Intravenous ferric carboxymaltose versus standard care in the management of postoperative anaemia: a prospective, open-label, randomised controlled trial

Early Postoperative Intravenous Iron Versus Oral Iron for the Treatment of Anemia Following Cardiac Surgery: A Randomized Controlled Trial

BACKGROUND

Postoperative anemia is a common complication after cardiac surgery, often persisting for months and substantially affecting patient recovery. Despite its prevalence, optimal treatment strategies are lacking. We aimed to evaluate whether early postoperative intravenous (IV) iron is more effective than daily oral iron in correcting anemia after cardiac surgery.

METHODS

This single-center, pragmatic randomized controlled trial enrolled 110 cardiac surgery patients with moderate postoperative anemia (hemoglobin 8-11 g/dL). Participants were randomized 1:1 to receive either a single infusion of 20 mg/kg ferric derisomaltose on postoperative day 1 (IV iron group, n = 57) or 100 mg oral ferrous sulfate twice daily for 4 weeks (oral iron group, n = 53). All outcomes were assessed at 4 weeks postrandomization. The primary composite outcome aimed to measure treatment success, defined as the proportion of participants who were (a) no longer anemic (per World Health Organization criteria) and (b) neither had received allogeneic red blood cell (RBC) transfusions after randomization. Secondary end points included differences in hemoglobin levels, RBC transfusion rates, iron metrics, 6-minute walk test distances, hospital length of stay, and patient-reported outcomes.

RESULTS

Primary outcome data were available for 53 participants in the IV iron group and 51 in the oral iron group. The proportion of participants who achieved the primary end point did not differ significantly between groups (28% vs 16%; risk difference 13%, 95% confidence interval [CI], -3% to 28%; P = .121). No statistically significant differences were observed in anemia prevalence (66% vs 82%; P = .058) or RBC transfusion rates (17% vs 33%; P = .054). Mean hemoglobin levels (± standard deviation) were higher in the IV iron group (12.0 ± 1.1 g/dL vs 11.4 ± 1.3 g/dL; P = .013). None of the participants in the IV iron group had ferritin levels <100 µg/L, compared to 26% in the oral iron group (P < .001, accounting for 95% CI for 0 numerators). No significant differences were observed in the 6-minute walk test, hospital length of stay, or patient-reported outcomes. Notably, no serious adverse events related to ferric derisomaltose were reported.

CONCLUSIONS

Early postoperative IV iron did not demonstrate superiority over oral iron for the primary outcome. However, secondary end points suggest it may improve hemoglobin levels and reduce the prevalence of postoperative iron deficiency. These findings warrant further investigation in larger trials to confirm the clinical effectiveness of early postoperative IV iron.

High-Dose Intravenous Iron Supplementation During Hospitalization Improves Hemoglobin Level and Transfusion Rate Following Total Knee or Hip Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Intravenous (IV) iron supplementation is a potential strategy to address anemia and reduce the need for blood transfusion following total knee or hip arthroplasty (TKA or THA). We aimed to investigate the effect and safety of IV iron supplementation as optimal blood management in patients after TKA or THA.

METHODS

The MEDLINE, Embase, Cochrane Library, CINAHL, and Scopus databases were systematically searched for studies comparing patients undergoing total knee arthroplasty or total hip arthroplasty with and without IV iron supplementation. Blood transfusion rate and postoperative hemoglobin drop were assessed for effectiveness, while adverse events and surgical site infection were evaluated for the safety of IV iron supplementation. Additionally, subgroup analyses were performed to investigate the effect of IV iron supplementation based on the iron dose or patient's indication. There were 14 studies included.

RESULTS

The use of IV iron supplementation significantly decreased the blood transfusion rate compared to no supplementation after TKA or THA (odds ratio [OR] 0.43; 95% confidence interval [CI], 0.27 to 0.68; P < 0.001) as clinical manifestations were considered for the transfusion, although no significant difference was found between postoperative days one and seven. Furthermore, IV iron supplementation significantly reduced postoperative Hb drop compared to no supplementation at postoperative two to six weeks (postoperative weeks two to three: mean difference [MD], -0.61; 95% CI, -1.01 to -0.20; P = 0.003 and postoperative weeks four to six: MD, -0.50; 95% CI, -0.70 to -0.31; P < 0.001). The safety profile did not significantly differ between the two groups. Adverse events occurred in 0.5% of the treatment group. Subgroup analysis showed that high-dose iron in high-risk patients led to a faster recovery of Hb drop than low-dose iron in routine patients following TKA or THA.

CONCLUSIONS

Perioperative IV iron supplementation was effective and safe in blood management for reducing blood transfusion and Hb drop in patients following TKA or THA. High-dose iron supplementation provided faster recovery of Hb than low-dose iron, which was more effective in high-risk patients.

LEVEL OF EVIDENCE

Meta-analysis of level 3 studies.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Prognostic value of post-operative iron biomarkers in colorectal cancer: population-based patient cohort

BACKGROUND

Post-operative anaemia is linked to iron deficiency. We investigated the prognostic value of post-operative iron biomarkers in colorectal cancer (CRC).

METHODS

Ferritin, transferrin, iron, and transferrin saturation (TS%) were measured from blood collected at a single time-point post-surgery in 2769 CRC patients. Associations between iron biomarkers with cancer-specific survival (CSS) and overall survival (OS) were assessed using Cox regression with hazard ratios (HR), stratified by post-operative time of blood collection (<1-month/≥1-month).

RESULTS

After a median follow-up of 9.5 years, 52.6% of patients had died. For iron biomarkers assessed <1-month post-surgery, higher compared to normal TS% was associated with shorter CSS (HR [95% CI] = 2.36 [1.25-4.46]), and higher iron levels with better OS (upper vs. median tertile: HR [95% CI] = 0.79 [0.65-0.97]). When assessed ≥1-month post-surgery, elevated ferritin was associated with poor CSS (high vs. normal: HR [95% CI] = 1.44 [1.10-1.87]), and low TS% with worse CSS (low vs. normal: HR [95% CI] = 1.60 [1.24-2.06]). Similar but weaker associations were observed for OS.

CONCLUSION

Monitoring of serum ferritin and TS% beyond 1-month post-surgery may be relevant for risk stratification of patients with operable CRC. Future studies should validate our findings.

Postoperative Intravenous Iron Infusion in Anemic Colorectal Cancer Patients: An Observational Study

Anemia is the most common extraintestinal symptom of colorectal cancer, with a prevalence of 30-75%. While the preoperative anemia in this patient population has been well studied and its correction 4-6 weeks prior to surgery is recommended when feasible, there is a paucity of data regarding the management of postoperative anemia, which has a prevalence of up to 87% in these patients. To address this issue, we conducted an observational cohort study of surgically treated postoperative anemic patients with colorectal cancer. The objective of this study was to evaluate the effect of intravenous ferric carboxymaltose on the correction of postoperative anemia by postoperative day 30 (POD30). The primary outcome was the change in hemoglobin on POD30, while the secondary outcomes were the change in iron and other laboratory parameters, postoperative complications and transfusions. The results demonstrated that patients treated with intravenous iron exhibited a significant increase in hemoglobin levels by POD30, along with a concomitant increase in hematocrit, ferritin, and transferrin saturation levels, compared to the control group. The findings imply that patients undergoing colorectal cancer surgery with anemia that was not corrected in the preoperative setting may benefit from early postoperative intravenous iron infusion.

Functional iron deficiency anemia in patients with cancer

Anemia is frequently observed in patients with cancer owing to anticancer chemotherapy, radiation therapy, and inflammatory responses. This often leads to functional iron deficiency, characterized by adequate iron stores but impaired use of iron for red blood cell production. This condition, termed functional iron deficiency anemia (IDA), is identified by a ferritin level of 30-500 µg/dL and a transferrin saturation < 50%. Functional iron deficiency often develops with the prolonged use of erythropoiesis-stimulating agents, leading to a diminished response to anemia treatment. Although oral iron supplementation is common, intravenous iron is more effective and recommended in such cases. Recent studies have shown that ferric carboxymaltose (FCM) is effective in treating functional IDA in patients with cancer. However, because of its potential to induce asymptomatic severe phosphate deficiency, it is important to closely monitor phosphate levels in patients receiving FCM.

Case Report: High-Dose Ferric Carboxymaltose as an Antianaemic Agent to Avoid Haemotransfusions after Total Hip Replacement

This article highlights a case of high-dose ferric carboxymaltose (Ferinject®) for the treatment of perioperative iron deficiency anaemia in a 39-year-old patient with dysplastic coxarthrosis. The patient was admitted routinely for a total hip replacement of the left hip joint. She had been suffering from pain, lameness, and restriction of movement in her left hip joint for the past several years. The patient was admitted with initial iron deficiency anaemia of a medium severity (Hgb-96.5 g/L, RBC-3.97 × 1012/L). Laboratory tests were taken to determine the iron deficiency, and transfusion readiness was submitted. The patient received ferric carboxymaltose infusion before surgery. The intraoperative blood loss was-100 mL with an operation duration of 50 min. On the first postoperative day, haemoglobin decreased to 86 g/L. No haemoglobin decrease was observed in the postoperative period, and 92 g/L was the amount of haemoglobin at the time of hospital discharge. The optimal dose for the treatment of perioperative anaemia has not been established; some studies recommend ferric carboxymaltose at a dose of 15 to 20 mg/kg and a maximum of 1000 mg once on the first day after surgery. The uniqueness of this case report is that a high dose of ferric carboxymaltose (1340 mg) during the preoperative period was applied. No side effects such as hypophosphatemia were reported. We believe that, in this clinical case, the patient managed to avoid large intraoperative blood loss and transfusions by using high doses of ferric carboxymaltose.

Postoperative Intravenous Iron Supplementation Increases Hemoglobin Level in Total Knee Arthroplasty

Iron supplementation provides iron storage and facilitates effective production of hemoglobin. The purpose of this study was to investigate the effect of early postoperative intravenous (IV) iron supplementation in different types of total knee arthroplasty (TKA) surgery. We retrospectively analyzed 863 patients who underwent TKA between September 2017 and September 2021. The IV iron (I) and non-IV iron (NI) groups were compared. Hemoglobin responders, defined as patients who showed a change in hemoglobin level of ≥2 g/dL at 6 weeks of surgery compared to the baseline immediate postoperative hemoglobin level, were identified and they were compared with the nonresponders. After logistic regression analysis, the patients were classified according to the type of surgery (unilateral TKA, staged bilateral TKA, and simultaneous bilateral TKA). A subgroup analysis was performed according to the comorbidity as Charlson Comorbidity Index (CCI). The type of surgery and the rate of hemoglobin responders differed between the I and NI groups. The surgery type and iron supplementation significantly affected the hemoglobin responder in the logistic regression model. In each surgery type, hemoglobin drop in the I group was generally lower in the second and sixth weeks than that in the NI group. It was also effective in reducing hemoglobin drop on the first day of the second surgery in staged bilateral TKA. In addition, the number of hospital days was lower in the IV iron supplementation group who underwent a staged bilateral TKA. CCI did not affect hemoglobin responder, hemoglobin drop, and transfusion rate in both the I and NI groups. Postoperative IV iron supplementation affected the outcome of hemoglobin responders. In addition, it reduced early postoperative hemoglobin drop. However, iron supplementation did not affect the transfusion rate, complications, and clinical outcome, regardless of the type of surgery. LEVEL OF EVIDENCE:  Level III, case-control study.

Patient blood management in major digestive surgery: Recommendations from the Italian multisociety (ACOI, SIAARTI, SIdEM, and SIMTI) modified Delphi consensus conference

Patient blood management (PBM) is defined as the timely application of evidence-based medical and surgical concepts designed to maintain a surgical patient’s hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve the outcomes. PBM is able to reduce mortality up to 68%, reoperation up to 43%, readmission up to 43%, composite morbidity up to 41%, infection rate up to 80%, average length of stay by 16%–33%, transfusion from 10% to 95%, and costs from 10% to 84% after major surgery. It should be noticed, however, that the process of PBM implementation is still in its infancy, and that its potential to improve perioperative outcomes could be strictly linked to the degree of adherence/compliance to the whole program, with decoupling and noncompliance being significant factors for failure. Therefore, the steering committees of four major Italian scientific societies, representing general surgeons, anesthesiologists and transfusion medicine specialists (Associazione Chirurghi Ospedalieri Italiani; Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva; Società Italiana di Emaferesi e Manipolazione Cellulare; Società Italiana di Medicina Trasfusionale e Immunoematologia), organized a joint modified Delphi consensus conference on PBM in the field of major digestive surgery (upper and lower gastrointestinal tract, and hepato-biliopancreatic resections), whose results and recommendations are herein presented.

The effect of postoperative intravenous iron in anaemic, older cardiac surgery patients on disability-free survival (AGE ANEMIA study): study protocol for a multi-centre, double-blind, randomized, placebo-controlled trial

BACKGROUND

Postoperative anaemia is common in older cardiac surgery patients and often caused by iron deficiency. Anaemia may negatively affect recovery after cardiac surgery. This study aims to determine the efficacy of treatment of postoperative iron deficiency anaemia (IDA) with intravenous iron (IVI) on disability 90 days after cardiac surgery in older patients.

METHODS

This is a randomized placebo-controlled double-blind multi-centre trial. In total, 310 patients aged ≥ 70 years with moderate IDA on postoperative day 1 (haemoglobin 85-110 g/L and ferritin concentration < 100 μg/L or iron saturation < 20%) after uncomplicated elective cardiac surgery (aortic valve repair or coronary artery bypass graft surgery) will be included. Patients will be randomly allocated to receive either IVI (ferric derisomaltose) or placebo (sodium chloride 0.9%) on postoperative day 1 in a 1:1 ratio, stratified by centre and type of cardiac surgery. The primary outcome is disability measured by the 12-item World Health Organization Disability Assessment score 2.0 after 90 days. Secondary outcome measures are the number of postoperative red blood cell (RBC) transfusions, change in reticulocyte haemoglobin content (pg) from randomization to hospital discharge, Hb levels at discharge, hospital complications, dyspnoea (assessed with the Rose Dyspnoea Scale) and health-related quality of life (HRQL) (assessed with The Older Persons and Informal Caregivers-Short Form (TOPICS-SF) questionnaire) after 90 days and days alive and out of hospital after 90 days. Lastly, the functional outcomes (e.g. steep ramp or 6-min walk test) and Hb level after 90 days will be assessed as an exploratory endpoint.

DISCUSSION

The results of this study will demonstrate whether early treatment of postoperative IDA with IVI improves disability at 90 days in older cardiac surgery patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04913649. Registered on June 4, 2021.

What we should consider to facilitate recovery of the hematological profile in all patients after pancreaticoduodenectomy: the role of preoperative intravenous iron treatment

BACKGROUND

In pancreaticoduodenectomy (PD), the duodenum and upper jejunum responsible for iron absorption are removed, which can lead to massive hemorrhage during surgery and cause iron deficiency anemia after PD. The aim of this study was to evaluate overall changes in hematologic profiles of patients who underwent pancreaticoduodenectomy. Effect of preoperative intravenous iron treatment on recovery of anemia after surgery was also investigated.

METHODS

From March 2021 to December 2021, patients who underwent curative PD at our institution due to periampullary lesions were enrolled. They were divided into two groups according to whether or not iron was administered before surgery. In the IV iron group, all patients had been routinely administered with 1000 mg of ferric carboxymaltose intravenously once about 3-7 days before the operation day. Contrarily, patients in the control group did not receive intravenous iron before PD. Changes in hematological profile were measured preoperatively and at 5, 14, and 30 days postoperatively. Clinical results of the two groups were compared and analyzed. Additionally, a subgroup analysis was performed for selected non-anemic patients who had preoperative hemoglobin level of 12.0 g/dl or higher to compare changes in hematologic profiles between the two groups.

RESULTS

Thirty patients of the IV iron group and 34 patients of the control group were analyzed. Although no difference was observed in postoperative complications or mortality, hemoglobin and iron levels were recovered significantly faster at two weeks postoperatively in the IV iron group than in the control group. Iron levels were significantly higher in the IV iron group throughout the postoperative period. In subgroup analysis conducted for non-anemic patients, hemoglobin levels were recovered significantly faster and maintained higher in the IV iron group throughout the postoperative period, although baseline levels of hemoglobin were similar between the two groups. In addition, the length of intensive care unit stay was significantly shorter in the IV iron group than in the control group.

CONCLUSIONS

Preoperative intravenous iron treatment might be effective in facilitating recovery of hematologic profiles of patients during the recovery period after PD regardless of the presence of preoperative anemia, thus preventing postoperative iron deficiency anemia.

Perioperative Blood Management Programme in Jehovah’s Witnesses Undergoing Total Hip Arthroplasty

Total hip arthroplasties aim to improve quality of life and reduce pain in patients suffering from late-stage hip osteoarthritis. On the other hand, it may represent a risky surgical procedure in people who refuse blood products because of religious beliefs, such as Jehovah’s Witnesses (JW). Preoperative optimisation protocols of these patients allow medical professionals to perform arthroplasties in a safer manner, avoiding allogeneic blood transfusion. In our retrospective study, two groups of patients were evaluated. Group 1 included JW patients who underwent a preoperative Hb optimisation program; Group 2 included non-JW patients authorizing transfusion in case of necessity. Differences in Hb levels were as follows: before surgery (JW 14.24 ± 1.10 vs. non-JW 12.48 ± 1.00, p-value ≤ 0.05), and after surgery (day 1 Hb: JW 12.88 ± 0.90 vs. non-JW 10.04 ± 1.30, p-value ≤ 0.05; day 3 Hb: JW 14.65 ± 0.80 vs. non-JW 9.10 ± 0.90 p-value ≤ 0.05). Moreover, cost-effectiveness strategies were evaluated in both groups. Our findings support that patient blood management programs are a safe and good strategy in hip prosthetic surgery, decreasing risks and transfusion overuse.

Perioperative Iron Deficiency in Patients Scheduled for Major Elective Surgeries: A French Prospective Multicenter Cross-Sectional Study

BACKGROUND

The management of perioperative iron deficiency is a component of the concept of patient blood management. The objective of this study was to update French data on the prevalence of iron deficiency in patients scheduled for major surgery.

METHODS

The CARENFER PBM study was a prospective cross-sectional study in 46 centers specialized in orthopedic, cardiac, urologic/abdominal, or gynecological surgery. The primary end point was the prevalence of iron deficiency at the time of surgery (D-1/D0) defined as serum ferritin <100 µg/L and/or transferrin saturation (TSAT) <20%.

RESULTS

A total of 1494 patients (mean age, 65.7 years; women, 49.3%) were included from July 20, 2021 to January 3, 2022. The prevalence of iron deficiency in the 1494 patients at D-1/D0 was 47.0% (95% confidence interval [CI], 44.5-49.5). At 30 days after surgery, the prevalence of iron deficiency was 45.0% (95% CI, 42.0-48.0) in the 1085 patients with available data. The percentage of patients with anemia and/or iron deficiency increased from 53.6% at D-1/D0 to 71.3% at D30 ( P < .0001), mainly due to the increase of patients with both anemia and iron deficiency (from 12.2% at D-1/D0 to 32.4% at D30; P < .0001). However, a treatment of anemia and/or iron deficiency was administered preoperatively to only 7.7% of patients and postoperatively to 21.7% (intravenous iron, 14.2%).

CONCLUSIONS

Iron deficiency was present in half of patients scheduled for major surgery. However, few treatments to correct iron deficiency were implemented preoperatively or postoperatively. There is an urgent need for action to improve these outcomes, including better patient blood management.

Efficacy of ferric carboxymaltose in iron deficiency anemia patients scheduled for pancreaticoduodenectomy

Purpose

Perioperative transfusion is reported to be an independent risk factor not only for postoperative complications but also for early recurrence of periampullary carcinoma after pancreaticoduodenectomy (PD). The purpose of this study was to evaluate the safety and efficacy of ferric carboxymaltose (FCM) in reducing the need for perioperative transfusion in iron deficiency anemia patients scheduled for PD.

Methods

Twenty-two male patients (hemoglobin [Hb] 7 to <13 g/dL) and 18 female patients (Hb 7 to <12 g/dL) were enrolled in the study group and administered FCM 1-3 weeks before PD. The perioperative transfusion rate was the primary endpoint; morbidity, length of postoperative hospital stay, change in hematological parameters after FCM injection, and adverse effects of FCM were also investigated.

Results

The perioperative transfusion rate of the study group was 22.5% (9 of 40). Hb level was significantly higher on the day of the operation compared to baseline (P < 0.001). Levels of Hb, transferrin saturation, and ferritin were higher at the follow-up compared to baseline (P = 0.008, P = 0.033, and P < 0.001, respectively).

Conclusions

FCM administration was associated with a reduced need for perioperative transfusion and can safely stabilize hematological parameters.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

A systematic literature review and meta-analysis of the incidence of serious or severe hypersensitivity reactions after administration of ferric derisomaltose or ferric carboxymaltose

BACKGROUND

Intravenous iron is the preferred treatment for patients with iron deficiency anemia in a variety of clinical situations. Although uncommon, administration of modern IV iron formulations can result in hypersensitivity reactions (HSRs) and, rarely, anaphylactic or anaphylactoid reactions.

AIM

The objective of the present study was to systematically review the literature to identify and analyze data on the incidence of HSRs after administration of ferric derisomaltose (FDI) or ferric carboxymaltose (FCM).

METHOD

A prospectively-registered systematic literature review was conducted to identify prospective randomized controlled trials comparing FDI and FCM with other intravenous iron formulations or oral iron. Searches were conducted in PubMed (including MEDLINE), EMBASE, and the Cochrane Library in November 2020. The relative incidence of serious or severe HSRs occurring on the day or day after dosing of intravenous iron, recorded under the standardized Medical Dictionary for Regulatory Activities query for anaphylactic reaction.

RESULTS

Data were obtained from seven randomized controlled trials of FCM (N = 2683) and ten of FDI (N = 3474) enrolling 10,467 patients in total. The number of patients experiencing any serious or severe HSR event was 29/2683 (1.08%) with FCM versus 5/3474 with FDI (0.14%). Bayesian inference of proportions showed the event rates to be significantly lower with FDI relative to FCM.

CONCLUSION

HSR events were uncommon with both intravenous iron formulations; however, the present study showed a significantly lower incidence of HSRs with FDI relative to FCM. Further large-scale, head-to-head trials of the iron formulations would be required to confirm this finding.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

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.

Recommendations From the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS)

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.

Impact of the COVID-19 Pandemic on the Usage of Blood for Transfusions: A 2-Year Experience from a Tertiary Center in Korea

The coronavirus disease (COVID-19) outbreak affected the utilization and management of blood products in hospitals. Blood shortages occurred owing to social distancing policies and reduction in blood donors. However, only a few studies examined whether these changes affected blood usage and transfusion patterns. We retrospectively reviewed blood component usage according to hospital departments and phases of surgery in transfused patients admitted between 1 March 2019 and 28 February 2021, in a single center in Anyang, Korea. We also analyzed the length of hospital stay and mortality to determine prognosis. In 2020, 32,050 blood components were transfused to 2877 patients, corresponding to 15.8% and 11.8% less than the rates in 2019, respectively. Postoperative usage of blood products significantly decreased in 2020 (3.87 ± 6.50) compared to 2019 (7.12 ± 21.71) (p = 0.047). The length of hospital stay of the patients who underwent postoperative transfusion in 2019 (n = 197) was 13.97 ± 11.95 days, which was not significantly different from that in 2020 (n = 167), i.e., 16.44 ± 17.90 days (p = 0.118). Further, 9 of 197 postoperative transfusion patients died in 2019, while 8 of 167 patients died in 2020 (p = 0.920). The COVID-19 pandemic resulted in limited blood supply and reduced postoperative transfusions; however, patient prognosis was not affected.

Blood Transfusions and Adverse Events after Colorectal Surgery: A Propensity-Score-Matched Analysis of a Hen-Egg Issue

Blood transfusions are considered a risk factor for adverse outcomes after colorectal surgery. However, it is still unclear if they are the cause (the hen) or the consequence (the egg) of adverse events. A prospective database of 4529 colorectal resections gathered over a 12-month period in 76 Italian surgical units (the iCral3 study), reporting patient-, disease-, and procedure-related variables, together with 60-day adverse events, was retrospectively analyzed identifying a subgroup of 304 cases (6.7%) that received intra- and/or postoperative blood transfusions (IPBTs). The endpoints considered were overall and major morbidity (OM and MM, respectively), anastomotic leakage (AL), and mortality (M) rates. After the exclusion of 336 patients who underwent neo-adjuvant treatments, 4193 (92.6%) cases were analyzed through a 1:1 propensity score matching model including 22 covariates. Two well-balanced groups of 275 patients each were obtained: group A, presence of IPBT, and group B, absence of IPBT. Group A vs. group B showed a significantly higher risk of overall morbidity (154 (56%) vs. 84 (31%) events; OR 3.07; 95%CI 2.13-4.43; p = 0.001), major morbidity (59 (21%) vs. 13 (4.7%) events; OR 6.06; 95%CI 3.17-11.6; p = 0.001), and anastomotic leakage (31 (11.3%) vs. 8 (2.9%) events; OR 4.72; 95%CI 2.09-10.66; p = 0.0002). No significant difference was recorded between the two groups concerning the risk of mortality. The original subpopulation of 304 patients that received IPBT was further analyzed considering three variables: appropriateness of BT according to liberal transfusion thresholds, BT following any hemorrhagic and/or major adverse event, and major adverse event following BT without any previous hemorrhagic adverse event. Inappropriate BT was administered in more than a quarter of cases, without any significant influence on any endpoint. The majority of BT was administered after a hemorrhagic or a major adverse event, with significantly higher rates of MM and AL. Finally, a major adverse event followed BT in a minority (4.3%) of cases, with significantly higher MM, AL, and M rates. In conclusion, although the majority of IPBT was administered with the consequence of hemorrhage and/or major adverse events (the egg), after adjustment accounting for 22 covariates, IPBT still resulted in a definite source of a higher risk of major morbidity and anastomotic leakage rates after colorectal surgery (the hen), calling urgent attention to the implementation of patient blood management programs.

Perioperative Tracking of Intravenous Iron in Patients Undergoing On-Pump Cardiac Surgery: A Prospective, Single-Center Pilot Trial

BACKGROUND

Preoperative intravenous iron administration is a frequently used patient blood management procedure. If the timeframe of intravenous iron administration before surgery is short, (1) the concentration of the intravenous iron compound might still be high in patients' plasma when undergoing surgery and (2) this iron in patients' plasma is at risk to be lost due to blood loss. The aim of the current study was, therefore, to track the iron compound ferric carboxymaltose (FCM) before, during, and after cardiac surgery requiring cardiopulmonary bypass, with an emphasis on intraoperative iron losses in shed blood and potential recovery through autologous cell salvage.

METHODS

Concentrations of FCM were analyzed in patients' blood using a hyphenation of liquid chromatography and inductively coupled plasma-mass spectrometry to distinguish between pharmaceutical compound FCM and serum iron. In this prospective, single-center pilot trial, 13 anemic and 10 control patients were included. Anemic patients with hemoglobin levels ≤12/13 g/dL in women and men were treated with 500 milligrams (mg) intravenous FCM 12 to 96 hours before elective on-pump cardiac surgery. Patients' blood samples were collected before surgery and at days 0, 1, 3, and 7 after surgery. One sample each was taken of the cardiopulmonary bypass, the autologous red blood cell concentrate generated by cell salvage, and the cell salvage disposal bag.

RESULTS

Patients who had received FCM <48 hours before surgery had higher FCM serum levels (median [Q1-Q3], 52.9 [13.0-91.6]) compared to ≥48 hours (2.1 [0.7-5.1] µg/mL, P = .008). Of 500-mg FCM administered <48 hours, 327.37 (257.96-402.48) mg were incorporated compared to administration ≥48 hours with 493.60 (487.78-496.70) mg. After surgery, patients' plasma FCM concentration in the FCM <48 hours group was decreased (-27.1 [-30 to -5.9] µg/mL). Little FCM was found in the cell salvage disposal bag (<48 hours, 4.2 [3.0-25.8] µg/mL, equivalent to 29.0 [19.0-40.7] mg total; equivalent to 5.8% or 1/17th of the 500 mg FCM initially administered), almost none in the autologous red blood cell concentrate (<48 hours, 0.1 [0.0-0.43] µg/mL).

CONCLUSIONS

The data generate the hypotheses that nearly all FCM is incorporated into iron stores with administration ≥48 hours before surgery. When FCM is given <48 hours of surgery, the majority is incorporated into iron stores by the time of surgery, although a small amount may be lost during surgical bleeding with limited recovery by cell salvage.

Effect of Preoperative Administration of Intravenous Ferric Carboxymaltose in Patients with Iron Deficiency Anemia after Off-Pump Coronary Artery Bypass Grafting: A Randomized Controlled Trial

Patients scheduled for cardiac surgery often have anemia and iron deficiency. We investigated the effect of the preoperative administration of intravenous ferric carboxymaltose (IVFC) in patients with iron deficiency anemia (IDA) who were due to undergo off-pump coronary artery bypass grafting (OPCAB). Patients who were due to undergo elective OPCAB between February 2019 and March 2022 who had IDA (n = 86) were included in this single center, randomized, parallel-group controlled study. The participants were randomly assigned (1:1) to receive either IVFC or placebo treatment. Postoperative hematologic parameters [hemoglobin (Hb), hematocrit, serum iron concentration, total iron-binding capacity, transferrin saturation, transferrin concentration, and ferritin concentration] and the changes in these parameters during the follow-up period were the primary and secondary outcomes, respectively. The tertiary endpoints were early clinical outcomes, such as the volume of mediastinal drainage and the need for blood transfusions. IVFC treatment significantly reduced the need for red blood cell (RBC) and platelet transfusions. Despite receiving fewer RBC transfusions, patients in the treatment group had higher levels of Hb, hematocrit, and serum iron and ferritin concentrations during weeks 1 and 12 after surgery. No serious adverse events occurred during the study period. Preoperative IVFC treatment in patients with IDA undergoing OPCAB improved the values of the hematologic parameters and iron bioavailability. Therefore, is a useful strategy for stabilizing patients prior to OPCAB.

Impact of postoperative intravenous iron therapy on postoperative infections in older patients with severe anaemia after hip fracture surgery

BACKGROUND

Anaemia is common following hip fracture in ortho-geriatric patients and is associated with postoperative infections.. This study investigated whether intravenous iron supplements reduced the rate of postoperative infections within 30 days postoperatively in older adults after hip fracture surgery.

METHODS

This observational study included 198 ortho-geriatric patients July 2018-May 2020. In May 2019 a local guideline was implemented and recommended II therapy on the 3^rd postoperative day if haemoglobin concentration was < 6.5 mmol/L after hip fracture surgery.

RESULTS

The patients were divided into four treatment groups: blood transfusion (n = 44), IV iron (n = 69), blood transfusion + IV iron (n = 35) and no treatment (n = 50). The number of patients who had an infection within 30 days was similar in the two time periods (38.8% before vs. 38.9% after systematic I.V. iron supplementation, P = 1.00) and no significant difference according to risk of infection was found between treatment groups.

CONCLUSION

This study documents no effect of intravenous iron supplements on postoperative infections in older adults after hip fracture surgery.

TRIAL REGISTRATION

The study was registered with the Danish Data Protection Authority (2008-58-0028) the 2^th of September 2019.

Effects of ferric carboxymaltose on hemoglobin level after cardiac surgery: A randomized controlled trial

BACKGROUND

Perioperative anemia is common in cardiac surgery. Few studies investigated the effect of postoperative intravenous (IV) iron supplementation and were mostly inconclusive.

METHODS

Design: A randomized single-center, double-blind, placebo-controlled, parallel-group trial.

PARTICIPANTS

195 non-anemic patients were recruited from December 2018 to December 2020: 97 patients received 1 g of ferric carboxymaltose (FCM) and 98 patients received 100 mL of physiological serum on postoperative day 1.

MEASUREMENTS

hemoglobin levels, reticulocyte count, serum iron, serum ferritin, and transferrin saturation were measured at induction of anesthesia, postoperative days 1, 5, and 30. Transfusion rate, duration of mechanical ventilation, critical care unit length of stay, and side effects associated with IV iron administration were measured. The primary outcome was hemoglobin level on day 30. Secondary outcomes included iron balance, transfused red cell packs, and critical care unit length of stay.

RESULTS

At day 30, the hemoglobine level was higher in the FCM group than in the placebo group (mean 12.9 ± 1.2 vs. 12.1 ± 1.3 g/dL (95%CI 0.41-1.23, p-value <0.001)). Patients in the FCM group received fewer blood units (median 1[0-2] unit vs. 2 [0-3] units, p-value = 0.037) and had significant improvement in iron balance compared to the control group. No side effects associated with FCM administration were reported.

CONCLUSION

In this randomized controlled trial, administration of FCM on postoperative day 1 in non-anemic patients undergoing cardiac surgery increased hemoglobin levels by 0.8 g/dL on postoperative day 30, leading to reduced transfusion rate, and improved iron levels on postoperative day 5 and 30.

CLINICAL TRIAL REGISTRY NUMBER

NCT03759964.

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

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

Clinical, economical and safety impact of ferric carboxymaltose use in Patient Blood Management programme in Portuguese National Health Service hospitals

Ferric carboxymaltose (FCM) can be used in Patient Blood Management (PBM) to promote the optimization of preoperative haemoglobin (Hb), which aims to minimise the use of allogeneic blood components and improve clinical outcomes, with better cost-effectiveness. This was an observational study conducted in a retrospective and multicentre cohort with adults from elective orthopaedic, cardiac and colorectal surgeries, treated according to local standards of PBM with allogeneic blood product transfusions (ABTs) on demand and with FCM to correct iron deficiency with or without anaemia. In this work, only the first pillar of the PBM model issue by Directorate-General for Health (DGS) was evaluated, which involves optimising Hb in the preoperative period with iron treatment if it's necessary/indicated. Before the implementation of PBM in Portugal, most patients did not undergo preoperative laboratory evaluation with blood count and iron kinetics. Therefore, the existence of Iron Deficiency Anaemia (IDA) or Iron Deficiency (ID) without anaemia was not early detected, and there was no possibility of treating these patients with iron in order to optimise their Hb and/or iron stores. Those patients ended up being treated with ABTs on demand. A total of 405 patients from seven hospitals were included; 108 (26.7%) underwent FCM preoperatively and 197 (48.6%) were transfused with ABTs on demand. In the FCM preoperative cohort, there was an increase in patients with normal preoperative Hb, from 14.4 to 45.7%, before and after FCM, respectively, a decrease from 31.7 to 9.6% in moderate anaemia and no cases of severe anaemia after FCM administration, while 7.7% of patients were severely anaemic before FCM treatment. There were significant differences (p < 0.001) before and after correction of preoperative anaemia and/or iron deficiency with FCM in Hb, serum ferritin and transferrin saturation rate (TS). In the ABT group, there were significant differences between pre- and postoperative Hb levels (p < 0.001). Hb values tended to decrease, with 44.1% of patients moving from mild anaemia before transfusion to moderate anaemia in the postoperative period. Concerning the length of hospital stay, the group administered with ABTs had a longer hospital stay (p < 0.001). Regarding the clinical outcomes of nosocomial infection and mortality, there was no evidence that the rate of infection or mortality differed in each group (p = 0.075 and p = 0.243, respectively). However, there were fewer nosocomial infections in the FCM group (11.9% versus 21.2%) and mortality was higher in the transfusion group (21.2% versus 4.2%). Economic analysis showed that FCM could reduce allogenic blood products consumption and the associated costs. The economic impact of using FCM was around 19%. The preoperative Hb value improved when FMC was used. Patients who received ABTs appeared to have a longer hospital stay. The FCM group reported fewer infections during hospitalisation. The economic results showed savings of around €1000 for each patient with FCM administration. The use of FCM as part of the PBM program had a positive impact on patients' outcomes and on economic results. However, it will be essential to perform studies with a larger sample to obtain more robust and specific results.

Perioperative Quality Initiative and Enhanced Recovery After Surgery-Cardiac Society Consensus Statement on the Management of Preoperative Anemia and Iron Deficiency in Adult Cardiac Surgery Patients

Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.

Patient Blood Management: Improving Outcomes for Millions While Saving Billions. What Is Holding It Up?

Patient blood management (PBM) offers significantly improved outcomes for almost all medical and surgical patient populations, pregnant women, and individuals with micronutrient deficiencies, anemia, or bleeding. It holds enormous financial benefits for hospitals and payers, improves performance of health care providers, and supports public authorities to improve population health. Despite this extraordinary combination of benefits, PBM has hardly been noticed in the world of health care. In response, the World Health Organization (WHO) called for its 194 member states, in its recent Policy Brief, to act quickly and decidedly to adopt national PBM policies. To further support the WHO's call to action, this article addresses 3 aspects in more detail. The first is the urgency from a health economic perspective. For many years, growth in health care spending has outpaced overall economic growth, particularly in aging societies. Due to competing economic needs, the continuation of disproportionate growth in health care spending is unsustainable. Therefore, the imperative for health care leaders and policy makers is not only to curb the current spending rate relative to the gross domestic product (GDP) but also to simultaneously improve productivity, quality, safety of patient care, and the health status of populations. Second, while PBM meets these requirements on an exceptional scale, uptake remains slow. Thus, it is vital to identify and understand the impediments to broad implementation. This includes systemic challenges such as the so-called "waste domains" of failure of care delivery caused by malfunctions of health care systems, failure of care coordination, overtreatment, and low-value care. Other impediments more specific to PBM are the misperception of PBM and deeply rooted cultural patterns. Third, understanding how the 3Es-evidence, economics, and ethics-can effectively be used to motivate relevant stakeholders to take on their respective roles and responsibilities and follow the urgent call to implement PBM as a standard of care.

Postoperative anaemia and patient-centred outcomes after major abdominal surgery: a retrospective cohort study

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).

Iron status in patients with burn anaemia

PURPOSE

The iron status of burn patients is poorly understood, limited by difficulty interpreting conventional iron studies in the context of the acute phase response triggered by critical illness. The aim of this study was to evaluate the iron status of patients with burn anaemia using recent post-operative guidelines.

METHODOLOGY

This retrospective cohort study utilised data collected from records for adult patients admitted to the Royal Brisbane and Women's Hospital with burns to at least 15% TBSA. Rates of iron deficiency, defined as ferritin< 100 µg/L or ferritin 100-300 µg/L with transferrin saturation< 20%, and low iron availability, defined as transferrin saturation< 20%, were calculated.

RESULTS

Of 60 included patients (90% male), 16 (27%) underwent iron studies. 11 (18%) were treated with intravenous iron. Iron studies showed that five (31%) patients had evidence of iron deficiency, and ten out of 12 (83%) had evidence of reduced iron availability. Two patients (40%) with evidence of iron deficiency were not treated with intravenous iron.

CONCLUSION

Application of recent guidelines for interpretation of conventional iron studies in patients with inflammatory states may improve the identification of iron deficiency in burn patients. Iron deficiency may be an under-recognised and under-treated contributor to burn anaemia.

Impact on blood loss and transfusion rates following administration of tranexamic acid in major oncological abdominal and pelvic surgery: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Major bleeding and receiving blood products in cancer surgery are associated with increased postoperative complications and worse outcomes. Tranexamic acid (TXA) reduces blood loss and improves outcomes in various surgical specialities. We performed a systematic review and meta-analysis to investigate TXA use on blood loss in elective abdominal and pelvic cancer surgery.

METHODS

A literature search was performed for studies comparing intravenous TXA versus placebo/no TXA in patients undergoing major elective abdominal or pelvic cancer surgery.

RESULTS

Twelve articles met the inclusion criteria, consisting of 723 patients who received TXA and 659 controls. Patients receiving TXA were less likely to receive a red blood cell (RBC) transfusion (p < 0.001, OR 0.4 95% CI [0.25, 0.63]) and experienced less blood loss (p < 0.001, MD -197.8 ml, 95% CI [-275.69, -119.84]). The TXA group experienced a smaller reduction in haemoglobin (p = 0.001, MD -0.45 mmol/L, 95% CI [-0.73, -0.18]). There was no difference in venous thromboembolism (VTE) rates (p = 0.95, OR 0.98, 95% CI [0.46, 2.08]).

CONCLUSIONS

TXA use reduced blood loss and RBC transfusion requirements perioperatively, with no significant increased risk of VTE. However, further studies are required to assess its benefit for cancer surgery in some sub-specialities.

Patient blood management in the ICU: A narrative review of the literature

The majority of ICU patients are anaemic. Anaemia is associated with worse outcomes and a necessity for red blood cell transfusions. ICU patients are a heterogeneous patient group with a broad spectrum of main diagnoses and comorbidities. Evidence-based transfusion trigger guidelines have been established that are dependent on comorbidities. Special attention has been given to blood saving measures and point-of-care diagnosis of coagulation disorders in ICU patients. The administration of intravenous iron and erythropoiesis-stimulating agents can provide useful and individualised alternatives to the administration of red blood cell concentrates in treatment of iron deficiency anaemia. In presence of inflammation and infection, it is challenging to identify the cause of anaemia. The hepcidin-ferroportin pathway may facilitate the diagnosis of anaemia in ICU patients and indicate novel targets in anaemia treatment. This review article presents patient blood management measures and summarises the current literature on transfusion thresholds and alternative therapeutic options using intravenous iron and erythropoiesis-stimulating agents with a key focus on the ICU.

A Global Definition of Patient Blood Management

While patient blood management (PBM) initiatives are increasingly adopted across the globe as part of standard of care, there is need for a clear and widely accepted definition of PBM. To address this, an expert group representing PBM organizations, from the International Foundation for Patient Blood Management (IFPBM), the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), the Society for the Advancement of Patient Blood Management (SABM), the Western Australia Patient Blood Management (WAPBM) Group, and OnTrac (Ontario Nurse Transfusion Coordinators) convened and developed this definition: "Patient blood management is a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood, while promoting patient safety and empowerment." The definition emphasizes the critical role of informed choice. PBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts aimed at screening for, diagnosing and appropriately treating anemia, minimizing surgical, procedural, and iatrogenic blood losses, managing coagulopathic bleeding throughout the care and supporting the patient while appropriate treatment is initiated. We believe that having a common definition for PBM will assist all those involved including PBM organizations, hospital administrators, individual clinicians and policy makers to focus on the appropriate issues when discussing and implementing PBM. The proposed definition is expected to continue to evolve, making this endeavor a work in progress.

Hematinic and Iron Optimization in Peri-operative Anemia and Iron Deficiency

Purpose of Review

Preoperative anemia is independently associated with worse postoperative outcomes following cardiac and noncardiac surgery. This article explores the current understanding of perioperative anemia and iron deficiency with reference to definition, diagnosis, and treatment.

Recent Findings

Iron deficiency is the most common cause of anemia. It can arise from reduced iron intake, poor absorption, or excess iron loss. Inflammation throughout the preoperative period can drive iron sequestration, leading to a functional deficiency of iron and the development of what was referred to until recently as the “anemia of chronic disease.” Current best practice guidance supports the routine administration of preoperative intravenous iron to treat anemia despite limited evidence. This “one size fits all” approach has been called into question following results from a recent large, randomized trial (the PREVENTT trial) that assessed the use of a single dose of intravenous iron compared to placebo 10–42 days before major abdominal surgery. Although there were no improvements in patient-centered outcomes apparent during the initial hospital stay, secondary endpoints of this trial suggested there may be some late benefit after discharge from the hospital (8 weeks postoperatively). This trial raises questions on (1) the mechanisms of iron deficiency in the perioperative patient; (2) the need to reassess our opinions on generic anemia management; and (3) the need to address patient outcomes after discharge from hospital.

Summary

Despite the known associations between preoperative anemia (particularly iron deficiency anemia) and poor postoperative outcome, recent evidence suggests that administering intravenous iron relatively close to surgery does not yield a tangible short-term benefit. This is made more complex by the interplay between iron and innate immunity. Iron deficiency irrespective of hemoglobin concentration may also impact postoperative outcomes. Therefore, further research into associations between iron deficiency and postoperative outcomes, and between postoperative anemia, delayed outcomes (hospital readmission), and the efficacy of postoperative intravenous iron is required.

Evaluating the Importance of Patient Blood Management During COVID-19 Pandemic

Due to the COVID-19 pandemic, the demand for blood products may decrease as the health care system shifts toward treating the increased number of patients afflicted with COVID-19 and delaying selective surgeries and emergency procedures. One of the most important problems for blood transfusion services during COVID-19 pandemic is the reduction in the number of donors and a decrease in blood stocks. This happens due to the limitations of attendance of donors in blood centers, lack of awareness, misinformation, fear of being infected while donating blood, and restricting the freedom of blood collection teams to attend public places. Blood transfusion services should be prepared and well-responded in a timely manner. In this regard, appropriate use of blood, diminishing unnecessary transfusions, and implementation of patient blood management (PBM) principles are considered as significant measurements. PBM can help maintain blood supply throughout the crisis and reduce the pressure on blood demand. As a result, blood products can be saved for patients who need it urgently. PBM focuses on the patient, as well as the conditions that make patients transfuse blood, such as blood loss, coagulopathy, platelet dysfunction, and anemia. Thus, the majority of health systems in different countries have made recommendations to the PBM in hospitals.

Blood management strategies in congenital Glanzmann thrombasthenia at a hematology referral center

Background

Glanzmann thrombasthenia is associated with abnormalities in the glycoprotein IIb/IIIa receptor. This study, conducted at Ampang Hospital, Malaysia, aimed to assess outcomes of blood management strategies for Glanzmann thrombasthenia.

Methods

Ten patients with Glanzmann thrombasthenia aged 9 years (2009‒2018) were examined. Data on clinical characteristics, transfusion practices, and patient blood management were obtained from medical records. Patient blood management methods included parenteral iron, erythropoietin, hormonal pills, intrauterine progesterone contraceptive devices, tranexamic acid, and recombinant factor VIIa. Primary outcomes were hemoglobin levels and the proportion of patients who received blood transfusion. Secondary outcomes were morbidity and mortality.

Results

The median age at diagnosis was 8.2 years (range, 1‒15 yr). The female-to-male ratio was 9:1. Eight patients had type 2 disease (5‒20% of normal GPIIb/IIIa), and two patients had type 1 disease (normal GPIIb/IIIa <5%). All patients had iron deficiency. All female patients presented with significant menorrhagia. Other bleeding symptoms included epistaxis, spontaneous skin bruising, hemoptysis, gingival bleeding, knee hemarthrosis, and pelvic hematoma. No patient experienced life-threatening bleeding. Our patients had a mean hemoglobin level of 5.6 g/dL at diagnosis. All patients were optimized using non-transfusion methods as described above. Our patient had a current mean hemoglobin level of 11 g/dL. Approximately 70% (7/10) of patients did not experience receiving blood transfusions in the last 5 years. No patient experienced non-transfusion-related morbidities such as sepsis, thromboembolism, or cardiorespiratory events.

Conclusion

High cost, transfusion-related adverse events, and immunomodulation could be effectively prevented by avoiding unnecessary blood transfusions.

Short-term high-dose intravenous iron reduced peri-operative transfusion after staggered bilateral total knee arthroplasty: A retrospective cohort study

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.

Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis

Importance

Intravenous iron is recommended by many clinical guidelines based largely on its effectiveness in reducing anemia. However, the association with important safety outcomes, such as infection, remains uncertain.

Objective

To examine the risk of infection associated with intravenous iron compared with oral iron or no iron.

Data Sources

Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials (RCTs) from 1966 to January 31, 2021. Ongoing trials were sought from ClinicalTrials.gov, CENTRAL, and the World Health Organization International Clinical Trials Search Registry Platform.

Study Selection

Pairs of reviewers identified RCTs that compared intravenous iron with oral iron or no iron across all patient populations, excluding healthy volunteers. Nonrandomized studies published since January 1, 2007, were also included. A total of 312 full-text articles were assessed for eligibility.

Data Extraction and Synthesis

Data extraction and risk of bias assessments were performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) and Cochrane recommendations, and the quality of evidence was assessed using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. Two reviewers extracted data independently. A random-effects model was used to synthesize data from RCTs. A narrative synthesis was performed to characterize the reporting of infection.

Main Outcomes and Measures

The primary outcome was risk of infection. Secondary outcomes included mortality, hospital length of stay, and changes in hemoglobin and red blood cell transfusion requirements. Measures of association were reported as risk ratios (RRs) or mean differences.

Results

A total of 154 RCTs (32 920 participants) were included in the main analysis. Intravenous iron was associated with an increased risk of infection when compared with oral iron or no iron (RR, 1.17; 95% CI, 1.04-1.31; I2 = 37%; moderate certainty of evidence). Intravenous iron also was associated with an increase in hemoglobin (mean difference, 0.57 g/dL; 95% CI, 0.50-0.64 g/dL; I2 = 94%) and a reduction in the risk of requiring a red blood cell transfusion (RR, 0.93; 95% CI, 0.76-0.89; I2 = 15%) when compared with oral iron or no iron. There was no evidence of an effect on mortality or hospital length of stay.

Conclusions and Relevance

In this large systematic review and meta-analysis, intravenous iron was associated with an increased risk of infection. Well-designed studies, using standardized definitions of infection, are required to understand the balance between this risk and the potential benefits.

Cardiac Surgery in Patients With Blood Disorders

Blood disorders that can contribute to abnormal bleeding can have a detrimental effect during cardiac surgery. Patients who are known to have such pathologies should be investigated thoroughly and cautious measures would need to be taken when cardiac surgery is needed in this cohort. The majority of current literature for cardiac surgery in patients with von Willebrand Disease and haemophilia are case reports. Nevertheless, evidence shows that optimising factor levels pre, intra and postoperatively offers outcomes similar to that of patients without these disorders. Preoperative screening followed by appropriate iron therapy reduces mortality for patients with anaemia. In this group, haemoglobin levels can be improved postoperatively through iron supplementation. The management strategy of cardiac surgery for people with blood disorders requires a multidisciplinary approach that is highly individualised for each patient. It is essential to adequately adjust preoperative, perioperative and postoperative care to the patient's blood disorder in order to achieve outcomes similar to that of patients without blood disorders.

Need for preoperative anemia management clinics in Japan: initiatives at a university hospital in the USA

Untreated preoperative anemia increases the risk of morbidity and mortality and there is increasing evidence that early intervention for preoperative anemia improves outcomes after major surgery. Accordingly, anemia management clinics have been established in various institutions in the USA. As an example, the University of Iowa Hospitals and Clinics outpatient clinic treats pre-surgical anemic patients, who undergo major surgery with anticipated blood loss of more than 500 mL, by providing effective standardized care in a timely manner. This standardized care is an integral part of patient blood management to reduce perioperative blood transfusion and improve patient outcomes. The importance of preoperative anemia management has not yet been sufficiently recognized in Japan. Timely intervention for preoperative anemia should be incorporated into routine pre-surgical patient care in Japan.

Immediate intravenous iron administration improves anaemia recovery following total knee arthroplasty: A propensity-matched analysis

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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