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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 95-98

Preoperative packed cell volume (PCV) and category of surgery as predictors of intra-operative blood transfusion


1 Department of Anaesthesia, Ahmadu Bello University, Zaria, Nigeria
2 Department of Haematology and Blood Transfusion, Ahmadu Bello University, Zaria, Nigeria
3 Department of Haematology, Kaduna State University, Kaduna, Nigeria

Date of Web Publication29-Oct-2018

Correspondence Address:
Dr. S Y Yakubu
Department of Anaesthesia, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_10_18

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  Abstract 


Background: Preoperative anemia in surgical patients scheduled for major procedures results in poor outcomes, hence the need for full optimization of packed cell volume (PCV) before surgery. This study aims to assess preoperative PCV and category of surgery as predictors of intraoperative blood transfusion in a tertiary healthcare facility in Zaria, Nigeria.
Patients and Methods: This was a retrospective study where hospital records of patient's ≥13 years undergoing elective surgeries at a tertiary hospital in Zaria over a period of 6 months were reviewed. Patients' ages, gender, preoperative PCV, category of surgery, American Society of Anesthesiologists (ASA) scores, and number of units of blood transfused intraoperatively were analyzed using SPSS 20.0.
Results: There were 164 surgeries conducted during the study period. Females constituted 96 (58.5%) of the patients. The mean age and preoperative PCV were 38.9 ± 14.9 years and 36.6 ± 4.9%, respectively. The median (interquartile range) units transfused intraoperatively and ASA scores were 0 (0) and 2 (0), respectively. Spearman's correlation to compare the number of units transfused as a reference point was significant for preoperative PCV (ρ = −0.222, P = 0.004). Regression analyses using category of surgery, ASA scores, age, and preoperative PCV predicted intraoperative transfusion; F(2, 161) = 5.120, P = 0.007, adjusted R2 = 0.048 with preoperative PCV and category of surgery predicting the number of units transfused (β =-0.176, P = 0.023) and (β = −0.158, P = 0.041), respectively.
Conclusion: Preoperative PCV and category of surgery although important have a low ability to predict the number of blood units transfused intraoperatively.

Keywords: Category of surgery, intraoperative blood transfusion, packed cell volume, preoperative


How to cite this article:
Yakubu S Y, Awwalu S, Dogara L G, Waziri A D, Mamman A I. Preoperative packed cell volume (PCV) and category of surgery as predictors of intra-operative blood transfusion. Arch Int Surg 2017;7:95-8

How to cite this URL:
Yakubu S Y, Awwalu S, Dogara L G, Waziri A D, Mamman A I. Preoperative packed cell volume (PCV) and category of surgery as predictors of intra-operative blood transfusion. Arch Int Surg [serial online] 2017 [cited 2020 Jul 11];7:95-8. Available from: http://www.archintsurg.org/text.asp?2017/7/3/95/244401




  Introduction Top


The World Health Organization cutoff for anemia for men and women is hemoglobin (Hb) concentration of <130 g/L [packed cell volume (PCV) <39%] and <120 g/L (PCV <36%), respectively, at sea level.[1] Surgery exposes patients to unique stressors both intra- and postoperatively. The function of Hb in oxygenation is important in wound healing. This may be why a target Hb concentration of at least 130 g/L has been suggested for all adult patients undergoing surgical procedures.[2] Munoz et al. reported significant associations between preoperative anemia and poor patients' outcomes. These outcomes include length of hospital stay, postoperative complications, and death.[3]

Major elective surgeries may lead to perioperative blood loss which may cause acute severe anemia, especially in patients with low preoperative Hb concentrations.[4] Thus, preoperative red cell transfusions are usually administered to increase Hb levels in these patients, thus improving oxygenation and tissue perfusion. However, blood transfusion has some risks especially transfusion transmissible infections (TTIs).[4],[5]

The perennial dearth of adequate and safe blood coupled with the capital intensive nature of blood and blood products demands proactive measures are taken to predict surgical cases that may require blood transfusion intraoperatively. Unfortunately, baseline published data on the relationship between preoperative PCV/Hb, categories of surgeries, and intraoperative blood transfusion are not available. Hence, this study was conducted to assess preoperative PCV and category of surgery as predictors of intraoperative blood transfusion in our center with a view to providing evidence-based means of assessing intraoperative blood transfusion requirements.


  Patients and Methods Top


This was a retrospective study where the case notes of patient's ≥13 years who had undergone elective surgical procedures at Ahmadu Bello University Teaching Hospital (ABUTH), a tertiary healthcare facility in Zaria, North-West, Nigeria, over a 6-month period (1st November 2016 and 30th April 2017), were reviewed and analyzed. Patients' ages, gender, preoperative PCV, category of surgery, American Society of Anesthesiologists (ASA) score, and number of units of blood transfused intraoperatively were determined.

Data were analyzed using IBM SPSS version 20.0. Continuous variables were summarized as means ± standard deviations or medians and interquartile ranges (IQRs = 75th percentile value –25th percentile value) as dictated by tests of normality. Categorical variables were summarized as percentages. Spearman's correlation analyses were conducted to determine the relationships between the number of units transfused intraoperatively, patients' ages, and preoperative PCV. Multiple regression analyses were performed to predict the number of units transfused intraoperatively from preoperative PCV, category of surgery, ASA score, and gender. A P value of ≤0.05 was considered significant.


  Results Top


A total of 164 surgeries were conducted during the study period with females constituting 96 (58.5%) of the patients. The mean age and preoperative PCV of the patients were 38.9 ± 14.9 years and 36.6 ± 4.9%, respectively. The median units transfused intraoperatively and ASA scores were 0 (IQR = 0, range = 0–2) and 2 (IQR = 0, range = 1–4). Categories of surgeries undertaken are depicted in [Table 1]. Spearman's correlation analyses to compare the number of units transfused as a reference point were conducted for age (ρ = −0.034, P = 0.669), preoperative PCV (ρ = −0.222, P = 0.004), and ASA scores (ρ =0.104, P = 0.183).
Table 1: Category of surgeries

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Backward multiple regression analyses using category of surgery, ASA scores, age, and preoperative PCV revealed that the model produced by category of surgery and preoperative PCV produced the best fit in predicting intraoperative transfusion; F(2, 161) =5.120, P = 0.007, adjusted R2 = 0.048. In this model, preoperative PCV and category of surgery significantly predicted the number of blood units transfused intraoperatively (β = −0.176, P = 0.023) and (β = −0.158, P = 0.041), respectively.


  Discussion Top


The finding of a significant correlation between preoperative PCV and intraoperative blood transfusion in this study is consistent with the findings of some previous studies which suggest that preoperative anemia is associated with subsequent transfusions, morbidity, and mortality.[6],[7],[8] Beattie et al. in their study on risk associated with preoperative anemia in noncardiac surgery reported that anemia is a common condition in surgical patients and is independently associated with increased mortality. They went further to state that although anemia increases mortality independent of transfusion, it is associated with increased requirement for transfusion, which is also associated with increased mortality.[7] Similarly, Musallam et al. reported that preoperative anemia, even to a mild degree, is independently associated with risk of 30-day morbidity and mortality in patients undergoing major noncardiac surgery.[8] The proportion of patients transfused after a given operation varies substantially between hospitals.[9],[10],[11] Roubinian et al. in their study of 21 medical facilities in Northern California reported that variation in RBC transfusion incidence across hospitals decreased from 2010 to 2013.[10] This may be due to differences in institutional practices and surgical protocols even though patient selection criteria for different types of surgeries may be contributory.

This study produced a model indicating that both preoperative PCV and category of surgeries are important predictors of intraoperative blood transfusion. This is an expected finding as earlier studies have demonstrated that suboptimal Hb levels (<130 g/L for both sexes) are independent predictive factors for perioperative red cell transfusion.[2] An additional finding in this study is that the category of surgery is a stronger predictor of intraoperative blood transfusion than preoperative PCV. This may be because different surgeries have varying complexities with some involving highly vascular tissues or organs.

We found that only a small proportion of intraoperative transfusions could be predicted by both preoperative PCV and category of surgery. This may be attributed to some limitations in this study as certain variables such as intraoperative blood loss and the proficiency and/or techniques of surgeons were not evaluated in this study. In addition, stages and extents of underlying surgical conditions and specific type of surgery were not assessed. The latter is important as major orthopedic surgeries for example require significant number of blood units compared to other surgeries.[12] Similarly, the presence of comorbidities and nature of underlying pathology necessitating surgery have been described as important factors in determining preoperative anemia.[13],[14]

Red cell transfusions are often necessary in major surgeries, comorbidities, and because of perioperative blood loss and are more likely to be required if patients are anemic before operation.[12],[15],[16]

This study thus indicates the need for proactive strategies to predict and meet intraoperative blood transfusion demands. This will entail the hospital blood transfusion committee to elucidate maximum blood ordering schedules for each surgical procedure. This will require the determination of indices such as cross-match transfusion ratio, transfusion probability, and transfusion index for each surgical procedure.[17]

Finally, we recommend the institution of patient blood management modalities which will involve multidisciplinary, multimodal but individualized strategies that identify modifiable risks and optimize patients' preoperative PCV with the ultimate goal of improving surgical operation outcomes.[18],[19]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest



 
  References Top

1.
WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. World Health Organization, Geneva, 2011 (WHO/NMH/NHD/MNM/11.1). Available from: http://www.who.int/vmnis/indicators/haemoglobin.pdf. [Last accessed on 2018 Apr 02].  Back to cited text no. 1
    
2.
Munoz M, Gomez-Ramirez S, Kozek-Langeneker S, Shander A, Richards T, Pavia J, et al. “Fit to fly”: Overcoming the barriers to preoperative haemoglobin optimization in surgical patients. Br J Anaesth 2015;115:152–24.  Back to cited text no. 2
    
3.
Munoz M, Gomez-Ramirez S, Campos A, Ruiz J, Liumbruno GM. Pre-operative anaemia: Prevalence, consequences and approaches to management. Blood Transfus 2015;13:370-9.  Back to cited text no. 3
    
4.
Gombotz H, Rehak PH, Shander A, Hofmann A. Blood use in elective surgery: The Austrian benchmark study. Transfusion 2007;47:1468-80.  Back to cited text no. 4
    
5.
Klein AA, Collier TJ, Brar MS, Evans C, Hallward G, Fletcher SN, et al. Association of Cardiothoracic Anaesthetists (ACTA). The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK – The first Association of Cardiothoracic Anaesthetists national audit. Anaesthesia 2016;71:627-35.  Back to cited text no. 5
    
6.
Wu WC, Schifftner TL, Henderson WG, Eaton CB, Poses RM, Uttley G, et al. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing non-cardiac surgery. JAMA 2007;297:2481-8.  Back to cited text no. 6
    
7.
Beattie WS, Karkouti K, Wijeysundera DN, Tait G. Risk associated with preoperative anemia in non-cardiac surgery: A single-center cohort study. Anesthesiology 2009;110:574-81.  Back to cited text no. 7
    
8.
Musallam KM, Tamim HM, Richards T, Sphan DR, Rosendaal FR, Habbal A, et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: A retrospective cohort study. Lancet 2011;378:1396-407.  Back to cited text no. 8
    
9.
Norgaard A, De Lichtenberg TH, Nielsen J, Johansson PI. Monitoring compliance with transfusion guidelines in hospital departments by electronic data capture. Blood Transfus 2014;12:509-19.  Back to cited text no. 9
    
10.
Roubinian NH, Escobar GJ, Liu V, Swain BE, Gardner MN, Kipnis P, et al. Trends in red blood cell transfusion and 30-day mortality among hospitalized patients. Transfusion 2014;54:2678-86.  Back to cited text no. 10
    
11.
Gombotz H, Rehak PH, Shander A, Hofmann A. The second Austrian benchmark study for blood use in elective surgery: Results and practice change. Transfusion 2014;54:2646-57.  Back to cited text no. 11
    
12.
Wells AW, Mounter PJ, Chapman CE, Stainsby D, Wallis JP. Where does blood go? Prospective observational study of red cell transfusion in north England. Br Med J 2002;325:803.  Back to cited text no. 12
    
13.
Shander A, Goodnough LT, Javidroozi M, Auerbach M, Carson J, Ershler WB, et al. Iron deficiency anemia – Bridging the knowledge and practice gap. Transfus Med Rev 2014;28:156-66.  Back to cited text no. 13
    
14.
Shander A, Knight K, Thurer R, Adamson J, Spence R. Prevalence and outcomes of anemia in surgery: A systematic review of the literature. Am J Med 2004;116(Suppl. 7A): 58S.69S.  Back to cited text no. 14
    
15.
Feagan BG, Wong CJ, Kirkley A, Johnston DW, Smith FC, Whitsitt P, et al. Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial. Ann Intern Med 2000;131:845-54  Back to cited text no. 15
    
16.
Perioperative blood transfusion for elective surgery: A National Clinical Guideline (SIGN 54). Available from: www.sign.ac.uk. [Last accessed on 2007 Feb 20].  Back to cited text no. 16
    
17.
Vibhute M, Kamath S K, Shetty A. Blood utilisation in elective general surgery cases: Requirements, ordering and transfusion practices. J Postgrad Med 2000;46:13.  Back to cited text no. 17
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18.
Shander A, Van Aken H, Colomina MJ, Gombotz H, Hofmann A, Krauspe R, et al. Patient blood management in Europe. Br J Anaesth 2012;109:55-68.  Back to cited text no. 18
    
19.
The Society for the Advancement of Blood Management 2012 Definition of PBM. Available from: http://SABM.org. [Last accessed on 2014 Aug 03].  Back to cited text no. 19
    



 
 
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