Relationships Between Body Mass Index, Allogeneic Transfusion, and Surgical Site Infection After Knee and Hip Arthroplasty Surgery

Abstract

BACKGROUND: Increased body mass index (BMI) is considered as an important factor that affects the need for total knee and hip arthroplasty (TKA/THA) and the rate of perioperative complications. Previous investigations have not fully established the relationship of BMI and perioperative transfusion with surgical site infection (SSI) or the relationship of BMI and perioperative transfusion after TKA or THA. METHODS: The National Surgical Quality Improvement Program database was used to perform a retrospective cohort study involving 333,223 TKA and 41,157 THA cases between 2011 and Multivariable regression assessed the associations of BMI (5 standard categories) and transfusion with SSI. Odds ratio (OR) of SSI was calculated relative to a normal BMI (18.5-24.9 kg/m 2 ) after adjustment of potential confounding factors. RESULTS: Perioperative transfusion decreased significantly over time for both TKA and THA; however, SSI rates remained steady at just under 1% for TKA and 3% for THA. In TKA, a higher OR for SSI was associated only with a BMI of 40+ (OR, 1.86; 95% confidence interval [CI], 1.60-2.18) compared to a referent BMI. In THA, increased ORs of SSI were seen for all BMI levels above normal and were highest for a BMI 40+ (OR, 3.08; 95% CI, 2.47-3.83). In TKA, ORs of transfusion decreased with increasing BMI and were lowest for a BMI 40+ (OR, 0.51; 95% CI, 0.47-0.54). In THA, ORs of transfusion began to increase slightly in overweight patients, reaching an OR of 1.36 (95% CI, 1.21-1.54) for a BMI 40+. CONCLUSIONS: SSI incidence remained unchanged despite continuous reductions in blood transfusion in TKA and THA patients over 8 years. In TKA, ORs for SSI increased, but ORs for transfusion decreased with increasing BMI above normal. Conversely, in THA, ORs for SSI and transfusion both increased for a BMI 40+, but only OR for transfusion increased in underweight patients. These findings suggest the importance of controlling obesity in reducing SSI following TKA and THA. (Anesth Analg 2023;136:123-9) KEY POINTS• Question: How is body mass index (BMI) associated with allogeneic transfusion, and surgical site infection after total knee and hip arthroplasty (TKA/THA) surgery? • Findings: Odds of transfusion decreased with increasing BMI in TKA, while odds of infection and transfusion were increased in THA patients with a BMI over 40. • Meaning: Our results indicate that severe obesity is a dominant risk factor for surgical site infection (SSI) and highlights the need to address preoperative anemia and obesity in an ageing THA population. GLOSSARY-= not included the final model; ANOVA = analysis of variance; ASA = American Society of Anesthesiologists; BMI = body mass index; CI = confidence interval; CPT = Current Procedural Terminology codes; DM = diabetes mellitus; Hgb = hemoglobin; IRB = institutional review board; NSQIP = National Surgical Quality Improvement Program; OP time = operation duration; OR = odds ratio; PUF = participant use files; RBC = red blood cells; REG = regression; SD = standard deviation; SSI = su...

Granulocyte products: The saga continues

“…Baykara et al argue an absence of any significant differences in the functionality between standard GC and purified GC after more than 24 h of storage. However, Schwanke et al have already reported a decrease in phagocytosis and oxidative burst performance of standard GC of as much as 50% after 24 h and about 15% after 72 h of storage, underlining the tremendous functional improvement in purified GC after 72 h. 4 We completely agree with Baykara et al that any new medical technology/treatment should finally be judged in practice. Demonstrating that purified GC also provides real benefit to our patients is of enormous importance and should therefore be clinically tested.…”

“…Some suggest that certain clinical situations require focused emphasis of blood products, such as early platelet and fibrinogen replacement in obstetrical hemorrhage for example, but how often do these sound suggestions based on differing bleeding pathophysiologies make it to bedside protocols and decision support? 3,4 Herein lies the risk; the blood bank protocolizes massive transfusion delivery to rapidly mobilize resources, and then relies on clinicians to resuscitate appropriately, including using protocols and transfusion ratios as clinically indicated. By calling it a protocol, two dangers emerge.…”

“…Over the last two decades, attention to the massive transfusion of bleeding patients has resulted in increased accessibility of fixed ratio resuscitation packs, often called massive transfusion protocols (MTPs), to various clinical settings. [1][2][3] Although stemming from battlefield and trauma settings, they are more commonly used in nontrauma surgery, GI bleeding, and obstetrical hemorrhage 2,4 where 74% of hospitals utilize a generic MTP regardless of the indication. 2 Additionally, non-trauma MTPs are associated with less adherence to fixed transfusion ratios, less viscoelastic testing, less antifibrinolytic use, and more frequent use of vasopressor support.…”

“…3 Thereafter, transfusion rates declined in both total knee arthroplasty (17.5%-0.92%) and total hip arthroplasty (35.9%-16.9%) between 2011 and 2018. 4 In this regard, a sub-analysis of earlier versus later hip arthroplasty data by Lim et al would have been useful in evaluating whether predictive values of abnormal coagulation tests changed over time in a specialty-specific manner. Restrictive transfusion strategies and antifibrinolytic therapy as part of patient blood management contributed to the recent transfusion practice changes.…”

Beware of heterogeneity when assessing the bleeding risk using multi‐specialty and multi‐year database

“…3 Thereafter, transfusion rates declined in both total knee arthroplasty (17.5%-0.92%) and total hip arthroplasty (35.9%-16.9%) between 2011 and 2018. 4 In this regard, a sub-analysis of earlier versus later hip arthroplasty data by Lim et al would have been useful in evaluating whether predictive values of abnormal coagulation tests changed over time in a specialty-specific manner. Restrictive transfusion strategies and antifibrinolytic therapy as part of patient management contributed to the recent transfusion practice changes.…”