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Lasocki S, Belbachir A, Mertes PM, Le Pelley E, Bosch L, Bezault C, Belarbia S, Capdevila X. Changes in Practices After Implementation of a Patient Blood Management Program in French Surgical Departments: The National Multicenter Observational PERIOPES Study. Anesth Analg 2024:00000539-990000000-00769. [PMID: 38412110 DOI: 10.1213/ane.0000000000006917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Patient blood management (PBM) is an evidence-based approach recommended to improve patient outcomes. Change in practices is often challenging. We report here data from French surgical departments before and after a standardized implementation of a PBM program. METHODS This was a national, multicenter, observational study in surgical centers ("expert" centers with an already established protocol for preoperative anemia or "pilot" centers). Data from consecutive surgical patients of different specialties were retrieved before and after the implementation of a PBM program. Primary outcome variables (preoperative anemia treatment rates, transfusion rates, and length of hospital stay) before and after the implementation of a PBM program were analyzed with segmented regression adjusted on confounders (American Society of Anesthesiologists [ASA] scores and centers). RESULTS A total of 1618 patients (ASA physical status III and IV, 38% in the first period and 45% in the second period) were included in expert (N = 454) or pilot (N = 1164) centers during the first period (January 2017-August 2022) and 1542 (N = 440 and N = 1102, respectively) during the second period (January 2020-February 2023). After implementation of the PBM program, the rate of preoperative anemia treatment increased (odds ratio, 2.37; 95% confidence interval [CI], 1.20-4.74; P = .0136) and length of hospital stay in days decreased (estimate, -0.11; 95% CI, -0.21 to -0.02; P = .0186). Transfusion rate significantly decreased only in expert centers (odds ratio, 0.17; 95% CI, 0.03-0.88; P = .0354). CONCLUSIONS PBM practices in various surgical specialties improved significantly after the implementation of a PBM program. However, too many patients with preoperative anemia remained untreated.
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Affiliation(s)
- Sigismond Lasocki
- From the Département Anesthésie Réanimation, CHU Angers, Angers, France
| | - Anissa Belbachir
- Department of Anesthesia and Critical Care Medicine, Cochin University Paris-Descartes Hospital, Paris, France
| | - Paul-Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, INSERM U1255, FMTS de Strasbourg, Strasbourg, France
| | | | | | | | | | - Xavier Capdevila
- Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital and Montpellier University, Montpellier, France
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Butragueño-Laiseca L, de la Mata Navazo S, Sánchez Galindo AC, Santiago Lozano MJ. Intravenous iron for critically ill children. Comparison of three dose regimens. Pediatr Blood Cancer 2024; 71:e30734. [PMID: 37880937 DOI: 10.1002/pbc.30734] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 10/01/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Anemia is extremely common among patients admitted to pediatric intensive care. Alternative treatments to transfusions such as intravenous iron must be considered. There are no published data for a prospective intravenous (IV) iron study focused in the critically ill children. The objective is to examine the safety and efficacy of intravenous iron sucrose infusion to manage anemia in pediatric critical care. A secondary objective is to examine the effect of different dose regimens of iron sucrose (3, 5, and 7 mg/kg dose). PROCEDURE Prospective investigation of intravenous iron sucrose utilization at a tertiary pediatric intensive care unit between October 2017 and November 2022. RESULTS In all 115 patients received a total of 616 infusions of IV iron. Transferrin saturation index (TSI) was the most common altered iron deficiency biomarker (91.8%). After IV iron treatment, hemoglobin showed a significant increase within a 30-day follow-up (9.2 vs. 11.6 g/dL, p < .001). There was also a significant improvement in TSI and serum iron (p < .001). Iron deficit replacement was higher in the 7 mg/kg dose group (94%) compared to 85.9% in the 5 mg/kg regimen and 77.5% in the lower dose group (p = .008), requiring less doses and a shorter time. Very few mild adverse reactions were reported (1.3% of infusions), with no differences between groups. The most frequent adverse effect was gastrointestinal in three cases. There were no anaphylaxis-like or other serious/life-threatening adverse effects. CONCLUSIONS This is the first study to evaluate intravenous iron therapy in pediatric critical care, providing preliminary evidence of safety and efficacy of IV iron sucrose. The 7 mg/kg dose regimen showed higher iron deficit replacement in a shorter time, which could be beneficial in critically ill children.
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Affiliation(s)
- Laura Butragueño-Laiseca
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain
- Pediatrics Department, Universidad Complutense de Madrid, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Sara de la Mata Navazo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain
- Pediatrics Department, Universidad Complutense de Madrid, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Amelia Caridad Sánchez Galindo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain
- Pediatrics Department, Universidad Complutense de Madrid, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - María José Santiago Lozano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain
- Pediatrics Department, Universidad Complutense de Madrid, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
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Shah A, Acheson A, Sinclair R. Perioperative iron deficiency anaemia. BJA Educ 2023; 23:372-381. [PMID: 37720558 PMCID: PMC10501883 DOI: 10.1016/j.bjae.2023.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/24/2023] [Accepted: 06/05/2023] [Indexed: 09/19/2023] Open
Affiliation(s)
- A. Shah
- University of Oxford, Oxford, UK
| | - A. Acheson
- University of Nottingham, Nottingham, UK
| | - R.C.F. Sinclair
- Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle, UK
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Shander A, Corwin HL, Meier J, Auerbach M, Bisbe E, Blitz J, Erhard J, Faraoni D, Farmer SL, Frank SM, Girelli D, Hall T, Hardy JF, Hofmann A, Lee CK, Leung TW, Ozawa S, Sathar J, Spahn DR, Torres R, Warner MA, Muñoz M. Recommendations From the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS). Ann Surg 2023; 277:581-590. [PMID: 36134567 PMCID: PMC9994846 DOI: 10.1097/sla.0000000000005721] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Perioperative anemia has been associated with increased risk of red blood cell transfusion and increased morbidity and mortality after surgery. The optimal approach to the diagnosis and management of perioperative anemia is not fully established. OBJECTIVE To develop consensus recommendations for anemia management in surgical patients. METHODS An international expert panel reviewed the current evidence and developed recommendations using modified RAND Delphi methodology. RESULTS The panel recommends that all patients except those undergoing minor procedures be screened for anemia before surgery. Appropriate therapy for anemia should be guided by an accurate diagnosis of the etiology. The need to proceed with surgery in some patients with anemia is expected to persist. However, early identification and effective treatment of anemia has the potential to reduce the risks associated with surgery and improve clinical outcomes. As with preoperative anemia, postoperative anemia should be treated in the perioperative period. CONCLUSIONS Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology, Critical Care Medicine, Hyperbaric Medicine and Pain Management, Englewood Hospital and Medical Center, Englewood, NJ
- Society for the Advancement of Blood Management (SABM), Englewood, NJ
| | | | - Jens Meier
- Clinic of Anaesthesiology and Intensive Care Medicine, Kepler University Hospital, Linz, Austria
- Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Brussels, Belgium
| | - Michael Auerbach
- School of Medicine, Georgetown University, Washington, DC
- Auerbach Hematology and Oncology, Baltimore, MD
| | - Elvira Bisbe
- Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Brussels, Belgium
- Department of Anaesthesiology, Perioperative Medicine Research Group, Hospital del Mar Medical Research Institute, IMIM, Barcelona, Spain
| | - Jeanna Blitz
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Jochen Erhard
- Department of Surgery, Evangelisches Klinikum Niederrhein, Duisburg, Germany
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Shannon L. Farmer
- Discipline of Surgery, Medical School, The University of Western Australia, Perth, Australia
- Department of Haematology, Royal Perth Hospital, Perth, Australia
| | - Steven M. Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Domenico Girelli
- Department of Medicine, University of Verona and Integrated University Hospital of Verona, Verona, Italy
| | | | - Jean-François Hardy
- Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Brussels, Belgium
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Axel Hofmann
- Discipline of Surgery, Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - Cheuk-Kwong Lee
- Hong Kong Red Cross Blood Transfusion Service, Hong Kong SAR, China
| | - Tsin W. Leung
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong SAR, China
| | - Sherri Ozawa
- Patient Blood Management, Accumen Inc., San Diego, CA
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Ampang, Malaysia
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Rosalio Torres
- Section of Hematology, Department of Internal Medicine, Makati Medical Center, Makati City, Philippines
| | - Matthew A. Warner
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Manuel Muñoz
- Department of Surgical Specialties, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
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Warner MA, Hanson AC, Plimier C, Lee C, Liu VX, Richards T, Kor DJ, Roubinian NH. Association between anaemia and hospital readmissions in patients undergoing major surgery requiring postoperative intensive care. Anaesthesia 2023; 78:45-54. [PMID: 36074010 PMCID: PMC9742142 DOI: 10.1111/anae.15859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 01/07/2023]
Abstract
Anaemia is a common sequela of surgery, although its relationship with patient recovery is unclear. The goal of this investigation was to assess the associations between haemoglobin concentrations at the time of hospital discharge following major surgery and early post-hospitalisation outcomes, with a primary outcome of 30 day unanticipated hospital readmissions. This investigation includes data from two independent population-based observational cohorts of adult surgical patients (aged ≥ 18 years) requiring postoperative intensive care unit admission between 1 January 2010 and 31 December 2019 in hospitals in Olmsted County, Minnesota, and between 1 July 2010 and 30 June 2017 in the Kaiser Permanente Northern California integrated healthcare system, California. Cox proportional hazards models assessed the associations between discharge haemoglobin concentrations (per 10 g.l-1 ) and outcomes, with prespecified multivariable adjustment. A total of 3260 patients were included from Olmsted County hospitals and 29,452 from Kaiser Permanente Northern California. In adjusted analyses, each 10 g.l-1 decrease in haemoglobin at hospital discharge was associated with a 9% (hazard ratio 1.09, 95%CI 1.02-1.18; p = 0.014) and 8% increase (hazard ratio 1.08, 95%CI 1.06-1.11; p < 0.001) in the hazard for readmission within 30 days in Olmsted County and Kaiser Permanente Northern California, respectively. In a sensitivity analysis exploring relationships across varying levels of pre-operative anaemia severity, these associations remained consistent, with lower discharge haemoglobin concentrations associated with higher readmissions irrespective of pre-operative anaemia severity. Anaemia at hospital discharge in surgical patients requiring postoperative intensive care is associated with increased rates of hospital readmission in two large independent cohorts. Future studies are necessary to evaluate strategies to prevent and/or treat anaemia in these patients for the improvement of post-hospitalisation outcomes.
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Affiliation(s)
- M. A. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - A. C. Hanson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - C. Plimier
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - C. Lee
- Kaiser Permanente Northern California Division of Research; Assistant Professor, Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Oakland, CA, USA
| | - V. X. Liu
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - T. Richards
- Department of Surgery, University of Western Australia, Perth, Australia
| | - D. J. Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - N. H. Roubinian
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA, Vitalant Research Institute, San Francisco, CA, USA
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Postoperative anaemia and patient-centred outcomes after major abdominal surgery: a retrospective cohort study. Br J Anaesth 2022; 129:346-354. [PMID: 35843746 DOI: 10.1016/j.bja.2022.06.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Compared with anaemia before surgery, the underlying pathogenesis and implications of postoperative anaemia are largely unknown. METHODS This retrospective cohort study analysed prospective data obtained from 2983 adult patients across 47 centres enrolled in a clinical trial evaluating restrictive and liberal intravenous fluids. The primary endpoint was persistent disability or death up to 90 days after surgery. Secondary endpoints included major septic complications, hospital stay, and patient quality of recovery using a 15-item quality of recovery (QoR-15) score, hospital re-admissions, and disability-free survival up to 12 months after surgery. Anaemia and disability were defined according to the WHO definitions. Multivariable regression was used to adjust for baseline risk and surgery. RESULTS A total of 2983 patients met inclusion criteria for this study, of which 78.5% (95% confidence interval [CI], 76.7-80.1%) had postoperative anaemia. Patients with postoperative anaemia had a higher adjusted risk of death or disability up to 90 days after surgery when compared with those without anaemia: 18.2% vs 9.2% (risk ratio [RR]=1.51; 95% CI, 1.10-2.07, P=0.011); lower QoR-15 scores on Day 3 and Day 30, 105 (95% CI, 87-119) vs 114 (95% CI, 99-128; P<0.001), and 130 (95% CI, 112-140) vs 139 (95% CI, 121-144; P<0.011), respectively; higher adjusted risk of a composite of mortality/septic complications, 2.01 (95% CI, 1.55-42.67; P<0.001); unplanned admission to ICU (RR=2.65; 95% CI, 1.65-4.23; P<0.001); and longer median (inter-quartile range [IQR]) hospital stays, 6.6 (4.4-12.4) vs 3.7 (2.5-6.5) days (P<0.001). CONCLUSIONS Postoperative anaemia is common and is independently associated with poor outcomes after surgery. Optimal prevention and treatment strategies need to be investigated. CLINICAL TRIAL REGISTRATION NCT04978285 (ClinicalTrials.gov).
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Intravenous iron therapy to treat burn anaemia: A retrospective cohort study. Burns 2022; 49:813-819. [PMID: 35717364 DOI: 10.1016/j.burns.2022.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 05/14/2022] [Accepted: 05/15/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Intravenous iron is an effective treatment for anaemia in many populations but has not been evaluated in those with burn anaemia. This study aimed to evaluate the efficacy and safety of intravenous iron to manage burn anaemia. METHODOLOGY This was a retrospective cohort study of patients admitted to the Royal Brisbane and Women's Hospital with burns to at least 15% total body surface area (TBSA). Data collected from patient records included demographics, treatment details, and outcomes including length of stay, blood transfusions, and serum haemoglobin concentrations. Linear mixed effects regression models were used to assess the effect of treatment with intravenous iron on haemoglobin over time. RESULTS Sixty patients met inclusion criteria, with 11 (18%) treated using intravenous iron. Those treated with intravenous iron had higher TBSA burns (median 39% vs 18%, P = 0.0005), more operations (3 vs 1, P = 0.0012), and more blood transfusions (median 8 units vs 0 units, P = 0.0002). One patient (9%) experienced a minor adverse drug reaction from intravenous iron. When examining the change in modelled haemoglobin levels over the first 14 days following the last major operation, the change in the intravenous iron group (11.22 g/L) was 14.56 g/L greater than the change in the group not receiving intravenous iron (-3.34 g/L, P = 0.0282). CONCLUSION This exploratory study provides preliminary evidence of benefit and safety of intravenous iron treatment on burn anaemia recovery.
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Helmer P, Kranke P, Schlesinger T, Hottenrott S, Zacharowski K, Choorapoikayil S, Meybohm P. [Peri- and Postoperative Anaemia Management]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:115-126. [PMID: 35172342 DOI: 10.1055/a-1390-3581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patient Blood Management (PBM) aims to diagnose and treat preoperative anaemia, avoid unnecessary blood loss, and enable rational use of blood products. Due to various limitations, treatment of preoperative anaemia has been successful in only a few German hospitals to date. Thus, the peri- and postoperative phase is increasingly becoming important for implementing various preventive and therapeutic measures for the treatment of (postoperative) anaemia. These will be comprehensively presented in the following.
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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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Park HS, Bin SI, Kim HJ, Kim TY, Kim J, Kim H, Ro Y, Koh WU. Short-term high-dose intravenous iron reduced peri-operative transfusion after staggered bilateral total knee arthroplasty: A retrospective cohort study. Vox Sang 2021; 117:562-569. [PMID: 34897718 DOI: 10.1111/vox.13230] [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: 09/02/2021] [Revised: 11/23/2021] [Accepted: 11/28/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Staggered bilateral total knee arthroplasty, two procedures performed 4-7 days apart during a single hospitalization, has an increased risk of blood transfusion. This observational study aimed to evaluate whether immediate post-operative single, high-dose intravenous iron supplementation could reduce transfusion requirements and facilitate anaemia recovery in patients. MATERIALS AND METHODS We retrospectively analysed 131 patients who underwent staggered bilateral total knee arthroplasty. The ferric carboxymaltose (FCM) group received 1000 mg of FCM after the first operation. The non-FCM group did not receive intravenous iron. The transfusion rate and post-operative complications were compared between the groups. The anaemia rate was evaluated pre-operatively, during hospitalization, and 5 weeks after the second total knee arthroplasty. RESULTS The FCM group comprised 78 patients (59.5%). The rate (21.8% vs. 47.2%, p = 0.004) and amount of transfusion (0 [0-2] vs. 0 [0-0], p = 0.001) was significantly lower in the FCM group than in the non-FCM group. Although both groups' pre-operative haemoglobin concentrations were not significantly different, the FCM group demonstrated higher haemoglobin values 5 weeks post surgery (12.25 ± 0.83 mg/dl vs. 11.48 ± 1.36 mg/dl, p < 0.001). More non-FCM patients developed moderate to severe anaemia at 5 weeks post surgery (p < 0.001). The mortality and complication rates were not significantly different. CONCLUSIONS Immediate post-operative, high-dose, intravenous iron treatment may contribute to reduced transfusion rates, facilitate haemoglobin recovery after staggered bilateral total knee arthroplasty, and minimize the development of moderate to severe anaemia.
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Affiliation(s)
- Hee-Sun Park
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Il Bin
- Department of Orthopaedic Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ha-Jung Kim
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae-Yop Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jiyoung Kim
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyungtae Kim
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Youngjin Ro
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Uk Koh
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Tang G, Zhang L, Huang W, Wei Z. Iron Supplementation Effectively Ameliorates Anemia and Reduces the Need for Blood Transfusion in Patients Undergoing Colorectal Cancer Surgery: A Meta-Analysis. Nutr Cancer 2021; 74:2303-2312. [PMID: 34890292 DOI: 10.1080/01635581.2021.2014900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Anemia is common and harmful in patients undergoing colorectal cancer (CRC) surgery. Blood transfusion (BT) is used to treat anemia, but results in a poor oncology prognosis. Iron supplementation may be effective in improving anemia and reducing the need for BT, however, the results remain controversial. This meta-analysis was conducted to evaluate the efficacy of iron supplementation in improving hemoglobin concentrations (Hb) and reducing the need for BT. METHODS Up to February 10, 2021, PubMed, Web of Science, Cochrane Library, Embase databases were searched for studies evaluating the effects of iron supplementation on CRC surgery patients. Meta-analysis was conduct using the random-effects model. RESULTS Seven trials with 879 participants in total were included in the meta-analysis. The pooled findings suggested that iron supplementation effectively increased Hb (MD 0.41; 95% CI: 0.12, 0.69, P = 0.006) and reduced the risk of BT (RR 0.60, 95% CI 0.45, 0.78, P = 0.0002) compared with the control group. In addition, subgroup analyses showed that these benefits were observed with both oral and intravenous iron supplementation. CONCLUSION Iron supplementation is effective in ameliorating anemia and reducing the need for BT in CRC surgery patients.
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Affiliation(s)
- Gang Tang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Linyu Zhang
- Department of Clinical Medicine, Chongqing Medical University, Chongqing, China
| | - Wang Huang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengqiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Intraoperative and Postoperative Iron Supplementation in Elective Total Joint Arthroplasty: A Systematic Review. J Am Acad Orthop Surg 2021; 29:e1200-e1207. [PMID: 33591126 DOI: 10.5435/jaaos-d-20-01171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/01/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Postoperative anemia is associated with substantial morbidity and mortality in total joint arthroplasty (TJA). Our primary objective was to determine whether perioperative iron supplementation improves postoperative hemoglobin levels in TJA. Secondary objectives were to determine the effects of perioperative iron on adverse events, quality of life, and functional measures in TJA. METHODS We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using six databases. We included English-language, randomized controlled trials investigating intraoperative or postoperative iron supplementation in elective TJA that reported postoperative hemoglobin levels in patients aged 18 years or older. Seven eligible studies were identified, among which substantial heterogeneity was noted. Bias risk was low in four studies, unclear in two studies, and high in one study. Three studies assessed oral iron supplementation, three assessed intravenous iron supplementation, and one compared oral and intravenous iron supplementation. All intravenous iron was administered intraoperatively, except in the oral versus intravenous comparison. RESULTS Postoperative oral iron supplementation had no effect on postoperative hemoglobin levels. Intraoperative and postoperative intravenous iron supplementation was associated with higher postoperative hemoglobin levels and greater increases in hemoglobin levels. Two studies reported rates of anemia and found that intraoperative and postoperative intravenous iron supplementation reduced rates of postoperative anemia at postoperative day 30. No adverse events were associated with iron supplementation. One study found that intravenous iron improved quality of life in TJA patients with severe postoperative anemia compared with those treated with oral iron. Perioperative iron had no effects on functional outcomes. DISCUSSION We found no evidence that postoperative oral iron supplementation improves hemoglobin levels, quality of life, or functional outcomes in elective TJA patients. However, intraoperative and postoperative intravenous iron supplementation may accelerate recovery of hemoglobin levels in these patients. LEVEL OF EVIDENCE Level I, systematic review of randomized controlled trials.
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Park HS, Bin SI, Kim HJ, Kim J, Kim H, Ro Y, Koh WU. Immediate intravenous iron administration improves anaemia recovery following total knee arthroplasty: A propensity-matched analysis. Vox Sang 2021; 117:243-250. [PMID: 34270101 DOI: 10.1111/vox.13181] [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: 02/16/2021] [Revised: 06/22/2021] [Accepted: 06/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients who undergo total knee arthroplasty (TKA) have a risk of postoperative anaemia. This observational study evaluated whether single-dose intravenous ferric carboxymaltose (FCM) administered immediately after TKA facilitates the correction of anaemia. MATERIALS AND METHODS We retrospectively analysed 722 patients who underwent primary TKA. The FCM group receiving 1000 mg intravenous FCM within one postoperative hour was compared with the non-FCM group that did not receive the medication. A propensity score matching with multiple logistic regression analysis was used to minimize intergroup differences in the baseline characteristics and postoperative blood loss. The rate and severity of postoperative anaemia were compared between the groups, along with haemoglobin (Hb) value, transfusion rate and complications. RESULTS After propensity score matching, 231 patients were included in each group. In the FCM group, the rate of anaemia at postoperative day (POD) 7 (p = 0.021) and postoperative week (POW) 5 (p < 0.001) and the transfusion rate were significantly lower (p = 0.008). The rate of moderate to severe anaemia at POW-5 was also significantly lower in the FCM group (p < 0.001). In patients without preoperative anaemia (n = 322), the transfusion rate and rate and severity of anaemia at POD-7 and POW-5 were significantly lower in the FCM group than in the non-FCM group. CONCLUSION Postoperative intravenous FCM administration facilitated recovery of surgery-related anaemia by improving Hb and may reduce the need for transfusion in TKA patients. Preoperative non-anaemic patients could also benefit from accelerated recovery by intravenous iron treatment.
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Affiliation(s)
- Hee-Sun Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong-Il Bin
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ha-Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jinsun Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Youngjin Ro
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Won Uk Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Nabi V, Ayhan S, Yuksel S, Adhikari P, Vila-Casademunt A, Pellise F, Perez-Grueso FS, Alanay A, Obeid I, Kleinstueck F, Acaroglu E. The Effect of Discharging Patients with Low Hemoglobin Levels on Hospital Readmission and Quality of Life after Adult Spinal Deformity Surgery. Asian Spine J 2021; 16:261-269. [PMID: 34130379 PMCID: PMC9066263 DOI: 10.31616/asj.2020.0629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/29/2021] [Indexed: 12/27/2022] Open
Abstract
Study Design Retrospective cohort. Purpose This study aims to evaluate the impact of anemia on functional outcomes, health-related quality of life (HRQoL), and early hospital readmission (EHR) rates after adult spinal deformity (ASD) surgery at the time of discharge from the hospital. Overview of Literature Concerns with risks of transfusion, insufficient evidence for its benefits, and the possibility of associated adverse outcomes have led to restrictive transfusion practices. Therefore, patients are discharged according to patient blood management programs that are implemented in hospitals nationwide to reduce unnecessary blood transfusions. However, not many comprehensive kinds of studies exist on the effect of postoperative anemia on functional life and complications. Methods Anemia severity was defined following the 2011 World Health Organization guidelines. All patients had HRQoL tests as well as complete blood counts pre- and postoperatively. EHR is the admission within 30 days of discharge and was used as the dependent parameter. Results This study comprised 225 surgically treated ASD patients with a median age of 62.0 years, predominantly women (80%). Of the 225 patients, 82, 137, and six had mild, moderate, and severe anemia at the time of discharge, respectively. Seventeen of the patients (mild [11, 64.7%]; moderate [5, 29.4%]; severe [1, 5.9%]) were readmitted within 30 days. The mean hemoglobin values were higher in readmitted patients (p=0.071). Infection was the leading cause of readmission (n=12), but a low hemoglobin level was not observed in any of these patients at the time of discharge. Except for Scoliosis Research Society-22 questionnaire, HRQoL improvements did not reach statistical significance in early readmitted patients in the first year after surgery. Conclusions The results of this study demonstrated that the occurrence and the severity of postoperative anemia are not associated with EHR in surgically treated patients with ASD. The findings of the current research suggested that clinical awareness of the parameters other than postoperative anemia may be crucial. Thus, improvements in HRQoL scores were poor in early readmitted patients 1 year after surgery.
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Affiliation(s)
- Vugar Nabi
- Department of Orthopaedics and Traumatology, Antalya Research and Education Hospital, Ministry of Health, University of Health Science, Antalya, Turkey
| | - Selim Ayhan
- Department of Neurosurgery, Baskent University Hospital, Ankara, Turkey
| | - Selcen Yuksel
- Department of Biostatistics, Yildirim Beyazit University, Ankara, Turkey
| | | | | | | | | | - Ahmet Alanay
- Department of Orthopaedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
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- Hospital Universitari Valld'Hebron, Barcelona, Spain
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Benson CS, Shah A, Stanworth SJ, Frise CJ, Spiby H, Lax SJ, Murray J, Klein AA. The effect of iron deficiency and anaemia on women's health. Anaesthesia 2021; 76 Suppl 4:84-95. [PMID: 33682105 DOI: 10.1111/anae.15405] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 12/14/2022]
Abstract
Iron deficiency and anaemia are global health problems and major causes of morbidity in women. Current definitions of anaemia in women are historic and have been challenged by recent data from observational studies. Menstrual loss, abnormal uterine bleeding and pregnancy put women at risk of developing iron deficiency which can result in severe fatigue, reduced exercise capacity and poor work performance. Iron deficiency and anaemia during pregnancy are associated with adverse maternal and fetal outcomes, including neurocognitive deficits in children born to iron-deficient mothers. Both iron deficiency and anaemia are common in women undergoing surgery but their association with poor outcomes remains uncertain. The enduring burden of iron deficiency and anaemia in women suggests that current strategies for recognition, prevention and treatment are limited in their utility. Improvements in our understanding of iron homeostasis and the development of new iron preparations, which are better absorbed with fewer side-effects, may improve therapeutic effectiveness of oral iron. Intravenous iron is efficacious for correcting anaemia rapidly but high-quality data on patient-centred outcomes and cost-effectiveness are currently lacking. Many recommendations for the treatment of iron deficiency and anaemia in national guidelines are not supported by high-quality evidence. There is a need for robust epidemiological data and well-designed clinical trials. The latter will require collaborative working between researchers and patients to design studies in ways that incorporate patients' perspectives on the research process and target outcomes that matter to them.
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Affiliation(s)
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S J Stanworth
- NIHR Oxford Biomedical Research Centre, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NHS Blood and Transplant, Oxford, UK.,Fetal Maternal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C J Frise
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK.,School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - S J Lax
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - J Murray
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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Preoperative Anemia Treatment with Intravenous Iron Therapy in Patients Undergoing Abdominal Surgery: A Systematic Review. Adv Ther 2021; 38:1447-1469. [PMID: 33580485 PMCID: PMC7932933 DOI: 10.1007/s12325-021-01628-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/15/2021] [Indexed: 12/21/2022]
Abstract
Introduction Preoperative anemia is associated with increased morbidity, mortality, and healthcare costs. As a result of the increased incidence of chronic blood loss and iron deficiency anemia in abdominal surgery patients and its impact on patient outcomes, we systematically evaluated the quality of evidence for preoperative intravenous (IV) administration of iron to patients with anemia undergoing major abdominal surgery with the focus on clinical outcomes. Methods In this systematic review, PubMed, Cochrane, The Cumulative Index to Nursing and Allied Health Literature, Web Of Science, and Excerpta Medica Database databases were searched up to 2019 using specific keywords. Inclusion criteria were patients that were over 18 years of age, underwent abdominal surgery, and received an IV iron treatment in the preoperative setting. Results The nine studies included in the final systematic review do not provide consistent evidence of a reduced incidence of allogeneic blood transfusions with preoperative IV iron administration. However, IV iron administration did consistently cause a significant increase in hemoglobin levels relative to oral iron therapy or no iron. Conclusion Overall, these findings are consistent in that IV iron administration is highly effective at rapidly increasing hemoglobin levels in patients with iron deficiency anemia undergoing major abdominal surgery. Unfortunately, there is currently no evidence of reduced incidence of allogeneic blood transfusions or other enhanced outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01628-7.
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Elhenawy AM, Meyer SR, Bagshaw SM, MacArthur RG, Carroll LJ. Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis. Syst Rev 2021; 10:36. [PMID: 33485392 PMCID: PMC7824930 DOI: 10.1186/s13643-021-01579-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 01/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Preoperative anemia is a common comorbidity that often necessitates allogeneic blood transfusion (ABT). As there is a risk associated with blood transfusions, preoperative intravenous iron (IV) has been proposed to increase the hemoglobin to reduce perioperative transfusion; however, randomized controlled trials (RCT) investigating this efficacy for IV iron are small, limited, and inconclusive. Consequently, a meta-analysis that pools these studies may provide new and clinically useful information. METHODS/DESIGN Databases of MEDLINE, EMBASE, EBM Reviews; Cochrane-controlled trial registry; Scopus; registries of health technology assessment and clinical trials; Web of Science; ProQuest Dissertations and Theses; Clinicaltrials.gov; and Conference Proceedings Citation Index-Science (CPCI-S) were searched. Also, we screened all the retrieved reference lists. SELECTION CRITERIA Titles and abstracts were screened for relevance (i.e., relevant, irrelevant, or potentially relevant). Then, we screened full texts of those citations identified as potentially applicable. RESULTS Our search found 3195 citations and ten RCTs (1039 participants) that met our inclusion criteria. Preoperative IV iron supplementation significantly decreases ABT by 16% (risk ratio (RR): 0.84, 95% confidence interval [CI]: 0.71, 0.99, p = 0.04). In addition, preoperatively, hemoglobin levels increased after receiving IV iron (mean difference [MD] between the study groups: 7.15 g/L, 95% CI: 2.26, 12.04 g/L, p = 0.004) and at follow-up > 4 weeks postoperatively (MD: 6.46 g/L, 95% CI: 3.10, 9.81, p = 0.0002). Iron injection was not associated with increased incidence of non-serious or serious adverse effects across groups (RR: 1.13, 95% CI: 0.78, 1.65, p = 0.52) and (RR: 0.96, 95% CI: 0.44, 2.10, p = 0.92) respectively. CONCLUSIONS With moderate certainty, due to the high risk of bias in some studies in one or two domains, we found intravenous iron supplementation is associated with a significant decrease in the blood transfusions rate, and modest hemoglobin concentrations rise when injected pre-surgery compared with placebo or oral iron supplementation. However, further full-scale randomized controlled trials with robust methodology are required. In particular, the safety, quality of life, and cost-effectiveness of different intravenous iron preparations require further evaluation.
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Affiliation(s)
- Abdelsalam M Elhenawy
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada. .,Division of Cardiothoracic Surgery, Al Azhar University, Cairo, Egypt.
| | - Steven R Meyer
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Roderick G MacArthur
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Linda J Carroll
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Pasricha SR, Tye-Din J, Muckenthaler MU, Swinkels DW. Iron deficiency. Lancet 2021; 397:233-248. [PMID: 33285139 DOI: 10.1016/s0140-6736(20)32594-0] [Citation(s) in RCA: 358] [Impact Index Per Article: 119.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/06/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023]
Abstract
Iron deficiency is one of the leading contributors to the global burden of disease, and particularly affects children, premenopausal women, and people in low-income and middle-income countries. Anaemia is one of many consequences of iron deficiency, and clinical and functional impairments can occur in the absence of anaemia. Iron deprivation from erythroblasts and other tissues occurs when total body stores of iron are low or when inflammation causes withholding of iron from the plasma, particularly through the action of hepcidin, the main regulator of systemic iron homoeostasis. Oral iron therapy is the first line of treatment in most cases. Hepcidin upregulation by oral iron supplementation limits the absorption efficiency of high-dose oral iron supplementation, and of oral iron during inflammation. Modern parenteral iron formulations have substantially altered iron treatment and enable rapid, safe total-dose iron replacement. An underlying cause should be sought in all patients presenting with iron deficiency: screening for coeliac disease should be considered routinely, and endoscopic investigation to exclude bleeding gastrointestinal lesions is warranted in men and postmenopausal women presenting with iron deficiency anaemia. Iron supplementation programmes in low-income countries comprise part of the solution to meeting WHO Global Nutrition Targets.
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Affiliation(s)
- Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.
| | - Jason Tye-Din
- Immunology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Martina U Muckenthaler
- Department of Pediatric Oncology, Hematology, and Immunology and Molecular Medicine Partnership Unit, University of Heidelberg, Heidelberg, Germany; Molecular Medicine Partnership Unit, European Molecular Biology Laboratory, Heidelberg, Germany; Translational Lung Research Center, German Center for Lung Research, Heidelberg, Germany; German Centre for Cardiovascular Research, Partner Site Heidelberg, Mannheim, Germany
| | - Dorine W Swinkels
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
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Țigliș M, Neagu TP, Niculae A, Lascăr I, Grințescu IM. Incidence of Iron Deficiency and the Role of Intravenous Iron Use in Perioperative Periods. MEDICINA-LITHUANIA 2020; 56:medicina56100528. [PMID: 33053625 PMCID: PMC7601561 DOI: 10.3390/medicina56100528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 01/01/2023]
Abstract
Iron deficiency is a major problem in worldwide populations, being more alarming in surgical patients. In the presence of absolute iron deficiency (depletion of body iron), functional iron deficiency (during intense bone marrow stimulation by endogenous or exogenous factors), or iron sequestration (acute or chronic inflammatory conditions), iron-restricted erythropoiesis can develop. This systemic review was conducted to draw attention to the delicate problem of perioperative anemia, and to provide solutions to optimize the management of anemic surgical patients. Systemic reviews and meta-analyses, clinical studies and trials, case reports and international guidelines were studied, from a database of 50 articles. Bone marrow biopsy, serum ferritin levels, transferrin saturation, the mean corpuscular volume, and mean corpuscular hemoglobin concentration were used in the diagnosis of iron deficiency. There are various intravenous iron formulations, with different pharmacological profiles used for restoring iron. In surgical patients, anemia is an independent risk factor for morbidity and mortality. Therefore, anemia correction should be rapid, with parenteral iron formulations—the oral ones—being inefficient. Various studies showed the safety and efficacy of parenteral iron formulations in correcting hemoglobin levels and decreasing the blood transfusion rate, the overall mortality, the postoperative infections incidence, hospitalization days, and the general costs.
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Affiliation(s)
- Mirela Țigliș
- Department of Anaesthesiology and Intensive Care, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (M.Ț.); (I.M.G.)
- Clinical Department No. 14, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Tiberiu Paul Neagu
- Department of Plastic Surgery and Reconstructive Microsurgery, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania;
- Clinical Department No. 11, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Correspondence:
| | - Andrei Niculae
- Department of Nephrology and Dialysis, “St. John” Emergency Clinical Hospital, 042122 Bucharest, Romania;
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ioan Lascăr
- Department of Plastic Surgery and Reconstructive Microsurgery, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania;
- Clinical Department No. 11, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ioana Marina Grințescu
- Department of Anaesthesiology and Intensive Care, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (M.Ț.); (I.M.G.)
- Clinical Department No. 14, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Mosieri C, Chandler D, Reed DS, Craig MK, Hyatali F, Kallurkar A, Cornett EM, Urman RD, Kaye AD. Managing preoperative anemia: Evolving concepts and strategies for improving patient outcomes. Best Pract Res Clin Anaesthesiol 2020; 34:183-197. [PMID: 32711828 DOI: 10.1016/j.bpa.2020.04.005] [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: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 01/28/2023]
Abstract
Anemia is the most common hematological disease, and is defined by the World Health Organization as a condition in which the number of red blood cells and consequently oxygen-carrying capacity is insufficient to meet the physiological needs of the body. Anemia can occur throughout the perioperative period and has important clinical consequences. Preoperative anemia is usually regarded as no more than a surrogate marker of a patient's physical status, and it is not always adequately addressed before surgery. Postoperative anemia is a common event and occurs in 80-90% of patients who have undergone major surgery. This manuscript discusses the detection and management of preoperative anemia, the three pillars of patient blood management, perioperative anemia management, and risk stratification for anemia in the surgical setting.
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Affiliation(s)
- Chizoba Mosieri
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Debbie Chandler
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Devin S Reed
- Department of Anesthesiology, LSU Health Science Center New Orleans, 1542 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Madelyn K Craig
- Department of Anesthesiology, LSU Health Science Center New Orleans, 1542 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Farees Hyatali
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Anusha Kallurkar
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA; Provost, Chief Academic Officer, and Vice Chancellor of Academic Affairs, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
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Smith A, Moon T, Pak T, Park B, Urman RD. Preoperative Anemia Treatment With Intravenous Iron in Patients Undergoing Major Orthopedic Surgery: A Systematic Review. Geriatr Orthop Surg Rehabil 2020; 11:2151459320935094. [PMID: 32637197 PMCID: PMC7323265 DOI: 10.1177/2151459320935094] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction Based upon the Third National Health and Nutrition Examination Survey data, iron deficiency anemia is the cause of at least 20% of cases of anemia in adults over the age of 65. This is especially relevant in patients undergoing major orthopedic surgery as substantial perioperative blood loss is possible, leading to a high rate of allogeneic blood transfusion in total hip replacements, total knee replacements, and hip fracture repairs. Significance The results of this systematic review may be of interest to clinicians and hospital administrators evaluating the clinical efficacy and cost effectiveness of intravenous (IV) iron administration prior to major orthopedic surgery. Materials and Methods The original studies considered for this review included patients who were over 18 years of age, undergoing major orthopedic surgery, and who received an IV iron treatment in the preoperative setting. A total of 1083 articles were identified and reviewed. After removing duplicates, 1031 publications were screened, and 105 full-text studies were assessed for eligibility. A total of 98 were excluded and 7 articles remained which met the criteria for this review. The primary outcome examined in the included studies was the allogeneic blood transfusion rate. The secondary areas of interest were changes in serum hemoglobin, morbidity and mortality, length of stay, and cost effectiveness. Results This systematic review found little evidence that IV iron therapy is effective at reducing transfusion in patients undergoing major orthopedic surgery. Conclusions We do not recommend preoperative IV iron therapy for all patients scheduled for major orthopedic surgery.
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Affiliation(s)
- Aaron Smith
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tiffany Moon
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Taylor Pak
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian Park
- Department of Anesthesiology, Perioperative Pain and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative Pain and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Harvard Medical School, Boston, MA, USA
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Dao P, Massin P. Blood management in enhanced recovery after hip and knee replacement. Orthop Traumatol Surg Res 2020; 106:S1-S5. [PMID: 31836497 DOI: 10.1016/j.otsr.2019.05.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 04/30/2019] [Accepted: 05/10/2019] [Indexed: 02/02/2023]
Abstract
Enhanced recovery in orthopedic surgery is a global patient management strategy to achieve early functional recovery. Blood management is central to rehabilitation protocols after hip or knee replacement. Coagulation physiology in hip and knee replacement is now well described, showing aggravation of bleeding by hyperfibrinolysis. The present study approaches blood management via 3 questions. 1/How to anticipate and prevent transfusion risk preoperatively? Screening for predictive factors can target the at-risk population, enabling a strategy of preoperative hemoglobin level optimization. 2/How to improve intraoperative hemostasis so as to minimize blood loss? Anti-fibrinolytic and topical hemostatic agents have proven efficacy. Tranexamic acid plays a central role. The impact of the usual surgical techniques, such as pneumatic tourniquet and postoperative drainage, on bleeding needs assessment. 3/How to manage postoperative anemia? Anemia without signs of general intolerance is frequent at discharge, but has been little studied. This raises the question of the medical interest of correcting postoperative anemia. LEVEL OF EVIDENCE: Expert opinion, V.
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Affiliation(s)
- Pierre Dao
- CMC Ambroise-Paré, 25-27, boulevard Victor-Hugo, 92200 Neuilly-sur-Seine, France.
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Shin HW, Park JJ, Kim HJ, You HS, Choi SU, Lee MJ. Efficacy of perioperative intravenous iron therapy for transfusion in orthopedic surgery: A systematic review and meta-analysis. PLoS One 2019; 14:e0215427. [PMID: 31059515 PMCID: PMC6502310 DOI: 10.1371/journal.pone.0215427] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/02/2019] [Indexed: 01/07/2023] Open
Abstract
Perioperative anemia frequently occurs in patients undergoing orthopedic surgery. We aimed to evaluate the efficacy of perioperative intravenous iron therapy (IVIT) on transfusion and recovery profiles during orthopedic surgery. We searched PubMed, Embase, Cochrane, and Google Scholar for eligible clinical trials (randomized controlled trials, RCTs; case-control studies, CCSs) in comparing IVIT and no iron therapy, up to September 2018. Primary outcomes were the effects of IVIT on the proportion of patients transfused and units of red blood cells (RBCs) transfused perioperatively. Secondary outcomes were the effects of IVIT on recovery profiles, such as length of hospital stay (LOS), post-operative infection, and mortality. Subgroup analysis was performed based on iron dose (low: ≤ 300 mg, high: > 400 mg), IVIT period (pre-operative, post-operative, perioperative), and study design. We identified 12 clinical trials (4 RCTs with 616 patients and 8 CCSs with 1,253 patients). IVIT significantly reduced the proportion of patients transfused by 31% (RR, 0.69; P = 0.0002), and units of RBCs transfused by 0.34 units/person (MD, -0.34; P = 0.0007). For subgroup analysis by iron dose, low- or high-dose IVIT significantly reduced the proportion of patients transfused (RR, 0.73, P = 0.005; RR, 0.68, P = 0.008), and RBC units transfused (MD, -0.47, P < 0.0001; MD, -0.28, P = 0.04). For subgroup analysis by period, IVIT administered post-operatively significantly reduced the proportion of patients transfused (post-operative: RR, 0.60, P = 0.002; pre-operative: RR, 0.74, P = 0.06) and RBC units transfused (post-operative: MD, -0.44, P <0.00001; pre-operative: MD, -0.29, P = 0.06). For subgroup analysis by study design, IVIT decreased the proportion of patients transfused and RBC units transfused in the group of CCSs, but IVIT in the group of RCTs did not. IVIT significantly shortened LOS by 1.6 days (P = 0.0006) and reduced post-operative infections by 33% (P = 0.01). IVIT did not change mortality. Perioperative IVIT during orthopedic surgery, especially post-operatively, appears to reduce the proportion of patients transfused and units of RBCs transfused, with shorter LOS and decreased infection rate, but no change in mortality rate. These were only found in CCSs and not in RCTs due to the relatively small number of RCTs with low to high risk of bias.
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Affiliation(s)
- Hye Won Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
- * E-mail:
| | - Jeong Jun Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hyun Jung Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hae Sun You
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Mee Ju Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
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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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Shah A, Palmer AJR, Fisher SA, Rahman SM, Brunskill S, Doree C, Reid J, Sugavanam A, Stanworth SJ. What is the effect of perioperative intravenous iron therapy in patients undergoing non-elective surgery? A systematic review with meta-analysis and trial sequential analysis. Perioper Med (Lond) 2018; 7:30. [PMID: 30559962 PMCID: PMC6290500 DOI: 10.1186/s13741-018-0109-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/13/2018] [Indexed: 01/01/2023] Open
Abstract
Background Guidelines to treat anaemia with intravenous (IV) iron have focused on elective surgical patients with little attention paid to those undergoing non-elective/emergency surgery. Whilst these patients may experience poor outcomes because of their presenting illness, observational data suggests that untreated anaemia may also be a contributing factor to poor outcomes. We conducted a systematic review to investigate the safety and efficacy of IV iron in patients undergoing non-elective surgery. Methods We followed a pre-defined review protocol and included randomised controlled trials (RCTs) in patients undergoing non-elective surgery who received IV iron. Primary outcomes were all-cause infection and mean difference in haemoglobin (Hb) at follow-up. Secondary outcomes included transfusion requirements, hospital length of stay (LOS), health-related quality of life (HRQoL), mortality and adverse events. Results Three RCTs (605 participants) were included in this systematic review of which two, in both hip fracture (HF) patients, provided data for meta-analysis. Both of these RCTs were at low risk of bias. We found no evidence of a difference in the risk of infection (RR 0.99, 95% CI 0.55 to 1.80, I 2 = 9%) or in the Hb concentration at 'short-term' (≤ 7 days) follow-up (mean difference - 0.32 g/L, 95% CI - 3.28 to 2.64, I 2 = 37%). IV iron did not reduce the risk of requiring a blood transfusion (RR 0.90, 95% CI 0.73 to 1.11, p = 0.46, I 2 = 0%), and we observed no difference in mortality, LOS or adverse events. One RCT reported on HRQoL and found no difference between treatment arms. Conclusion We found no conclusive evidence of an effect of IV iron on clinically important outcomes in patients undergoing non-elective surgery. Further adequately powered trials to evaluate its benefit in emergency surgical specialties with a high burden of anaemia are warranted. Trial registration This systematic review was registered on PROSPERO (CRD42018096288).
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Affiliation(s)
- Akshay Shah
- 1Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Level 4 Academic Block, Oxford, OX3 9DU UK
| | - Antony J R Palmer
- 2Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sheila A Fisher
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Shah M Rahman
- 3Frimley Health NHS Foundation Trust, Camberley, Surrey GU16 7UJ UK
| | - Susan Brunskill
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Carolyn Doree
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Jack Reid
- 5Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Anita Sugavanam
- 5Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Simon J Stanworth
- 1Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Level 4 Academic Block, Oxford, OX3 9DU UK.,3Frimley Health NHS Foundation Trust, Camberley, Surrey GU16 7UJ UK.,4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
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Shah A, Fisher SA, Wong H, Roy NB, McKechnie S, Doree C, Litton E, Stanworth SJ. Safety and efficacy of iron therapy on reducing red blood cell transfusion requirements and treating anaemia in critically ill adults: A systematic review with meta-analysis and trial sequential analysis. J Crit Care 2018; 49:162-171. [PMID: 30448516 DOI: 10.1016/j.jcrc.2018.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/25/2018] [Accepted: 11/09/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE To evaluate the safety (risk of infection) and efficacy (transfusion requirements, changes in haemoglobin (Hb)) of iron therapy in adult intensive care unit (ICU) patients. MATERIALS AND METHODS We systematically searched seven databases for all relevant studies until January 2018 and included randomized (RCT) studies comparing iron, by any route, with placebo/no iron. RESULTS 805 participants from 6 RCTs were included. Iron therapy, by any route, did not decrease the risk of requirement for a red blood cell (RBC) transfusion (Risk ratio (RR) 0.91, 95% CI 0.80 to 1.04, p = 0.15) or mean number of RBCs transfused per participant (mean difference (MD) -0.30, 95% CI -0.68 to 0.07, p = 0.15). Iron therapy did increase mean Hb concentration (MD 0.31 g/dL, 95% CI 0.04 to 0.59, p = 0.03). There was no difference in infection (RR 0.95, 95% CI 0.79 to 1.19, p = 0.44). Trial Sequential Analysis suggests that the required participant numbers to detect or reject a clinically important effect of iron therapy on transfusion requirements or infection in ICU patients has not yet been reached. CONCLUSION Iron therapy results in a modest increase in Hb. The current evidence is inadequate to exclude an important effect on transfusion requirements or infection.
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Affiliation(s)
- Akshay Shah
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | - Sheila A Fisher
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Henna Wong
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Noémi B Roy
- Weatherall Institute of Molecular Medicine, University of Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Stuart McKechnie
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Nuffield Division of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Simon J Stanworth
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Gómez-Ramírez S, Maldonado-Ruiz MÁ, Campos-Garrigues A, Herrera A, Muñoz M. Short-term perioperative iron in major orthopedic surgery: state of the art. Vox Sang 2018; 114:3-16. [DOI: 10.1111/vox.12718] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/13/2018] [Accepted: 09/18/2018] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | - Antonio Herrera
- Ortopaedic and Trauma Surgery; School of Medicine; Zaragoza Spain
| | - Manuel Muñoz
- Perioperative Transfusion Medicine; School of Medicine; Málaga Spain
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28
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Montano-Pedroso JC, Bueno Garcia E, Alcântara Rodrigues de Moraes M, Francescato Veiga D, Masako Ferreira L. Intravenous iron sucrose versus oral iron administration for the postoperative treatment of post-bariatric abdominoplasty anaemia: an open-label, randomised, superiority trial in Brazil. LANCET HAEMATOLOGY 2018; 5:e310-e320. [DOI: 10.1016/s2352-3026(18)30071-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/13/2018] [Accepted: 05/16/2018] [Indexed: 12/19/2022]
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