Smilowitz Nathaniel R, Oberweis Brandon S, Nukala Swetha, Rosenberg Andrew, Zhao Sibo, Xu Jinfeng, Stuchin Steven, Iorio Richard, Errico Thomas, Radford Martha J, Berger Jeffrey S
Division of Cardiology, Department of Medicine, New York University School of Medicine, New York.
Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY.
Am J Med. 2016 Mar;129(3):315-23.e2. doi: 10.1016/j.amjmed.2015.10.012. Epub 2015 Oct 30.
Preoperative anemia is a well-established risk factor for short-term mortality in patients undergoing noncardiac surgery, but appropriate thresholds for transfusion remain uncertain. The objective of this study was to determine long-term outcomes associated with anemia, hemorrhage, and red blood cell transfusion in patients undergoing noncardiac surgery.
We performed a long-term follow-up study of consecutive subjects undergoing hip, knee, and spine surgery between November 1, 2008 and December 31, 2009. Clinical data were obtained from administrative and laboratory databases, and retrospective record review. Preoperative anemia was defined as baseline hemoglobin < 13 g/dL for men and < 12 g/dL for women. Hemorrhage was defined by International Classification of Diseases, Ninth Revision coding. Data on long-term survival were collected from the Social Security Death Index database. Logistic regression models were used to identify factors associated with long-term mortality.
There were 3050 subjects who underwent orthopedic surgery. Preoperative anemia was present in 17.6% (537) of subjects, hemorrhage occurred in 33 (1%), and 766 (25%) received at least one red blood cell transfusion. Over 9015 patient-years of follow-up, 111 deaths occurred. Anemia (hazard ratio [HR] 3.91; confidence interval [CI], 2.49-6.15) and hemorrhage (HR 5.28; 95% CI, 2.20-12.67) were independently associated with long-term mortality after multivariable adjustment. Red blood cell transfusion during the surgical hospitalization was associated with long-term mortality (HR 3.96; 95% CI, 2.47-6.34), which was attenuated by severity of anemia (no anemia [HR 4.39], mild anemia [HR 2.27], and moderate/severe anemia [HR 0.81]; P for trend .0015).
Preoperative anemia, perioperative bleeding, and red blood cell transfusion are associated with increased mortality at long-term follow-up after noncardiac surgery. Strategies to minimize anemia and bleeding should be considered for all patients, and restrictive transfusion strategies may be advisable. Further investigation into mechanisms of these adverse events is warranted.
术前贫血是接受非心脏手术患者短期死亡的一个公认危险因素，但合适的输血阈值仍不确定。本研究的目的是确定接受非心脏手术患者贫血、出血和红细胞输血相关的长期结局。
我们对2008年11月1日至2009年12月31日期间连续接受髋、膝和脊柱手术的受试者进行了一项长期随访研究。临床数据来自行政和实验室数据库以及回顾性病历审查。术前贫血定义为男性基线血红蛋白<13 g/dL，女性<12 g/dL。出血根据国际疾病分类第九版编码定义。长期生存数据从社会保障死亡指数数据库收集。使用逻辑回归模型确定与长期死亡相关的因素。
共有3050名受试者接受了骨科手术。17.6%（537名）受试者存在术前贫血，33名（1%）发生出血，766名（25%）接受了至少一次红细胞输血。在超过9015患者年的随访中，发生了111例死亡。多变量调整后，贫血（风险比[HR] 3.91；置信区间[CI]，2.49 - 6.15）和出血（HR 5.28；95% CI，2.20 - 12.67）与长期死亡独立相关。手术住院期间的红细胞输血与长期死亡相关（HR 3.96；95% CI，2.47 - 6.34），这因贫血严重程度而减弱（无贫血[HR 4.39]、轻度贫血[HR 2.27]和中度/重度贫血[HR 0.81]；趋势P值为0.0015）。
术前贫血、围手术期出血和红细胞输血与非心脏手术后长期随访中的死亡率增加相关。应考虑为所有患者采取尽量减少贫血和出血的策略，并且限制性输血策略可能是可取的。有必要对这些不良事件的机制进行进一步研究。
