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Original Investigation |

Effect of Relative Decrease in Blood Hemoglobin Concentrations on Postoperative Morbidity in Patients Who Undergo Major Gastrointestinal Surgery

Gaya Spolverato, MD1,2; Yuhree Kim, MD, MPH1,2; Aslam Ejaz, MD, MPH1,2; Steven M. Frank, MD1,2; Timothy M. Pawlik, MD, MPH, PhD1,2
[+] Author Affiliations
1Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
2Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
JAMA Surg. 2015;150(10):949-956. doi:10.1001/jamasurg.2015.1704.
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Importance  Delta hemoglobin (ΔHb), defined as the difference between the preoperative hemoglobin (Hb) level and the nadir Hb level during a patient’s hospitalization, may be associated with adverse outcomes even if the absolute level of Hb remains greater than the transfusion threshold of 7 g/dL.

Objective  To evaluate the association between ΔHb and morbidity in patients who undergo major gastrointestinal surgery as an independent factor or combined with the nadir Hb concentration.

Design, Setting, and Participants  Retrospective review of prospectively collected data on patients who underwent pancreatic, hepatic, or colorectal resection from January 1, 2010, through April 30, 2014, at Johns Hopkins Hospital were included in the study. Data regarding the ΔHb concentration following surgery, nadir Hb level, and overall perioperative blood use were obtained and analyzed. Multivariable-adjusted logistic regression models were used to identify the preoperative factors associated with ΔHb and the effect of ΔHb on perioperative morbidity. The study and data analysis took place from January 22 through February 20, 2015.

Interventions  Major gastrointestinal surgery and packed red blood cell transfusion.

Main Outcomes and Measures  Overall morbidity and ischemic-specific complications.

Results  Of the 4669 patients who underwent major gastrointestinal surgery, the median ΔHb level after surgery was 40%. Patients with multiple comorbidities (American Society of Anesthesiologists Physical Status score of 3-4: odds ratio [OR], 1.96; 95% CI, 1.30-2.97; P <.001; ≥3 coexisting medical conditions: OR, 1.62; 95% CI, 1.08-2.42; P = .001) and those who underwent pancreatic surgery (OR, 1.98; 95% CI, 1.18-3.33; P = .01) were at increased risk of having a ΔHb of 50% or greater. Compared with patients who had a ΔHb level of less than 50% and a nadir Hb level of 7 g/dL or greater, patients with a ΔHb level of 50% or greater whose nadir Hb level was less than 7 g/dL were at a high risk of developing postoperative complications (OR, 6.60; 95% CI, 4.34-10.03; P < .001); in particular, a ΔHb level of 50% or greater was strongly correlated with a risk of ischemic complications, even if the nadir Hb level was 7 g/dL or greater (OR, 5.68; 95% CI, 1.44-22.39; P = .01).

Conclusions and Relevance  A ΔHb level of 50% or greater following gastrointestinal surgery was associated with complications, especially ischemic adverse events, even if the nadir Hb level remained at 7 g/dL or greater.

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Figure 1.
Incidence of Complications Stratified by Different Combinations of ΔHb and Nadir Hb Levels

Of the patients with a hemoglobin (Hb) level of 7 g/dL or greater (to convert to grams per liter, multiply by 10.0), those with a delta hemoglobin (ΔHb) level of 50% or greater were at higher risk of complications (P < .001).

Graphic Jump Location
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Figure 2.
Spline Function Plot of the Relationship Between Decrease in Hemoglobin Level and Morbidity

A, Relationship stratified by sex. B, Relationship stratified by type of surgery.

Graphic Jump Location

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