Plastic Surgery Research Council
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PSRC 60th Annual Meeting

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Preoperative Anemia Increases the Risk of Adverse Outcomes in Patients Undergoing Free Tissue Transfer: a Critical Analysis of 2135 Patients from the ACS-NSQIP Database
Sashank Reddy, MD, PhD, Karim Sarhane, MD, Jose Flores, MPH, Pablo Baltodano, MD, Gedge D. Rosson, MD.
Johns Hopkins University, Baltimore, MD, USA.

Purpose: Perioperative anemia is associated with adverse outcomes in general surgery, vascular surgery, cardiac surgery, and breast surgery. Perioperative anemia increases complications in patients undergoing extensive surgical procedures and procedures with major blood loss. Since free tissue transfers are among the most lengthy and complicated plastic surgery procedures, we hypothesized that patients undergoing free tissue transfer would be particularly susceptible to the effects of preoperative anemia. This study examines the effects of preoperative anemia on free flap outcomes.
Methods: Patients who underwent free tissue transfer from 2008 to 2011 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). De-identified data on patient demographics, perioperative risk factors, and incidence of complications were obtained. Pre-defined outcomes included overall morbidity, flap failure, surgical site infection, wound breakdown, and repeat operation. Logistic regression was used to assess the crude and adjusted effect of anemia (defined as a hematocrit concentration <36% in women or <39% in men) on postoperative 30-day morbidity.
Results: The study population included 2135 patients, among whom 653 (30.6%) had preoperative anemia. Compared to patients with normal hematocrit levels, anemic patients had 2.16 times higher odds of experiencing overall morbidity within 30-days of their operation (OR = 2.16, p < 0.005). Patients with anemia were significantly more likely to have wound breakdown (OR 2.20, p < 0.005) and were more likely to return to the operating room (OR 1.54, p < 0.005). However, preoperative anemia was not associated with a significantly increased risk of flap loss or surgical site infections.
Conclusions: Preoperative anemia is associated with an increased incidence of overall morbidity and is specifically associated with wound healing difficulties and repeat operations. However, anemia may not predispose patients to flap loss. As many patients undergoing free flap reconstruction are chronically ill, screening for preoperative anemia should be strongly considered. If found, preoperative anemia is often easy to correct. Additional prospective studies should clarify whether treating preoperative anemia can improve outcomes in microsurgical procedures.
Univariate logistic model for adverse outcomes associated with preoperative anemia
Odds Ratio95%C.I.p value
Overall Morbidity2.161.30-2.20p<0.005
Superficial SSI0.840.53-1.34p=0.468
Deep SSI1.270.73-2.20p=0.400
Wound Breakdown2.201.36-3.57p<0.005
Flap Failure1.020.64-1.63p=0.941
Return to OR1.541.21-1.97p<0.005


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