Preoperative blood transfusion is an independent risk factor for postoperative infection, readmission, and mortality following surgery for femoral shaft fractures

Background: Femoral shaft fractures (FSFs) are often associated with significant blood loss, frequently necessitating preoperative blood transfusion, which may increase the risk of complications. This study evaluated the relationship between preoperative transfusion and postoperative outcomes, including infection, readmission, reoperation, hemodynamic complications, and mortality in patients undergoing surgical fixation for FSF. Methods: A retrospective cohort analysis was conducted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012 to 2021. Adult patients (≥18 years) who underwent surgical fixation for FSF were included. The primary exposure was transfusion of ≥1 unit of whole or packed red blood cells within 72 h before surgery. Patients were grouped by transfusion status. Demographic, clinical, and procedural variables were compared using chi-square tests, and multivariable regression adjusted for potential confounders. Primary outcomes were 30-day postoperative infection, hospital readmission, reoperation, hemodynamic complications, and mortality. Results: Of 6812 patients identified, 373 (5.5 %) received a preoperative transfusion. Most patients were 80–89 years, White, female, non-Hispanic, ASA 3, with normal BMI, independent functional status, hypertension, low hematocrit, normal WBC, and non-emergent cases. Most were nonsmokers and without major comorbidities (COPD, CHF, cancer, diabetes, immunosuppression, bleeding disorders, or weight loss) [Table 1]. After adjustment, preoperative transfusion was independently associated with increased odds of postoperative infection (OR 1.67, 95 % CI 1.12–2.42, p = 0.009), hospital readmission (OR 1.49, 95 % CI 1.03–2.13, p = 0.031), and mortality (OR 1.73, 95 % CI 1.15–2.55, p = 0.007). No significant associations were found for reoperation (p = 0.207) or hemodynamic complications (p = 0.57) [Table 4]. Conclusions: Preoperative blood transfusion in patients undergoing surgical fixation for femoral shaft fractures is associated with higher risks of infection, readmission, and mortality. No significant differences were observed for hemodynamic complications or reoperation. These findings can help guide surgeons as they balance optimal hemoglobin levels preoperatively with risks of postoperative complications associated with transfusion. Level of evidence: Level III.