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Transfusion targets and adverse events in pediatric perioperative acute Anemia
Lindsay L Warner1, Leanne Thalji1, Lindsay R Hunter Guevara1
1Department of Anesthesiology and Perioperative Medicine (Drs L. Warner, Thalji, Hunter Guevara, M. Warner, Kor, D. Warner, and Nemergut) and Division of Biomedical Statistics and Informatics (Mr Hanson), Mayo Clinic, Rochester, MN, United States of America.
Insights
Posttransfusion hemoglobin levels in children undergoing noncardiac surgery did not correlate with clinical outcomes, except for the need for re-transfusion. Many pediatric patients had anemia before surgery, indicating a chance for pre-operative health optimization.
Area of Science:
- Pediatric Surgery
- Transfusion Medicine
- Anemia Management
Background:
- Assessing the adequacy of red blood cell transfusions in pediatric surgery is crucial for patient outcomes.
- Pretransfusion hemoglobin levels are often used as triggers, but may not be obtainable during acute surgical bleeding.
- Postoperative hemoglobin concentrations offer a potentially more reliable indicator of transfusion effectiveness.
Purpose of the Study:
- To determine the association between pretransfusion and posttransfusion hemoglobin concentrations and clinical outcomes in pediatric patients undergoing noncardiac surgery.
- To evaluate if initial postoperative hemoglobin levels predict adverse outcomes or the need for further transfusions.
Main Methods:
- Retrospective observational cohort study of pediatric patients undergoing noncardiac surgery who received intraoperative red blood cell transfusions.
- Analysis included over 741 procedures from January 2008 to December 2018.
- Multivariable regression modeling was used to assess associations between hemoglobin levels and outcomes like hospital-free days, ICU admission, mechanical ventilation, and infectious complications.
Main Results:
- A decrease of 1 g/dL in initial postoperative hemoglobin was linked to a higher likelihood of requiring transfusion within 24 hours (OR, 1.62; P < .001).
- No significant associations were found between postoperative hemoglobin concentrations and hospital-free days, ICU admission, mechanical ventilation, or infectious complications.
- Most transfused pediatric patients (68%) presented with preoperative anemia.
Conclusions:
- Postoperative hemoglobin concentrations were not associated with clinical outcomes in transfused pediatric patients, apart from the need for subsequent transfusions.
- The high prevalence of preoperative anemia suggests a critical window for optimizing patient health before noncardiac surgery.
- Focusing on preoperative anemia management may improve perioperative care in pediatric surgical patients.
Study Objective:
To evaluate the association between pretransfusion and posttransfusion hemoglobin concentrations and the outcomes of children undergoing noncardiac surgery.
Design:
Retrospective review of patient records. We focused on initial postoperative hemoglobin concentrations, which may provide a more useful representation of transfusion adequacy than pretransfusion hemoglobin triggers (the latter often cannot be obtained during acute surgical hemorrhage).
Setting:
Single-center, observational cohort study.
Patients:
We evaluated all pediatric patients undergoing noncardiac surgery who received intraoperative red blood cell transfusions from January 1, 2008, through December 31, 2018.
Interventions:
None.
Measurements:
Associations between pre- and posttransfusion hemoglobin concentrations (g/dL), hospital-free days, intensive care unit admission, postoperative mechanical ventilation, and infectious complications were evaluated with multivariable regression modeling.
Main Results:
In total, 113,713 unique noncardiac surgical procedures in pediatric patients were evaluated, and 741 procedures met inclusion criteria (median [range] age, 7 [1-14] years). Four hundred ninety-eight patients (68%) with a known preoperative hemoglobin level had anemia; of these, 14% had a preexisting diagnosis of anemia in their health record. Median (IQR) pretransfusion hemoglobin concentration was 8.1 (7.4-9.2) g/dL and median (IQR) initial postoperative hemoglobin concentration was 10.4 (9.3-11.6) g/dL. Each decrease of 1 g/dL in the initial postoperative hemoglobin concentration was associated with increased odds of transfusion within the first 24 postoperative hours (odds ratio [95% CI], 1.62 [1.37-1.93]; P < .001). No significant relationships were observed between postoperative hemoglobin concentrations and hospital-free days (P = .56), intensive care unit admission (P = .71), postoperative mechanical ventilation (P = .63), or infectious complications (P = .74).
Conclusions:
In transfused patients, there was no association between postoperative hemoglobin values and clinical outcomes, except the need for subsequent transfusion. Most transfused patients presented to the operating room with anemia, which suggests a potential opportunity for perioperative optimization of health before surgery.
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