Warner, Matthew A

BACKGROUND: Anemia affects more than two billion people worldwide and is common among surgical patients. Despite growing recognition of the risks associated with preoperative anemia, we have limited understanding of the epidemiology of anemia development and recovery. METHODS: This is an observational cohort study of adults undergoing surgery at a large tertiary care medical center from August 2012 to July 2023. Hemoglobin concentrations were obtained preoperatively, during postoperative hospitalization, and through 12 months after surgery. Anemia was defined primarily using World Health Organization criteria (hemoglobin <12 g/dL in women, <13 g/dL in men) and secondarily with a gender-neutral threshold of <13 g/dL. Descriptive analyses summarize preoperative anemia prevalence, postoperative anemia prevalence and incidence, and post-hospitalization anemia recovery across demographic, clinical, and surgical features. RESULTS: 281,217 patients undergoing 423,066 procedures (51.9% among women) were included. Among those with available preoperative hemoglobin assessments (n = 308,959), 28.9% had anemia, with similar prevalence in men (29.5%) and women (28.4%) using World Health Organization (WHO) definitions, but with prevalence increasing to 51.0% in women when using the gender-neutral anemia definition. Preoperative anemia was most common in Black patients (44.0%) and in those ≥75 years (39.6%). Surgical subspecialties showed wide variation in preoperative anemia prevalence, ranging from 18.6% in spine surgery to 45.8% in vascular surgery. Among previously nonanemic patients admitted to the hospital postoperatively, 76.9% developed new postoperative anemia, with the highest incidence in cardiac surgery (97.5%). Women experienced more severe postoperative anemia than men. Overall, 81.1% of patients were anemic at hospital discharge. Recovery was gradual and incomplete: among those discharged with mild, moderate, or severe anemia, 28.5%, 51.9%, and 66.3%, respectively, remained anemic at 12 months. Among patients who were nonanemic preoperatively but developed new postoperative anemia, 29.3% remained anemic at 12 months. CONCLUSIONS: Preoperative and postoperative anemia are highly prevalent, and anemia frequently persists for months after hospitalization. Older adults, women, and Black patients bear a disproportionate burden. Despite this, anemia evaluations and treatments remain underutilized. These findings highlight substantial opportunities for patient blood management (PBM) programs to improve perioperative anemia detection, optimization, and post-discharge management.

AbstractBackgroundSome patients express concerns regarding receipt of allogeneic blood transfusions from donors potentially vaccinated against SARS‐CoV‐2 (COVID‐19). However, limited information exists about patients' expression of these concerns or how to address them during the blood transfusion consent process. In this study, we describe our experience of working collaboratively with patients with vaccine‐related transfusion concerns prior to elective surgery, summarizing treatment decisions and clinical outcomes.Study Design and MethodsThis observational descriptive study includes patients seen in our Bloodless Medicine and Surgery clinic between June 2022 and June 2024 for vaccine‐related transfusion concerns prior to elective surgery. A shared decision‐making framework was employed to foster conversation, share information, provide reassurance, reconcile conflict, and match preferences with available care options. Patient characteristics, treatment decisions, and surgical outcomes were reviewed and summarized.ResultsThirty‐five patients were included, with median (1st, 3rd quartile) age of 61 (53, 69) years. Cardiac surgery was the most common type of surgery (29%). Twelve patients (34%) were anemic preoperatively, and all received preoperative treatment. After discussion with a Bloodless Medicine specialist, 24 (68.6%) decided to consent to the use of all blood products, 5 (14.3%) accepted only red blood cells, and 6 (17.1%) declined all blood products. Among 28 patients undergoing surgery, only 4 (14%) received allogeneic transfusion perioperatively.ConclusionMany patients concerned about the vaccination status of blood donors may ultimately consent to allogeneic blood products after shared decision‐making with a Bloodless Medicine specialist, highlighting the importance of patient empowerment and collaborative care.

AbstractBackgroundEvaluations of critical bleeding and massive transfusion have focused on traumatic hemorrhage. However, most critical bleeding in hospitalized patients occurs outside trauma. The purpose of this study was to provide an in‐depth description examining the critical administration threshold (CAT; ≥3 units red blood cells (RBCs) in a 1‐h period) occurrences in nontraumatic hemorrhage. This will assist in establishing the framework for future investigations in nontraumatic hemorrhage.MethodsThis is an observational cohort study of adults experiencing critical bleeding defined as being CAT+ during hospitalization from 2016 to 2021 at a single academic institution. A CAT episode started with administration of the first qualifying RBC unit and ended at the time of completion of the last allogeneic unit prior to a ≥4‐h gap without subsequent transfusion. The primary goal was to describe demographic, clinical and transfusion characteristics of participants with nontraumatic critical bleeding.Results2433 patients suffered critical bleeding, most often occurring in the operating room (71.1%) followed by the intensive care unit (20.8%). 57% occurred on the initial day of hospitalization, with a median duration of 138 (36, 303) minutes. The median number of RBCs transfused during the episode was 5 (4, 8), with median total allogeneic units of 9 (4, 9). Hospital mortality was 19.2%. The most common cause of death was multi‐organ failure (50.3%), however death within 24 h was due to exsanguination (72.7%).DiscussionThe critical administration threshold may be employed to identify critical bleeding in non‐trauma settings of life‐threatening hemorrhage, with a mortality rate of approximately 20%.

Background: Hospitalization represents a major access point for prescription opioids, yet little is known regarding patterns and outcomes of opioid exposures before and after hospitalization for critical illness. Methods: This is an observational, population-based cohort study of adults (≥18 years) hospitalized for critical illness from 2010 to 2019. Multivariable models assess associations between opioid exposures prior to hospitalization, classified according to the Consortium to Study Opioid Risks and Trends, and posthospitalization opioid exposures and clinical outcomes through 1-year posthospitalization. Results: Of 11 496 patients, 6318 (55%) were men with a median age of 66 (51, 79) years and 40% (n = 4623) surgical admissions. Prehospitalization opioid availability included 8449 (73%) none, 2117 (18%) short-term, 471 (4%) episodic, and 459 (4%) long-term. Thirty-nine percent (4144/10 708) of hospital survivors were discharged with opioids, with higher prescribing rates for surgical admissions (55%). Greater preadmission opioid exposures were associated with higher prevalent opioid availability at 1 year (odds ratio [95% confidence interval] 24.1 [18.3-31.8], 9.42 [7.18-12.3], and 2.55 [2.08-3.12] for long-term, episodic, and short-term exposures, respectively, vs none, P < .001). Greater preadmission opioid exposures were associated with longer hospitalizations (1.13 [1.04-1.23], 1.15 [1.06-1.25], and 1.08 [1.04-1.13] multiplicative increase in geometric mean, P < .001), more readmissions (hazard ratio [HR] 2.08 [1.74-2.49], 1.88 [1.56-2.26], and 1.48 [1.33-1.64], P < .001), and higher 1-year mortality (HR 1.59 [1.28-1.98], 1.75 [1.41-2.18], and 1.49 [1.32-1.69], P < .001). Similar associations were observed across surgical and nonsurgical admissions. Conclusions: Prehospitalization opioid exposures in survivors of critical illness are associated with clinical outcomes through 1 year and may serve as important prognostic markers.

Background Delayed cold storage of room temperature platelets may extend shelf life from 5 to 14 days. The study hypothesized that the use of delayed cold-stored platelets in cardiac surgery would be associated with decreased postoperative platelet count increments but similar transfusion and clinical outcomes compared to room temperature-stored platelets. Methods This is an observational cohort study of adults transfused with platelets intraoperatively during elective cardiac surgery between April 2020 and May 2021. Intraoperative platelets were either room temperature-stored or delayed cold-stored based on blood bank availability rather than clinical features or provider preference. Differences in transfusion and clinical outcomes, including a primary outcome of allogenic transfusion exposure in the first 24 h postoperatively, were compared between groups. Results A total of 713 patient encounters were included: 529 (74%) room temperature-stored platelets and 184 (26%) delayed cold-stored platelets. Median (interquartile range) intraoperative platelet volumes were 1 (1 to 2) units in both groups. Patients receiving delayed cold-stored platelets had higher odds of allogeneic transfusion in the first 24 h postoperatively (81 of 184 [44%] vs. 169 of 529 [32%]; adjusted odds ratio, 1.65; 95% CI, 1.13 to 2.39; P = 0.009), including both erythrocytes (65 of 184 [35%] vs. 135 of 529 [26%]; adjusted odds ratio, 1.54; 95% CI, 1.03 to 2.29; P = 0.035) and platelets (48 of 184 [26%] vs. 79 of 529 [15%]; adjusted odds ratio, 1.91; 95% CI, 1.22 to 2.99; P = 0.005). There was no difference in the number of units administered postoperatively among those transfused. Platelet counts were modestly lower in the delayed cold-stored platelet group (−9 × 109/l; 95% CI, −16 to −3]) through the first 3 days postoperatively. There were no significant differences in reoperation for bleeding, postoperative chest tube output, or clinical outcomes. Conclusions In adults undergoing cardiac surgery, delayed cold-stored platelets were associated with higher postoperative transfusion utilization and lower platelet counts compared to room temperature-stored platelets without differences in clinical outcomes. The use of delayed cold-stored platelets in this setting may offer a viable alternative when facing critical platelet inventories but is not recommended as a primary transfusion approach. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

AbstractBackgroundPreoperative anemia is common and associated with adverse postoperative outcomes. Assessment of hemoglobin concentrations may facilitate optimization prior to surgery. However, phlebotomy‐based hemoglobin measurement may contribute to patient discomfort and iatrogenic blood loss, which makes non‐invasive hemoglobin estimation attractive in this setting.Study Design and MethodsThis is a prospective study of adult patients presenting for preoperative evaluation before elective surgery at a tertiary care medical center. The Masimo Pronto Pulse CO‐Oximeter was utilized to estimate blood hemoglobin concentrations (SpHb), which were then compared with hemoglobin concentrations obtained via complete blood count. Receiver operating curves were used to identify SpHb values maximizing specificity for anemia detection while meeting a minimum sensitivity of 80%.ResultsA total of 122 patients were recruited with a median (interquartile range) age of 66 (58, 72) years. SpHb measurements were obtained in 112 patients (92%). SpHb generally overestimated hemoglobin with a mean (± 1.96 × standard deviation) difference of 0.8 (−2.2, 3.9) g/dL. Preoperative anemia, defined by hemoglobin <12.0 g/dL in accordance with institutional protocol, was present in 22 patients (20%). The optimal SpHb cut‐point to identify anemia was 13.5 g/dL: sensitivity 86%, specificity 81%, negative predictive value 96%, and positive predictive value 53%. Utilizing this cut‐point, 60% (73/122) of patients could have avoided phlebotomy‐based hemoglobin assessment, while an anemia diagnosis would have been missed in <3% (3/122).ConclusionThe use of SpHb devices for anemia screening in surgical patients is feasible with the potential to reliably rule‐out anemia despite limited accuracy.

Summary Anaemia is a common sequela of surgery, although its relationship with patient recovery is unclear. The goal of this investigation was to assess the associations between haemoglobin concentrations at the time of hospital discharge following major surgery and early post‐hospitalisation outcomes, with a primary outcome of 30 day unanticipated hospital readmissions. This investigation includes data from two independent population‐based observational cohorts of adult surgical patients (aged ≥ 18 years) requiring postoperative intensive care unit admission between 1 January 2010 and 31 December 2019 in hospitals in Olmsted County, Minnesota, and between 1 July 2010 and 30 June 2017 in the Kaiser Permanente Northern California integrated healthcare system, California. Cox proportional hazards models assessed the associations between discharge haemoglobin concentrations (per 10 g.l –1 ) and outcomes, with prespecified multivariable adjustment. A total of 3260 patients were included from Olmsted County hospitals and 29,452 from Kaiser Permanente Northern California. In adjusted analyses, each 10 g.l –1 decrease in haemoglobin at hospital discharge was associated with a 9% (hazard ratio 1.09, 95%CI 1.02–1.18; p = 0.014) and 8% increase (hazard ratio 1.08, 95%CI 1.06–1.11; p < 0.001) in the hazard for readmission within 30 days in Olmsted County and Kaiser Permanente Northern California, respectively. In a sensitivity analysis exploring relationships across varying levels of pre‐operative anaemia severity, these associations remained consistent, with lower discharge haemoglobin concentrations associated with higher readmissions irrespective of pre‐operative anaemia severity. Anaemia at hospital discharge in surgical patients requiring postoperative intensive care is associated with increased rates of hospital readmission in two large independent cohorts. Future studies are necessary to evaluate strategies to prevent and/or treat anaemia in these patients for the improvement of post‐hospitalisation outcomes.