Preoperative Hb Level Research Articles

Is there a need for routine post-operative hemoglobin level estimation in total knee arthroplasty with tranexamic acid use?

BackgroundTotal knee arthroplasty (TKA) can result in significant blood loss, leading to a need for blood transfusion. The major indication of transfusion is post-operative hemoglobin (Hb) levels in association with symptomatic anemia. The aim of this study was to determine the possibility of eliminating routine post-operative Hb tests in patients undergoing TKA with intra-articular tranexamic acid (TXA) use based on the predictability of pre-operative factors. MethodsWe conducted a retrospective analysis of 487 patients who underwent TKA with intra-articular TXA use. Statistical analysis was done to predict the transfusion risk based on multiple pre-operative parameters. ResultsPost-operative blood transfusions were required in 2.5% of all patients. Pre-operative-Hb was the only significant predictor of post-operative transfusion (p<0.0001). Age, sex, weight, height and body mass index (BMI) were not related to post-operative transfusion risk. Transfusions were needed in 4.2% of patients with pre-operative Hb levels <14g/dl. No patient with a pre-operative Hb >14g/dl required a transfusion (p<0.0001). ConclusionsPre-operative Hb is a strong predictor of post-operative blood transfusion risk. Patients who receive TXA in TKA, with a pre-operative Hb >14g/dl do not require routine post-operative Hb evaluation.Level of evidence: IV

Effects of a single rectal dose of Misoprostol prior to abdominal hysterectomy in women with symptomatic leiomyoma: a randomized double blind clinical trial.

BackgroundFibroma, the most common benign pelvic tumor in women, affects 25 to 30% of women of reproductive age. Primary treatment for patients with symptomatic or large fibroma is surgery.ObjectiveThe purpose of this study was to investigate the effect of a single rectal dose of Misoprostol on bleeding during abdominal hysterectomy.MethodsThis double blind randomized clinical trial was conducted with 80 candidates for abdominal hysterectomy, due to uterine myoma, in the Shahid Sadoughi hospital of Yazd in 2012. The aim of this study was to assess the effect of single rectal dose of Misoprostol on peri-operational abdominal hysterectomy bleeding. Following administration of 400 micrograms of Misoprostol in the case group (n=40), predetermined criteria were compared with control group (n=40).ResultsVolume of bleeding during the operation was significantly lower in cases where Misoprostol was used. (268.71 ± 156.85 vs. 350.38 ± 152.61 cc in the case and control groups, respectively). Our findings also showed that Hemoglobin (Hb) levels before, 8, and 30 hours following the operation differed significantly (p=0.001), but these changes were similar in both groups. Pre-operative Hb levels were 11.90 ± 1.7 and 11.90 ± 2.0 in the case and control groups, respectively.ConclusionA single rectal dose of Misoprostol has positive effect on reducing peri-operational bleeding in women undergoing abdominal hysterectomy due to symptomatic leiomyoma.

Impact of preoperative hemoglobin and CRP levels on cancer-specific survival in patients undergoing radical cystectomy for transitional cell carcinoma of the bladder: results of a single-center study

Different blood parameters have shown to be associated with patient's oncological outcome. There is only limited knowledge about the prognostic relevance of routine blood parameters in patients undergoing radical cystectomy for transitional cell carcinoma (TCC). Therefore, we retrospectively analyzed the influence of preoperative C-reactive protein (CRP) and hemoglobin (Hb) levels on overall survival (OS) and cancer-specific survival (CSS). Preoperative CRP and Hb levels were available in 664 patients who underwent RC due to TCC from 2004 to 2013 at our institution. More men than women (77 vs. 23%) underwent surgery with a median age of 70years (35-97). Median follow-up time was 24months (max. 108). Outcome was analyzed using Kaplan-Meier method, log-rank test, and Cox regression models. Median CRP level was 0.5mg/dl (0.1-28.3), and median Hb level was 13.4g/dl (6.7-17.9). Patients with CRP value above the median died significantly earlier due to their disease than those with CRP below the median (median CSS 19 vs. 70months; p<0.001). Patients with preoperative Hb level below the median had significantly worse outcome than those with Hb level above the median (median CSS 25 vs. 78months; p<0.001). In multivariate analysis, CRP and Hb levels were independent prognostic parameters regarding CSS/OS (CRP p=0.016/p=0.004; Hb p=0.006/p=0.004, respectively). In our single-center study, preoperative CRP and Hb levels were found to be independent prognostic factors, indicating impaired outcome in patients undergoing RC for TCC. These findings could be used for individual risk stratification and optimization of therapeutic strategies.

Complete blood count before and after total hip or knee arthroplasty.

To validate our transfusion protocol based on pre- and post-operative complete blood count (CBC) data in patients undergoing primary total hip or knee arthroplasty (THA or TKA). Records of 113 men and 205 women aged 32 to 94 (mean, 70) years who underwent primary uncemented THA (n=123) or cemented TKA (n=195) for osteoarthritis by 2 senior surgeons were reviewed. A post-surgical drain was used in 29 THA patients and 74 TKA patients, based on the surgeon's preference. CBC was assessed preoperatively, during postanaesthesia care, and at the beginning of postoperative days 1, 2, and 3 to determine their predictive power for transfusion rate. According to our transfusion protocol, blood was transfused when the haemoglobin (Hb) level was <80 g/l, or when hypotension, tachycardia, light-headedness, dizziness, or syncope occurred. Respectively in 123 and 195 patients who underwent THA and TKA, the transfusion rates within 3 days were 31.7% (n=39) and 25.6% (n=50). No patient required transfusion during postanaesthesia care; the transfusion rates of all patients during day 1 to day 2 and day 2 to day 3 were 15.1% (n=48) and 12.9% (n=41), respectively. The transfusion rate was higher in women than men (36.6% vs. 12.4%, p<0.001), but did not differ significantly in patients with or without a post-surgical drain (29.1% vs. 27.4%, p=0.754). Respectively for the Hb level of <130 g/l, 130-150 g/l, and >150 g/l, the overall transfusion rates were 48.5%, 22.0%, and 4.3% based on the preoperative level; 32.6%, 7.6%, and 0% based on the postanaesthesia care level; and 28.9%, 8.3%, and 0% based on the day 1 level. The predictive power of the preoperative Hb level was highest, followed by that during postanaesthesia care and the on day 1. CBC during postanaesthesia care is no more predictive than preoperative CBC. Preoperative optimisation and close monitoring of the Hb level from day 1 to day 3 is recommended.

Living donor liver transplantation with body-weight more or less than 10 kilograms.

To compare the outcomes of pediatric patients weighing less than or more than 10 kg who underwent liver transplantation. Data for 196 pediatric patients who underwent living donor liver transplantation between June 1994 and February 2011 were reviewed retrospectively. The information for each patient was anonymized and de-identified before analysis. The data included information regarding the pre-transplant conditions, intraoperative fluid replacement and outcomes for each patient. The 196 patients were divided into two groups: those with body weights of less than 10 kg were included in group 1 (G1; n = 101), while those with body weights of more than 10 kg were included in group 2 (G2; n = 95). For each group, the patients' ages, body weights, heights, pediatric end stage liver disease scores, anesthesia times, and warm and cold ischemic times were analyzed. In addition, between-group comparisons were also made. Mann-Whitney U tests were used to compare all the variables except for complications and survival rates, which were analyzed using χ(2) tests and Kaplan-Meier tests, respectively. The general medical conditions of the G1 patients were worse than those of the G2 patients, as shown by the higher pediatric end stage liver disease scores and poorer Z-scores. In addition, the pre-operative Hb and serum albumin levels were all lower for the G1 patients than for the G2 patients. The G1 patients also had significantly more intraoperative blood loss than the G2 patients. In addition, the intraoperative fluid requirements for the G1 patients, including leukocyte poor red blood cell transfusions, 5% albumin infusions and crystalloid infusions, were significantly higher than those for the G2 patients. The risk of intraoperative portal vein thrombosis was higher for the patients in G1 than for those in G2. However, the one-year survival rates (95.9% and 96.8% for G1 and G2, respectively) and three-year survival rates (94.9% and 94.6% for G1 and G2, respectively) for both groups were similar. Patients weighing less than 10 kg typically have poorer conditions, but their survival rates are comparable to those of children weighing more than 10 kg.

The Impact of Perioperative Blood Transfusion on Survival of Bladder Cancer Patients Submitted to Radical Cystectomy: Role of Anemia Status

BackgroundThe prognostic role of perioperative blood transfusion (PBT) in patients who underwent radical cystectomy (RC) for bladder cancer (BCa), although supported by clinical evidence, still remains to be assessed definitively. ObjectiveTo investigate the impact of PBT on RC patients for overall survival and after stratifying according to preoperative anemia status and to define whether the oncologic impact may be assumed to be a primary effect of PBT or attributed to the reduced preoperative hemoglobin (Hb) level. Design, setting, and participantsA total of 1490 consecutive patients with nonmetastatic BCa who underwent RC and pelvic lymph node dissection between January 1990 and August 2013 at a single referral center entered the study. PBT and preoperative Hb levels were statistically correlated with postoperative oncologic outcomes. Outcome measurements and statistical analysisKaplan-Meier analyses were used to evaluate the impact of PBT on overall mortality (OM) and cancer-specific mortality (CSM). Multivariable Cox regression analyses tested the relationship between PBT and the risk of OM and CSM in the overall population and after stratifying patients according to the severity of their anemia. Results and limitationsA total of 580 patients (38.9%) received PBT. Mean postoperative follow-up was 125.13 mo (median: 110 mo). Overall 5- and 10-yr CSM survival rates were 58.3% and 47.6%, respectively. At multivariable Cox regression analyses, PBT could not be associated with an increased risk of either CSM or OM (all p > 0.3). Conversely, preoperative Hb levels were significantly associated with OM (hazard ratio [HR]: 0.88; confidence interval [CI], 0.83–0.95) and CSM (HR: 0.84; 95% CI, 0.77–0.95) (all p<0.001). A significant detrimental effect of PBT on OM (HR: 1.65; 95% CI, 1.08–2.52) and CSM (HR: 1.68; 95% CI, 1.04–2.70) (all p<0.03) was found in patients without preoperative anemia status. ConclusionsIn nonanemic BCa patients proposed for RC, PBT is associated with a significant detrimental effect on CSM and OM. This effect seems to be attributable to the direct impact of PBT, regardless of the preoperative Hb value. Patient summaryIn nonanemic patients proposed for radical cystectomy, a negative prognostic impact of perioperative blood transfusion should be taken into account.

Effect of dutasteride treatment on reducing blood loss and in perioperative period of open prostatectomy

Open prostatectomy (OP) is a valid option for the surgical treatment of large prostates in the absence of holmium laser enucleation. The most frequent complication of OP is intra- and perioperative bleeding. Preoperative use of dutasteride has been shown to reduce vascularity and perioperative bleeding in transurethral resection of the prostate (TUR-P). However, there has been no study addresing this effect in OP. The aim of this study was to evaluate whether pretreatment with dutasteride for 6 weeks before OP can reduce surgical blood loss. Data of 218 patients with benign prostatic hyperplasia (BPH) who underwent OP was investigated retrospectively. Of the 218 patients, 46 were treated with dutasteride for at least 6 weeks and the rest were dutasteride naïve. Age, prostate volume, prostate-specific antigen (PSA) levels, coagulation tests, platelet counts, pre- and postoperative hemoglobin (Hb) levels, and transfusion history were recorded. Blood loss was estimated as follows: preoperative Hb (-) postoperative Hb (+) amount of transfusion. The 2 groups were compared by independent samples t-test and a p value of 0.05 was considered significant. The groups were similar in terms of age, prostate volume, platelet counts, coagulation tests, and postoperative Hb levels. Preoperative Hb levels were lower in the dutasteride group (13.4 vs. 14.3, p=0.002) and amount of bleeding (-2.72 g/dL vs. -1.93 g/dL, p= 0.01) was shown to be significantly lower in dutasteride group. Our results showed that pretreatment with dutasteride for 6 weeks before OP considerably reduces perioperative surgical bleeding. Further prospective randomized trials should be conducted to confirm the effectiveness of such treatment.

PREPARE: the prevalence of perioperative anaemia and need for patient blood management in elective orthopaedic surgery: a multicentre, observational study.

Patient blood management (PBM) can prevent preoperative anaemia, but little is known about practice in Europe. To assess the pre and postoperative prevalence and perioperative management of anaemia in patients undergoing elective orthopaedic surgery in Europe. An observational study; data were collected from patient records via electronic case report forms. Seventeen centres in six European countries. Centres were stratified according to whether they had a PBM programme or not. One thousand five hundred and thirty-four patients undergoing major elective hip, knee or spine surgery [49.9% hip, 37.2% knee, 13.0% spine; age 64.0 years (range 18 to 80), 61.3% female]. Prevalence of preoperative (primary endpoint) and postoperative anaemia [haemoglobin (Hb) <13 g dl (male), Hb <12 g dl (female)], perioperative anaemia management, time to first blood transfusion and number of transfused units. Data are shown as mean (SD) or median (interquartile range). Anaemia prevalence increased from 14.1% preoperatively to 85.8% postoperatively. Mean Hb decrease was 1.9 (1.5) and 3.0 (1.3) g dl in preoperatively anaemic and nonanaemic patients, respectively (P < 0.001). In PBM (n = 7) vs. non-PBM centres, preoperative anaemia was less frequent (8.0 vs. 18.5%; P < 0.001) and iron status was assessed more frequently (ferritin 11.0 vs. 2.6%, transferrin saturation 11.0 vs. 0.1%; P < 0.001). Perioperative anaemia correction (mainly transfusion) was given to 34.3%. Intraoperatively, 14.8% of preoperatively anaemic and 2.8% of nonanaemic patients received transfusions [units per patient: 2.4 (1.5) and 2.2 (1.4), median time to first intraoperative transfusion: 130 (88, 158) vs. 179 (135, 256) min; P < 0.001]. Postoperative complications were more frequent in preoperatively anaemic vs. nonanaemic patients (36.9 vs. 22.2%; P = 0.009). Most patients who underwent elective orthopaedic surgery had normal preoperative Hb levels but became anaemic after the procedure. Those who were anaemic prior to surgery had an increased intraoperative transfusion risk and postoperative complication rate. PBM measures such as iron status assessment and strategies to avoid transfusion are still underused in Europe.

Impact of Blood Transfusions and Transfusion Practices on Long-Term Outcome Following Hepatopancreaticobiliary Surgery

BackgroundThe long-term impact of transfusions with packed red blood cells (PRBC) among patients undergoing hepatopancreaticobiliary (HPB) surgery remains ill-defined. We sought to determine the impact of overall blood utilization, as well as a restrictive transfusion strategy, on long-term outcomes among patients undergoing an HPB resection for a malignancy. MethodsData on overall blood utilization and hemoglobin (Hb) levels that triggered a transfusion were obtained for patients with cancer undergoing pancreas or liver surgery between 2009 and 2013. Risk-adjusted recurrence-free (RFS) and overall survival (OS) were assessed based on receipt of PRBC and whether the patient received a transfusion using a restrictive transfusion strategy (intraoperative: Hb <10 g/dL; postoperative: Hb <8 g/dL). ResultsFour hundred forty-two patients underwent either a pancreas (58.1 %) or liver (41.9 %) resection. Most tumors were pancreatic in origin (41.8 %), while a subset were primary (23.1 %) or secondary (18.8 %) liver tumors. One hundred seventy-five (39.6 %) patients received ≥1 PRBC transfusion either intraoperatively (16.7 %), postoperatively (12.7 %), or both (10.2 %). There was a higher incidence of PRBC transfusion among patients undergoing a pancreas resection, those with higher comorbidities, and those with lower preoperative Hb levels. Perioperative morbidity was higher among patients receiving either 1–2 units (OR 3.14) or 3 or more units of PRBC (OR 8.54). Median OS was 31.9 months. Receipt of a blood transfusion was associated with a worse OS (1–2 units: HR 1.76; 3 + units: HR 2.50; both P < 0.05), and RFS (3 + units: HR 2.91; P = 0.02). Utilization of a restrictive transfusion strategy did not impact perioperative morbidity or long-term RFS or OS. ConclusionsAdoption of a more restrictive transfusion strategy in patients undergoing resection for cancer may preserve a limited resource, reduce costs, as well as avoid exposing oncology patients to the unnecessary risks associated with a transfusion.

A single dose of misoprostol for reducing hemorrhage during myomectomy: a randomized clinical trial

To evaluate the effect of vaginal misoprostol on intraoperative bleeding during myomectomy. In this randomized clinical trial, 80 women with myomas were randomly assigned to receive 200 µg misoprostol or placebo (vitamin B6) 3 h before surgery. Blood loss during surgery, postoperative need for blood transfusion, and the hemoglobin level before surgery, and 6 and 12 h after surgery were assessed in two groups. Mean age and the mean preoperative and postoperative Hb levels were not significantly different between the two groups. Mean duration of surgery and mean estimated blood loss were significantly higher in control group. Nine (22.5 %) patients in control group needed blood transfusion while there was no need blood transfusion in misoprostol group (p = 0.001). A single dose of vaginal misoprostol is effective in reducing hemorrhage during myomectomy.

Effect of tubeless percutaneous nephrolithotomy on early renal function: Does it deteriorate?

Background:The impact of standard percutaneous nephrolithotomy (PCNL) on short or long-term renal function has been evaluated in many studies. We evaluated the effect of tubeless PCNL on early renal function.Materials and Methods:A total of 117 patients referring to our university center for PCNL were enrolled in the study if they were matched with the inclusion criteria. Serum creatinine and hemoglobin (Hb) levels were measured before PCNL and 6, 24, 48, and 72 h after the operation. Glomerular filtration rate (GFR) was calculated using Cockroft-Gault formula.Results:There were 79 (67.5%) men and 38 women (32.5%) with the mean age of 49.94 years ranging from 18 to 80 years in the study group. The mean creatinine level elevated in the first 48 h after PCNL but it started to reduce on the 3rd day (mean preoperative creatinine level: 1.32 ± 0.18 mg/dL, mean creatinine level after 48 h: 1.59 ± 0.24 mg/dL, creatinine level after 72 h: 1.42 ± 0.21245 mg/dL) (P < 0.0001). GFR values had the same rise and fall pattern as serum creatinine level (mean preoperative GFR: 74.89 mL/min, mean GFR after 48 h: 64.04 mL/min, GFR after 72 h: 69.54 mL/min, P < 0.0001). PCNL also affected blood Hb level. The mean preoperative Hb level was 15.06 ± 0.87 g/dL and it significantly decreased to 13.09 ± 1.06 g/dL after the operation (P < 0.0005).Conclusions:Tubeless PCNL like standard PCNL decreases GFR in the very early postoperative days. It is recommended that factors that might have a negative impact on renal function during first few days after PCNL be avoided.

Pre-treatment anemia is a poor prognostic factor in soft tissue sarcoma patients.

BackgroundAnemia refers to low hemoglobin (Hb) levels, represents a common symptom and complication in cancer patients and was reported to negatively influence survival in patients with various malignancies. In the present study, we aimed to explore the prognostic impact of pre-operative Hb levels on clinical outcome in a large cohort of soft tissue sarcoma (STS) patients after curative surgery.MethodsRetrospective data from 367 STS patients, which were operated between 1998 and 2013, were included in the study. Cut-off levels for anemia were defined as Hb<13 g/dl in males and Hb<12 g/dl in females according to the current WHO guidelines. The impact of pre-operative Hb levels on cancer-specific survival (CSS) and overall survival (OS) was assessed using Kaplan-Meier curves. Additionally, Hb levels were compared for the prognostic influence on CSS and OS applying univariate and multivariate Cox proportional models.ResultsHb level was associated with established prognostic factors, including age, tumor grade, size and depth (p<0.05). Kaplan-Meier curves showed that low Hb levels were significantly associated with decreased CSS and OS in STS patients (p<0.001 for both endpoints, log-rank test). In multivariate analysis, we found an independent association between low Hb levels and poor CSS and OS (HR = 0.46, Cl 95% = 0.25–0.85, p = 0.012; HR = 0.34, Cl 95% = 0.23–0.51, p<0.001).ConclusionThe present data underline a negative prognostic impact of low pre-operative Hb levels on clinical outcome in STS patients. Thus, Hb levels may provide an additional and cost-effective tool to discriminate between STS patients that are at high risk of mortality.

Hemoglobin Level to Facilitate Off-Pump Coronary Artery Bypass without Transfusion.

BackgroundConservation of blood during cardiac surgery is important because of the shortage of donor blood, risks associated with transfusion, and the costs of allogeneic blood products. This retrospective study explored the feasibility of off-pump coronary artery bypass (OPCAB) without transfusion.MethodsOne hundred and two consecutive patients underwent OPCAB from January 2007 to June 2012 at Hallym University Sacred Heart Hospital. Excluding 10 chronic renal failures patients, 102 patients were enrolled. Their characteristics, clinical data, and laboratory data were analyzed. We investigated the success rate of OPCAB without transfusion according to pre-operative hemoglobin (Hb), and the cutoff point of the Hb level and the risk factors for transfusion. We implemented multidisciplinary blood-saving protocols.ResultsThe overall operative mortality and the success rate of OPCAB without transfusion were 2.9% (3/102) and 73.5% (75/102). The success rates in patients with Hb<11, 11 <Hb<14, and 14<Hb were 35.0%, 79.2%, and 89.7% (p=0.01), respectively. The risk factors for transfusion are age>70 years, diagnosis of acute myocardial infarction, preoperative Hb and creatinine levels, and operation time. The events precipitating the need for transfusion were low Hb level in 9 patients and hypotension or excessive bleeding in 18 patients.ConclusionThe preoperative Hb level of >11 facilitates OPCAB without transfusion. These results suggest that transfusion-free OPCAB can be performed by modifying the risk factors and correctable causes of transfusion and improving various blood salvage methods.

Variation in triggers and use of perioperative blood transfusion in major gastrointestinal surgery.

The decision to perform intraoperative blood transfusion is subject to a variety of clinical and laboratory factors. This study examined variation in haemoglobin (Hb) triggers and overall utilization of intraoperative blood transfusion, as well the impact of transfusion on perioperative outcomes. The study included all patients who underwent pancreatic, hepatic or colorectal resection between 2010 and 2013 at Johns Hopkins Hospital, Baltimore, Maryland. Data on Hb levels that triggered an intraoperative or postoperative transfusion and overall perioperative blood utilization were obtained and analysed. Intraoperative transfusion was employed in 437 (15·6 per cent) of the 2806 patients identified. Older patients (odds ratio (OR) 1·68), patients with multiple co-morbidities (Charlson co-morbidity score 4 or above; OR 1·66) and those with a lower preoperative Hb level (OR 4·95) were at increased risk of intraoperative blood transfusion (all P < 0·001). The Hb level employed to trigger transfusion varied by sex, race and service (all P < 0·001). A total of 105 patients (24·0 per cent of patients transfused) had an intraoperative transfusion with a liberal Hb trigger (10 g/dl or more); the majority of these patients (78; 74·3 per cent) did not require any additional postoperative transfusion. Patients who received an intraoperative transfusion were at greater risk of perioperative complications (OR 1·55; P = 0·002), although patients transfused with a restrictive Hb trigger (less than 10 g/dl) showed no increased risk of perioperative morbidity compared with those transfused with a liberal Hb trigger (OR 1·22; P = 0·514). Use of perioperative blood transfusion varies among surgeons and type of operation. Nearly one in four patients received a blood transfusion with a liberal intraoperative transfusion Hb trigger of 10 g/dl or more. Intraoperative blood transfusion was associated with higher risk of perioperative morbidity.

Tolerance of intraoperative hemoglobin decrease during cardiac surgery.

It has been suggested that a decrease of at least 50% from the preoperative hemoglobin (Hb) level during cardiac surgery is associated with adverse outcomes even if the absolute Hb level remains above the commonly used transfusion threshold of 7.0 g/dL. In this study the relation between intraoperative Hb decline of at least 50% and a composite endpoint was analyzed. This single-center study comprised 11,508 patients who underwent cardiac surgery and had normal preoperative Hb levels (12.0-16.0 g/dL in women, 13.0-18.0 g/dL in men) between January 2001 and December 2011. Logistic regression modeling was used. The composite endpoint comprised in-hospital mortality, stroke, myocardial infarction, and renal failure. Patients whose Hb did not decrease at least 50% and remained above 7 g/dL were used as reference (n = 9672). A total of 363 (3.2%) patients had an intraoperative Hb of less than 7 g/dL during surgery but a Hb decrease of less than 50%; 876 patients (7.4%) showed both a nadir Hb less than 7 g/dL and a Hb decrease of at least 50%, while 597 (5.2%) had a Hb decrease of at least 50% and a nadir Hb of at least 7 g/dL. In this last group the incidence of the composite endpoint was higher than in patients in the reference group (adjusted odds ratio, 1.27; 95% confidence interval, 1.14-1.41). Our findings show that a decrease of at least 50% from baseline Hb during cardiac surgery is associated with adverse outcomes, even if the absolute Hb level remains higher than the commonly used transfusion threshold of 7.0 g/dL.

Should all patients be optimized to the same preoperative hemoglobin level to avoid transfusion in primary knee arthroplasty?

Optimization of the preoperative hemoglobin (Hb) level is an effective way to reduce allogeneic transfusion in total knee arthroplasty (TKA) though the procedure is expensive, requires close monitoring and is often inconvenient for patients with reduced mobility. Our aim was to investigate the value of preoperative Hb levels to predict transfusion and thereby tailoring Hb optimization to patient characteristics. All consecutive patients who undergone primary TKA in our center over 2years, and received tranexamic acid intraoperatively, were reviewed. The adjusted association between preoperative Hb levels and transfusion was assessed by multivariate logistic regression, and the estimated probability of transfusion for individual patients was derived from the logistic model. Out of the 784 patients who meet the inclusion criteria, risk of transfusion was associated with poorer performance status, as measured by the America Association of Anestesiology (ASA) score III/IV (OR: 3·3, P<0·001) and lower preoperative Hb level (OR 3·8 for each g/dl below 13g/dl; P<0·001). According to the Hb level, the estimated probability of transfusion was 0·03 (range: 0·03-0·64) for ASA I/II patients and 0·10 (range: 0·10-0·84) for ASA III/IV. Not all the patients undergoing TKA who receive tranexamic acid need the same preoperative Hb optimization target. Two easily available factors, such as the ASA score and the Hb level, can help individualize the Hb optimization target.

MP60-09 PREOPERATIVE CRP AND HB-LEVEL ARE ASSOCIATED WITH DISEASE SPECIFIC SURVIVAL IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR BLADDER CANCER-RESULTS OF A MONOCENTER STUDY

You have accessJournal of UrologyBladder Cancer: Invasive III1 Apr 2014MP60-09 PREOPERATIVE CRP AND HB-LEVEL ARE ASSOCIATED WITH DISEASE SPECIFIC SURVIVAL IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR BLADDER CANCER-RESULTS OF A MONOCENTER STUDY Tobias Grimm, Alexander Buchner, Birte Schneevoigt, Maria Apfelbeck, Christian Stief, and Alexander Karl Tobias GrimmTobias Grimm More articles by this author , Alexander BuchnerAlexander Buchner More articles by this author , Birte SchneevoigtBirte Schneevoigt More articles by this author , Maria ApfelbeckMaria Apfelbeck More articles by this author , Christian StiefChristian Stief More articles by this author , and Alexander KarlAlexander Karl More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1763AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives In oncological patients different blood parameters have already shown to be associated with patients' outcomes. In our study we assessed such parameters in patients undergoing radical cystectomy (RC) for transitional cell carcinoma (TCC). Today there is only limited data available on this issue in patients with TCC. However various preoperative hematological disorders seem to be associated with the clinical and oncological outcome of TCC after RC. Therefore we analyzed the influence of preoperative c-reactive protein (CRP) and hemoglobin (Hb) as prognostic factors regarding cancer specific survival (CSS). Methods Preoperative CRP and Hb-values were measured in 664 patients who underwent RC due to TCC from 2004 to 2013 at our institution. Preoperative CRP and Hb were correlated with the length of CSS. More men than women (77% vs. 23%) underwent surgery with a median age of 70 years (35-97 years) and a median BMI of 26.3 (16.2-53.5). Median follow up time was 24 months (6.7-17.9). Median CSS was calculated using the Kaplan-Meier method and the logrank test. Multivariable Cox proportional hazards models were fitted. Results Median CRP-level was 0.5 mg/dl (0.1-28.3) and median Hb-level 13.4 g/dl (6.7–17.9). Patients with a preoperative CRP-value below the median showed a median CSS of 70 months whereas those with a CRP-value above the median died significantly earlier due to their disease (19 months) (p<0.001). Furthermore there was a positive correlation between preoperative Hb-level and CSS. Patients with a preoperative Hb-level below the median reached a median CSS of 25 months whereas those with Hb-values above the median died after a median of 78 months due to their disease (p<0.001). In the multivariable analysis our results could be illustrated as independent of tumor stage. Conclusions In our large monocenter study we could demonstrate a direct association of preoperative CRP and Hb-level with CSS in patients with TCC after RC. Thus elevated CRP and low Hb-level are shown to be independent and quite unfavorable prognostic factors. This observation could be useful in the individual risk stratification and further therapeutic strategies of our patients. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e636 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Tobias Grimm More articles by this author Alexander Buchner More articles by this author Birte Schneevoigt More articles by this author Maria Apfelbeck More articles by this author Christian Stief More articles by this author Alexander Karl More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Can the female gender influence risk factor identification for aortic valve surgery?

We have read the interesting article by Elmistekawy et al. [1], which showed that preoperative haemoglobin (Hb) was an independent predictor of mortality after aortic valve replacement (AVR) [1]. Although the authors defined that anaemia depends on gender and showed no difference in the incidence of preoperative anaemia between both males and females [1], we believe that gender should be considered a confounder in assessing preoperative Hb as a risk factor for AVR. Several studies showed that female AVR patients have a worse preoperative risk profile than males [2]. Whether gender is an independent risk factor of mortality after AVR is controversial. Several studies showed that female gender was an independent predictor in the AVR population for risk-adjusted 30-day mortality [2], but others failed to show the association between gender and mortality after AVR [3]. In these aspects, gender could be a confounder, while the association between preoperative Hb and mortality after AVR is evaluated. The authors showed that mortality was significantly higher with lower levels of preoperative Hb, with threshold effect at Hb of 120 g/l [1]. We would like to know whether the threshold effect was the same in both genders. Although baseline and nadir haematocrit were lower in females than males, females had a lower relative risk of mortality than males at lower nadir haematocrit [4]. In other words, females have better tolerance to haemodilution than males during cardiopulmonary bypass [4]. In this aspect, we believe that the threshold effect of preoperative Hb on mortality after AVR may differ between males and females. van Straten et al. [5] showed that preoperative low Hb level is an independent risk factor for late mortality, but not for early mortality in patients undergoing isolated AVR. The authors described that the association between preoperative low Hb level and early mortality after heart surgery is more remarkable in coronary artery bypass surgery (CABG) than AVR, because the pathophysiological adverse effects of anaemia are more marked in the presence of coronary artery disease [5, 6]. Elmistekawy et al. [1] reported that the concomitant procedures were equally distributed between the two groups, so the conclusion that mortality of AVR is affected by preoperative Hb is still valid in the appendix section. We think the number of concomitant CABG case might affect the result of study, because it can be a confounder.

Is the Newest Fibrin Sealant an Effective Strategy to Reduce Blood Loss After Total Knee Arthroplasty? A Randomized Controlled Study

An RCT was conducted to ascertain whether, compared to control management, topical application of a novel fibrin sealant (Evicel, J&J) in patients undergoing primary TKA reduces peri-operative blood loss. Sixty-two patients were randomized to receive topical application of Evicel (N=31) or not (N=31). The mean total blood loss was 1.9L(±0.7) in the control group and 1.8L(±0.5) in the treatment group (P=0.4). The transfusion rate was 32.3% in the control group and 25.8% in the treatment group (P=0.5). The transfusion rate decreased linearly with increasing preoperative Hb levels in the treatment group (P=0.005). The results of this study suggest that topical application of this novel fibrin sealant doesn't reduce perioperative blood loss and the need for allogeneic blood transfusion.

Predicting the necessity of autologous blood collection and storage before surgery for hepatocellular carcinoma

It remains unclear what kinds of patients undergoing hepatectomy for hepatocellular carcinoma (HCC) actually need autologous blood storage/transfusion. Prior to surgery, autologous blood storage was prospectively performed in 245 patients with HCC, whereas it was not performed in 40 patients. Based on the use of the deposited autologous blood and the estimated postoperative hemoglobin (Hb) level when blood was not deposited, they were divided into necessary group and unnecessary group. By comparing the two groups, a scoring system to predict the need for autologous blood was established. The 245 patients from whom blood was collected and stored were categorized into necessary group (32 patients with homologous blood transfusion and 11 with estimated postoperative Hb of <8.0 g/dl) and unnecessary group (30 patients with autologous blood discarded and 172 with estimated Hb ≥ 8.0 g/dl). Using factors that were significantly different between the two groups, a scoring system to predict the need for autologous blood was developed; preoperative Hb level, tumor size, and tumor thrombus. The area under the receiver-operator characteristic curve of the score was 0.836. The established scoring system was found useful in identifying those HCC patients who need autologous blood storage/transfusion during hepatectomy.