title: Morbidity and mortality after massive transfusion in patients undergoing non-cardiac surgery.
abstract: BACKGROUND
  Massive transfusion is associated with high morbidity and mortality, yet existing reports of massive transfusion are limited. Our primary aim was to determine the incidence of complications and 30-day mortality among patients who received massive transfusions and to explore risk factors associated with 30-day mortality.
  
  
  METHODS
  We evaluated 971,455 patients from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We assessed the associations between 30-day mortality and baseline, intraoperative, and postoperative factors among 5,143 patients who received massive transfusions and for whom complete data were available.
  
  
  RESULTS
  The crude 30-day postoperative mortality of the non-transfused, low transfusion (1-4 units), and massive transfusion (≥ 5 units) patients in the NSQIP was 1.2%, 8.9%, and 21.5%, respectively. Of the 5,143 massive transfusion patients with non-missing covariable data, 17% (95% confidence interval [CI] 16% to 18%) died within 30 days of surgery, while 54% (95% CI 53% to 56%) had at least one non-fatal major complication. The following baseline and intraoperative variables were independently associated with 30-day mortality after adjusting for multiple testing: age, American Society of Anesthesiologists (ASA) physical status, emergency case, surgical types, coma > 24 hr before surgery, systemic sepsis, preoperative international normalized ratio of prothrombin time, the number of intraoperative transfusions, and requirement of postoperative transfusion.
  
  
  CONCLUSIONS
  Massive transfusion is associated with substantial risk for respiratory and infectious complications and for mortality. Patients who died within 30 days of a massive perioperative transfusion were generally older, more likely to have vascular surgical procedure and abnormal international normalized ratio of prothrombin time, higher ASA physical status, preoperative coma and sepsis, and higher postoperative bleeding requiring transfusion, and they were likely given more intraoperative red cell units.
authors.affiliation: Department of Outcomes Research, Cleveland Clinic, 9500 Euclid Avenue, P-77, Cleveland, OH 44195, USA. alparslanturan@yahoo.com
authors.forename: Alparslan
authors.initials: A
authors.lastname: Turan
authors.forename: Dongsheng
authors.initials: D
authors.lastname: Yang
authors.forename: Angela
authors.initials: A
authors.lastname: Bonilla
authors.forename: Ayako
authors.initials: A
authors.lastname: Shiba
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
authors.forename: Leif
authors.initials: L
authors.lastname: Saager
authors.forename: Andrea
authors.initials: A
authors.lastname: Kurz
mesh_terms: D000367:Age Factors; D000368:Aged; D001778:Blood Coagulation Disorders / Q000453:epidemiology / Q000401:mortality; D001803:Blood Transfusion / Q000401:mortality; D015331:Cohort Studies; D003128:Coma / Q000453:epidemiology / Q000401:mortality; D004630:Emergencies / Q000453:epidemiology; D017707:Erythrocyte Transfusion / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006305:Health Status Indicators; D006333:Heart Failure / Q000453:epidemiology / Q000401:mortality; D006801:Humans; D019934:International Normalized Ratio; D007430:Intraoperative Care / Q000706:statistics & numerical data; D007431:Intraoperative Complications / Q000453:epidemiology / Q000401:mortality; D008297:Male; D009203:Myocardial Infarction / Q000453:epidemiology / Q000401:mortality; D061646:Operative Time; D011182:Postoperative Care / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology / Q000401:mortality; D019106:Postoperative Hemorrhage / Q000453:epidemiology / Q000401:mortality; D006435:Renal Dialysis / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000453:epidemiology / Q000401:mortality; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000401:mortality; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000401:mortality; D065227:Transfusion Reaction; D014481:United States / Q000453:epidemiology; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality