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Preoperative Transfusion Does Not Alter Surgical Outcomes in Children with Hemolytic Disorders
Pooja Shah, Daniel Solomon, Robert A. Cowles
Pediatric Surgery, Yale School of Medicine, New Haven, Connecticut, United States

Objective: Current society guidelines recommend perioperative transfusion for children with hemolytic disorders (HD) undergoing surgery. The evidence supporting these guidelines is conflicting. This study utilizes the National Surgical Quality Improvement Project Pediatric (NSQIP-Peds) database to identify a large cohort of pediatric patients with HD undergoing low to medium risk abdominal surgery, in order to evaluate the effect of preoperative transfusion on perioperative outcomes. Design: Cohort study. Setting: NSQIP-Peds participant sites from 2013-2019. Patients: 872 patients were included who had a HD; underwent cholecystectomy, splenectomy or appendectomy; and had a preoperative hematocrit <30% measured ≤7 days of surgery. Intervention: Preoperative red blood cell (RBC) transfusion within 48 hours of surgery. Main outcome measures: Incidence of postoperative transfusion and median hospital length of stay (LOS). Secondary outcomes included rates of specific surgical complications and 30-day readmission. Results: Preoperative RBC transfusion occurred in 40.1% of patients. The transfused group included more ASA-IV patients (73% vs 61.2%, p=0.005) and had a lower median baseline hematocrit (26.2% vs 27.5%, p <0.01) than the non-transfused group. Postoperative complications occurred at similar rates, irrespective of transfusion status (14.3% vs 15.3%, p=0.673), and no differences in specific surgical complications were detected. Both groups required postoperative transfusion at a similar rate (10.7% vs 12%, p=0.316) and median LOS did not differ (3 vs 2 days, p=0.534). Furthermore, there were no instances of 30-day readmission for bleeding or anemia. Conclusions: Fewer than half of anemic children with HD undergoing common abdominal surgeries received preoperative transfusion. Preoperative transfusion was not associated with a reduced rate of postoperative transfusion or shortened LOS. These data suggest that preoperative transfusion for hematocrit less than 30%, as recommended by current guidelines, may not improve outcomes in the absence of other indications such as severe systemic disease.

Surgical outcomes of pediatric patients with hemolytic disease and anemia by preoperative transfusion status, % (n)
VariableNot transfused (N = 522)Transfused (N = 350)All patients (N = 872)p-value (if calculated)
Procedure  
 Cholecystectomy75.7 (385)75.7 (265)74.5 (650) 
 Splenectomy6.5 (34)10.6 (37)8.1 (71) 
 Appendectomy19.7 (103)13.7 (48)17.3 (151) 
ASA Class   p = 0.005
ASA-13.8 (17)1.4 (4)2.9 (21) 
 ASA-II1.1 (5)0.4 (1)0.8 (6) 
 ASA-III33.8 (149)25.3 (72)30.4 (221) 
 ASA-IV or higher61.2 (441)73.0 (208)65.8 (478) 
Median preoperative hematocrit (IQR), %27.5 (25.4, 28.9)26.2 (23.8, 28.1)27.0 (24.8, 28.7)p < 0.001
Median length of stay (IQR), days3 (2,6)2 (2,5)3 (2,6)p = 0.534
Surgical complications15.3 (80)14.3 (50)14.9 (130)p = 0.673
 Surgical site infection2.9 (15)1.1 (4)2.2 (19)p = 0.066
 Wound dehiscence0.2 (1)0.0 (0)0.1 (1)p = 0.599
 Pneumonia1.0 (5)1.7 (6)1.3 (11)p = 0.248
 Unplanned intubation0.0 (0)0.9 (3)0.3 (3)p = 0.064
 Urinary tract infection0.2 (1)0.0 (0)0.1 (1)p = 0.599
 Postoperative transfusion10.7 (56)12.0 (42)11.2 (98)p = 0.316
 Sepsis0.8 (4)0.3 (1)0.2 (2)p = 0.334
 Death within 30 days0.2 (1)0.3 (1)0.2 (2)p = 0.637
Readmission within 30 days18.1 (60)15.2 (34)16.9 (94)p = 0.637
Readmission diagnosis of bleeding or anemia0.0 (0)0.0 (0)0.0 (0) 


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