Patient Blood Management Strategies to Avoid Transfusions in Body Contouring Operations: Controlled Clinical Trial

BACKGROUND

Anemia is a frequent process of morbidity and mortality in body contouring procedures. In aesthetic surgery, there are no standardized processes to minimize bleeding during surgery. For this reason, a study was designed to implement patient blood management strategies to reduce bleeding and transfusions in patients undergoing body contouring operations.

METHODS

From January of 2017 to May of 2018, a prospective cohort-type observational study was conducted, including two groups of patients undergoing single or combined body contouring procedures. The first group did not receive patient blood management strategies, whereas the second group did receive these strategies. These measures consisted of preoperative strategies to ensure the patient had optimal hemoglobin and hematocrit levels and supportive intraoperative measures to minimize blood loss. The results were validated with different statistical tests according to the variables studied.

RESULTS

A total of 409 patients were included in the study and were divided into two groups. The anthropometric and hemoglobin variables were similar in both groups. The 207 patients for whom patient blood management strategies were implemented lost an average of 1.2 g/dl less hemoglobin at 72 hours than the 202 patients for whom patient blood management strategies were not implemented (p ≤ 0.0001).

CONCLUSIONS

Patient blood management strategies, such as increasing hemoglobin before surgery, and strategies to minimize blood loss during surgery, proved to be effective at reducing bleeding in patients undergoing body contouring surgery, also decreasing the need to perform postoperative blood transfusions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Preoperative hemogram as a predictive factor for iron deficit and/or transfusion in patients scheduled for arthroplasty

INTRODUCTION

Anemia and iron deficiency predispose to an increased risk of transfusion with a consequent increase in morbidity and mortality. The study analyzes whether blood cell count parameters in addition to detecting anemia can predict iron deficiency and/or transfusional risk in patients undergoing mostly to scheduled primary hip and knee arthroplasty.

OBJECTIVE

To analyze how blood cell count parameters predict iron deficiency and/or transfusional risk in patients undergoing programmed arthroplasty.

MATERIAL AND METHODS

The analytical and transfusion results of 522 patients undergoing arthroplasty have been prospectively collected between 2013 and 2019 and the discriminative and predictive capacity of the basic parameters of the red cells have been analyzed; hemoglobin (Hb), mean cell volume, mean cell hemoglobin (HCM) and red blood cell distribution width (RDW) for the identification of presurgical iron deficiency and postsurgical transfusion.

RESULTS

Anaemia was detected in 6.6%, "suboptim" Hb (<13g/dL) in 14.5% and iron deficiency in 32.4%. Anemia detects only 13.8% of ID. After logistic regression analysis, the multivariate model significantly related Hb (p=.004), mean corpuscular hemoglobin (MCH) (p=.026), and the red cell distribution width (RDW) (p=.001) with ID; but mean corpuscular volume (MCV) is not significant. Hb, age and transferrin saturation index have been the only risk factors for transfusional risk of the parameters analyzed.

CONCLUSIONS

The hemogram contains parameters that correlate with iron deficiency, however, mean cell volume, so widely used for the orientation of iron deficiency, is not valid as a discriminator of iron deficiency in this group of patients. Low Hb and transferrin saturation index are modifiable predictors for transfusion risk.

Making patient blood management the new norm(al) as experienced by implementors in diverse countries

BACKGROUND

Patient blood management (PBM) describes a set of evidence-based practices to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This concepts aims to detect and treat anemia, minimize the risk for blood loss and the need for blood replacement for each patient through a coordinated multidisciplinary care process. In combination with blood loss, anemia is the main driver for transfusion and all three are independent risk factors for adverse outcomes including morbidity and mortality. Evidence demonstrates that PBM significantly improves outcomes and safety while reducing cost by macroeconomic magnitudes. Despite its huge potential to improve healthcare systems, PBM is not yet adopted broadly. The aim of this study is to analyze the collective experiences of a diverse group of PBM implementors across countries reflecting different healthcare contexts and to use these experiences to develop a guidance for initiating and orchestrating PBM implementation for stakeholders from diverse professional backgrounds.

METHODS

Semi-structured interviews were conducted with 1-4 PBM implementors from 12 countries in Asia, Latin America, Australia, Central and Eastern Europe, the Middle East, and Africa. Responses reflecting the drivers, barriers, measures, and stakeholders regarding the implementation of PBM were summarized per country and underwent qualitative content analysis. Clustering the resulting implementation measures by levels of intervention for PBM implementation informed a PBM implementation framework.

RESULTS

A set of PBM implementation measures were extracted from the interviews with the implementors. Most of these measures relate to one of six levels of implementation including government, healthcare providers, funding, research, training/education, and patients/public. Essential cross-level measures are multi-stakeholder communication and collaboration.

CONCLUSION

The implementation matrix resulting from this research helps to decompose the complexity of PBM implementation into concrete measures on each implementation level. It provides guidance for diverse stakeholders to design, initiate and develop strategies and plans to make PBM a national standard of care, thus closing current practice gaps and matching this unmet public health need.

Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review

About 15 years ago, Patient Blood Management (PBM) emerged as a new paradigm in perioperative medicine and rapidly found support of all major medical societies and government bodies. Blood products are precious, scarce and expensive and their use is frequently associated with adverse short- and long-term outcomes. Recommendations and guidelines on the topic are published in an increasing rate. The concept aims at using an evidence-based approach to rationalize transfusion practices by optimizing the patient's red blood cell mass in the pre-, intra- and postoperative periods. However, elegant as a concept, the implementation of a PBM program on an institutional level or even in a single surgical discipline like cardiac surgery, can be easier said than done. Many barriers, such as dogmatic ideas, logistics and lack of support from the medical and administrative departments need to be overcome and each center must find solutions to their specific problems. In this paper we present a narrative overview of the challenges and updated recommendations for the implementation of a PBM program in cardiac surgery.

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.

Association of perioperative red blood cell transfusions with all-cause and cancer-specific death in patients undergoing surgery for gastrointestinal cancer: Long-term outcomes from a population-based cohort

BACKGROUND

Red blood cell transfusions are common in patients undergoing gastrointestinal cancer surgery. Yet, to adequately balance their risks and benefits, clinicians must understand how transfusions may affect long-term outcomes. We aimed to determine if perioperative red blood cell transfusions are associated with a higher risk of all-cause and cancer-specific death among patients who underwent gastrointestinal cancer resection.

METHOD

We identified a population-based cohort of patients who underwent gastrointestinal cancer resection in Ontario, Canada (2007-2019). All-cause death was compared between transfused and nontransfused patients using Cox proportional hazards regression, while cancer-specific death was compared with competing risk regression.

RESULT

A total of 74,962 patients (mean age, 67.7 years; 55.4% male; 79.7% colorectal cancer) had gastrointestinal cancer surgery during the study period; 20.8% received perioperative red blood cell transfusions. Patients who received red blood cell transfusions had increased hazards of all-cause and cancer-specific death relative to patients who did not (hazard ratio: 1.39, 95% confidence interval 1.34-1.44; cause-specific hazard ratio: 1.36, 1.30-1.43). The adjusted risk of all-cause death was higher in early follow-up intervals (3-6 months postoperatively) but remained elevated in each interval over 5 years. The association persisted after restricting to patients without postoperative complications or bleeding and was robust to unmeasured confounding.

CONCLUSION

Red blood cell transfusion among patients with gastrointestinal cancer is associated with increased all-cause death. This was observed long beyond the immediate postoperative period and independent of short-term postoperative morbidity and mortality. These findings should help clinicians balance the risks and benefits of transfusion before well-designed trials are conducted in this patient population.

Perioperative anemia: clinical practice update

Perioperative medicine is an evolving area of medicine in which collaboration between internists, hospitalists, surgeons and anesthesiologists is the key to delivering high-quality care. Research in all areas of perioperative medicine, including perioperative anemia, is constantly evolving. Perioperative anemia is a major contributor to mortality and morbidity in the perioperative period. It is associated with an increased likelihood of postoperative wound complications, infections, delirium, increased length of stay and increased risk of readmissions. However, there is a lack of comprehensive guidelines for management of perioperative anemia. We performed an exhaustive review of contemporary literature on perioperative anemia and present evaluation and management recommendations that have the potential to impact clinical practice in the perioperative period.

Associations of a Preoperative Anemia and Suboptimal Iron Stores Screening and Management Clinic in Colorectal Surgery With Hospital Cost, Reimbursement, and Length of Stay: A Net Cost Analysis

BACKGROUND

In 2016, a preoperative clinic was implemented to screen, evaluate, and manage anemia and suboptimal iron stores at a major tertiary care medical center in Western Australia. Few studies compare the costs and reimbursements associated with preoperative anemia and suboptimal iron stores management. The objective of our study was to conduct a net cost analysis associated with the implementation of this clinic.

METHODS

We designed a retrospective cohort study involving elective colorectal surgical admissions over a 3-year period. The baseline year selected was the 2015-2016 financial year, with outcomes in the 2016-2017 and 2017-2018 year compared to baseline. The study perspective was the Western Australian Health System. Hospital costs were extracted from the health service clinical costing system, which captures costs at the admission level. The primary outcome was net cost, defined as gross cost minus reimbursement (or funding) received.

RESULTS

Our 3-year study included 544 admissions for elective colorectal surgery. After the implementation of the preoperative clinic, 73.4% (n = 257) of admissions were screened for anemia and suboptimal iron stores, and 31.4% (n = 110) received intravenous iron. In our adjusted analysis, when comparing the final year (2017-2018) with baseline (2015-2016), the units of red blood cells transfused per admission decreased 53% (142 vs 303 units per 1000 discharges; P = .006), and mean hospital length of stay decreased 15% (7.7 vs 9.1 days; P = .008). When comparing the final year with baseline, rectal resection admissions were associated with a mean decrease in the net cost of Australian dollar (A$) 7619 (95% confidence interval, 4230-11,008; P < .001) between 2015-2016 and 2017-2018. For small and large bowel procedures, there was a mean decrease of A$6744 (95% confidence interval, 2430-11,057; P = .002).

CONCLUSIONS

The implementation of a preoperative anemia and suboptimal iron stores screening and management clinic in elective colorectal surgery was associated with reductions in red cell transfusions, length of stay, and net costs.

Perioperative management and anaesthetic considerations in pelvic exenterations using Delphi methodology: results from the PelvEx Collaborative

BACKGROUND

The multidisciplinary perioperative and anaesthetic management of patients undergoing pelvic exenteration is essential for good surgical outcomes. No clear guidelines have been established, and there is wide variation in clinical practice internationally. This consensus statement consolidates clinical experience and best practice collectively, and systematically addresses key domains in the perioperative and anaesthetic management.

METHODS

The modified Delphi methodology was used to achieve consensus from the PelvEx Collaborative. The process included one round of online questionnaire involving controlled feedback and structured participant response, two rounds of editing, and one round of web-based voting. It was held from December 2019 to February 2020. Consensus was defined as more than 80 per cent agreement, whereas less than 80 per cent agreement indicated low consensus.

RESULTS

The final consensus document contained 47 voted statements, across six key domains of perioperative and anaesthetic management in pelvic exenteration, comprising preoperative assessment and preparation, anaesthetic considerations, perioperative management, anticipating possible massive haemorrhage, stress response and postoperative critical care, and pain management. Consensus recommendations were developed, based on consensus agreement achieved on 34 statements.

CONCLUSION

The perioperative and anaesthetic management of patients undergoing pelvic exenteration is best accomplished by a dedicated multidisciplinary team with relevant domain expertise in the setting of a specialized tertiary unit. This consensus statement has addressed key domains within the framework of current perioperative and anaesthetic management among patients undergoing pelvic exenteration, with an international perspective, to guide clinical practice, and has outlined areas for future clinical research.

Real-world results of the implementation of preoperative anaemia clinic with intravenous iron therapy for treating iron-deficiency anaemia: a propensity-matched case-control study

Background

Preoperative anaemia is associated with blood transfusion and longer hospital length of stay. Preoperative iron deficiency anaemia (IDA) can be treated with oral or intravenous (IV) iron. IV iron can raise haemoglobin faster compared with oral iron. However, its ability to reduce blood transfusion and length of stay in clinical trials is inconclusive. This study aims to compare blood transfusion and hospital length of stay between anemic patients who received preoperative IV iron versus standard care, after implementation of a protocol in 2017 to screen patients for preoperative IDA, and its treatment with IV iron.

Methods

Retrospective before-after cohort study comparing 89 patients who received IV iron preoperatively in 2017, with historic patients who received oral iron therapy (selected by propensity score matching (PSM) from historic cohort of 7,542 patients who underwent surgery in 2016). Propensity score was calculated using ASA status, age, gender, surgical discipline, surgical risk and preoperative haemoglobin concentration. Both 1:1 and 1:2 matching were performed as sensitivity analysis.

Results

After PSM, there was no statistically significant difference in distribution of preoperative clinical variables. There was no significant difference in proportion of cases requiring transfusion nor a difference in average units transfused per patient. IV iron cohort stayed in hospital on average 8.0 days compared to non-IV iron cohort 14.1–15.1 days (P=0.006, P=0.013 respectively). Average time from IV iron therapy to surgery was 10.5 days.

Conclusions

Preoperative IV iron therapy for patients with IDA undergoing elective surgery may not reduce perioperative blood transfusion, but this could be due to the short time between therapy and surgery. Implementation of IV iron therapy may reduce hospital length of stay compared to standard care for anemic patients, although this may be enhanced by concomitant improvement in perioperative care.

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.

Non-invasive haemoglobin measurement as an index test to detect pre-operative anaemia in elective surgery patients - a prospective study

Non-invasive haemoglobin measurement using absolute values lacks the precision to be the sole basis for the treatment of pre-operative anaemia. However, it can possibly serve as a screening test, indexing 'anaemia' with high sensitivity when values remain under prespecified cut-off values. Based on previous data, non-invasive haemoglobin cut-off values (146 g.l^-1 for women and 152 g.l^-1 for men) detect true anaemia with 99% sensitivity. An index test with these prespecified cut-off values was verified by prospective measurement of non-invasive and invasive haemoglobin pre-operatively in elective surgical patients. In 809 patients, this showed an estimated sensitivity (95%CI) of 98.9% (94.1-99.9%) in women and 96.4% (91.0-99.0%) in men. This saved invasive blood tests in 9% of female and 28% of male patients. In female patients, a lower non-invasive haemoglobin cut-off value (138 g.l^-1 ) would save 28% of invasive blood tests with a sensitivity of 95%. The target 99% sensitivity would be reached by non-invasive haemoglobin cut-off values of 152 g.l^-1 in female and 162 g.l^-1 in male patients, saving 3% and 9% of invasive blood tests, respectively. Bias and limits of agreement between non-invasive and laboratory haemoglobin levels were 2 and - 25 to 28 g.l^-1 , respectively. Patient and measurement characteristics did not influence the agreement between non-invasive and laboratory haemoglobin levels. Although sensitivity was very high, the index test using prespecified cut-off values just failed to reach the target sensitivity to detect true anaemia. Nevertheless, with respect to blood-sparing effects, the use of the index test in men may be clinically useful, while an index test with a lower cut-off (132 g.l^-1 ) could be more clinically appropriate in women.

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.

A randomised trial evaluating the effect of intraoperative iron administration

Perioperative anaemia increases postoperative morbidity and mortality, and iron deficiency is anaemia’s most common cause in surgical patients. Preoperative intravenous iron increases postoperative haemoglobin; however, data regarding intraoperative intravenous iron’s effectiveness are inadequate. This study examined intraoperative intravenous iron’s effects on postoperative haemoglobin levels in adults. Fifty-seven healthy subjects (aged 19–40 years) scheduled for bimaxillary orthognathic surgery were assigned randomly to the iron (n = 28) or control (n = 29) groups. The iron group received intravenous ferric derisomaltose (1,000 mg) after anaesthetic induction. The control group received an identical volume of intravenous normal saline. The primary outcome was postoperative haemoglobin level. Secondary outcomes included other postoperative haematologic and iron parameters. Laboratory data were obtained preoperatively and at 1 day, 2 weeks, and 4 weeks postoperatively. Haemoglobin was higher in the iron group 2 weeks postoperatively (12.9 g/dL vs. 12.2 g/dL), but the between-group difference was not significant after adjustment for multiple testing. However, the reticulocyte production index was significantly higher in the iron group 2 weeks postoperatively. Intraoperative intravenous iron maintains postoperative haemoglobin values in patients undergoing bimaxillary orthognathic surgery by increasing haematopoietic function and iron bioavailability and therefore appears to be a useful strategy for blood management.

[Health policy strategies for Patient Blood Management implementation throughout the Spanish health systems]

Los programas de Patient Blood Management (PBM) permiten reducir intervenciones sanitarias innecesarias e incorporar prácticas clínicas de alto valor que mejoran los resultados en salud y la eficiencia. Su adopción en España es todavía limitada y con una alta variabilidad entre hospitales. Las recientes guías de la Unión Europea sobre cómo implementar el PBM, así como las recomendaciones de expertos, indican que para conseguir un avance en este campo se requiere, no solo de la implicación de los profesionales, sino también de las autoridades sanitarias y direcciones hospitalarias. Este artículo proporciona algunas propuestas en materia de gestión y política sanitaria para promover el desarrollo del PBM en los sistemas de salud en España.

Maturity Assessment model for Patient Blood Management to assist hospitals in improving patients' safety and outcomes. The MAPBM project

BACKGROUND

Patient blood management (PBM) is an evidence-based care bundle with proven ability to improve patients' outcomes by managing and preserving the patient's own blood. Since 2010, the World Health Organisation has urged member states to implement PBM. However, there has been limited progress in developing PBM programmes in hospitals due to the implicit challenges of implementing them. To address these challenges, we developed a Maturity Assessment Model (MAPBM) to assist healthcare organisations to measure, benchmark, assess in PBM, and communicate the results of their PBM programmes. We describe the MAPBM model, its benchmarking programme, and the feasibility of implementing it nationwide in Spain.

MATERIALS AND METHODS

The MAPBM considers the three dimensions of a transformation effort (structure, process and outcomes) and grades these within a maturity scale matrix. Each dimension includes the various drivers of a PBM programme, and their corresponding measures and key performance indicators. The structure measures are qualitative, and obtained using a survey and structured self-assessment checklist. The key performance indicators for process and outcomes are quantitative, and based on clinical data from the hospitals' electronic medical records. Key performance indicators for process address major clinical recommendations in each PBM pillar, and are applied to six common procedures characterised by significant blood loss.

RESULTS

In its first 5 years, the MAPBM was deployed in 59 hospitals and used to analyse 181,826 hospital episodes, which proves the feasibility of implementing a sustainable model to measure and compare PBM clinical practice and outcomes across hospitals in Spain.

CONCLUSION

The MAPBM initiative aims to become a useful tool for healthcare organisations to implement PBM programmes and improve patients' safety and outcomes.

Screening and treating pre-operative anaemia and suboptimal iron stores in elective colorectal surgery: a cost effectiveness analysis

Our study investigated whether pre-operative screening and treatment for anaemia and suboptimal iron stores in a patient blood management clinic is cost effective. We used outcome data from a retrospective cohort study comparing colorectal surgery patients admitted pre- and post-implementation of a pre-operative screening programme. We applied propensity score weighting techniques with multivariable regression models to adjust for differences in baseline characteristics between groups. Episode-level hospitalisation costs were sourced from the health service clinical costing data system; the economic evaluation was conducted from a Western Australia Health System perspective. The primary outcome measure was the incremental cost per unit of red cell transfusion avoided. We compared 441 patients screened in the pre-operative anaemia programme with 239 patients not screened; of the patients screened, 180 (40.8%) received intravenous iron for anaemia and suboptimal iron stores. The estimated mean cost of screening and treating pre-operative anaemia was AU$332 (£183; US$231; €204) per screened patient. In the propensity score weighted analysis, screened patients were transfused 52% less red cell units when compared with those not screened (rate ratio = 0.48, 95%CI 0.36-0.63, p < 0.001). The mean difference in total screening, treatment and hospitalisation cost between groups was AU$3776 lower in the group screened (£2080; US$2629; €2325) (95%CI AU$1604-5947, p < 0.001). Screening elective patients pre-operatively for anaemia and suboptimal iron stores reduced the number of red cell units transfused. It also resulted in lower total costs than not screening patients, thus demonstrating cost effectiveness.

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.

Managing preoperative anemia: Evolving concepts and strategies for improving patient outcomes

Anemia is the most common hematological disease, and is defined by the World Health Organization as a condition in which the number of red blood cells and consequently oxygen-carrying capacity is insufficient to meet the physiological needs of the body. Anemia can occur throughout the perioperative period and has important clinical consequences. Preoperative anemia is usually regarded as no more than a surrogate marker of a patient's physical status, and it is not always adequately addressed before surgery. Postoperative anemia is a common event and occurs in 80-90% of patients who have undergone major surgery. This manuscript discusses the detection and management of preoperative anemia, the three pillars of patient blood management, perioperative anemia management, and risk stratification for anemia in the surgical setting.

Essential Role of Patient Blood Management in a Pandemic: A Call for Action

The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.

The Interplay between Preoperative Anemia and Postoperative Blood Transfusion on Survival following Fenestrated Aortic Aneurysm Repair

BACKGROUND

Anemia is associated with a higher mortality following standard endovascular aortic repair (EVAR). This study evaluates the impact of anemia on fenestrated endovascular aneurysm repair (FEVAR) for complex aneurysm (AAA) repair.

METHODS

All elective FEVARs performed between 2010 and 2018 at a tertiary vascular center were analyzed. Anemia was defined as a preoperative hemoglobin (Hb) of <120 g/L for women and <130 g/L for men (World Health Organization definition). Primary outcome was overall survival by Kaplan-Meier. Secondary outcomes included length of hospital stay (LOS) and myocardial infarction (MI). Cox proportional hazard analyses were conducted.

RESULTS

In total, 132 FEVAR patients were followed up for 3.7 (2.2) years. Thirty-eight patients were anemic [average Hb of 112 (13) g/L]. Groups were comparable for age, AAA diameter, body mass index, and comorbidity. Anemic patients had a lower baseline estimated glomerular filtration rate [64.1 (23.2) vs. 70.9 (18.8) mL/min/1.73 m², P = 0.022] and a longer procedural time [242 (103) vs. 195.4 (88) min, P = 0.009] with no difference in the number of fenestrations (P = 0.696). Kaplan-Meier analysis demonstrated a higher mortality (log-rank P = 0.03) with 40% deceased versus 21% nonanemic (P = 0.04) at the end of follow-up. Anemic patients had more postoperative myocardial infarctions (MIs) (4 vs. 2, P = 0.037) and a longer LOS [9.2 (7.1) vs. 6.3 (6.8) days, P = 0.001]. Increasing Hb increased the likelihood of survival [hazard ratio, HR -0.8 (0.65-0.94), P = 0.038]. Postoperative transfusion was adversely associated with survival [HR 3.65 (1.05-12.8), P = 0.043].

CONCLUSIONS

Anemia appears to be associated with an increased rate of postoperative MI, LOS, frequency of blood transfusion, and mortality rate following FEVAR but this surpassed by postoperative blood transfusion. Optimization of preoperative Hb should be considered as a potential target for improvements in clinical outcomes and hypothetically a consequential reduction in postoperative red blood cell transfusion need.

Efficacy and Safety of Treatment With Ferric Carboxymaltose in Patients With Cirrhosis and Gastrointestinal Bleeding

Background: Patients with liver cirrhosis and gastrointestinal bleeding (GIB) often develop anemia. Ferric carboxymaltose (FCM) is an intravenous (i.v.) iron formulation approved for use in patients with iron deficiency with inadequate response to oral iron therapy or when oral iron cannot be used. Here we analyzed the efficacy and safety of FCM treatment in cirrhotic patients with anemia and GIB.

Methods: Retrospective observational study of patients with cirrhosis and acute or chronic GIB treated with 1,000 mg FCM at the University Hospital Arnau de Vilanova (Lleida, Spain) that follows a restrictive-transfusion strategy. All data were obtained from the patients' medical records. We used the Wilcoxon test to evaluate statistical significance.

Results: Patients with cirrhosis and GIB (n = 34) were treated with 1,000 mg FCM. Portal hypertension were present in 88.2% of the patients. For hospitalized patients (n = 21), median serum hemoglobin (s-Hb) levels increased by 3.0 g/dL (p < 0.02) and 3.9 g/dL (p < 0.07) for patients treated with FCM who had or had not received also a transfusion, respectively, compared to levels recorded upon admission. For outpatients (n = 13) the mean s-Hb levels was 9.8 ± 1.6 g/dL before FCM treatment and 11.3 ± 2.1 g/dL after treatment, demonstrating a mean increase of 1.5 g/dL (p < 0.001). No serious adverse reactions to FCM were observed.

Conclusion: FCM administration achieved optimal s-Hb levels in most cirrhotic patients with acute or chronic GIB, suggesting that early FCM infusion improves and maintains optimal s-Hb levels in these patients and may be an appropriate first-line therapy to treat their anemia.

Patient Blood Management for primary hip and knee replacement. A survey among POWER.2 study researchers

BACKGROUND

Implementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices.

OBJECTIVES AND METHODS

We conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery).

RESULTS

A total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use "restrictive thresholds", and 90% follow the single unit transfusion policy.

CONCLUSIONS

The results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs.

Improving the treatment of pre-operative anemia in hepato-pancreato-biliary patients: a quality improvement initiative

Background

Pre-operative anemia is a common, but treatable, condition encountered by surgical patients. It has been associated with increased perioperative complications, length of stay, and blood transfusions. The aim of this project was to increase the treatment rate of pre-operative anemia to 75% of patients consented for major hepato-pancreato-biliary (HPB) surgery.

Methods

This was an interrupted time series study and a spread initiative from a similar project in a colorectal surgery population. Interventions included an anemia screening and treatment algorithm, standardized blood work, referral to a patient blood management program, and standardized oral iron prescriptions. The primary outcome measure was the change in pre-operative anemia treatment rate and the secondary outcome measure was the post treatment increase in hemoglobin.

Results

A total of 208 patients were included (n = 124 pre-intervention and n = 84 post-intervention). Anemia was present in 39.9% of patients. The treatment rate of pre-operative anemia increased to 44.1% from 28.6%. The mean hemoglobin increased from 110 g/L to 119 g/L in patients who were treated (p = 0.03). There was no significant increase or decrease in blood transfusions or mean number of red cell units transfused per patient. Screening rates for pre-operative anemia increased from 41.1 to 64.3% and appropriate referrals to the patient blood management program increased from 14.3 to 67.6%.

Conclusions

This study demonstrates a small scale spread initiative focused on the treatment of pre-operative anemia. Although the goal to treat 75% of anemic patients was not reached, an effective referral pathway to an existing patient blood management program was developed, and a significant increase in the mean hemoglobin in anemic patients who have been treated pre-operatively was demonstrated.

Risk factors for major adverse cardiovascular events after osteoporotic hip fracture repair surgery

Osteoporotic hip fracture (OHF) is an increasingly frequent age-related pathology, which results in high rates of functional loss and mortality within the first year after surgery. This study assessed whether preoperative levels of brain natriuretic peptide (NT-proBNP) and troponin I were related to early occurrence (30d) of major adverse cardio-vascular events (MACE) after OHF repair surgery. During a 6-month period, perioperative clinical and analytical data from consecutive patients, without known history of cardiovascular disease and undergoing surgery for OHF repair at a single centre, were prospectively collected. MACE was defined as acute myocardial ischaemia or infarction, acute heart failure or cardiovascular death. amongst the 140 patients included, 23 (16.4%) developed postoperative MACE (MACE group) and 117 did not (Control group). Compared to those from control group, patients from MACE group were older, had poorer physical status (ASA III-IV), received preoperative red blood cell transfusion (RBCT) more frequently, presented with lower haemoglobin concentrations and higher NT-proBNP, creatinine and troponin I concentrations. Overall, RBCT requirements and 30d mortality rate were also higher in MACE group. However, in multivariate analysis, only preoperative RBCT, creatinine >1 mg/dL and NT-proBNP >450 pg/mL remained as independent preoperative risks factors for postoperative MACE, while 95% confidence intervals of odds ratios were wide. Though our findings require confirmation in a larger multicentre cohort, identifying risk factors for early postoperative MACE after OHF repair surgery, might facilitate assessing patients' risk prior to and following surgery, and targeting them the appropriate preventive and/or therapeutic interventions.

Scaling up Quality Improvement for Surgical Teams (QIST) - avoiding surgical site infection and anaemia at the time of surgery: protocol for a cluster randomised controlled trial

Background

Measures shown to improve outcomes for patients often fail to be adopted into routine practice in the NHS. The Institute for Health Improvement Breakthrough Series Collaborative (BSC) model is designed to support implementation at scale. This trial aims to assess the effectiveness and cost-effectiveness of quality improvement collaboratives (QICs) based on the BSC method for introducing service improvements at scale in the NHS.

Methods

Forty Trusts will be randomised (1:1) to introduce one of two protocols already shown to improve outcomes in patients undergoing elective total hip and knee replacement surgery.

The intervention is improvement collaboratives based on the BSC model, a learning system that brings together a large number of teams to seek improvement focussed on a proven intervention. Collaboratives aim to deliver at scale, maximise local engagement and leadership and are designed to build capacity, enable learning and prepare for sustainability. Collaboratives involve Learning Sessions, Action Periods, and a summative congress.

Trusts will be supported to introduce either: decolonisation for Methicillin Sensitive Staphylococcus aureus (MSSA) to reduce post-operative infection (QIST: Infection), or an anaemia optimisation programme to reduce peri-operative blood transfusions (QIST: Anaemia). Trusts will continue with their usual practice for whichever protocol they are not introducing. Anonymised data related to both infection and anaemia outcomes for patients undergoing hip or knee arthroplasty at all sites will mean that the two groups act as controls for each other.

The primary outcome for the QIST: Infection collaborative is deep MSSA surgical site infection within 90 days of surgery, and for the QIST: Anaemia collaborative is blood transfusion within 7 days of surgery. Patient-level secondary outcomes include length of hospital stay and readmission, which will also inform the economic costings. Qualitative interviews will evaluate the support provided to teams.

Discussion

The scale of this trial brings considerable challenges and potential barriers to delivery. Anticipated challenges relate to recruiting and sustaining up to 40 organisations, each with its own culture and context. This complex project with multiple stakeholders across a large geographical area will be managed by experienced senior-level project leaders with a proven track record in advanced project management. The team should ensure effective project governance and communications.

Trial registration

ISRCTN, ISRCTN11085475. Prospectively registered on 15 February 2018.

Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion

PURPOSE

Patient blood management [PBM] has been acknowledged and successfully introduced in a wide range of medical specialities, where blood transfusions are an important issue, including anaesthesiology, orthopaedic surgery, cardiac surgery, or traumatology. Although pregnancy and obstetrics have been recognized as a major field of potential haemorrhage and necessity of blood transfusions, there is still little awareness among obstetricians regarding the importance of PBM in this area. This review, therefore, summarizes the importance of PBM in obstetrics and the current evidence on this topic.

METHOD

We review the current literature and summarize the current evidence of PBM in pregnant women and postpartum with a focus on postpartum haemorrhage (PPH) using PubMed as literature source. The literature was reviewed and analysed and conclusions were made by the Swiss PBM in obstetrics working group of experts in a consensus meeting.

RESULTS

PBM comprises a series of measures to maintain an adequate haemoglobin level, improve haemostasis and reduce bleeding, aiming to improve patient outcomes. Despite the fact that the WHO has recommended PBM early 2010, the majority of hospitals are in need of guidelines to apply PBM in daily practice. PBM demonstrated a reduction in morbidity, mortality, and costs for patients undergoing surgery or medical interventions with a high bleeding potential. All pregnant women have a significant risk for PPH. Risk factors do exist; however, 60% of women who experience PPH do not have a pre-existing risk factor. Patient blood management in obstetrics must, therefore, not only be focused on women with identified risk factor for PPH, but on all pregnant women. Due to the risk of PPH, which is inherent to every pregnancy, PBM is of particular importance in obstetrics. Although so far, there is no clear guideline how to implement PBM in obstetrics, there are some simple, effective measures to reduce anaemia and the necessity of transfusions in women giving birth and thereby improving clinical outcome and avoiding complications.

CONCLUSION

PBM in obstetrics is based on three main pillars: diagnostic and/or therapeutic interventions during pregnancy, during delivery and in the postpartum phase. These three main pillars should be kept in mind by all professionals taking care of pregnant women, including obstetricians, general practitioners, midwifes, and anaesthesiologists, to improve pregnancy outcome and optimize resources.

Oral Supplementation with Sucrosomial Ferric Pyrophosphate Plus L-Ascorbic Acid to Ameliorate the Martial Status: A Randomized Controlled Trial

Altered martial indices before orthopedic surgery are associated with higher rates of complications and greatly affect the patient’s functional ability. Oral supplements can optimize the preoperative martial status, with clinical efficacy and the patient’s tolerability being highly dependent on the pharmaceutical formula. Patients undergoing elective hip/knee arthroplasty were randomized to be supplemented with a 30-day oral therapy of sucrosomial ferric pyrophosphate plus L-ascorbic acid. The tolerability was 2.7% among treated patients. Adjustments for confounding factors, such as iron absorption influencers, showed a relevant response limited to older patients (≥ 65 years old), whose uncharacterized Hb loss was averted upon treatment with iron formula. Older patients with no support lost −2.8 ± 5.1%, while the intervention group gained +0.7 ± 4.6% of circulating hemoglobin from baseline (p = 0.019). Gastrointestinal diseases, medications, and possible dietary factors could affect the efficacy of iron supplements. Future opportunities may consider to couple ferric pyrophosphate with other nutrients, to pay attention in avoiding absorption disruptors, or to implement interventions to obtain an earlier martial status optimization at the population level.

Development and feasibility of a Patient Blood Management implementation programme in vascular surgery

Vascular surgery is the largest (non-cardiac) user of blood transfusion which is associated with increased risk to patients. Patient Blood Management (PBM) is a quality improvement programme in transfusion medicine involving educational change and recommendations through preoperative, operative, and postoperative surgery. We wished to assess the feasibility to implement a PBM programme in vascular surgery. A multidisciplinary programme was developed at a vascular unit by PBM experts. The PBM programme involved a series of educational lectures, consultations, and discussions with doctors, nurses, and theatre staff. A one-page PBM checklist of recommendations was developed for all patients undergoing vascular surgery. Prospective audits were conducted before (October 2014 to March 2015) and after (November 2015 to February 2016) PBM implementation. Outcomes were blood transfusion and haemoglobin concentration (Hb) trigger threshold. A total of 211 patients were admitted under vascular surgery: 127 for Audit 1 and 84 for Audit 2. Overall, 30% of patients were transfused, with 193 units transfused in Audit 1 and 85 in Audit 2. PBM implementation was associated with a reduction in patients receiving a blood transfusion (37% to 20%; p = 0.01). However, there was no difference in Hb trigger threshold (76 g/L vs 72 g/L, p = 0.051). A PBM programme is feasible and can be implemented in vascular surgery. PBM was associated with an improvement in transfusion use and length of patient stay that merits further investigation.

The association of pre-operative anaemia with survival after orthotopic liver transplantation

Anaemia is common in patients with end-stage liver disease. Pre-operative anaemia is associated with greater mortality after major surgery. We analysed the association of pre-operative anaemia (World Health Organization classification) with survival and complications after orthotopic liver transplantation using Cox and logistic regression models. We included patients undergoing their first orthotopic liver transplantation between 2004 and 2016. Out of 599 included patients, 455 (76%) were anaemic before transplantation. Pre-operative anaemia was not associated with the survival of 485/599 (81%) patients to 1 year after liver transplantation, OR (95%CI) 1.04 (0.64-1.68), p = 0.88. Pre-operative anaemia was associated with higher rates of intra-operative blood transfusions and acute postoperative kidney injury on multivariable analysis, OR (95%CI) 1.70 (0.82-2.59) and 1.72 (1.11-2.67), respectively, p < 0.001 for both. Postoperative renal replacement therapy was associated with pre-operative anaemia on univariate analysis, OR (95%CI) 1.87 (1.11-3.15), p = 0.018.

Consensus Report on Patient Blood Management in Cardiac Surgery by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care (SCTAIC)

Anemia, transfusion and bleeding independently increase the risk of complications and mortality in cardiac surgery. The main goals of patient blood management are to treat anemia, prevent bleeding, and optimize the use of blood products during the perioperative period. The benefit of this program has been confirmed in many studies and its utilization is strongly recommended by professional organizations. This consensus report has been prepared by the authors who are the task members appointed by the Turkish Society of Cardiovascular Surgery, Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care to raise the awareness of patient blood management. This report aims to summarize recommendations for all perioperative blood- conserving strategies in cardiac surgery.

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

BACKGROUND AND PURPOSE

Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research.

METHODS AND MATERIALS

We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital.

RESULTS

Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction.

CONCLUSION

The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.

The efficacy of pre-operative preparation with intravenous iron and/or erythropoietin in anaemic patients undergoing orthopaedic surgery: An observational study

BACKGROUND

Pre-operative anaemia and transfusion are common among patients undergoing elective orthopaedic surgery. Application of 'patient blood management' might be the most effective way to reduce both anaemia and transfusion. Pre-operative administration of iron and/or erythropoietin (EPO) is one of the cornerstones of the first pillar of patient blood management, but in a daily clinical setting, efficacy and long-term safety of this measure have not been analysed thoroughly to date.

OBJECTIVE

To investigate the influence of pre-operative preparation (PREP) of patients with iron and/or EPO on peri-operative transfusion needs and long-term survival.

DESIGN

Single-centre, retrospective study.

SETTING

Anaesthesia department, University hospital.

INTERVENTIONS

Pre-operative preparation with iron and/or EPO versus no preparation.

METHODS

After approval of our local ethics committee, data of 5518 patients who received total hip or total knee replacement between 2008 and 2014 were included. Patients receiving iron and/or EPO were included in the PREP group, whereas patients without iron and/or EPO were included in the no preparation group. From the full data set, a bias-reduced subset of 662 patients was obtained by means of propensity score-matching to compare peri-operative red blood cell utilisation and long-term survival of patients between groups.

RESULTS

Patients in the PREP group needed a lower number of units of red blood cells than patients in the no preparation group (0.2 ± 0.8 vs. 0.5 ± 1.3, P < 0.001), had a lower transfusion rate (12 vs. 24%, P < 0.05) and had a similar haemoglobin concentration (10.7 ± 1.3 vs. 10.6 ± 1.1 g dl, not significant) at discharge. No differences in long-term survival were observed between the two study groups.

CONCLUSION

PREP of patients with iron and/or EPO in orthopaedic patients can be considered highly effective in terms of transfusion reduction, without influencing long-term survival.

Enhanced recovery after cardiac surgery

The concept of early recovery after surgery (ERAS) consists of bundle interventions during the pre-, intra- and postoperative periods and team work. The ERAS, which is a multimodal strategy, enables one to limit the neurohumoral response to the surgery, maintain homeostasis, reduce the risk of complications, shorten the hospital stay, accelerate the return to everyday functioning, improve the patient’s satisfaction, achieve a satisfactory quality of life and finally reduce the treatment costs and eliminate any redundant and ineffective practices. Almost every patient can be classified for the ERAS strategy except for patients undergoing urgent and emergency surgery. The necessity to give up ERAS can result from poor organisation and management. Moreover, the procedure itself can be the cause of the lack of adherence to the planned standard. It is necessary to use protocols and checklists. While fulfilling this doctrine, the anaesthesiologist becomes a perioperative specialist.

Management of Perioperative Iron Deficiency Anemia

Preoperative anemia affects 30-40% of patients undergoing major surgery and is an independent risk factor for perioperative blood transfusion, morbidity, and mortality. Absolute or functional iron deficiency is its leading cause. Nonanemic hematinic deficiencies are also prevalent and may hamper preoperative hemoglobin optimization and/or recovery from postoperative anemia. As modifiable risk factors, anemia and hematinic deficiencies should be detected and corrected prior to major surgical procedures. Postoperative anemia is even more common (up to 80-90%) due to surgery-associated blood loss, inflammation-induced blunted erythropoiesis, and/or preexisting anemia. Preoperative oral iron may have a role in mild-to-moderate anemia, provided there is sufficient time (6-8 weeks) and adequate tolerance of oral preparations. Postoperative oral iron is of little value and rife with gastrointestinal adverse events. Intravenous iron should preferentially be used in cases of moderate-to-severe iron deficiency anemia, concomitant use of erythropoiesis-stimulating agents, short time to surgery or nonelective procedures, and for postoperative anemia management. Minor infusion reactions to intravenous iron are rare, the incidence of severe anaphylactic reactions is extremely low, and there is no increase in infections with intravenous iron. Currently available intravenous iron formulations allowing administration of large single doses are preferred.

Feasibility of a Preoperative Anemia Protocol in a Large Integrated Health Care System

BACKGROUND

Optimizing preoperative anemia is a required component of the Joint Commission Patient Blood Management Certification and an important component of Enhanced Recovery After Surgery.

OBJECTIVE

To describe a preoperative anemia protocol developed and implemented at the Kaiser Permanente San Jose Medical Center in California to facilitate preoperative identification and treatment of anemia.

METHODS

The protocol included all operations at risk of causing substantial blood loss. It excluded emergent operations and those for which the patient had a normal last hemoglobin value within the prior 12 months unless newly developed anemia was suspected. Eligible patients were screened for laboratory evaluation, and those with anemia were treated for reversible causes. Consistency was ensured by physician, staff, and patient education, and by use of electronic health records. Administration of intravenous iron and erythropoietin and consultation with specialists were expedited as part of a management algorithm.

RESULTS

Among 510 patients enrolled during 1 year, 442 (87%) received anemia screening laboratory tests. Half of those with laboratory results were eligible for further optimization: 207 had anemia and 21 had iron deficiency without anemia. Among the 228 patients eligible for optimization, 189 (83%) had anemia addressed preoperatively. Of 129 patients with iron deficiency anemia, 102 (79%) received intravenous iron preoperatively, with a mean preoperative increase in hemoglobin level by 0.98 g/dL (n = 79).

CONCLUSION

Integration of specialty services, optimization of technology, and consistency across practitioners were crucial for successful implementation and sustainability of a preoperative anemia protocol developed to expedite and enhance best practices.

Current transfusion practices of anesthesiologists in a major city in South India

BACKGROUND AND AIMS

Allogenic blood transfusion is a double edged sword with a delicate balance between benefits and risks. There is heavy use of blood products in the perioperative setting mostly initiated by anesthesiologists. Limited research has been done in evaluating the transfusion practices of anesthesiologists especially in Indian setting. We conducted a survey among the anesthesiologists in our city to assess their blood transfusion practices, to evaluate the level of adherence to principles of Patient Blood Management and to look for innovative strategies to improve the perioperative transfusions.

METHODS

A validated questionnaire with four sets of questions was distributed among the practitioners in the Indian Society of Anaesthesiologists city branch and the responses were collected and analysed. The first and second parts were structured to assess the current blood transfusion practices. The third part evaluated the keenness of participants in further updating their practices as per the recommended protocols of patient blood management. The last part assessed how the participants would act in a given clinical scenario. Statistical analysis was done using Statistical Package for the Social Sciences version 21. Results are expressed in numbers and percentages.

RESULTS

Moderate preoperative anemia was acceptable to majority of the responders. There was a high demand for continuing medical education in transfusion medicine and for formulating Indian guidelines for perioperative transfusion. The clinical scenarios demonstrated the restrictive transfusion strategy of the majority of our anesthesiologists. The lack of institutional protocols and blood transfusion committees was also seen.

CONCLUSION

The restrictive strategy of our practitioners was an encouraging finding. There is lack of uniformity in patient blood management services. Regular educational interventions are needed to update the clinicians. Formulation and implementation of institutional protocols for perioperative blood transfusion is mandatory.

Clinical standards for patient blood management and perioperative hemostasis and coagulation management. Position Paper of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new "standard of care" so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period.

Single dose of intravenous ferric carboxymaltose infusion versus multiple fractionated doses of intravenous iron sucrose in the treatment of postoperative anaemia in colorectal cancer patients: study protocol for a randomised controlled trial

Background

Patients with colorectal cancer (CRC) often present with associated anaemia which is usually present at the time of diagnosis and is aggravated during the postoperative period due to blood loss during the surgery process. Several guidelines advocate for the treatment of postoperative anaemia in these patients in order to prevent complications and allogeneic blood transfusions. However, there are no publications to shed light on the effectiveness of intravenous iron (IVI) administration after CRC surgery and the optimal dose and regimen. We have started a clinical trial with the objective of comparing the effectiveness of 1000 mg of ferric carboxymaltose with fractionated iron sucrose 200 g/48 h for the treatment of postoperative anaemia, by measuring the change of haemoglobin (Hb) levels from postoperative day (POD) 1 to POD 30.

Methods

We designed an open label randomised controlled trial to compare two postoperative IVI treatment regimens. Patients aged > 18 years undergoing CRC surgery, with Hb < 11 g/dL on POD 1 are randomly assigned to receive either 1000 mg of ferric carboxymaltose (single dose) or 200 g/48 h of iron sucrose. The main study endpoint will be the change from POD 1 to POD 30 in Hb levels and the key secondary endpoint the percentage of patients with Hb levels ≥ 13 g/dL at POD 30. Other secondary endpoints include: changes in iron metabolism parameters (Fe, ferritin, transferrin, % saturated trasferrin) at POD 30; total doses of iron received; number of postoperative transfusions; compliance with oral iron treatment; number of medical and surgical complications; adverse reactions reported by the patient; use of health resources after surgery; and changes in quality of life (QoL). It has been estimated that a sample of 48 patients per group will allow detecting a difference of 0.75 g/dL in Hb in the change in Hb levels from POD 1 to POD 30.

Discussion

The results of this study will confirm if the single dose of 1000 mg ferric carboxymaltose should be preferred in front of the fractionated doses and in which type of patients this regimen should be used preferably.

Trial registration

European Union Clinical Trials Register, EudraCT 2015-001005-13. Registered on 6 January 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3125-2) contains supplementary material, which is available to authorized users.