Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines

Postoperative anaemia is associated with poor long term postoperative outcomes after elective colorectal oncologic surgery within an enhanced recovery after surgery pathway

BACKGROUND

Anaemia is an independent risk factor for poor perioperative outcomes after major abdominal surgery, and is associated with an increased risk of 30-day postoperative mortality after noncardiac surgery.

OBJECTIVE

To investigate the frequency of postoperative anaemia and short- and long-term survival after colorectal oncologic surgery at a centre with a well-established Enhanced Recovery After Surgery (ERAS) program.

METHODS

We conducted a retrospective cohort study of all patients undergoing elective colorectal oncologic surgery within an ERAS pathway at our institution between 2013 and 2017. Overall survival was calculated with the Kaplan-Meier log rank method and Cox proportional hazard regression based on anaemia at hospital discharge.

RESULTS

A total of 680 patients were included. Patients with anaemia at discharge showed a lower overall survival at 5 years (53.9% vs. 44%, p 0.05). Patients who were anaemic at discharge had a lower 5-year overall survival (hazard ratio [HR] 95% CI 2.663 [1.619-4.379], p < 0.001). Kaplan-Meier survival and Cox regression proportional hazard survival for overall survival in the combined preoperative, postoperative, and RBC transfusion model were 1.55 (1.038 2.318) p = 0.032.

CONCLUSIONS

The combined prognostic value of preoperative anaemia, postoperative anaemia, and blood transfusion created a 40.7% higher risk of not surviving 5 years.

Laboratory Markers of Impaired Erythropoiesis in Early Diagnosis of Perioperative Anemias

The aim of the study was to assess the diagnostic value of laboratory indicators of hemoglobin content in reticulocytes for the early detection of predisposition for perioperative anemia in patients with total hemoglobin within the reference range.

Materials and Methods

Observational retrospective single-center continuous cross-sectional study has been carried out to determine the need for transfusion of erythrocyte-containing components (ECC) depending on the values of reticulocyte hemoglobin (Ret-He) and delta-hemoglobin (Delta-He) in patients with unchanged (within the reference range) values of the total hemoglobin. The groups of comparison were formed using the diagnostic Hema-Plot algorithm, under which Ret-He and Delta-He values deviate from the reference range towards greater or smaller magnitudes in various types of anemia.

Results

Deviations from the reference intervals of Ret-He and Delta-He values were observed in 26% of patients not formally meeting the WHO criteria for anemia on admission. Indications for ECC transfusion therapy were more likely to occur in patients who had changes in Ret-He and Delta-He corresponding to the signs of anemias of different genesis according to the Hema-Plot algorithm.

Conclusion

The Ret-He and Delta-He values in patients with unchanged hemoglobin allow for making a decision on the need for ECC transfusion therapy in the postoperative period.The differences between the groups formed on the basis of Ret-He and Delta-He deviations from the reference values are in line with the diagnostic signs of anemias of various origins. They also allow one to discuss the variants of impaired erythropoiesis at the very early stages of the disorder and the risk of anemia development in patients with formally unchanged total hemoglobin levels.

Blood transfusion in older surgical patients: the only option or is there a better approach?

Anemia is a common clinical condition that can significantly affect patient outcomes, particularly in those undergoing surgery. In older adults, the presence of anemia combined with cardiovascular disease can increase surgical morbidity and mortality, influencing surgical decisions and creating a cascade of complications that may negatively impact recovery. Blood transfusion remains the primary response to anemia in the perioperative setting, despite evidence suggesting potential adverse effects on survival and recovery. However, older adults present unique challenges due to age-related physiological changes anda reduced tolerance to anemia and blood loss. The debate between restrictive and liberal blood transfusion strategies in this population remains unresolved. Patient Blood Management (PBM) protocols have been developed to systematically address perioperative anemia. This review emphasizes the need for a nuanced approach to transfusion in older adults, suggesting that while a restrictive strategy may not be universally applicable, decisions should be guided by thorough clinical evaluations. These assessments should prioritize not only hemoglobin levels but also patient-specific factors, including life expectancy, comorbidities, and patient preferences, with the involvement of a multidisciplinary team to tailor the best approach for everyone.

Real-world evaluation of an intravenous iron service for the treatment of iron deficiency with or without anemia

Intravenous (IV) iron is a guideline-recommended treatment for iron deficiency when oral iron is contraindicated, ineffective, or not tolerated, or when rapid iron delivery is necessary. However, evidence suggests that some patients receive less IV iron than needed. This retrospective audit assessed the effectiveness and safety of ferric derisomaltose (FDI), a high-dose IV iron, in 2,468 patients. Efficacy outcomes assessed at 4-12 weeks post-infusion included changes in hemoglobin (Hb) and ferritin, proportion of courses (a course was defined as the treatment episode required to administer one total dose) after which patients were non-anemic (Hb ≥ 130 g/L [men] or ≥ 120 g/L [women]), and response rate (proportion of courses after which patients were non-anemic or Hb increased by ≥ 20 g/L). Safety was assessed through adverse events. Across 2,775 FDI courses, the mean dose was 1,244 mg, but mean estimated iron need was 1,580 mg. At follow-up, mean Hb had increased by 20.9 g/L and mean ferritin by 188.8 µg/L. Patients were non-anemic after 33.4% (n = 494/1,478) of courses and responded after 65.1% (n = 962/1,478) of courses. One patient (n = 1/2,468; 0.04%) had a serious allergic reaction. Patients remained anemic after > 65% of courses, demonstrating the need to optimize dosing based on iron need.

[Current AWMF guidelines on knee and hip arthroplasty - individual risks]

BACKGROUND

In the year 2022, more than 300,000 total hip and knee primary arthroplasties were recorded in the German Arthroplasty Registry. The ever-increasing number of interventions naturally leads to an increase in the absolute number of possible complications. The abundance of internationally available data makes it possible to determine risk factors for postoperative complications.

RISK FACTORS

Professional societies involved in the German guidelines in the field of orthopedics place great emphasis on modifiable risk factors, as their adequate management can consequently reduce the likelihood of postoperative complications. One of the most common modifiable risk factors is obesity, with its prevalence remaining consistently high in most developed countries. In the field of orthopedics, the Association of the Scientific Medical Societies in Germany focuses on modifiable risk factors including obesity, diabetes mellitus and smoking.

OBESITY

In the case of obesity in particular, the guidelines for knee and hip arthroplasty recommend a weight loss attempt for patients with a BMI > 30 kg/m2. A BMI ≥ 40 kg/m2 is considered a "relative contraindication" in the guidelines. Shared decision making is emphasized in both guidelines. Ultimately, the particularly critical individual assessment of risk and benefit for each obese patient remains crucial for the final decision.

Impact of Iron Deficiency Anemia on Postoperative Outcomes of Thoracolumbar Spinal Fusion (2+ levels) on Patients with Adult Spinal Deformity with Minimum 2-Year Follow-Up

Introduction

Iron deficiency anemia (IDA) is a common hematological disorder and cause of low hemoglobin. Preoperative anemia has been demonstrated to increase the risk of adverse outcomes after posterior cervical fusion and other spinal surgeries. The need for a transfusion during lumbar fusion has been shown to increase length of stay. This study aimed to assess the impact of IDA on outcomes after spinal fusion for adult spinal deformity (ASD).

Methods

The New York Statewide Planning and Research Cooperative System (SPARCS) database was searched from 2009 to 2013 to identify all patients undergoing ≥2-level thoracolumbar spinal fusion (primary and revision) for ASD with a 2-year follow-up. The patients were then stratified by the presence or absence of IDA. Patients with IDA and patients without IDA were subjected to 1:1 propensity score matching based on age, sex, and obesity. Univariate analysis was employed to compare demographics, hospital parameters, and rates of adverse outcomes. Multivariate binary logistic regression with odds ratio (OR) was employed to identify independent risk factors for adverse postoperative outcomes.

Results

A total of 524 patients (262 with IDA and 262 without IDA) were identified. Patients with IDA experienced higher rates of overall surgical complications (50.4% vs 23.7%, P<0.001), wound complications (3.4% vs 0.4%, P=0.011), and blood transfusion (10.3% vs 6.5%, P<0.001). No difference was observed in the rate of overall medical complications. Patients with and without IDA had comparable rates of readmission (8.0% vs 13.0%, P=0.064), although patients with IDA had lower rates of reoperation (7.6% vs 13.0%, P=0.044). There was no mortality in either cohort. IDA was independently associated with wound complications (OR=10.6, P=0.028), blood transfusion (OR=3.9, P<0.001), and surgical complications (OR=3.5, P<0.001).

Conclusions

Baseline IDA was predictive of increased wound complications, postoperative blood transfusion, and overall surgical complications after thoracolumbar fusion surgery for ASD. Our findings could inform potential medical interventions to mitigate the risks of adverse outcomes in patients with IDA. Level of Evidence: III, retrospective cohort.

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.

Preoperative Anemia Is Associated With Worse Postoperative Outcomes After Open Reduction Internal Fixation of Distal Radius Fractures

BACKGROUND

Preoperative anemia has been shown to be associated with complications after numerous orthopedic procedures. No studies to our knowledge have examined its impact on outcomes after open reduction internal fixation (ORIF) of distal radius fracture (DRF). We hypothesized that patients with preoperative anemia would have increased likelihood of adverse outcomes, and likelihood would increase with severity of anemia.

METHODS

A total of 14 136 patients underwent ORIF for DRF over 2012-2021, identified in the National Surgical Quality Improvement Program database. Patients were classified by World Health Organization criteria as nonanemic (hematocrit >36% for women, >39% for men), mildly anemic (hematocrit 33%-36% for women, 33%-39% for men), or moderately to severely anemic (hematocrit <33% for women or men). Multivariable regressions adjusted for age, sex, race, and comorbidities statistically different between anemic and nonanemic patients were used to examine the effect of anemia on postoperative outcomes.

RESULTS

Mildly anemic patients had significantly longer length of stay and were significantly more likely to experience readmission and sepsis (P < .05 all). Moderately to severely anemic patients had significantly longer length of stay and were significantly more likely to experience readmission, postoperative transfusion, septic shock, and any adverse event (P < .05 all).

CONCLUSIONS

Preoperative anemia is associated with increased likelihood of adverse outcomes after ORIF for DRF, and likelihood increases with severity of anemia. Surgeons should monitor patients for preoperative anemia and endeavor to identify the source of and, if safe and possible, correct the anemia preoperatively or manage and educate patients postoperatively.

Design and Staged Implementation of a Multidisciplinary Preoperative Anemia Clinic at a Tertiary Care Medical Center

BACKGROUND

Preoperative anemia is common and associated with adverse outcomes in surgical patients. There is limited information to guide the design and implementation of preoperative anemia clinics (PAC), which represents a critical barrier to entry for many practices.

METHODS

This is a descriptive observational study highlighting the design and implementation of a multidisciplinary PAC, including key steps in planning, stakeholder engagement, organizational structure, identification of target populations, establishing anemia treatments, information technology and electronic health record integration, provider training, and data infrastructure. Demographic and clinical characteristics, laboratory results, and anemia treatments for individuals evaluated in the PAC from November 4, 2019 through September 15, 2023 are enumerated. Patient-reported outcomes (PROs) assessing changes in anemia symptoms and well-being after surgery are evaluated for 2 subsets of patients (one before PAC implementation [pre-PAC], another after PAC implementation [post-PAC]), without formal statistical comparison given limited sample sizes.

RESULTS

The PAC was initiated as a multidisciplinary effort under support from a Mayo Clinic Practice Transformation Award in 2019, including broad representation from anesthesiology, surgery, and medical practices, along with institutional project management support (eg, project manager, information technologists, systems engineers). While initially limited to cardiac surgery patients, the PAC underwent planned incremental expansion to include other surgical services. Over the study period, 1188 PAC consultations across 1159 unique patients met eligibility criteria, with a median age of 66 (57-73) years and 58.1% women. The most common etiology of anemia was iron deficiency (69.1%) followed by anemia related to cancer (17.3%). Anemia-directed therapies were recommended in 1038 (87.4%) encounters, with 730 (70.3%) of those receiving recommended treatment preoperatively. Seven hundred nine (97.1%) treatments included intravenous iron and 146 (20.0%) included erythropoiesis-stimulating agents. Fifteen pre-PAC and 38 post-PAC implementation patients completed PROs. PAC implementation was accompanied by earlier resolution of anemia symptoms and less pronounced declines in postoperative well-being scores.

CONCLUSIONS

This report highlights the key steps for successful PAC implementation. Treatment is possible for most patients and may be accompanied by improvements in patient-important outcomes.

[Diagnosis and treatment of perioperative anaemia in elective primary hip and knee arthroplasty : Consensus statement of the "Committee for Perioperative Management" of the Working Group for Endoprosthetics]

BACKGROUND

Hip and knee arthroplasty remain risk procedures for bleeding complications. The prevalence of preoperative anaemia prior to elective joint replacement is high. There are no standardized guidelines in Germany for the diagnosis and treatment of perioperative anaemia in elective hip and knee arthroplasty. The aim of this work, initiated by the "Perioperative Management" committee of the German Society for Endoprosthetics (AE), was to develop a treatment recommendation.

MATERIALS AND METHODS

A systematic review of relevant publications between 2010 and 2023 was conducted. Medline, the Cochrane Library, existing national and international guidelines, and recommendations from other professional societies were considered. A total of 38 relevant articles were identified. Questions with clinical relevance were prepared in advance by the committee, and these were answered after studying and evaluating the literature. Finally, a recommendation was determined by expert consensus using the GRADE system.

CONSENSUS

All patients scheduled for elective joint replacement should undergo preoperative diagnostics. Preoperative anaemia is a risk factor for increased mortality and the likelihood of transfusions; therefore, the cause of anaemia should be investigated preoperatively and treated accordingly. The administration of iron should be considered in diagnosed iron deficiency and can be done either orally or intravenously. Oral substitution therapy should be started 3 months preoperatively. Intravenous therapy requires less time, causes fewer side effects and should be administered 4 weeks preoperatively. Persistent iron deficiency anaemia despite substitution, anaemia due to chronic inflammation and renal anaemia may indicate the need for erythropoietin substitution.

Changes in Practices After Implementation of a Patient Blood Management Program in French Surgical Departments: The National Multicenter Observational PERIOPES Study

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.

Preoperative management in octogenarian patients with rectal cancer

Background

In recent years, the rise in average lifespan has been linked to an increase in the occurrence of diseases associated with aging worldwide. Rectal tumors often occur in elderly patients.

Methods

Between January and August 2024, 6 experts in colorectal cancer met to develop an algorithm to organize the interdisciplinary and multimodal preoperative approaches in the octogenarian population with rectal cancer. To develop the algorithm, we conducted a straightforward search within the PubMed database and also reviewed the citations of the most pertinent articles we discovered. The quality of the methods used in the final selection of 76 sources was evaluated, every single source was scrutinized and analyzed, and a team of six experts created an algorithm.

Results

An algorithm for preoperative management of octogenarian patients with rectal cancer was created to encapsulate essential information and provide a contemporary resource for physicians, surgeons, physiotherapists, and nutritionists to utilize in optimal clinical practice.

Conclusions

Octogenarian patients with rectal cancer are special-character groups and require specific preoperative management to better the surgical outcome.

The association between preoperative anemia and postoperative mortality among non-cardiac surgical patients in Northwest Ethiopia: a prospective cohort study

INTRODUCTION

In a low-income country, the impact of preoperative anemia on postoperative mortality among noncardiac surgery patients is little understood. As a result, we aim to investigate the association between preoperative anemia and postoperative mortality in noncardiac surgery patients in Northwest Ethiopia.

METHODS

This is a prospective follow-up study of 3506 noncardiac surgery patients who were included in the final analysis between June 1, 2019, and July 1, 2021. We used a propensity score-match analysis to group anemic and non-anemic patients. The propensity score match analysis took into account age, gender, comorbidities, American Society of Anesthesiologists physical status, urgency of surgery, and trauma. Patients with and without preoperative anemia were divided into a 1:1 ratio in a propensity score balance. The association between preoperative anemia and postoperative mortality was determined using adjusted odds ratios and 95% confidence interval.

RESULTS

This study included 3506 noncardiac surgery patients, of which 1532 (43.7%) had preoperative anemia. The propensity score-matching results reveal that one-to-one nearest neighbour propensity score matching without replacement was successful for 1351 pairs of surgical patients. The postoperative 28-day mortality rate for anemic patients was 53 (3.9%), with (OR:1.63; 95% CI: 1.05-2.54).

CONCLUSION

The study found that patients undergoing noncardiac surgery in Northwest Ethiopia had a higher rate of preoperative anemia than those in high-income countries. Preoperative anemia had a significant association with 28-day mortality after surgery.

The relationship between preoperative anemia and length of hospital stay among patients undergoing orthopedic surgery at a teaching hospital in Ethiopia: a retrospective cohort study

INTRODUCTION

Preoperative anemia in orthopedic surgery is linked to adverse outcomes such as longer hospital stays, higher rates of blood transfusion, and increased risk of death. Effectively addressing and managing this condition is essential for improving patient outcomes and shortening the length of hospital stays. In Ethiopia and other low-income countries, studies on preoperative anemia and its impact on the length of hospital stay following orthopedic surgery are limited. Therefore, this study aimed to assess the relationship between preoperative anemia and length of hospital stay among patients who underwent orthopedic surgery in Northwest Ethiopia.

METHODS

A retrospective cohort study was conducted from June 01, 2019, to June 30, 2021, at Tibebe Ghion Specialized Hospital, Bahir Dar, Ethiopia. Data on demographic and clinical characteristics were collected using the Research Electronic Data Capture (REDCap) data collection system. Prolonged length of stay was defined as when a patient stays more than the 75th percentile of the LOS of all patients after orthopedic surgery. Multivariable logistic regression assessed the association between preoperative anemia and prolonged hospital stay length.

RESULTS

Of 959 orthopedic patients enrolled in this study, 481 (50.16%) had preoperative anemia. The majority of patients underwent intramedullary nailing (27.63%) followed by debridement and irrigation (19.29%), and open reduction and internal fixation (17.00%) orthopedic procedures. The median length of hospital stays of all patients who underwent orthopedic surgery was 6 days (IQR 3, 13). During the follow-up, 212 patients had a prolonged length of stay following orthopedic surgery in the hospital. Of 212 patients who had prolonged hospital stays, 124 (58.49%) patients were anemic compared to 88 (41.51%) non-anemic patients. The odds of prolonged stay after orthopedic surgery were 1.77 (AOR = 1.77, 95% CI 1.25, 2.50) times higher among patients with preoperative anemia than those without preoperative anemia.

CONCLUSION

Preoperative anemia was independently associated with prolonged hospital stay among orthopedic surgery patients. Appropriate screening and treatment of preoperative anemia in orthopedic patients is essential.

The implementation of preoperative optimization in British Columbia: a quality improvement initiative

PURPOSE

Surgical patient optimization is a proactive approach to improve postoperative outcomes. This article reviews the development of the Surgical Patient Optimization Collaborative, an initiative supporting preoperative optimization in British Columbia, Canada.

METHODS

The Collaborative facilitated optimization programs over two cohorts between 2019 and 2024. A "Change Package" offered screening, intervention, and measurement tools for the following 13 surgical risk factors: anemia, anxiety, body mass index (cohort 2 only), cardiac status, frailty, glycemic control, nutrition, sleep apnea, pain management, physical activity, smoking, social support, substance use, and venous thromboembolism (cohort 1 only). Monthly data submissions from participating sites included the number of patients undergoing optimization, National Surgical Quality Improvement Program-defined 30-day outcomes, length of stay, and patient-reported measures. Run charts were used to analyze the progress of optimization implementation across both cohorts.

RESULTS

Fourteen sites participated in each cohort. In total, 9,686 patients were screened for optimization, with 7,100/7,505 (95%) patients receiving at least one optimization intervention. Improvement shifts in the number of patients screened were identified in the run charts across both cohorts. Most patients felt that their optimization improved their surgical experience and outcomes. Data for clinical outcomes were inconsistently reported from sites and precluded analyses. Barriers to implementation included project complexity and structural characteristics, and facilitators were knowledge and beliefs about the intervention, reflection, and evaluation.

CONCLUSION

Preoperative optimization programs were successfully implemented across multiple sites in British Columbia. High-quality clinical outcome analyses are still needed to determine the impact of preoperative optimization on postoperative outcomes. The insight gained from the Collaborative's implementation process may help inform future multicentre preoperative optimization efforts.

Use and Effectiveness of Carboximaltose Iron in Preoperative Anemia Treatment: A Multicenter and Retrospective Study

Aim

Anemia, primarily due to iron deficiency, is a key risk factor in both elective and emergency surgeries. Immediate preoperative treatment with ferric carboxymaltose (FCM) in anemic patients can reduce the need for transfusions and the length of hospital stay, thereby optimizing surgical outcomes. The objective of this study was to assess the effectiveness and describe the use of administering intravenous FCM prior to elective scheduled surgery for patients diagnosed with anemia.

Methods

Multicenter, retrospective cohort study that encompassed patients aged 18 years and older who underwent surgery between January 2017 and December 2018. Demographic variables, dose scheme, baseline and perioperative haemoglobin (Hb), transfusion requirements, and admission days were collected. The primary endpoints were the response rate and effectiveness of FCM, defined as the proportion of patients with Hb preoperative levels of ≥13 g/dL. A patient response was deemed to occur when Hb level increased by 1 g/dL or more. The secondary endpoints were the appropriateness of FCM dose, transfusion requirement rate, and length of hospital stay.

Results

446 patients (55.2% women, median age 69 IQR:52-78 years) were included. The median total dose of FCM administered was 1000 mg over a span of 5 day (IQR: 0-16) days before surgery. 62.8% of patients received lower doses, 24.9% had an INCREASE of Hb ≥ 1 g/dL, 11.6% had Hb ≥ 13 g/dL and 21.3% required blood transfusions, with a mean of 0.73 units transfused. The length of the hospital stay was 12 days (IQR:6-23).

Conclusion

Low percentage of patients achieved a hemoglobin level of 13 g/dL or experienced an increase in hemoglobin of 1 g/dL or more following the administration of FCM, indicating the low effectiveness of FCM in treating perioperative anaemia in our surgical patients. There is underdosing of FCM and insufficient time between FCM administration and surgery in most patients. Both transfused and non-transfused patients show similar Hb increases, while those receiving a standard 1000 mg dose of FCM experience shorter hospital stays compared to those receiving 500 mg, and patients with more transfusions have longer hospital stays.

Over the Past Decade, Preoperative Anemia Has Become a Greater Predictor of Transfusions After Total Knee Arthroplasty

BACKGROUND

With advancements in perioperative blood management and the use of tranexamic acid, the rate of transfusions after total knee arthroplasty (TKA) has substantially decreased. As these principles are refined, other modifiable risk factors, such as preoperative anemia, may play an increasingly important role in transfusion risk for patients undergoing TKA.

METHODS

A multicenter, national database was utilized to identify patients undergoing TKA from 2010 to 2021. Anemia was defined by World Health Organization definitions as < 12 g/dL for women and < 13 g/dL for men. A predictive model was created using backwards elimination logistic regression to predict transfusion risk, controlling for demographic and medical covariates. The coefficient of anemia was then analyzed for each year. The trend over time was fitted with a best-fit linear regression equation.

RESULTS

There were 509,117 patients who underwent TKA, and had a mean age of 67 years (range, 18 to 89). There were 57,716 (11%) patients who were anemic preoperatively, and 15,426 (3%) of patients required a transfusion. Rate of transfusion decreased from 10.6% in 2010 to 0.6% in 2021. The odds ratio associated with anemia as a predictor of transfusion increased from 3.1 (95% confidence interval: 2.1 to 4.6) in 2010 to 14.0 (95% confidence interval: 8.9 to 24) in 2021.

CONCLUSIONS

The results of this study demonstrate that the importance of preoperative anemia as a predictor of transfusion has increased over the past decade as rates of transfusion have decreased. As perioperative blood management protocols improve, preoperative anemia should be considered an important focus of intervention to reduce the risk of transfusion prior to TKA.

LEVEL OF EVIDENCE

III.

Perioperative Patient Blood Management (excluding obstetrics): Guidelines from the French National Authority for Health

The French National Authority for Health (HAS) recently issued guidelines for patient blood management (PBM) in surgical procedures. These recommendations are based on three usual pillars of PBM: optimizing red cell mass, minimizing blood loss and optimizing anemia tolerance. In the preoperative period, these guidelines recommend detecting anemia and iron deficiency and taking corrective measures well in advance of surgery, when possible, in case of surgery with moderate to high bleeding risk or known preoperative anemia. In the intraoperative period, the use of tranexamic acid and some surgical techniques are recommended to limit bleeding in case of high bleeding risk or in case of hemorrhage, and the use of cell salvage is recommended in some surgeries with a major risk of transfusion. In the postoperative period, the limitation of blood samples is recommended but the monitoring of postoperative anemia must be carried out and may lead to corrective measures (intravenous iron in particular) or more precise diagnostic assessment of this anemia. A "restrictive" transfusion threshold considering comorbidities and, most importantly, the tolerance of the patient is recommended postoperatively. The implementation of a strategy and a program for patient blood management is recommended throughout the perioperative period in healthcare establishments in order to reduce blood transfusion and length of stay. This article presents an English translation of the HAS recommendations and a summary of the rationale underlying these recommendations.

Iron deficiency anemia in pregnancy and the postpartum: a practical approach by the Italian GOAL Working Group

BACKGROUND

Iron deficiency and iron deficiency anemia represent global health issues, particularly during pregnancy and the postpartum. The present paper aims to summarize the appropriate management of these conditions in order to try to improve how clinicians perceive, diagnose and treat iron deficiency and iron deficiency anemia.

METHODS

An expert panel of Italian obstetricians of Lazio region was convened to evaluate the available literature on iron deficiency and iron deficiency anemia during pregnancy and the post-partum in order to try to define a flow chart on the appropriate management of such conditions; aspects related to the patient blood management have also been investigated.

RESULTS

According to both hemoglobin level and ferritin values, five the flow charts on the appropriate management of iron deficiency and iron deficiency anemia have been drawn.

CONCLUSIONS

It is desired to define appropriate flow charts to treat iron deficiency and iron deficiency anemia, which are too often not promptly diagnosed and managed, in order to try to improve antenatal care.

Pro-Con Debate: Anesthesiologists Should Be Responsible for Treating Preoperative Anemia

In this Pro-Con commentary article, we discuss whether anesthesiologists should be responsible for treating preoperative anemia. This debate was proposed based on the article published in this issue of Anesthesia & Analgesia by Warner et al, which is an advisory on managing preoperative anemia endorsed by both the Society of Cardiovascular Anesthesiologists and the Society for Advancement of Patient Blood Management. All evidence suggests that anemia is not just an innocent "bystander" which can be solved by transfusion. In fact, both anemia and transfusion are independently associated with adverse outcomes, so why not avoid both? It just makes sense that patients show up for surgery with enough red blood cells to avoid needing transfusion with someone else's. Even if we agree that preoperative anemia is worth treating before surgery, the question remains who should be responsible for doing so, and therein lies the reason for this Pro-Con debate. Should it be the responsibility of the anesthesiologist, or not? Let the readers decide.

Comparative evaluation of postoperative outcomes and expenditure between robotic and conventional single-level lumbar fusion surgery: a comprehensive analysis of nationwide inpatient sample data

INTRODUCTION

In this study, we investigate the evolution of lumbar fusion surgery with robotic assistance, specifically focusing on the impact of robotic technology on pedicle screw placement and fixation. Utilizing data from the Nationwide Inpatient Sample (NIS) covering 2016 to 2019, we conduct a comprehensive analysis of postoperative outcomes and costs for single-level lumbar fusion surgery. Traditionally, freehand techniques for pedicle screw placement posed risks, leading to the development of robotic-assisted techniques with advantages such as reduced misplacement, increased precision, smaller incisions, and decreased surgeon fatigue. However, conflicting study results regarding the efficacy of robotic assistance in comparison to conventional techniques have prompted the need for a thorough evaluation. With a dataset of 461,965 patients, our aim is to provide insights into the impact of robotic assistance on patient care and healthcare resource utilization. Our primary goal is to contribute to the ongoing discourse on the efficacy of robotic technology in lumbar fusion procedures, offering meaningful insights for optimizing patient-centered care and healthcare resource allocation.

METHODS

This study employed data from the Nationwide Inpatient Sample (NIS) spanning the years 2016 to 2019 from USA, 461,965 patients underwent one-level lumbar fusion surgery, with 5770 of them having the surgery with the assistance of robotic technology. The study focused primarily on one-level lumbar fusion surgery and excluded non-elective cases and those with prior surgeries. The analysis encompassed the identification of comorbidities, surgical etiologies, and complications using specific ICD-10 codes. Throughout the study, a constant comparison was made between robotic and non-robotic lumbar fusion procedures. Various statistical methods were applied, with a p value threshold of < 0.05, to determine statistical significance.

RESULTS

Robotic-assisted lumbar fusion surgeries demonstrated a significant increase from 2016 to 2019, comprising 1.25% of cases. Both groups exhibited similar patient demographics, with minor differences in payment methods, favoring Medicare in non-robotic surgery and more private payer usage in robotic surgery. A comparison of comorbid conditions revealed differences in the prevalence of hypertension, dyslipidemia, and sleep apnea diagnoses-In terms of hospitalization outcomes and costs, there was a slight shorter hospital stay of 3.06 days, compared to 3.13 days in non-robotic surgery, showcasing a statistically significant difference (p = 0.042). Robotic surgery has higher charges, with a mean charge of $154,673, whereas non-robotic surgery had a mean charge of $125,467 (p < 0.0001). Robotic surgery demonstrated lower rates of heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury compared to non-robotic surgery, with statistically significant differences (p < 0.05). Conversely, robotic surgery demonstrated increased post-surgery anemia and blood transfusion requirements compared to non-robotic patients (p < 0.0001). Renal disease prevalence was similar before surgery, but acute kidney injury was slightly higher in the robotic group post-surgery (p = 0.038).

CONCLUSION

This is the first big data study on this matter, our study showed that Robotic-assisted lumbar fusion surgery has fewer post-operative complications such as heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury in comparison to conventional methods. Conversely, robotic surgery demonstrated increased post-surgery anemia, blood transfusion and acute kidney injury. Robotic surgery has higher charges compared to non-robotic surgery.

Preoperative factors predict prolonged length of stay, serious adverse complications, and readmission following operative intervention of proximal humerus fractures: a machine learning analysis of a national database

Background

Proximal humerus fractures are a common injury, predominantly affecting older adults. This study aimed to develop risk-prediction models for prolonged length of hospital stay (LOS), serious adverse complications, and readmission within 30 days of surgically treated proximal humerus fractures using machine learning (ML) techniques.

Methods

Adult patients (age >18) who underwent open reduction internal fixation (ORIF), hemiarthroplasty, or total shoulder arthroplasty for proximal humerus fracture between 2016 and 2021 were included. Preoperative demographic and clinical variables were collected for all patients and used to establish ML-based algorithms. The model with optimal performance was selected according to area under the curve (AUC) on the receiver operating curve (ROC) curve and overall accuracy, and the specific predictive features most important to model derivation were identified.

Results

A total of 7473 patients were included (72.1% male, mean age 66.2 ± 13.7 years). Models produced via gradient boosting performed best for predicting prolonged LOS and complications. The model predicting prolonged LOS demonstrated good discrimination and performance, as indicated by (Mean: 0.700, SE: 0.017), recall (Mean: 0.551, SE: 0.017), accuracy (Mean: 0.717, SE: 0.010), F1-score (Mean: 0.616, SE: 0.014), AUC (Mean: 0.779, SE: 0.010), and Brier score (Mean: 0.283, SE: 0.010) Preoperative hematocrit, preoperative platelet count, and patient age were considered the strongest predictive features. The model predicting serious adverse complications exhibited comparable discrimination [precision (Mean: 0.226, SE: 0.024), recall (Mean: 0.697, SE: 0.048), accuracy (Mean: 0.811, SE: 0.010), F1-score (Mean: 0.341, SE: 0.031)] and superior performance relative to the LOS model [AUC (Mean: 0.806, SE: 0.024), Brier score (Mean: 0.189, SE: 0.010), noting preoperative hematocrit, operative time, and patient age to be most influential. However, the 30-day readmission model achieved the weakest relative performance, displaying low measures of precision (Mean: 0.070, SE: 0.012) and recall (Mean: 0.389, SE: 0.053), despite good accuracy (Mean: 0.791, SE: 0.009).

Conclusion

Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. Modifiable preoperative factors such as hematocrit and platelet count were identified as significant predictive features, suggesting that clinicians could address these factors during preoperative patient optimization to enhance outcomes. Overall, these findings highlight the potential for ML techniques to enhance preoperative management, facilitate shared decision-making, and enable more effective and personalized orthopedic care by exploring alternative approaches to risk stratification.

Preoperative consultation for determining the appropriate transfusion strategy

Surgical patients are at risk of postoperative complications and mortality, necessitating preoperative patient optimization through the identification and correction of modifiable risk factors. Although preoperative platelet transfusions aim to reduce the risk of bleeding, their efficacy remains uncertain. Similarly, red blood cell transfusion in patients with anemia does not reduce the risk of postoperative mortality and may exacerbate complications. Therefore, developing individualized strategies that focus on correcting preoperative complete blood count abnormalities and minimizing transfusion requirements are essential. This review aimed to examine complete blood count abnormalities and appropriate transfusion strategies to minimize postoperative complications.

Iron deficiency in children with a focus on inflammatory conditions

Iron deficiency (ID) tends to be overlooked compared with anemia. However, its prevalence is estimated to be twice as high as that of ID anemia, and ID without anemia can be accompanied by clinical and functional impairments. The symptoms of ID are nonspecific, such as fatigue and lethargy, but can lead to neurodevelopmental disorders in children, restless legs syndrome, and recurrent infections due to immune system dysregulation. In particular, the risk of ID is high in the context of chronic inflammatory diseases (CIDs) due to the reaction of various cytokines and the resulting increase in hepcidin levels; ID further exacerbates these diseases and increases mortality. Therefore, the diagnosis of ID should not be overlooked through ID screening especially in high-risk groups. Ferritin and transferrin saturation levels are the primary laboratory parameters used to diagnose ID. However, as ferritin levels respond to inflammation, the diagnostic criteria differ among guidelines. Therefore, new tools and criteria for accurately diagnosing ID should be developed. Treatment can be initiated only with an accurate diagnosis. Oral iron is typically the first-line treatment for ID; however, the efficacy and safety of intravenous iron have recently been recognized. Symptoms improve quickly after treatment, and the prognosis of accompanying diseases can also be improved. This review highlights the need to improve global awareness of ID diagnosis and treatment, even in the absence of anemia, to improve the quality of life of affected children, especially those with CIDs.

Increasing severity of preoperative anemia is associated with higher postoperative medical and surgical complications after primary shoulder arthroplasty

BACKGROUND

Anemia is a major cause of morbidity worldwide and compounds numerous medical conditions. Studies have found associations between anemia and both medical and surgical complications after shoulder arthroplasty (SA); however, most of these studies have used commercially available national databases with limited information on outcomes and typically short-term follow-up. Our study sought to evaluate the midterm outcomes of primary SA at a single institution when stratified by the degree of preoperative anemia.

METHODS

Between 2000 and 2020, 5231 primary SA (477 hemiarthroplasties, 2091 anatomic total SA, and 2335 reverse SA) with preoperative hematocrit values available and a minimum follow-up of 2 years were collected from a single-institution joint registry database. The severity of anemia was subclassified as no anemia (hematocrit >39% for males, >36% for females; n = 4194 [80.2%]), mild anemia (hematocrit 33%-39% for males, 33%-36% for females; n = 742 [14.2%]), and moderate-to-severe anemia (hematocrit <33% for both males and females; n = 295 [5.6%]). The mean follow-up time for the entire cohort was 5.9 years (range, 2-22 years). Medical and surgical complications, reoperations, revisions, and implant survivorship were assessed.

RESULTS

SA with moderate-to-severe anemia had the highest rate of nonfatal and nontransfusion medical complications (5.1%) relative to the nonanemic (1.2%; P < .001) and mild anemic groups (1.5%; P < .001). Similarly, SA with moderate-to-severe anemia had the highest rate of surgical complications (19.3%) compared with mild anemia (14.3%; P = .044) and no anemia (11.6%; P < .001). Postoperative transfusion was most frequent in the moderate-to-severe anemia cohort (40.3%) compared with the mild anemia (14.2%; P < .001) and nonanemic groups (2.5%; P < .001). Furthermore, SA who received postoperative transfusions had a higher risk of nonfatal medical complications (8.2% vs. 1.0%; P < .001), 90-day mortality (1.5% vs. 0.03%; P = .001), and surgical complications (19.5% vs. 12.0%; P < .001) when compared with those without transfusion.

CONCLUSIONS

Moderate-to-severe anemia (hematocrit <33% for both males and females) was identified in approximately 5.6% of patients who underwent SA at a single institution and was associated with increased medical and surgical complications. Patients who received postoperative transfusions presented elevated rates of medical complications, 90-day mortality, and surgical complications. Health care teams should be aware of these risks in order to provide more individualized medical optimization and postoperative monitoring.

[Fragility Fractures: Preoperative assessment and optimisation]

Fragility fractures are associated with high morbidity and mortality. An interdisciplinary collaboration and an individualized, patient-centered approach are essential to ensure an optimized preoperative period and to improve perioperative safety. Preoperative responsibilities of trauma surgery include in the first step the identification of fragility fractures and the necessity for geriatric involvement. Orthogeriatric co-management (OCM) focuses on the identification of the medical, functional and social needs of the patient. In the preoperative period attention is focussed on acute diseases in need of treatment that have a negative impact on the course of further treatment and the prevention of delirium.

The Definition of Anemia Matters When Using Preoperative Hemoglobin as a Screening Tool Prior to Total Hip and Knee Arthroplasty

BACKGROUND

Preoperative anemia is common in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Several definitions of anemia have been described, with no clear consensus on the optimal one for preoperative screening. We hypothesized that depending on the definition used preoperatively, the proportion of anemic patients identified who would require a postoperative allogeneic blood transfusion would vary significantly.

METHODS

A total of 681,141 patients were identified in a national database who underwent either THA or TKA. Preoperative anemia was classified according to the World Health Organization (WHO) definition, Cleveland Clinic (CC) definition, or race, age, and sex-specific definition described by Beutler et al in 2006. The optimal preoperative (OP) hemoglobin thresholds to predict perioperative transfusions were also calculated using receiver operating characteristic curves.

RESULTS

When using the WHO definition, 18% of anemic patients required a transfusion versus 14% (OP definition), 12% (CC definition), and 16% (Beutler definition). Similarly, 0.69% of anemic patients sustained a periprosthetic joint infection within 30 days using the WHO definition versus 0.59% (OP definition), 0.60% (CC definition), or 0.66% (Beutler definition). Using the WHO definition, 5.3% of patients would have sustained a major complication versus 4.5% (OP definition), 4.4% (CC definition), and 5.0% (Beutler definition).

CONCLUSIONS

Variation in the definition of anemia for preoperative screening in THA and TKA results in substantial differences in discriminative ability to predict perioperative transfusions. The WHO definition identified the largest proportion of patients who ultimately received a perioperative transfusion.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Preoperative Phase - Preoperative management of the patient's anemia

Managing anemia before surgery is extremely important as it is a clinical condition that can significantly increase surgical risk and affect patient outcomes. Anemia is characterized by a reduction in the number of red blood cells or hemoglobin levels leading to a lower oxygen-carrying capacity of the blood. Proper treatment requires a multifaceted approach to ensure patients are in the best possible condition for surgery and to minimize potential complications. The challenge is recognizing anemia early and implementing a timely intervention to correct it. Anemic patients are more susceptible to surgical complications such as increased infection rates, slower wound healing and increased risk of cardiovascular events during and after surgery. Additionally, anemia can exacerbate existing medical conditions, causing greater strain on organs and organ systems. To correct anemia and optimize patient outcomes, several essential measures must be taken with the most common being identifying and correcting iron deficiency.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Obesity and Malnutrition-Part Four of the Movement Is Life Special ONJ Series

Obesity and malnutrition affect many patients with osteoarthritis and can predispose patients to worse outcomes after total joint arthroplasty (TJA). However, these modifiable risk factors can be addressed in preoperative optimization programs driven by nurse navigators. Our aim is to provide resources and recommendations for nurse navigators when addressing obesity and malnutrition among TJA patients. In addition to discussions with nurse navigators regarding obesity and malnutrition, a literature review was conducted to assess the current practice standards for management. Nurse navigators often had difficulty implementing long-term interventions, but interventions in the literature included medical and bariatric treatments for obesity and more targeted assessment of nutrition status. These findings are incorporated into our recommendations for nurse navigators. Addressing obesity and malnutrition in preoperative optimization can contribute to improved outcomes, as has been demonstrated in current practice and in the literature.

Association of Serum Soluble Transferrin Receptor Concentration With Markers of Inflammation: Analysis of 1001 Patients From a Tertiary Rheumatology Center

OBJECTIVE

Soluble transferrin receptor (sTfR) is considered to be a useful biomarker for the diagnosis of iron deficiency, especially in the setting of inflammation, as it is thought to not be affected by inflammation. We analyzed the relationship between sTfR levels and inflammatory markers in patients with known or suspected inflammatory rheumatic disease (IRD).

METHODS

Blood samples of 1001 patients with known or suspected IRD referred to a tertiary rheumatology center were analyzed. Study participants were classified as patients with active IRD and patients with inactive IRD or without IRD. Correlation analyses were used to explore the relationship between sTfR levels and inflammatory markers (ie, C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]). We applied multiple linear regression analysis to evaluate the predictive value of CRP levels for sTfR concentrations after adjustment for potential confounding factors.

RESULTS

There were positive correlations between inflammatory markers (CRP, ESR) and serum sTfR levels (ρ 0.44, ρ 0.43, respectively; P < 0.001), exceeding the strength of correlation between inflammatory markers and the acute phase reactant ferritin (ρ 0.30, ρ 0.23, respectively; P < 0.001). Patients with active IRD demonstrated higher serum sTfR levels compared to patients with inactive or without IRD (mean 3.99 [SD 1.69] mg/L vs 3.31 [SD 1.57] mg/L; P < 0.001). After adjustment for potential confounding factors, CRP levels are predictive for serum sTfR concentrations (P < 0.001).

CONCLUSION

The study provides evidence against the concept that sTfR is a biomarker not affected by inflammation.

A review of issues and challenges of implementation of patient blood management

INTRODUCTION

Patient blood management (PBM) is outlined as evidence-based medical and surgical concepts with a multidisciplinary method.

AIMS AND OBJECTIVES

The aim of this article is to review the PBM implementation and analyses the issues, challenges, and opportunities.

METHODOLOGY

In this article, we have an overview of PBM implementation in literature and our experience in one hospital in Iran. We used databases including Embase, CINAHL, Scopus, Google Scholar, Google, Science Direct, ProQuest, ISI Web of Knowledge, and PubMed to attain the related literature published in the English language.

RESULTS

There are different barriers and challenges of implementation of PBM, such as hospital culture confrontation, reduced staff with restricted time, lack of interdisciplinary conversation, change of practice, the lack of experience with PBM, the feasibility to integrate PBM, electronic documentation and schedule budget for required instruments, resources, and personnel. Hospitals differ globally in the aspect of infrastructure, personnel and properties, and it is necessary to individualize according to the local situation.

CONCLUSION

The review highlights the importance of PBM and its implementation for obtaining patient safety. PBM establishing in hospitals as a complex process have different challenges and barriers. Sharing experiences is essential to success in the PBM programs. Cooperation between countries will be useful in PBM spreading.

Low Body Mass Index Patients Undergoing an Anterior Lumbar Fusion May Have an Increased Risk of Perioperative Complications

BACKGROUND

Previous research has shown that underweight patients may be at a greater risk of experiencing postsurgical complications. The purpose of this study was to investigate the association between body mass index (BMI) and postoperative complications following single-level anterior lumbar fusion (ALF).

METHODS

All single-level elective ALF procedures performed between 2010 and 2020 were identified in the PearlDiver Mariner Database. Patients were separated into 6 groups based on the World Health Organization BMI classifications. Differences in postsurgical complications (ie, deep vein thrombosis, pulmonary embolism, surgical site infection, hardware malfunction, wound dehiscence, and blood transfusion) among BMI categories were assessed using a χ2 contingency test.

RESULTS

Results indicated that underweight patients (BMI <20) were at a significantly greater risk of developing deep vein thromboses, experiencing hardware malfunction, and requiring blood transfusion compared with any other BMI classification (P < 0.001). Results also demonstrated that underweight individuals had similar risks of developing surgical site infection and wound dehiscence compared with patients classified as having obesity class III.

CONCLUSION

Underweight patients may be at a greater risk than currently believed of experiencing postoperative complications following single-level ALF procedures.

CLINICAL RELEVANCE

Patients with a BMI of 20 or less should be carefully evaluated prior to surgical intervention to ensure they are optimized for surgery.

LEVEL OF EVIDENCE: 3

Prevalence and risk factors of preoperative anemia in patients undergoing elective orthopedic procedures in Northwest Ethiopia: a multicenter prospective observational cohort study

BACKGROUND

Preoperative anemia is a common hematologic problem in major orthopedic surgery in developing countries. It is a condition in which the number and size of red blood cells are insufficient to meet the body's physiologic needs, consequently impairing the capacity of the blood to transport oxygen to the body. Preoperative anemia is common in elective orthopedic surgical patients and is an independent risk factor for perioperative morbidity and mortality. This study aimed to assess preoperative anemia prevalence and risk factors in patients undergoing elective orthopedic procedures.

METHOD

A multicenter prospective observational cohort study was conducted from June 01 to August 30, 2022. A systematic random sampling technique was used to select the study unit. Data were collected using a structured questionnaire. Descriptive statistics were expressed in percentages and presented with tables and figures. Binary logistic regression was used to see the association between independent and dependent variables. A P-value < 0.05 was considered statistically significant.

RESULT

Preoperative anemia's prevalence and risk factors in patients undergoing elective orthopedic procedures was 24.1[95%CI= (18.2-30.6)]. Multivariable logistic analyses showed that low monthly income level [AOR:5,95%CI:(1.36-7.98)], patient with cancer [AOR:3.4,95%CI:(3.7-8.84)], patient with malaria infectious [AOR: 3.2,95%CI:( 1.13-8.91)], patient with anti-retroviral therapy [AOR: 5.2,95%CI:( 1.8-11.04)], and previous history of surgery [AOR:1,95%CI(1.43-2.4)], were factors significantly associated with preoperative anemia.

CONCLUSION

The prevalence of preoperative anemia among adult patients who underwent elective orthopedics procedures was high. Low Monthly income, patients with cancer, patient with malaria infection, and patients with anti-retroviral therapy, previous histories of surgery were found significantly associated with preoperative anemia. So, we recommend to health professional's early identification, diagnosis and treatment of preoperative anemia should be done to reduce the risks of anemia and related adverse outcomes.

[Iron in pre-operative stage and transfusion in patients undergoing hysterectomy]

Background

The correction of preoperative anemia is part of the patient blood management program, in order to improve the patient's clinical results by reducing the number of transfusions in surgery. Uterine fibroids can cause anemia, so the application of iron before hysterectomy could reduce transfusion.

Objective

To evaluate the impact of iron treatment in the preoperative stage on the need for transfusion in patients with anemia secondary to myomatosis in the trans and postoperative stage of hysterectomy.

Material and methods

Patients with uterine myomatosis who presented with microcytic anemia in the preoperative stage were included; clinical records were reviewed, the clinical characteristics of the population were obtained; The patients were distributed into two study groups according to whether or not they had received iron treatment; the outcome variable was the transfusion of packed erythrocytes in the first 7 days after surgery.

Results

134 patients were included, with a median fibroid size of 4 cm. 21 (15.6%) patients used iron. Patients who used iron had a relative risk (RR): 0.36 (95%CI: 0.12-1.07). Delta hemoglobin < 1 g/dL, RR: 1.59 (95%CI: 0.94-2.67). Uterine fibroid size > 5cm had a RR of 1.96 (95%CI: 1.25-3.05).

Conclusion

Treatment with iron in the pre-surgical stage showed a tendency to protect transfusions in the trans and post-surgical stage. The main factor related to transfusion was fibroid size > 5 cm.

Enhanced recovery after surgery: a narrative review on patient blood management recommendations

This review aims to analyze and document the presence of patient blood management (PBM) recommendations in enhanced recovery after surgery (ERAS) guidelines. The aim of ERAS programs is to improve outcomes and optimize patient recovery by reducing the stress response to surgery. PBM programs pursue the objective of improving outcomes by boosting and conserving the patient's own blood. From the early development of ERAS, there was little attention paid to the three pillars of perioperative blood management. Preoperative anemia is an important risk factor in perioperative outcomes and should be diagnosed and treated. Bleeding and unnecessary transfusions should be avoided. We analyzed clinical guidelines for scheduled surgery in adults published by the ERAS Society between 2018 and 2022. The guidelines selected were searched for recommendations related to the three pillars of PBM. We selected 15 ERAS guidelines in programmed surgery in adults. Until 2018, none of the ERAS guidelines analyzed included any recommendations related to pillars I and III of PBM. In 2019, recommendations related to the three pillars of PBM were introduced in the ERAS clinical guidelines for colorectal surgery, gynecology/oncology surgery, and lung resection surgery. However, many ERAS guidelines for surgeries with a high risk of bleeding, such as cardiac surgery, contain no clear recommendations on the management of preoperative anemia. This review shows that the ERAS guidelines published to date make very few recommendations related to PBM. The authors emphasize the need to include the most efficient PBM recommendations in ERAS clinical guidelines, given improved outcomes with a good perioperative management of blood transfusion.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

The severity of preoperative anemia escalates risk of poor short-term outcomes after lumbar spine fusion

OBJECTIVE

To evaluate how preoperative anemia severity affects 90-day outcomes of spinal fusion surgery.

METHODS

A retrospective cohort study was conducted on adult lumbar fusion patients at a tertiary medical center. Patients were classified by World Health Organization anemia severity definitions for comparisons. Multivariate regression models were created to control for confounding variables, for all primary outcomes of transfusion requirements, non-home discharge, readmissions, complications, and length of stay.

RESULTS

A total of 2582 patients were included: 2.7% with moderate-severe anemia, 11.0% with mild anemia, and 86.3% without anemia. Moderate-severe patients had the longest hospital stay (5.03 days vs 4.14 and 3.59 days, p < 0.001) and highest risk of transfusion (52.2% vs 13.0% vs 2.69%, p < 0.001), non-home discharge (39.1% vs 27.8% vs 15.4%, p < 0.001), readmission (7.25% vs 5.99% vs 3.36%, p = 0.023), and complications (13.0% vs 9.51% vs 6.20%, p = 0.012). On multivariable logistic regression, both patients with mild and moderate-severe anemia had an increased risk of transfusion (OR: 37.3, p < 0.001; OR: 5.25, p < 0.001, respectively) and non-home discharge (OR: 2.00, p = 0.021; OR: 1.71, p = 0.001, respectively) compared to patients without anemia. Anemia severity was not independently associated with complications or 90-day readmission. On multivariable linear regression, mild anemia (β: 0.37, p = 0.001) and moderate-severe anemia (β: 1.07, p < 0.001) were independently associated with length of hospital stay.

CONCLUSION

Patients with moderate-severe preoperative anemia are at increased risk for longer length of stay, transfusions, and non-home discharge. Improved optimization of preoperative anemia may significantly reduce healthcare utilization, and surgeons should consider these risks in preoperative planning.

LEVEL OF EVIDENCE

III.

Sensitivity and Specificity of Diagnostic Algorithms of Preoperative Anemia

OBJECTIVES

Preoperative management of anemia is one of the pillars of patient blood management. Diagnostic algorithms developed to support an anemia diagnosis have not yet been validated. The aim of this study was to validate and compare three commonly used diagnostic algorithms for preoperative anemia.

METHODS

We performed a prospective diagnostic study to detect the types of anemia present and compare the specificity and sensitivity of three diagnostic algorithms for preoperative anemia in patients scheduled to undergo major abdominal surgery. We used Cohen κ to compare the interrater reliability (agreement) of the diagnostic anemia algorithms with its standard reference.

RESULTS

Of the 10 tested types of anemia, six had a prevalence of >10% in the studied patients, namely iron deficiency, vitamin B12 deficiency, anemia of chronic disease, renal anemia, thyroid-related anemia, and anemia of bleeding. The Network for the Advancement of Transfusion Alternatives algorithm had substantial agreement with the standard reference for renal anemia but performed less appropriately for the other types of anemia. The Society for the Advancement of Blood Management algorithm displayed moderate agreement with the standard reference for deficiency of iron and B12 and for renal anemia and had substantial agreement detecting anemia of bleeding, whereas the other types of anemia were detected less appropriately. The Institute for Blood Management, Gotha, Germany algorithm had a moderate agreement with the standard reference for anemia of bleeding and near perfect agreement for all other types of anemia.

CONCLUSIONS

We were able to show that the diagnostic anemia algorithm of the Institute for Blood Management, Gotha, Germany is superior to those of the Network for the Advancement of Transfusion Alternatives and the Society for the Advancement of Blood Management in its ability to detect the six common types of preoperative anemia in patients scheduled to undergo abdominal surgery, the presence of multiple types of anemias in a given patient, and its ability to detect rare anemias that have a clinical implication for management.

Evaluation of Anemia and Iron Deficiency in French Surgical Departments: The National Multicenter Observational PERIOPES Study

BACKGROUND

Assessment of anemia and iron deficiency before surgery is pivotal for patient blood management (PBM), but few data on current practices are available in the French context. The objective of this study was to describe anemia and iron deficiency management and blood transfusion use in surgical departments in France.

METHODS

This was a national multicenter cross-sectional study in 13 public hospitals and 3 private ones (all with an interest for PBM). Data of consecutive surgical patients from different specialties were retrieved from their chart between July 30, 2019, and December 31, 2021. Data included hemoglobin, iron workup, treatment with oral/intravenous iron or erythropoiesis-stimulating agent, and transfusions.

RESULTS

Data from 2345 patients (median age, 68 years; women, 50.9%; American Society of Anesthesiologists [ASA] physical status III-IV, 35.4%) were obtained. Only 5 centers had a formalized PBM program. At preoperative anesthesia visit, hemoglobin (Hb) level was assessed in 2112 (90.1%) patients and anemia diagnosed in 722 of them (34.2%). Complete iron workup was performed in 715 (30.5%) of the 2345 patients. Iron deficiency anemia was present in 219 (30.3%) of the 722 anemic patients. Among patients with anemia, only 217 (30.1%) of them were treated. A total of 479 perioperative blood transfusions were reported in 315 patients. Restrictive transfusion was not applied in 50% of transfusion episodes, and the single-unit red blood cell transfusion was also not frequent (37.2%).

CONCLUSIONS

Our observational study showed that preoperative anemia was frequent, but iron deficiency was often not assessed and few patients were treated. There is an urgent need for PBM implementation in these centers.

A nomogram to predict postoperative surgical site infection of adult patients who received orthopaedic surgery: a retrospective study

Surgical site infection is a common postoperative complication with serious consequences. This study developed a nomogram to estimate the probability of postoperative surgical site infection for orthopaedic patients. Adult patients following orthopaedic surgery during hospitalization were included in this study. We used univariate and multivariate logistic regression analyses to establish the predictive model, which was also visualized by nomogram. To evaluate the model performance, we applied the receiver operating characteristic curve, calibration curve, and decision curve analysis, which were utilized in external validation and internal validation. From January 2021 to June 2022, a total of 787 patients were enrolled in this study. After statistical analysis, five variables were enrolled in the predictive model, including age, operation time, diabetes, WBC, and HGB. The mathematical formula has been established as follows: Logit (SSI) = - 6.301 + 1.104 * (Age) + 0.669 * (Operation time) + 2.009 * (Diabetes) + 1.520 * (WBC) - 1.119 * (HGB). The receiver Operating Characteristic curve, calibration curve, and decision curve analysis presented a good performance of this predictive model. Our nomogram showed great discriminative ability, calibration, and clinical practicability in the training set, external validation, and internal validation.

Identification of the haemoglobin level associated with a lower risk of complications after total hip and knee arthroplasty

BACKGROUND

Preoperative anaemia is associated with poor outcomes in surgical patients, but the preoperative haemoglobin cut-off that determines lower morbidity in total knee arthroplasty (TKA) and total hip arthroplasty (THA) is not well established.

METHODS

Planned secondary analysis of data collected during a multicentre cohort study of patients undergoing THA and TKA in 131 Spanish hospitals during a single 2-month recruitment period. Anaemia was defined as haemoglobin <12 g dl-1 for females and < 13 g dl-1 for males. The primary outcome was the number of patients with 30-day in-hospital postoperative complications according to European Perioperative Clinical Outcome definitions and specific surgical TKA and THA complications. Secondary outcomes included the number of patients with 30-day moderate-to-severe complications, red blood cell transfusion, mortality, and length of hospital stay. Binary logistic regression models were constructed to assess association between preoperative Hb concentrations and postoperative complications, and variables significantly associated with the outcome were included in the multivariate model. The study sample was divided into 11 groups based on preoperative Hb values in an effort to identify the threshold at which increased postoperative complications occurred.

RESULTS

A total of 6099 patients were included in the analysis (3818 THA and 2281 TKA), of whom 8.8% were anaemic. Patients with preoperative anaemia were more likely to suffer overall complications (111/539, 20.6% vs. 563/5560, 10.1%, p < .001) and moderate-to-severe complications (67/539, 12.4% vs. 284/5560, 5.1%, p < .001). Multivariable analysis showed preoperative haemoglobin ≥14 g dl-1 was associated with fewer postoperative complications.

CONCLUSION

Preoperative haemoglobin ≥14 g dl-1 is associated with a lower risk of postoperative complications in patients undergoing primary TKA and THA.

A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

Treatment Strategies in Anemic Patients Before Cardiac Surgery

Both preoperative anemia and the transfusion of red blood cells have been associated with increased morbidity and mortality after cardiac surgery. To reduce the need for blood transfusion during surgery and improve patient outcomes, patient blood management programs have been developed. A primary focus of patient blood management in the preoperative period is the identification, diagnosis, and treatment of preoperative anemia, as anemia is associated with an increased risk of preoperative blood transfusion. In this narrative review, the authors focus on the laboratory screening of anemia before surgery and the evidence and limitations of different treatment strategies in anemic patients scheduled for cardiac surgery. To accurately correct preoperative anemia, the timely detection and definition of the etiology of anemia before elective cardiac surgery are crucial. Multiple randomized studies have been performed using preoperative iron supplementation and/or administration of erythropoiesis-stimulating agents in patients undergoing cardiac surgery. Although preoperative iron substitution in patients with iron deficiency is recommended, the evidence of its effectiveness is limited. In patients with nonpure iron deficiency anemia, combined therapy with erythropoiesis-stimulating agents and intravenous iron is recommended. Combined therapy might effectively reduce the need for red blood cell transfusion, even if applied shortly before cardiac surgery. The therapeutic effect on morbidity and mortality remains unclear. Nonetheless, the timely preoperative assessment of anemia and determination of iron status, eventually leading to targeted therapy, should become a standard of care and might potentially improve patient outcomes.

Centre for Perioperative Care anaemia guideline: implications for anaesthesia

The Centre for Perioperative Care (CPOC) has published in September 2022 guidance addressing perioperative anaemia. This editorial addresses the definition of anaemia for women and management of borderline anaemia in women. We also address implications of the CPOC guidance for anaesthetists and the future direction of anaemia research and management.

Current concepts in evaluation and management of preoperative anaemia in patients undergoing thoracic surgery

PURPOSE OF REVIEW

The purpose of this review is to evaluate the current recommendations for management of perioperative anaemia in patients undergoing thoracic surgery, present the impact of anaemia on outcomes in this patient population and suggest an algorithm for evaluating and treating anaemia preoperatively.

RECENT FINDINGS

Anaemia is a common medical issue noted preoperatively in patients presenting for thoracic surgery and carries significant morbidity. Preoperative anaemia increases the likelihood of receiving a perioperative transfusion, which represents a significant risk factor for morbidity and reduced disease-free survival in lung cancer patients presenting for thoracic surgery. It is also associated with longer hospital lengths of stay and increased risk for reoperation following lung transplantation. An algorithm-based approach to management of anaemia is beneficial and treatment with iron has been shown to reduce transfusions.

SUMMARY

Patients undergoing thoracic surgery have a high incidence of preoperative anaemia that increases the risk of transfusion and postoperative morbidity. Preoperative evaluation and tailored treatment based on the underlying cause of anaemia reduces the incidence of anaemia prior to surgery and decreases transfusion rates.

Dynamic laboratory control of iron deficiency correction in neurosurgical patients

Introduction. The concept of blood management in relation to the surgical treatment of surgical diseases recommends the correction of iron defi ciency anemia (IDA) at the prehospital stage. However, surgery is often performed for emergency indications, making it necessary to carry out treatment as soon as possible.

Aim – to evaluate the possibilities of using delta hemoglobin (Delta-He) to monitor the effectiveness of IDA therapy in neurosurgical patients at the prehospital stage to reduce the time required to prepare patients for hospitalization.

Materials and methods. A total of 42 patients were treated with high-dose iron preparations (iron [III] carboxymaltosate and iron [III] hydroxide oligoisomaltosate). During the treatment, the dynamics of the number of reticulocytes and the values of the hemoglobin delta were evaluated. Data are presented as median (IQR).

Results. Treatment with high-dose iron preparations led to an increase in Delta-He values starting from days 1–2. Significant changes were recorded by days 3–4 from the start of therapy: from 2.2 (0.3–4.9) pg to 15.5 (13.8–10) pg on day 7. These changes were 2–3 days ahead of the increase in the number of reticulocytes in the corresponding blood samples: the number of reticulocytes significantly increased by days 5–6 from the start of treatment.

Conclusion. The use of high-dose preparations of iron [III] carboxymaltosate and iron [III] hydroxide oligoisomaltosate in the form of infusion made it possible to prepare neurosurgical patients for hospitalization within a week. None of the patients required transfusion of erythrocyte-containing components of donated blood at any stage of surgical treatment. The ability to focus on Delta-He values instead of the number of reticulocytes during iron therapy made it possible to shorten the waiting period for the effect of drug exposure by 2–3 days.