Introduction: While red blood cell (RBC) transfusion used to be considered a benign treatment of suboptimal hematocrit levels peri-operatively, studies in various surgical specialties have revealed potential deleterious effects. We assessed the impact of intra- and postoperative transfusion on postoperative morbidity and mortality in patients undergoing elective spine surgery.
Methods: We identified 36,901 adult patients in the 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patients who received intra- or post-operative transfusion were matched to those who did not, using propensity scores; we analyzed baseline factors and comorbidities previously suggested affecting spine surgery outcomes, preoperative hematocrit levels, and length of surgery. Logistic regression predicted adverse postoperative outcomes. Sensitivity analyses were done separately according to surgical subspecialty. NSQIP reports outcomes to 30 days from surgery.
Results: 3,262 (8.8%) patients received RBC transfusion. Upon matching, preoperative hematocrit and LOS were no longer significantly different between transfused and non-transfused patients. However, after matching and adding unbalanced covariates to the final model, transfusion remained directly and adversely associated with several negative outcomes: a prolonged length of stay (LOS) in hospital (OR 2.6, 95% CI 2.3-2.9); more postoperative complications (OR 1.6, 95% CI 1.4-1.9); and increased return to surgery within 30 days (OR 1.7, 95% CI 1.3-2.2). Sensitivity analyses confirmed these findings separately in patients operated on by neurological and orthopedic surgeons.
Conclusions: RBC transfusion increased LOS and postoperative morbidity in patients undergoing elective spine surgery, independent of preoperative hematocrit level and patient comorbidities. With increasing attention to enhancing patient outcomes, while controlling healthcare expenditures, minimizing peri-operative blood loss should be a priority in elective spine surgery, and RBC transfusion must be given with greater appreciation of its potential deleterious effects and increased costs. Pre-operative measures to treat anemia should be considered in anemic patients undergoing elective spine surgery, when feasible.
Patient Care: Red blood cell (RBC) transfusion increased prolonged length of stay and postoperative morbidity in patients undergoing elective spine surgery, independent of preoperative hematocrit level and patient comorbidities. Minimizing peri-operative blood loss should be a priority in elective spine surgery, and RBC transfusion must be given with greater appreciation of its potential deleterious effects and increased costs. Pre-operative measures to treat anemia should be considered in anemic patients undergoing elective spine surgery, when feasible.
Learning Objectives: By the conclusion of this session, the participants should be able to 1) describe the relevance of blood transfusion to spine surgery outcomes, 2) discuss the results of this study and its impact on neurosurgical practice.