Preoperative Anemia and Postoperative Outcomes in Cardiac Surgery: A Mediation Analysis Evaluating Intraoperative Transfusion Exposures

被引:6
作者
Warner, Matthew A. [1 ,4 ]
Hanson, Andrew C. [2 ]
Schulte, Phillip J. [2 ]
Sanz, Juan Ripoll [1 ]
Smith, Mark M. [1 ]
Kauss, Marissa L. [1 ]
Crestanello, Juan A. [3 ]
Kor, Daryl J. [1 ]
机构
[1] Mayo Clin, Dept Anesthesiol & Perioperat Med, Rochester, MN USA
[2] Mayo Clin, Dept Biomed Stat & Informat, Rochester, MN USA
[3] Mayo Clin, Dept Cardiovasc Surg, Rochester, MN USA
[4] Mayo Clin, Div Crit Care Med, Dept Anesthesiol & Perioperat Med, 200 1st St SW, Rochester, MN 55905 USA
关键词
BLOOD-CELL TRANSFUSION; CLINICAL-PRACTICE GUIDELINES; CARDIOPULMONARY BYPASS; MORTALITY; ADULT; RISK; ASSOCIATION; PREVENTION; MORBIDITY; IMPACT;
D O I
10.1213/ANE.0000000000006765
中图分类号
R614 [麻醉学];
学科分类号
100217 ;
摘要
BACKGROUND: Preoperative anemia is associated with adverse outcomes in cardiac surgery, yet it remains unclear what proportion of this association is mediated through red blood cell (RBC) transfusions. METHODS: This is a historical observational cohort study of adults undergoing coronary artery bypass grafting or valve surgery on cardiopulmonary bypass at an academic medical center between May 1, 2008, and May 1, 2018. A mediation analysis framework was used to evaluate the associations between preoperative anemia and postoperative outcomes, including a primary outcome of acute kidney injury (AKI). Intraoperative RBC transfusions were evaluated as mediators of preoperative anemia and outcome relationships. The estimated total effect, average direct effect of preoperative anemia, and percent of the total effect mediated through transfusions are presented with 95% confidence intervals and P-values. RESULTS: A total of 4117 patients were included, including 1234 (30%) with preoperative anemia. Overall, 437 of 4117 (11%) patients went on to develop AKI, with a greater proportion of patients having preoperative anemia (219 of 1234 [18%] vs 218 of 2883 [8%]). In multivariable analyses, the presence of preoperative anemia was associated with increased postoperative AKI (6.4% [4.2%-8.7%] absolute difference in percent with AKI, P < .001), with incremental decreases in preoperative hemoglobin concentrations displaying greater AKI risk (eg, 11.9% [6.9%-17.5%] absolute increase in probability of AKI for preoperative hemoglobin of 9 g/dL compared to a reference of 14 g/dL, P < .001). The association between preoperative anemia and postoperative AKI was primarily due to direct effects of preoperative anemia (5.9% [3.6%-8.3%] absolute difference, P < .001) rather than mediated through intraoperative RBC transfusions (7.5% [-4.3% to 21.1%] of the total effect mediated by transfusions, P = .220). Preoperative anemia was also associated with longer hospital durations (1.07 [1.05-1.10] ratio of geometric mean length of stay, P < .001). Of this total effect, 38% (22%, 62%; P < .001) was estimated to be mediated through subsequent intraoperative RBC transfusion. Preoperative anemia was not associated with reoperation or vascular complications. CONCLUSIONS: Preoperative anemia was associated with higher odds of AKI and longer hospitalizations in cardiac surgery. The attributable effects of anemia and transfusion on postoperative complications are likely to differ across outcomes. Future studies are necessary to further evaluate mechanisms of anemia-associated postoperative organ injury and treatment strategies.
引用
收藏
页码:728 / 737
页数:10
相关论文
共 29 条
[1]   THE MODERATOR MEDIATOR VARIABLE DISTINCTION IN SOCIAL PSYCHOLOGICAL-RESEARCH - CONCEPTUAL, STRATEGIC, AND STATISTICAL CONSIDERATIONS [J].
BARON, RM ;
KENNY, DA .
JOURNAL OF PERSONALITY AND SOCIAL PSYCHOLOGY, 1986, 51 (06) :1173-1182
[2]   The Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society for Extracorporeal Technology Clinical Practice Guidelines for the Prevention of Adult Cardiac Surgery-Associated Acute Kidney Injury [J].
Brown, Jeremiah R. ;
Baker, Robert A. ;
Shore-Lesserson, Linda ;
Fox, Amanda A. ;
Mongero, Linda B. ;
Lobdell, Kevin W. ;
LeMaire, Scott A. ;
De Somer, Filip M. J. J. ;
von Ballmoos, Moritz Wyler ;
Barodka, Viachaslau ;
Arora, Rakesh C. ;
Firestone, Scott ;
Solomon, Richard ;
Parikh, Chirag R. ;
Shann, Kenneth G. ;
Hammon, John .
ANESTHESIA AND ANALGESIA, 2023, 136 (01) :176-184
[3]   Anemia increases the risk of renal cortical and medullary hypoxia during cardiopulmonary bypass [J].
Darby, P. J. ;
Kim, N. ;
Hare, G. M. T. ;
Tsui, A. ;
Wang, Z. ;
Harrington, A. ;
Mazer, C. D. .
PERFUSION-UK, 2013, 28 (06) :504-511
[4]   Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: Should current practice be changed? [J].
Habib, RH ;
Zacharias, A ;
Schwann, TA ;
Riordan, CJ ;
Durham, SJ ;
Shah, A .
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY, 2003, 125 (06) :1438-1450
[5]   Tolerance of intraoperative hemoglobin decrease during cardiac surgery [J].
Hogervorst, Esther ;
Rosseel, Peter ;
van der Bom, Johanna ;
Bentala, Mohamed ;
Brand, Anneke ;
van der Meer, Nardo ;
van de Watering, Leo .
TRANSFUSION, 2014, 54 (10) :2696-2704
[6]   A General Approach to Causal Mediation Analysis [J].
Imai, Kosuke ;
Keele, Luke ;
Tingley, Dustin .
PSYCHOLOGICAL METHODS, 2010, 15 (04) :309-334
[7]   Risk associated with preoperative anemia in cardiac surgery - A multicenter cohort study [J].
Karkouti, Keyvan ;
Wijeysundera, Duminda N. ;
Beattie, W. Scott .
CIRCULATION, 2008, 117 (04) :478-484
[8]   Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery [J].
Kulier, Alexander ;
Levin, Jack ;
Moser, Rita ;
Rumpold-Seitlinger, Gudrun ;
Tudor, Iulia Cristina ;
Snyder-Ramos, Stephanie A. ;
Moehnle, Patrick ;
Mangano, Dennis T. .
CIRCULATION, 2007, 116 (05) :471-479
[9]   Preoperative anemia versus blood transfusion: Which is the culprit for worse outcomes in cardiac surgery? [J].
LaPar, Damien J. ;
Hawkins, Robert B. ;
McMurry, Timothy L. ;
Isbell, James M. ;
Rich, Jeffrey B. ;
Speir, Alan M. ;
Quader, Mohammed A. ;
Kron, Irving L. ;
Kern, John A. ;
Ailawadi, Gorav .
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY, 2018, 156 (01) :66-+
[10]   The least of 3 evils: Exposure to red blood cell transfusion, anemia, or both? [J].
Loor, Gabriel ;
Rajeswaran, Jeevanantham ;
Li, Liang ;
Sabik, Joseph F., III ;
Blackstone, Eugene H. ;
McCrae, Keith R. ;
Koch, Colleen G. .
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY, 2013, 146 (06) :1480-+