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

THANK YOU!

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)