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Red Blood Cell Transfusions Following Resection of Skull Base
Meningiomas: Risk Factors and Clinical Outcomes
Carlito Lagman, MD, John P. Sheppard, MS, Joel S. Beckett, MD, Alexander M. Tucker, MD, Daniel T. Nagasawa, MD, Giyarpuram N. Prashant, MD, Alyssa F. Ziman, MD, Isaac Yang, MD
Departments of Neurosurgery and Pathology, Ronald Reagan UCLA Medical Center of the David Geffen School of Medicine at the University of California, Los Angeles
STATUS: Submitted to WORLD NEUROSURGERY
DISCLOSURES None
RECOMMENDATION 1: a restrictive RBC transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL is recommended for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than when the hemoglobin is 10 g/dL (strong recommendation, moderate quality evidence). A restrictive RBC transfusion threshold of 8 g/dL is recommended for patients undergoing orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular disease (strong recommendation, moderate quality evidence). The restrictive transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but RCT evidence is not available for all patient categories. These recommendations do not apply to patients with acute coronary syndrome, severe thrombocytopenia (patients treated for hematological or oncological reasons who are at risk of bleeding), and chronic transfusion-dependent anemia (not recommended due to insufficient evidence).
METHODSStudy Setting: Single institution
Study Design: Retrospective case-control
Study Period: March 2013 to January 2017
Inclusion Criteria:
Adults
Antiplatelet d/c > 7 days
Baseline Hb > 9 g/dL
Normal INR
Pathologic diagnosis (NR-meningioma, all Grades)
Transfusion > 1U of pRBCs < 7 days of surgery
Data Collection:
Baseline characteristics
Preoperative embolization status
Transfusion parameters
Primary Outcomes:
In-hospital complications
Length of stay, days
Discharge disposition
TABLE 1. Univariate analyses
Transfusion No transfusion p Value
No. of Pts n = 7 n = 30
Age, yrs 67.29 + 7.06 57.03 + 11.58 .03
Postoperative hemoglobin, g/dL 9.45 + 1.06 11.48 + 1.55 .003
Meningioma size, cm 5.64 + 1.27 3.44 + 1.30 < .001
Operative time, hrs 10.52 + 1.83 7.19 + 2.51 .002
Length of stay, days 19.93 + 13.37 4.93 + 3.59 < .001
Non-routine discharge, n (%) 5 (71.43) 3 (10) < .001
WHO, World Health Organization
TRANSFUSION PARAMETERS
Days: 2.10 + 1.61 daysUnits: 1.86 + 0.69 U
Size (R = 0.60, P =.16)Vol (R = 0.64, P = .13)
Volume: 520.71 + 193.98 mLSize (R = 0.63, P = .13)Vol (R = 0.68, P = .09)
No adverse transfusion reactionsNo intraop or in-hospital deaths
TABLE 2. Multivariate analyses
Transfusion (ref: no RBCT)
OR [95% CI]
Age, yrs 1.11 [1, 1.24]
Male 0.76 [0.62, 0.93]
Postoperative hemoglobin, g/dL 0.30 [0.11, 0.78]
Skull base location 3.89 [1.34, 11.25]
Meningioma size > 5 cm 75 [5.80, 970.66]
Operative time > 10 hours 16.25 [2.32, 114.06]
TRANSFUSION
Increased risk of prolonged LOS (over 14 days) OR 38.67 [3.20, 467.74]
Increased risk of non-routine discharge OR 11.30 [1.37, 92.72]
TABLE 3. Summary of patients transfused with packed red blood cells
Patient Skull base meningioma Management Transfusion Outcomes
Age/sex Location Size Volume Embo Crani Simpson WHO OT Days Hb U mL† Comp LOS Dispo
74/F SW/PC 6.5 120.4 Yes PT IV I 11 0.25 8.6 2 620 Other 23.83 SNF
65/F SW 8 161.8 No PT IV II 7 2.75 7.3 3 825 Seizure 46.36 SNF
65/F PS 5.2 34.75 Yes FR IV I 12 1.19 8.4 1 275 Stroke 10.11 Home
58/F SW/PC 5.1 34.7 Yes FT II I 12 1.90 7.4 2 550 None 7.58 ARU
60/F SW 5.4 67.32 No FT IV II 9 3.99 7.3 2 550 None 17.84 SNF
75/F PS/OG 4 22.95 No FR III I 11 4.21 7.6 2 550 Seizure 23.47 SNF
74/F SW 5.3 65.18 Yes PT IV I 11 0.38 8.2 1 275 None 10.33 Home
Size, maximal tumor diameter in centimeters; Vol, tumor volume in millimeters; Embo, preoperative embolization; Crani, craniotomy (approach); SW, sphenoid
wing; PC, paraclinoid; PS, planum sphenoidale; OG, olfactory groove; PT, pterional; FR, frontal; FT, frontotemporal; WHO, World Health Organization; OT,
operative time in hours (rounded up); Days, days from surgery to transfusion; Hb, pretransfusion hemoglobin value; Comp, in-hospital complications; LOS, length
of stay; Dispo, discharge disposition. †1 unit of packed red blood cells is defaulted to a volume of 275 mL
LIMITATIONS AND FUTURE DIRECTIONS
Retrospective Prospective studies, RCTs comparing restrictive versus liberal transfusion strategies
Focus on SBM Include all tumor types
Open craniotomy only Case-control study (open craniotomy versus endoscopic)
Small sample size Large database studies (eg, NIS, MarketScan)
SUMMARYTransfusion group
Older
Larger meningiomas
Longer operative time
Lower postop Hb
Risk factors
Age
Female
Lower postop Hb
Skull base (independent)
“10/5” Rule ($$$)
Outcomes
Longer LOS
Non-routine discharge
Daniel T. Nagasawa, MD Winward Choy, MD Daniel Azzam, BS Nikhilesh S. Bhatt, BS
Alexander M. Tucker, MD Lawrance K. Chung, BS Yasmine Alkhalid, BS Natalie E. Barnette, BS
Joel S. Beckett, MD Thien P. Nguyen, BS Prasanth Romiyo, BS Cheng Hao Jacky Chen
Giyarpuram N. Prashant, MD John P. Sheppard, MS Courtney Q. Duong, BS Vera Elizabeth Ong
Restrictive Transfusion Threshold is Safe in High-Risk
Patients Undergoing Brain Tumor Surgery
Yasmine Alkhalid, BS, Carlito Lagman, MD, John P. Sheppard, MS, Thien Nguyen, BS, Daniel Azzam, Prasanth Romiyo, Giyarpuram N. Prashant, Alyssa F. Ziman, Isaac Yang
Departments of Neurosurgery and Pathology, Ronald Reagan UCLA Medical Center of the David Geffen School of Medicine at the University of California, Los Angeles
DISCLOSURES None
SUMMARYStudy Setting: Single institution
Study Design: Retrospective case-control
Study Period: March 2013 to January 2017
Inclusion Criteria:
50 years of age or older
ASA physical status class II-IV
25 Patient Stratified:
Restrictive-threshold (n = 17, 68%)
Liberal-threshold (n = 8, 32%)
Restrictive vs Liberal-threshold:
ICU stay: 8.58 days vs 6.00 days (p = 0.69)
Hospital stay: 22.41 vs 15.01 days (p = 0.20)
In-hospital death: OR 0.93, 95% CI: 0.07-12.11
In-hospital complication: OR 1.13, 95% CI: 0.21-6.05
Discharge disposition: OR 2.40, 95% CI: 0.42-13.60
Conclusion:
No clinical variance between transfusion thresholds
Risk Factors for Platelet Transfusion in Glioblastoma Surgery
Carlito Lagman, MD, John P. Sheppard, MS, Prasanth Romiyo, BS, Thien Nguyen, BS, Giyarpuram N. Prashant, MD, Daniel T. Nagasawa, MD, Linda M. Liau, MD, PhD, Isaac Yang, MD
Departments of Neurosurgery and Pathology, Ronald Reagan UCLA Medical Center of the David Geffen School of Medicine at the University of California, Los Angeles
DISCLOSURES None
SUMMARYStudy Setting: Single institution
Study Design: Retrospective 1:1 matched case-control
Study Period: March 2013 to January 2017
Inclusion Criteria:
Adult patients
Glioblastoma
105 Patients Stratified:
Platelets transfused (n = 13, 12.38%)
NOT transfused w/ PLT (n = 92, 87.62%)
Risk Factors (P < .05):
Prior antiplatelet therapy (OR 8.21)
Preoperative PLT count < 200 (OR 8.41)
Prolonged operative time (OR 1.73)
Subgroup analysis: Prophylactic vs therapeutic
In-hospital complications (OR 30)