Advertisement

Blood transfusion is associated with increased risk of perioperative complications and prolonged hospital duration of stay among patients undergoing amputation

      Objective

      We evaluated the outcomes of patients undergoing major lower-extremity amputation who received packed red blood cell transfusion.

      Methods

      Using the dataset of the National Surgical Quality Improvement Program (2005–2011), we examined 5,739 above-knee and 6,725 below-knee amputations. Patients were stratified by perioperative (preoperative, intraoperative, or postoperative) blood transfusion. Outcomes included perioperative mortality, myocardial infarction (MI), thromboembolism, and duration of stay (DOS) at the hospital. Adjusted comparisons of outcomes between transfused and not-transfused patients were performed by matching the 2 groups for age, smoking, diabetes, renal failure, coronary artery disease, classification of the American Society of Anesthesiologists, functional status, and procedure type. Multivariable logistic and gamma regression were used to examine associations between transfusion and outcomes.

      Results

      Of the 12,464 amputations in the study cohort 2,133 (17%) required transfusion. The majority of the cases were performed for critical limb ischemia (8,205 amputations; 66%) and the overall 30-days mortality was 9%. In both crude and matched cohorts, although perioperative mortality and cardiac complication rates were similar, transfusion was associated with a greater incidence of pneumonia (crude: 6.1% vs 3%, P < .001; matched: 5.9% vs 3.7%, P < .001), thromboembolism (2.5% vs 1.6%, P = .003; 2.5% vs 1.4%, P = .002) and longer DOS (18 ± 19 vs 13.6 ± 14.3 days, P < .001; 17.8 ± 18.4 vs 14.2 ± 14.5 days, P < .001). Multivariable adjustment for confounding variables in the crude cohort demonstrated that transfusion was independently associated with a greater odds of perioperative pneumonia (odds ratio [OR]:1.6; 95% confidence interval [CI]:1.3–2; P < .001), thromboembolism (OR 1.3, 95% CI 1.0–1.9, P = .09) and longer DOS (mean ratio: 1.1; 95% CI 1.1–1.6; P = .006).

      Conclusion

      Among patients who had major lower-extremity amputation, perioperative transfusion independently predicted greater risks for perioperative pneumonia, thromboembolism, and prolonged hospital DOS.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Tunis S.R.
        • Bass E.B.
        • Steinberg E.P.
        The use of angioplasty, bypass surgery, and amputation in the management of peripheral vascular disease.
        N Engl J Med. 1991; 325: 556-562
        • Goodney P.P.
        • Beck A.W.
        • Nagle J.
        • Welch H.G.
        • Zwolak R.M.
        • et al.
        National trends in lower extremity bypass surgery, endovascular interventions, and major amputations.
        J Vasc Surg. 2009; 50: 54-60
        • Goodney P.P.
        • Holman K.
        • Henke P.K.
        • Travis L.L.
        • Dimick J.B.
        • Stukel T.A.
        • et al.
        Regional intensity of vascular care and lower extremity amputation rates.
        J Vasc Surg. 2013; 57 (1480 e1–e3. discussion 1479–1480): 1471-1479
        • Goodney P.P.
        • Travis L.L.
        • Brooke B.S.
        • DeMartino R.R.
        • Goodman D.C.
        • Fisher E.S.
        • et al.
        Relationship between regional spending on vascular care and amputation rate.
        JAMA Surg. 2014; 149: 34-42
        • Ziegler-Graham K.
        • MacKenzie E.J.
        • Ephraim P.L.
        • Travison T.G
        • Brookmeyer R.
        • et al.
        Estimating the prevalence of limb loss in the United States: 2005 to 2050.
        Arch Phys Med Rehabil. 2008; 89: 422-429
        • Norgren L.
        • Hiatt W.R.
        • Dormandy J.A.
        • Nehler M.R.
        • Harris K.A.
        • Fowkes F.G.
        • et al.
        Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).
        J Vasc Surg. 2007; 45: S5-67
        • Nehler M.R.
        • Hiatt W.R.
        • Taylor Jr., L.M.
        Is revascularization and limb salvage always the best treatment for critical limb ischemia?.
        J Vasc Surg. 2003; 37: 704-708
        • Belmont Jr., P.J.
        • Davey S.
        • Orr J.D.
        • Ochoa L.M.
        • Bader J.O.
        • Schoenfeld A.J.
        • et al.
        Risk factors for 30-day postoperative complications and mortality after below-knee amputation: a study of 2,911 patients from the national surgical quality improvement program.
        J Am Coll Surg. 2011; 213: 370-378
        • Aulivola B.
        • Hile C.N.
        • Hamdan A.D.
        • Sheahan M.G.
        • Veraldi J.R.
        • Skillman J.J.
        • et al.
        Major lower extremity amputation: outcome of a modern series.
        Arch Surg. 2004; 139 (discussion 399): 395-399
        • Bates B.
        • Stineman M.G.
        • Reker D.M.
        • Kurichi J.E.
        • Kwong P.L.
        • et al.
        Risk factors associated with mortality in veteran population following transtibial or transfemoral amputation.
        J Rehabil Res Dev. 2006; 43: 917-928
        • Stone P.A.
        • Flaherty S.K.
        • Aburahma A.F.
        • Hass S.M.
        • Jackson J.M.
        • Hayes J.D.
        • et al.
        Factors affecting perioperative mortality and wound-related complications following major lower extremity amputations.
        Ann Vasc Surg. 2006; 20: 209-216
        • Nelson M.T.
        • Greenblatt D.Y.
        • Soma G.
        • Rajimanickam V.
        • Greenberg C.C.
        • Kent K.C.
        • et al.
        Preoperative factors predict mortality after major lower-extremity amputation.
        Surgery. 2012; 152 (discussion 694–696): 685-694
        • Bates M.C.
        • Rashid M.
        • Campbell J.E.
        • Stone P.A.
        • Broce M.
        • Lavigne P.S.
        • et al.
        Factors influencing the need for target vessel revascularization after renal artery stenting.
        J Endovasc Ther. 2006; 13: 569-577
        • Hasanadka R.
        • McLafferty R.B.
        • Moore C.J.
        • Hood D.B.
        • Ramsey D.E.
        • Hodgson K.J.
        • et al.
        Predictors of wound complications following major amputation for critical limb ischemia.
        J Vasc Surg. 2011; 54: 1374-1382
        • Curran T.
        • Zhang J.Q.
        • Lo R.C.
        • Fokkema M.
        • McCallum J.C.
        • Buck D.B.
        • et al.
        Risk factors and indications for readmission after lower extremity amputation in the American College of Surgeons National Surgical Quality Improvement Program.
        J Vasc Surg. 2014; 60: 1315-1324
        • O'Brien P.J.
        • Cox M.W.
        • Shortell C.K.
        • Scarborough J.E.
        • et al.
        Risk factors for early failure of surgical amputations: an analysis of 8,878 isolated lower extremity amputation procedures.
        J Am Coll Surg. 2013; 216 (discussion 842–844): 836-842
        • Easterlin M.C.
        • Chang D.C.
        • Wilson S.E.
        A practical index to predict 30-day mortality after major amputation.
        Ann Vasc Surg. 2013; 27: 909-917
        • Tan T.W.
        • Farber A.
        • Hamburg N.M.
        • Eberhardt R.T.
        • Rybin D.
        • Doros G.
        • et al.
        Blood transfusion for lower extremity bypass is associated with increased wound infection and graft thrombosis.
        J Am Coll Surg. 2013; 216 (quiz 1031–1033): 1005-1014.e2
        • O'Keeffe S.D.
        • Davenport D.L.
        • Minion D.J.
        • Sorial E.E.
        • Endean E.D.
        • Xenos E.S.
        • et al.
        Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization.
        J Vasc Surg. 2010; 51: 616-621.e1–e3
        • Carson J.L.
        • Brooks M.M.
        • Abbott J.D.
        • Chaitman B.
        • Kelsey S.F.
        • Triulzi D.J.
        • et al.
        Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease.
        Am Heart J. 2013; 165: 964-971.e1
        • Goodnough L.T.
        • Schrier S.L.
        Evaluation and management of anemia in the elderly.
        Am J Hematol. 2014; 89: 88-96
        • Murphy G.J.
        • Reeves B.C.
        • Rogers C.A.
        • Rizvi S.I.
        • Culliford L.
        • Angelini G.D.
        • et al.
        Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.
        Circulation. 2007; 116: 2544-2552
        • Salpeter S.R.
        • Buckley J.S.
        • Chatterjee S.
        Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review.
        Am J Med. 2014; 127: 124-131.e3
        • Leal-Noval S.R.
        • Rincon-Ferrari M.D.
        • Garcia-Curiel A.
        • Herruzo-Aviles A.
        • Camacho-Larana P.
        • Garnacho-Montero J.
        • et al.
        Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery.
        Chest. 2001; 119: 1461-1468
        • Chelemer S.B.
        • Prato B.S.
        • Cox Jr., P.M.
        • O'Connor G.T.
        • Morton J.R.
        • et al.
        Association of bacterial infection and red blood cell transfusion after coronary artery bypass surgery.
        Ann Thorac Surg. 2002; 73: 138-142
        • Banbury M.K.
        • Brizzio M.E.
        • Rajeswaran J.
        • Lytle B.W.
        • Blackstone E.H.
        • et al.
        Transfusion increases the risk of postoperative infection after cardiovascular surgery.
        J Am Coll Surg. 2006; 202: 131-138
        • Edna T.H.
        • Bjerkeset T.
        Association between transfusion of stored blood and infective bacterial complications after resection for colorectal cancer.
        Eur J Surg. 1998; 164: 449-456
        • Walz J.M.
        • Paterson C.A.
        • Seligowski J.M.
        • Heard S.O.
        • et al.
        Surgical site infection following bowel surgery: a retrospective analysis of 1446 patients.
        Arch Surg. 2006; 141 (discussion 1018): 1014-1018
        • Carson J.L.
        • Terrin M.L.
        • Noveck H.
        • Sanders D.W.
        • Chaitman B.R.
        • Rhoads G.G.
        • et al.
        Liberal or restrictive transfusion in high-risk patients after hip surgery.
        N Engl J Med. 2011; 365: 2453-2462
        • Goodnough L.T.
        • Murphy M.F.
        Do liberal blood transfusions cause more harm than good?.
        BMJ. 2014; 349: g6897
        • Carson J.L.
        • Carless P.A.
        • Hebert P.C.
        Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion.
        Cochrane Database Syst Rev. 2012; : CD002042
        • Hajjar L.A.
        • Vincent J.L.
        • Galas F.R.
        • Nakamura R.E.
        • Silva C.M.
        • Santos M.H.
        • et al.
        Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.
        JAMA. 2010; 304: 1559-1567
        • Khuri S.F.
        • Daley J.
        • Henderson W.
        • Hur K.
        • Gibbs J.O.
        • Barbour G.
        • et al.
        Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study.
        J Am Coll Surg. 1997; 185: 315-327
        • Khuri S.F.
        • Henderson W.G.
        • Daley J.
        • Jonasson O.
        • Jones R.S.
        • Campbell Jr., D.A.
        • et al.
        Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study.
        Ann Surg. 2008; 248: 329-336
        • Greevy R.
        • Lu B.
        • Silber J.H.
        • Rosenbaum P.
        • et al.
        Optimal multivariate matching before randomization.
        Biostatistics. 2004; 2: 263-275
        • Stuart E.A.
        Matching methods for causal inference: a review and a look forward.
        Stat Sci. 2010; 25: 1-21
        • Middelburg R.A.
        • van de Watering L.M.
        • van der Bom J.G.
        Blood transfusions: good or bad? Confounding by indication, an underestimated problem in clinical transfusion research.
        Transfusion. 2010; 50: 1181-1183
        • Carson J.L.
        • Grossman B.J.
        • Kleinman S.
        • Tinmouth A.T.
        • Marques M.B.
        • Fung M.K.
        • et al.
        Red blood cell transfusion: a clinical practice guideline from the AABB*.
        Ann Intern Med. 2012; 157: 49-58
        • Napolitano L.M.
        • Kurek S.
        • Luchette F.A.
        • Anderson G.L.
        • Bard M.R.
        • Bromberg W.
        • et al.
        Clinical practice guideline: red blood cell transfusion in adult trauma and critical care.
        J Trauma. 2009; 67: 1439-1442
        • Horvath K.A.
        • Acker M.A.
        • Chang H.
        • Bagiella E.
        • Smith P.K.
        • Iribarne A.
        • et al.
        Blood transfusion and infection after cardiac surgery.
        Ann Thorac Surg. 2013; 95: 2194-2201
        • Rohde J.M.
        • Dimcheff D.E.
        • Blumberg N.
        • Saint S.
        • Langa K.M.
        • Kuhn L.
        • et al.
        Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis.
        JAMA. 2014; 311: 1317-1326
        • Refaai M.A.
        • Blumberg N.
        Transfusion immunomodulation from a clinical perspective: an update.
        Expert Rev Hematol. 2013; 6: 653-663
        • Blajchman M.A.
        Transfusion immunomodulation or TRIM: what does it mean clinically?.
        Hematology. 2005; 10: 208-214
        • Xenos ES,Vargas H.D.
        • Davenport D.L.
        Association of blood transfusion and venous thromboembolism after colorectal cancer resection.
        Thromb Res. 2012; 129: 568-572
        • Gangireddy C.
        • Rectenwald J.R.
        • Upchurch G.R.
        • Wakefield T.W.
        • Khuri S.
        • Henderson W.G.
        • et al.
        Risk factors and clinical impact of postoperative symptomatic venous thromboembolism.
        J Vasc Surg. 2007; 45 (discussion 341–342): 335-341
        • Khorana A.A.
        • Francis C.W.
        • Blumberg N.
        • Culakova E.
        • Refaai M.A.
        • Lyman G.H.
        • et al.
        Blood transfusions, thrombosis, and mortality in hospitalized patients with cancer.
        Arch Intern Med. 2008; 168: 2377-2381
        • Engoren M.
        • Schwann T.A.
        • Jewell E.
        • Neill S.
        • Benedict P.
        • Likosky D.S.
        • et al.
        Is transfusion associated with graft occlusion after cardiac operations?.
        Ann Thorac Surg. 2015; 99: 502-508
        • Urbich C.
        • Dernbach E.
        • Aicher A.
        • Zeiher A.M.
        • Dimmeler S.
        • et al.
        CD40 ligand inhibits endothelial cell migration by increasing production of endothelial reactive oxygen species.
        Circulation. 2002; 106: 981-986
        • Brodsky S.V.
        • Malinowski K.
        • Golightly M.
        • Jesty J.
        • Goligorsky M.S.
        • et al.
        Plasminogen activator inhibitor-1 promotes formation of endothelial microparticles with procoagulant potential.
        Circulation. 2002; 106: 2372-2378
        • Hovav T.
        • Yedgar S.
        • Manny N.
        • Barshtein G.
        • et al.
        Alteration of red cell aggregability and shape during blood storage.
        Transfusion. 1999; 39: 277-281
        • Fransen E.
        • Maessen J.
        • Dentener M.
        • Senden N.
        • Buurman W.
        • et al.
        Impact of blood transfusions on inflammatory mediator release in patients undergoing cardiac surgery.
        Chest. 1999; 116: 1233-1239