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(1)PREVALENCE OF PREOPERATIVE ANEMIA AND TRANSFUSION PRACTICE IN ADULT ELECTIVE NON-CARDIAC SURGERY: A PROSPECTIVE SINGLE CENTRE 3 MONTHS AUDIT. ay. a. VANESSA LOUIS LIONEL LOUIS. of. M. al. DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ANESTHESIOLOGY. U ni. ve. rs. ity. DEPARTMENT OF ANESTHESIOLOGY UNIVERSITY OF MALAYA KUALA LUMPUR. 2018.

(2) UNIVERSITY OF MALAYA ORIGINAL LITERARY WORK DECLARATION Name of candidate: Vanessa Louis Lionel Louis Registration/Matrics No: MGE140015 Name of Degree: Masters of Anesthesiology Title of Project Paper/Research Report/Dissertation/ Thesis (“this work”):. ay. a. Prevalance of Anemia and Transfusion Practice in Adult Elective Non Cardiac Surgery: A Prospective Single Centre 3 Months Audit. U ni. ve. rs. ity. of. M. al. Field of Study: I do solemnly and sincerely declare that: (1) I am the sole author/writer of this Work; (2) This Work is original; (3) Any use of any work in which copyright exists was done by way of fair dealing and for permitted purposes and any excerpt or extract from, or reference to or reproduction of any copyright work has been disclosed expressly and sufficiently and the title of the Work and its authorship have been acknowledged in this Work; (4) I do not have any actual knowledge nor do I ought reasonably to know that the making of this work constitutes an infringement of any copyright work; (5) I hereby assign all and every rights in the copyright to this Work to the University of Malaya (“UM”), who henceforth shall be owner of the copyright in this Work and that any reproduction or use in any form or by any means whatsoever is prohibited without the written consent of UM having been first had and obtained; (6) I am fully aware that if in the course of making this Work I have infringed any copyright whether intentionally or otherwise, I may be subject to legal action or any other action as may be determined by UM Candidate’s Signature. Date:. Subscribed and solemnly declared before,. Witness’s Signature. Date:. Name: Designation :. ii.

(3) ABSTRACT Background Anemia is defined as a condition in which the red blood cells or the oxygen carrying capacity is insufficient to meet the physiological needs. According to WHO sex based criteria, anemia is diagnosed as less than 13 g/dl for men and less than 12. a. g/dl for women. We audited patients undergoing elective non cardiac surgeries in our. ay. hospital setting to see the prevalence of anemia, the timing of detection of anemia and the type of anemia. We also wanted to audit the incidence of transfusion preoperatively,. al. intraoperatively and post operatively and the transfusion trigger. We also looked into. M. the complications of blood transfusion and the morbidity and mortality including length of hospital stay, any death within hospitalization and the 30 day mortality. Elective. of. procedures likely to be associated with high transfusion use were audited which. ity. included : gynaecological, colorectal, urological and arthroplasty surgeries.. rs. Methods. ve. Our audit was a prospective single centre audit over the period of 3 months, from December 2017 up to mid March 2018 at the University Malaya Medical Centre,. U ni. Kuala Lumpur and got a total of 306 patients. Patients that were included were all patients above the age of 18 in the following elective gynaecological, colorectal, urological and arthroplasty surgeries. Pregnant patients, any patients with American Society of Anaesthesiologists score 6 and all cancelled operations were excluded. Relevant data was extracted from the Hospital EMR (Electronic Medical Records). Data that was collected included patients characteristics and comorbiditites, type of operation and surgical discipline, selected laboratory investigations eg hemoglobin level, perioperative data for blood loss, blood transfusion, autologous. iii.

(4) techniques, post operative transfusion and complications of blood transfusion. We also measured the mortality and morbidity including length of hospital stay, death within hospitalization and the 30 days mortality as a secondary outcome for the audit. Results Our audit revealed that out of the 306 patients, according to the anemia. a. definition of hb<13 for males and hb<12 for females, a total of 126 patients. ay. were anemic, 52 were males and 74 females. Out of the 126 anemic patients, 33.3%. al. had their anemias detected only 1-6 days prior to surgery and none of the anemic. M. patients had a complete blood profile to determine the type of anemia. As for the transfusion practice, 17 anemic patients received preoperative blood transfusion, 14. of. received intraoperative transfusion and 14 also received postoperative transfusion, and our study showed that persons who were anemic were more likely to receive blood. ity. transfusions. Morbidity and mortality of our study revealed that patients were anemia. rs. experienced more complications compared to those were not anemic, anemic patients were significantly associated with infections (p value: 0.0024) and cardiac. ve. complications (p value: 0.011) during their postoperative stay in the hospital.. U ni. There was also significant difference in median for their length of stay in hospital between patients who were anemic (4 days) and patient who were not anemic (2 days). Conclusion. A larger population of patients should have been audited over a longer duration of time to determine a better incidence and prevalence of anemia, transfusion practices and morbidity and mortality in our centre. From our study, it shows that incidence and prevalence of anemia is significant in our population and they show a higher need for. iv.

(5) blood transfusion. Also those anemic patients had more postoperative complications and longer hospital stays. It is important to note these findings so that we can work our. U ni. ve. rs. ity. of. M. al. ay. a. way towards the formation of a patient blood management protocol for our centre.. v.

(6) ABSTRAK Latar belakang Anemia ditakrifkan sebagai suatu keadaan di mana sel darah merah atau kapasiti penyimpanan oksigen tidak mencukupi untuk memenuhi keperluan fisiologi. Menurut kriteria berdasarkan seks WHO, anemia didiagnosis kurang dari 13 g / dl untuk lelaki. a. dan kurang daripada 12 g / dl untuk wanita. Kami telah mengaudit pesakit yang. ay. menjalani pembedahan bukan jantung elektif di hospital kami untuk melihat kelaziman. al. anemia, masa pengesanan anemia dan jenis anemia. Kami juga ingin mengaudit. M. kejadian transfusi sebelum pembedahan,semasa pembedahan dan selepas pembedahan dan pencetus transfusi. Kami juga melihat komplikasi pemindahan darah dan morbiditi. of. dan mortaliti termasuk tempoh penginapan hospital, mana-mana kematian di hospital dan kematian dalam tempoh 30 hari. Prosedur elektif yang mungkin dikaitkan dengan. ity. penggunaan pemindahan darah yang tinggi telah diaudit dan termasuk: pembedahan. ve. Metodologi. rs. ginekologi, kolorektal, urologi dan pembedahan sendi tulang.. U ni. Pengauditan kami adalah prospektif pusat audit tunggal dalam tempoh 3 bulan, dari Disember 2017 hingga pertengahan Mac 2018 di Pusat Perubatan Universiti Malaya, Kuala Lumpur dan mendapat sejumlah 306 pesakit. Pesakit yang dimasukkan adalah semua pesakit yang berumur diatas 18 tahun dalam. pembedahan elektif. ginekologi, pembedahan kolorektal, urologi dan pembedahan sendi tulang. Pesakit hamil, mana-mana pesakit dengan Persatuan Anaesthesiologi Amerika skor 6 dan semua pembedahan yang dibatalkan dikecualikan. Data yang berkaitan telah diekstrak dari Hospital EMR (Rekod Perubatan Elektronik). Data yang dikumpulkan termasuk. vi.

(7) ciri-ciri pesakit dan komorbiditit, jenis pebedahan dan disiplin pembedahan, penyiasatan makmal terpilih seperti paras hemoglobin, data perioperatif untuk kehilangan darah, pemindahan darah, teknik autologous, transfusi pasca operasi dan komplikasi pemindahan darah. Kami juga mengukur kematian dan morbiditi termasuk tempoh penginapan hospital, kematian dalam hospital dan kematian 30 hari sebagai. a. hasil menengah untuk audit.. ay. Keputusan. al. Audit kami mendedahkan bahawa daripada 306 pesakit, menurut anemia. M. definisi hb <13 untuk lelaki dan hb <12 untuk perempuan, sejumlah 126 pesakit didiagnosa anemia, 52 adalah lelaki dan 74 perempuan. Daripada 126 pesakit anemia,. of. 33.3% mempunyai anemia yang dikesan hanya 1-6 hari sebelum pembedahan dan tidak ada pesakit anemia yang mempunyai profil darah lengkap untuk menentukan jenis. ity. anemia. Bagi amalan transfusi, 17 pesakit anemia mendapat pemindahan darah sebelum. rs. pembedahan, 14 menerima pemindahan ketika pembedahan dan 14 juga menerima transfusi selepas pembedahan, dan kajian kami menunjukkan bahawa pesakit yang. ve. mengalami anemia lebih cenderung menerima pemindahan darah. Morbiditi dan. U ni. kematian kajian kami mendedahkan bahawa pesakit anemia mengalami komplikasi yang lebih tinggi berbanding dengan yang tidak didiagnosa anemia.. Pesakit anemia juga menunjukkan lebih cenderung mengalami jangkitan (p nilai: 0.0024) dan komplikasi jantung (p nilai: 0.011) semasa mereka berada di hospital selepas pembedahan. Terdapat perbezaan yang signifikan dalam median untuk tempoh tinggal mereka di hospital antara pesakit yang mengalami anemia (4 hari) dan pesakit yang tidak anemia (2 hari).. vii.

(8) Kesimpulan Populasi pesakit yang lebih besar sepatutnya telah diaudit sepanjang tempoh yang lebih lama untuk menentukan kejadian yang lebih baik dan kelaziman anemia, amalan transfusi dan morbiditi dan mortaliti di pusat kami. Dari kajian kami, ia menunjukkan bahawa kejadian dan kelaziman anemia adalah penting dalam populasi. a. kita dan mereka menunjukkan keperluan yang lebih tinggi untuk pemindahan darah.. ay. Juga pesakit anemia mempunyai lebih banyak komplikasi selepas pembedahan dan tinggal di hospital lebih banyak hari. Adalah penting untuk perhatikan penemuan ini. al. supaya kita boleh melakukan perjalanan ke arah pembentukan protokol pengurusan. U ni. ve. rs. ity. of. M. darah pesakit untuk pusat kami.. viii.

(9) ACKNOWLEDGEMENTS I would like to take this opportunity to first thank God for placing me exactly where I am today, because without Him I am nothing. I am overjoyed that He gave me the opportunity to be in the Masters programme and is still seeing me through my studies and my raising of a family. a. I would also like to thank my two supervisors Dr Carolyn Yim and Dr Chloe. ay. Ng who tirelessly helped throughout this process, who gave me so much of advice and. al. who patiently guided me through the audit and my thesis writing. Their dedication,. M. effort and time is deeply appreciated and I will be forever indebted to them. I wouldn’t be where I am today if not for my father, mother and sisters who has. ity. to them for all they are to me.. of. always prayed for me and helped give me motivation to carry on. My heartfelt gratitude. rs. A huge thank you also to my dear husband Yohen who has helped me with my thesis and encouraged me not to give up and who has supported and sacrificed a lot so. ve. that I can finish my masters programme.. U ni. To my babies Everly and Micah, you are the reason for everything. I love u two. deeply.. And last but certainly not the least, I would like to take this opportunity to thank. all the patients involved in this audit, as without them this will not be possible.. ix.

(10) TABLE OF CONTENTS Abstract…………………………………………………………………….....iii Abstrak…………………………………………………………………...…...vi Acknowledgements………………………………………………………...…ix Table of Contents………………………………………………………………x List of Figures…………………………………………………………..……..xi. a. List of Tables…………………………………………………………………xii. ay. List of Symbols and Abbreviations………………………………......………xiii. al. List of Appendices……………………………………………………...……xiv. M. CHAPTER 1 : INTRODUCTION……………………………………………..1 CHAPTER 2 : LITERATURE REVIEW……………………………….……..3. of. CHAPTER 3 : METHODOLOGY…………………………………………….6 CHAPTER 4 : RESULTS………………………………………………...……8. ity. CHAPTER 5 : DISCUSSION…………………………………………….…..15. rs. CHAPTER 6 : CONCLUSION………………………………………………17 References……………………………………………………………..……..18. U ni. ve. Appendix……………………………………………………………………20. x.

(11) LIST OF FIGURES AND TABLES TABLE 1………………………………………………………………………………8 TABLE 2.…………………………………………………………………………….11 TABLE 3……………………………………………………………………………..12 TABLE 4……………………………………………………………………………..14. a. FIGURE 1……………………………………………………………………………...9. ay. FIGURE 2……………………………………………………………………………...9 FIGURE 3…………………………………………………………………………….10. U ni. ve. rs. ity. of. M. al. FIGURE 4…………………………………………………………………………….10. xi.

(12) LIST OF SYMBOLS AND ABBREVIATIONS WHO. : World Health Organization. HB. : Hemoglobin. EMR. : Electronic Medical Record. : Patient Blood Management. ASA. : American Society of Anaesthesiologists. HIV. : Human Immunodeficiency Virus. USA. : United States of America. U ni. ve. rs. ity. of. M. al. ay. PBM. a. UMMC : University Malaya Medical Centre. xii.

(13) LIST OF APPENDICES. U ni. ve. rs. ity. of. M. al. ay. a. APPENDIX A……………………………………………………….……….20. xiii.

(14) CHAPTER 1: INTRODUCTION According to WHO, anemia is defined as a condition where the number of red blood cells or their oxygen carrying capacity is unable due to insufficiency so as to meet the basic physiological needs which varies with a person’s age, gender, altitude, smoking, behavior and pregnancy [1]. Iron deficiency anemia is the most common cause of anemia globally [1]. For men hemoglobin <13 g/dl is anemia and for women hemoglobin levels. a. less than 12 g/dl is anemic. Table 1.1 shows the hemoglobin levels to diagnose anemia at. ay. sea level.. al. Each year more than 230million patients undergo surgery world wide[4].Anemia. M. is the most common hematological problem in the preoperative patient and often, it is a sign of an underlying disease or condition that could affect the surgical outcome[5].. of. Consequently, blood transfusions are commonly given perioperatively to anemic patients. Perioperatively, anemia can be encountered at anytime. Patients hospitalized for. ity. surgery may have an underlying anemia or blood loss during surgery can cause anemia. rs. [2]. The etiology of preoperative anemia may be multifactorial and complex. Nutritional deficiencies and some drugs may contribute to reduced red blood cell production [3].. ve. There are many other causes for preoperative anemia for example activation of the. U ni. immune system by underlying processes as well as certain inflammatory cytokines that can decrease RBC half life due to dyserythropoiesis[3]. Repeated diagnostic phlebotomies, gastrointestinal or genitourinary blood loss, coagulopathies and hemodilution can also contribute to development of anemia. Many studies have shown that preoperative anemia is associated with poorer patient outcomes (length of hospital stay, post operative complications and death)[3].Transfusion outcomes include higher mortality, more ischemic complications,. 1.

(15) organ dysfunction, infections, delayed wound healing and increased length of hospital stay[6]. The concept of patient blood management was introduced to promote best practice in the timely detection and management of preoperative anemia[4]. Our audits primary outcome was to find out the prevalence of anemia among patients who are scheduled for elective non-cardiac surgery, timing of detection of anemia. a. and the type of anemia. Our secondary outcome was to see the incidence of transfusion. ay. preoperatively, intra operatively, post operatively and the transfusion trigger. We also. al. looked into complications of blood transfusion and morbidity and mortality including. M. length of hospital stay, death within hospitalization and 30 days mortality in our centre UMMC in the span of 3 months.. of. The information from this audit is planned to be used to come up with a PBM protocol which is defined as a timely application of evidence based medicine and surgical. ity. concepts designed to maintain hemoglobin concentration, optimize hemostasis and. U ni. ve. rs. minimize blood loss in an attempt to improve patient outcome for our centre.. 2.

(16) CHAPTER 2: LITERATURE REVIEW There is so much importance in finding out the prevalence of preoperative anemia as it can show its correlation with increase in mortality or morbidity preoperatively, effects of transfusion, transfusion practices and could also be used as a foundation for the planning of a PBM protocol and many others. Anemia is defined by WHO as Hb < 13g/dl. a. in non pregnant females and Hb< 12g/dl in males. According to Klein et al (2016) there. ay. is considerable evidence that preoperative anemia is associated with poor surgical outcomes in non cardiac surgical patients[7].. al. Beattie et al (2009) undertook a single centre retrospective cohort study to. M. determine the independent association between preoperative anemia and mortality after non-cardiac surgery. Data were collected on 7760 consecutive adult patients from March. of. 2003 to June 2006. All patients receiving patient-controlled analgesia, patient-controlled. ity. epidural anesthesia, epidural, and intravenous pain management were included, comprising virtually all patients having major surgery. Patients having emergent surgery. rs. were excluded. For patients who underwent more than one relevant procedure during the. ve. study period, only their initial surgery was included for analysis. Transplantation and cardiac surgery cases were excluded. They found that preoperative anemia was a highly. U ni. prevalent condition that was strongly and independently associated with postoperative mortality. Fully one-third of patients who presented for non emergent surgery had a hemoglobin concentration that the World Health Organization would define as anemia. They noted that patients with preoperative anemia had more than two-fold greater odds of dying within 90 days of surgery[8] Carson JL et al(1996) did a retrospective cohort study on the effect of anemia and. cardiovascular disease on surgical mortality and morbidity. The primary outcome was 30day mortality and the secondary outcome was 30-day mortality or in-hospital 30-day. 3.

(17) morbidity. Cardiovascular disease was defined as a history of angina, myocardial infarction, congestive heart failure, or peripheral vascular disease. Findings were the 30day mortality was 3.2%. The mortality was 1.3% in patients with preoperative hemoglobin 12 g/dL or greater and 33.3% in patients with preoperative hemoglobin less than 6 g/dL. The increase in risk of death associated with low preoperative hemoglobin was more pronounced in patients with cardiovascular disease than in patients without. The effect of. a. blood loss on mortality was larger in patients with low preoperative hemoglobin than in. ay. those with a higher preoperative hemoglobin. The results were similar in analyses of. al. postoperative hemoglobin and 30-day mortality or in-hospital morbidity[9].. M. C bernard et al(2009) conducted a study entitled intraoperative transfusion of 1u to 2u packed red blood cells is associated with increased 30 day mortality, surgical site. of. infection, pneumonia and sepsis in general surgery patients. The results showed that 1u RBC significantly increased risk of 30 day mortality, composite morbidity, pneumonia. ity. and sepsis/shock. Transfusion of 2u increased risk for these outcomes plus surgical site. ve. rs. infection.. U ni. W Scott Beattie et al (2009) conducted an observational study to measure the prevalence of anemia and assess the relationship between preoperative anemia and postoperative mortality[11] The results of the study showed that preoperative anemia was common and equal between genders and was associated with a 5 fold increase in post operative mortality and was concluded that although anemia increases mortality independent of transfusion, it is associated with increased in requirement for transfusion which is also then associated with increased mortality.. 4.

(18) According to a single institution, large case controlled study conducted by Jessica Viola et al in 2015 to examine the association between preoperative anemia and adverse outcomes following total joint arthroplasty, anemic patients had a higher rate of complications namely cardiovascular [12]. The study confirmed that patients with preoperative anemia are likely to exhibit a higher incidence of post operative complications following total joint arthroplasty.. a. Gregory MT Hare et al [2013] wrote an article entitled risks of anemia and related. ay. management strategies: can perioperative blood management improve patient safety? The. U ni. ve. rs. ity. of. M. blood management may improve patient outcomes.. al. conclusion of the article was that ongoing initiatives to treat anemias and optimize patient. 5.

(19) CHAPTER 3: METHODOLOGY We undertook a prospective single center audit over the period of 3 months from December 2017 to March 2018. The subjects were patients undergoing elective non-. a. cardiac surgery, which included the gynecology, urology, colorectal, and arthroplasty. ay. disciplines of surgery. Since this was an observational study without any intervention,. al. consent from patients was not required.. Inclusion criteria were patients aged above 18 years old undergoing surgery in the. M. gynecology, urology, colorectal and arthroplasty disciplines.. of. Exclusion criteria was any cancellation of surgery, pregnant patients and patients. ity. with ASA score 6. All patients who were eligible for the audit was identified through the daily. rs. elective operation list, relevant data was extracted from the hospital EMR and the patients. ve. were followed up through the hospital admission period up to 30 days post operation.. U ni. Patient’s characteristics and comorbidities, name of operation and surgical. category, selected laboratory investigations (hemoglobin level, hematocrit, red blood cell indices, serum ferritin etc) are recorded. Perioperative data for allogeneic blood transfusion, transfusion trigger, blood loss,. anesthetic technique and involvement of autologous technique are recorded. All information was added onto a paper case report form. Complications of blood transfusion eg: febrile reaction, hemolytic reaction (acute/delayed), transfusion associated circulatory overload, transfusion related acute lung 6.

(20) injury, transfusion related bacterial sepsis (contamination) and transfusion transmitted infection like hepatitis, HIV etc was recorded Secondary outcome measured the 30 days mortality and morbidities which included events affecting the cardiovascular system (acute coronary syndromes, cardiac arrest necessitating cardiopulmonary resuscitation), respiratory system (pneumonia,. a. ventilator support more than 48hrs, unplanned intubation), vascular/thrombotic. ay. complications (deep vein thrombosis or pulmonary embolism), renal system (acute or progressive renal failure), neurological system (stroke) , infection, hemorrhage and. al. duration of hospital stay.. M. Data were analyzed using SPSS version 21.00 (Chicago, IL, USA). Numerical. of. variable were presented using mean and standard deviation if the data were normally skewed; while median and interquartile range were used to present skewed numerical data.. ity. Categorical variables were presented using frequency and percentage. Pearson Chi-square. rs. was used to test the association between anemic status and the incidence of peri-operative blood transfusion. In order to test the association between anemic status and patients’. ve. outcomes (morbidity and mortality), several analyses such as Pearson Chi-Square, Fisher. U ni. Exact test and Mann Whitney U test were employed. Level of significance is set at p < 0.05.. CHAPTER 4: RESULTS. 7.

(21) A total number of 306 patients were recruited in our study from December 2017 to March 2018. Table 1 shows the characteristics of the study population. Out of the 306 patients, 126 patients were anemic. The majority of patients belonged to the middle age group with mean age of 56 years old. The anemic patients at 57.34 years old and the nonanemic patients at 55.45 years old. In our study there were 106 male patients, where 52 were anemic and 200 female patients where 74 were anemic. Figure 1 shows a pie chart. a. on the gender distribution among all the patients. Out of the 126 anemic patients 58.7%. ay. were females. This could also be due to the fact that most of our patients were from the. al. gynecology discipline, a total number of 145 out of the 306 patients (47.1%). 7.8% of. M. patients were from the arthroplasty discipline, 10.4% from colorectal and 34.1% form the urology discipline. Figure 2 depicts the different disciplines covered. Most of the patients. of. were from ASA 2 category (59.7%) and out of the 306 patients, 208 patients were seen preoperatively in our anesthesia clinic and 98 patients were not seen as shown on Figure. ity. 4.. ve. rs. Table 1: Characteristics of study population (n=306). U ni. Age, Mean (SD) Gender Male Female Discipline Gynecology Arthroplasty Colorectal Urology ASA I II III Pre-op anesthesia assessment Yes No SD: standard deviation. Anemia Non-anemic All (n=180) (n=126) (n=306) 56.23 (16.33) 57.34 (17.69) 55.45 (15.31). 106 (34.4) 200 (64.9). 52 (41.3) 74 (58.7). 54 (30.0) 126 (70.0). 145 (47.1) 24 (7.8) 32 (10.4) 105 (34.1). 50 (39.7) 8 (6.3) 19 (15.1) 49 (38.9). 95 (52.8) 16 (8.9) 13 (7.2) 56 (31.1). 74 (24.0) 184 (59.7) 48 (15.6). 27 (21.4) 72 (57.1) 27 (21.4). 47 (26.1) 112 (62.2) 21 (11.7). 208 (67.5) 98 (31.8). 76 (60.3) 50 (39.7). 132 (73.3) 48 (26.7). 8.

(22) a ay al M ity. of. Discipline. 11%. 47%. Gynaecology DJR Colorectal Urology. 8%. U ni. ve. rs. 34%. Figure 2: Pie chart based on the different disciplines (n=306). 9.

(23) 10. ity. rs. ve. U ni of. a. ay. al. M.

(24) The time of detection for the anemic status of the patients were computed. Majority of the anemic patients were detected one to six days prior to surgery (33.3%), mostly during the pre-operative assessment after hospitalization. There were 28 (22.2%) of patients detected with anemia 7-13 days prior to surgery, followed by 30 (23.8%) patients detected 14-20 days prior to surgery, 8 patients were detected 21-27 days prior to surgery, 3 patients detected 35 to 41 days prior to surgery and 11 patients detected more. al. Frequency (%). 42 (33.3) 28 (22.2) 30 (23.8) 8 (6.3) 4 (3.2) 3 (2.4) 11 (8.7). ity. of. M. Table 2: Time of detection of anemia (n=126) Variable Time of detection 1-6 days prior surgery 7-13 days prior surgery 14-20 days prior surgery 21-27 days prior surgery 28-34 days prior surgery 35-41 days prior surgery ≥ 42 days prior surgery. ay. a. than 42 days prior to surgery. Table 2 shows the time of detection of anemia.. rs. From our audit, we also wanted to determine if the anemic patients were. ve. investigated to determine the type of anemia they had, however all the anemic patients did not have a complete blood profile to determine their type of anemia for example not all. U ni. were investigated if they had thalassemia, vitamin b12 deficiency, folate deficiency or iron deficiency anemia. For the incidence of pre-operative, intra-operative and post operative transfusion,. Pearson Chi-square was used in this study after assumption checking and found met and showed that most of the patients did not receive blood transfusion pre-operatively (94.2%), intra-operatively (92.5%) and post-operatively (93.8%). However, there was more incidence on the need of blood transfusion intra-operatively compared to pre-. 11.

(25) operation and post-operation. There were 23 cases on blood transfusion intra-operatively, 18 cases pre-operatively and 19 cases post operatively. Pearson Chi-square was used to test the association on the anemic status of patients and the need of blood transfusion. Results were significant for all phases: preoperation (p value: <0.001), intra-operation (p value: 0.046) and post-operation (p value:. a. 0.003). Patients who were anemic were more likely to receive blood transfusion compared. ay. to patients who were not anemic. These findings are depicted in table 3. rs. ity. of. M. al. Table 3: Incidence of pre-operative, intra-operative and post-operative transfusion (N=306) Variable All Anemia Non-anemic p-value (n=306) (n=126) (n=180) Pre-op Yes 18 (5.8) 17 (13.5) 1 (0.6) <0.001 No 290 (94.2) 109 (86.5) 179 (99.4) Intra-op Yes 23 (7.5) 14 (11.1) 9 (5.0) 0.046 No 285 (92.5) 112 (88.9) 171 (95.0) Post-op Yes 19 (6.2) 14 (11.1) 5 (2.8) 0.003 No 289 (93.8) 112 (88.9) 175 (97.2) Pearson’s Chi square. ve. Another outcome from the study that we wanted to analyze were the complications of blood transfusion, however out of all the patients who received transfusion, none of. U ni. them developed any documented complications towards blood transfusion. As for the morbidity, mortality and length of hospital stay, assumption checking. was done before the analysis as well. Mann-Whitney U test was used in this study, as the normality assumption was not met. Expected count was checked before the decision was made whether to use Pearson Chi-square or Fisher Exact test. Pearson Chi-square was used when the expected count more than five is more than 20% of the cell while Fisher Exact test was used when the expected count less than five is more than 20% of the cell.. 12.

(26) The morbidity and mortality of the patients were computed in Table 4. In general, patients who has anemia experience more complications compared to patients who were not anemic. There were 3 anemic patients who passed away, and one patient who was not anemic died during hospitalization. Pearson Chi-square and Fisher Exact test were used to test the association. a. between the anemic status and patient’s outcome (complications, death during. ay. hospitalization and mortality within 30 days). Mann-Whitney U test was used to test the difference in hospital stay among patients who were and were not anemic. Anemic status. al. of patients was significantly associated with infections (p value: 0.0024), and cardiac. M. complications (p value: 0.011). While for the length of stay, there were significant difference in median between patients who were anemic (4 days) and patient who were. U ni. ve. rs. ity. stays according to our audit.. of. not anemic (2 days) (p value: 0.003). Hence, anemic patients tend to have longer hospital. 13.

(27) U ni. ve. rs. ity. of. M. al. ay. a. Table 4: Morbidity and mortality of study population (n=306) Anemia Non-anemic p-value Variable All (n=180) (n=126) (n=306) Complication Infection Yes 18 (5.8) 12 (9.5) 6 (3.3) 0.024c No 285 (92.5) 113 (89.7) 172 (95.6) Cardiac Yes 5 (1.6) 5 (4.0) 0 (0.0) 0.011d No 298 (96.8) 120 (95.2) 178 (98.9) Respiratory Yes 8 (2.6) 6 (4.8) 2 (1.1) 0.068d No 294 (95.5) 118 (93.7) 176 (97.8) Gastrointestinal Yes 3 (1.0) 3 (2.4) 0 (0.0) 0.069d No 300 (97.4) 122 (96.8) 178 (98.9) Renal Yes 11 (3.6) 8 (6.3) 3 (1.7) 0.056d No 292 (94.8) 117 (92.9) 175 (97.2) Other Yes 11 (3.6) 7 (5.6) 4 (2.2) 0.210d No 292 (94.8) 118 (93.7) 174 (96.7) Length of hospitalization 4.00 (4.00) 4.00 (7.00) 3.00 (3.00) 0.003e Death during hospitalization 4 (1.3) 3 (2.4) 1 (0.6) 0.309d Yes 298 (96.8) 121 (96.0) 177 (98.3) No Mortality within 30 days Yes 4 (1.3) 3 (2.4) 1 (0.6) 0.308d No 297 (96.4) 120 (95.2) 177 (98.3) a Median (IQR); bFrequency (%); cPearson Chi-Square test; dFisher Exact test; eMannWhitney U test. 14.

(28) CHAPTER 5: DISCUSSION From our study, it showed that out of the 306 patients, 126 patients were anemic equating to about 41.7%. Out of the 126 patients, 74 females. This could have been due to the fact that the largest group of patients was from the gynecology discipline, which were all female patients. It was also shown that 98 out of the total 306 patients were not seen in the anesthesia clinic for preoperative assessment and 50 of those not seen were. a. anemic. It was also revealed that out of all the anemic patients most of them were only. ay. detected to have anemia 1-6 days prior to their surgery, only 11 were detected more than. al. 42 days prior to surgery. The results also showed patients who were anemic were more. M. likely to receive blood transfusions compared to patients who were not anemic. Also the anemic patients experienced more complications and out of the 4 patients who passed. of. away, 3 of them were anemic. Anemic patients also were showed to have a longer duration. ity. of hospital stay.. From this results, some of the improvements that could have been done were, a. rs. larger population of patients should have been audited over a longer duration of time to. ve. determine a better incidence and prevalence of anemia, transfusion practices and morbidity and mortality in our center and also other disciplines could also have been. U ni. included. This would give us a bigger sample and more accurate and better results could have been seen.. We could also advice all disciplines to send all patients going for operations for preoperative assessment so that earlier detection of anemia could happen. It is vital to detect and treat anemia as we could see in the results that anemic patients have more complications and longer duration of hospital stay which will then require more hospital resources being used. Anemic patients were also found to have more complications. 15.

(29) compared to the non anemic ones, thus the importance of detecting anemia earlier and treating it. More thorough investigations need to be done to determine the cause of anemia, from our study out of 126 anemic patients, none of them had a full blood workout to determine the cause of their anemia. From our study and its results we can see the importance of detecting anemia and. a. treating it as many lives could be saved as preoperative anemia was associated with poorer. ay. patient outcomes. This study can be used as a stepping stone to the development of a. al. patient blood management protocol for UMMC and would need cooperation from all. M. disciplines to work together and help detect and come up with the proper treatment for. U ni. ve. rs. ity. of. preoperative anemia.. 16.

(30) CHAPTER 6: CONCLUSION Anemia is one of the most common hematological problems preoperatively and has been shown to affect the surgical outcome. It is of grave importance to detect anemia preoperatively and to manage it accordingly to reduce the incidence of intraoperative transfusion, which can lead to poorer surgical outcomes, which then predisposes the. a. patients to longer hospital stay and more healthcare resources being used.. ay. A larger population of patients should have been audited over a long duration of. al. time to determine a better incidence and prevalence of anemia, transfusion practices and morbidity and mortality in our center. From our study, it shows that incidence and. M. prevalence of anemia is significant in our non-cardiac surgical patients and they show a. of. higher need for blood transfusion. Also those anemic patients had more postoperative complications and longer hospital stays.. ity. It is important to note these findings as it showed increase in hospital mortality. rs. and worse outcomes in anemic patients. Using the results of this study, we can come up. ve. with a patient blood management protocol to help in the management and treatment of preoperative anemia, which can then reduce mortality and reduce usage of hospital. U ni. resources.. 17.

(31) REFERENCES Beattie, W., Karkouti, K., Wijeysundera, D. N., & Tait, G. (2009). Risk Associated with Preoperative Anemia in Noncardiac Surgery. Anesthesiolgoy, 110(3), 574-581. Doi” 10.1097/aln.0b013e31819878d3. a. Bernard, A., Davenport, D., Chang, P., Vaughan, T., & Zwschenberger, J. (2009). Intraoperative Transfusion of 1 U to 2 U Packed Red Blood Cells Is Associated with Increased 30-Day Mortality, Surgical-Site Infection, Pneumonia, and Sepsis in General Surgery Patients. Journal of the American College of Surgeons, 208(5), 931-937.e2. doi: 10.1016/j.jamcollsurg.2008.11.019. ay. Carson, J., Duff, A., Poses, R., Berlin, J., Spence, R., & Trout, R. et al. (1996). Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. The Lancet, 348(9034), 1055-1060. Doi: 10.1016/s0140-6736(96)04330-9. M. al. Hare, G., Freedman, J., & David Mazer, C. (2013). Review article: Risks of anemia and related management strategies: can perioperative blood management improve patient safety? Canadian Journal of Anesthesia/Journal Canadien D’anesthesie, 60(2), 168-175. Doi: 10.1007/s12630-012-9861-y. ity. of. Klein, A., Collier, T., Brar, M., Evans, C., Hallward, G., Fletcher, S., & Richards, T. (2016). The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK - the first Association of Cardiothoracic Anaesthetists national audit. Anaesthesia, 71(6), 627-635. Doi: 10.1111/anae.13423. rs. Manuel Munoz, Susana Gomez-Ramirez. Pre-operative anaemia: prevalence, consequences and approaches to management. Blood Transfus.2015 Jul; 13(3): 370-379. ve. Organization, W. (2019). Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Retrieved from http://apps.who.int/iris/handle/10665/85839. U ni. Patel, M., & Carson, J. (2009). Anemia in the Preoperative Patient. Medical Clinics of North America, 93(5), 1095-1104. doi: 10.1016/j.mcna.2009.05.007 Shander, A., Knight, K., Thurer, R., Adamson, J., & Spence, R. (2004). Prevalence and outcomes of anemia in surgery: a systematic review of the literature. The American Journal of Medicine, 116(7), 58-69. doi: 10.1016/j.amjmed.2003.12.013 Spahn, D., Theusinger, O., & Hofmann, A. (2012). Patient blood management is a winwin: a wake-up call. British Journal of Anaesthesia, 108(6), 889-892. doi: 10.1093/bja/aes166. 18.

(32) U ni. ve. rs. ity. of. M. al. ay. a. Viola, J., Gomez, M., Restrepo, C., Maltenfort, M., & Parvizi, J. (2015). Preoperative Anemia Increases Postoperative Complications and Mortality Following Total Joint Arthroplasty. The Journal of Arthroplasty, 30(5), 846-848. doi: 10.1016/j.arth.2014.12.026. 19.

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