Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines

Correlation of the severity of anemia in patients undergoing total joint arthroplasty with preoperative deep vein thrombosis: a retrospective cohort study

BACKGROUND

To explore the correlation of the severity of preoperative anemia with deep vein thrombosis (DVT) in patients undergoing total joint arthroplasty (TJA).

METHODS

A total of 2461 TJA patients were classified into anemia and non-anemia groups or DVT and non-DVT groups. A logistic regression model was established using propensity score matching (PSM) analysis with preoperative anemia of TJA patients as a dependent variable and DVT-related variables as covariates. The caliper value was set as 0.01, and the anemia and non-anemia groups were matched based on the ratio of 1:1 (835 pairs). Finally, data of all patients were analyzed by binary logistic regression.

RESULTS

Preoperative anemia was observed in 872 cases (35.43%) and DVT in 170 cases (6.91%). Binary logistic regression after PSM revealed that the DVT risk of patients with preoperative, moderate and severe anemia increased by 1.82 [P = 0.00, 95% confidence interval (95% CI) (1.32-2.48)], 2.77 [P = 0.00, 95% CI (1.72-4.45)], and 8.26 [P = 0.00, 95% CI (3.22-21.16)] times, respectively. The risks of blood transfusion in the perioperative period in patients with anemia, mild anemia, moderate anemia, and severe anemia increased by 3.52 times [P = 0.00, 95% CI (2.78-4.47)], 2.13 [P = 0.00, 95% CI (1.63-2.79)], 7.22 [P = 0.00, 95% CI (5.30-9.83)], and 61.37 [P = 0.00, 95% CI (14.21-265.04)] times, respectively.

CONCLUSION

Preoperative anemia is an independent risk factor for preoperative DVT and blood transfusion in the perioperative period for TJA patients. The more severe the preoperative anemia, the greater the risk of preoperative DVT and perioperative blood transfusion in TJA patients. Therefore, patients with preoperative anemia, especially with moderate and severe anemia, should be screened for DVT formation before undergoing TJA. Trial registration ChiCRT2100054844.

Low-dose CT from myocardial perfusion SPECT/CT allows the detection of anemia in preoperative patients

BACKGROUND

To assess whether low-dose CT for attenuation correction of myocardial perfusion single-photon emission computed tomography (SPECT) allows for identification of anemic patients and grading anemia severity.

METHODS AND RESULTS

Patients who underwent a preoperative blood-test and low-dose CT scan, as a part of a cardiac SPECT exam, between 01 January 2015 and 31 December 2017 were enrolled in this retrospective study. Hemoglobin (Hb) levels and hematocrit were derived from clinical records. CT images were visually assessed (qualitative analysis) for the detection of inter-ventricular septum sign (IVSS) and aortic rim sign (ARS) and quantitative analysis were performed. The diagnostic accuracy for detecting anemia was compared using Hb values as the standard of reference. A total of 229 patients were included (110 with anemia; 57 mild; 46 moderate; 7 severe). The AUC of IVSS and ARS were 0.830 and 0.669, respectively (p<0.0001). The quantitative analysis outperformed ARS and IVSS; (AUC of 0.893, p=0.29). The optimal anemia cut-off using Youden index was 4.5 HU.

CONCLUSION

Quantitative analysis derived from low-dose CT images, as a part of cardiac SPECT exams, have a diagnostic accuracy similar to that of hematocrit for the detection of anemia and may allow discriminating different anemia severities.

Current Practices and Guidelines for Perioperative Blood Management in Post-Bariatric Body Contouring Surgery: A Comprehensive Review of Literature

With the increase in obesity prevalence, a noticeable increase in bariatric surgeries has been reported in national and international statistics. Therefore, body contouring surgeries have increased to help individuals achieve their desired body shape. Plastic surgeons need to consider potential hematologic complications that may occur in this specific group of patients before performing body contouring surgery. This review illustrates the perioperative medical, laboratory, and management strategies needed to minimize blood loss and blood transfusion requirements during body contouring. Using Google Scholar and PubMed, a comprehensive literature review was conducted to identify articles discussing post-bariatric body contouring perioperative blood management strategies, including the effects of bariatric surgery on hemostasis as well as basic hematology and coagulation. In preoperative blood management, blood investigations aid in the early detection of electrolytes, protein, and vitamin deficiencies and anemia, resulting in the early correction of nutritional deficiencies. In order to reduce postoperative complications, surgical and anesthesia techniques, as well as intraoperative pharmacological therapy, play an essential role. Postoperative blood transfusion and restrictive transfusion thresholds are tailored to the patient's needs and depend on various physiological indicators, such as heart rate, blood pressure, urine output, and laboratory findings, such as acidosis and hematocrit level. Generally, post-bariatric body contouring blood management measures are still lacking, and more research is required to develop standardized guidelines for optimizing patient safety and satisfaction.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Anemia and Sickle Cell Disease Disparities

Anemia and sickle cell anemia before surgery are often unrecognized medical comorbidities that can and should be addressed. Nearly 6% of the American population meets the criteria for anemia. The elderly, along with patients with renal disease, cancer, heart failure, or diabetes mellitus are more likely to be anemic. The most common form of anemia is due to iron deficiency, which can be easily treated before surgery. Sickle cell anemia occurs in 1 in 365 Black births and 1 in 16,300 Hispanic births, with 100,000 Americans currently living with sickle cell anemia. Patients who have anemia or sickle cell anemia are at increased risk for postoperative complications, including the need for blood transfusions and delayed healing. For those with sickle cell disease, surgeries can precipitate a sickle cell crisis. Patients with sickle cell anemia face barriers in accessing appropriate care; however, these patients can be optimized using preoperative red blood cell transfusions to dilute sickle cells and elevate the hemoglobin level. There should also be careful consideration and monitoring of the pain level of patients with sickle cell anemia in the perioperative period.

Lung resection surgery in Jehovah's Witness patients: a 20-year single-center experience

Background

The paucity of literature on surgical outcomes of Jehovah’s Witness (JW) patients undergoing lung resection suggests some patients with operable lung cancers may be denied resection. The aim of this study is to better understand perioperative outcomes and long-term cancer survival of JW patients undergoing lung resection.

Methods

All pulmonary resections in JW patients at one institution from 2000 through 2020 were examined. Demographics, comorbidities, operative parameters, and perioperative outcomes were reviewed. Among operations performed for primary non-small cell lung cancer (NSCLC), details regarding staging, extent of resection, additional therapies, recurrence, and survival were abstracted.

Results

Seventeen lung resections were performed in fourteen patients. There were nine anatomic resections and eight wedge resections. Fourteen resections (82%) were approached thoracoscopically, of which 3 of 6 anatomic resections were converted to thoracotomy as compared to 1 of 8 wedge resections. There was one (6%) perioperative death. Ten resections in 8 patients were performed for primary pulmonary malignancies, and two patients underwent procedures for recurrent disease. Median survival for resected NSCLCs (N = 7) was 65 months. Three of 6 patients who survived the immediate perioperative period underwent additional procedures: 2 pulmonary wedge resections for diagnosis and one pleural biopsy.

Conclusions

This series of JW patients undergoing lung resections demonstrates that resections for cancer and inflammatory etiologies can be performed safely in the setting of both primary and re-operative procedures.

Adverse events of iron and/or erythropoiesis-stimulating agent therapy in preoperatively anemic elective surgery patients: a systematic review

BACKGROUND

Iron supplementation and erythropoiesis-stimulating agent (ESA) administration represent the hallmark therapies in preoperative anemia treatment, as reflected in a set of evidence-based treatment recommendations made during the 2018 International Consensus Conference on Patient Blood Management. However, little is known about the safety of these therapies. This systematic review investigated the occurrence of adverse events (AEs) during or after treatment with iron and/or ESAs.

METHODS

Five databases (The Cochrane Library, MEDLINE, Embase, Transfusion Evidence Library, Web of Science) and two trial registries (ClinicalTrials.gov, WHO ICTRP) were searched until 23 May 2022. Randomized controlled trials (RCTs), cohort, and case-control studies investigating any AE during or after iron and/or ESA administration in adult elective surgery patients with preoperative anemia were eligible for inclusion and judged using the Cochrane Risk of Bias tools. The GRADE approach was used to assess the overall certainty of evidence.

RESULTS

Data from 26 RCTs and 16 cohort studies involving a total of 6062 patients were extracted, on 6 treatment comparisons: (1) intravenous (IV) versus oral iron, (2) IV iron versus usual care/no iron, (3) IV ferric carboxymaltose versus IV iron sucrose, (4) ESA+iron versus control (placebo and/or iron, no treatment), (5) ESA+IV iron versus ESA+oral iron, and (6) ESA+IV iron versus ESA+IV iron (different ESA dosing regimens). Most AE data concerned mortality/survival (n=24 studies), thromboembolic (n=22), infectious (n=20), cardiovascular (n=19) and gastrointestinal (n=14) AEs. Very low certainty evidence was assigned to all but one outcome category. This uncertainty results from both the low quantity and quality of AE data due to the high risk of bias caused by limitations in the study design, data collection, and reporting.

CONCLUSIONS

It remains unclear if ESA and/or iron therapy is associated with AEs in preoperatively anemic elective surgery patients. Future trial investigators should pay more attention to the systematic collection, measurement, documentation, and reporting of AE data.

Usefulness of Soluble Transferrin Receptor in the Diagnosis of Iron Deficiency Anemia in Rheumatoid Arthritis Patients in Clinical Practice

Aim. We analyzed the added value of sTfR measurement in routine clinical practice to standard parameters (SP) of iron deficiency in the detection of iron deficiency anemia (IDA) in patients with rheumatoid arthritis (RA). Methods. Blood samples from 116 patients with RA were analyzed in a prospective study. Based on biochemical parameters, patients were classified as having IDA, anemia of chronic disease (ACD), IDA with concomitant ACD (ACD/IDA), or “other anemia.” Sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of sTfR and SP of iron status alone and in combination were calculated for the diagnosis of IDA in general, i.e., IDA or ACD/IDA. Results. In the whole sample, with regard to the diagnosis of iron deficiency (IDA or ACD/IDA), sTfR had a higher sensitivity compared both to the combined use of SP and to the combination of SP with sTfR (80.9% versus 66.7/54.8%). Specificity, PPV and NPV did not differ substantially. When patients were stratified in groups with high (CRP levels above the median, i.e., 24.1 mg/l) and low (CRP levels less or equal to the median) inflammation, the diagnostic superiority of sTfR was restricted to patients with high inflammation. In this group, the diagnostic performance of sTfR was superior both to the combined use of SP and the combination of SP with sTfR with higher sensitivity (100% versus 52.4%) and NPV (100% versus 77.7/76.7%) and comparable specificity and PPV. Conclusion. For the detection of iron depletion (IDA or ACD/IDA) in anemic RA patients, sTfR is superior to SP of iron deficiency only in highly inflammatory states.

Interaction of basic diseases and low red blood cell count as critical murderer of wound infection after osteosarcoma resection: Wound infection after osteosarcoma resection

BACKGROUND

Surgical wound infection is one of the common complications in patients after osteosarcoma resection. It is imperative to grasp the risk factors comprehensively. Therefore, this study aimed to explore the risk factors of wound infection and deeply analyze the correlation between risk factors and wound infection.

METHODS

The study subjects were 101 patients who underwent osteosarcoma resection between April 2018 and August 2021. The diagnosis of postoperative wound infection was confirmed by postoperative observation of the incision, ultrasound imaging, and pathogenic examination. This study included a series of potential factors, mainly laboratory examination indicators and patients' general information. The statistical methods had Pearson Chi-square test, Spearman-rho correlation test, multifactorial linear regression model, logistic regression analysis, and receiver operating characteristic (ROC) curve.

RESULTS

Pearson Chi-square test and Spearman correlation test showed that red blood cell (RBC) count (P = .033) and basic diseases (P = .020) were significantly correlated with a surgical wound infection after osteosarcoma resection. Logistic regression analysis manifested that basic disease (OR = 0.121, 95% CI: 0.015-0.960, P = .046) and RBC (OR = 0.296, 95% CI: 0.093-0.944, P = .040) have a clear correlation with whether the patients have surgical wound infection after osteosarcoma resection. And the interaction of basic diseases and RBC could diagnose the surgical wound infection sensitively and accurately (AUC = 0.700, P = .014, 95% CI = 0.564-0.836) via the ROC analysis.

CONCLUSION

Patients with basic diseases and low RBC were risk factors for surgical wound infection after osteosarcoma resection.

Blood Conservation Techniques and Strategies in Orthopedic Anesthesia Practice

Orthopedic surgery procedures involving joint arthroplasty, complex spine, long bone and pelvis procedure, and trauma and oncological cases can be associated with a high risk of bleeding and need for blood transfusion, making efforts to optimize patient care and reduce blood loss very important. Patient blood management programs incorporate efforts to optimize preoperative anemia, develop transfusion protocols and restrictive hemoglobin triggers, advance surgical and anesthesia practice, and use antifibrinolytic therapies. Perioperative management of anticoagulant therapies, a multidisciplinary decision-making task, weighs in risks and benefits of thromboembolic risk and surgical bleeding and is patient- and surgery-specific.

Community Pharmacists’ Perceptions of Their Role in Provision of Anemia Management in Jazan Region, Saudi Arabia, and the Associated Barriers

Background: As a result of the lack of research exploring community pharmacists’ perspectives on anemia care, this study examined the perceived practices and barriers to anemia management services in Saudi Arabia. Methods: A questionnaire was administered to community pharmacists to validate pharmacist perceptions of their role in anemia care. Using an 11-item role test, pharmacists were asked about their perceptions of anemia management. Pharmacy anemia management barriers were explored using 20 items, and their perceptions of inter-professional contact were examined by two items. Data analyses were performed using SPSS version 22. Results: This research involved 324 community pharmacists, 62.3% of whom were males. There were significant differences between the location of pharmacy education and the perceived practice of anemia management. The most common barriers to anemia counseling were patients’ lack of knowledge about anemia, health beliefs, patients’ perceptions that their doctor takes care of them, and time constraints. The majority of respondents said they would like to have more contact with other healthcare professionals regarding the care of anemia patients. Conclusions: A positive perception of pharmacists’ role in anemia management is prevalent among Saudi pharmacists in the Jazan region. Anemia management is challenging due to time limitations and patient-related problems.

Preoperative Patient Optimization in Total Joint Arthroplasty-The Paradigm Shift from Preoperative Clearance: A Narrative Review

Background: Total joint arthroplasty (TJA) is one of the most common procedures performed in the United States. Outcomes of this elective procedure may be improved via preoperative optimization of modifiable risk factors. Purposes: We sought to summarize the literature on the clinical implications of preoperative risk factors in TJA and to develop recommendations regarding preoperative optimization of these risk factors. Methods: We searched PubMed in August 2019 with an update in September 2020 for English-language, peer-reviewed publications assessing the influence on outcomes in total hip and knee replacement of 7 preoperative risk factors-obesity, malnutrition, hypoalbuminemia, diabetes, anemia, smoking, and opioid use-and recommendations to mitigate them. Results: Sixty-nine studies were identified, including 3 randomized controlled trials, 8 prospective cohort studies, 42 retrospective studies, 6 systematic reviews, 3 narrative reviews, and 7 consensus guidelines. These studies described worse outcomes associated with these 7 risk factors, including increased rates of in-hospital complications, transfusions, periprosthetic joint infections, revisions, and deaths. Recommendations for strategies to screen and address these risk factors are provided. Conclusions: Risk factors can be optimized, with evidence suggesting the following thresholds prior to surgery: a body mass index <40 kg/m², serum albumin ≥3.5 g/dL, hemoglobin A1C ≤7.5%, hemoglobin >12.0 g/dL in women and >13.0 g/dL in men, and smoking cessation and ≥50% decrease in opioid use by 4 weeks prior to surgery. Surgery should be delayed until these risk factors are adequately optimized.

Perioperative anemia and its implications

Preoperative anemia is very common and is related to adverse clinical outcomes, including mortality. The immediate and most widely used treatment for postoperative anemia is blood transfusion. However, also blood transfusion carries some risks. Patient blood management (PBM) is defined as the timely application of evidence-based medical and surgical concepts designed to maintain a patient’s hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve the outcome. The aim of this narrative review is to describe in detail what is PBM and how it should be part of the Enhanced Recovery After Surgery (ERAS) protocols.

Analysis of the reasons why patients cancel shoulder surgery despite recommendation

Background

To determine the reasons and factors that contribute to the cancellations of shoulder surgeries at a tertiary referral center and to analyze the characteristics of these patients.

Methods

Patients scheduled for shoulder surgery from June 2017 to July 2019 were allocated to a surgery group (n=224) or a cancellation group (n=96). These groups were compared with respect to patient characteristics, types of surgery, distance from patient’s home to the hospital, traveling time to the hospital, and waiting period before surgery. Reasons for cancellation and responses were acquired using a telephone interview and were subsequently analyzed.

Results

The cancellation group was older, had a less frequent history of trauma, and had a lower proportion of patients undergoing arthroscopic rotator cuff repair than the surgery group (p=0.009, p=0.014, and p=0.017, respectively). In addition, mean distance from the patients’ homes to the hospital and preoperative waiting time were both longer in the cancellation group (p=0.001 and p<0.01, respectively). The most common reason given for cancellation was another medical condition (28.1%).

Conclusions

Older age, need for arthroscopic rotator cuff repair surgery, longer distance from the patient’s home to the hospital, and longer waiting period significantly increased the chance of cancellation. The main reason for canceling surgery was a concurrent medical condition. Therefore, identification of other medical conditions in advance is an important consideration when surgeons recommend shoulder surgery to patients. Surgeons should also consider patient's age, type of surgery, distance from the hospital, and waiting time when assessing the possibility of surgery cancellation.

Prevalence and factors associated with preoperative anemia among adult patients scheduled for major elective surgery at University hospital in Northwest Ethiopia; a cross-sectional study

BACKGROUND

Anemia is the most common hematological finding in surgical patients. One-third of surgical patients were anemic during preoperative assessment. The presence of preoperative anemia was found to be related with increased morbidity, mortality, length of hospital stay, intensive care unit admissions and postoperative infections.

OBJECTIVE

To determine the prevalence and factors associated with preoperative anemia among adult patients scheduled for major elective surgery at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2020.

METHODS

After obtaining an ethical approval, hospital-based cross-sectional quantitative study was conducted from June to August 2020 in University of Gondar Hospital. Full blood count within two weeks of preoperative period was considered valid if there were no any factors that affect the hematologic system Descriptive statistics, cross-tabulations and binary logistic regression analysis were performed to identify factors associated withpreoperative anemia. The strength of the association was presented using AOR with 95% confidence interval and p-value < 0.05 was considered as statistically significant.

RESULT

A total of 185 patients enrolled with 100% response rate. We observed preoperative anemia in 36.8% patients. The multi-variable binary logistic analysis showed that ASA II and III [AOR: 3.8, CI: 1.6-9.2], recent prior surgery [AOR: 3.3, CI: 1.3-8.5], history of malignancy [AOR: 9.4, CI: 2.0-43.4], orthopedic procedure [AOR: 11.2, CI: 4.0-31.6] and gynecologic procedure [AOR: 5.2, CI: 1.7-14.5] were significantly associated with preoperative anemia.

CONCLUSION

The prevalence of preoperative anemia was high and ASA ≥2, recent prior surgery, history of malignancy, orthopedic surgery and gynecologic procedure were significantly associated with preoperative anemia. We recommend to clinicians to aim prevention, early detection and treatment of preoperative anemia among adult patients scheduled for major elective surgery to reduce risk of anemia and related adverse outcomes.

Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

Optimization of Preoperative Anemia in Lower Limb Joint Replacement Surgery: Assessing the Rates of Allogenic Blood Transfusion and Duration of Hospital Stay

BACKGROUND

Orthopaedic procedures such as total hip and total knee replacements carry a significant risk of postoperative anemia, necessitating allogenic blood transfusions (ABTs), and an increased hospital length of stay.

AIM

Our aim was to investigate whether the implementation of a local protocol designed to detect and treat preoperative anemia resulted in reduced ABT rates and a shorter duration of length of hospital stay (LOS).

METHODS

We retrospectively audited 683 patients undergoing primary hip and knee replacements. We collated data for all patients about hospital length of stay and blood transfusions received. Both descriptive statistics and univariate analysis were performed.

RESULTS

Approximately 21.6% of the cohort within the study who were anemic at preoperative clinic had a significantly increased median LOS of 2 days (p < .001) and an increased packed red cell transfusion rate compared with non-anemic patients (26.1% vs. 2.21%, p < 001). However, treatment of preoperative anemia did not show any significant difference in transfusion rates compared with patients who did not receive corrective treatment. The median LOS was higher by 1 day in the treated group compared with the nontreated cohort (p = .005).

CONCLUSION

There is significant evidence to suggest that preoperative anemia can increase LOS and increase the risk of requiring postoperative blood transfusions. However, anemia should be regarded as a characteristic that can add to the outcome in a cumulative manner, as opposed to an isolated factor. Further research is needed on how to better manage preoperative anemia in order to improve patients' outcomes.

Intraoperative transfusion practices and perioperative outcome in the European elderly: A secondary analysis of the observational ETPOS study

The demographic development suggests a dramatic growth in the number of elderly patients undergoing surgery in Europe. Most red blood cell transfusions (RBCT) are administered to older people, but little is known about perioperative transfusion practices in this population. In this secondary analysis of the prospective observational multicentre European Transfusion Practice and Outcome Study (ETPOS), we specifically evaluated intraoperative transfusion practices and the related outcomes of 3149 patients aged 65 years and older. Enrolled patients underwent elective surgery in 123 European hospitals, received at least one RBCT intraoperatively and were followed up for 30 days maximum. The mean haemoglobin value at the beginning of surgery was 108 (21) g/l, 84 (15) g/l before transfusion and 101 (16) g/l at the end of surgery. A median of 2 [1-2] units of RBCT were administered. Mostly, more than one transfusion trigger was present, with physiological triggers being preeminent. We revealed a descriptive association between each intraoperatively administered RBCT and mortality and discharge respectively, within the first 10 postoperative days but not thereafter. In our unadjusted model the hazard ratio (HR) for mortality was 1.11 (95% CI: 1.08-1.15) and the HR for discharge was 0.78 (95% CI: 0.74-0.83). After adjustment for several variables, such as age, preoperative haemoglobin and blood loss, the HR for mortality was 1.10 (95% CI: 1.05-1.15) and HR for discharge was 0.82 (95% CI: 0.78-0.87). Pre-operative anaemia in European elderly surgical patients is undertreated. Various triggers seem to support the decision for RBCT. A closer monitoring of elderly patients receiving intraoperative RBCT for the first 10 postoperative days might be justifiable. Further research on the causal relationship between RBCT and outcomes and on optimal transfusion strategies in the elderly population is warranted. A thorough analysis of different time periods within the first 30 postoperative days is recommended.

High-dose intravenous iron supplementation after preoperative autologous blood donation is useful to prevent post-donation/preoperative anemia

To estimate the effectiveness of high-dose intravenous (IV) iron supplementation for iron deficiency anemia after preoperative autologous blood donation (PAD), 155 donors who visited the donation office of the University of Tokyo Hospital from December 2020 to June 2021 and showed suspected post-donation anemia were analyzed. The participants were treated with high-dose intravenous (IV) iron supplementation (high-dose group, n = 30) or a combination of low-dose IV iron and oral iron supplementation (low-dose group, n = 125). The preoperative hemoglobin (Hb) and Hb decreasing ratios during PAD (ΔHb) were compared between the two groups. Multivariate linear regression analyses were also performed to identify the confounding factors associated with preoperative Hb and ΔHb as well as high-dose IV iron supplementation. Preoperative Hb level was slightly higher in the high-dose group than in the low-dose group (12.1 ± 1.1 vs. 11.9 ± 1.1 g/dL, p = 0.27). ΔHb was significantly higher in the high-dose group than in the low-dose group (3.7 % ± 8.8 % vs. 7.7 % ± 6.5 %, p = 0.011). On the multivariate linear regression analyses, high-dose IV iron supplementation was significantly associated with higher preoperative Hb and lower ΔHb levels (p = 0.021 and 0.017, respectively) as well as the donation available period (period from the first visit to the donation office to the operation) and administration of erythropoiesis-stimulating agents. High-dose IV iron supplementation after PAD will be useful in the treatment of post-donation anemia.

Peripheral arterial disease and anaemia. A review

Iron deficiency anaemia is highly prevalent worldwide. In the surgical patient, anaemia of any cause implies higher morbidity and mortality in the post-operative period. This is especially important in patients with peripheral artery disease, as they have very high rates of anaemia due to iron deficiency or other causes. In intermittent claudication, anaemia is a predictor of death in the medium term. Patients with critical ischaemia have higher prevalence of anaemia and it is an indicator of amputation and death in the medium term. Specific protocols need to be developed for these patients since the natural history of their disease does not allow for the correction of anaemia before surgery.

Preoperative risk factors for postoperative pneumonia following primary Total Hip and Knee Arthroplasty

BACKGROUND

The purpose of this study is to evaluate risk factors for pneumonia following THA and TKA.

METHODS

Patients were identified from the American College of Surgeons National Quality Improvement Database (NSQIP) who experienced postoperative pneumonia after undergoing primary THA and TKA.

RESULTS

Many characteristics including old age, anemia, diabetes, cardiac comorbidities, dialysis, and smoking were independent risk factors for postoperative pneumonia after THA or TKA.

CONCLUSION

This analysis offers new evidence on risk factors associated with the development of pneumonia after THA and TKA. These risk factors can help guide clinicians in preventing postoperative pneumonia after THA and TKA.

The Reticulocyte Hemoglobin Equivalent as a Screening Marker for Iron Deficiency and Iron Deficiency Anemia in Children

Background: Iron deficiency (ID) is one of the most common nutritional deficiencies in children worldwide and may result in iron deficiency anemia (IDA). The reticulocyte hemoglobin equivalent (Ret-He) provides information about the current availability of iron in erythropoiesis. This study aims to examine the validation of Ret-He as a screening marker for ID and IDA in children. Methods: Blood samples were retrospectively obtained from medical records. Anemia was defined according to the definition provided by the World Health Organization (WHO) for children. ID was defined by transferrin saturation (TSAT) < 20% and ferritin < 100 ng/mL. Children were classified into four groups: IDA, non-anemia iron deficiency (NAID), control and others. Results: Out of 970 children, 332 (34.2%) had NAID and 278 (28.7%) presented with IDA. Analysis revealed that Ret-He significantly correlates with ferritin (rho = 0.41; p < 0.001), TSAT (rho = 0.66; p < 0.001) and soluble transferrin receptor (sTfR) (rho = −0.72; p < 0.001). For ROC analysis, the area under the curve (AUC) was 0.771 for Ret-He detecting ID and 0.845 for detecting IDA. The cut-off value for Ret-He to diagnose ID was 33.5 pg (sensitivity 90.7%; specificity 35.8%) and 31.6 pg (sensitivity 90.6%; specificity 50.4%) to diagnose IDA. Conclusions: The present study demonstrates Ret-He to be a screening marker for ID and IDA in children. Furthermore, Ret-He can be used as a single screening parameter for ID and IDA in children without considering other iron parameters. Economically, the use of Ret-He is highly relevant, as it can save one blood tube per patient and additional costs.

Early mobilization after total hip or knee arthroplasty: a substudy of the POWER.2 study

BACKGROUND

Early mobilization after surgery is a cornerstone of the Enhanced Recovery After Surgery (ERAS) programs in total hip arthroplasty (THA) or total knee arthroplasty (TKA). Our goal was to determine the time to mobilization after this surgery and the factors associated with early mobilization.

METHODS

This was a predefined substudy of the POWER.2 study, a prospective cohort study conducted in patients undergoing THA and TKA at 131 Spanish hospitals. The primary outcome was the time until mobilization after surgery as well as determining those perioperative factors associated with early mobilization after surgery.

RESULTS

A total of 6093 patients were included. The median time to achieve mobilization after the end of the surgery was 24.áhours [16.Çô30]. 4,222 (69.3%) patients moved in .ëñ 24.áhours after surgery. Local anesthesia [OR.á=.á0.80 (95% confidence interval [CI]: 0.72.Çô0.90); p.á=.á0.001], surgery performed in a self-declared ERAS center [OR = 0.57 (95% CI: 0.55.Çô0.60); p.á<.á0.001], mean adherence to ERAS items [OR.á=.á0.93 (95% CI: 0.92.Çô0.93); p.á<.á0.001], and preoperative hemoglobin [OR.á=.á0.97 (95% CI: 0.96.Çô0.98); p.á<.á0.001] were associated with shorter time to mobilization.

CONCLUSIONS

Most THA and TKA patients mobilize in the first postoperative day, early time to mobilization was associated with the compliance with ERAS protocols, preoperative hemoglobin, and local anesthesia, and with the absence of a urinary catheter, surgical drains, epidural analgesia, and postoperative complications. The perioperative elements that are associated with early mobilization are mostly modifiable, so there is room for improvement.

Preoperative Platelet and International Normalized Ratio Thresholds and Risk of Complications After Primary Hip Fracture Surgery

BACKGROUND

A paucity of data exists on safe platelet and international normalized ratio (INR) thresholds for hip fracture surgery. Recent work has called into question the safety of preoperative INRs < 1.5 for total knee arthroplasty, and optimal platelet thresholds are unknown. The purpose of this study was to identify the risk of 30-day postoperative morbidity and mortality in patients with thrombocytopenia or elevated INRs undergoing hip fracture surgery.

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing surgical treatment of a native hip fracture from 2012 to 2017 (N = 86,850). Patient demographic, laboratory, and complication data were collected. Patients with preoperative platelet counts or INRs within one day of surgery were included for analysis. Preoperative platelet counts and INRs were divided into four groups (<50 k/μL, ≥50 k to 100 k/μL, ≥100 k to 150 k/μL, ≥150 k/μL, and ≤1.0, >1.0 to 1.5, >1.5 to 2.0, and >2.0, respectively). Multivariable logistic regressions were used to assess the independent association between platelet count and INR on bleeding complications requiring transfusion, wound complications, reoperations, readmissions, and deaths.

RESULTS

A total of 72,306 and 56,027 patients were included for analysis of preoperative platelet and INR levels, respectively. In reference to platelet levels ≥150 k/μL, a notably increased risk of bleeding events was observed for patients with platelet counts ≥100 k to 150 k/μL (odds ratio [OR] 1.21, 95% confidence interval 1.15 to 1.27), ≥50 to 100 k/μL (OR 1.85, 1.69 to 2.03), and <50 k/μL (OR 1.60, 1.25 to 2.04). Decreasing platelet counts were associated with a stepwise increased risk of mortality from OR 1.12 (1.02 to 1.22) for platelet counts ≥100 k to 150 k/μL to OR 1.63 (1.41 to 1.90) and OR 1.59 (1.06 to 2.39) for platelet counts ≥50 k to 100 k/μL and <50 k/μL, respectively. Elevated INR was associated with an increased risk of reoperations, readmissions, and death (P < 0.001 for all), with largest effect sizes observed starting at INRs >1.5.

DISCUSSION

The results of this study suggest that preoperative platelet thresholds of <100,000/μL and INR thresholds of 1.5 serve as an important risk factor for complications after hip fracture surgery. Future work is warranted to determine whether preoperative platelet transfusions and/or INR reversal will improve outcomes for these patients.

LEVEL OF EVIDENCE

Prognostic Level III.

Attitude changes in prescribing intravenous iron supplementation in different settings at a hospital consortium in Italy

BACKGROUND

Iron deficiency anaemia is a public health problem. In case oral iron treatment is ineffective, poorly tolerated or contraindicated, the intravenous route becomes the first choice. The aim of the study was to evaluate the shift between ferrous gluconate (FG) and ferric carboxymaltose (FCM) usage at our hospitals over the years. We also performed a cost comparison between pre and post-FCM availability periods, taking into account the acquisition costs of both intravenous iron and red blood cell units (PRBC).

STUDY DESIGN AND METHODS

The amount and costs of FG and FCM released by hospital Pharmacy Services from 2010 to 2019 were analysed, along with the number of transfused PRBC units in the same timeframe.

RESULTS

Overall, the proportion of FCM usage rose from 8.6 % in 2014 to 71.9 % in 2019, as percentage of total intravenous iron released. After exclusion of haemodialysis, where FG is still widely used, the FCM use in the last four years raised from 12.9% to 92.5%. Despite the higher FCM cost, the mean yearly expenditure for intravenous iron plus PRBC units did not differ between pre- and post-FCM eras (2010-2013, € 2,396,876 € versus 2014-2019, € 2,307,875 - p = 0.234), as a result of a net decrease of PRBC usage, namely from 15,083 to 12,654 (-16.1 %), respectively.

DISCUSSION

Intravenous iron has a major role in treating iron deficiency anaemia in several settings. Third generation compounds are paving the way to more updated and safer treatments.

Effectiveness of Iron Supplementation With or Without Erythropoiesis-Stimulating Agents on Red Blood Cell Utilization in Patients With Preoperative Anaemia Undergoing Elective Surgery: A Systematic Review and Meta-Analysis

Patient Blood Management (PBM) is an evidence-based, multidisciplinary, patient-centred approach to optimizing the care of patients who might need a blood transfusion. This systematic review aimed to collect the best available evidence on the effectiveness of preoperative iron supplementation with or without erythropoiesis-stimulating agents (ESAs) on red blood cell (RBC) utilization in all-cause anaemic patients scheduled for elective surgery. Five databases and two trial registries were screened. Primary outcomes were the number of patients and the number of RBC units transfused. Effect estimates were synthesized by conducting meta-analyses. GRADE (Grades of Recommendation, Assessment, Development and Evaluation) was used to assess the certainty of evidence. We identified 29 randomized controlled trials (RCTs) and 2 non-RCTs comparing the effectiveness of preoperative iron monotherapy, or iron + ESAs, to control (no treatment, usual care, placebo). We found that: (1) IV and/or oral iron monotherapy may not result in a reduced number of units transfused and IV iron may not reduce the number of patients transfused (low-certainty evidence); (2) uncertainty exists whether the administration route of iron therapy (IV vs oral) differentially affects RBC utilization (very low-certainty evidence); (3) IV ferric carboxymaltose monotherapy may not result in a different number of patients transfused compared to IV iron sucrose monotherapy (low-certainty evidence); (4) oral iron + ESAs probably results in a reduced number of patients transfused and number of units transfused (moderate-certainty evidence); (5) IV iron + ESAs may result in a reduced number of patients transfused (low-certainty evidence); (6) oral and/or IV iron + ESAs probably results in a reduced number of RBC units transfused in transfused patients (moderate-certainty evidence); (7) uncertainty exists about the effect of oral and/or IV iron + ESAs on the number of patients requiring transfusion of multiple units (very low-certainty evidence). Effect estimates of different haematological parameters and length of stay were synthesized as secondary outcomes. In conclusion, in patients with anaemia of any cause scheduled for elective surgery, the preoperative administration of iron monotherapy may not result in a reduced number of patients or units transfused (low-certainty evidence). Iron supplementation in addition to ESAs probably results in a reduced RBC utilization (moderate-certainty evidence).

How I treat anemia in the perisurgical setting

Anemia is a common finding in the perioperative setting with significant untoward consequences including worsening of outcomes and diminished quality of life as well as increased risk of allogeneic blood transfusions. Here, we present 3 cases that illustrate how anemia can be perioperatively managed in patients undergoing cardiac, orthopedic, and oncology surgeries. Timely detection of anemia prior to high-blood loss surgeries can allow clinicians to manage it and optimize hemoglobin level, making patients better prepared for the surgery. Treatment of anemia should be guided by the etiology and may include erythropoietic agents, folic acid, B12, and iron preparations. Other blood management strategies geared toward reducing surgical blood loss such as autologous transfusion techniques and agents to optimize hemostasis are used during surgery and in the immediate postoperative period. Patients should be closely monitored following surgery for signs of ongoing bleeding in need of control. Finally, screening for and management of anemia should continue in the postoperative and postdischarge period, as persistence and recurrence of anemia can further undermine patient's outcomes.

Anaemia and iron deficiency in patients with rheumatoid arthritis and other chronic diseases

Anaemia is one of the most common symptoms accompanying many chronic diseases, e.g. collagenases, neoplasms, and chronic inflammations (inflammatory bowel disease, chronic kidney disease and heart failure). Iron deficiency anaemia is the most common type of anaemia (80%). It affects 1% to 2% of the population. Iron deficiency (ID) – absolute or functional – is characterised by reduced ferritin levels and transferrin saturation (TSAT) of less than 20%. Iron deficiency is the most common dietary deficiency. However, iron deficiency might be one of the common causes of anaemia of chronic disease (ACD). Anaemia affects 33% to 60% of patients with RA. Rheumatoid arthritis (RA) is a chronic immune-mediated systemic connective tissue disease, in which chronic inflammation of the synovial tissue of the joints damages articular cartilages, bones and other joint structures. The prevalence of RA is approximately 0.3% to 2%. Low haemoglobin levels in RA patients are significantly correlated with disability, activity and duration of the disease as well as damage to joints and joint pain. Treatment of anaemia in RA patients includes iron supplementation, blood transfusions, the use of erythropoiesis-stimulating agents, and treatment of the underlying condition. Biological treatments used in RA patients, such as e.g. infliximab, tocilizumab and anakinra, not only slow the progression of joint involvement but also prevent anaemia.

Our experience of lung resection in patients who decline blood transfusion for religious reasons

Objective

Surgical treatment for patients who refuse blood transfusion due to religious beliefs is an important issue related to medical safety. Few reports have examined pulmonary surgery for these patients, and we analyzed clinical characteristics in such cases.

Methods

Ten Jehovah’s Witness (JW) patients with lung tumor resection who declined blood transfusion for religious reasons between December 2013 and February 2020 at the Fukushima Medical University Hospital were included. Median total intraoperative blood loss was 17.5 mL (range 5–150 mL). Fibrin glue was used intraoperatively for 8 patients. Final pathological examination revealed pulmonary adenocarcinoma in 9 cases and metastasis of bladder cancer in 1 case. In 8 patients with pulmonary adenocarcinoma examined for epidermal growth factor receptor (EGFR) gene mutation, 6 cases showed mutation. No patients had serious complications, but 1 patient displayed temporary anemia due to postoperative hemorrhagic gastrointestinal ulcer.

Result and conclusions

Our findings confirm that pulmonary resection is feasible and safe for JW patients if performed by experienced medical staff. However, awareness of complications associated with perioperative bleeding is important. Each JW patient should be interviewed individually and every available perioperative option aimed at blood-sparing management, including use of blood coagulation factors and fibrinogen concentrates, should be carefully discussed and clarified. In this study, the EGFR gene mutation rate was higher than usual for cases of lung adenocarcinoma. Further studies are necessary to assess clinical features in JW patients with lung cancer.

Perioperative and Anesthetic Considerations for Patients with Degenerative Spine Disease

The demand for spine surgery has dramatically increased over the last 2 decades. As the population ages and surgical and anesthetic techniques advance, the perioperative care of spine surgery patients poses challenges to anesthesiologists. Perioperative outcomes in terms of a decrease in complication rates and total health care expenditures have directed perioperative care to focus on enhanced recovery after surgery protocols, which many institutions have adopted. The role of anesthesiologists in the care of patients undergoing spine surgery is expanding beyond intraoperative care; consequently, a multidisciplinary approach is the best direction for optimal patient care.

Determining Optimal Treatment to Correct Preoperative Anemia and Reduce Perioperative Allogeneic Blood Transfusions in Cardiac Surgery: A Retrospective Cohort Study

OBJECTIVE

Preoperative anemia management reduces red blood cell (RBC) transfusion and adverse outcomes, but how best to optimize the patient's hemoglobin (Hgb) before cardiac surgery remains unclear. The authors sought to determine the optimal treatment of anemia using iron and epoetin alfa before cardiac surgery.

DESIGN

Retrospective cohort study.

SETTING

Sunnybrook Health Sciences Centre, University of Toronto.

PARTICIPANTS

The study comprised 532 consecutive patients referred to the outpatient Blood Conservation Clinic and who underwent cardiac surgery between 2008 and 2018.

INTERVENTIONS

Of the 532 patients, 207 received oral iron, 84 received intravenous (IV) iron, 71 received epoetin alfa, 92 received combination therapy, and 78 received no treatment.

MEASUREMENTS AND MAIN RESULTS

Multivariate linear, logistic, and Poisson regressions modelled preoperative Hgb, the change from referral to preoperative Hgb (∆Hgb), the odds of transfusion, and the number of RBC units transfused, while accounting for baseline covariates. Higher ∆Hgb was associated with IV iron >600 mg (9.80 g/L [6.17-13.42]), epoetin alfa >80,000 U (5.80 g/L [2.20-9.40]), and higher referral Hgb (1.91 g/L [1.09-2.74] per 10 g/L). Higher preoperative Hgb (odds ratio 0.76 [0.64-0.90]; count ratio 0.84 [0.77-0.93] per 10 g/L) corresponded to a lower likelihood of being transfused and transfusion of fewer RBC units.

CONCLUSIONS

Preoperative IV iron >600 mg and epoetin alfa >80,000 U each was associated with significant increases in Hgb. Higher preoperative Hgb was associated with a lower likelihood of transfusion and transfusion of fewer RBC units. The authors recommend that cumulative preoperative doses of IV iron >600 mg and epoetin alfa >80,000 U be used for treatment of anemia before cardiac surgery.

Perioperative Blood Management Strategies for Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand on This Matter?

Total hip replacement (THR) has proved to be a reliable treatment for the end stage of hip osteoarthritis. It is a common orthopaedic procedure with excellent results, but is associated with significant blood loss and high rates of allogeneic blood transfusion (ABT). The potential complications and adverse events after ABT, combined with the ongoing research, have resulted in multimodel, multidisciplinary blood management strategies adoption, aiming to reduce the blood loss and transfusion rates. Many reviews and meta-analyses have tried to demonstrate the best blood management strategies. The purpose of this study is to review any evidence-based blood conserving technique, dividing them in three stages: preoperative, intraoperative and postoperative.

Anemia before reimplantation surgery - An overlooked modifiable risk factor of septic revision knee arthroplasty failure

Introduction: Preoperative anemia in patients undergoing a two-stage septic revision arthroplasty may be a factor of reinfection, even in the presence of aggressive antimicrobial therapy. Patient Blood Management (PBM) in such patients is challenging. We evaluate the impact of anemia existing before re-implantation on a failure rate after two-stage septic total knee arthroplasty (rTKA), and explore feasibility of a PBM strategy implementation in these patients. Materials and methods: A retrospective study of patients from January 2010 to January 2015 in a French regional referral center was performed. Patients undergoing a two-stage rTKA for infection after successful primary TKA were identified and followed up to 31.12.2018. The primary outcome (failure) was defined as surgical site infection after re-implantation requiring new surgery. The secondary outcomes were time to failure, the time between explantation/reimplantation, transfusion rate during the second stage. Preoperative anemia was defined as Hb level < 12 g/L before the re-implantation. Results: 69 patients were identified; 17 (24%) developed reinfection of rTKA in 105 [11.4–156] days. In these patients pre-implantation anemia was more frequent (n = 13(76.5%) in failed vs. n = 21(40%) in non-failed, p = 0.0110). During the explantation stage, there were no significant group differences in age, sex, comorbidity, type of spacer and antimicrobial therapy, iron supplementation, or transfusion rate. The median time between explantation/reimplantation surgery was 51 [43–71.5] days, indifferent between the two groups. Intraoperative transfusion during reimplantation was required in 12 (17%) patients, more frequent in failed patients. None of the patients had contraindications for the PBM strategy except the cell-saver use. Conclusion: In two-stage septic rTKA preoperative anemia was almost two times more frequent and associated with an elevated rate of septic failure. The time-frame between explantation and-re-implantation is sufficient to implement a PBM strategy for all anemic patients. Before-after studies would be of interest to determine the best PBM strategy to prevent anemia-associated septic failure in such a condition.

Risk Factors for 30-Day Non-Neurological Morbidity and Cerebrospinal Fluid Leak in Patients Undergoing Surgery for Vestibular Schwannoma

Introduction  We analyzed perioperative risk factors for morbidity and mortality for the patients undergoing surgical intervention for vestibular schwannoma along with rates of cerebrospinal fluid (CSF) leaks that required surgery. Materials and Methods  Patients undergoing surgery vestibular schwannoma were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016 using current procedural terminology (CPT) codes for posterior fossa surgical approaches and International Classification of Diseases 9th revision (ICD 9) and ICD 10 codes for peripheral nerve sheath tumor. Preoperative laboratories, comorbidities, and operative times were analyzed along with CSF leaks and unplanned returns to the operating room. Results  Nine-hundred ninety-three patients fit the inclusion criteria. Average age was 51, 41% were male, and 58% were female. Mortality within 30 days of the operation was very low at 0.4%, complications were 7% with infection being the most common at 2.3%, and unplanned reoperations happened in 7.4% of the cases. Dependent functional status (odds ratio [OR]: 5.7, 95% confidence interval [CI]: 1.9-16.6, p  = 0.001), preoperative anemia (OR: 2.4, 95% CI: 1.2-4.5, p  = 0.009), and operative time over 8 hours (OR: 1.9, 95% CI: 1.1-3.4, p  = 0.017) were the only significant predictors of perioperative complications. CSF leak postoperatively occurred in 37 patients (3.7%). Reoperation for CSF leak was necessary in 56.3% of the cases. Operative time over 8 hours was the only independent significant predictor of postoperative CSF leak (OR: 2.2, 95% CI: 1.1-4.3, p  = 0.028). Conclusion  Dependent functional status preoperatively, preoperative anemia, and duration of surgery over 8 hours are the greatest predictors of complications in the 30-day postoperative period.

Systematic review of guidelines for the diagnosis and treatment of iron deficiency anemia using intravenous iron across multiple indications

OBJECTIVE

To explore current recommendations for intravenous (IV) iron use in clinical guidelines for iron deficiency anemia (IDA) across different therapeutic areas and identify recommendations, if any, for the treatment of IDA.

METHODS

A literature search was conducted in Medline, EMBASE, BIOSIS, Cochrane Collaboration, and on websites of relevant professional associations. Searches were limited to English publications. 1292 citations were identified, 219 papers were assessed, and 35 guidelines were identified for inclusion.

RESULTS

The guidelines covered a variety of geographies: United States (US; n = 10); Europe (n = 11); "Rest-of-World" (n = 9); and "Other" organizations (n = 5). These covered a variety of specialties. Guidelines defined iron deficiency and IDA generally by serum ferritin and transferrin saturation levels. One-fifth of the reviewed guidelines (7 of 35) included no mention or recommendation regarding parenteral iron's utility in the management of IDA. Fifteen guidelines recommended using parenteral iron in the management of IDA. Fewer US guidelines included recommendations around IV iron than in Europe or the rest of the world. Approximately 60% of the guidelines have not been updated in ≥5 years and consequently do not reflect current evidence on the safety and efficacy of IV iron.

CONCLUSIONS

While national and international guidelines for management of IDA exist, many are outdated and do not reflect current evidence including, but not limited to, parenteral iron use. Urgent consideration should be given to updating and clarifying management guidelines for IDA using the latest treatment modalities and options, particularly in the US.

Clinical and Budget Impact of Treating Preoperative Anemia in Major Orthopedic Surgery-A Retrospective Observational Study

BACKGROUND

Preoperative anemia (POA) in elective surgery is associated with worse outcome. In this retrospective study, in elective hip and knee arthroplasties, the prevalence of POA and its associations with outcome were analyzed, followed by a model estimating the budget impact of screening and treatment of POA.

METHODS

All elective hip/knee arthroplasties performed during the period 2016-2018 were included. Patients with normal hemoglobin and patients with POA (hemoglobin < 13.0 g/dL in men and <12.0 g/dL in women) were compared. Outcome measures were allogeneic blood transfusion (ABT), length of stay (LOS), complications, mortality, and costs. The budget impact of screening for POA and treatment with intravenous iron when relevant was modeled based on the results of the costs related to POA.

RESULTS

In 881 procedures, the prevalence of POA was 21.5%. POA independently predicted increased risks of ABT (odds ratio [OR]_adj, 9.5 [confidence interval-CI, 6.4-13.9]), prolonged LOS (OR_adj, 2.8 [CI, 1.8-4.2]), and was associated with increased complications (OR_adj, 1.9 [CI, 0.7-4.9]) and mortality (OR_adj, 3.2 [CI, 0.8-13.5]). POA resulted in increased costs per patient (P < .001). The budget impact model showed a cost reduction of 254 euros per patient based on the assumption that patients screened and treated for iron-deficient anemia would have the same outcome as non-POA.

CONCLUSION

The prevalence of POA in elective orthopedic surgery in Sweden is at the same level as previously reported by others. Screening and treatment of POA would reduce costs based on less ABT and decreased LOS and may reduce complications in elective major orthopedic surgery.

Preoperative iron treatment in anaemic patients undergoing elective total hip or knee arthroplasty: a systematic review and meta-analysis

OBJECTIVES

Preoperative anaemia is associated with increased risks of postoperative complications, blood transfusion and mortality. This meta-analysis aims to review the best available evidence on the clinical effectiveness of preoperative iron in anaemic patients undergoing elective total hip (THR) or total knee replacement (TKR).

DESIGN

Electronic databases and handsearching were used to identify randomised and non-randomised studies of interventions (NRSI) reporting perioperative blood transfusion rates for anaemic participants receiving iron before elective THR or TKR. Searches of CENTRAL, MEDLINE, Embase, PubMed and other databases were conducted on 17 April 2019 and updated on 15 July 2020. Two investigators independently reviewed studies for eligibility and evaluated risk of bias using the Cochrane risk of bias tool for randomised controlled trials (RCTs) and a modified Newcastle-Ottawa scale for NRSIs. Data extraction was performed by ABS and checked by AB. Meta-analysis used the Mantel-Haenszel method and random-effects models.

RESULTS

807 records were identified: 12 studies met the inclusion criteria, of which 10 were eligible for meta-analyses (one RCT and nine NRSIs). Five of the NRSIs were of high-quality while there were some concerns of bias in the RCT. Meta-analysis of 10 studies (n=2178 participants) showed a 39% reduction in risk of receiving a perioperative blood transfusion with iron compared with no iron (risk ratio 0.61, 95% CI 0.50 to 0.73, p<0.001, I²=0%). There was a significant reduction in the number of red blood cell units transfused with iron compared with no iron (mean difference -0.37units, 95% CI -0.47 to -0.27, p<0.001, I²=40%); six studies (n=1496). Length of stay was significantly reduced with iron, by an average of 2.08 days (95% CI -2.64 to -1.51, p<0.001, I²=40%); five studies (n=1140).

CONCLUSIONS

Preoperative iron in anaemic, elective THR or TKR patients, significantly reduces the number of patients and number of units transfused and length of stay. However, high-quality, randomised trials are lacking.

PROSPERO REGISTRATION NUMBER

CRD42019129035.

Reliability of a spot check non-invasive hemoglobin monitoring (SpHb) of the Masimo RAD-67™ and the HemoCue® for anemia screening

Background : To test the reliability of the spot check Masimo Rad-67 (Masimo Corp., Irvine, CA, USA) as part of a preoperative anemia screening, hemoglobin measurements were compared to those of the HemoCue® Hb 201+ System (HemoCue AB, Ängelholm, Sweden) and the standard laboratory measurement. Methods : During preoperative evaluation of patients scheduled for elective orthopedic surgery hemoglobin concentration was simultaneously determined by standard laboratory analysis (HbLab), the HemoCue® Hb 201+ System (HbHemocue) and by Pulse Co-Oximetry using the Masimo Rad-67 (SpHb) with the rainbow® DCI®-mini Sensor (Masimo Corp., Irvine, CA, USA). Linear correlation, agreement (Bland-Altman analysis), sensitivity/specificity and positive/negative prediction values (PPV/NPV) for anemic hemoglobin values were determined. P-values less than 0.05 were considered statistically significant. Results : 303 patients were analyzed. Twenty-one patients (12 male and 9 female) had mild or moderate anemia, detected by HbLab. In 20 patients, the HbHemocue, and in 34 patients, the SpHb detected anemia. Linear correlation and mean bias (limits of agreement, LOA) for HbHemocue and HbLab were r = 0.969 and -1.08 (+6.44/-8.60) g/L, and for SpHb and HbLab r = 0.61 and +1.76 (+26.92/-23.4) g/L. Sensitivity/specificity of the HbHemocue to detect anemia in all, male and female patients were 85.0/99.3%, 75.0/100/% and 88.9/98.9/% with a PPV/NPV of 89.5/98.9%, 100/98.0% and 80.0/99.3%, respectively. Sensitivity/specificity of SpHb to detect anemia for all, male and female patients were 71.4%, 93.3%, 75.0/95.2/% and 66.7/91.1%, with a PPV/NPV for all, male and female patients of 44.1/97.8%, 56.3/97.9% and 33.3/97.7%, respectively. Conclusions : HbHemocue and HbLab show a strong linear correlation and a good agreement, while linear correlation of SpHb and HbLab is moderate and agreement poor. For both devices, anemia detection is moderate, but the positive prediction value for anemia is much better with the HbHemocue. Both devices reliably detected non-anemic patients. Glossary : CO = carbon monoxide ; PPV = positive predicted value ; NPV = negative predicted value ; HbLab = hemoglobin determined by the laboratory ; HbHemocue = hemoglobin determined by the HemoCue device ; SpHb = hemoglobin determined by the Masimo-RAD67 device ; LOA = limits of agreement ; LOS = length of stay ; POC = point of care ; SpO2 = arterial hemoglobin ; PR = pulse rate ; PI = perfusion index ; PVI = plethysmography variability index ; SpCO = carboxyhemoglobin ; SpMet = methemoglobin ; LED = Light Emitting Diodes ; HiCN = hemiglobincyanide ; SLS = Sodium Lauryl Sulphate ; BMI = body mass index ; BT = body temperature ; WHO = World Health Organization ; IQR = interquartile range ; MAP = mean arterial pressure ; HF = heart frequency ; SD = standard deviation Key point Summary : – Question : Is Hb measurement of the Masimo Rad-67 and of the HemoCue reliable? – Findings : Non-anemic patients are reliably detected with the Masimo Rad-67. Of the 303 patients examined, HbLab detected twenty-one patients (12 male and 9 female) with mild or moderate anemia. The Hbhemocue showed anemia in 20 patients, while the SpHb identified 34 patients as anemic. HbHemocue and HbLab showed a strong linear correlation and a good agreement, while linear correlation of SpHb and HbLab was moderate and agreement poor. For both devices, anemia detection is moderate, but the positive prediction value for anemia is much better with the HbHemocue. Both devices reliably detected non-anemic patients. – Meaning : With both devices, non-anemic patients are reliably recognized, while anemia detection is moderate. However, the prediction for the presence of anemia is much better with the Hbhemocue.

Erythropoietin plus iron versus control treatment including placebo or iron for preoperative anaemic adults undergoing non-cardiac surgery

BACKGROUND

Approximately 30% of adults undergoing non-cardiac surgery suffer from preoperative anaemia. Preoperative anaemia is a risk factor for mortality and adverse outcomes in different surgical specialties and is frequently the reason for blood transfusion. The most common causes are renal, chronic diseases, and iron deficiency. International guidelines recommend that the cause of anaemia guide preoperative anaemia treatment. Recombinant human erythropoietin (rHuEPO) with iron supplementation has frequently been used to increase preoperative haemoglobin concentrations in patients in order to avoid the need for perioperative allogeneic red blood cell (RBC) transfusion.

OBJECTIVES

To evaluate the efficacy of preoperative rHuEPO therapy (subcutaneous or parenteral) with iron (enteral or parenteral) in reducing the need for allogeneic RBC transfusions in preoperatively anaemic adults undergoing non-cardiac surgery.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE(R), Ovid Embase, ISI Web of Science: SCI-EXPANDED and CPCI-S, and clinical trial registries WHO ICTRP and ClinicalTrials.gov on 29 August 2019.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared preoperative rHuEPO + iron therapy to control treatment (placebo, no treatment, or standard of care with or without iron) for preoperatively anaemic adults undergoing non-cardiac surgery. We used the World Health Organization (WHO) definition of anaemia: haemoglobin concentration (g/dL) less than 13 g/dL for males, and 12 g/dL for non-pregnant females (decision of inclusion based on mean haemoglobin concentration). We defined two subgroups of rHuEPO dosage: 'low' for 150 to 300 international units (IU)/kg body weight, and 'high' for 500 to 600 IU/kg body weight.

DATA COLLECTION AND ANALYSIS

Two review authors collected data from the included studies. Our primary outcome was the need for RBC transfusion (no autologous transfusion, fresh frozen plasma or platelets), measured in transfused participants during surgery (intraoperative) and up to five days after surgery. Secondary outcomes of interest were: haemoglobin concentration (directly before surgery), number of RBC units (where one unit contains 250 to 450 mL) transfused per participant (intraoperative and up to five days after surgery), mortality (within 30 days after surgery), length of hospital stay, and adverse events (e.g. renal dysfunction, thromboembolism, hypertension, allergic reaction, headache, fever, constipation).

MAIN RESULTS

Most of the included trials were in orthopaedic, gastrointestinal, and gynaecological surgery and included participants with mild and moderate preoperative anaemia (haemoglobin from 10 to 12 g/dL). The duration of preoperative rHuEPO treatment varied across the trials, ranging from once a week to daily or a 5-to-10-day period, and in one trial preoperative rHuEPO was given on the morning of surgery and for five days postoperatively. We included 12 trials (participants = 1880) in the quantitative analysis of the need for RBC transfusion following preoperative treatment with rHuEPO + iron to correct preoperative anaemia in non-cardiac surgery; two studies were multiarmed trials with two different dose regimens. Preoperative rHuEPO + iron given to anaemic adults reduced the need RBC transfusion (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.38 to 0.80; participants = 1880; studies = 12; I2 = 84%; moderate-quality evidence due to inconsistency). This analysis suggests that on average, the combined administration of rHuEPO + iron will mean 231 fewer individuals will need transfusion for every 1000 individuals compared to the control group. Preoperative high-dose rHuEPO + iron given to anaemic adults increased the haemoglobin concentration (mean difference (MD) 1.87 g/dL, 95% CI 1.26 to 2.49; participants = 852; studies = 3; I2 = 89%; low-quality evidence due to inconsistency and risk of bias) but not low-dose rHuEPO + iron (MD 0.11 g/dL, 95% CI -0.46 to 0.69; participants = 334; studies = 4; I2 = 69%; low-quality evidence due to inconsistency and risk of bias). There was probably little or no difference in the number of RBC units when rHuEPO + iron was given preoperatively (MD -0.09, 95% CI -0.23 to 0.05; participants = 1420; studies = 6; I2 = 2%; moderate-quality evidence due to imprecision).  There was probably little or no difference in the risk of mortality within 30 days of surgery (RR 1.19, 95% CI 0.39 to 3.63; participants = 230; studies = 2; I2 = 0%; moderate-quality evidence due to imprecision) or of adverse events including local rash, fever, constipation, or transient hypertension (RR 0.93, 95% CI 0.68 to 1.28; participants = 1722; studies = 10; I2 = 0%; moderate-quality evidence due to imprecision). The administration of rHuEPO + iron before non-cardiac surgery did not clearly reduce the length of hospital stay of preoperative anaemic adults (MD -1.07, 95% CI -4.12 to 1.98; participants = 293; studies = 3; I2 = 87%; low-quality evidence due to inconsistency and imprecision).

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests that preoperative rHuEPO + iron therapy for anaemic adults prior to non-cardiac surgery reduces the need for RBC transfusion and, when given at higher doses, increases the haemoglobin concentration preoperatively. The administration of rHuEPO + iron treatment did not decrease the mean number of units of RBC transfused per patient. There were no important differences in the risk of adverse events or mortality within 30 days, nor in length of hospital stay. Further, well-designed, adequately powered RCTs are required to estimate the impact of this combined treatment more precisely.

Risks associated with perioperative anaemia and perioperative blood transfusion in patients undergoing neurosurgical operation

OBJECTIVE

To investigate the prevalence of preoperative anaemia and the risks associated with perioperative anaemia and blood transfusion in patients who underwent neurological surgery.

BACKGROUND

Perioperative anaemia has an important impact on neurosurgery patients. The prevalence and risks of perioperative anaemia and blood transfusion in Chinese patients are still unknown.

METHODS

Logistic regression was used to predict adverse outcomes of red blood cell (RBC) transfusion and different levels of anaemia. Anaemia and transfusion were compared as independent variables by using a 1:1 match on propensity score.

RESULTS

The prevalence of preoperative anaemia in neurosurgical patients was 20.05%; 10.33% patients received RBC transfusion. Perioperative RBC and plasma transfusion rates (P < .001) and average hospital costs (P = .0365) were higher in preoperative moderate-to-severe anaemia patients than in no anaemia patients. Perioperative RBC transfusion patients had longer hospital length of stay (LOS) (P < .001) and higher average hospital costs (P < .001) than no-transfusion patients. The rates of return to the operating room (OR) within 30 days and intensive care unit stay did not demonstrate any significant difference in anaemia and transfusion cohorts, respectively.

CONCLUSION

The status of preoperative anaemia in Chinese neurosurgical patients is associated with increased transfusion rates and hospital costs. Perioperative RBC transfusion is associated with increased length and cost of hospitalisation.

Estimating the Epidemiological and Economic Impact of Implementing Preoperative Anaemia Measures in the German Healthcare System: The Health Economic Footprint of Patient Blood Management

INTRODUCTION

This study aimed to quantify the potential epidemiological and health economic benefits of implementing preoperative anaemia measures (PAMs) in clinical practice in the German healthcare system.

METHODS

An evidence-based health economic model was developed to assess the possible impact of implementing PAMs, the first pillar of patient blood management (PBM), in a German population. The analysis of two risk factors-iron-deficiency anaemia (IDA) and receipt of a red blood cell concentrate (RBC) transfusion during elective surgery-allowed the estimation of relative risks (RRs), average cost per patient, average length of hospital stay, and avoided hospital deaths after the implementation of PAMs.

RESULTS

A total of 4,591,060 patients who had undergone elective surgery during 2015 were identified, of which 29,170 (0.64%) were diagnosed with preoperative IDA. These patients had an increased RR of receiving a RBC transfusion during surgery (RR 5.031; 95% confidence interval [CI] 4.928, 5.136) and increased mortality risk (RR 3.630; 95% CI 3.401, 3.874) versus patients without IDA. Patients who received a RBC transfusion during surgery had a 24.6-times higher risk of death than those who did not (RR 24.593; 95% CI 24.121, 25.075). Average cost of treatment was €7883 in patients with IDA, €21,744 in patients with IDA and RBC transfusion, and €4560 in patients without risk factors. The model identified 29,714 patients (0.65%) who had received a RBC transfusion and who potentially had IDA but remained undiagnosed before surgery. Hypothetical implementation of PAMs would have resulted in an estimated annual net hospital direct cost saving of €1029 million (1.58%) of total hospital direct costs of the German healthcare system and 3036 hospital deaths (0.07%) avoided.

CONCLUSIONS

This model estimated the impact of implementing PAMs for patients with IDA undergoing elective surgery. A significant number of deaths, costly treatments, and hospital days could have been avoided by the introduction of PAMs in routine clinical practice in Germany.

Preoperative erythropoietin within a patient blood management program decreases both blood transfusion and postoperative anemia: a prospective observational study

BACKGROUND

In orthopedic surgery, a patient blood management program (PBM) has been proposed to reduce blood transfusion. The aim of this observational study was to assess, within a PBM, the specific efficacy of preoperative erythropoietin (EPO).

STUDY DESIGN AND METHODS

In a single hospital, 723 patients undergoing elective primary hip or knee arthroplasty were prospectively studied. The PBM included EPO if preoperative hemoglobin was lower than 13 g/dL, intraoperative administration of tranexamic acid, use of recommended transfusion thresholds, and postoperative infusion of iron. Blood transfusion and hemoglobin were noted until discharge. Major thromboembolic or cardiovascular events were assessed during admission and 1 month after discharge.

RESULTS

Transfusion was noted in 2.5% patients with EPO. Transfusion rate was higher in patient for whom EPO was not indicated (13.6% transfusion rate; odds ratio [OR], 13.7; 95% confidence interval [CI], 2.6-66; p = 10^-3 ) or if erythropoietin was indicated but not administrated (36.8% transfusion rate; OR, 18.2; 95% CI, 3.9-84.5; p < 10^-3 ). Hemoglobin was significantly higher during the postoperative period in patients with erythropoietin. At hospital discharge, 57% of patients were anemic if EPO was used compared to 88% when EPO was not indicated and 87% when EPO was indicated but not administered (p < 10^-6 ). There were no significant differences in the odds of major complications between patients with or without EPO.

CONCLUSIONS

Within a PBM, preoperative treatment of anemia with EPO decreased both the rate of blood transfusion and postoperative anemia. Further studies are necessary to confirm these results.

Malnutrition in Orthopaedic Sports Medicine: A Review of the Current Literature

CONTEXT

Malnutrition is well-studied in various aspects of the orthopaedic literature, most commonly in relation to arthroplasty, spine surgery, and trauma. However, the management of nutritional deficiencies is commonly overlooked among orthopaedic sports medicine providers. The purpose of this article is to analyze the available sports medicine literature to review the associations between malnutrition and the management of orthopaedic sports medicine patients from a treatment and performance standpoint.

EVIDENCE ACQUISITION

PubMed was searched for relevant articles published from 1979 to 2019.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Few studies exist on the implications of macronutrient deficiencies specific to orthopaedic sports medicine procedures. Interestingly, micronutrient disorders-namely, hypovitaminosis D and iron deficiency-have been well studied and may lead to worse postoperative outcomes, injury rates, and athletic performance. Nutritional supplementation to correct such deficiencies has been shown to mitigate these effects, though further study is required.

CONCLUSION

Nutritional deficiencies are highly prevalent in orthopaedic sports medicine patients, and practitioners should be aware of their potential effects on treatment and performance outcomes. Management of such deficiencies and their effect on surgical patients remain an area of potential future research. Future studies are warranted in order to explore the potential therapeutic role of nutritional supplementation to prevent complications after common orthopaedic sports medicine procedures, improve athletic performance, and reduce injury rates.

Effect of the application of the "Patient blood management" programme on the approach to elective hip and knee arthroplasties

BACKGROUND AND OBJECTIVES

The "Patient Blood Management" (PBM) programmes have demonstrated their value in the continuous improvement of care practice, due to continuous systematic reviewing of results and their dynamic and multidisciplinary updating in accordance with new clinical evidence. Our goal is to demonstrate the effectiveness of simple protocols, applicable in second level hospitals.

PATIENTS AND METHODS

702 patients undergoing scheduled arthroplasty from 2011 to 2018 were retrospectively analysed. During this period, the evolution of transfusion rates and anaemia and bleeding management were recorded in the patients' computerised clinical histories.

RESULTS

Stages and transfusion rates were: Year 2011-2012, "Universal self-donation programme": 62.4%; year 2013, "Optimization of preoperative haemoglobin and universal self-donation withdrawal", 22.5%; year 2015, "Stopping the use of cell-savers and drains", 13.2%; and year 2017, "Introduction of routine tranexamic acid", 3.6%. A significant reduction in the transfusion rate and volume (P<.001) and the average hospital stay (8 to 6 days) (P<.001) was achieved. In multivariate models, transfused patients have a .5-day stay and there is a trend towards a reduction in complications, being fewer in patients receiving tranexamic acid (OR .44).

CONCLUSION

A simple progressive and multidisciplinary PBM programme, with continued re-evaluation, has allowed a reduction in transfusion rates and average hospital stay.