Patients with anaemia that undergo a range of non-cardiac surgical procedures have a 42% increased risk of death and a 35% increased risk of serious comorbidities compared with patients who are not anaemic. The findings are reported in an article published Online First and in the upcoming Surgery Special Issue of The Lancet, written by Dr Khaled M Musallam and Dr Faek R Jamali, American University of Beirut Medical Center, Beirut, Lebanon, and colleagues.
Preoperative anaemia is known to be associated with adverse outcomes after cardiac surgery but outcomes after non-cardiac surgery are not well established. In this study, the authors aimed to assess the effect of preoperative anaemia on 30-day postoperative morbidity and mortality in patients undergoing major non-cardiac surgery, by analysing a large dataset from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).
The types of surgery covered by the study were general, vascular, orthopaedic, gynaecological, urological, neurosurgical, otolaryngological, plastic, and thoracic. The data included postoperative outcomes of death, and major morbidities including cardiac, respiratory, CNS, urinary tract, wound, sepsis, and venous thromboembolism, as well as demographics, and preoperative and perioperative risk factors.
Data from 227,425 patients was assessed, of whom 69,229 (30%) had preoperative anaemia. Postoperative mortality at 30 days was 42% higher in patients with anaemia than in those without anaemia. This increased risk was consistent for mild anaemia (41%) and moderate-to-severe anaemia (44%). Patients with anaemia were also 35% more likely to have postoperative morbidities (for example cardiac, respiratory, urinary, wound, sepsis and thromboembolic problems) than in those without anaemia, again both in patients with mild anaemia (31% increased risk) and moderate-to-severe anaemia (56% increased risk). When compared with patients without anaemia or a defined risk factor, patients with anaemia and most risk factors (for example age ≥65 years, cardiac disease, severe chronic obstructive pulmonary disease, CNS disease, renal disease, cancer, or systemic sepsis) had a higher adjusted risk for 30-day mortality and morbidity than did patients with either anaemia or the risk factor.
The authors conclude: "Because even mild anaemia increases the risk of postoperative morbidity and mortality in patients undergoing major non-cardiac surgery, doctors need to consider preoperative treatment of anaemia when possible. Further research is needed to establish the efficacy, safety, and cost-effectiveness of such preoperative anaemia management."
In a linked Comment, Professor Hans Gombotz, Department of Anaesthesiology and Intensive Care, General Hospital Linz, Austria, says that, in some patients, there are risks associated with anaemia treatments such as iron supplementation or stimulation of red blood cell production (erythropoeisis).
However he concludes: "The study strongly indicates that the implementation of treatment of anaemia as part of a universal patient blood management should become standard of care in patients undergoing elective surgical procedures, particularly in those where substantial blood loss is to be expected.
However, additional studies are urgently needed to secure the efficacy and safety of preoperative treatment of anaemia."
Dr Khaled M Musallam, American University of Beirut Medical Center, Beirut, Lebanon. (but currently in Italy) T) 39-3453397008 E) kmm06@aub.edu.lb
Dr Faek R Jamali, American University of Beirut Medical Center, Beirut, Lebanon. T) 961-3-750954 E) fj03@aub.edu.lb
Professor Hans Gombotz, Department of Anaesthesiology and Intensive Care, General Hospital Linz, Austria. T) 43-73278062157 / 43-664806522157 E) hans.gombotz@akh.linz.at
Journal
The Lancet