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Caserta D, Costanzi F, De Marco MP, Besharat AR, Napoli C, Aromatario MR, Palomba S. Bloodless Gynecological Surgery in Blood Products Refusing Patients: Experience of a Single Institution. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:346-351. [PMID: 38666224 PMCID: PMC11044853 DOI: 10.1089/whr.2023.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 04/28/2024]
Abstract
Propose This pilot study aimed to apply the central tenets of bloodless surgery and to analyze the effectiveness of specific preoperative, intraoperative, and postoperative strategies to minimize the risk for blood transfusion after gynecological surgery in a specific group of patients who refused blood products. Methods A total of 83 patients undergoing gynecological surgery were included in the study. Forty-two patients received preoperatively oral iron, acid folic, and vitamin B12 supplementation in the 30 days before surgery, and 41 patients did not receive therapy. Results No significant differences were found when comparing the two study groups. The implementation of all procedures to maintain a bloodless surgery has been helpful, in association with the other available procedures, in achieving optimal management and maintenance of hemoglobin levels, even in the most critical situations. Conclusion In conclusion, implementing the bloodless approach as much as possible could guarantee the patient better and safer clinical and care management. Furthermore, well-designed research is required to clarify further the effects of bloodless surgery in gynecological patients.
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Affiliation(s)
- Donatella Caserta
- Gynecology Division, Department of Medical Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Flavia Costanzi
- Gynecology Division, Department of Medical Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Maria Paola De Marco
- Gynecology Division, Department of Medical Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Aris Raad Besharat
- Gynecology Division, Department of Medical Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Christian Napoli
- Department of Medical Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Maria Rosaria Aromatario
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Science, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Stefano Palomba
- Gynecology Division, Department of Medical Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
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Ruan N, Shi C, Al-Momani Z, Jaber F, Ghaly R, Wooldridge D. Management of Severe Anemia in a Jehovah's Witness Patient With Lung Abscess Secondary to Malpositioned Laparoscopic Adjustable Gastric Band: A Case Report. J Investig Med High Impact Case Rep 2024; 12:23247096241231649. [PMID: 38353220 PMCID: PMC10868478 DOI: 10.1177/23247096241231649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/14/2024] [Accepted: 01/23/2024] [Indexed: 02/16/2024] Open
Abstract
Jehovah's Witnesses is a Christian denomination widely recognized for their steadfast refusal of blood transfusions, even when facing severe anemia. We describe a unique case of a 42-year-old Jehovah's Witness woman with severe iron deficiency anemia. She necessitated surgical correction of a malpositioned gastric band within the context of a complex necrotizing aspiration pneumonia secondary to esophageal obstruction. Medical management of this severe anemia has been a challenge as traditional approaches, like a blood transfusion, are not possible. Instead, a multifaceted approach has been described with intravenous iron infusions, recombinant human erythropoietin, vitamin B12, folate, and vitamin C administration. We emphasize the lack of consensus on guideline protocols regarding management of severe anemia for Jehovah's Witness patients and the subsequent need for more investigation into that matter. It also underscores the significance of respecting patient autonomy through close collaboration between patients and their health care providers to ensure effective patient-centered care.
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Affiliation(s)
- Nina Ruan
- University of Missouri-Kansas City, USA
| | - Chloe Shi
- University of Missouri-Kansas City, USA
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3
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Lewis SR, Pritchard MW, Estcourt LJ, Stanworth SJ, Griffin XL. Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD013737. [PMID: 37294864 PMCID: PMC10249061 DOI: 10.1002/14651858.cd013737.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Following hip fracture, people sustain an acute blood loss caused by the injury and subsequent surgery. Because the majority of hip fractures occur in older adults, blood loss may be compounded by pre-existing anaemia. Allogenic blood transfusions (ABT) may be given before, during, and after surgery to correct chronic anaemia or acute blood loss. However, there is uncertainty about the benefit-risk ratio for ABT. This is a potentially scarce resource, with availability of blood products sometimes uncertain. Other strategies from Patient Blood Management may prevent or minimise blood loss and avoid administration of ABT. OBJECTIVES To summarise the evidence from Cochrane Reviews and other systematic reviews of randomised or quasi-randomised trials evaluating the effects of pharmacological and non-pharmacological interventions, administered perioperatively, on reducing blood loss, anaemia, and the need for ABT in adults undergoing hip fracture surgery. METHODS In January 2022, we searched the Cochrane Library, MEDLINE, Embase, and five other databases for systematic reviews of randomised controlled trials (RCTs) of interventions given to prevent or minimise blood loss, treat the effects of anaemia, and reduce the need for ABT, in adults undergoing hip fracture surgery. We searched for pharmacological interventions (fibrinogen, factor VIIa and factor XIII, desmopressin, antifibrinolytics, fibrin and non-fibrin sealants and glue, agents to reverse the effects of anticoagulants, erythropoiesis agents, iron, vitamin B12, and folate replacement therapy) and non-pharmacological interventions (surgical approaches to reduce or manage blood loss, intraoperative cell salvage and autologous blood transfusion, temperature management, and oxygen therapy). We used Cochrane methodology, and assessed the methodological quality of included reviews using AMSTAR 2. We assessed the degree of overlap of RCTs between reviews. Because overlap was very high, we used a hierarchical approach to select reviews from which to report data; we compared the findings of selected reviews with findings from the other reviews. Outcomes were: number of people requiring ABT, volume of transfused blood (measured as units of packed red blood cells (PRC)), postoperative delirium, adverse events, activities of daily living (ADL), health-related quality of life (HRQoL), and mortality. MAIN RESULTS We found 26 systematic reviews including 36 RCTs (3923 participants), which only evaluated tranexamic acid and iron. We found no reviews of other pharmacological interventions or any non-pharmacological interventions. Tranexamic acid (17 reviews, 29 eligible RCTs) We selected reviews with the most recent search date, and which included data for the most outcomes. The methodological quality of these reviews was low. However, the findings were largely consistent across reviews. One review included 24 RCTs, with participants who had internal fixation or arthroplasty for different types of hip fracture. Tranexamic acid was given intravenously or topically during the perioperative period. In this review, based on a control group risk of 451 people per 1000, 194 fewer people per 1000 probably require ABT after receiving tranexamic acid (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.46 to 0.68; 21 studies, 2148 participants; moderate-certainty evidence). We downgraded the certainty for possible publication bias. Review authors found that there was probably little or no difference in the risks of adverse events, reported as deep vein thrombosis (RR 1.16, 95% CI 0.74 to 1.81; 22 studies), pulmonary embolism (RR 1.01, 95% CI 0.36 to 2.86; 9 studies), myocardial infarction (RR 1.00, 95% CI 0.23 to 4.33; 8 studies), cerebrovascular accident (RR 1.45, 95% CI 0.56 to 3.70; 8 studies), or death (RR 1.01, 95% CI 0.70 to 1.46; 10 studies). We judged evidence from these outcomes to be moderate certainty, downgraded for imprecision. Another review, with a similarly broad inclusion criteria, included 10 studies, and found that tranexamic acid probably reduces the volume of transfused PRC (0.53 fewer units, 95% CI 0.27 to 0.80; 7 studies, 813 participants; moderate-certainty evidence). We downgraded the certainty because of unexplained high levels of statistical heterogeneity. No reviews reported outcomes of postoperative delirium, ADL, or HRQoL. Iron (9 reviews, 7 eligible RCTs) Whilst all reviews included studies in hip fracture populations, most also included other surgical populations. The most current, direct evidence was reported in two RCTs, with 403 participants with hip fracture; iron was given intravenously, starting preoperatively. This review did not include evidence for iron with erythropoietin. The methodological quality of this review was low. In this review, there was low-certainty evidence from two studies (403 participants) that there may be little or no difference according to whether intravenous iron was given in: the number of people who required ABT (RR 0.90, 95% CI 0.73 to 1.11), the volume of transfused blood (MD -0.07 units of PRC, 95% CI -0.31 to 0.17), infection (RR 0.99, 95% CI 0.55 to 1.80), or mortality within 30 days (RR 1.06, 95% CI 0.53 to 2.13). There may be little or no difference in delirium (25 events in the iron group compared to 26 events in control group; 1 study, 303 participants; low-certainty evidence). We are very unsure whether there was any difference in HRQoL, since it was reported without an effect estimate. The findings were largely consistent across reviews. We downgraded the evidence for imprecision, because studies included few participants, and the wide CIs indicated possible benefit and harm. No reviews reported outcomes of cognitive dysfunction, ADL, or HRQoL. AUTHORS' CONCLUSIONS Tranexamic acid probably reduces the need for ABT in adults undergoing hip fracture surgery, and there is probably little or no difference in adverse events. For iron, there may be little or no difference in overall clinical effects, but this finding is limited by evidence from only a few small studies. Reviews of these treatments did not adequately include patient-reported outcome measures (PROMS), and evidence for their effectiveness remains incomplete. We were unable to effectively explore the impact of timing and route of administration between reviews. A lack of systematic reviews for other types of pharmacological or any non-pharmacological interventions to reduce the need for ABT indicates a need for further evidence syntheses to explore this. Methodologically sound evidence syntheses should include PROMS within four months of surgery.
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Affiliation(s)
- Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael W Pritchard
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Simon J Stanworth
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Trauma & Orthopaedics Surgery Group, Blizard Institute, Queen Mary University of London, London, UK
- The Royal London Hospital Barts Health NHS Trust, London, UK
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Cao S, Lv K, Peng C, Bai G, Gao X, Wang J, Cao J, Ning R, Chu J, Liu T. Efficacy and safety of erythropoietin in isolated spinal metastasis patients with total en bloc spondylectomy surgery: a case-control study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1021-1028. [PMID: 36715756 DOI: 10.1007/s00586-023-07554-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/07/2022] [Accepted: 01/21/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The purpose of our study is to identify the effect of short-term and high-dose use of erythropoietin (EPO) in spinal isolated metastatic patients with Total en bloc spondylectomy (TES) surgery by assessing hematological parameters, transfusion volume, postoperative complications, recurrence-free survival (RFS), and overall survival (OS). METHODS From January 2015 and January 2022, 93 isolated spinal metastasis patients were selected and separated into 2 groups based on the treatment method used (EPO + TXA (Tranexamic acid) group, n = 47; and TXA group, n = 46). Indexes for evaluation included hemoglobin (Hb), hematocrit (Hct), red blood cells (RBC), RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, transfusion rate, and mean units transfused. RESULTS The average follow-up duration was 38.13 months. There was no significant difference (P > 0.05) in RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, and transfusion rate between the two groups. However, patients in EPO + TXA group have significantly higher Hb, Hct, and RBC values than those in the TXA group on postoperative days 1, 2, 3, and 5. Moreover, the mean transfusion volume in EPO + TXA group was significantly lower than those in the TXA group (P = 0.011). CONCLUSIONS Perioperative short-term and high-dose administration of EPO could improve the anemia-related hematological parameters and reduce the requirement for blood transfusion without increasing the risk of deep vein thrombosis and tumor progression in solitary spinal metastatic patients with TES surgery.
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Affiliation(s)
- Shuang Cao
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Kai Lv
- Department of Orthopedics, Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Cheng Peng
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Guangjian Bai
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Xin Gao
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Jing Wang
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Jiashi Cao
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Rende Ning
- Department of Orthopedics, Third Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China.
| | - Jianjun Chu
- Department of Orthopedics, The Second People's Hospital of Hefei, Hefei, Anhui Province, China.
| | - Tielong Liu
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China.
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Kelly LS, Munley JA, Kannan KB, Pons EE, Coldwell PS, Bible LE, Parvataneni HK, Hagen JE, Efron PA, Mohr AM. Anemia Recovery after Trauma: A Longitudinal Study. Surg Infect (Larchmt) 2023; 24:39-45. [PMID: 36579920 PMCID: PMC9894600 DOI: 10.1089/sur.2022.299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Post-injury inflammation and its correlation with anemia recovery after severe trauma is poorly described. Severe injury induces a systemic inflammatory response associated with critical illness and organ dysfunction, including disordered hematopoiesis, and anemia. This study sought to characterize the resolution of post-injury inflammation and anemia to identify risk factors associated with persistence of anemia. Patients and Methods: This single-institution study prospectively enrolled 73 trauma patients with an injury severity score >15, hemorrhagic shock, and a lower extremity long bone orthopedic injury. Blood was obtained at enrollment and after 14 days, one, three, and six months. Analytes were compared using Mann-Whitney U tests with correction for multiple comparisons. Results: Median age was 45 years and Injury Severity Score (ISS) was 27, with anemia rates of 97% at two weeks, 80% at one month, 52% at three months, and 30% at six months. Post-injury elevations in erythropoietin, interleukin-6, and C-reactive protein resolved by one month, three months, and six months, respectively. Median granulocyte colony-stimulating factor (G-CSF) and tumor necrosis factor (TNF)-α concentrations remained elevated throughout the six-month follow-up period. Patients with persistent anemia had longer intensive care unit and hospital lengths of stay, more infectious complications, and received more packed red blood cell transfusions compared to those with early anemia recovery. Conclusions: Severe trauma is associated with a prolonged inflammatory response, which is associated with increased transfusion requirements, lengths of stay, and persistent anemia. Further analysis is needed to identify correlations between prolonged inflammation and clinical outcomes after discharge.
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Affiliation(s)
- Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Preston S. Coldwell
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Letitia E. Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Hari K. Parvataneni
- Department of Orthopedic Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jennifer E. Hagen
- Department of Orthopedic Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
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Xiong X, Li T, Cheng B. Anemia and formation of deep vein thrombosis before operation in patients with knee osteoarthritis: a cross-sectional study. J Orthop Surg Res 2023; 18:33. [PMID: 36631873 PMCID: PMC9835343 DOI: 10.1186/s13018-023-03518-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 01/08/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Preoperative anemia is a common complication in knee osteoarthritis (KOA) patients. However, the association between anemia and preoperative deep vein thrombosis (DVT) in osteoarthritis patients remains unknown. The aim of this study was to investigate such association. METHODS In this retrospective study, we included 1005 KOA patients undergoing total knee arthroplasty (TKA) in our hospital. According to preoperative hemoglobin levels, the patients were divided into anemia group and non-anemia group. According to the results of Doppler ultrasonography for the lower extremities, the patients were divided into DVT group and non-DVT group. A logistic model was established through propensity score matching (PSM), with anemia before TKA as the dependent variable, DVT-related variable as the covariate, and 0.03 as the Caliper value. The anemia group and non-anemia group were matched at a 1:1 ratio and 310 successfully matched. After matching, logistic regression analysis was used to evaluate the correlation between preoperative anemia and DVT in KOA patients. RESULTS In this study, 342 cases (33.6%) had preoperative anemia and 73 cases (7.2%) had DVT before TKA. After matching, 46 DVT cases (7.42%) were found. By using binary logistic regression after PSM, we found that the risk for preoperative DVT formation in TKA patients with preoperative anemia increased by 1.97 times [95% (CI 1.05-3.69)], P = 0.035. CONCLUSION Preoperative anemia is considered as an independent risk factor for the formation of preoperative DVT in KOA patients. TRIAL REGISTRATION ChiCRT2100054844.
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Affiliation(s)
- Xiaojuan Xiong
- grid.414048.d0000 0004 1799 2720Department of Anesthesiology, Army Medical Center of PLA, Daping Hospital, Army Medical University, 10 ChangjiangZhilu, Yuzhong District, Chongqing, 400042 China
| | - Ting Li
- grid.414048.d0000 0004 1799 2720Department of Anesthesiology, Army Medical Center of PLA, Daping Hospital, Army Medical University, 10 ChangjiangZhilu, Yuzhong District, Chongqing, 400042 China
| | - Bo Cheng
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University Yuzhong District, 1 Youyi Road, Yuzhong District, Chongqing, 400000 China
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8
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Naveed K, Goldberg N, Shore E, Dhoot A, Gabrielson D, Goodarzi Z, Lin Y, Pai M, Pardy NA, Robinson S, Andreou R, Sood M, Price V, Storm S, Verduyn A, Parker ML, Fralick M, Beriault D, Sholzberg M. Defining ferritin clinical decision limits to improve diagnosis and treatment of iron deficiency: A modified Delphi study. Int J Lab Hematol 2023; 45:377-386. [PMID: 36602151 DOI: 10.1111/ijlh.14016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Iron deficiency is highly prevalent worldwide and is an issue of health inequity. Despite its high prevalence, uncertainty on the clinical applicability and evidence-base of iron-related lab test cut-offs remains. In particular, current ferritin decision limits for the diagnosis of iron deficiency may not be clinically appropriate nor scientifically grounded. METHODS A modified Delphi study was conducted with various clinical experts who manage iron deficiency across Canada. Statements about ferritin decision limits were generated by a steering committee, then distributed to the expert panel to vote on agreement with the aim of achieving consensus and acquiring feedback on the presented statements. Consensus was reached after two rounds, which was defined as 70% of experts rating their agreement for a statement as 5 or higher on a Likert scale from 1 to 7. RESULTS Twenty-six clinical experts across 10 different specialties took part in the study. Consensus was achieved on 28 ferritin decision limit statements in various populations (including patients with multiple comorbid conditions, pediatric patients, and pregnant patients). For example, there was consensus that a ferritin <30 μg/L rules in iron deficiency in all adult patients (age ≥ 18 years) and warrants iron replacement therapy. CONCLUSION Consensus statements generated through this study corresponded with current evidence-based literature and guidelines. These statements provide clarity to facilitate clinical decisions around the appropriate detection and management of iron deficiency.
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Affiliation(s)
- Kanza Naveed
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicola Goldberg
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Eliane Shore
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Arti Dhoot
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Denise Gabrielson
- Division of Hematology/Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Zahra Goodarzi
- Department of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Menaka Pai
- Hamilton Regional Laboratory Medicine Program, Hamilton Health Sciences and St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Natasha A Pardy
- Department of Hematology, Eastern Health, St. John's, Newfoundland and Labrador, Canada
| | - Sue Robinson
- Division of Hematology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Roseann Andreou
- Division of Hematology/Oncology, Toronto East Health Network Michael Garron Hospital, Toronto, Ontario, Canada
| | - Manish Sood
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Vicky Price
- Division of Pediatric Hematology/Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sherri Storm
- Academic Family Health Team & Women's and Children's Health Program, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ashley Verduyn
- Department of Rehabilitative Care, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle L Parker
- DynaLIFE Medical Labs and Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Fralick
- Department of Internal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Daniel Beriault
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, Toronto, Ontario, Canada
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9
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Bartakke AA, Carmona-Garcia P, Fuster-Gonzalez M, Reparaz-Vives X. Manejo anestésico en la cirugía de reparación valvular mitral. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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10
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Efficacy and Safety of Intravenous Iron Therapy for Treating Anaemia in Critically ill Adults: A Rapid Systematic Review With Meta-Analysis. Transfus Med Rev 2021; 36:97-106. [PMID: 35031197 DOI: 10.1016/j.tmrv.2021.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 12/16/2022]
Abstract
Our objective was to systematically evaluate the efficacy and safety of intravenous (IV) iron therapy for treating anaemia in critically ill adults (>16 years) admitted to intensive care or high dependency units. We excluded quasi-RCTs and other not truly randomised trials. We searched 7 electronic databases (including CENTRAL, MEDLINE, and Embase) using a pre-defined search strategy from inception to June 14, 2021. One reviewer screened, extracted, and analysed data, with verification by a second reviewer of all decisions. We used Cochrane risk of bias (ROB) 1 and GRADE to assess the certainty of the evidence. We reported 3 comparisons across 1198 patients, in 8 RCTs: (1) IV iron vs control (7 RCTs, 748 participants); our primary outcome (hemoglobin (Hb) concentration at 10 to 30 days) was reported in 7 of the 8 included trials. There was evidence of an effect (very-low certainty) in favour of IV iron over control in the main comparison only (6 RCTs, n = 528, mean difference (MD) 0.52g/dL [95%CI 0.23, 0.81], P = .0005). For the remaining outcomes there was no evidence of an effect in either direction (low certainty of evidence for Hb concentration at <10 days; very-low certainty of evidence for hospital duration, ICU duration, hospital readmission, infection, mortality; HRQoL outcomes were not GRADED). (2) IV iron + subcutaneous erythropoietin (EPO) vs control (2 RCTs, 104 participants); reported outcomes showed no evidence of effect in either direction, based on very-low certainty evidence (Hb concentration at 10-30 days, and <10 days, infection, mortality). (3) Hepcidin-guided treatment with IV iron or iron+ EPO vs standard care (1 RCT, 399 participants) reported evidence of an effect in favour of the intervention for 90-day mortality (low certainty of evidence), but no other group differences for the reported outcomes (low certainty evidence for Hb concentration at 10-30 days, hospital duration; HRQoL was not GRADED). The evidence across all comparisons was downgraded for high and unclear ROB for lack of blinding, incomplete outcome data, baseline imbalance, and imprecision around the estimate (wide CIs and small sample size). In conclusion, the current evidence continues to support further investigation into the role for iron therapy in increasing Hb in critically ill patients. Recent, small, trials have begun to focus on patient-centred outcomes but a large, well conducted, and adequately powered trial is needed to inform clinical practice.
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11
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Hamilton CM, Davenport DL, Bernard AC. Demonstration of a U.S. nationwide reduction in transfusion in general surgery and a review of published transfusion reduction methodologies. Transfusion 2021; 61:3119-3128. [PMID: 34595745 DOI: 10.1111/trf.16677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 06/24/2021] [Accepted: 08/04/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Red blood cell transfusions in surgical procedures can be lifesaving. However, recent studies show transfusions are associated with a dose-dependent increase in postoperative morbidity and mortality; hospitals and physicians have attempted to reduce them. We sought to determine the success of these efforts and review and summarize published reduction methods employed. STUDY DESIGN/METHODS An analysis of transfusion data from ACS-NSQIP public use files of general surgical procedures for 2012 and 2018; a retrospective review of the literature surrounding general surgical transfusion reduction from 2008 to 2018. RESULTS The rate of general surgical transfusion in the NSQIP dataset decreased from 5.5% in 2012 to 4.0% in 2018, a 27% relative reduction in transfusion. After extensive multivariable adjustment for patient risk and operative complexity, this effect remained (Odds ratio 0.65, 95% CI 0.63-0.67, p < .001). Furthermore, there was a positive correlation between specific procedure decreases in transfusion and decreases in 30-day morbidity (rho =0.41, p = .003) and mortality (rho = 0.37, p = .007). There were 866 published studies matching our search term "red blood cell transfusion reduction." Forty-four were relevant to general surgery. Seven dominant strategies for transfusion reduction by descending frequency of report included restrictive transfusion thresholds, management of preoperative anemia, perioperative interventions, educational programs, electronic clinical decision support, waste reduction, and audits of transfusion practices. CONCLUSION Our study demonstrates a 27% decrease in general surgery transfusion between 2012 and 2018 with associated reductions in morbidity and mortality, suggesting published employed strategies have been successful and safely implemented.
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Affiliation(s)
| | | | - Andrew C Bernard
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
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12
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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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13
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Roberts SI, Ladi-Seyedian S, Daneshmand S. Vena Cava Tumor Thrombus Associated With Renal Angiomyolipoma in a Jehovah's Witness Patient. Urology 2021; 156:e86-e87. [PMID: 34416200 DOI: 10.1016/j.urology.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 11/20/2022]
Abstract
We present a case of a young premenopausal female patient who was found to have a left-sided renal mass consistent with angiomyolipoma (AML) with Mayo Level IIIa vena caval tumor thrombus. The patient is of Jehovah's witness faith and would not accept blood transfusion. The following case report discusses workup and treatment for AML with tumor thrombus extension, as well as pre-operative optimization and intra-operative techniques during nephrectomy and thrombectomy to minimize blood loss in a patient unaccepting of blood transfusion.
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Affiliation(s)
- Sidney I Roberts
- Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Sanam Ladi-Seyedian
- Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Siamak Daneshmand
- Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
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14
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de Boer WJ, Visser C, van Kuijk SMJ, de Jong K. A prognostic model for the preoperative identification of patients at risk for receiving transfusion of packed red blood cells in cardiac surgery. Transfusion 2021; 61:2336-2346. [PMID: 34292607 DOI: 10.1111/trf.16438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 02/02/2021] [Accepted: 04/01/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Patients undergoing cardiothoracic surgery are at substantial risk for blood transfusion. Increased awareness and patient blood management have resulted in a significant reduction over the past years. The next step is preoperative treatment of patients at high risk for packed red blood cells (RBC) transfusion, with the ultimate goal to eventually prevent RBC transfusion. A prediction model was developed to select patients at high risk for RBC transfusion. MATERIALS AND METHODS Data of all patients that underwent cardiac surgery in our center between 2008 and 2013 (n = 2951) were used for model development, and between 2014 and 2016 for validation (n = 1136). Only preoperative characteristics were included in a multinomial regression model with three outcome categories (no, RBC, other transfusion). The accuracy of the estimated risks and discriminative ability of the model were assessed. Clinical usefulness was explored. RESULTS Risk factors included are sex, type of surgery, redo surgery, age, height, body mass index, preoperative hemoglobin level, and preoperative platelet count. The model has excellent discriminative ability for predicting RBC transfusion versus no transfusion (area under the curve [AUC] = 94%) and good discriminative ability for RBC transfusion versus other transfusion (AUC = 84%). With a cut-off value of RBC risk of 16.8% and higher, the model is well able to identify a high proportion of patients at risk for RBC transfusion (sensitivity = 87.1%, specificity = 82.3%). CONCLUSION In the current study, a prediction tool was developed to be used for risk stratification of patients undergoing elective cardiac surgery at risk for blood transfusions.
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Affiliation(s)
- Wiebe J de Boer
- Heart Center, Department Extra Corporeal Circulation, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Cornelis Visser
- Heart Center, Department Extra Corporeal Circulation, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Sander M J van Kuijk
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
| | - Kim de Jong
- Department of Epidemiology, MCL Academy, Medical Center Leeuwarden, Leeuwarden, The Netherlands
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15
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16
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Kelly LS, Darden DB, Fenner BP, Efron PA, Mohr AM. The Hematopoietic Stem/Progenitor Cell Response to Hemorrhage, Injury, and Sepsis: A Review of Pathophysiology. Shock 2021; 56:30-41. [PMID: 33234838 PMCID: PMC8141062 DOI: 10.1097/shk.0000000000001699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
ABSTRACT Hematopoietic stem/progenitor cells (HSPC) have both unique and common responses following hemorrhage, injury, and sepsis. HSPCs from different lineages have a distinctive response to these "stress" signals. Inflammation, via the production of inflammatory factors, including cytokines, hormones, and interferons, has been demonstrated to impact the differentiation and function of HSPCs. In response to injury, hemorrhagic shock, and sepsis, cellular phenotypic changes and altered function occur, demonstrating the rapid response and potential adaptability of bone marrow hematopoietic cells. In this review, we summarize the pathophysiology of emergency myelopoiesis and the role of myeloid-derived suppressor cells, impaired erythropoiesis, as well as the mobilization of HSPCs from the bone marrow. Finally, we discuss potential therapeutic options to optimize HSPC function after severe trauma or infection.
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Affiliation(s)
- Lauren S Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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17
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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18
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Apple CG, Miller ES, Kannan KB, Stortz JA, Cox M, Loftus TJ, Parvataneni HK, Patrick M, Hagen JE, Brakenridge S, Efron PA, Mohr AM. Vitamin D status is associated with hepcidin and hemoglobin concentrations in patients with severe traumatic injury. J Trauma Acute Care Surg 2021; 89:1124-1130. [PMID: 32769953 DOI: 10.1097/ta.0000000000002895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Severe traumatic injury leads to persistent injury-associated anemia that is associated with hypercatecholaminemia, systemic inflammation, increased hepcidin, and a functional iron deficiency. Vitamin D has been shown to reduce proinflammatory cytokines and hepcidin concentrations. This study aimed to investigate the association of vitamin D status with inflammation, iron biomarkers, and anemia following blunt trauma. METHODS A prospective observational cohort study comparing blunt trauma patients (n = 45) with elective hip replacement patients (n = 22) and healthy controls (n = 8) was performed. Bone marrow ferroportin, transferrin receptor, and erythroferrone expression was measured using quantitative polymerase chain reaction (qPCR). Plasma was assessed for systemic inflammation, erythropoietin (EPO), iron regulation, and vitamin D (25-OH) concentrations using enzyme-linked immunosorbent assay. Hemoglobin was measured on the day of discharge. RESULTS Compared with hip replacement, trauma patients had higher plasma interleukin-6 (90.1 vs. 3.8 pg/mL), C-reactive protein (6,223 vs. 2,612 ng/mL), and hepcidin (79.3 vs. 21.2 ng/mL) concentrations. Trauma patients had lower vitamin D (25-OH) (12.8 vs. 18.1 ng/mL) and iron (23.5 vs. 59.9 μg/mL) levels compared with hip replacement patients. Despite the higher hepcidin EPO levels, bone marrow erythroferrone expression was increased 69% following trauma. CONCLUSION Following elective hip replacement, patients did have anemia and impaired iron homeostasis without a significant change in inflammatory biomarkers, EPO, and vitamin D status. Vitamin D status did correlate with systemic inflammation, iron dysfunction, and persistent injury-associated anemia following severe blunt trauma. Further research is needed to determine whether supplementation with vitamin D in the trauma population could improve the persistent injury-associated anemia. LEVEL OF EVIDENCE Prospective study, prognostic, level III.
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Affiliation(s)
- Camille G Apple
- From the Department of Surgery and Sepsis and Critical Illness Research Center (C.G.A., E.S.M., K.B.K., J.A.S., M.C., T.J.L., S.B., P.A.E., A.M.M.), University of Florida Health; and Department of Orthopedic Surgery (H.K.P., M.P., J.E.H.), University of Florida, Gainesville, Florida
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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20
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Role of preoperative erythropoietin in the optimization of preoperative anemia among surgical patients - A systematic review and meta-analysis. Hematol Transfus Cell Ther 2021; 44:76-84. [PMID: 33583767 PMCID: PMC8885371 DOI: 10.1016/j.htct.2020.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/02/2020] [Accepted: 12/07/2020] [Indexed: 11/23/2022] Open
Abstract
Preoperative anemia is a common finding. Preoperative allogeneic transfusion, iron therapy, vitamin supplementation and erythropoietin therapy are the current management strategies for preoperative anemia. Previous reviews regarding erythropoietin were limited to specialties, provided little evidence regarding the benefits and risks of erythropoietin in managing preoperative anemia and included non-anemic patients. The purpose of our systematic review was to determine the role of erythropoietin solely in preoperatively anemic patients and to investigate the complications of this treatment modality to produce a guideline for preoperative management of anemic patients for all surgical specialties. The PubMed/Medline, Google Scholar, and Cochrane Library were searched for randomized trials evaluating the efficacy of erythropoietin in preoperative anemia. The risk ratio (RR) and standardized mean difference (SMD) was used to pool the estimates of categorical and continuous outcomes, respectively. Allogeneic transfusion and complications and the 90-day mortality were the primary outcomes, while the postoperative change in hemoglobin, bleeding in milliliters and the number of red blood cell (RBC) packs transfused were the secondary outcomes. Results: Eight studies were included, comprising 734 and 716 patients in the erythropoietin group and non-erythropoietin group, respectively. The pooled estimate by RR for allogeneic transfusion was 0.829 (p = 0.049), while complications and the 90-day mortality were among the 1,318 (p = 0.18) patients. Conclusion: Preoperative erythropoietin provides better outcomes, considering the optimization of preoperative anemia for elective surgical procedures. The benefits of erythropoietin are significantly higher, compared to the control group, while the risks remain equivocal in both groups. We recommend preoperative erythropoietin in anemic patients.
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Scrimshire AB, Booth A, Fairhurst C, Kotze A, Reed M, McDaid C. Preoperative iron treatment in anaemic patients undergoing elective total hip or knee arthroplasty: a systematic review and meta-analysis. BMJ Open 2020; 10:e036592. [PMID: 33130561 PMCID: PMC7783611 DOI: 10.1136/bmjopen-2019-036592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Ashley B Scrimshire
- Department of Health Sciences, University of York, York, UK
- Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Alison Booth
- Department of Health Sciences, University of York, York, UK
| | | | | | - Mike Reed
- Northumbria Healthcare NHS Foundation Trust, Ashington, UK
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How to approach orthognathic surgery in patients who refuse blood transfusion. Arch Plast Surg 2020; 47:404-410. [PMID: 32971591 PMCID: PMC7520241 DOI: 10.5999/aps.2020.00493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/14/2020] [Indexed: 11/12/2022] Open
Abstract
Background Some patients who need surgery refuse a blood transfusion because of their religious beliefs or concerns about blood-borne infections. In recent years, bloodless surgery has been performed successfully in many procedures, and is therefore of increasing interest in orthognathic surgery. Methods Ten Jehovah’s Witnesses who visited our bloodless surgery center for orthognathic surgery participated in this study. To maintain hemoglobin (Hb) levels above 10 g/dL before surgery, recombinant erythropoietin (rEPO) was subcutaneously administered and iron supplements were intravenously administered. During surgery, acute normovolemic hemodilution (ANH) and induced hypotensive anesthesia were used. To elevate the Hb levels to >10 g/dL after surgery, a similar method to the preoperative approach was used. Results The 10 patients comprised three men and seven women. Their average Hb level at the first visit was 11.1 g/dL. With treatment according to our protocol, the average preoperative Hb level rose to 12.01 g/dL, and the average Hb level on postoperative day 1 was 10.01 g/dL. No patients needed a blood transfusion, and all patients were discharged without any complications. Conclusions This study presents a way to manage patients who refuse blood transfusions while undergoing orthognathic surgery. rEPO and iron supplementation were used to maintain Hb levels above 10 g/dL. During surgery, blood loss was minimized by a meticulous procedure and induced hypotensive anesthesia, and intravascular volume was maintained by ANH. Our practical approach to orthognathic surgery for Jehovah’s Witnesses can be applied to the management of all patients who refuse blood transfusions.
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Kaufner L, von Heymann C, Henkelmann A, Pace NL, Weibel S, Kranke P, Meerpohl JJ, Gill R. Erythropoietin plus iron versus control treatment including placebo or iron for preoperative anaemic adults undergoing non-cardiac surgery. Cochrane Database Syst Rev 2020; 8:CD012451. [PMID: 32790892 PMCID: PMC8095002 DOI: 10.1002/14651858.cd012451.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Lutz Kaufner
- Department of Anaesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Berlin, Germany
| | - Christian von Heymann
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Anne Henkelmann
- Department of Anaesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Berlin, Germany
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Stephanie Weibel
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Peter Kranke
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Ravi Gill
- Department of Anaesthetics, Southampton University Hospital NHS Trust, Southampton, UK
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Kholaki O, Wentland TR, Kim RY. Substernal goiter excision in a Jehovah's Witness. Proc (Bayl Univ Med Cent) 2020; 33:462-464. [PMID: 32675989 DOI: 10.1080/08998280.2020.1739483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/24/2020] [Accepted: 02/27/2020] [Indexed: 10/24/2022] Open
Abstract
Jehovah's Witnesses present a unique challenge in oral and head and neck surgery. We report a case of a substernal goiter excised on a Jehovah's Witness without the use of blood transfusion, in accordance with the patient's beliefs. Additionally, we review the literature on the care of this patient population, focusing on preoperative optimization, perioperative management, and postoperative care.
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Affiliation(s)
- Omar Kholaki
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Parkland/University of Texas Southwestern Medical CenterDallasTexas
| | - Todd R Wentland
- Division of Maxillofacial Oncology and Reconstructive Surgery, Department of Oral and Maxillofacial Surgery, John Peter Smith Health NetworkFort WorthTexas
| | - Roderick Y Kim
- Division of Maxillofacial Oncology and Reconstructive Surgery, Department of Oral and Maxillofacial Surgery, John Peter Smith Health NetworkFort WorthTexas
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25
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Cammalleri V, Muscoli S, Versaci F, Romeo F. Periprocedural anemia management in severe aortic stenosis patients undergoing transcatheter aortic valve implantation. J Cardiol 2020; 75:117-123. [DOI: 10.1016/j.jjcc.2019.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/29/2019] [Accepted: 08/13/2019] [Indexed: 12/17/2022]
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26
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Chang X, Li Q, Tang H. Use of preoperative erythropoietin therapy to facilitate autologous blood donation in orthopedic surgery: A meta-analysis. Medicine (Baltimore) 2020; 99:e18577. [PMID: 31914036 PMCID: PMC6959933 DOI: 10.1097/md.0000000000018577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Autologous blood transfusion helps to avoid or reduce the need for allogenic blood transfusion in patients undergoing major surgery. We examined the value of erythropoietin therapy to support preoperative autologous blood donation (PABD) in patients undergoing orthopedic surgery. METHODS For this systematic review and meta-analysis, Medline, Cochrane, EMBASE, and Google Scholar databases were searched from October 26th, 1989 until September 30th, 2017. Primary outcomes were percentages of patients able to donate ≥4 units of blood for autologous transfusion, amount of allogeneic blood transfused, changes in hematocrit and hemoglobin levels from before PABD to immediately before surgery, and adverse events. RESULTS Of 256 studies identified, 18 studies met the inclusion criteria with a total of 1914 patients (mean age 51-69 years), of whom 1153 were treated with erythropoietin. Erythropoietin was associated with a greater percentage of patients able to donate ≥4 units of blood for autologous use compared to controls (OR = 6.00, 95% CI = 3.97 to 9.09, P < .001). Patients receiving preoperative erythropoietin had significantly less of a reduction in hematocrit and hemoglobin levels from before PABD to immediately before surgery compared with controls (hematocrit: mean differences = -1.438, 95% CI = -2.14 to -0.73, P < .001; hemoglobin: mean differences = -1.426, 95% CI = -1.78 to -1.07, P < .001). No significant differences were observed in the amount of allogenic blood transfused between patients receiving erythropoietin and controls (difference in means = -0.220, 95% CI = -0.536 to 0.097, P = .174). Patients who received erythropoietin were less likely to experience dizziness than controls, but the incidence of nausea or fatigue were similar between groups. CONCLUSION Erythropoietin therapy during the PABD period results in less of a reduction in hematocrit and hemoglobin levels and an increase in the percentage of patients able to donate blood preoperatively.
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Apple CG, Miller ES, Loftus TJ, Kannan KB, Parvataneni HK, Hagen JE, Efron PA, Mohr AM. Impact of Injury Severity on the Inflammatory State and Severe Anemia. J Surg Res 2019; 248:109-116. [PMID: 31881381 DOI: 10.1016/j.jss.2019.10.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 10/14/2019] [Accepted: 10/22/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Severe traumatic injury is a major cause of morbidity and mortality. Our goal was to analyze blunt traumatic injury by injury severity score (ISS) and compare with elective hip repair, as a transient injury, and healthy control with the hypothesis that more severe injury would lead to an increase in neuroendocrine activation, systemic inflammation, and worse anemia. MATERIALS AND METHODS A prospective observational cohort study was performed at a level 1 trauma center, comparing blunt trauma patients (n = 37), elective hip replacement patients (n = 26), and healthy controls (n = 8). Bone marrow and plasma were assessed for hyperadrenergic state, erythropoiesis, and systemic inflammation. Trauma patient's ISS ranged from 4 to 41 and were broken down into quartiles for analysis. The ISS quartiles were 4-13, 14-20, 21-26, and 27-41. RESULTS Plasma norepinephrine, interleukin-6, tumor necrosis factor-alpha, and hepcidin increased progressively as ISS increased. Hemoglobin significantly decreased as ISS increased and packed red blood cell (pRBC) transfusion increased as ISS increased. Elective hip replacement patients had an appropriate increase in the bone marrow expression of erythropoietin and the erythropoietin receptor, which was absent in all trauma patient groups. CONCLUSIONS Increased neuroendocrine activation, systemic inflammation, and anemia correlated with worsening injury severity, lower age, and increased pRBC transfusions. Elective hip replacement patients have only minimal systemic inflammation with an appropriate bone marrow response to anemia. This study demonstrates a link between injury severity, neuroendocrine activation, systemic inflammation, and the bone marrow response to anemia.
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Affiliation(s)
- Camille G Apple
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Elizabeth S Miller
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Tyler J Loftus
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Kolenkode B Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Hari K Parvataneni
- Department of Orthopedic Surgery, University of Florida, Gainesville, Florida
| | - Jennifer E Hagen
- Department of Orthopedic Surgery, University of Florida, Gainesville, Florida
| | - Philip A Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Alicia M Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida.
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28
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Loftus TJ, Mira JC, Miller ES, Kannan KB, Plazas JM, Delitto D, Stortz JA, Hagen JE, Parvataneni HK, Sadasivan KK, Brakenridge SC, Moore FA, Moldawer LL, Efron PA, Mohr AM. The Postinjury Inflammatory State and the Bone Marrow Response to Anemia. Am J Respir Crit Care Med 2019; 198:629-638. [PMID: 29768025 DOI: 10.1164/rccm.201712-2536oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE The pathophysiology of persistent injury-associated anemia is incompletely understood, and human data are sparse. OBJECTIVES To characterize persistent injury-associated anemia among critically ill trauma patients with the hypothesis that severe trauma would be associated with neuroendocrine activation, erythropoietin dysfunction, iron dysregulation, and decreased erythropoiesis. METHODS A translational prospective observational cohort study comparing severely injured, blunt trauma patients who had operative fixation of a hip or femur fracture (n = 17) with elective hip repair patients (n = 22). Bone marrow and plasma obtained at the index operation were assessed for circulating catecholamines, systemic inflammation, erythropoietin, iron trafficking pathways, and erythroid progenitor growth. Bone marrow was also obtained from healthy donors from a commercial source (n = 8). MEASUREMENTS AND MAIN RESULTS During admission, trauma patients had a median of 625 ml operative blood loss and 5 units of red blood cell transfusions, and Hb decreased from 10.5 to 9.3 g/dl. Compared with hip repair, trauma patients had higher median plasma norepinephrine (21.9 vs. 8.9 ng/ml) and hepcidin (56.3 vs. 12.2 ng/ml) concentrations (both P < 0.05). Bone marrow erythropoietin and erythropoietin receptor expression were significantly increased among patients undergoing hip repair (23% and 14% increases, respectively; both P < 0.05), but not in trauma patients (3% and 5% increases, respectively), compared with healthy control subjects. Trauma patients had lower bone marrow transferrin receptor expression than did hip repair patients (57% decrease; P < 0.05). Erythroid progenitor growth was decreased in trauma patients (39.0 colonies per plate; P < 0.05) compared with those with hip repair (57.0 colonies per plate; P < 0.05 compared with healthy control subjects) and healthy control subjects (66.5 colonies per plate). CONCLUSIONS Severe blunt trauma was associated with neuroendocrine activation, erythropoietin dysfunction, iron dysregulation, erythroid progenitor growth suppression, and persistent injury-associated anemia. Clinical trial registered with www.clinicaltrials.gov (NCT 02577731).
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Affiliation(s)
- Tyler J Loftus
- 1 Department of Surgery.,2 Sepsis and Critical Illness Research Center, and
| | - Juan C Mira
- 1 Department of Surgery.,2 Sepsis and Critical Illness Research Center, and
| | - Elizabeth S Miller
- 1 Department of Surgery.,2 Sepsis and Critical Illness Research Center, and
| | | | - Jessica M Plazas
- 3 College of Liberal Arts and Sciences, University of Florida, Gainesville, Florida
| | | | - Julie A Stortz
- 1 Department of Surgery.,2 Sepsis and Critical Illness Research Center, and
| | - Jennifer E Hagen
- 4 Department of Orthopedic Surgery, University of Florida Health, Gainesville, Florida; and
| | - Hari K Parvataneni
- 4 Department of Orthopedic Surgery, University of Florida Health, Gainesville, Florida; and
| | - Kalia K Sadasivan
- 4 Department of Orthopedic Surgery, University of Florida Health, Gainesville, Florida; and
| | | | - Frederick A Moore
- 1 Department of Surgery.,2 Sepsis and Critical Illness Research Center, and
| | - Lyle L Moldawer
- 1 Department of Surgery.,2 Sepsis and Critical Illness Research Center, and
| | - Philip A Efron
- 1 Department of Surgery.,2 Sepsis and Critical Illness Research Center, and
| | - Alicia M Mohr
- 1 Department of Surgery.,2 Sepsis and Critical Illness Research Center, and
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Preoperative Epoetin-α with Intravenous or Oral Iron for Major Orthopedic Surgery: A Randomized Controlled Trial. Anesthesiology 2019; 129:710-720. [PMID: 30074935 DOI: 10.1097/aln.0000000000002376] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Preoperative administration of epoetin-α with iron is commonly used in anemic patients undergoing major orthopedic surgery, but the optimal route of iron intake is controversial. The aim of this study was to compare the clinical effects of erythropoietin in combination with oral or intravenous iron supplementation. METHODS This study was a prospective, randomized, single-blinded, parallel arm trial. Patients scheduled for elective hip or knee arthroplasty with hemoglobin 10 to 13 g/dl received preoperative injections of erythropoietin with oral ferrous sulfate or intravenous ferric carboxymaltose. The primary endpoint was the hemoglobin value the day before surgery. RESULTS One hundred patients were included in the analysis. The day before surgery, hemoglobin, increase in hemoglobin, and serum ferritin level were higher in the intravenous group. For the intravenous and oral groups, respectively, hemoglobin was as follows: median, 14.9 g/dl (interquartile range, 14.1 to 15.6) versus 13.9 g/dl (interquartile range, 13.2 to 15.1), group difference, 0.65 g/dl (95% CI, 0.1 to 1.2; P = 0.017); increase in hemoglobin: 2.6 g/dl (interquartile range, 2.1 to 3.2) versus 1.9 g/dl (interquartile range, 1.4 to 2.5), group difference, 0.7 g/dl (95% CI, 0.3 to 1.1; P < 0.001); serum ferritin: 325 µg/l (interquartile range, 217 to 476) versus 64.5 µg/l (interquartile range, 44 to 107), group difference, 257 µg/l (95% CI, 199 to 315; P < 0.001). The percentage of patients with nausea, diarrhea, or constipation was higher in the oral group, 52% versus 2%; group difference, 50% (95% CI, 35 to 64%; P < 0.0001). CONCLUSIONS After preoperative administration of erythropoietin, body iron stores and stimulation of the erythropoiesis were greater with intravenous ferric carboxymaltose than with oral ferrous sulfate supplementation.
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30
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Hare GMT, Mazer CD. A one-shot solution for improved patient blood management in cardiac surgery? Lancet 2019; 393:2177-2178. [PMID: 31030985 DOI: 10.1016/s0140-6736(18)32979-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/06/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Gregory M T Hare
- Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada; Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Toronto, ON, Canada; St Michael's Hospital Center of Excellence for Patient Blood Management, Toronto, ON, Canada
| | - C David Mazer
- Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada; Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Toronto, ON, Canada.
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The efficacy of pre-operative preparation with intravenous iron and/or erythropoietin in anaemic patients undergoing orthopaedic surgery: An observational study. Eur J Anaesthesiol 2019; 35:289-297. [PMID: 29303906 DOI: 10.1097/eja.0000000000000752] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Efficacy and safety of erythropoietin and iron therapy to reduce red blood cell transfusion in surgical patients: a systematic review and meta-analysis. Can J Anaesth 2019; 66:716-731. [DOI: 10.1007/s12630-019-01351-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/19/2018] [Accepted: 12/29/2018] [Indexed: 12/21/2022] Open
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Loftus TJ, Miller ES, Millar JK, Kannan KB, Alamo IG, Efron PA, Mohr AM. The effects of propranolol and clonidine on bone marrow expression of hematopoietic cytokines following trauma and chronic stress. Am J Surg 2019; 218:858-863. [PMID: 30827533 DOI: 10.1016/j.amjsurg.2019.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/08/2019] [Accepted: 02/14/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Attenuating post-injury neuroendocrine stress abrogates persistent injury-associated anemia. Our objective was to examine the mechanisms by which propranolol and clonidine modulate this process. We hypothesized that propranolol and clonidine would decrease bone marrow expression of high-mobility group box-1 (HMGB1) and increase expression of stem cell factor (SCF) and B-cell lymphoma-extra large (Bcl-xL). METHODS Male Sprague-Dawley rats were allocated to naïve control, lung contusion followed by hemorrhagic shock (LCHS), or LCHS plus daily chronic restraint stress (LCHS/CS) ±propranolol, ±clonidine. Day seven bone marrow expression of HMGB1, SCF, and Bcl-xL was assessed by polymerase chain reaction. RESULTS Following LCHS, HMGB1 was decreased by propranolol (49% decrease, p = 0.012) and clonidine (54% decrease, p < 0.010). SCF was decreased following LCHS/CS, and was increased by propranolol (629% increase, p < 0.001) and clonidine (468% increase, p < 0.001). Bcl-xL was decreased following LCHS/CS, and was increased by propranolol (59% increase, p = 0.006) and clonidine (77% increase, p < 0.001). CONCLUSIONS Following severe trauma, propranolol and clonidine abrogate persistent injury-associated anemia by modulating bone marrow cytokines, favoring effective erythropoiesis.
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Affiliation(s)
- Tyler J Loftus
- University of Florida, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Elizabeth S Miller
- University of Florida, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Jessica K Millar
- University of Florida, College of Medicine, Gainesville, FL, USA.
| | - Kolenkode B Kannan
- University of Florida, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Ines G Alamo
- University of Florida, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Philip A Efron
- University of Florida, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Alicia M Mohr
- University of Florida, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
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Cinnella G, Pavesi M, De Gasperi A, Ranucci M, Mirabella L. 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). Minerva Anestesiol 2019; 85:635-664. [PMID: 30762323 DOI: 10.23736/s0375-9393.19.12151-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Gilda Cinnella
- Unit of Anesthesia and Resuscitation, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Marco Pavesi
- Division of Multispecialty Anesthesia Service of Polispecialistic Anesthesia, San Donato IRCCS Polyclinic, San Donato Milanese, Milan, Italy
| | - Andrea De Gasperi
- Division of Anesthesia and Resuscitation, Niguarda Hospital, Milan, Italy
| | - Marco Ranucci
- Division of Anesthesia and Cardio-Thoraco-Vascular Therapy, San Donato IRCCS Polyclinic, San Donato Milanese, Milan, Italy
| | - Lucia Mirabella
- Unit of Anesthesia and Resuscitation, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy -
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Patient-Centered Outcomes in the Management of Anemia: A Scoping Review. Transfus Med Rev 2019; 33:7-11. [DOI: 10.1016/j.tmrv.2018.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/19/2018] [Accepted: 07/05/2018] [Indexed: 01/16/2023]
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Burton BN, A'Court AM, Brovman EY, Scott MJ, Urman RD, Gabriel RA. Optimizing Preoperative Anemia to Improve Patient Outcomes. Anesthesiol Clin 2018; 36:701-713. [PMID: 30390789 DOI: 10.1016/j.anclin.2018.07.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Anemia is a decrease in red blood cell mass, which hinders oxygen delivery to tissues. Preoperative anemia has been shown to be associated with mortality and morbidity following major surgery. The preoperative care clinic is an ideal place to start screening for anemia and discussing potential interventions in order to optimize patients for surgery. This article (1) reviews the relevant literature and highlights consequences of preoperative anemia in the surgical setting, and (2) suggests strategies for screening and optimizing anemia in the preoperative setting.
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Affiliation(s)
- Brittany N Burton
- School of Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Alison M A'Court
- Department of Anesthesiology, Preoperative Care Clinic, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Ethan Y Brovman
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiothoracic Anesthesia, Harvard Medical School, Brigham & Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University Health System, 1200 East Broad Street, PO Box 980695, Richmond, VA 23298, USA; Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Rodney A Gabriel
- Division of Regional Anesthesia and Acute Pain, Department of Anesthesiology, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA.
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Khalili M, Morano WF, Marconcini L, Shaikh MF, Gleeson EM, Styler M, Zebrower M, Bowne WB. Multidisciplinary strategies in bloodless medicine and surgery for patients undergoing pancreatectomy. J Surg Res 2018; 229:208-215. [DOI: 10.1016/j.jss.2018.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/20/2018] [Accepted: 04/03/2018] [Indexed: 01/05/2023]
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Duce L, Cooter ML, McCartney SL, Lombard FW, Guinn NR. Outcomes in Patients Undergoing Cardiac Surgery Who Decline Transfusion and Received Erythropoietin Compared to Patients Who Did Not. Anesth Analg 2018; 127:490-495. [DOI: 10.1213/ane.0000000000002418] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
To successfully deliver greater perioperative value-based care and to effectively contribute to sustained and meaningful perioperative population health management, the scope of existing preoperative management and its associated services and care provider skills must be expanded. New models of preoperative management are needed, which rely extensively on continuously evolving evidence-based best practice, as well as telemedicine and telehealth, including mobile technologies and connectivity. Along with conventional comorbidity optimization, prehabilitation can effectively promote enhanced postoperative recovery. This article focuses on the opportunities and mechanisms for delivering value-based, comprehensive preoperative assessment and global optimization of the surgical patient.
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Affiliation(s)
- Neil N Shah
- Department of Medicine, Dell Medical School, The University of Texas at Austin, Health Discovery Building, 1701 Trinity Street, Austin, TX 78712-1875, USA
| | - Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA; Department of Population Health, Dell Medical School, The University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA.
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McConachie SM, Almadrahi Z, Wahby KA, Wilhelm SM. Pharmacotherapy in Acutely Anemic Jehovah’s Witnesses: An Evidence-Based Review. Ann Pharmacother 2018; 52:910-919. [DOI: 10.1177/1060028018766656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective: To determine the pharmacological treatment methods available to anemic Jehovah’s Witnesses (JW). Data Sources: MEDLINE and PubMed were searched from inception through February 2018 using the search terms Jehovah’s Witnesses, treatment, erythropoietin, hemoglobin-based oxygen carrier, Sanguinate, Hemopure, bleeding, and anemia. Study Selection and Data Extraction: All clinical trials, cohort studies, case-control studies, and observational trials involving pharmacotherapy in anemic JW patients were evaluated. Case reports and bibliographies were also analyzed for inclusion. Data Synthesis: Two studies involving the use of erythropoietin (EPO) and one study involving recombinant factor VIIa were included. Information was also included from other pharmacotherapeutic modalities that had case report data only. Current published evidence is limited with regard to evidence-based management of JW patients. High-dose EPO, intravenous iron supplementation, and hemostatic agents have demonstrated good clinical outcomes in case reports. EPO doses as high as 40 000 units daily have been advocated by some experts; however, pharmacokinetic studies do not support dose-dependent effects. Hemoglobin-based oxygen carriers (HBOCs) are currently not Food and Drug Administration approved. They are available through expanded access programs and may represent a lifesaving modality in the setting of severe anemia. Conclusions: There are currently not enough data to make definitive recommendations on the use of pharmacological agents to treat severe anemia in the JW population. Further evidence utilizing EPO and HBOCs will be beneficial to guide therapy.
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Affiliation(s)
- Sean M. McConachie
- Wayne State University, Detroit, MI, USA
- Harper University Hospital, Detroit, MI, USA
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Lu Q, Peng H, Zhou G, Yin D. Perioperative Blood Management Strategies for Total Knee Arthroplasty. Orthop Surg 2018; 10:8-16. [PMID: 29424017 PMCID: PMC6594499 DOI: 10.1111/os.12361] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/24/2017] [Indexed: 01/28/2023] Open
Abstract
Total knee arthroplasty (TKA) often causes a significant amount of blood loss with an accompanying decline in hemoglobin and may increase the frequency of allogeneic blood transfusion rates. Unfortunately, allogeneic blood transfusions have associated risks including postoperative confusion, infection, cardiac arrhythmia, fluid overload, increased length of hospital stay, and increased mortality. Other than reducing the need for blood transfusions, reducing perioperative blood loss in TKA may also minimize intra-articular hemorrhage, limb swelling, and postoperative pain, and increase the range of motion during the early postoperative period. These benefits improve rehabilitation success and increase patients' postoperative satisfaction. Preoperative anemia, coupled with intraoperative and postoperative blood loss, is a major factor associated with higher rates of blood transfusion in TKA. Thus, treatment of preoperative anemia and prevention of perioperative blood loss are the primary strategies for perioperative blood management in TKA. This review, combined with current evidence, analyzes various methods of blood conservation, including preoperative, intraoperative, and postoperative methods, in terms of their effectiveness, safety, and cost. Because many factors can be controlled to reduce blood loss and transfusion rates in TKA, a highly efficient, safe, and cost-effective blood management strategy can be constructed to eliminate the need for transfusions associated with TKA.
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Affiliation(s)
- Qiang Lu
- Department of OrthopaedicsRenmin Hospital of Wuhan UniversityWuhanChina
| | - Hao Peng
- Department of OrthopaedicsRenmin Hospital of Wuhan UniversityWuhanChina
| | - Guan‐jin Zhou
- Department of Orthopaedics, Puai Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Dong Yin
- Department of OrthopaedicsThe People’s Hospital of Guangxi Zhuang Autonomous RegionNanningChina
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D’Errigo P, Biancari F, Rosato S, Tamburino C, Ranucci M, Santoro G, Barbanti M, Ventura M, Fusco D, Seccareccia F. Transcatheter aortic valve implantation compared with surgical aortic valve replacement in patients with anaemia. Acta Cardiol 2018; 73:50-59. [PMID: 28812435 DOI: 10.1080/00015385.2017.1327627] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES We compared the outcome of anaemic patients undergoing transcatheter (TAVI) and surgical aortic valve replacement (SAVR) for severe aortic valve stenosis. METHODS Anaemic patients (haemoglobin <13.0 g/dL in men and <12.0 g/dL in women) undergoing TAVI and SAVR from the OBSERVANT study were the subjects of this analysis. RESULTS Preoperative anaemia was an independent predictor of 3-year mortality after either TAVI (HR 1.37, 95% CI 1.12-1.68) and SAVR (HR 1.63, 95% CI 1.37-1.99). Propensity score matching resulted in 302 pairs with similar characteristics. Patients undergoing SAVR had similar 30-d mortality (3.6% versus 3.3%, p = .81) and stroke (1.3% versus 2.0%, p = .53) compared with TAVI. The rates of pacemaker implantation (18.6% versus 3.0%, p < .001), major vascular damage (5.7% versus 0.4%, p < .001) and mild-to-severe paravalvular regurgitation (47.4% versus 9.3%, p < .001) were higher after TAVI, whereas acute kidney injury (50.7% versus 27.9%, p < .001) and blood transfusion (70.0% versus 38.6%, p < .001) were more frequent after SAVR. At 3-year, survival was 74.0% after SAVR and 66.3% after TAVI, respectively (p = .065), and freedom from MACCE was 67.6% after SAVR and 58.7% after TAVI, respectively (p = .049). CONCLUSIONS These results suggest that TAVI is not superior to SAVR in patients with anaemia.
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Affiliation(s)
- Paola D’Errigo
- Centre for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Stefano Rosato
- Centre for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Marco Ranucci
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Marco Barbanti
- Ferrarotto Hospital, University of Catania, Catania, Italy
| | - Martina Ventura
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Preoperative Anemia in Cardiac Operation: Does Hemoglobin Tell the Whole Story? Ann Thorac Surg 2018; 105:100-107. [DOI: 10.1016/j.athoracsur.2017.06.074] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 06/05/2017] [Accepted: 06/28/2017] [Indexed: 01/26/2023]
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Patient Blood Management in the Intensive Care Unit. Transfus Med Rev 2017; 31:264-271. [DOI: 10.1016/j.tmrv.2017.07.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/14/2017] [Accepted: 07/25/2017] [Indexed: 01/28/2023]
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Butcher A, Richards T. Cornerstones of patient blood management in surgery. Transfus Med 2017; 28:150-157. [PMID: 28940786 DOI: 10.1111/tme.12476] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/11/2017] [Accepted: 08/28/2017] [Indexed: 12/22/2022]
Abstract
Pre-operative anaemia and perioperative red blood cell transfusion carry significant consequence when it comes to surgical outcomes. The establishment of patient-centred clinical pathways has been designed to harness and endorse good transfusion practice, termed the three pillars of patient blood management (PBM). These focus on the timely and appropriate management of anaemia, prevention of blood loss and restrictive transfusion where appropriate. This article reviews the current evidence and ongoing research in the field of PBM in surgery. Strategies to implement PBM have shown significant benefits in appropriate transfusion practice, reduced costs and improved length of hospital stay. Recently published national quality standards have recognised the features of the PBM blueprint such as the consideration of alternatives to red blood cell transfusion, the active measures to reduce perioperative blood loss and the appropriate management of post-operative anaemia. Adopting PBM in surgical patients should be paramount to reduce the risks posed by perioperative anaemia and blood transfusions. The principles of PBM help structure the interventions and decisions relating to anaemia and blood transfusion, but, more importantly, represent a paradigm shift towards a more considered approach to blood transfusion, acknowledging its risks, preventatives and alternatives.
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Affiliation(s)
- A Butcher
- Division of Surgery and Interventional Science, University College London, London, UK
| | - T Richards
- Division of Surgery and Interventional Science, University College London, London, UK
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Abstract
PURPOSE OF REVIEW With the prevalence of obesity rapidly growing, bariatric anaesthesia becomes everyday anaesthesia rather than a subspecialty. In this review, we are aiming to draw attention to this complex group of patients and their comorbidities, relevant to everyday practice for contemporary anaesthetists. RECENT FINDINGS We wanted to focus greatly on sleep-related breathing disorders, because preoperative screening, diagnosis and treatment of the aforementioned make a huge impact in the improvement of preoperative morbidity and mortality, including positive effects on the cardiovascular system. The overview is touching on main obesity-related comorbidities and guides the anaesthetist and associated health professionals on how to approach and manage them. A multidisciplinary approach widely used in bariatric care may be adopted in the care of obese patients in order to reduce preoperative morbidity and mortality. We advocate the early involvement of the anaesthetic team in the preoperative assessment of obese patients in order to achieve appropriate risk stratification and optimise the care.
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Affiliation(s)
- Asta Lukosiute
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed St, London, W2 1NY, UK.
| | - Anil Karmali
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed St, London, W2 1NY, UK
| | - Jonathan Mark Cousins
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed St, London, W2 1NY, UK
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Barni S, Gascòn P, Petrelli F, García-Erce JA, Pedrazzoli P, Rosti G, Giordano G, Mafodda A, Múñoz M. Position paper on management of iron deficiency in adult cancer patients. Expert Rev Hematol 2017; 10:685-695. [PMID: 28656800 DOI: 10.1080/17474086.2017.1343140] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Disorders of iron metabolism are commonly seen in onco-hematological clinical practice. Iron-deficiency anemia and cancer-associated anemia are usually treated with supportive therapies. Optimal management of these conditions are discussed in this perspective paper. Areas covered: A position paper discussing a number of hot topics on anemia in cancer patients is presented. The main areas covered by experts in the field are: definitions, prevalence and consequences of anemia and iron deficiency, incidence of anemia resulting from targeted therapies, importance of anemia diagnosis and monitoring, evaluation of iron status before and during treatment, role of transfusions and erythropoiesis-stimulating agents, management of iron deficiency with or without anemia, parenteral iron supplementation, role of new oral iron formulations, safety and cost issues regarding different iron compounds and administration routes. Expert commentary: Despite the availability of newer therapeutic options for its management, anemia still represents a major complication of treatment in cancer patients (surgery, chemotherapy, radiotherapy, targeted therapies), aggravating physical impairment, and negatively affecting general outcome. The view expressed by the panelists, attendees of the 4th Mediterranean Course on Iron Anemia, summarizes what they consider optimal clinical practice for screening, diagnosis, treatment and monitoring of iron deficiency and anemia in cancer patients.
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Affiliation(s)
- Sandro Barni
- a Oncology Department , Medical Oncology Unit , Treviglio , Italy
| | - Pere Gascòn
- b Division of Medical Oncology , Hospital Clinic, University of Barcelona , Barcelona , Spain
| | - Fausto Petrelli
- a Oncology Department , Medical Oncology Unit , Treviglio , Italy
| | | | - Paolo Pedrazzoli
- d Medical Oncology , Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Giovanni Rosti
- d Medical Oncology , Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Giulio Giordano
- e General Medicine and Hematology Department , General Medicine and Hematology Regional Hospital 'A. Cardarelli' , Campobasso , Italy
| | - Antonio Mafodda
- f Medical Oncology Unit , A.O. B.M.M , Reggio Calabria , Italy
| | - Manuel Múñoz
- g Peri-operative Transfusion Medicine , School of Medicine, University of Malaga , Malaga , Spain
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Abstract
Anemia is a common and often ignored condition in surgical patients. Anemia is usually multifactorial and iron deficiency and inflammation are commonly involved. An exacerbating factor in surgical patients is iatrogenic blood loss. Anemia has been repeatedly shown to be an independent predictor of worse outcomes. Patient blood management (PBM) provides a multimodality framework for prevention and management of anemia and related risk factors. The key strategies in PBM include support of hematopoiesis and improving hemoglobin level, optimizing coagulation and hemostasis, use of interdisciplinary blood conservation modalities, and patient-centered decision making throughout the course of care.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, TeamHealth Research Institute, 350 Engle Street, Englewood, NJ 07631, USA.
| | - Gregg P Lobel
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, TeamHealth Research Institute, 350 Engle Street, Englewood, NJ 07631, USA
| | - Mazyar Javidroozi
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, TeamHealth Research Institute, 350 Engle Street, Englewood, NJ 07631, USA
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50
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Blood Conservation in Orthopedic Trauma. Tech Orthop 2017. [DOI: 10.1097/bto.0000000000000208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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