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Original Investigation
September 2018

Association of Perioperative Red Blood Cell Transfusions With Venous Thromboembolism in a North American Registry

Author Affiliations
  • 1Division of Transfusion Medicine, Department of Pathology, New York Presbyterian Hospital, Weill Cornell Medicine, New York
  • 2Division of Pediatric Hematology/Oncology, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medicine, New York
  • 3Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
  • 4Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
  • 5Division of Pediatric Hematology, Johns Hopkins University, Baltimore, Maryland
  • 6Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medicine, New York
  • 7New York Blood Center, New York
JAMA Surg. 2018;153(9):826-833. doi:10.1001/jamasurg.2018.1565
Key Points

Question  What is the association between perioperative red blood cell transfusions and postoperative venous thromboembolism within 30 days of a surgical procedure?

Findings  In this registry study of 750 937 patients undergoing surgery, perioperative red blood cell transfusions (preoperative and intraoperative or postoperative) were significantly associated with higher risk for venous thromboembolism. The effect of this association was dose dependent, and the association remained robust with propensity score matching.

Meaning  These findings should reinforce the importance of rigorous perioperative patient blood management practices.

Abstract

Importance  Increasing evidence supports the role of red blood cells (RBCs) in physiological hemostasis and pathologic thrombosis. Red blood cells are commonly transfused in the perioperative period; however, their association with postoperative thrombotic events remains unclear.

Objective  To examine the association between perioperative RBC transfusions and postoperative venous thromboembolism (VTE) within 30 days of surgery.

Design, Setting, and Participants  This analysis used prospectively collected registry data from the American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database, a validated registry of 525 teaching and nonteaching hospitals in North America. Participants included patients in the ACS-NSQIP registry who underwent a surgical procedure from January 1 through December 31, 2014. Data were analyzed from July 1, 2016, through March 15, 2018.

Main Outcomes and Measures  Risk-adjusted odds ratios (aORs) were estimated using multivariable logistic regression. The primary outcome was the development of postoperative VTE (deep venous thrombosis [DVT] and pulmonary embolism [PE]) within 30 days of surgery that warranted therapeutic intervention; DVT and PE were also examined separately as secondary outcomes. Subgroup analyses were performed by surgical subtypes. Propensity score matching was performed for sensitivity analyses.

Results  Of 750 937 patients (56.8% women; median age, 58 years; interquartile range, 44-69 years), 47 410 (6.3%) received at least 1 perioperative RBC transfusion. Postoperative VTE occurred in 6309 patients (0.8%) (DVT in 4336 [0.6%]; PE in 2514 [0.3%]; both DVT and PE in 541 [0.1%]). Perioperative RBC transfusion was associated with higher odds of VTE (aOR, 2.1; 95% CI, 2.0-2.3), DVT (aOR, 2.2; 95% CI, 2.1-2.4), and PE (aOR, 1.9; 95% CI, 1.7-2.1), independent of various putative risk factors. A significant dose-response effect was observed with increased odds of VTE as the number of intraoperative and/or postoperative RBC transfusion events increased (aOR, 2.1 [95% CI, 2.0-2.3] for 1 event; 3.1 [95% CI, 1.7-5.7] for 2 events; and 4.5 [95% CI, 1.0-19.4] for ≥3 events vs no intraoperative or postoperative RBC transfusion; P < .001 for trend). In subgroup analyses, the association between any perioperative RBC transfusion and postoperative VTE remained statistically significant across all surgical subspecialties analyzed. The association between any perioperative RBC transfusion and the development of postoperative VTE also remained robust after 1:1 propensity score matching (47 142 matched pairs; matched OR, 1.9; 95% CI, 1.8-2.1).

Conclusions and Relevance  The results of this study suggest that perioperative RBC transfusions may be significantly associated with the development of new or progressive postoperative VTE, independent of several putative confounders. These findings, if validated, should reinforce the importance of rigorous perioperative management of blood transfusion practices.

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