Background:The impact of intraoperative erythrocyte transfusion on outcomes of anemic patients undergoing noncardiac surgery has not been well characterized. The objective of this study was to examine the association between blood transfusion and mortality and morbidity in patients with severe anemia (hematocrit less than 30%) who are exposed to one or two units of erythrocytes intraoperatively. Methods: This was a retrospective analysis of the association of blood transfusion and 30-day mortality and 30-day morbidity in 10,100 patients undergoing general, vascular, or orthopedic surgery. We estimated separate multivariate logistic regression models for 30-day mortality and for 30-day complications. Results: Intraoperative blood transfusion was associated with an increased risk of death (odds ratio [OR], 1.29; 95% CI, 1.03-1.62). Patients receiving an intraoperative transfusion were more likely to have pulmonary, septic, wound, or thromboembolic complications, compared with patients not receiving an intraoperative transfusion. Compared with patients who were not transfused, patients receiving one or two

T here is a strong association between a reduced estimated glomerular filtration rate (eGFR) and an increase in cardiovascular disease and all-cause mortality. Associations with morbidity in elective moderate-risk noncardiac surgery have not been examined. It was hypothesized that chronic kidney disease (CKD) would be associated with excess morbidity after elective, moderate-risk orthopedic surgery. Because they represent a large proportion of global surgical procedures and are characterized by highly homogeneous anesthetic and surgical practice, patients undergoing elective orthopedic joint replacement procedures were studied. Calculation of eGFR was done based on routine creatinine measurements using the Modification of Diet in Renal Disease equation. Chronic kidney disease was defined as eGFR G60 mL/min per 1.73 m 2 . Cardiac risk (Revised Cardiac Risk Index) and evidence-based preoperative factors associated with perioperative morbidity, such as operative time, blood loss, and perioperative temperature, were prospectively recorded using the postoperative morbidity survey. Differences in morbidity were analyzed between patients with CKD and normal preoperative renal function (W 2 test for trend) and presented as a hazard ratio (HR) or odds ratio (OR) with 95% confidence intervals (95% CIs). Secondary end points were time to hospital discharge and freedom from morbidities (analyzed by the log-rank test), both between and within CKD patients compared with those with normal renal function. Multiple regression analysis was performed to assess the association of CKD and perioperative factors with morbidity and length of hospital stay. A morbidity survey was conducted postoperatively in 526 patients undergoing elective orthopedic surgery. Chronic kidney disease patients (n = 142; 27%) sustained excess morbidity on postoperative day 5 (OR, 2.1 [95% CI, 1.2Y3.7]). It took longer (HR, 1.6 [95% CI, 1.2Y1.9]) for CKD patients to become free of morbidities (log-rank test). Time to hospital discharge was delayed by 4 days in CKD patients (HR, 1.4 [95% CI, 1.2Y1.7], log-rank test). Such patients sustained more pulmonary (OR, 2.2 [95% CI, 1.3Y3.6]), infectious (OR, 1.7 [95% CI, 1.1Y2.7]), cardiovascular (OR, 2.4 [95% CI, 1.2Y4.8]), renal (OR, 2.3 [95% CI, 1.5Y3.5]), neurological (OR, 4.3 [95% CI, 1.3Y17.7]), and pain (OR, 1.8 [95% CI, 1.03Y3.1]) morbidities.Additional stratification of CKD patients showed a preoperative eGFR of 50 mL/min per 1.73 m 2 or less to be associated with more frequent morbidity and a longer hospital stay, independent of age. Multiple regression analysis revealed CKD and congestive cardiac failure to be preoperative factors associated with a prolonged hospital stay. A sizable minority of CKD patients undergoing elective orthopedic procedures are at greater risk of prolonged morbidity and a longer hospital stay. Preoperative eGFR may enhance perioperative risk stratification beyond traditional risk factors. COMMENTIn recent years, the cardiovascular literature has focused on the relationship between C...

Black and Hispanic women in labor are less likely than non-Hispanic white women to receive epidural analgesia. These differences remain after accounting for differences in insurance coverage, provider practice, and clinical characteristics.

Background:Previous studies have demonstrated that obesity is paradoxically associated with a lower risk of mortality after noncardiac surgery. This study will determine the impact of the modified metabolic syndrome (defined as the presence of obesity, hypertension, and diabetes) on perioperative outcomes. Methods: This study is based on data from 310,208 patients in the American College of Surgeons National Surgical Quality Improvement Program database. We estimated separate multivariate logistic regression models for 30-day mortality and for 30-day complications. Results: Patients with the modified metabolic syndrome who are super obese had a 2-fold increased risk of death (adjusted odds ratio [AOR] 1.99; 95% CI 1.41-2.80). As stratified by body mass index, patients with the modified metabolic syndrome had a 2-to 2.5-fold higher risk of cardiac adverse events (CAE) compared with normal-weight patients: obese (AOR 1.70; 95% CI 1.40 -2.07), morbidly obese (AOR 2.01; 95% CI 1.48 -2.73), and super obese (AOR 2.66; 95% CI 1.68 -4.19). In addition, the risk of acute kidney injury (AKI) was 3-to 7-fold higher in these patients: obese (AOR 3.30; 95% CI 2.75-3.94), morbidly obese (AOR 5.01; 95% CI 3.87-6.49), and super obese (AOR 7.29; 95% CI 5.27-10.1). Conclusion:Patients with the modified metabolic syndrome undergoing noncardiac surgery are at substantially higher risk of complications compared with patients of normal weight.

There was dramatic hospital variability in perioperative transfusion rates among patients undergoing major noncardiac surgery at academic medical centers. In light of the potential complications of transfusion therapy, reducing this variability in hospital transfusion practices may result in improved surgical outcomes.