Thursday, July 20, 2017

Shoulder arthroplasty transfusion and complications, egg vs chicken.

Analysis of complication rates following perioperative transfusion in shoulder arthroplasty

These authors sought to examine the postoperative outcomes of patients receiving blood transfusions following TSA and RTSA using the Medicare Standard Analytic Files database between 2005 and 2010. They identified 7,794 patients who received a perioperative blood transfusion following TSA or RTSA, as well as 34,293 age- and gender-matched controls.

Patients who received a perioperative transfusion were sicker, having statistically significantly higher rates of myocardial infarction, pneumonia, systemic inflammatory response syndrome or sepsis, venous thromboembolic events, cerebrovascular accidents, surgical complications, including periprosthetic infection and mechanical complications.

Comment: This study raises at least three possibilities: (1) that patients with complications and co-morbidities are at increased risk for transfusion, (2) patients with transfusion are at increased risk for complications, or (3) both of these interactions are at play. 

What we'd like to know is whether changing our threshold for using transfusions might affect the complication rate. For example, would the complication risk of a patient with a hematocrit of 25 be lower if transfusion was withheld than if blood was transfused? A partial answer to this question might be available if a multivariate analysis was carried out that investigated the relationship of patient age, sex, comorbidities, preoperative hematocrit, surgical procedure, diagnosis, procedure length, and transfusion to surgical and medication complications.

Some related posts are of interest

Blood transfusion in primary total shoulder arthroplasty: incidence, trends, and risk factors in the United States from 2000 to 2009.

These authors used the National Inpatient Sample between 2000 and 2009 to assess the overall blood transfusion rate as well as trends in transfusion patterns over time and the patient and hospital characteristics that independently influenced the likelihood that a given patient undergoes allogeneic blood transfusion. They found that the overall blood transfusion rate (ie, the proportion of patients who received at least 1 transfusion of any kind) was 6.7%. This rate increased over time, from 4.9% in 2000 to 7.1% in 2009 (P < .001).

With respect to the 4 Ps, the risk of allogeneic blood transfusion was increased for patients over 85 years of age, women, non-white patients, patients with other than private insurance, patients with comorbidities and provider hospitals with low case loads and hospitals in the Northeast.

Comment: There are many factors that influence the use of blood transfusion. This study would have been stronger had a multivariate analysis been carried out to determine the most influential factors among those studied. However, other factors could not be identified in such a study, such as the individual surgeon's threshold for transfusion (?based on hematocrit or symptoms?), the time of surgery, the attention to hemostasis, the use of topical thrombin, the time of implementation of motion after surgery, the method of fixation of the components and many more. 

Our approach has been to attempt to minimize the use of blood so that it is saved for those whose life depends on it. We strive for short wound times and excellent hemostasis. We reserve transfusion for those patients with symptoms of anemia, such as orthostatic hypotension that does not respond to fluids, and for those at high risk for complications related to diminished arterial oxygenation.

Medical comorbidities and perioperative allogeneic red blood cell transfusion are risk factors for surgical site infection after shoulder arthroplasty

These authors sought to determine surgical site infection (SSI) risk due to medical comorbidities or blood transfusion after primary or revision shoulder arthroplasty. They collected data on medical comorbidities, surgical indication, perioperative transfusion, and SSI were obtained for 707 patients who underwent primary or revision hemiarthroplasty or total shoulder.

For the purpose of this study, SSI was defined in a rather particular manner:  either (1) treatment of a superficial infection within 30 days of surgery with débridement by the treating surgeon or with antibiotics by either the treating surgeon or an infectious disease specialist or (2) treatment of a suspected or confirmed deep infection by return to the operating room for débridement, component exchange, or explantation of components or treatment with therapeutic or long-term suppressive antibiotics by an infectious disease specialist. Positive cultures on return to the operating room were not a requirement for diagnosis of SSI.

Using this set of definitions, the SSI rate was 1.9% for primary hemiarthroplasties and 1.3% for primary total shoulder arthroplasties.

Revision arthroplasty or prior open reduction and internal fixation had higher SSI risk than primary arthroplasties (incidence risk ratio [IRR], 11.4; 95% confidence interval [CI], 3.84-34.0; P < .001).

Among primary arthroplasties, SSI risk factors included male gender (IRR, 60.0; CI, 4.39-819; P = .002), rheumatoid arthritis (IRR, 8.63; CI, 1.84-40.4; P = .006), and long-term corticosteroid use (IRR, 37.4; CI, 5.79-242; P < .001). 

Perioperative allogeneic red blood cell transfusion significantly increased SSI risk and was dose dependent (IRR, 1.68 per unit packed red blood cell; CI, 1.21-2.35; P = .002).

The culture results are shown below.

Comment: This series of cases points to the complex and uncertain relationship between cultures and clinical findings. Patients without the characteristic signs of infection can have positive cultures. Patients with characteristic signs of infection can have negative cultures.

The culture protocol used for these patients is not explained. Specifically, we do not know which cases were cultured, how many specimens were submitted for culture, what culture media were used, and how long the cultures were observed. It is known that unless 5 deep specimens are cultured on three different media and observed for 3 weeks, there is a substantial risk of overlooking Propionibacterium in the wound.

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