Transfusions in Autologous Breast Reconstructions: An Analysis of Risk Factors, Complications, and Cost.
ABSTRACT PURPOSE: Free tissue transfer requires lengthy operative times and can be associated with significant blood loss. The goal of our study was to determine independent risk factors for blood transfusions and transfusion-related complications and costs. METHODS: We reviewed our prospectively maintained free flap database and identified all patients undergoing breast reconstruction receiving blood transfusions. These patients were compared with those not receiving a postoperative transfusion. We examined baseline patient comorbidities, preoperative and postoperative hemoglobin (HgB) levels, intraoperative and postoperative complications, and blood transfusions. Factors associated with transfusion were identified using univariate analyses, and multivariate logistic regression was used to determine independently associated factors. RESULTS: A total of 70 (8.2%) patients received postoperative blood transfusions. Multivariate analysis revealed associations between length of surgery (P = 0.01), intraoperative arterial thrombosis [odds ratio (OR), 6.75; P = 0.01], major surgical complications (OR, 25.9; P < 0.001), medical complications (OR, 7.2; P = 0.002), and postoperative HgB levels (OR, 0.2; P < 0.001). Transfusions were independently associated with higher rates of medical complications (OR, 2.7; P = 0.03). A significantly lower rate of medical complications was observed when a restrictive transfusion (HgB level, <7 g/dL) was administered (P = 0.04). A cost analysis demonstrated that each blood transfusion was independently associated with an added $1,500 in total cost. CONCLUSIONS: Several key perioperative factors are associated with allogenic transfusion, including intraoperative complications, operative time, HgB level, and postoperative medical and surgical complications. Blood transfusions were independently associated with greater morbidity and added hospital costs. Overall, a restrictive transfusion strategy (HgB level, <7 g/dL or clinically symptomatic) may help minimize medical complications. LEVEL OF EVIDENCE: Prognostic/risk category, level III.
- [Show abstract] [Hide abstract]
ABSTRACT: Introduction: Appropriate and adequate blood flow and oxygen delivery to a free flap is paramount to viability and success. We present a comprehensive examination of perioperative anemia, determining its prevalence and effect on complications and outcomes in autologous breast reconstruction. Methods: We analyzed all autologous free flap breast reconstruction at the Hospital of the University of Pennsylvania from 2005 to 2011 with regards to anemia (hemoglobin (Hgb) <12 g dL−1). Anemic patients were compared to those with Hgb > 12 g dL−1 at preoperative and postoperative timepoints. Complications were analyzed relative to HgB levels and the incidence of anemia. Subgroups were analyzed based on worsening degrees of anemia. Results: Overall, 839 patients were included in the analysis with an 18.3% incidence of preoperative anemia. No significant differences were noted in outcomes of these patients relative to their anemic state, although a higher percent did receive a blood transfusion (18% of anemic patients vs. 6% of nonanemic patients, P < 0.0001). There was a significant incidence of postoperative anemia (93.4%). A subgroup analysis demonstrated that worsening postoperative anemia was significantly related to preoperative HgB (P < 0.0001), bilateral cases (P < 0.0001), immediate reconstructions (P < 0.0001), increased estimated blood loss (P = 0.0001), and higher rates of intraoperative fluid administration (P = 0.025). A higher incidence of medical complications was observed in cohorts with HgB < 10 (P = 0.018). Conclusions: Anemia affects a significant portion of breast reconstruction patients. While preoperative anemia is not associated with increased risk of flap related complications, postoperative anemia may be associated with an increased risk of medical complications. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.Microsurgery 05/2014; 34(4). DOI:10.1002/micr.22202 · 2.42 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Background: Free tissue transfer is an accepted method for breast reconstruction. Surgically uncorrectable venous congestion is a rare but real occurrence after these procedures. Here, we report our experience with the management of surgically uncorrectable venous congestion after free flap breast reconstruction using medicinal leech therapy. Methods: We queried our prospectively maintained institutional database for all patients with venous congestion after free flap breast reconstruction since 2005. Chart review was performed for all patients having post-operative venous congestion. We compared patients with surgically correctable venous congestion and surgically uncorrectable venous congestion requiring medicinal leech therapy. Results: Twenty-three patients had post-operative venous congestion, and four of these patients were surgically uncorrectable requiring medicinal leech therapy. Patients who required leech therapy had lower hemoglobin nadirs, received more blood transfusions, and received a higher number of total units of red blood cells than patients who did not require leech therapy. Among four patients who required leech therapy, one flap was partially salvaged and three flaps were completely lost. Leech therapy was associated with higher total flap loss rates (75.0% vs. 42.1%) and longer length of stay (8.0 +/- 3.6 days vs. 6.5 +/- 2.1 days) when compared to non-leeched flaps. These differences were not statistically significant (P = 0.32 and P = 0.43, respectively). Conclusions: In patients with surgically uncorrectable venous congestion after free flap breast reconstruction, total flap loss is common despite leech therapy. When venous congestion cannot be corrected, total flap removal may be a better option than attempted salvage with leech therapy. (C) 2014 Wiley Periodicals, Inc.Microsurgery 10/2014; 34(7). DOI:10.1002/micr.22277 · 2.42 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Anesthetic management remains an understudied aspect of free autologous breast reconstruction. This study aims to critically examine intraoperative anesthetic management as it relates to free flap perfusion and its effect on major complications. A retrospective cohort study was performed examining all abdominally based free autologous breast reconstructions from 2005 to 2011 at a single institution. Analysis focused on perioperative care and specifically fluid administration, urine output (UOP), vasopressor administration, and case duration. Outcomes included major intraoperative and postoperative complications. A post-hoc analysis was performed to determine anesthetic factors associated with thrombotic events. Overall, 682 patients (1033 flaps) were included. Patients with low UOP had lower rates of intraoperative fluid infusion rates/kg (p = 0.0001), Estimated Blood Loss (EBL) (p = 0.006) and pressor administration (p = 0.03), but no significant differences were noted in intraoperative thrombotic events according to UOP. However, the below normal UOP cohort demonstrated a significant increased rate of delayed postoperative thromboses (p = 0.03). A post hoc analysis of postoperative thrombotic events revealed that low rates of fluid resuscitation (OR = 3.01, p = 0.04) and low intraoperative UOP (OR = 3.67, p = 0.04) were independently associated with delayed thrombosis. A sub-analysis demonstrated that patients with ≥2 comorbidities and below normal UOP were at particular risk (any delayed thrombotic event OR = 4.3, p = 0.03; any delayed venous thrombosis OR = 9.1, p = 0.03). This study demonstrates that intraoperative fluid under-resuscitation may place patients at increased risk for postoperative flap thrombosis, and low UOP is an important metric whereby intraoperative resuscitation should be gauged. Patients with comorbid conditions and below normal intraoperative UOP should be monitored particularly closely for delayed thrombotic events. Level of evidence: Prognostic/risk category, level II. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.Journal of Plastic Reconstructive & Aesthetic Surgery 10/2014; 68(2). DOI:10.1016/j.bjps.2014.10.002 · 1.47 Impact Factor