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Effect Of Intraoperative Blood Transfusion On Outcome In Patients Undergoing Non-Traumatic Lower Extremity Amputation
Muhammad Asad Khan, MD, Kuldeep Singh, MD, Jonathan Schor, MD, Jonathan Deitch, MD.
Staten Island University Hospital, Staten Island, NY, USA.

OBJECTIVE: The aim of this study was to evaluate outcomes associated with red blood transfusion in patients undergoing lower extremity amputation.
METHODS: Using National Surgical Quality Improvement (NSQIP) database from 2005-2007, we identified patients undergoing non-traumatic lower extremity amputation. Patients were categorized into two groups based on those who received intraoperative transfusion and those who did not. Patient demographics, co-morbidities, baseline hemoglobin, perioperative morbidity and mortality were compared between groups using chi-square and t-test as appropriate. Logistic regression analysis was performed to analyze factor independently related to postoperative mortality.
RESULTS: 9,275 patients were identified in the study, 971 (10.4%) had one or more unit packed or whole red blood cell transfusion intraoperative, 8304 (89.6%) patients had no transfusion. Among 971 patients who received transfusion, 143 (15%) had preoperative hemoglobin (hgb)< 8mg/dl, 613 (63%) had hgb 8-10 mg/dl and 215 (22%) had hgb > 10 mg/dl. Mean number of unit transfused was 1.7 (range 1-9 units). Comparing to no-transfusion group, those who received transfusion had lower baseline hemoglobin (9.0 ± 3.3 vs. 10.0 ± 5.7 mg/dl, p <.001), higher number of CHF patients (10.5% vs. 7.5%, p<.001), and patients at increase bleeding risk (32.6% vs. 26.7%, p<.001). After adjusting for baseline risk profile and trigger hemoglobin level, intraoperative transfusion (RR 1.36), congestive heart failure (RR, 3.09), bleeding disorder (RR, 1.26) and having end-stage renal disease (RR, 2.79) were independently related to significant increase in 30-day mortality (Table1). Patient who received transfusion had higher incidence of postoperative complications including sepsis, pneumonia, acute renal failure, incidence of pulmonary embolism and deep venous thrombosis (Table2)
CONCLUSION: Regardless of preoperative hemoglobin levels, intraoperative blood transfusion in patients undergoing lower extremity amputation is related to increase risk of postoperative mortality and morbidity. Further studies are required to identify criteria for transfusion and alternative treatment modality.
Table 1. Independent predictors of postoperative mortality
VariablesRelative riskConfidence interval (95%)P- value
Transfusion1.361.07-1.72.011
Smoking0.98.80-1.21.887
CHF3.092.50-3.81<.001
ESRD2.792.36-3.22<.001
Bleeding disorder1.261.06-1.49.007

Table 2. Postoperative complications
ComplicationsNo Transfusion
N=8304
Transfusion
N=971
P Value
Superficial surgical site infection415 (5%)37 (3.8%)0.115
Deep Incisional SSI255 (3.1%)40 (4.1%)0.082
Wound disruption147 (1.85)14 (1.4%)0.518
Pneumonia301 (3.6%)64 (6.6%)<.001
Reintubation315 (3.8%)52 (5.4%)0.023
Pulmonary embolism39 (0.5%)16 (1.6%)<.001
Failure to wean317 (3.8%)94 (9.7%)<.001
ARF121 (1.5%)29 (3.0%)0.001
Progressive renal failure78 (0.9%)10 (1.0%)0.727
UTI369 (4.4%)55 (5.7%)0.088
Cardiac arrest187 (2.3%)29 (3%)0.176
MI99 (1.2%)13 (1.3%)0.642
DVT104 (1.3)25 (2.6%)0.002
Return to OR1630 (19.6%)207 (21.3%)0.217
Sepsis424 (5.1%)70 (7.2%)0.008
Septic Shock279 (3.4%)54 (5.6%)0.001
Mortality681 (8.2%)100 (10.3%)0.028


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