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Low WX, Friend H, Dulleston J, Heppenstall S, Spacey K, Liew I. Outcomes of perioperative intravenous iron infusion in femoral fracture surgery: A systematic review and meta-analysis of randomised controlled trials. Surgeon 2024:S1479-666X(24)00070-2. [PMID: 39009491 DOI: 10.1016/j.surge.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 07/04/2024] [Accepted: 07/10/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Patient blood management recommends the use of intravenous (IV) iron infusion to reduce inappropriate blood transfusion perioperatively for anaemic surgical patients. However, evidence regarding its use in urgent femoral fracture surgery is limited. This systematic review aims to collate the current evidence regarding the utilisation of IV iron in femoral fracture surgery. METHOD MEDLINE, Embase, Cochrane CENTRAL, Clinicaltrials.gov, and the WHO ICTRP databases were systematically searched for randomised controlled trials (RCT) comparing the outcomes of perioperative IV iron infusion with placebo in adults requiring surgical management for femoral fractures. Risk ratios (RR) were calculated using the Mantel-Haenszel method for dichotomous outcomes, and mean differences (MD) were calculated with the inverse-variance method for continuous outcomes. RESULTS Six RCTs with 1292 patients were included. No statistically significant difference was found in the proportion of patients receiving red blood cell (RBC) transfusion (RR = 0.87, 95%CI: 0.75; 1.01, p = 0.058) between groups. Statistically significant difference in postoperative haemoglobin concentration was found between groups measured between day 4-7 of admission (MD = 1.93 g/L, 95%CI: 0.48; 3.39, p = 0.024), but not clinically significant. No statistically significant differences were found between groups in mortality rate, length of hospital stay, infection rate, or return to home rate. CONCLUSION Current evidence indicates that IV iron infusion alone does not provide any clinically significant benefit in femoral fracture surgery. Further high-quality RCTs are needed to explore its synergistic potential when used in combination with other perioperative optimisation methods, including tranexamic acid, erythropoietin and cell salvage.
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Affiliation(s)
- Wen Xian Low
- Queen Mary University of London, Garrod Building, Turner St, London, E1 2AD, UK.
| | - Hetta Friend
- Clinical School of Medicine, University of Cambridge, Hill's Rd, Cambridge, CB2 0SP, UK
| | - Joseph Dulleston
- Clinical School of Medicine, University of Cambridge, Hill's Rd, Cambridge, CB2 0SP, UK
| | | | - Kate Spacey
- Norfolk and Norwich University Hospital, Colney Ln, Norwich, NR4 7UY, UK
| | - Ignatius Liew
- Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
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Krohn JN, Habboub B, Gosch M. [Fragility Fractures: Preoperative assessment and optimisation]. Z Gerontol Geriatr 2024; 57:235-243. [PMID: 38668778 DOI: 10.1007/s00391-024-02299-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/13/2024] [Indexed: 05/09/2024]
Abstract
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.
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Affiliation(s)
- Jan-Niklas Krohn
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Prof. Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland.
| | - Basel Habboub
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Prof. Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland
| | - Markus Gosch
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Prof. Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland
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Lasocki S, Capdevila X, Vielle B, Bijok B, Lahlou-Casulli M, Collange V, Grillot N, Danguy des Deserts M, Duchalais A, Delannoy B, Drugeon B, Bouzat P, David JS, Rony L, Loupec T, Léger M, Rineau E. Ferric derisomaltose and tranexamic acid, combined or alone, for reducing blood transfusion in patients with hip fracture (the HiFIT trial): a multicentre, 2 × 2 factorial, randomised, double-blind, controlled trial. Lancet Haematol 2023; 10:e747-e755. [PMID: 37524101 DOI: 10.1016/s2352-3026(23)00163-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/09/2023] [Accepted: 05/23/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Anaemia and blood transfusion are associated with poor outcomes after hip fracture. We evaluated the efficacy of intravenous iron and tranexamic acid in reducing blood transfusions after hip fracture surgery. METHODS In this double-blind, randomised, 2 × 2 factorial trial, we recruited adults hospitalised for hip fractures in 12 medical centres in France who had preoperative haemoglobin concentrations between 9·5 and 13·0 g/dL. We randomly allocated participants (1:1:1:1), via a secure web-based service, to ferric derisomaltose (20 mg/kg intravenously) and tranexamic acid (1 g bolus followed by 1 g over 8 h intravenously at inclusion and 3 g topically during surgery), iron plus placebo (normal saline), tranexamic acid plus placebo, or double placebo. Unmasked nurses administered study drugs; participants and other clinical and research staff remained masked to treatment allocation. The primary outcome was the percentage of patients transfused during hospitalisation (or by day 30). The primary analysis included all randomised patients. This study is registered on ClinicalTrials.gov (NCT02972294) and is closed to new participants. FINDINGS Of 413 patients (51-104 years old, median [IQR] 86 [78-91], 312 [76%] women, 101 [24%] men), 104 received iron plus tranexamic acid, 103 iron plus placebo, 103 tranexamic acid plus placebo, and 103 double placebo between March 31, 2017 and June 18, 2021 (study stopped early for efficacy after the planned interim analysis done on the first 390 patients included on May 25, 2021). Data for the primary outcome were available for all participants. Among patients on double placebo, 31 (30%) were transfused versus 16 (15%) on both drugs (relative risk 0·51 [98·3% CI 0·27-0·97]; p=0·012). 27 (26%) participants on iron (0·81 [0·50-1·29]; p=0·28) and 28 (27%) on tranexamic acid (0·85 [0·54-1·33]; p=0·39) were transfused. 487 adverse events were reported with similar event rates among the groups; among prespecified safety endpoints, severe postoperative anaemia (haemoglobin <8 g/dL) was more frequent in the double placebo group. Main common adverse event were sepsis, pneumonia, and urinary infection, with similar rates among all groups. INTERPRETATION In patients hospitalised for hip fracture surgery with a haemoglobin concentration 9·5-13·0 g/dL, preoperative infusion of ferric derisomaltose plus tranexamic acid reduced the risk of blood transfusion by 50%. Our results suggest that combining treatments from two different pillars improves patient blood-management programmes. Either treatment alone did not reduce transfusion rates, but we might not have had the power to detect it. FUNDING French Ministry of Health, HiFIT trial.
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Affiliation(s)
- Sigismond Lasocki
- Département Anesthésie-Réanimation, Pôle Anesthésie Samu Urgences Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France.
| | - Xavier Capdevila
- Department of Anesthesiology and Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Bruno Vielle
- Département de Biostatistiques, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Benjamin Bijok
- Centre Hospitalier Universitaire de Lille, Pôle d'anesthésie-réanimation, Lille, France
| | - Maria Lahlou-Casulli
- Department of Anesthesiology, Critical Care Medicine and Perioperative Medicine, Rennes University Hospital and School of Medicine, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Vincent Collange
- Department of Anesthesiology, Médipole Lyon Villeurbanne, Lyon, France
| | - Nicolas Grillot
- Nantes Université, Centre Hospitalier Universitaire de Nantes, Service d'Anesthésie Réanimation Chirurgicale, Immunologie et Infectiologie, Nantes, France
| | - Marc Danguy des Deserts
- Pôle Bloc Anesthésie Réanimation Urgences, Hôpital d'Instruction des Armées Clermont-Tonnerre, INSERM, Université de Bretagne Occidentale, Brest, France
| | - Alexis Duchalais
- Centre Hospitalier Départemental Vendée, La Roche sur Yon, France
| | - Bertrand Delannoy
- Department of Anesthesiology and Intensive Care Medicine, Ramsay Sante, Sauvegarde Clinic, Lyon, France
| | - Bertrand Drugeon
- Service des Urgences-SAMU-SMUR, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Pierre Bouzat
- Université Grenoble Alpes, Inserm, Centre Hospitalier Universitaire de Grenoble Alpes, Grenoble Institut Neurosciences, Grenoble, France
| | - Jean-Stéphane David
- Service d'Anesthésie Réanimation, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre Bénite and Research on Healthcare Performance, Inserm, University Claude Bernard Lyon, Lyon, France
| | - Louis Rony
- Département de Chirurgie osseuse, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Thibault Loupec
- Department of Anesthesiology and Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Maxime Léger
- Département Anesthésie-Réanimation, Pôle Anesthésie Samu Urgences Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Emmanuel Rineau
- Département Anesthésie-Réanimation, Pôle Anesthésie Samu Urgences Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
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Jung HJ, Kang MW, Lee JH, Lee JK, Kim JI. The Association of Intravenous Iron Administered the Day before Total Knee Arthroplasty with Postoperative Anemia and Functional Recovery. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1212. [PMID: 37512024 PMCID: PMC10384006 DOI: 10.3390/medicina59071212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: Total knee arthroplasty (TKA) involves blood loss, increasing the risk of postoperative anemia and delayed functional recovery. Intravenous (IV) iron supplementation limits postoperative anemia; however, the effectiveness of IV iron, administered one day before TKA, on postoperative anemia and functional recovery has scarcely been studied. Materials and Methods: We conducted a retrospective cohort study with propensity score matching using two consecutive groups of patients who underwent TKA using tranexamic acid: the iron group received 500 mg ferric derisomaltose intravenously one day before surgery (n = 46); the non-iron group did not (n = 46). Hemoglobin (Hb) level was determined at postoperative days (PODs) 2, 4, 6, 14, and 30. Ferritin, transferrin saturation (TSAT), and functional iron deficiency anemia (IDA) rate were measured at PODs 2, 4, 6, and 14. Length of hospital stay and transfusion rate were also evaluated. Results: The iron group had higher Hb levels at PODs 6, 14, and 30 and higher ferritin and TSAT at PODs 2, 4, 6, and 14. The functional IDA rate was significantly higher in the non-iron group at PODs 2, 4, 6, and 14. Length of hospital stay was significantly shorter in the iron group; however, the rate of transfusion did not differ between the two groups. Conclusions: IV iron administered one day before TKA was associated with postoperative anemia recovery and length of hospital stay; however, it did not lower the postoperative transfusion rate.
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Affiliation(s)
- Ho Jung Jung
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77, Sakju-ro, Chuncheon-si 24253, Republic of Korea
| | - Min Wook Kang
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Jong Hwa Lee
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Joon Kyu Lee
- Department of Orthopaedic Surgery, Konkuk University Medical Center, Konkuk University School of Medcine, Seoul 05030, Republic of Korea
| | - Joong Il Kim
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
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Gonzalez CA, O'Mara A, Cruz JP, Roth D, Van Rysselberghe NL, Gardner MJ. Postoperative sepsis and septic shock after hip fracture surgery. Injury 2023:110833. [PMID: 37365091 DOI: 10.1016/j.injury.2023.05.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/09/2023] [Accepted: 05/15/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION There is a paucity of research in the rates for sepsis and septic shock in the hip fracture population specifically, despite marked clinical and prognostic differences between these conditions. The purpose of this study was to determine the incidence, risk factors, and mortality rates for sepsis and septic shock as well as evaluate potential infectious causes in the surgical hip fracture population. METHODS The ACS-NSQIP (2015-2019) was queried for patients who underwent hip fracture surgery. A backward elimination multivariate regression model was used to identify risk factors for sepsis and septic shock. Multivariate regression that controlled for preoperative variables and comorbidities was used to calculate the odds of 30-day mortality. RESULTS Of 86,438 patients included, 871 (1.0%) developed sepsis and 490 (0.6%) developed septic shock. Risk factors for both postoperative sepsis and septic shock were male gender, DM, COPD, dependent functional status, ASA class ≥3, anemia, and hypoalbuminemia. Unique risk factors for septic shock were CHF and ventilator dependence. The 30-day mortality rate was 4.8% in aseptic patients, 16.2% in patients with sepsis, and 40.8% in patients who developed septic shock (p < 0.001). Patients with sepsis (OR 2.87 [95% CI 2.37-3.48], p < 0.001) and septic shock (OR 11.27 [95% CI 9.26-13.72], p < 0.001) had increased odds of 30-day mortality compared to patients without postoperative septicemia. Infections that preceded a diagnosis of sepsis or septic shock included urinary tract infections (24.7%, 16.5%), pneumonia (17.6%, 30.8%), and surgical site infections (8.5%, 4.1%). CONCLUSIONS The incidence of sepsis and septic shock after hip fracture surgery was 1.0% and 0.6%, respectively. The 30-day mortality rate was 16.2% in patients with sepsis and 40.8% in patients with septic shock. Potentially modifiable risk factors for both sepsis and septic shock were anemia and hypoalbuminemia. Urinary tract infections, pneumonia, and surgical site infections preceded the majority of cases of sepsis and septic shock. Prevention, early identification, and successful treatment of sepsis and septic shock are paramount to lowering mortality after hip fracture surgery.
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Affiliation(s)
| | - Alana O'Mara
- Stanford University School of Medicine, Stanford, CA, USA
| | - Jacquelyn P Cruz
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Dylan Roth
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
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The Efficacy and Safety of Intravenous Iron in Geriatric Hip Fracture Surgeries: A Systematic Review and Meta-Analysis. World J Surg 2022; 46:2595-2606. [PMID: 35947180 DOI: 10.1007/s00268-022-06690-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND With the increasing evidence provided by recent high-quality studies, the intravenous iron appears to be a reliable therapy for blood administration in geriatric patients with hip fractures. Here, this systematic review and meta-analysis were aimed to assess the effectiveness and safety of intravenous iron in geriatric patients sustaining hip fractures. METHODS Potential pertinent literatures evaluating the effects of intravenous iron in the geriatric patients undergoing hip fractures were identified from Web of Science, PubMed, Embase, and Scopus. We performed a pairwise meta-analysis using fixed- and random-effects models, and the pooling of data was carried out by using RevMan 5.1. RESULTS Four randomized controlled trials and four observational studies conform to inclusion criteria. The results of meta-analysis showed that intravenous iron reduced transfusion rates compared to the control group, yet the result did not reach statistical significance. The intravenous iron was related to lower transfusion volumes, shorter length of stay, and a reduced risk of nosocomial infections. And there was no significant difference in terms of the mortality and other complications between the treatment group and the control group. CONCLUSION Current evidence suggests that intravenous iron reduces the transfusion volume, length of hospital stay, and risk of nosocomial infections. It takes about 7 days for intravenous iron to elevate hemoglobin by 1 g/dl and about 1 month for 2 g/dl. The safety profile of intravenous iron is also reassuring, and additional high-quality studies are needed.
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Maniar AR, Mishra A, Sanghavi N, Maniar RN. Does Postoperative Intravenous Ferric Carboxymaltose Hasten the Recovery of Hemoglobin in Patients Post Total Knee Arthroplasty? J Arthroplasty 2022; 37:S155-S158. [PMID: 35202759 DOI: 10.1016/j.arth.2022.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/03/2022] [Accepted: 02/11/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Timely and effective iron supplementation may help reduce the incidence of postoperative anemia and its associated problems. In this study, we aim to assess the efficacy of intravenous ferric carboxy maltose (FCM) on improving hemoglobin(Hb) level posttotal knee arthroplasty (TKA). METHODS We retrospectively reviewed 263 patients who had undergone unilateral TKA with 157 patients in the study group (year 2019) and 106 in the control group (year 2016). Patients in the study group received FCM (500 mg IV) on postoperative day 1, whereas patients in the control group did not receive FCM or any other iron supplementation postoperatively. Hb levels were recorded preoperatively (Pr-Hb), postoperatively on day 3 (Day3-Hb) and postoperatively at 5(+1) weeks (Week5-Hb). Statistical analysis was performed using student's paired and unpaired t-tests. RESULTS Pr-Hb and Day3-Hb levels were comparable in the control and study group, while Week5-Hb levels were significantly higher (P < .001) in the study group. The drop in Hb at Day3 from preoperative values was comparable between the two groups (P = 1.0). The rise in Hb from Day3 to 5 weeks was significantly higher in the study group as compared to the control group (P < .001). The difference between Pr-Hb and Week5-Hb was significantly lower (P < .001) in the study group compared to the control group. However, Week5-Hb in both groups remained lower than Pr-Hb (P < .001) in all patients. CONCLUSION Intravenous FCM (500 mg) was found to be a safe method of iron supplementation to improve hemoglobin levels rapidly and consistently, post-TKA. We need to further study the additive effect of higher dose FCM (1000 mg) on hemoglobin recovery.
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Affiliation(s)
- Adit R Maniar
- Department of Orthopaedics, HBT Medical College and Dr. R N Cooper Municipal General Hospital, Juhu Mumbai, Maharashtra, India
| | - Abhinav Mishra
- Trauma and Joint Replacement Consultant, Department of Orthopaedics, Shriram Care Hospital and KIMS Superspeciality Hospital, Bilaspur, Chhattisgarh, India
| | | | - Rajesh N Maniar
- Department of Orthopaedics, Lilavati Hospital and Research Centre, Bandra (West), Mumbai, India; Consultant Orthopaedic Surgeon, Breach Candy Hospital Trust, Mumbai, India
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Sinclair RCF, Bowman MJA, Moppett IK, Gillies MA. Perioperative intravenous iron to treat patients with fractured hip surgery: A systematic review and meta‐analysis. Health Sci Rep 2022; 5:e633. [PMID: 35620535 PMCID: PMC9125168 DOI: 10.1002/hsr2.633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 04/21/2022] [Accepted: 04/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background Treatment of preoperative anemia with intravenous iron is common within elective surgical care pathways. It is plausible that this treatment may improve care for people with hip fractures many of whom are anemic because of pre‐existing conditions, fractures, and surgery. Objective To review the evidence for intravenous iron administration on outcomes after hip fracture. Design We followed a predefined protocol and conducted a systematic review and meta‐analysis of the use of intravenous iron to treat anemia before and after emergency hip fracture surgery. The planned primary outcome was a difference in length of stay between those treated with intravenous iron and the control group. Other outcomes analyzed were 30‐day mortality, requirement for blood transfusion, changes in quality of life, and hemoglobin concentration on discharge from the hospital. Data Sources EMBASE, MEDLINE, The Cochrane Library (CENTRAL, DARE) databases, Clinicaltrials.gov, and ISRCTN trial registries. Date of final search March 2022. Eligibility Criteria Adult patients undergoing urgent surgery for hip fracture. Studies considered patients who received intravenous iron and were compared with a control group. Results Four randomized controlled trials (RCT, 732 patients) and nine cohort studies (2986 patients) were included. The RCTs were at low risk of bias, and the nonrandomized studies were at moderate risk of bias. After metanalysis of the RCTs there was no significant difference in the primary outcome, length of hospital stay, between the control group and patients receiving intravenous iron (mean difference: −0.59, 95% confidence interval [CI]; −1.20 to 0.03; I2 = 30%, p = 0.23). Intravenous iron was not associated with a difference in 30‐day mortality (n = 732, OR: 1.14, 95% CI: 0.62−2.1; I2 = 0%, p = 0.50), nor with the requirement for transfusion (n = 732, OR: 0.85, 95% CI: 0.63−1.14; I2 = 0%, p < 0.01) in the analyzed RCTs. Functional outcomes and quality of life were variably reported in three studies. Conclusion The evidence on the use of intravenous iron in patients with hip fracture is low quality and shows no difference in length of acute hospital stay and transfusion requirements in this population. Improved large, multicentre, high‐quality studies with patient‐centered outcomes will be required to evaluate the clinical and cost‐effectiveness of this treatment.
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Affiliation(s)
| | | | - Iain K. Moppett
- Professor of Anaesthesia and Perioperative Medicine, Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, Queens Medical Centre University of Nottingham Nottingham UK
| | - Michael A. Gillies
- Consultant and Honorary Professor in Intensive Care Royal Infirmary of Edinburgh, NHS Lothian Edinburgh UK
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Cui Y, Lu Y, Huang Q, Zhang C, Sun L, Ren C, Wang Q, Ma T, Li Z, Zhang K, Wang Z, Xue H. Clinical Application Effects of Different Preoperative Blood Management Schemes in Older Patients with Delayed Intertrochanteric Fracture Surgery. Clin Interv Aging 2022; 17:825-835. [PMID: 35620020 PMCID: PMC9129265 DOI: 10.2147/cia.s362020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/14/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Yu Cui
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Yao Lu
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Qiang Huang
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Congming Zhang
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Liang Sun
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Cheng Ren
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Qian Wang
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Teng Ma
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Zhong Li
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Kun Zhang
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Zhimeng Wang
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
- Correspondence: Zhimeng Wang; Hanzhong Xue, Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China, Email ;
| | - Hanzhong Xue
- Department of Orthopedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
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Yuan M, Tao Q, Wang D, Wang H, Zhou Z. Finding the optimal regimen for short-term daily recombinant human erythropoietin treatment for blood-saving purpose in patients undergoing unilateral primary total hip arthroplasty: a double-blinded randomized placebo-controlled trial. BMC Musculoskelet Disord 2022; 23:243. [PMID: 35279105 PMCID: PMC8917634 DOI: 10.1186/s12891-022-05184-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 03/04/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose To find the best short-term daily recombinant human erythropoietin (rhEPO)-based treatment protocols for blood-saving purpose in THA. Method The patients were randomized to 1 of 3 interventions: Patients in group A received 10,000 IU (150 IU/kg) of subcutaneous rhEPO (1 ml) daily from 5 days preoperatively to 3 days postoperatively (9 doses in total); Patients in group B received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to 3 days preoperatively and then 10,000 IU (150 IU/kg) of subcutaneous rhEPO daily until 3 days postoperatively (6 doses in total). Patients in group C received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to one day preoperatively and then 10,000 IU (150 IU/kg) of subcutaneous rhEPO daily from the day of surgery to 3 days postoperatively (4 doses in total). Results One hundred eighty patients were included. On postoperative day one, patients in the group A showed significantly higher Hb level (108.4 ± 11.4 g/L) than group C (103.9 ± 8.8 g/L). Group B (107.8 ± 8.4 g/L) also showed significantly higher Hb level than group C (103.9 ± 8.8 g/L) (p < 0.05). On postoperative day 3, no significant difference was found between group B and group C in Hb level (98.7 ± 10.5 and 94.9 ± 8.7 g/L, respectively) (p = 0.094), but the Hb level in group A (103.6 ± 11.0 g/L) was still markedly higher than in group B and the Hb level in group A was also markedly higher than in group C. In terms of blood loss, no markedly difference was found in intraoperative blood loss among group A, B and C (78.3 ± 22.4, 84.6 ± 29.1, and 80.3 ± 23.9 ml, respectively) (p = 0.381), but on postoperative day one, the mean blood loss in group C (522.4 ± 189.4 ml) was significantly more than group B (371.2 ± 124.6 ml), and group B was also significantly more than group A (284.8 ± 112.9 ml) with 95% confidence interval, and group B had significantly less blood loss than group C (p < 0.001). With respect to the total blood loss, the total blood loss in group C (881.6 ± 314.9 ml) was significantly more than group B (642.6 ± 232.9 ml), and group B was also significantly more than group A (514.5 ± 204.6 ml) with 95% confidence interval (Table 2). Only 2 patients in each group received allogeneic blood transfusion and each patient received 2 units of red blood cells, so, the transfusion requirements among the three groups were comparable. Conclusions Daily small-dose of subcutaneous rhEPO administered from 5 days before THA could significantly decrease perioperative blood loss and improve postoperative Hb levels, without increasing risks of complications, when compared with the application of rhEPO from 3 days before THA or from the day of surgery. However, surgeons should choose the regimen individually according to different patients’ personal circumstances.
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11
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Park HS, Bin SI, Kim HJ, Kim TY, Kim J, Kim H, Ro Y, Koh WU. Short-term high-dose intravenous iron reduced peri-operative transfusion after staggered bilateral total knee arthroplasty: A retrospective cohort study. Vox Sang 2021; 117:562-569. [PMID: 34897718 DOI: 10.1111/vox.13230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/23/2021] [Accepted: 11/28/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Staggered bilateral total knee arthroplasty, two procedures performed 4-7 days apart during a single hospitalization, has an increased risk of blood transfusion. This observational study aimed to evaluate whether immediate post-operative single, high-dose intravenous iron supplementation could reduce transfusion requirements and facilitate anaemia recovery in patients. MATERIALS AND METHODS We retrospectively analysed 131 patients who underwent staggered bilateral total knee arthroplasty. The ferric carboxymaltose (FCM) group received 1000 mg of FCM after the first operation. The non-FCM group did not receive intravenous iron. The transfusion rate and post-operative complications were compared between the groups. The anaemia rate was evaluated pre-operatively, during hospitalization, and 5 weeks after the second total knee arthroplasty. RESULTS The FCM group comprised 78 patients (59.5%). The rate (21.8% vs. 47.2%, p = 0.004) and amount of transfusion (0 [0-2] vs. 0 [0-0], p = 0.001) was significantly lower in the FCM group than in the non-FCM group. Although both groups' pre-operative haemoglobin concentrations were not significantly different, the FCM group demonstrated higher haemoglobin values 5 weeks post surgery (12.25 ± 0.83 mg/dl vs. 11.48 ± 1.36 mg/dl, p < 0.001). More non-FCM patients developed moderate to severe anaemia at 5 weeks post surgery (p < 0.001). The mortality and complication rates were not significantly different. CONCLUSIONS Immediate post-operative, high-dose, intravenous iron treatment may contribute to reduced transfusion rates, facilitate haemoglobin recovery after staggered bilateral total knee arthroplasty, and minimize the development of moderate to severe anaemia.
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Affiliation(s)
- Hee-Sun Park
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Il Bin
- Department of Orthopaedic Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ha-Jung Kim
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae-Yop Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jiyoung Kim
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyungtae Kim
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Youngjin Ro
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Uk Koh
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Shah AA, Donovan K, Seeley C, Dickson EA, Palmer AJR, Doree C, Brunskill S, Reid J, Acheson AG, Sugavanam A, Litton E, Stanworth SJ. Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2133935. [PMID: 34767026 PMCID: PMC8590171 DOI: 10.1001/jamanetworkopen.2021.33935] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Akshay A. Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Killian Donovan
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Claire Seeley
- Department of Anaesthesia, Royal Berkshire Hospitals NHS Foundation Trust, Reading, United Kingdom
| | - Edward A. Dickson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Antony J. R. Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Jack Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Austin G. Acheson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Anita Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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13
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Thin TN, Tan BPY, Sim EY, Shum KL, Chan HSP, Abdullah HR. Preoperative Single-Dose Intravenous Iron Formulation to Reduce Postsurgical Complications in Patients Undergoing Major Abdominal Surgery: A Randomized Control Trial Feasibility Study (PIRCAS Trial Pilot). Cureus 2021; 13:e17357. [PMID: 34567897 PMCID: PMC8452824 DOI: 10.7759/cureus.17357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 12/01/2022] Open
Abstract
Background Preoperative anemia is associated with an increased need for blood transfusion, complications, and prolonged hospital stay. Iron deficiency anemia (IDA) may be treated with oral or intravenous (IV) iron. IV iron repletes iron stores more rapidly. Its impact on perioperative blood transfusion, postoperative complications, patients’ recovery, and long-term quality of life is unclear. Newer agents, such as ferric carboxymaltose (FCM), are costly but have higher maximum approved doses and a very low incidence of anaphylactic-type reactions. This study aims to explore the feasibility of a randomized control trial to compare the preoperative treatment of IDA with IV FCM versus oral ferrous fumarate, in patients undergoing elective major abdominal surgery. Experimental design This is an open-label pilot randomized controlled trial. A total of 30 adults with IDA scheduled for elective major abdominal surgery were recruited for the study. They were randomized into two groups to receive either oral iron or IV FCM. Primary outcomes are defined as the time from enrollment to study drug administration, recruitment rate, and follow-up rate up to three months. Secondary outcomes are hemoglobin rise from recruitment to surgery, perioperative blood transfusion, postoperative complications, EQ-5D-3L scores at baseline, and three months and adverse events related to IV FCM therapy. Results All patients received study drugs within five days of enrollment; 30 patients were recruited within four months, 15 patients in each group. Two in each group were withdrawn for surgery postponement. All patients were followed up for three months and there was no crossover of patients. Per protocol, analysis was performed. No severe adverse events related to IV FCM therapy occurred. Both groups had similar baseline characteristics, similar hemoglobin rise from enrollment to the day of surgery [0.2 (+1.6) g/dL in the FCM group and 0.8 (+0.7) g/dL in the Oral Iron group, p=0.3] and similar mean units of perioperative blood transfused (recruitment to discharge) per patient [1.3 (+ 2.1) in the FCM group and 0.9 (+1.3) in the Oral Iron group, p=0.6]. Postoperatively, there was a similar hospital length of stay [11.5 (+13.6 days) in the FCM group and 9.0 (+9.8 days) in the Oral Iron group, p=0.6]; there were similar postoperative complications as reflected by the average Comprehensive Complication Index [12.8 (+19.6) in the FCM group and 22.6 (+30.7) in the Oral Iron group, p=0.3]; similar postoperative health-related quality of life as reflected by mean EQ-5D-3L scores at one month [70.4 (+21.8) in the FCM group and 84.5 (+12.1) in the Oral Iron group] and three months [80.0 (+18.4) in the FCM group and 85.9 (+10.7) in the Oral Iron group]. Conclusions A full-scale randomized controlled trial to evaluate the effectiveness of preoperative IV FCM compared to oral iron in patients with IDA undergoing major abdominal surgery is feasible.
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Affiliation(s)
- Thiri Naing Thin
- Department of Anesthesiology, Singapore General Hospital, Singapore, SGP
| | - Brenda Pei Yi Tan
- Department of Anesthesiology, Singapore General Hospital, Singapore, SGP
| | - Eileen Y Sim
- Department of Anesthesiology, Singapore General Hospital, Singapore, SGP
| | - Koin Lon Shum
- Department of Internal Medicine, Singapore General Hospital, Singapore, SGP
| | - Hazel Su Pin Chan
- Department of Anesthesiology, Singapore General Hospital, Singapore, SGP
| | - Hairil Rizal Abdullah
- Department of Anesthesiology, Singapore General Hospital, Singapore, SGP.,Anesthesiology, Duke-National University of Singapore (NUS) Medical School, Singapore, SGP
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14
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Jones JJ, Mundy LM, Blackman N, Shwarz M. Ferric Carboxymaltose for Anemic Perioperative Populations: A Systematic Literature Review of Randomized Controlled Trials. J Blood Med 2021; 12:337-359. [PMID: 34079413 PMCID: PMC8165212 DOI: 10.2147/jbm.s295041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/29/2021] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Perioperative anemia is a common comorbid condition associated with increased risk of morbidity and mortality in patients undergoing elective surgical procedures. OBJECTIVE We conducted a systematic literature review (SLR) to determine the efficacy and safety of the use of intravenous ferric carboxymaltose (FCM) for the treatment of perioperative anemia in preoperative, intraoperative, and postoperative elective surgical care. EVIDENCE REVIEW Studies meeting inclusion criteria for the SLR reported on treatment efficacy in an adult study population randomly allocated to FCM for the treatment of perioperative anemia during the perioperative period. After screening, 10 of 181 identified studies from searches in MEDLINE and EMBASE databases were identified for inclusion in this review. FINDINGS Preoperative treatment was reported in six studies, intraoperative treatment in one study, postoperative treatment in two studies, and both pre- and postoperative treatment in one study. Together, 1975 patients were studied, of whom 943 were randomized to FCM, of whom 914 received FCM treatment. The 10 studies reported elective surgical populations for colorectal, gastric, orthopedic, abdominal, urologic, plastic, neck, gynecologic, and otolaryngologic procedures. Given the clinical and methodological heterogeneity of the studies, the analyses were limited to qualitative assessments without meta-analyses. All 10 studies reported statistically greater changes in hemoglobin concentration, serum ferritin, and/or transferrin saturation with FCM treatment compared with comparators (placebo, oral iron, standard care, or a combination of these). Two studies reported statistically significant differences in transfusion rate and 2 studies reported significant differences in length of hospital stay between FCM and its comparator(s). CONCLUSIONS AND RELEVANCE This SLR adds to existing data that administration of FCM in preoperative and postoperative settings improves hematologic parameters. Several studies in the review supported the beneficial effects of FCM in reducing transfusion rate and length of stay. Larger, well-designed, longer-term studies may be needed to further establish the efficacy and safety of FCM in elective surgery patients with perioperative anemia.
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Affiliation(s)
- John Jeffrey Jones
- College of Pharmacy and Health Sciences, St. John’s University, Queens, NY, USA
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15
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Clemmensen SZ, Kragholm KH, Melgaard D, Hansen LT, Riis J, Cavallius C, Mørch MM, Krogager ML. Association between intravenous iron therapy and short-term mortality risk in older patients undergoing hip fracture surgery: an observational study. J Orthop Surg Res 2021; 16:320. [PMID: 34006287 PMCID: PMC8130414 DOI: 10.1186/s13018-021-02462-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/06/2021] [Indexed: 12/22/2022] Open
Abstract
Background Anemia is common among ortho-geriatric hip fracture patients and is associated with prolonged recovery and increased postoperative mortality rate. Intravenous iron seems to increase hemoglobin recovery and reduce the mortality rate in patients undergoing orthopedic surgeries. This study investigated the association between short-term mortality risk and intravenous iron therapy in older patients undergoing hip fracture surgery. Methods This observational study included 210 patients undergoing hip fracture surgery from July 2018 to May 2020. These 210 patients were alive and had a hemoglobin ≤ 6.5 mmol/L on the 3rd postoperative day. In May 2019, a local intravenous iron therapy protocol was implemented and recommended intravenous iron (Monofer©) if hemoglobin on the 3rd postoperative day was ≤ 6.5 mmol/L. According to the treatment of postoperative anemia between the 1st and 3rd day post-surgery, the patients were divided into four groups: no treatment (n=52), blood transfusion (n=38), IV Monofer (n=80), and blood transfusion and IV Monofer (n=40). Primary outcome was 30-day mortality post-surgery. The secondary outcome was the impact on hemoglobin level 14–30 days postoperatively. Multivariable Cox regression was used to estimate the 30-day mortality standardized for covariates. Results Of 210 patients, 17 (8.1%) died within 30 days after surgery. There was a significantly lower mortality among the patients who received IV Monofer compared to those who received no treatment (HR 0.17, 95% CI [0.03–0.93], P = 0.041). Among the 86 patients with available hemoglobin measurements within 14 to 30 days post-surgery, there was no significant difference in hemoglobin level between the various treatment groups (mean 6.6 mmol/L, P = 0.1165). Conclusion IV Monofer on the 3rd postoperative day in older hip fracture patients seemed to reduce 30-day mortality compared with no treatment. No significant differences in hemoglobin levels between 14 and 30 days post-surgery across treatment groups were found, although this was assessed in a subset of patients with available hemoglobin levels warranting further study. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02462-x.
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Affiliation(s)
- Silas Zacharias Clemmensen
- Center for Clinical Research, North Denmark Regional Hospital, Hjørring, Denmark. .,Department of Orthopedic Surgery, Aalborg University Hospital, Hjørring, Denmark.
| | - Kristian H Kragholm
- Center for Clinical Research, North Denmark Regional Hospital, Hjørring, Denmark.,Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Dorte Melgaard
- Center for Clinical Research, North Denmark Regional Hospital, Hjørring, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lene T Hansen
- Department of Geriatric Medicine, North Denmark Regional Hospital, Hjørring, Denmark
| | - Johannes Riis
- Center for Clinical Research, North Denmark Regional Hospital, Hjørring, Denmark
| | - Christian Cavallius
- Department of Orthopedic Surgery, Aalborg University Hospital, Hjørring, Denmark
| | - Marianne M Mørch
- Department of Geriatric Medicine, North Denmark Regional Hospital, Hjørring, Denmark
| | - Maria Lukács Krogager
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Emergency Medicine, Aalborg University Hospital, Aalborg, Denmark
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16
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Role of preoperative erythropoietin in the optimization of preoperative anemia among surgical patients - A systematic review and meta-analysis. Hematol Transfus Cell Ther 2021; 44:76-84. [PMID: 33583767 PMCID: PMC8885371 DOI: 10.1016/j.htct.2020.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/02/2020] [Accepted: 12/07/2020] [Indexed: 11/23/2022] Open
Abstract
Preoperative anemia is a common finding. Preoperative allogeneic transfusion, iron therapy, vitamin supplementation and erythropoietin therapy are the current management strategies for preoperative anemia. Previous reviews regarding erythropoietin were limited to specialties, provided little evidence regarding the benefits and risks of erythropoietin in managing preoperative anemia and included non-anemic patients. The purpose of our systematic review was to determine the role of erythropoietin solely in preoperatively anemic patients and to investigate the complications of this treatment modality to produce a guideline for preoperative management of anemic patients for all surgical specialties. The PubMed/Medline, Google Scholar, and Cochrane Library were searched for randomized trials evaluating the efficacy of erythropoietin in preoperative anemia. The risk ratio (RR) and standardized mean difference (SMD) was used to pool the estimates of categorical and continuous outcomes, respectively. Allogeneic transfusion and complications and the 90-day mortality were the primary outcomes, while the postoperative change in hemoglobin, bleeding in milliliters and the number of red blood cell (RBC) packs transfused were the secondary outcomes. Results: Eight studies were included, comprising 734 and 716 patients in the erythropoietin group and non-erythropoietin group, respectively. The pooled estimate by RR for allogeneic transfusion was 0.829 (p = 0.049), while complications and the 90-day mortality were among the 1,318 (p = 0.18) patients. Conclusion: Preoperative erythropoietin provides better outcomes, considering the optimization of preoperative anemia for elective surgical procedures. The benefits of erythropoietin are significantly higher, compared to the control group, while the risks remain equivocal in both groups. We recommend preoperative erythropoietin in anemic patients.
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17
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Elhenawy AM, Meyer SR, Bagshaw SM, MacArthur RG, Carroll LJ. Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis. Syst Rev 2021; 10:36. [PMID: 33485392 PMCID: PMC7824930 DOI: 10.1186/s13643-021-01579-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 01/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Preoperative anemia is a common comorbidity that often necessitates allogeneic blood transfusion (ABT). As there is a risk associated with blood transfusions, preoperative intravenous iron (IV) has been proposed to increase the hemoglobin to reduce perioperative transfusion; however, randomized controlled trials (RCT) investigating this efficacy for IV iron are small, limited, and inconclusive. Consequently, a meta-analysis that pools these studies may provide new and clinically useful information. METHODS/DESIGN Databases of MEDLINE, EMBASE, EBM Reviews; Cochrane-controlled trial registry; Scopus; registries of health technology assessment and clinical trials; Web of Science; ProQuest Dissertations and Theses; Clinicaltrials.gov; and Conference Proceedings Citation Index-Science (CPCI-S) were searched. Also, we screened all the retrieved reference lists. SELECTION CRITERIA Titles and abstracts were screened for relevance (i.e., relevant, irrelevant, or potentially relevant). Then, we screened full texts of those citations identified as potentially applicable. RESULTS Our search found 3195 citations and ten RCTs (1039 participants) that met our inclusion criteria. Preoperative IV iron supplementation significantly decreases ABT by 16% (risk ratio (RR): 0.84, 95% confidence interval [CI]: 0.71, 0.99, p = 0.04). In addition, preoperatively, hemoglobin levels increased after receiving IV iron (mean difference [MD] between the study groups: 7.15 g/L, 95% CI: 2.26, 12.04 g/L, p = 0.004) and at follow-up > 4 weeks postoperatively (MD: 6.46 g/L, 95% CI: 3.10, 9.81, p = 0.0002). Iron injection was not associated with increased incidence of non-serious or serious adverse effects across groups (RR: 1.13, 95% CI: 0.78, 1.65, p = 0.52) and (RR: 0.96, 95% CI: 0.44, 2.10, p = 0.92) respectively. CONCLUSIONS With moderate certainty, due to the high risk of bias in some studies in one or two domains, we found intravenous iron supplementation is associated with a significant decrease in the blood transfusions rate, and modest hemoglobin concentrations rise when injected pre-surgery compared with placebo or oral iron supplementation. However, further full-scale randomized controlled trials with robust methodology are required. In particular, the safety, quality of life, and cost-effectiveness of different intravenous iron preparations require further evaluation.
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Affiliation(s)
- Abdelsalam M Elhenawy
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada. .,Division of Cardiothoracic Surgery, Al Azhar University, Cairo, Egypt.
| | - Steven R Meyer
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Roderick G MacArthur
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Linda J Carroll
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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18
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Lasocki S, Loupec T, Parot-Schinkel E, Vielle B, Danguy des Déserts M, Roquilly A, Lahlou-Casulli M, Collange V, Desebbe O, Duchalais A, Drugeon B, Bouzat P, Garrigue D, Mounet B, Hamard F, David JS, Leger M, Rineau E. Study protocol for a multicentre, 2×2 factorial, randomised, controlled trial evaluating the interest of intravenous iron and tranexamic acid to reduce blood transfusion in hip fracture patients (the HiFIT study). BMJ Open 2021; 11:e040273. [PMID: 33455926 PMCID: PMC7813351 DOI: 10.1136/bmjopen-2020-040273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Blood transfusion and anaemia are frequent and are associated with poor outcomes in patients with hip fracture (HF). We hypothesised that preoperative intravenous iron and tranexamic acid (TXA) may reduce the transfusion rate in these patients. METHODS AND ANALYSIS The HiFIT study is a multicentre, 2×2 factorial, randomised, double-blinded, controlled trial evaluating the effect of iron isomaltoside (IIM) (20 mg/kg) vs placebo and of TXA (intravenously at inclusion and topically during surgery) versus placebo on transfusion rate during hospitalisation, in patients undergoing emergency surgery for HF and having a preoperative haemoglobin between 95 and 130 g/L. 780 patients are expected. The primary endpoint is the proportion of patients receiving an allogenic blood transfusion of packed red blood cells from the day of surgery until hospital discharge (or until D30 if patient is still hospitalised). Enrolment started on March 2017 in 11 French hospitals. The study was stopped between July 2017 and August 2018 (because of investigation of serious AEs with IIM in Spain) and slowed down since March 2020 (COVID-19 crisis). The expected date of final follow-up is May 2022. Analyses of the intent-to-treat and per-protocol populations are planned. ETHICS AND DISSEMINATION The HiFIT trial protocol has been approved by the Ethics Committee of Comité de Protection des Personnes Ouest II and the French authorities (ANSM). It will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. The HiFIT trial will be the largest study evaluating iron and TXA in patients with HF. TRIAL REGISTRATION NUMBER clinicalTrials.gov identifier: NCT02972294; EudraCT Number 2016-003087-40.
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Affiliation(s)
- Sigismond Lasocki
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Thibault Loupec
- Service d'anesthésie réanimation A, Université de Montpellier, CHU de Montpellier, Montpellier, France
| | - Elsa Parot-Schinkel
- Département de Biostatistiques et Méthodologie, Centre Hospitalier Universitaire d'Angers, Angers, Pays de la Loire, France
| | - Bruno Vielle
- Département de Biostatistiques et Méthodologie, Centre Hospitalier Universitaire d'Angers, Angers, Pays de la Loire, France
| | | | | | | | - Vincent Collange
- Département Anesthésie Réanimation, Medipole Lyon-Villeurbanne, Villeurbanne, France
| | | | - Alexis Duchalais
- Service d'anesthésie reanimation, CHD Vendée, La Roche-sur-Yon, France
| | - Bertrand Drugeon
- Emergency Department and Prehospital Care, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Universite de Poitiers UFR Medecine et Pharmacie, Poitiers, France
| | - Pierre Bouzat
- Département d'Anesthésie Réanimation, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Delphine Garrigue
- Pôle d'Anesthésie Réanimation, Pôle de l'Urgence, CHRU, Lille, Hauts-de-France, France
| | - Benjamin Mounet
- Service d'anesthésie réanimation A, Université de Montpellier, CHU de Montpellier, Montpellier, France
| | - Franck Hamard
- Service d'Anesthésie Réanimation, Clinique de l'Anjou, Angers, France
| | | | - Maxime Leger
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Emmanuel Rineau
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
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Bielza R, Llorente J, Thuissard IJ, Andreu-Vázquez C, Blanco D, Sanjurjo J, López N, Herráez MR, Molano C, Morales A, Arias E, Neira M, Lung A, Escalera J, Portillo L, Larrubia Y, García C, Zambrana F, Gómez Cerezo J. Effect of intravenous iron on functional outcomes in hip fracture: a randomised controlled trial. Age Ageing 2021; 50:127-134. [PMID: 32542370 DOI: 10.1093/ageing/afaa107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES to determine the safety and effect of intravenous iron sucrose on functional outcomes, delirium, nosocomial infections and transfusion requirements in older patients with hip fracture. DESIGN single-centre randomised, double-blind, placebo-controlled clinical trial. SETTING AND PARTICIPANTS orthogeriatric share care service at an academic tertiary care hospital. A total of 253 patients were recruited: 126 patients were assigned to intravenous iron and 127 to placebo. METHODS on days 1, 3 and 5 after admission, the iron group received 200 mg Venofer® (iron sucrose) in 100 ml saline and the placebo group 100 ml saline. The primary outcome was absolute functional gain, considered as Barthel index (BI) at discharge minus BI on admission. Secondary outcomes included incidence of postoperative delirium according to the confusion assessment method, proportion of patients recovering prior functional status at 3 months, postoperative transfusion requirements, haemoglobin at 3 months, incidence of nosocomial infections and safety. RESULTS the median participant age was 87 (interquartile range, 82.5-91.5) years. Most patients were female (72.7%), and the median previous BI was 81(59-95). No significant effect of intravenous iron was observed for the primary outcome: the median AFG score was 17.1 points (4.8-23.3) in the intravenous iron group and 16 points (6-26) in the placebo group (P = 0.369). No significant treatment effects were observed for other functional outcomes or secondary end points. CONCLUSION while we found no impact of intravenous iron sucrose on functional recovery, incidence of postoperative delirium, transfusion requirements, haemoglobin at 3 months, mortality and nosocomial infections rates in older patients with hip fracture, we did find that the intervention was safe.
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Affiliation(s)
- Rafael Bielza
- Department of Geriatric Medicine, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
| | - Jesús Llorente
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Pharmacy, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - Israel J Thuissard
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
| | - Cristina Andreu-Vázquez
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
| | - David Blanco
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Orthopedics, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - Jorge Sanjurjo
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Orthopedics, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - Néstor López
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Orthopedics, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - María Regina Herráez
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Hematology, San Sebastián de los Reyes, Madrid, Spain
| | - Cristina Molano
- Department of Geriatric Medicine, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - Adoración Morales
- Department of Geriatric Medicine, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - Estefanía Arias
- Department of Geriatric Medicine, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
| | - Marta Neira
- Department of Geriatric Medicine, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
| | - Ana Lung
- Department of Geriatric Medicine, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
| | - Javier Escalera
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Orthopedics, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - Laura Portillo
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Pharmacy, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - Yolanda Larrubia
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Pharmacy, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - Cristina García
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Pharmacy, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - Francisco Zambrana
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Oncology, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
| | - Jorge Gómez Cerezo
- Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
- Department of Internal Medicine, Hospital Universitario Infanta Sofía (San Sebastián de los Reyes), Madrid, Spain
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Abdullah HR, Thamnachit T, Hao Y, Lim WY, Teo LM, Sim YE. Real-world results of the implementation of preoperative anaemia clinic with intravenous iron therapy for treating iron-deficiency anaemia: a propensity-matched case-control study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:6. [PMID: 33553299 PMCID: PMC7859766 DOI: 10.21037/atm-20-4942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Preoperative anaemia is associated with blood transfusion and longer hospital length of stay. Preoperative iron deficiency anaemia (IDA) can be treated with oral or intravenous (IV) iron. IV iron can raise haemoglobin faster compared with oral iron. However, its ability to reduce blood transfusion and length of stay in clinical trials is inconclusive. This study aims to compare blood transfusion and hospital length of stay between anemic patients who received preoperative IV iron versus standard care, after implementation of a protocol in 2017 to screen patients for preoperative IDA, and its treatment with IV iron. Methods Retrospective before-after cohort study comparing 89 patients who received IV iron preoperatively in 2017, with historic patients who received oral iron therapy (selected by propensity score matching (PSM) from historic cohort of 7,542 patients who underwent surgery in 2016). Propensity score was calculated using ASA status, age, gender, surgical discipline, surgical risk and preoperative haemoglobin concentration. Both 1:1 and 1:2 matching were performed as sensitivity analysis. Results After PSM, there was no statistically significant difference in distribution of preoperative clinical variables. There was no significant difference in proportion of cases requiring transfusion nor a difference in average units transfused per patient. IV iron cohort stayed in hospital on average 8.0 days compared to non-IV iron cohort 14.1–15.1 days (P=0.006, P=0.013 respectively). Average time from IV iron therapy to surgery was 10.5 days. Conclusions Preoperative IV iron therapy for patients with IDA undergoing elective surgery may not reduce perioperative blood transfusion, but this could be due to the short time between therapy and surgery. Implementation of IV iron therapy may reduce hospital length of stay compared to standard care for anemic patients, although this may be enhanced by concomitant improvement in perioperative care.
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Affiliation(s)
- Hairil R Abdullah
- Department of Anaesthesiology, Singapore General Hospital, 169608, Singapore
| | - Tanakorn Thamnachit
- Department of Anaesthesiology, Singapore General Hospital, 169608, Singapore
| | - Ying Hao
- Health Services Research Centre (HSRC), Singapore Health Services, 169608, Singapore
| | - Wan Yen Lim
- Department of Anaesthesiology, Singapore General Hospital, 169608, Singapore
| | - Li Ming Teo
- Department of Anaesthesiology, Singapore General Hospital, 169608, Singapore
| | - Yilin Eileen Sim
- Department of Anaesthesiology, Singapore General Hospital, 169608, Singapore
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21
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袁 铭, 丁 子, 陵 廷, 周 宗. [Perioperative blood management for total hip/knee arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1612-1618. [PMID: 33319545 PMCID: PMC8171565 DOI: 10.7507/1002-1892.202002162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/04/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To review the perioperative blood management (PBM) of total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS Recent researches on PBM for TKA and THA were comprehensively read and summarized. Then the advantages and disadvantages of various measures together with the clinical experience of West China Hospital of Sichuan University were evaluated from three aspects, including optimizing hematopoiesis, reducing blood loss and blood transfusion, which could provide a basis for clinical selection. RESULTS There are many PBM methods in TKA and THA, among which the optimization of hematopoiesis mainly includes the application of perioperative iron and erythropoietin. Measures to reduce bleeding include the use of tourniquet, intraoperative controlled hypotension, and perioperative antifibrinolytic agents. Autologous blood transfusion includes preoperative autologous blood donation, hemodilution and cell salvage. Allogeneic blood transfusion is the ultimate treatment for anemia. The application of erythropoietin combined with iron therapy for blood mobilization before surgery together with intraoperative controlled hypotension for bleeding control and the multiple use of tranexamic acid can achieve satisfactory clinical results. CONCLUSION In the perioperative period of TKA and THA, single or multiple use of different blood management measures should be considered carefully according to the physical and economic conditions of patients individually, so as to reduce the blood loss and allogeneic blood transfusion optimally, and finally accelerate the recovery of patients.
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Affiliation(s)
- 铭成 袁
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 子川 丁
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 廷贤 陵
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 宗科 周
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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22
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Postoperative Intravenous Iron Supplementation Does Not Improve Hemoglobin Level and Transfusion Rate Following Staged Bilateral Total Knee Arthroplasty. J Arthroplasty 2020; 35:2444-2450. [PMID: 32487501 DOI: 10.1016/j.arth.2020.04.086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/09/2020] [Accepted: 04/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We determined whether postoperative intravenous (IV) iron supplementation could reduce transfusion rate in patients undergoing staged bilateral total knee arthroplasty (TKA). Furthermore, we examined whether hemoglobin (Hb) levels and iron profile differed between patients with and without postoperative IV iron supplementation. METHODS This retrospective, comparative cohort study included 126 patients who underwent primary staged bilateral TKA during a single hospitalization. The second TKA was performed at a week's interval. Group iron (n = 65) received IV iron immediately after each surgery, while patients in group no-iron (n = 61) received no iron after surgery. Transfusion rate, change in Hb levels, and iron profile including serum iron, ferritin, total iron binding capacity, and transferrin saturation were evaluated preoperatively; on postoperative days 1, 2, and 4 after the first TKA; and postoperative days 1, 2, 4, and 7, 6 weeks, and 3 months after the second TKA. RESULTS There were no significant differences in Hb levels and transfusion rate following staged bilateral TKA between patients with and without postoperative IV iron supplementation although serum iron profiles were improved in patients with IV iron supplementation. CONCLUSION Postoperative IV iron supplementation immediately after acute blood loss caused by TKA was not effective in improving the transfusion rate. Therefore, surgeons should use protocols other than postoperative IV iron supplementation for reducing the transfusion rate in patients undergoing staged bilateral TKA in a single hospitalization. LEVEL OF EVIDENCE III.
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23
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Kaufner L, von Heymann C, Henkelmann A, Pace NL, Weibel S, Kranke P, Meerpohl JJ, Gill R. Erythropoietin plus iron versus control treatment including placebo or iron for preoperative anaemic adults undergoing non-cardiac surgery. Cochrane Database Syst Rev 2020; 8:CD012451. [PMID: 32790892 PMCID: PMC8095002 DOI: 10.1002/14651858.cd012451.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Approximately 30% of adults undergoing non-cardiac surgery suffer from preoperative anaemia. Preoperative anaemia is a risk factor for mortality and adverse outcomes in different surgical specialties and is frequently the reason for blood transfusion. The most common causes are renal, chronic diseases, and iron deficiency. International guidelines recommend that the cause of anaemia guide preoperative anaemia treatment. Recombinant human erythropoietin (rHuEPO) with iron supplementation has frequently been used to increase preoperative haemoglobin concentrations in patients in order to avoid the need for perioperative allogeneic red blood cell (RBC) transfusion. OBJECTIVES To evaluate the efficacy of preoperative rHuEPO therapy (subcutaneous or parenteral) with iron (enteral or parenteral) in reducing the need for allogeneic RBC transfusions in preoperatively anaemic adults undergoing non-cardiac surgery. SEARCH METHODS We searched CENTRAL, Ovid MEDLINE(R), Ovid Embase, ISI Web of Science: SCI-EXPANDED and CPCI-S, and clinical trial registries WHO ICTRP and ClinicalTrials.gov on 29 August 2019. SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared preoperative rHuEPO + iron therapy to control treatment (placebo, no treatment, or standard of care with or without iron) for preoperatively anaemic adults undergoing non-cardiac surgery. We used the World Health Organization (WHO) definition of anaemia: haemoglobin concentration (g/dL) less than 13 g/dL for males, and 12 g/dL for non-pregnant females (decision of inclusion based on mean haemoglobin concentration). We defined two subgroups of rHuEPO dosage: 'low' for 150 to 300 international units (IU)/kg body weight, and 'high' for 500 to 600 IU/kg body weight. DATA COLLECTION AND ANALYSIS Two review authors collected data from the included studies. Our primary outcome was the need for RBC transfusion (no autologous transfusion, fresh frozen plasma or platelets), measured in transfused participants during surgery (intraoperative) and up to five days after surgery. Secondary outcomes of interest were: haemoglobin concentration (directly before surgery), number of RBC units (where one unit contains 250 to 450 mL) transfused per participant (intraoperative and up to five days after surgery), mortality (within 30 days after surgery), length of hospital stay, and adverse events (e.g. renal dysfunction, thromboembolism, hypertension, allergic reaction, headache, fever, constipation). MAIN RESULTS Most of the included trials were in orthopaedic, gastrointestinal, and gynaecological surgery and included participants with mild and moderate preoperative anaemia (haemoglobin from 10 to 12 g/dL). The duration of preoperative rHuEPO treatment varied across the trials, ranging from once a week to daily or a 5-to-10-day period, and in one trial preoperative rHuEPO was given on the morning of surgery and for five days postoperatively. We included 12 trials (participants = 1880) in the quantitative analysis of the need for RBC transfusion following preoperative treatment with rHuEPO + iron to correct preoperative anaemia in non-cardiac surgery; two studies were multiarmed trials with two different dose regimens. Preoperative rHuEPO + iron given to anaemic adults reduced the need RBC transfusion (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.38 to 0.80; participants = 1880; studies = 12; I2 = 84%; moderate-quality evidence due to inconsistency). This analysis suggests that on average, the combined administration of rHuEPO + iron will mean 231 fewer individuals will need transfusion for every 1000 individuals compared to the control group. Preoperative high-dose rHuEPO + iron given to anaemic adults increased the haemoglobin concentration (mean difference (MD) 1.87 g/dL, 95% CI 1.26 to 2.49; participants = 852; studies = 3; I2 = 89%; low-quality evidence due to inconsistency and risk of bias) but not low-dose rHuEPO + iron (MD 0.11 g/dL, 95% CI -0.46 to 0.69; participants = 334; studies = 4; I2 = 69%; low-quality evidence due to inconsistency and risk of bias). There was probably little or no difference in the number of RBC units when rHuEPO + iron was given preoperatively (MD -0.09, 95% CI -0.23 to 0.05; participants = 1420; studies = 6; I2 = 2%; moderate-quality evidence due to imprecision). There was probably little or no difference in the risk of mortality within 30 days of surgery (RR 1.19, 95% CI 0.39 to 3.63; participants = 230; studies = 2; I2 = 0%; moderate-quality evidence due to imprecision) or of adverse events including local rash, fever, constipation, or transient hypertension (RR 0.93, 95% CI 0.68 to 1.28; participants = 1722; studies = 10; I2 = 0%; moderate-quality evidence due to imprecision). The administration of rHuEPO + iron before non-cardiac surgery did not clearly reduce the length of hospital stay of preoperative anaemic adults (MD -1.07, 95% CI -4.12 to 1.98; participants = 293; studies = 3; I2 = 87%; low-quality evidence due to inconsistency and imprecision). AUTHORS' CONCLUSIONS Moderate-quality evidence suggests that preoperative rHuEPO + iron therapy for anaemic adults prior to non-cardiac surgery reduces the need for RBC transfusion and, when given at higher doses, increases the haemoglobin concentration preoperatively. The administration of rHuEPO + iron treatment did not decrease the mean number of units of RBC transfused per patient. There were no important differences in the risk of adverse events or mortality within 30 days, nor in length of hospital stay. Further, well-designed, adequately powered RCTs are required to estimate the impact of this combined treatment more precisely.
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Affiliation(s)
- Lutz Kaufner
- Department of Anaesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Berlin, Germany
| | - Christian von Heymann
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Anne Henkelmann
- Department of Anaesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Berlin, Germany
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Stephanie Weibel
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Peter Kranke
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Ravi Gill
- Department of Anaesthetics, Southampton University Hospital NHS Trust, Southampton, UK
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Chen R, Li L, Xiang Z, Li H, Hou XL. Association of iron supplementation with risk of transfusion, hospital length of stay, and mortality in geriatric patients undergoing hip fracture surgeries: a meta-analysis. Eur Geriatr Med 2020; 12:5-15. [PMID: 32691389 DOI: 10.1007/s41999-020-00366-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 07/13/2020] [Indexed: 02/08/2023]
Abstract
AIMS To assess the efficacy and safety of iron supplementation for perioperative anemia in geriatric patients with hip fracture. METHODS A systematic search was conducted for studies published using PubMed, EMBASE and Cochrane Library Databases that compared iron supplementation with placebo in patients undergoing hip fracture surgery. The outcomes were blood transfusion rate and volume, length of stay, infection and mortality (last follow-up). Sub-group and sensitivity analyses were performed in cases of substantial heterogeneity. RESULTS The meta-analysis (6 studies: 1201 patients) indicated that iron supplements were not associated with reducing blood transfusion rate (OR 0.92, 95% CI 0.60-1.41; P = 0.69), but high heterogeneity (I2 = 61%) was detected and a significant association was found in sensitivity analysis of four studies (n = 637; OR 0.68, 95% CI 0.49-0.95; P = 0.02). A significant reduction was detected in transfusion volume (two studies: n = 234; MD - 0.45 units/patient, 95% CI - 0.74 to - 0.16; P = 0.002), hospital stay (five studies: n = 998; MD - 1.42, 95% CI - 2.18 to - 0.67; P = 0.0002) and caused no increased risk of mortality (five studies: n = 937; OR 0.94, 95% CI 0.65-1.36; P = 0.76) and infection (four studies: n = 701; OR 0.58, 95% CI 0.38-0.90; P = 0.01). Sub-group analyses of four studies showed that the preoperative intravenous use of iron at 200-300 mg (two studies) may be the beneficial option for hip fractures patients. CONCLUSIONS Iron supplementation, especially preoperative intravenous use of 200-300 mg iron, is safe and associated with reducing transfusion requirement and hospital stay. Unfortunately, data were too limited to draw a definite conclusion. Further evaluation is required before recommending iron supplementation for older patients with hip fracture surgeries.
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Affiliation(s)
- Ran Chen
- Department of Orthopedics, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610000, China.,Trauma Center, State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Lang Li
- Department of Orthopedics, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610000, China.,Department of Orthopedics, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu, 610041, Sichuan, China
| | - Zhou Xiang
- Department of Orthopedics, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610000, China
| | - Hong Li
- School of Stomatology, Zhejiang Chinese Medical University, Hangzhou, 310006, China
| | - Xiao-Ling Hou
- Department of Orthopedics, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610000, China.
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Smith A, Moon T, Pak T, Park B, Urman RD. Preoperative Anemia Treatment With Intravenous Iron in Patients Undergoing Major Orthopedic Surgery: A Systematic Review. Geriatr Orthop Surg Rehabil 2020; 11:2151459320935094. [PMID: 32637197 PMCID: PMC7323265 DOI: 10.1177/2151459320935094] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction Based upon the Third National Health and Nutrition Examination Survey data, iron deficiency anemia is the cause of at least 20% of cases of anemia in adults over the age of 65. This is especially relevant in patients undergoing major orthopedic surgery as substantial perioperative blood loss is possible, leading to a high rate of allogeneic blood transfusion in total hip replacements, total knee replacements, and hip fracture repairs. Significance The results of this systematic review may be of interest to clinicians and hospital administrators evaluating the clinical efficacy and cost effectiveness of intravenous (IV) iron administration prior to major orthopedic surgery. Materials and Methods The original studies considered for this review included patients who were over 18 years of age, undergoing major orthopedic surgery, and who received an IV iron treatment in the preoperative setting. A total of 1083 articles were identified and reviewed. After removing duplicates, 1031 publications were screened, and 105 full-text studies were assessed for eligibility. A total of 98 were excluded and 7 articles remained which met the criteria for this review. The primary outcome examined in the included studies was the allogeneic blood transfusion rate. The secondary areas of interest were changes in serum hemoglobin, morbidity and mortality, length of stay, and cost effectiveness. Results This systematic review found little evidence that IV iron therapy is effective at reducing transfusion in patients undergoing major orthopedic surgery. Conclusions We do not recommend preoperative IV iron therapy for all patients scheduled for major orthopedic surgery.
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Affiliation(s)
- Aaron Smith
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tiffany Moon
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Taylor Pak
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian Park
- Department of Anesthesiology, Perioperative Pain and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative Pain and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Harvard Medical School, Boston, MA, USA
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Rubinger DA, Cahill C, Ngo A, Gloff M, Refaai MA. Preoperative Anemia Management: What’s New in 2020? CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00385-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Koo CH, Shin HJ, Cho H, Ryu JH. The Effect of Perioperative Intravenous Iron on Hemoglobin in Surgical Patients: A Meta-Analysis. J Surg Res 2020; 246:42-51. [DOI: 10.1016/j.jss.2019.08.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/26/2019] [Accepted: 08/29/2019] [Indexed: 12/26/2022]
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Treating Preoperative Anemia to Improve Patient Outcomes After Orthopaedic Surgery. J Am Acad Orthop Surg 2019; 27:e1077-e1085. [PMID: 31149970 DOI: 10.5435/jaaos-d-18-00810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
For patients undergoing orthopaedic surgery, preoperative risk modification and control of comorbidities can maximize safety and improve outcomes. Anemia is common among orthopaedic patients, and its prevalence increases with patient age. Although surgeons are well versed in intraoperative blood conservation, preoperative anemia treatment is often deferred to primary care physicians, who may not understand the importance of a thorough assessment and treatment. Orthopaedic surgeons should understand the causes and treatments of anemia to advocate that patients receive appropriate preoperative care. Mean corpuscular volume and reticulocyte count can help determine the cause of anemia and assess the bone marrow's ability to produce red blood cells. These values can be used to aid in diagnosis and treatment plans. Iron deficiency anemia, the most common type, is a microcytic anemia easily treated with iron supplementation. In cases of trauma, anemia can be related to acute blood loss and underlying conditions. Fracture patterns and preexisting comorbidities should be assessed. The role of intravenous iron supplementation in this setting has not been clearly shown. Patients needing urgent procedures that might involve substantial blood loss should receive transfusions if they have hemoglobin levels <8 g/dL or symptomatic anemia.
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Abstract
Approximately 14-40% of patients in industrialized countries present with preoperative anemia. Depending on the severity, anemia is associates with increased perioperative morbidity and mortality. One of the most important causes of preoperative anemia is iron deficiency which is usually easy to treat. Implemented in the multimodal concept of patient blood management, the diagnostics and treatment of preoperative anemia are important aspects for improvement of perioperative outcome. Adequate and early diagnostics of the cause of anemia before treatment is important because treatment options, e.g. with iron, erythropoetin, folic acid and vitamin B12, may be expensive, may have severe side effects, and in the case of a wrong indication, will not improve anemia. In addition, an adequate regeneration of the erythrocyte volume requires time. This review article presents important aspects of the epidemiology and prognostic implications of preoperative anemia, the physiology and pathophysiology of anemia as well as diagnostic features and the evidence base for preoperative treatment options.
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Affiliation(s)
- C Rosenthal
- Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Deutschland.
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Shin HW, Park JJ, Kim HJ, You HS, Choi SU, Lee MJ. Efficacy of perioperative intravenous iron therapy for transfusion in orthopedic surgery: A systematic review and meta-analysis. PLoS One 2019; 14:e0215427. [PMID: 31059515 PMCID: PMC6502310 DOI: 10.1371/journal.pone.0215427] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/02/2019] [Indexed: 01/07/2023] Open
Abstract
Perioperative anemia frequently occurs in patients undergoing orthopedic surgery. We aimed to evaluate the efficacy of perioperative intravenous iron therapy (IVIT) on transfusion and recovery profiles during orthopedic surgery. We searched PubMed, Embase, Cochrane, and Google Scholar for eligible clinical trials (randomized controlled trials, RCTs; case-control studies, CCSs) in comparing IVIT and no iron therapy, up to September 2018. Primary outcomes were the effects of IVIT on the proportion of patients transfused and units of red blood cells (RBCs) transfused perioperatively. Secondary outcomes were the effects of IVIT on recovery profiles, such as length of hospital stay (LOS), post-operative infection, and mortality. Subgroup analysis was performed based on iron dose (low: ≤ 300 mg, high: > 400 mg), IVIT period (pre-operative, post-operative, perioperative), and study design. We identified 12 clinical trials (4 RCTs with 616 patients and 8 CCSs with 1,253 patients). IVIT significantly reduced the proportion of patients transfused by 31% (RR, 0.69; P = 0.0002), and units of RBCs transfused by 0.34 units/person (MD, -0.34; P = 0.0007). For subgroup analysis by iron dose, low- or high-dose IVIT significantly reduced the proportion of patients transfused (RR, 0.73, P = 0.005; RR, 0.68, P = 0.008), and RBC units transfused (MD, -0.47, P < 0.0001; MD, -0.28, P = 0.04). For subgroup analysis by period, IVIT administered post-operatively significantly reduced the proportion of patients transfused (post-operative: RR, 0.60, P = 0.002; pre-operative: RR, 0.74, P = 0.06) and RBC units transfused (post-operative: MD, -0.44, P <0.00001; pre-operative: MD, -0.29, P = 0.06). For subgroup analysis by study design, IVIT decreased the proportion of patients transfused and RBC units transfused in the group of CCSs, but IVIT in the group of RCTs did not. IVIT significantly shortened LOS by 1.6 days (P = 0.0006) and reduced post-operative infections by 33% (P = 0.01). IVIT did not change mortality. Perioperative IVIT during orthopedic surgery, especially post-operatively, appears to reduce the proportion of patients transfused and units of RBCs transfused, with shorter LOS and decreased infection rate, but no change in mortality rate. These were only found in CCSs and not in RCTs due to the relatively small number of RCTs with low to high risk of bias.
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Affiliation(s)
- Hye Won Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
- * E-mail:
| | - Jeong Jun Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hyun Jung Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hae Sun You
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Mee Ju Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
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Abstract
Intravenous ferric carboxymaltose (Ferinject®; Injectafer®) is a colloidal solution of nanoparticles which consist of a polynuclear iron (III)-(oxyhydr)oxide core stabilized by carboxymaltose and may be given as a single high-dose, 15-min infusion. This article reviews the clinical use of ferric carboxymaltose in various patient populations with iron deficiency (ID) [± anaemia] and briefly summarizes its pharmacological properties. Based on extensive experience in the clinical trial and real-world settings, ferric carboxymaltose is an effective and generally well tolerated treatment for rapidly replenishing iron stores and correcting anaemia in patients with ID (± anaemia) of various aetiologies, including patients with chronic heart failure (CHF), chronic kidney disease, inflammatory bowel disease or perioperative anaemia, and women with ID during pregnancy, postpartum or associated with heavy uterine bleeding. As it may be given as a single high-dose infusion, ferric carboxymaltose has the potential to provide cost savings from a healthpayer perspective. Thus, ferric carboxymaltose remains an important option for the treatment of ID in adults and, where approved, children aged ≥ 14 years, when oral iron preparations are ineffective or cannot be used.
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Affiliation(s)
- Lesley J Scott
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Efficacy and safety of erythropoietin and iron therapy to reduce red blood cell transfusion in surgical patients: a systematic review and meta-analysis. Can J Anaesth 2019; 66:716-731. [DOI: 10.1007/s12630-019-01351-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/19/2018] [Accepted: 12/29/2018] [Indexed: 12/21/2022] Open
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 676] [Impact Index Per Article: 135.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Litton E, Lim J. Iron Metabolism: An Emerging Therapeutic Target in Critical Illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:81. [PMID: 30850005 PMCID: PMC6408790 DOI: 10.1186/s13054-019-2373-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia. .,School of Medicine, University of Western Australia, Perth, Australia.
| | - Jolene Lim
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia
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Shah A, Palmer AJR, Fisher SA, Rahman SM, Brunskill S, Doree C, Reid J, Sugavanam A, Stanworth SJ. What is the effect of perioperative intravenous iron therapy in patients undergoing non-elective surgery? A systematic review with meta-analysis and trial sequential analysis. Perioper Med (Lond) 2018; 7:30. [PMID: 30559962 PMCID: PMC6290500 DOI: 10.1186/s13741-018-0109-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/13/2018] [Indexed: 01/01/2023] Open
Abstract
Background Guidelines to treat anaemia with intravenous (IV) iron have focused on elective surgical patients with little attention paid to those undergoing non-elective/emergency surgery. Whilst these patients may experience poor outcomes because of their presenting illness, observational data suggests that untreated anaemia may also be a contributing factor to poor outcomes. We conducted a systematic review to investigate the safety and efficacy of IV iron in patients undergoing non-elective surgery. Methods We followed a pre-defined review protocol and included randomised controlled trials (RCTs) in patients undergoing non-elective surgery who received IV iron. Primary outcomes were all-cause infection and mean difference in haemoglobin (Hb) at follow-up. Secondary outcomes included transfusion requirements, hospital length of stay (LOS), health-related quality of life (HRQoL), mortality and adverse events. Results Three RCTs (605 participants) were included in this systematic review of which two, in both hip fracture (HF) patients, provided data for meta-analysis. Both of these RCTs were at low risk of bias. We found no evidence of a difference in the risk of infection (RR 0.99, 95% CI 0.55 to 1.80, I 2 = 9%) or in the Hb concentration at 'short-term' (≤ 7 days) follow-up (mean difference - 0.32 g/L, 95% CI - 3.28 to 2.64, I 2 = 37%). IV iron did not reduce the risk of requiring a blood transfusion (RR 0.90, 95% CI 0.73 to 1.11, p = 0.46, I 2 = 0%), and we observed no difference in mortality, LOS or adverse events. One RCT reported on HRQoL and found no difference between treatment arms. Conclusion We found no conclusive evidence of an effect of IV iron on clinically important outcomes in patients undergoing non-elective surgery. Further adequately powered trials to evaluate its benefit in emergency surgical specialties with a high burden of anaemia are warranted. Trial registration This systematic review was registered on PROSPERO (CRD42018096288).
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Affiliation(s)
- Akshay Shah
- 1Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Level 4 Academic Block, Oxford, OX3 9DU UK
| | - Antony J R Palmer
- 2Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sheila A Fisher
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Shah M Rahman
- 3Frimley Health NHS Foundation Trust, Camberley, Surrey GU16 7UJ UK
| | - Susan Brunskill
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Carolyn Doree
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Jack Reid
- 5Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Anita Sugavanam
- 5Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Simon J Stanworth
- 1Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Level 4 Academic Block, Oxford, OX3 9DU UK.,3Frimley Health NHS Foundation Trust, Camberley, Surrey GU16 7UJ UK.,4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
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Gómez-Ramírez S, Maldonado-Ruiz MÁ, Campos-Garrigues A, Herrera A, Muñoz M. Short-term perioperative iron in major orthopedic surgery: state of the art. Vox Sang 2018; 114:3-16. [DOI: 10.1111/vox.12718] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/13/2018] [Accepted: 09/18/2018] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | - Antonio Herrera
- Ortopaedic and Trauma Surgery; School of Medicine; Zaragoza Spain
| | - Manuel Muñoz
- Perioperative Transfusion Medicine; School of Medicine; Málaga Spain
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Muñoz M, Acheson AG, Bisbe E, Butcher A, Gómez‐Ramírez S, Khalafallah AA, Kehlet H, Kietaibl S, Liumbruno GM, Meybohm P, Rao Baikady R, Shander A, So‐Osman C, Spahn DR, Klein AA. An international consensus statement on the management of postoperative anaemia after major surgical procedures. Anaesthesia 2018; 73:1418-1431. [PMID: 30062700 PMCID: PMC6686161 DOI: 10.1111/anae.14358] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2018] [Indexed: 01/28/2023]
Abstract
Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.
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Affiliation(s)
- M. Muñoz
- Department of Surgical Specialties, Biochemistry and ImmunologySchool of MedicineUniversity of MálagaMálagaSpain
| | - A. G. Acheson
- Department of Colorectal SurgeryNottingham Digestive Diseases CentreNational Institute for Health Research Biomedical Research UnitNottingham University HospitalsNottinghamUK
| | - E. Bisbe
- Department of AnaesthesiaUniversity Hospital Mar‐EsperanzaBarcelonaSpain
| | - A. Butcher
- Division of SurgeryUniversity College LondonLondonUK
| | - S. Gómez‐Ramírez
- Department of Internal MedicineUniversity Hospital Virgen de la VictoriaMálagaSpain
| | - A. A. Khalafallah
- Department of Haematology and MedicineLaunceston General HospitalLauncestonAustralia
- Menzies Institute for Medical ResearchUniversity of TasmaniaAustralia
| | - H. Kehlet
- Section of Surgical PathophysiologyRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - S. Kietaibl
- Department of Anaesthesia and Intensive CareEvangelical HospitalViennaAustria
| | - G. M. Liumbruno
- Italian National Blood CentreNational Institute of HealthRomeItaly
| | - P. Meybohm
- Department of AnaesthesiologyIntensive Care Medicine and Pain TherapyUniversity Hospital FrankfurtFrankfurtGermany
| | - R. Rao Baikady
- Department of AnaesthesiaRoyal Marsden NHS Foundation TrustLondonUK
| | - A. Shander
- AnaesthesiologyCritical Care and Hyperbaric MedicineEnglewood Hospital and Medical CentreEnglewoodNJUSA
- TeamHealth Research InstituteEnglewoodNJUSA
| | - C. So‐Osman
- Department of Transfusion MedicineSanquin Blood BankAmsterdamThe Netherlands
- Department of Internal MedicineGroene Hart HospitalGoudaThe Netherlands
| | - D. R. Spahn
- Institute of AnaesthesiologyUniversity Hospital of ZurichZurichSwitzerland
- Intensive Care Medicine and Operating Room ManagementUniversity Hospital of ZurichZurichSwitzerland
| | - A. A. Klein
- Department of Anaesthesia and Intensive CareRoyal Papworth HospitalCambridgeUK
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Li Y, Yin P, Lv H, Meng Y, Zhang L, Tang P. A meta-analysis and systematic review evaluating the use of erythropoietin in total hip and knee arthroplasty. Ther Clin Risk Manag 2018; 14:1191-1204. [PMID: 30022832 PMCID: PMC6044356 DOI: 10.2147/tcrm.s159134] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Purpose The debate is still ongoing on the effectiveness and safety of erythropoietin (EPO) treatment in orthopedic surgeries. Specifically, previous studies have not compared the dynamic change of hemoglobin (Hb) levels between different transfusion methods. Besides, complications or side effects of this alternative have not been quantitatively analyzed. We conducted a meta-analysis and systemic review to evaluate the efficacy of EPO on Hb levels observed during the whole perioperative period as well as the volume of allogeneic blood transfusion (ABT), the risk of venous thromboembolism, and application frequency of ABT in hip and knee surgery. Materials and methods PubMed, Embase, Web of Science, and the Cochrane library were systematically searched from inception to November 2017. The data from randomized controlled trials were extracted and the risk of bias assessed using Cochrane’s Collaboration’s tool. Results Twenty-five randomized controlled trials involving 4,159 patients were included in this meta-analysis. EPO could reduce exposure to allogeneic blood transfused (odds ratio [OR] =0.42, P=0.001) and reduce the average volume of allogeneic blood transfused (OR = −0.28, P=0.002). When EPO and preoperative autologous blood donation (PABD) were compared, the use of EPO was associated with lower exposure to ABT (OR =0.48, P=0.03), but no significant decrease in the average volume of allogeneic blood transfused (OR = −0.23, P=0.32). The use of EPO was associated with a higher level of Hb with or without use of PABD at all the 4 time points (preoperation, 24–48 hours postoperation, 3–5 days postoperation, discharge of last observation) (P<0.0001), which means EPO could increase the level of Hb significantly during the perioperative period. The results also indicated EPO does not increase the risk of a venous thromboembolism event. Conclusion Preoperative administration of EPO was shown to generally increase Hb levels during the whole perioperative period; however, the extent of the positive effects varies with time points. Additionally, EPO minimizes the need for transfusion significantly in patients undergoing hip or knee surgery without increasing the chance of developing thrombotic complications. Therefore, EPO offers an alternative blood management strategy in total hip arthroplasty and total knee arthroplasty.
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Affiliation(s)
- Yi Li
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, People's Republic of China, ;
| | - Pengbin Yin
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, People's Republic of China, ;
| | - Houchen Lv
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, People's Republic of China, ;
| | - Yutong Meng
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, People's Republic of China, ;
| | - Licheng Zhang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, People's Republic of China, ;
| | - Peifu Tang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, People's Republic of China, ;
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Siletz A, Childers CP, Faltermeier C, Singer ES, Hu QL, Ko CY, Kates SL, Maggard-Gibbons M, Wick E. Surgical Technical Evidence Review of Hip Fracture Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. Geriatr Orthop Surg Rehabil 2018; 9:2151459318769215. [PMID: 29844947 PMCID: PMC5964861 DOI: 10.1177/2151459318769215] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/16/2018] [Accepted: 03/07/2018] [Indexed: 01/04/2023] Open
Abstract
Background: Enhanced recovery pathways (ERPs) have been shown to improve patient outcomes in a variety of contexts. This review summarizes the evidence and defines a protocol for perioperative care of patients with hip fracture and was conducted for the Agency for Healthcare Research and Quality safety program for improving surgical care and recovery. Study Design: Perioperative care was divided into components or “bins.” For each bin, a semisystematic review of the literature was conducted using MEDLINE with priority given to systematic reviews, meta-analyses, and randomized controlled trials. Observational studies were included when higher levels of evidence were not available. Existing guidelines for perioperative care were also incorporated. For convenience, the components of care that are under the auspices of anesthesia providers will be reported separately. Recommendations for an evidence-based protocol were synthesized based on review of this evidence. Results: Eleven bins were identified. Preoperative risk factor bins included nutrition, diabetes mellitus, tobacco use, and anemia. Perioperative management bins included thromboprophylaxis, timing of surgery, fluid management, drain placement, early mobilization, early alimentation, and discharge criteria/planning. Conclusions: This review provides the evidence basis for an ERP for perioperative care of patients with hip fracture.
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Affiliation(s)
- Anaar Siletz
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Christopher P Childers
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Claire Faltermeier
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Emily S Singer
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Q Lina Hu
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,American College of Surgeons, Chicago, IL, USA
| | - Clifford Y Ko
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,American College of Surgeons, Chicago, IL, USA
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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Childers CP, Siletz AE, Singer ES, Faltermeier C, Hu QL, Ko CY, Golladay GJ, Kates SL, Wick EC, Maggard-Gibbons M. Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. Geriatr Orthop Surg Rehabil 2018; 9:2151458518754451. [PMID: 29468091 PMCID: PMC5813847 DOI: 10.1177/2151458518754451] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 11/30/2017] [Accepted: 12/28/2017] [Indexed: 12/12/2022] Open
Abstract
Background: Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study Design: This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Results: Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. Conclusion: This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.
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Affiliation(s)
| | - Anaar E Siletz
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Emily S Singer
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Q Lina Hu
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,American College of Surgeons, Chicago, IL, USA
| | - Clifford Y Ko
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,American College of Surgeons, Chicago, IL, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA
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Lim J, Miles L, Litton E. Intravenous Iron Therapy in Patients Undergoing Cardiovascular Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2017; 32:1439-1451. [PMID: 29246691 DOI: 10.1053/j.jvca.2017.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Jolene Lim
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Lachlan Miles
- Department of Anaesthesia, Austin Health, Melbourne, Australia; Anaesthesia, Perioperative and Pain Medicine Unit, School of Medicine, University of Melbourne, Parkville, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia; Australia.
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Feasibility of Hip Fracture Surgery Using a No Transfusion Protocol in Elderly Patients: A Propensity Score-Matched Cohort Study. J Orthop Trauma 2017; 31:414-419. [PMID: 28459771 DOI: 10.1097/bot.0000000000000870] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether hip fracture surgery (HFS) without transfusion affects postoperative mortality and complications in elderly patients. DESIGN Retrospective comparative study. PATIENTS Three hundred fourteen patients ≥65 years of age who underwent HFS between May 2003 and December 2014. Patients were divided into 2 groups: those who consented to blood transfusion if needed and those who did not. One-to-one propensity score matching generated 50 matched pairs of patients. INTERVENTION Patients underwent HFS with or without blood transfusion. In the no transfusion group, simultaneous administration of erythropoietin and iron was used as an alternative. MAIN OUTCOME MEASUREMENTS The primary outcome was postoperative mortality (90-day, 1-year, overall). The secondary outcomes were hemoglobin change and the incidence of postoperative complications. RESULTS HFS using a no transfusion protocol was not associated with increased mortality at any time point. Mean hemoglobin levels were significantly different between the 2 groups on postoperative day 1 (11.0 ± 1.3 vs. 10.5 ± 1.6, P = 0.002) but levels completely recovered within 2 weeks in both groups. There was also no difference in postoperative complication rates between the 2 groups, and overall hospital stays and charges were similar. CONCLUSIONS An HFS protocol without blood transfusion was not associated with increased mortality or complications in elderly patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Improving outcome of trauma patients by implementing patient blood management. Curr Opin Anaesthesiol 2017; 30:243-249. [DOI: 10.1097/aco.0000000000000427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Avenell A, Smith TO, Curtain JP, Mak JCS, Myint PK. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev 2016; 11:CD001880. [PMID: 27898998 PMCID: PMC6464805 DOI: 10.1002/14651858.cd001880.pub6] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Older people with hip fractures are often malnourished at the time of fracture, and subsequently have poor food intake. This is an update of a Cochrane review first published in 2000, and previously updated in 2010. OBJECTIVES To review the effects (benefits and harms) of nutritional interventions in older people recovering from hip fracture. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Embase, CAB Abstracts, CINAHL, trial registers and reference lists. The search was last run in November 2015. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture where the interventions were started within the first month after hip fracture. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data and assessed risk of bias. Where possible, we pooled data for primary outcomes which were: all cause mortality; morbidity; postoperative complications (e.g. wound infections, pressure sores, deep venous thromboses, respiratory and urinary infections, cardiovascular events); and 'unfavourable outcome' defined as the number of trial participants who died plus the number of survivors with complications. We also pooled data for adverse events such as diarrhoea. MAIN RESULTS We included 41 trials involving 3881 participants. Outcome data were limited and risk of bias assessment showed that trials were often methodologically flawed, with less than half of trials at low risk of bias for allocation concealment, incomplete outcome data, or selective reporting of outcomes. The available evidence was judged of either low or very low quality indicating that we were uncertain or very uncertain about the estimates.Eighteen trials evaluated oral multinutrient feeds that provided non-protein energy, protein, vitamins and minerals. There was low-quality evidence that oral feeds had little effect on mortality (24/486 versus 31/481; risk ratio (RR) 0.81 favouring supplementation, 95% confidence interval (CI) 0.49 to 1.32; 15 trials). Thirteen trials evaluated the effect of oral multinutrient feeds on complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was low-quality evidence that the number of participants with complications may be reduced with oral multinutrient feeds (123/370 versus 157/367; RR 0.71, 95% CI 0.59 to 0.86; 11 trials). Based on very low-quality evidence from six studies (334 participants), oral supplements may result in lower numbers with 'unfavourable outcome' (death or complications): RR 0.67, 95% CI 0.51 to 0.89. There was very low-quality evidence for six studies (442 participants) that oral supplementation did not result in an increased incidence of vomiting and diarrhoea (RR 0.99, 95% CI 0.47 to 2.05).Only very low-quality evidence was available from the four trials examining nasogastric multinutrient feeding. Pooled data from three heterogeneous trials showed no evidence of an effect of supplementation on mortality (14/142 versus 14/138; RR 0.99, 95% CI 0.50 to 1.97). One trial (18 participants) found no difference in complications. None reported on unfavourable outcome. Nasogastric feeding was poorly tolerated. One study reported no cases of aspiration pneumonia.There is very low-quality evidence from one trial (57 participants, mainly men) of no evidence for an effect of tube feeding followed by oral supplementation on mortality or complications. Tube feeding, however, was poorly tolerated.There is very low-quality evidence from one trial (80 participants) that a combination of intravenous feeding and oral supplements may not affect mortality but could reduce complications. However, this expensive intervention is usually reserved for people with non-functioning gastrointestinal tracts, which is unlikely in this trial.Four trials tested increasing protein intake in an oral feed. These provided low-quality evidence for no clear effect of increased protein intake on mortality (30/181 versus 21/180; RR 1.42, 95% CI 0.85 to 2.37; 4 trials) or number of participants with complications but very low-quality and contradictory evidence of a reduction in unfavourable outcomes (66/113 versus 82/110; RR 0.78, 95% CI 0.65 to 0.95; 2 trials). There was no evidence of an effect on adverse events such as diarrhoea.Trials testing intravenous vitamin B1 and other water soluble vitamins, oral 1-alpha-hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha-ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low- or very low-quality evidence of no clear effect on mortality or complications, where reported.Based on low-quality evidence, one trial evaluating the use of dietetic assistants to help with feeding indicated that this intervention may reduce mortality (19/145 versus 36/157; RR 0.57, 95% CI 0.34 to 0.95) but not the number of participants with complications (79/130 versus 84/125). AUTHORS' CONCLUSIONS There is low-quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low-quality evidence that oral supplements may reduce 'unfavourable outcome' (death or complications) and that they do not result in an increased incidence of vomiting and diarrhoea. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding or nasogastric feeding in very malnourished people require further evaluation.
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Affiliation(s)
- Alison Avenell
- University of AberdeenHealth Services Research Unit, School of Medicine, Medical Sciences and NutritionHealth Sciences BuildingForesterhillAberdeenUKAB25 2ZD
| | - Toby O Smith
- University of East AngliaFaculty of Medicine and Health SciencesQueen's BuildingNorwichNorfolkUKNR4 7TJ
| | - James P Curtain
- Addenbrookes NHS Trust, Cambridge University HospitalDepartment of General MedicineHills RoadCambridgeCambridgeshireUKCB2 0QQ
| | - Jenson CS Mak
- Gosford HospitalDepartment of Aged Care and RehabilitationGosfordNew South Wales (NSW)Australia2200
| | - Phyo K Myint
- University of AberdeenDivision of Applied Health Sciences, School of Medicine, Medical Sciences and NutritionRoom 4:013 Polwarth BuildingForesterhillAberdeenUKAB25 2ZD
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Muñoz M, Gómez‐Ramírez S, Auerbach M. Stimulating erythropoiesis before hip fracture repair for reducing blood transfusion: should we change the hemoglobin cutoff level for defining anemia in females? Transfusion 2016; 56:2160-3. [DOI: 10.1111/trf.13750] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 06/17/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Manuel Muñoz
- Perioperative Transfusion Medicine, School of MedicineUniversity of MálagaMálaga Spain
| | | | - Michael Auerbach
- Auerbach Hematology and OncologyBaltimore MD
- Georgetown University School of MedicineWashington DC
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