Independent preoperative predictors of day-of-surgery red cell transfusion in major orthopedic surgery: a sixyear retrospective cohort of 7072 patients
Preditores pré-operatórios independentes de transfusão de concentrado de hemácias no dia da cirurgia em cirurgia ortopédica de grande porte: uma coorte retrospectiva de seis anos com 7.072 pacientes
José R. Ortiz-Gómez, Andrea Ortiz-Domínguez, Inocencia Fornet-Ruíz, Francisco J. Palacio-Abizanda
Abstract
Background
Major Orthopedic Surgery (MOS) is frequently associated with significant blood loss, potentially resulting in perioperative anemia and the need for allogeneic blood transfusion,
which carries inherent risks. This study aimed to identify independent preoperative predictors of early Packed Red Blood Cell (PRBC) transfusion in patients undergoing MOS.
Methods
We analyzed, retrospectively, data from 7072 patients who underwent MOS. The variables assessed included age, sex, weight, height, Body Mass Index (BMI), ASA (American Society of Anesthesiologists) physical status classification, surgical category (hip, knee, spine), type of procedure (primary or revision total hip/knee arthroplasty, spinal arthrodesis, scoliosis surgery), preoperative hemoglobin levels and levels at 8:00 AM on postoperative day 1, hemoglobin thresholds (> 13, < 13, < 12, < 11, and < 10 g.dL-1), administration of tranexamic acid, and the requirement for PRBC transfusion.
Results
The overall transfusion rate was 4.8 % (3.6 % for hip, 2.7 % for knee, and 15.0 % for spine surgery). Independent predictors of PRBC transfusion included: preoperative hemoglobin < 13 g. dL-1 (Relative Risk [RR] 6.55), high-risk surgical procedures (RR = 7.40), ASA physical status III‒IV (RR = 2.00), absence of tranexamic acid use (RR = 2.52), and, to a lesser extent, age > 75 years (RR = 1.50). The combination of all identified risk factors was associated with a markedly increased transfusion risk (RR = 14.55; p < 0.0001).
Conclusion
These findings have informed modifications to our clinical practice, aimed at enhancing quality standards through the implementation of more effective Patient Blood Management (PBM) strategies.
Keywords
Resumo
Introdução
A Cirurgia Ortopédica de Grande Porte (COGP) está frequentemente associada à perda sanguínea significativa, podendo resultar em anemia perioperatória e necessidade de transfusão de sangue alogênico, a qual apresenta riscos inerentes. Este estudo teve como objetivo identificar preditores pré-operatórios independentes de transfusão precoce de concentrado de hemácias (CH) em pacientes submetidos à COGP.
Métodos
Foram analisados retrospectivamente dados de 7.072 pacientes submetidos à COGP. As variáveis avaliadas incluíram idade, sexo, peso, altura, Índice de Massa Corporal (IMC), classificação do estado físico ASA (American Society of Anesthesiologists), categoria cirúrgica (quadril, joelho, coluna), tipo de procedimento (artroplastia total primária ou de revisão de quadril/joelho, artrodese espinhal, cirurgia de escoliose), níveis de hemoglobina no pré-operatório e às 8:00 no primeiro dia pós-operatório, limiares de hemoglobina (> 13, < 13, < 12, < 11 e < 10 g.dL⁻¹), administração de ácido tranexâmico e necessidade de transfusão de CH.
Resultados
A taxa global de transfusão foi de 4,8% (3,6% para quadril, 2,7% para joelho e 15,0% para cirurgia de coluna). Os preditores independentes de transfusão de CH incluíram: hemoglobina pré-operatória < 13 g.dL⁻¹ (Risco Relativo [RR] = 6,55), procedimentos cirúrgicos de alto risco (RR = 7,40), estado físico ASA III‒IV (RR = 2,00), ausência do uso de ácido tranexâmico (RR = 2,52) e, em menor grau, idade > 75 anos (RR = 1,50). A combinação de todos os fatores de risco identificados esteve associada a um aumento acentuado no risco de transfusão (RR = 14,55; p < 0,0001).
Conclusão
Esses achados fundamentaram modificações na prática clínica, com o objetivo de aprimorar os padrões de qualidade por meio da implementação de estratégias mais eficazes de Patient Blood Management (PBM).
Palavras-chave
References
1. Ko MS, Choi CH, Yoon HK, et al. Risk factors of postoperative complications following total knee arthroplasty in Korea: a nationwide retrospective cohort study. Medicine. 2021;100: e28052.
2. Aoude A, Nooh A, Fortin M, et al. Incidence, predictors, and postoperative complications of blood transfusion in thoracic and lumbar fusion surgery: an analysis of 13,695 patients from the American College of Surgeons National Surgical Quality Improvement Program Database. Global Spine J. 2016;6:756−64.
3. Steinitz D, Harvey EJ, Leighton RK, Petrie DP. Is homologous blood transfusion a risk factor for infection after hip replacement? Can J Surg. 2001;44:355−8.
4. Frisch NB, Wessell NM, Charters MA, Yu S, Jeffries JJ. Silverton CD. Predictors and complications of blood transfusion in total hip and knee arthroplasty. J Arthroplasty. 2014;29(9 Suppl):189−92.
5. Farrow L, Brasnic L, Martin C, et al. A nationwide study of blood transfusion in hip fracture patients: linked analysis from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service. Bone Joint J. 2022;104-B(11):1266−72.
6. Althoff FC, Neb H, Herrmann E, et al. Multimodal patient blood management program based on a three-pillar strategy: a systematic review and meta-analysis. Ann Surg. 2019;269(5):794−804.
7. Ortiz-Gomez JR, Perep erez-Candel M, Torr on-Abad B, Fornet- Ruiz I, Ortiz-Domínguez A, FJ Palacio-Abizanda. Prophylactic tranexamic acid in major orthopedic surgery: our experience in 4921 patients. Anestezjologia i Ratownictwo. 2022(16):119−28.
8. Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2012;4:CD002042.
9. Carson JL, Stanworth SJ, Roubinian N, et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2016;10:CD002042.
10. Sarfani S, Rees A, Vickery J, et al. Patient complaints in orthopedic surgery: an analysis utilizing a large national database. Orthop Clin North Am. 2022;53:491−7.
11. Fang C, Pagani N, Gordon M, Talmo CT, Mattingly DA, Smith EL. Episode-of-care costs for revision total joint arthroplasties by decadal age groups. Geriatrics (Basel). 2021;6:49.
12. de Hond AAH, Steyerberg EW, van Calster B. Interpreting area under the receiver operating characteristic curve. Lancet Digit Health. 2022;4:e853.. e5.
13. Reitman CA, Watters 3rd WC, Sassard WR. The Cell Saver in adult lumbar fusion surgery: a cost-benefit outcomes study. Spine (Phila Pa 1976). 2004;29:1580−3. discussion 4.
14. Tay AYW, Thever Y, Bin Abd Razak HR, Hao Y, Tan AHC. Routine preoperative group crossmatching and postoperative check hemoglobin is not necessary in patients undergoing total knee arthroplasty. J Knee Surg. 2021;34:1359−67.
15. Chen Y, Cai X, Cao Z, et al. Prediction of red blood cell transfusion after orthopedic surgery using an interpretable machine learning framework. Front Surg. 2023;10:1047558.
16. Erben HC, Hess F, Welter J, et al. Perioperative blood transfusions in hip and knee arthroplasty: a retrospective assessment of combined risk factors. Arch Orthop Trauma Surg. 2022;142: 1817−22.
17. Huang Z, Martin J, Huang Q, Ma J, Pei F, Huang C. Predicting postoperative transfusion in elective total HIP and knee arthroplasty: comparison of different machine learning models of a case-control study. Int J Surg. 2021;96:106183.
18. Barr PJ, Donnelly M, Cardwell C, et al. Drivers of transfusion decision making and quality of the evidence in orthopedic surgery: a systematic review of the literature. Transfus Med Rev. 2011;25:304−16. e1-6.
19. Eisler L, Chihuri S, Lenke LG, Sun LS, Faraoni D, Li G. Development of a preoperative risk score predicting allogeneic red blood cell transfusion in children undergoing spinal fusion. Transfusion (Paris). 2022;62:100−15.
20. Huang Z, Huang C, Xie J, et al. Analysis of a large data set to identify predictors of blood transfusion in primary total hip and knee arthroplasty. Transfusion (Paris). 2018;58(8):1855−62.
21. Rosencher N, Kerkkamp HE, Macheras G, et al. Orthopedic surgery transfusion hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion. 2003;43:459−69.
22. Carling MS, Jeppsson A, Eriksson BI, Brisby H. Transfusions and blood loss in total hip and knee arthroplasty: a prospective observational study. J Orthop Surg Res. 2015;10:48.
23. Frisch N, Wessell NM, Charters M, et al. Effect of body mass index on blood transfusion in total hip and knee arthroplasty. Orthopedics. 2016;39(5):e844−9.
24. DeClercq MG, Sacchetti M, Coleman J, et al. The role of subcutaneous fat and BMI in predicting surgical outcomes and patient reported outcomes in robotic-assisted total hip arthroplasty. J Orthop. 2024;58:128−34.
25. Nuttall GA, Horlocker TT, Santrach PJ, Oliver Jr. WC, Dekutoski MB, Bryant S. Predictors of blood transfusions in spinal instrumentation and fusion surgery. Spine (Phila Pa 1976). 2000;25: 596−601.
26. Terada R, Stewart K, Hansen S, et al. Temporal changes and predictors of perioperative blood transfusion in elective spine surgery: a retrospective analysis of a large surgical database. Br J Anaesth. 2023;130:421−9.
27. Ohrt-Nissen S, Bukhari N, Dragsted C, et al. Blood transfusion in the surgical treatment of adolescent idiopathic scoliosis-a single-center experience of patient blood management in 210 cases. Transfusion (Paris). 2017;57:1808−17.
28. Lee JH, Han SB. Patient blood management in hip replacement arthroplasty. Hip Pelvis. 2015;27:201−8.
29. Zalba Marcos S, Galbete A, Urrechaga Igartua E, Antelo Caamano ML, Cerdan G, Garcia Erce JA. Preoperative hemogram as a predictive factor for iron deficit and/or transfusion in patients scheduled for arthroplasty. Rev Esp Anestesiol Reanim (Engl Ed). 2021;68:555−63.
30. Whiting DR, Duncan CM, Sierra RJ, Smith HM. Tranexamic acid benefits total joint arthroplasty patients regardless of preoperative hemoglobin value. J Arthroplasty. 2015;30:2098−101.
Submitted date:
03/02/2025
Accepted date:
09/11/2025
Facebook
Google+
Twitter
LinkedIn
Mendeley
StumbleUpon
CiteULike
Reddit
Email