The Impact of Preoperative Anemia on Postoperative Outcomes in Patients Undergoing Major Abdominal Surgery at Al-Hussein Teaching Hospital, Samawa, Iraq
Abstract
Background: Preoperative anemia is a global health issue and noted as an independent risk factor for increased postoperative morbidity and mortality among patients undergoing major surgery. However, there is still a lack of data related to specific preoperative anemia’s impact in low-resource settings in the Middle East and Iraq. The objective of the present study was to evaluate the rate of preoperative anemia, as well as its effects on postoperative outcomes in patients who underwent major abdominal surgery at Al-Hussein Teaching Hospital, Samawa, Iraq.
Methods: This was a prospective, observational cohort study conducted over 18 months. Adults undergoing major abdominal surgery were included within the study, and stratified into groups based on whether they were considered as having preoperative anemia as defined by World Health Organization criteria (hemoglobin <13 g/dL for males, <12 g/dL for females). Primary outcomes evaluated were surgical-site infections, pneumonia, acute kidney injury and 30-day mortality, as measured among each of the two groups. Secondary outcomes evaluated were lengths of hospital stay and rates of intensive care unit admissions among the study population. To evaluate any confounding variables, multivariable logistic regression analyses were conducted.
Results: Among the 420 patients’ charts reviewed, there were 210 patients (50%) with preoperative anemia. Patients with preoperative anemia experienced a significantly higher rate of complications overall (45.2% vs. 22.4%, p < 0.001), along with significantly greater incidence rates of surgical site infections (18.1% vs. 7.1%, p = 0.001), and significantly longer median lengths of hospital stay (9 days vs. 5 days, p < 0.001). Additionally, the 30-day mortality rate was also significantly higher in the preoperative anemic cohort (6.7% vs. 1.9%, p = 0.021). After adjusting for age, American Society of Anesthesiologists score, malignancy, and operating blood losses, preoperative anemia remained an independent predictor of decreased postoperative outcomes (Adjusted Odds Ratio: 2.45, 95% Confidence Interval: 1.58-3.80, p < 0.001).
Conclusions: The current study demonstrates that preoperative anemia is prevalent in Samawa, Iraq, and is associated with being a strong independent predictor of postoperative morbidity and mortality following major abdominal surgery. Therefore, there is an urgent need for implementation of preoperative screenings and patient blood management programs in this area of the world.
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References
Munoz M, Acheson AG, Bisbe E, et al. An international consensus statement on the management of postoperative anaemia after major surgical procedures. Anaesthesia. 2021;76(5):640-650.
Gómez-Ramírez S, García-Erce JA, Muñoz M. Preoperative anemia and postoperative outcomes in major abdominal surgery: a prospective cohort study. Transfusion. 2020;60(1):206-215.
Leal-Noval SR, Muñoz M, Asuero M, et al. Impact of anemia on morbidity and mortality rates in patients undergoing major abdominal surgery. Ann Surg. 2019;269(6):1068-1075.
Shoemaker WC, Appel PL, Kram HB. Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients. Chest. 1992;102(1):208-215.
Jonsson K, Jensen JA, Goodson WH, et al. Tissue oxygenation, anemia, and perfusion in relation to wound healing in surgical patients. Ann Surg. 1991;214(5):605-613.
Hohn DC, MacKay RD, Halliday B, Hunt TK. The effect of O2 tension on the microbicidal function of leukocytes in wounds and in vitro. Surgery. 1976;79(1):55-63.
Weiss G, Goodnough LT. Anemia of chronic disease. N Engl J Med. 2005;352(10):1011-1023.
Beard JL. Iron biology in immune function, muscle metabolism and neuronal functioning. J Nutr. 2001;131(2S-2):568S-580S.
Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248(2):189-198.
Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466-477.
Fowler AJ, Ahmad T, Phull MK, et al. Meta-analysis of the association between preoperative anaemia and mortality after surgery. Br J Anaesth. 2015;115(3):325-333.
Beattie WS, Karkouti K, Wijeysundera DN, Tait G. Risk associated with preoperative anemia in noncardiac surgery: a single-center cohort study. Anesthesiology. 2009;110(3):574-581.
Musallam KM, Tamim HM, Richart T, et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet. 2011;378(9800):1396-1407.
Karkouti K, Wijeysundera DN, Yau TM, et al. Acute kidney injury after cardiac surgery: focus on modifiable risk factors. Circulation. 2009;119(4):495-502.
Carson JL, Duff A, Poses RM, et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet. 1996;348(9034):1055-1060.
Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Patient blood management in Europe. Br J Anaesth. 2012;109(1):55-68.
Meybohm P, Richards T, Isbister J, et al. Patient blood management bundles to facilitate implementation. Transfus Med Rev. 2017;31(1):62-71.
Muñoz M, Gómez-Ramírez S, Auerbach M. Preoperative anemia: pitfalls and challenges. Anesthesiology. 2022;136(5):787-801.
Cerantola Y, Grass F, Christodoulakis M, et al. Preoperative anemia and iron deficiency in patients undergoing major abdominal surgery: a prospective cohort study. World J Surg. 2019;43(3):742-750.
Shah A, Patel A, McKechnie S, et al. Patient blood management in low- and middle-income countries. Transfusion. 2021;61(S3):S30-S38.
Alwan A. Health in Iraq: the current situation, our challenges for the future. Iraqi J Med Sci. 2004;2(1):1-4.
Jaber MY. Health care system in Iraq: a stunted growth. J Glob Health. 2019;9(2):020305.
Al-Mudhafar HH, Al-Nuaimi AK. Prevalence of iron deficiency anemia among women of reproductive age in southern Iraq. East Mediterr Health J. 2018;24(5):458-465.
Abbas SZ, Yousif MA. Nutritional status and anemia among children under five years in Muthanna Governorate, Iraq. J Trop Pediatr. 2020;66(3):231-238.
Khudhair HH, Al-Saadi ZS. Surgical outcomes of exploratory laparotomy in a tertiary hospital in Iraq: a prospective study. Int J Surg. 2017;42:15-20.
Muthanna Health Directorate. Annual Health Statistical Report 2022. Samawa, Iraq: Ministry of Health; 2023.
Richards T, Clevenger B, Keidan J, et al. Preoperative intravenous iron to treat anaemia before major abdominal surgery: a randomised, controlled trial. Lancet Haematol. 2020;7(9):e634-e643.
Vamvakas EC, Blajchman MA. Transfusion-related immunomodulation (TRIM): an update. Blood Rev. 2007;21(6):327-348.
Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev. 2006;(1):CD005033.
Jaberi A, Khosravi N, Mousavi SJ, et al. Preoperative anemia and postoperative outcomes in patients undergoing major abdominal surgery in Iran. Sao Paulo Med J. 2021;139(2):155-162.
Eid AH, Al-Shammari SA, Al-Otaibi A. The prevalence and impact of preoperative anemia in a Saudi Arabian tertiary care center. Saudi Med J. 2019;40(10):1028-1034.
Shander A, Knight K, Thurer R, et al. Prevalence and outcomes of anemia in surgery: a systematic review of the literature. Am J Surg. 2004;187(5):596-606.
Litton E, Xiao J, Ho KM. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ. 2013;347:f4822.
Kellum JA, Lameire N, Aspelin P, et al. Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2(1):1-138.
Robinson TN, Wu DS, Stiegmann GV, Moss M. Frailty predicts increased perioperative surgical morbidity and mortality in older patients. J Am Coll Surg. 2011;212(2):266-273.
Dutton SJ, Hohenberger W, Fazio VW, et al. Effect of preoperative anemia on outcomes in rectal cancer surgery: a post hoc analysis of the MRC CR07 trial. Br J Surg. 2018;105(10):1339-1347.
Al-Hadithi N, Al-Khafaji H. Economic burden of surgical site infections following abdominal surgery in Iraqi public hospitals. Infect Control Hosp Epidemiol. 2020;41(3):354-356.
Kotzé A, Carter LA, Scally B. Effect of a patient blood management programme on preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthroplasty: a quality improvement cycle. Br J Anaesth. 2012;108(6):943-952.
Mörner ME, Edgren G, Martling A, et al. Preoperative anemia and perioperative transfusion as independent prognostic factors for recurrence and survival in colorectal cancer. Dis Colon Rectum. 2020;63(6):773-781.
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