression of cellular immune function. Key words: Stomach neoplasms; Perioperative period; Erythrocyte transfusion; T-lymphocyte subsets; Killer cells, natural

Clinical Outcomes Associated With Allogeneic Red Blood Cell Transfusions in Spinal Surgery: A Systematic Review.

Study Design:Systematic review.Objectives:The objectives of this systematic review were to report the available clinical evidence on patient outcomes associated with perioperative allogeneic red blood cell (RBC) transfusions in adult patients undergoing spinal surgery and to determine whether there is any evidence to support an association between transfusion timing and clinical outcomes.Methods:A systematic review of the PubMed, EMBASE, and Cochrane Library databases was performed to identify all articles examining outcomes of adult spinal surgery patients who received perioperative allogeneic RBC transfusions. The level of evidence for each study was assessed using the “Oxford Levels of Evidence 2” classification system. Meta-analysis was not performed due to the heterogeneity of reports.Results:A total of 2759 unique citations were identified and 76 studies underwent full-text review. Thirty-four studies were selected for analysis. All the studies, except one, were retrospective. Eleven studies investigated intraoperative or postoperative transfusions. Only one article compared outcomes related to intraoperative versus postoperative transfusions.Conclusions:Perioperative transfusion is associated with increased rates of postoperative complications, especially infectious complications, and prolonged length of stay. Some evidence suggests that a dose-response relationship may exist between morbid events and the number of RBC units administered, but these findings are inconsistent. Because of the heterogeneity of reports and inconsistent findings, the incidence of specific complications remains unclear. Limited research activity has focused on intraoperative versus postoperative transfusions, or the effect of transfusion on functional outcomes of spine surgery patients. Further research is warranted to address these clinical issues.

Medical comorbidities and perioperative allogeneic red blood cell transfusion are risk factors for surgical site infection after shoulder arthroplasty

Multiple perioperative factors have been implicated in infection risk after shoulder arthroplasty. The purpose of this study was to determine surgical site infection (SSI) risk due to medical comorbidities or blood transfusion after primary or revision shoulder arthroplasty. Comprehensive data on medical comorbidities, surgical indication, perioperative transfusion, and SSI were obtained for 707 patients who underwent primary or revision hemiarthroplasty or total shoulder arthroplasty in a single hospital system. Multivariate Poisson regression was used to determine the independent association between allogeneic red blood cell transfusion, medical comorbidities, and SSI after controlling for procedure. The SSI rate was 1.9% for primary hemiarthroplasties and 1.3% for primary total shoulder arthroplasties. Among patients without prior shoulder infection, revision arthroplasty or prior open reduction and internal fixation had higher SSI risk than primary arthroplasties (incidence risk ratio [IRR], 11.4; 95% confidence interval [CI], 3.84-34.0; P < .001); among primary arthroplasties, SSI risk factors included male gender (IRR, 60.0; CI, 4.39-819; P = .002), rheumatoid arthritis (IRR, 8.63; CI, 1.84-40.4; P = .006), and long-term corticosteroid use (IRR, 37.4; CI, 5.79-242; P < .001). Perioperative allogeneic red blood cell transfusion significantly increased SSI risk and was dose dependent (IRR, 1.68 per unit packed red blood cell; CI, 1.21-2.35; P = .002). Gender, rheumatoid arthritis, and long-term (>1 year) corticosteroid use affect SSI risk after shoulder arthroplasty. Revision surgery, particularly in the setting of prior infection, increased risk of future infection. Finally, allogeneic red blood cell transfusion increases SSI risk after shoulder arthroplasty in a dose-dependent manner.

Erythropoietin with iron supplementation for preoperative anaemia in non-cardiac surgery

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: We aim to evaluate the efficacy and safety of preoperative erythropoietin (rHuEPO) with supplemental iron (parenteral or oral) in reducing perioperative allogeneic red blood cell transfusions in preoperatively anaemic people undergoing non-cardiac surgery.

Large Variation in Blood Transfusion Use After Colorectal Resection: A Call to Action.

Perioperative blood transfusions are associated with an increased risk of adverse postoperative outcomes through immunomodulatory effects. The purpose of this study was to identify factors associated with variation in blood transfusion use after elective colorectal resection and associated postoperative infectious complications This was a retrospective cohort study. The study included elective colorectal resections in New York State from 2001 to 2013. The study cohort consists of 125,160 colorectal resections. Patients who were admitted nonelectively or who were admitted before the date of surgery were excluded. Receipt of a perioperative allogeneic red blood cell transfusion and the secondary end points of postoperative pneumonia, surgical site infection, intra-abdominal abscess, and sepsis were measured. The overall rate of perioperative blood transfusion for the study cohort was 13.9%. The unadjusted blood transfusion rates ranged from 2.4% to 58.7% for individual surgeons and 2.9% to 32.8% for individual hospitals. After controlling for patient-, surgeon-, and hospital-level factors in a 3-level mixed-effects multivariable model, significant variation was still present across both surgeons (p < 0.0001) and hospitals (p < 0.0001), with a 16.8-fold difference in adjusted blood transfusion rates across surgeons and a 13.2-fold difference in adjusted blood transfusion rates across hospitals. Receipt of a blood transfusion was also independently associated with pneumonia (OR = 3.23 (95% CI, 2.92-3.57)), surgical site infection (OR = 2.27 (95% CI, 2.14-2.40)), intra-abdominal abscess (OR = 2.72 (95% CI, 2.41-3.07)), and sepsis (OR = 4.51 (95% CI, 4.11-4.94)). Limitations include the retrospective design and the possibility of miscoding within administrative data. Large surgeon- and hospital-level variations in perioperative blood transfusion use for patients undergoing colorectal resection are present despite controlling for patient-, surgeon-, and hospital-level factors. In addition, receipt of a blood transfusion was independently associated with an increased risk of postoperative infectious complications. These findings support the creation and implementation of perioperative blood transfusion protocols aimed at limiting unwarranted variation.

Significant Variation in Blood Transfusion Practice Persists following Upper GI Cancer Resection

PurposePerioperative blood transfusions are costly and linked to adverse clinical outcomes. We investigated the factors associated with variation in blood transfusion utilization following upper gastrointestinal cancer resection and its association with infectious complications. MethodsThe Statewide Planning and Research Cooperative System was queried for elective esophagectomy, gastrectomy, and pancreatectomy for malignancy in NY State from 2001 to 2013. Bivariate and hierarchical logistic regression analyses were performed to assess the factors associated with receiving a perioperative allogeneic red blood cell transfusion. Additional multivariable analysis examined the relationship between transfusion and infectious complications. ResultsAmong 14,875 patients who underwent upper GI cancer resection, 32 % of patients received a perioperative blood transfusion. After controlling for patient, surgeon, and hospital-level factors, significant variation in transfusion rates was present across both surgeons (p < 0.0001) and hospitals (p < 0.0001). Receipt of a blood transfusion was also independently associated with wound infection (OR = 1.68, 95% CI = 1.47 and 1.91), pneumonia (OR = 1.98, 95% CI = 1.74 and 2.26), and sepsis (OR = 2.49, 95% CI = 2.11 and 2.94). ConclusionSignificant variation in perioperative blood transfusion utilization is present at both the surgeon and hospital level. These findings are unexplained by patient-level factors and other known hospital characteristics, suggesting that variation is due to provider preferences and/or lack of standardized transfusion protocols. Implementing institutional transfusion guidelines is necessary to limit unwarranted variation and reduce infectious complication rates.