title: Preoperative Anemia and Postoperative Outcomes in Immediate Breast Reconstructive Surgery: A Critical Analysis of 10,958 Patients from the ACS-NSQIP Database.
abstract: BACKGROUND
  Preoperative anemia is independently associated with adverse outcomes after general and cardiac surgery. Outcomes after breast reconstruction are not established. We assessed the effect of preoperative anemia on 30-day postoperative morbidity and length of hospital stay (LOS) in patients undergoing immediate breast reconstruction.
  
  
  METHODS
  We identified patients undergoing immediate breast reconstruction from 2008 to 2010 from the American College of Surgeons' National Surgical Quality Improvement Program database (a prospective outcomes-based registry from hospitals worldwide). De-identified data were obtained for demographics, preoperative risk factors, 30-day morbidity, and LOS. Morbidity variables included flap/graft/prosthesis, cardiac, respiratory, neurological, urinary, wound, and venous thromboembolism outcomes. Logistic regression assessed the crude and adjusted effect of anemia (hematocrit <36%) on postoperative 30-day morbidity. Measures of central tendency of LOS were compared across increasing severities of anemia in patients developing adverse events versus controls.
  
  
  RESULTS
  The study population included 10,958 patients; 1556 (16.74%) had preoperative anemia. Crude odds ratio for 30-day morbidity was significantly higher in anemic patients, unadjusted odds ratio = 1.33 (P < 0.008). This prevailed after extensive adjustment for confounding, yielding an adjusted odds ratio = 1.38 (P < 0.03). Patients who experienced adverse effects had protracted LOS, and the presence of anemia significantly amplified this effect.
  
  
  CONCLUSIONS
  These data provide new insight into the effect of anemia in immediate breast reconstruction, demonstrating an independent association between preoperative anemia and 30-day morbidity. These findings suggest treating anemia when possible; however, prospective studies should explore the efficacy, safety, and cost-effectiveness of such treatments.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md.
authors.forename: Karim A
authors.initials: KA
authors.lastname: Sarhane
authors.affiliation: Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md.
authors.forename: José M
authors.initials: JM
authors.lastname: Flores
authors.affiliation: Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md.
authors.forename: Carisa M
authors.initials: CM
authors.lastname: Cooney
authors.affiliation: Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md.
authors.forename: Francis M
authors.initials: FM
authors.lastname: Abreu
authors.affiliation: Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Lacayo
authors.affiliation: Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md.
authors.forename: Pablo A
authors.initials: PA
authors.lastname: Baltodano
authors.affiliation: Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md.
authors.forename: Zuhaib
authors.initials: Z
authors.lastname: Ibrahim
authors.affiliation: Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Alrakan
authors.affiliation: Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md.
authors.forename: Gerald
authors.initials: G
authors.lastname: Brandacher
authors.affiliation: Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md.
authors.forename: Gedge D
authors.initials: GD
authors.lastname: Rosson