Abstract
Anemia is an indisputable finding in patients scheduled for coronary artery bypass graft (CABG) that can occur any time preoperatively. In presence of severe coronary artery disease, anemia can dramatically affect surgical outcomes. Therefore, we conducted this study to determine the effect of low preoperative hemoglobin (Hgb) on postoperative outcome in patients who underwent coronary artery bypass graft (CABG). In all, 4432 patients who had undergone isolated CABG at Tehran Heart Center over the 2-year period from March 2006 to February 2008 were studied. All medical records of the aforementioned patients were derived from our hospital surgery data bank. After adjustment for confounders, the association of different preoperative levels of Hgb with risk of cardiac, pulmonary, infectious, and ischemic complications, and also with prolonged ventilation and resource utilization, were assessed in a multivariable model. After adjustment for confounders that may affect mortality and morbidities, we found that cardiac, infectious, ischemic, and pulmonary complications, as well as postoperative mortality, were significantly higher in anemic patients compared to those with normal Hgb levels. In addition, total ventilation time, total intensive care unit hour stay (ICU), hospital length of stay (HLOS), and postsurgery length of stay (PLOS) were significantly longer in anemic patients. We concluded that isolated CABG patients with preoperative anemia have significantly higher mortality and morbidity, and use more health care resources. Preoperative anemia is an independent variable for increased resource utilization, morbidity, and mortality.
[1] Kulier A, Levin J, Moser R, Rumpold-Seitlinger G, Tudor IC, Snyder-Ramos SA, Moehnle P, Mangano DT. Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation 2007,116, 471–479 http://dx.doi.org/10.1161/CIRCULATIONAHA.106.65350110.1161/CIRCULATIONAHA.106.653501Search in Google Scholar
[2] 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, 58S–69S http://dx.doi.org/10.1016/j.amjmed.2003.12.01310.1016/j.amjmed.2003.12.013Search in Google Scholar
[3] Nappi J. Anemia in patients with coronary artery disease. Am J Health Syst Pharm. 2003, 60, S4–S8 10.1093/ajhp/60.suppl_3.S4Search in Google Scholar
[4] Carson JL, Duff A, Poses RM, Berlin JA, Spence RK, Trout R, Noveck H, Strom BL. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet. 1996, 348, 1055–1060 http://dx.doi.org/10.1016/S0140-6736(96)04330-910.1016/S0140-6736(96)04330-9Search in Google Scholar
[5] Zindrou D, Taylor KM, Bagger JP. Preoperative haemoglobin concentration and mortality rate after coronary artery bypass surgery. Lancet. 2002, 359, 1747–1748 http://dx.doi.org/10.1016/S0140-6736(02)08614-210.1016/S0140-6736(02)08614-2Search in Google Scholar
[6] 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, 5, 58S–69S http://dx.doi.org/10.1016/j.amjmed.2003.12.01310.1016/j.amjmed.2003.12.013Search in Google Scholar
[7] Ferraris VA, Ferraris SP. Risk factors for postoperative morbidity. J Thorac Cardiovasc Surg. 1996, 111, 731–738 http://dx.doi.org/10.1016/S0022-5223(96)70333-110.1016/S0022-5223(96)70333-1Search in Google Scholar
[8] Rady MY, Ryan T, Starr NJ. Perioperative determinants of morbidity and mortality in elderly patients undergoing cardiac surgery. Crit Care Med. 1998, 26, 225–235 http://dx.doi.org/10.1097/00003246-199802000-0001610.1097/00003246-199802000-00016Search in Google Scholar PubMed
[9] Izaks GJ, Westendorp RG, Knook DL. The definition of anemia in older persons. JAMA. 1999, 281, 1714–1717 http://dx.doi.org/10.1001/jama.281.18.171410.1001/jama.281.18.1714Search in Google Scholar PubMed
[10] Ania BJ, Suman VJ, Fairbanks VF, Rademacher DM, Melton LJ III. Incidence of anemia in older people: an epidemiologic study in a well defined population. J Am Geriatr Soc. 1997, 45, 825–831 10.1111/j.1532-5415.1997.tb01509.xSearch in Google Scholar PubMed
[11] Kulier A, Gombotz H. Perioperative anemia. Anaesthesist. 2001, 50, 73–86 http://dx.doi.org/10.1007/s00101005096810.1007/s001010050968Search in Google Scholar
[12] Fang WC, Helm RE, Krieger KH, Rosengart TK, DuBois WJ, Sason C, Lesser ML, Isom OW, Gold JP. Impact of minimum hematocrit during cardiopulmonary bypass on mortality in patients undergoing coronary artery surgery. Circulation. 1997, 96 II-194–II-199 Search in Google Scholar
[13] Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, Meier-Hellmann A, Nollet G, Peres-Bota D. Anemia and blood transfusion in critically ill patients. JAMA. 2002, 288, 1499–1507 http://dx.doi.org/10.1001/jama.288.12.149910.1001/jama.288.12.1499Search in Google Scholar
[14] Tang YD, Katz SD. Anemia in chronic heart failure: prevalence, etiology, clinical correlates, and treatment options. Circulation. 2006, 113, 2454–2461 http://dx.doi.org/10.1161/CIRCULATIONAHA.105.58366610.1161/CIRCULATIONAHA.105.583666Search in Google Scholar
[15] Al Falluji N, Lawrence-Nelson J, Kostis JB, Lacy CR, Ranjan R, Wilson AC. Effect of anemia on 1-year mortality in patients with acute myocardial infarction. Am Heart J. 2002, 144, 636–641 10.1067/mhj.2002.124351Search in Google Scholar
[16] STS Adult Cardiac Database. Definition of terms. Version 2.41. Society of Thoracic Surgeons. Available at www. Sts. org / file / CoreDef 241 Book. Pdf Search in Google Scholar
[17] Bell ML, Grunwald GK, Baltz JH, McDonald GO, Bell MR, Grover FL, Shroyer AL. Does preoperative Hgb independently predict short-term outcomes after coronary artery bypass graft surgery? Ann Thorac Surg. 2008, 86, 1415–1423 http://dx.doi.org/10.1016/j.athoracsur.2008.07.08810.1016/j.athoracsur.2008.07.088Search in Google Scholar
[18] Dunne JR, Malone D, Tracy JK, Gannon C, Napolitano LM. Perioperative anemia: an independent risk factor for infection, mortality, and resource utilization in surgery. J Surg Res. 2002, 102, 237–244 http://dx.doi.org/10.1006/jsre.2001.633010.1006/jsre.2001.6330Search in Google Scholar
[19] Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ, Shah A. Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: should current practice be changed? J Thorac Cardiovasc Surg. 2003, 125, 1438–1450 http://dx.doi.org/10.1016/S0022-5223(02)73291-110.1016/S0022-5223(02)73291-1Search in Google Scholar
[20] Spiess BD, Ley C, Body SC, Siegel LC, Stover EP, Maddi R, D’Ambra M, Jain U, Liu F, Herskowitz A, Mangano DT, Levin J; the Institutions of the Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Hematocrit value on intensive care unit entry influences the frequency of Q-wave myocardial infarction after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1998, 116, 460–467 http://dx.doi.org/10.1016/S0022-5223(98)70012-110.1016/S0022-5223(98)70012-1Search in Google Scholar
[21] Carson JL, Noveck H, Berlin JA, Gould SA. Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion. 2002, 42, 812–818 http://dx.doi.org/10.1046/j.1537-2995.2002.00123.x10.1046/j.1537-2995.2002.00123.xSearch in Google Scholar PubMed
[22] Kulier A. Anemia and morbidity and mortality in coronary bypass surgery. Curr Opin Anaesthesiol. 2007, 20, 57–64 http://dx.doi.org/10.1097/ACO.0b013e328013da2010.1097/ACO.0b013e328013da20Search in Google Scholar PubMed
[23] Van Straten AH, Soliman Hamad MA, van Zundert AJ, Martens EJ, Schönberger JP, de Wolf AM. Preoperative Hgb Level as a Predictor of Survival After Coronary Artery Bypass Grafting. A Comparison With the Matched General Population. Circulation; 2009; [Epub ahead of print] 10.1186/1749-8090-5-29Search in Google Scholar
[24] Weber WP, Zwahlen M, Reck S, et al. The association of preoperative anemia and perioperative allogeneic blood transfusion with the risk of surgical site infection. Transfusion 2009; [Epub ahead of print] 10.1111/j.1537-2995.2009.02204.xSearch in Google Scholar
[25] Magovern JA, Sakert T, Magovern GJ, et al. A model that predicts morbidity and mortality after coronary artery bypass graft surgery. J Am Coll Cardiol 1996, 28, 1147–1153 http://dx.doi.org/10.1016/S0735-1097(96)00310-510.1016/S0735-1097(96)00310-5Search in Google Scholar
[26] Weightman WM, Gibbs NM, Sheminant MR, Whitford EG, Mahon BD, Newman MA. Drug therapy before coronary artery surgery: nitrates are independent predictors of mortality and betaadrenergic blockers predict survival. Anesth Analg 1999, 88, 286–291 http://dx.doi.org/10.1097/00000539-199902000-0001110.1097/00000539-199902000-00011Search in Google Scholar
[27] Gruson KI, Aharonoff GB, Egol KA, et al. The relationship between admission Hgb level and outcome after hip fracture. J Orthop Trauma. 2002, 16, 39–44 http://dx.doi.org/10.1097/00005131-200201000-0000910.1097/00005131-200201000-00009Search in Google Scholar
[28] Dunne JR, Malone D, Tracy JK, et al. Perioperative anemia: an independent risk factor for infection, mortality, and resource utilization in surgery. J Surg Res. 2002, 102, 237–244 http://dx.doi.org/10.1006/jsre.2001.633010.1006/jsre.2001.6330Search in Google Scholar
[29] Dougenis D, Patrinou V, Filos KS, et al. Blood use in lung resection for carcinoma: perioperative elective anaemia does not compromise the early outcome. Eur J Cardiothorac Surg. 2001, 20, 372–377 http://dx.doi.org/10.1016/S1010-7940(01)00792-810.1016/S1010-7940(01)00792-8Search in Google Scholar
[30] Carson JL, Terrin ML, Barton FB, et al. A pilot randomized trial comparing symptomatic vs. Hgblevel- driven red blood cell transfusions following hip fracture. Transfusion. 1998, 38, 522–529 http://dx.doi.org/10.1046/j.1537-2995.1998.38698326331.x10.1046/j.1537-2995.1998.38698326331.xSearch in Google Scholar PubMed
[31] Anker SD, Voors A, Okonko D, Clark AL, James MK, von Haehling S, Kjekshus J, Ponikowski P, Dickstein K; for the OPTIMAAL investigators. Prevalence, incidence, and prognostic value of anaemia in patients after an acute myocardial infarction: data from the OPTIMAAL trial. Eur Heart J 2009; doi:10.1093/eurheartj/ehp116 10.1093/eurheartj/ehp116Search in Google Scholar PubMed
[32] Milman N, Pedersen AN. Blood haemoglobin concentrations are higher in smokers and heavy alcohol consumers than in non-smokers and abstainers-should we adjust the reference range? Ann Hematol 2008; [Epub ahead of print] 10.1007/s00277-008-0647-9Search in Google Scholar PubMed
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