Red Blood Cell Transfusions Following Resection of Skull Base Meningiomas: Risk Factors and Clinical Outcomes

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1 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 DISCLOSURES None STATUS: Submitted to WORLD NEUROSURGERY

3 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).

METHODS Study 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

7 METHODS Study 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

9 TABLE 1. Univariate analyses Transfusion No transfusion p Value No. of Pts n = 7 n = 30 Age, yrs Postoperative hemoglobin, g/dl Meningioma size, cm <.001 Operative time, hrs Length of stay, days <.001 Non-routine discharge, n (%) 5 (71.43) 3 (10) <.001 WHO, World Health Organization

10 TRANSFUSION PARAMETERS Days: days Units: U Size (R = 0.60, P =.16) Vol (R = 0.64, P =.13) Volume: ml Size (R = 0.63, P =.13) Vol (R = 0.68, P =.09) No adverse transfusion reactions No intraop or in-hospital deaths

11 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, ] Operative time > 10 hours [2.32, ] TRANSFUSION Increased risk of prolonged LOS (over 14 days) OR [3.20, ] Increased risk of non-routine discharge OR [1.37, 92.72]

12 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 Yes PT IV I Other SNF 65/F SW No PT IV II Seizure SNF 65/F PS Yes FR IV I Stroke Home 58/F SW/PC Yes FT II I None 7.58 ARU 60/F SW No FT IV II None SNF 75/F PS/OG No FR III I Seizure SNF 74/F SW Yes PT IV I None 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 Focus on SBM Open craniotomy only Small sample size Prospective studies, RCTs comparing restrictive versus liberal transfusion strategies Include all tumor types Case-control study (open craniotomy versus endoscopic) Large database studies (eg, NIS, MarketScan)

13 SUMMARY Transfusion 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

Chung, BS Yasmine Alkhalid, BS Natalie E. Barnette, BS Joel S. Beckett, MD Thien P.

14 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

15 THANK YOU!

16 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

17 SUMMARY Study 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: vs days (p = 0.20) In-hospital death: OR 0.93, 95% CI: In-hospital complication: OR 1.13, 95% CI: Discharge disposition: OR 2.40, 95% CI: Conclusion: No clinical variance between transfusion thresholds

18 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

38%) NOT transfused w/ PLT (n = 92, 87.62%) Risk Factors (P <.05): Prior antiplatelet therapy (OR 8.

19 SUMMARY Study 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)

Transfusion & Mortality. Philippe Van der Linden MD, PhD

Transfusion & Mortality. Philippe Van der Linden MD, PhD Transfusion & Mortality Philippe Van der Linden MD, PhD Conflict of Interest Disclosure In the past 5 years, I have received honoraria or travel support for consulting or lecturing from the following companies: