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Greenberg JA, Zwiep TM, Sadek J, Malcolm JC, Mullen KA, McIsaac DI, Musselman RP, Moloo H. Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking. Can J Surg 2021; 64:E491-E509. [PMID: 34598927 PMCID: PMC8526150 DOI: 10.1503/cjs.011519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 12/13/2022] Open
Abstract
Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.
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Affiliation(s)
- Joshua A Greenberg
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Greenberg, Zwiep, Sadek, Musselman, Moloo); the Department of Medicine, The Ottawa Hospital, Ottawa, Ont. (Saidenberg, Malcolm); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Saidenberg, McIsaac, Moloo); the University of Ottawa Heart Institute, Ottawa, Ont. (Mullen); and the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ont. (McIsaac)
| | - Terry M Zwiep
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Greenberg, Zwiep, Sadek, Musselman, Moloo); the Department of Medicine, The Ottawa Hospital, Ottawa, Ont. (Saidenberg, Malcolm); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Saidenberg, McIsaac, Moloo); the University of Ottawa Heart Institute, Ottawa, Ont. (Mullen); and the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ont. (McIsaac)
| | - Joseph Sadek
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Greenberg, Zwiep, Sadek, Musselman, Moloo); the Department of Medicine, The Ottawa Hospital, Ottawa, Ont. (Saidenberg, Malcolm); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Saidenberg, McIsaac, Moloo); the University of Ottawa Heart Institute, Ottawa, Ont. (Mullen); and the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ont. (McIsaac)
| | - Janine C Malcolm
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Greenberg, Zwiep, Sadek, Musselman, Moloo); the Department of Medicine, The Ottawa Hospital, Ottawa, Ont. (Saidenberg, Malcolm); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Saidenberg, McIsaac, Moloo); the University of Ottawa Heart Institute, Ottawa, Ont. (Mullen); and the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ont. (McIsaac)
| | - Kerri A Mullen
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Greenberg, Zwiep, Sadek, Musselman, Moloo); the Department of Medicine, The Ottawa Hospital, Ottawa, Ont. (Saidenberg, Malcolm); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Saidenberg, McIsaac, Moloo); the University of Ottawa Heart Institute, Ottawa, Ont. (Mullen); and the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ont. (McIsaac)
| | - Daniel I McIsaac
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Greenberg, Zwiep, Sadek, Musselman, Moloo); the Department of Medicine, The Ottawa Hospital, Ottawa, Ont. (Saidenberg, Malcolm); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Saidenberg, McIsaac, Moloo); the University of Ottawa Heart Institute, Ottawa, Ont. (Mullen); and the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ont. (McIsaac)
| | - Reilly P Musselman
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Greenberg, Zwiep, Sadek, Musselman, Moloo); the Department of Medicine, The Ottawa Hospital, Ottawa, Ont. (Saidenberg, Malcolm); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Saidenberg, McIsaac, Moloo); the University of Ottawa Heart Institute, Ottawa, Ont. (Mullen); and the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ont. (McIsaac)
| | - Husein Moloo
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Greenberg, Zwiep, Sadek, Musselman, Moloo); the Department of Medicine, The Ottawa Hospital, Ottawa, Ont. (Saidenberg, Malcolm); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Saidenberg, McIsaac, Moloo); the University of Ottawa Heart Institute, Ottawa, Ont. (Mullen); and the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ont. (McIsaac)
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Kumar L, Kumar AH, Grant SA, Gadsden J. Updates in Enhanced Recovery Pathways for Total Knee Arthroplasty. Anesthesiol Clin 2018; 36:375-386. [PMID: 30092935 DOI: 10.1016/j.anclin.2018.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Enhanced recovery after surgery (ERAS) programs for orthopedics involve a multidisciplinary approach to accelerating return to function, reducing pain, improving patient comfort and satisfaction, reducing complications from the surgical procedure, reducing hospital length of stay, and reducing costs. ERAS pathways for patients receiving total knee arthroplasty are different from those having intracavitary surgery; they are less focused on fluid homeostasis and gut motility than they are with optimizing systemic and local analgesics and providing a balance between the highest quality pain control and accelerated return to ambulation.
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Affiliation(s)
- Lisa Kumar
- Regional Anesthesiology and Acute Pain Medicine, Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Amanda H Kumar
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Stuart A Grant
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Jeff Gadsden
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.
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Polanco-García M, Capielo AM, Miret X, Chamero A, Sainz J, Revilla E, Guinjoan A, Arranz T. Effectiveness of a patient blood management protocol on reduction of allogeneic red blood cell transfusions in orthopedic surgery. Med Clin (Barc) 2018; 152:90-97. [PMID: 29887176 DOI: 10.1016/j.medcli.2018.04.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Patient blood management in orthopaedic surgery reduces transfusion risk. The best protocol is unknown. The effectiveness of a protocol based on the Seville Consensus on the reduction of transfusion risk is evaluated and a predictive transfusion equation is proposed in knee surgery. PATIENTS AND METHODS Cohort study in patients undergoing knee and hip arthroplasty from January 2014 to December 2015 at a second level complexity hospital in Vilafranca del Penedès (Barcelona). Patients with Hb between 10 and 13g/dL were classified as anaemic with or without iron deficiency and received iron or combination of iron and erythropoietin. On the day of surgery, tranexamic acid was administered, the Hb drop was measured the next day and the requirements and the transfusion lintel were measured during the stay. RESULTS A total of 334 patients were included in the study. The implementation of the programme decreased the transfusion risk from 41.5% to 14.8% at the end of the study. In hip surgery, transfused patients were significantly older, sicker and with lower preoperative Hb. Tranexamic acid did not decrease bleeding. In knee surgery, the administration of tranexamic acid was the variable that most decreased the transfusion risk followed by a high preoperative Hb. The equation predicts transfusion risk with a sensitivity of 55% and specificity of 95.7%. CONCLUSION The implementation of the programme reduces transfusion risk. The effectiveness of tranexamic acid varies according to surgery site. The use of iron and recombinant human erythropoietin is necessary to improve Hb.
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Affiliation(s)
- Mauricio Polanco-García
- Departamento de Anestesiología, Reanimación y Terapia del Dolor, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España.
| | - Ana María Capielo
- Departamento de Anestesiología, Reanimación y Terapia del Dolor, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Xavier Miret
- Departamento de Anestesiología, Reanimación y Terapia del Dolor, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Antonio Chamero
- Departamento de Anestesiología, Reanimación y Terapia del Dolor, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Julio Sainz
- Departamento de Anestesiología, Reanimación y Terapia del Dolor, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Elena Revilla
- Departamento de Hematología, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Antoni Guinjoan
- Departamento de Traumatología, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
| | - Teresa Arranz
- Departamento de Farmacia. Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, España
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Rosique RG, Rosique MJF, Rabelo MQ. Does Postoperative Erythropoietin Reduce Transfusions and Hemodynamic Instability Following Liposuction, Either Alone or Associated with Abdominoplasty or Mammaplasty? A Comparative, Prospective Study of 50 Consecutive Patients. Aesthetic Plast Surg 2017; 41:98-101. [PMID: 28039503 DOI: 10.1007/s00266-016-0748-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/18/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Erythropoietin (EPO) is a hematopoietic growth factor and an alternative to avoid blood transfusion in high-blood-loss surgeries. We evaluate EPO efficacy to reduce clinically relevant anemia and dehydration in patients undergoing liposuction. METHODS We prospectively evaluated 50 consecutive patients subjected to liposuction greater than 2.5 L and alternately assigned into two comparable groups (25 patients each), except for the postoperative administration of erythropoietin (4000 UI per day subcutaneously) during five consecutive days. Incidence data for blood transfusion or parenteral hydration were collected. Statistical analyses were performed with significance at p value <5%. RESULTS There was no significant difference between groups related to any preoperative feature or the incidence of dehydration (p = 0.1099) or transfusion (p = 1.0). CONCLUSION Postoperative erythropoietin administration was not effective in preventing blood transfusion for anemia or parenteral hydration for hemodynamic instability in patients undergoing major liposuction. 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 http://www.springer.com/00266.
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Affiliation(s)
- Rodrigo G Rosique
- Rosique Plastic Surgery, Antonio Diederichsen Street, 400, Suite 1204, Ribeirão Preto, São Paulo, 14020-250, Brazil.
| | - Marina J F Rosique
- Rosique Plastic Surgery, Antonio Diederichsen Street, 400, Suite 1204, Ribeirão Preto, São Paulo, 14020-250, Brazil
| | - Mariana Quintino Rabelo
- Rosique Plastic Surgery, Antonio Diederichsen Street, 400, Suite 1204, Ribeirão Preto, São Paulo, 14020-250, Brazil
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