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Transfusions in Autologous Breast Reconstructions: An Analysis of Risk Factors, Complications, and Cost

Fischer, John P. MD; Nelson, Jonas A. MD; Sieber, Brady BA; Stransky, Carrie MD; Kovach, Stephen J. MD; Serletti, Joseph M. MD; Wu, Liza C. MD

doi: 10.1097/SAP.0b013e318268a803

Purpose Free tissue transfer requires lengthy operative times and can be associated with significant blood loss. The goal of our study was to determine independent risk factors for blood transfusions and transfusion-related complications and costs.

Methods We reviewed our prospectively maintained free flap database and identified all patients undergoing breast reconstruction receiving blood transfusions. These patients were compared with those not receiving a postoperative transfusion. We examined baseline patient comorbidities, preoperative and postoperative hemoglobin (HgB) levels, intraoperative and postoperative complications, and blood transfusions. Factors associated with transfusion were identified using univariate analyses, and multivariate logistic regression was used to determine independently associated factors.

Results A total of 70 (8.2%) patients received postoperative blood transfusions. Multivariate analysis revealed associations between length of surgery (P = 0.01), intraoperative arterial thrombosis [odds ratio (OR), 6.75; P = 0.01], major surgical complications (OR, 25.9; P < 0.001), medical complications (OR, 7.2; P = 0.002), and postoperative HgB levels (OR, 0.2; P < 0.001). Transfusions were independently associated with higher rates of medical complications (OR, 2.7; P = 0.03). A significantly lower rate of medical complications was observed when a restrictive transfusion (HgB level, <7 g/dL) was administered (P = 0.04). A cost analysis demonstrated that each blood transfusion was independently associated with an added $1,500 in total cost.

Conclusions Several key perioperative factors are associated with allogenic transfusion, including intraoperative complications, operative time, HgB level, and postoperative medical and surgical complications. Blood transfusions were independently associated with greater morbidity and added hospital costs. Overall, a restrictive transfusion strategy (HgB level, <7 g/dL or clinically symptomatic) may help minimize medical complications.

Level of Evidence Prognostic/risk category, level III.

From the Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.

Received May 25, 2012, and accepted for publication, after revision, July 8, 2012.

Presented at the 58th Robert H. Ivy Society Meeting in Philadelphia, PA, March 10, 2012; and the 91st American Association of Plastic Surgeons, San Francisco, CA, April 16, 2012.

Conflicts of interest and sources of funding: none declared.

Reprints: John P. Fischer, MD, Division of Plastic Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. E-mail:

© 2014 by Lippincott Williams & Wilkins