Clifford, Leanne

Abstract Background Transfusion-associated circulatory overload remains underappreciated in the perioperative environment. The authors aimed to characterize risk factors for perioperative transfusion-associated circulatory overload and better understand its impact on patient-important outcomes. Methods In this case–control study, 163 adults undergoing noncardiac surgery who developed perioperative transfusion-associated circulatory overload were matched with 726 transfused controls who did not develop respiratory complications. Univariate and multivariable logistic regression analyses were used to evaluate potential risk factors for transfusion-associated circulatory overload. The need for postoperative mechanical ventilation, lengths of intensive care unit and hospital stay, and mortality were compared. Results For this cohort, the mean age was 71 yr and 56% were men. Multivariable analysis revealed the following independent predictors of transfusion-associated circulatory overload: emergency surgery, chronic kidney disease, left ventricular dysfunction, previous β-adrenergic receptor antagonist use, isolated fresh frozen plasma transfusion (vs. isolated erythrocyte transfusion), mixed product transfusion (vs. isolated erythrocyte transfusion), and increasing intraoperative fluid administration. Patients who developed transfusion-associated circulatory overload were more likely to require postoperative mechanical ventilation (73 vs. 33%; P < 0.001) and experienced prolonged intensive care unit (11.1 vs. 6.5 days; P < 0.001) and hospital lengths of stay (19.9 vs. 9.6 days; P < 0.001). Survival was significantly reduced (P < 0.001) in transfusion recipients who developed transfusion-associated circulatory overload (1-yr survival 72 vs. 84%). Conclusions Perioperative transfusion-associated circulatory overload was associated with a protracted hospital course and increased mortality. Efforts to minimize the incidence of transfusion-associated circulatory overload should focus on the judicious use of intraoperative blood transfusions and nonsanguineous fluid therapies, particularly in patients with chronic kidney disease, left ventricular dysfunction, chronic β-blocker therapy, and those requiring emergency surgery.

BACKGROUNDPerioperative hemorrhage impacts patient outcomes and health care resource utilization, yet the risks of transfusion therapies are significant. In patients with preoperative thrombocytopenia, the effects of prophylactic preoperative platelet (PLT) transfusion on perioperative bleeding complications remain uncertain.STUDY DESIGN AND METHODSThis is a retrospective cohort study of noncardiac surgical patients between January 1, 2008, and December 31, 2011. Propensity‐adjusted analyses were used to evaluate associations between preoperative thrombocytopenia, preoperative PLT transfusion, and the outcomes of interest, with a primary outcome of perioperative red blood cell (RBC) transfusion.RESULTSA total of 13,978 study participants were included; 860 (6.2%) had a PLT count of not more than 100 × 109/L with 71 (8.3%) receiving PLTs preoperatively. Administration of PLTs was associated with higher rates of perioperative RBC transfusion (66.2% vs. 49.1%, p = 0.0065); however, in propensity‐adjusted analysis there was no significant difference between groups (odds ratio [OR] [95% confidence interval {95% CI}], 1.68 [0.95‐2.99]; p = 0.0764]. Patients receiving PLTs had higher rates of intensive care unit (ICU) admission (OR [95% CI], 1.95 [1.10‐3.46]; p = 0.0224) and longer hospital lengths of stay (estimate [95% bootstrap CI], 7.2 [0.8‐13.9] days; p = 0.0006) in propensity‐adjusted analyses.CONCLUSIONPreoperative PLT transfusion did not attenuate RBC requirements in patients with thrombocytopenia undergoing noncardiac surgery. Moreover, preoperative PLT transfusion was associated with increased ICU admission rates and hospital duration. These findings suggest that more conservative management of preoperative thrombocytopenia may be warranted.

Abstract Background: Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related death in the United States; however, it remains poorly characterized in surgical populations. To better inform perioperative transfusion practice, and to help mitigate perioperative TRALI, the authors aimed to better define its epidemiology before and after TRALI mitigation strategies were introduced. Methods: This retrospective cohort study examined outcomes of adult patients undergoing noncardiac surgery with general anesthesia who received intraoperative transfusions during 2004 (n = 1,817) and 2011 (n = 1,562). The demographics and clinical characteristics of transfusion recipients, blood transfusion descriptors, and combined TRALI/possible TRALI incidence rates were evaluated. Univariate analyses were used to compare associations between patient characteristics, transfusion details, and TRALI mitigation strategies with TRALI/possible TRALI incidence rates in a before-and-after study design. Results: The incidence of TRALI/possible TRALI was 1.3% (23 of 1,613) in 2004 versus 1.4% (22 of 1,562) in 2011 (P = 0.72), with comparable overall rates in males versus females (1.4% [23 of 1,613] vs. 1.2% [22 of 1,766]) (P = 0.65). Overall, thoracic (3.0% [4 of 133]), vascular (2.7% [10 of 375]), and transplant surgeries (2.2% [4 of 178]) carried the highest rates of TRALI/possible TRALI. Obstetric and gynecologic surgical patients had no TRALI episodes. TRALI/possible TRALI incidence increased with larger volumes of blood product transfused (P < 0.001). Conclusions: Perioperative TRALI/possible TRALI is more common than previously reported and its risk increases with greater volumes of blood component therapies. No significant reduction in the combined incidence of TRALI/possible TRALI occurred between 2004 and 2011, despite the introduction of TRALI mitigation strategies. Future efforts to identify specific risk factors for TRALI/possible TRALI in surgical populations may reduce the burden of this life-threatening complication.

Abstract Background: Transfusion-associated circulatory overload (TACO) is a leading cause of transfusion-related fatalities, but its incidence and associated patient and transfusion characteristics are poorly understood. To inform surgical transfusion practice and to begin mitigating perioperative TACO, the authors aimed to define its epidemiology. Methods: In this retrospective cohort study, the medical records of adult patients undergoing noncardiac surgery with general anesthesia during 2004 or 2011 and receiving intraoperative transfusions were screened using an electronic algorithm for identification of TACO. Those patients who were screened as high probability for TACO underwent rigorous manual review. Univariate and multivariate analyses evaluated associations between patient and transfusion characteristics with TACO rates in a before-and-after study design. Results: A total of 2,162 and 1,908 patients met study criteria for 2004 and 2011, respectively. The incidence of TACO was 5.5% (119 of 2,162) in 2004 versus 3.0% (57 of 1,908) in 2011 ( P < 0.001), with comparable rates for men (4.8% [98 of 2,023]) and women (3.8% [78 of 2,047]) ( P = 0.09). Overall, vascular (12.1% [60 of 497]), transplant (8.8% [17 of 193]), and thoracic surgeries (7.2% [10 of 138]) carried the highest TACO rates. Obstetric and gynecologic patients had the lowest rate (1.4% [4 of 295]). The incidence of TACO increased with volume transfused, advancing age, and total intraoperative fluid balance (all P < 0.001). Conclusions: The incidence of perioperative TACO is similar to previous estimates in nonsurgical populations. There was a reduction in TACO rate between 2004 and 2011, with incidence patterns remaining comparable in subgroup analyses. Future efforts exploring risk factors for TACO may guide preventive or therapeutic interventions, helping to further mitigate this transfusion complication.