Predictors of Intraoperative Blood Transfusion in Free Tissue Transfer

Abstract

Free tissue transfer has become a safe and reliable procedure and is routinely used in a variety of settings. However, it is associated with lengthy operating times and a high potential for blood loss and consecutive red blood cell transfusions (RBCTs). To assess the risk for RBCTs, we retrospectively identified 398 patients undergoing free tissue transfer between 2005 and 2014. Based on a multivariate model of risk factors and their respective odds ratio, a risk score was developed to predict the likelihood of the need for intraoperative RBCT. The median age at the time of operation was 51.3 ± 15 years, and 278 (70%) patients were male. The average body mass index was 25.9 ± 4 and the median ASA score was 2 (range: 1-4). Mean duration of surgery was 319.8 ± 108 minutes and mean duration of hospital stay was 45.8 ± 40 days. A total of 231 patients (58%) required perioperative RBCTs, all of which were allogenic. RBCTs were performed 0 to 48 hours preoperatively in 36 patients (11.3%), intraoperatively in 166 patients (41.7%), and 0 to 48 hours postoperatively in 125 patients (31.4%). The mean amount of overall RBCTs given was 2.5 ± 3.7 units and 1.1 ± 1.9 units for intraoperative transfusions. The following risk factors were statistically significant in the multivariate regression analysis and included in the risk score: age >60 years; a preoperative hemoglobin concentration of <11 g/dL; a preoperative platelet count of >400/nL; history of renal (RI) and cardial insufficiency (CI); defect localization on the proximal extremities, head and neck, or trunk; and the use of myocutaneous flaps. This score assessed the risk for RBCTs with a sensitivity of 77%, a specificity of 81%, and an AUC of the ROC curve of 0.86. We were able to develop a risk score that allows for the assessment of RBCT likelihood. While most of the identified risk factors cannot be prevented or corrected, it still allows for improved patient counseling and can potentially reduce the number of ordered but not transfused RBCTs.

Red Blood Cell Transfusion and its Relationship with Pedicle Thrombosis in Microvascular Free Flaps

“…The present study was conducted with the goal of determining a The prevalence of RBCT during the perioperative period was 20.5%; a value that is related with the results of different studies (14.7-58%). 15,17,19,22 It is notable that the type of flap used was a determining factor for the use of RBCT in our study; finding that the osteocutaneous and musculocutaneous flaps were mainly associated with the perioperative requirement of RBCT (37.5% and 30.95%). These same results were published by Puram et al, who described a higher requirement for RBCT in fibula flap and anterolateral thigh free flaps.…”

“…This is in line with the results presented by Kolbenschlag et al, who described that intraoperative bleeding greater than 300ml had a statistically significant relationship with the risk of intraoperative RBCT. 22 The effect of preoperative anemia is a matter of considerable debate and the exact value of hemoglobin as a predictor of RBCT is not conclusive. Nevertheless, it has been shown that low levels of preoperative hemoglobin in patients with head and neck defects represent a greater risk of transfusion requirements 17,18,23 .…”

Effect of Perioperative Antithrombotics on Postoperative Transfusion and Hematoma in Head and Neck Free Flaps

“…Our results confirm prior studies demonstrating a higher transfusion requirement in patients with ALT compared to RFFF reconstructions, 21,26 though smaller studies have not seen an association between transfusion and flap type. 22 Previous studies have also demonstrated an association between transfusions and decreased preoperative hemoglobin 26,27 and elevated coagulation labs. 22 We confirm a significant effect of preoperative hemoglobin and hematocrit on postoperative transfusion rates in both the first 72 hours and the duration of the hospital LOS, but we did not have complete data on coagulation labs to examine the impact those values have on transfusion rates.…”

The effect of transfusion on survival in head and neck cancer after free tissue reconstruction

“…[8][9][10][11][12] On average, patients who require extirpation of a head and neck cancer with free tissue reconstruction are treated with 2 units of blood within a 2-to 3-day perioperative period. 13 While often beneficial to many patients with head and neck cancer, host immunosuppression and inflammation after a blood transfusion may affect overall survival (OS), recurrence, and recurrence-free survival (RFS). Despite the use of leucocyte-reduced blood products, transfused products still contain cytokines, growth factors, and inflammatory mediators that affect cancer outcomes, wound healing, and infection after surgery.…”