Outcomes of Nontransfusable and Transfusable Patients After Major Noncardiac Surgery: A Retrospective Cohort Study

Patients admitted to HELIOS Klinikum in Gotha and Erfurt, Germany, received one of 3 models of care. Nontransfusable patients received transfusion-free blood management, whereas transfusable patients received either patient blood management (PBM) or no PBM. Few studies have compared outcomes in patients undergoing these models of care within 1 hospital network. Our primary aim was to compare adult nontransfusable patients undergoing major surgery to transfusable patients. Our secondary aim was to compare transfusable patients receiving PBM strategies to those receiving no PBM.

A retrospective cohort study of 25,979 major adult noncardiac surgical admissions to 2 German hospitals between 2008 and 2020. We applied propensity score methods to multivariable regression models adjusting for age, sex, admission hemoglobin, comorbidities, surgical procedure group, surgical complexity, and admission year. Outcomes included in-hospital mortality, surgical site complications, renal complications, respiratory complications, acute myocardial infarction (AMI), readmissions within 30 days, length of stay, estimated blood loss, transfusion rate, and transfusion reactions.

Patients receiving transfusion-free blood management had lower mortality (odds ratio [OR] 0.33, 95% confidence interval [CI], 0.26-0.42; P < .001), renal complications (OR 0.40, 95% CI, 0.34-0.48; P < .001), respiratory complications (OR 0.43, 95% CI, 0.37-0.49; P < .001), readmissions (OR 0.54, 95% CI, 0.48-0.60; P < .001), and shorter hospital stay (risk ratio [RR] 0.91, 95% CI, 0.90-0.93; P < .001) compared to transfusable patients. There were no AMI complications in the transfusion-free group compared to 0.3% (n = 78) in the transfusable group. Surgical site complications were not significantly different between groups (OR 0.94, 95% CI, 0.86-1.02; P = .140). In our secondary analysis of transfusable patients, PBM was associated with lower mortality (OR 0.79, 95% CI, 0.66-0.95; P = .012), surgical site complications (OR 0.62, 95% CI, 0.57-0.69, P < .001), renal complications (OR 0.76, 95% CI, 0.65-0.88; P < .001), respiratory complications (OR 0.68, 95% CI, 0.60-0.78; P < .001), and shorter hospital stay when compared to no PBM (RR 0.86, 95% CI, 0.85-0.87; P < .001). Hospital readmissions were higher in the PBM group (OR 1.28, 95% CI, 1.18-1.40; P < .001). The proportion of patients receiving a red cell transfusion, units transfused per patient, and estimated blood loss were lower in the PBM group when compared to no PBM. There were no transfusion complications coded in the PBM or no PBM groups.

Our primary and secondary analyses demonstrate addressing anemia and minimizing or avoiding transfusion is associated with improved outcomes. The results of the study highlight the important role transfusion-free care and PBM have in improving outcomes for patients undergoing major surgery.