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Mendez E, Puig G, Barquero M, Leon A, Bellafont J, Colomina MJ. Enhanced recovery after surgery: a narrative review on patient blood management recommendations. Minerva Anestesiol 2023; 89:906-913. [PMID: 37307032 DOI: 10.23736/s0375-9393.23.17389-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
This review aims to analyze and document the presence of patient blood management (PBM) recommendations in enhanced recovery after surgery (ERAS) guidelines. The aim of ERAS programs is to improve outcomes and optimize patient recovery by reducing the stress response to surgery. PBM programs pursue the objective of improving outcomes by boosting and conserving the patient's own blood. From the early development of ERAS, there was little attention paid to the three pillars of perioperative blood management. Preoperative anemia is an important risk factor in perioperative outcomes and should be diagnosed and treated. Bleeding and unnecessary transfusions should be avoided. We analyzed clinical guidelines for scheduled surgery in adults published by the ERAS Society between 2018 and 2022. The guidelines selected were searched for recommendations related to the three pillars of PBM. We selected 15 ERAS guidelines in programmed surgery in adults. Until 2018, none of the ERAS guidelines analyzed included any recommendations related to pillars I and III of PBM. In 2019, recommendations related to the three pillars of PBM were introduced in the ERAS clinical guidelines for colorectal surgery, gynecology/oncology surgery, and lung resection surgery. However, many ERAS guidelines for surgeries with a high risk of bleeding, such as cardiac surgery, contain no clear recommendations on the management of preoperative anemia. This review shows that the ERAS guidelines published to date make very few recommendations related to PBM. The authors emphasize the need to include the most efficient PBM recommendations in ERAS clinical guidelines, given improved outcomes with a good perioperative management of blood transfusion.
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Affiliation(s)
- Esther Mendez
- Department of Anesthesiology and Intensive Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain -
| | - Guillermo Puig
- Department of Anesthesiology and Intensive Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
| | - Marta Barquero
- Department of Anesthesiology and Intensive Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
| | - Ariadna Leon
- Department of Anesthesiology and Intensive Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
| | - Javier Bellafont
- Department of Anesthesiology and Intensive Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
| | - Maria J Colomina
- Department of Anesthesiology and Intensive Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
- Department of Anesthesiology and Intensive Care, University of Barcelona, Barcelona, Spain
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Yan T, Lei S, Zhou B, Huang Y, Li X, Zhang J, Huang Q, Zhang L. Association between preoperative anemia and postoperative short-term outcomes in patients undergoing colorectal cancer surgery - a propensity score matched retrospective cohort study. BMC Anesthesiol 2023; 23:307. [PMID: 37697231 PMCID: PMC10494383 DOI: 10.1186/s12871-023-02270-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Based on previous studies which failed to analyze important confounding variables, the association between preoperative anemia and outcomes of patients who underwent colorectal cancer (CRC) surgery has not been clearly demonstrated. This study aimed to investigate the relationship between preoperative anemia and short-term outcomes in patients with CRC. METHODS Data from a retrospective collective database of patients who underwent CRC surgery at our hospital between September 1, 2019 and September 30, 2021 were retrieved and analyzed, and the short-term postoperative outcomes of anemic (hemoglobin < 120 g dL- 1 for female, hemoglobin < 130 g dL- 1 for male) and non-anemic patients were analyzed, using a 1:1 propensity score matching (PSM) analysis. RESULTS After excluding some cases, the remaining 1894 patients had complete data available for analysis. The incidence of preoperative anemia was 39.8% (754/1894). Before PSM, preoperative anemia patients had a higher risk of major morbidity than non-anemia patients (27.2% vs. 23.1%, odds ratio [OR] 1.245, 95% confidence interval [CI] 1.008-1.538, P = 0.042). After PSM was performed in the cohort, 609 patients remained in the anemic and non-anemic groups. The incidence of major morbidity (25.8% vs. 24.0%, OR 1.102, 95% CI 0.849-1.429, P = 0.446) between anemic and non-anemic patients was comparable. No significant difference was found between the anemic and non-anemic groups in postoperative length of stay (8.0 [6.0-12.0] vs. 8.0 [7.0-11.0], P = 0.311). The sensitivity analysis results were in accordance with the primary outcome. Furthermore, we did not ascertain any discernible correlation between the extent of anemia and significant major morbidity. CONCLUSIONS Compared with preoperative non-anemia, anemia status does not seem to be associated with major morbidity in patients with CRC surgery. It is noteworthy that, anemia is insufficient as a solitary risk factor and may be a better marker of poor health resulting from multiple factors. TRIAL REGISTRATION Registration Authority: Chinese Clinical Trial Registry; Registration number and date: ChiCTR2100049696, 08/08/2021; Principal investigator: Ting Yan; Link to trial registry: http://www.chictr.org.cn/showproj.aspx?proj=131698 ; .
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Affiliation(s)
- Ting Yan
- Department of Anesthesiology, Fujian Medical University Union Hospital, No. 29 Xin-Quan Road, Fuzhou, 350001, China
| | - Shaohui Lei
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bingbing Zhou
- Department of Anesthesiology, Fujian Medical University Union Hospital, No. 29 Xin-Quan Road, Fuzhou, 350001, China
| | - Yaqi Huang
- Department of Anesthesiology, Fujian Medical University Union Hospital, No. 29 Xin-Quan Road, Fuzhou, 350001, China
| | - Xiaoting Li
- Department of Anesthesiology, Fujian Medical University Union Hospital, No. 29 Xin-Quan Road, Fuzhou, 350001, China
| | - Jiaqi Zhang
- Department of Information Systems and Management Engineering, Southern Science and Technology University, Shenzhen, China
| | - Qijian Huang
- Department of Anesthesiology, Fujian Medical University Union Hospital, No. 29 Xin-Quan Road, Fuzhou, 350001, China
| | - Liangcheng Zhang
- Department of Anesthesiology, Fujian Medical University Union Hospital, No. 29 Xin-Quan Road, Fuzhou, 350001, China.
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Garganeeva AA, Tukish OV, Kuzheleva EA, Fediunina VA, Kozlov BN. [Iron deficiency in cardiac surgery patients and the possibility of its correction at the preoperative stage]. KARDIOLOGIIA 2023; 63:68-76. [PMID: 37522830 DOI: 10.18087/cardio.2023.7.n2471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 08/01/2023]
Abstract
Among cardio-surgical patients, the prevalence of iron deficiency conditions reaches 70 %, and anemia is detected in less than 50% cases. Meanwhile, both anemia and latent iron deficiency are risk factors for adverse outcomes in cardio-surgical patients. These conditions are associated with a high frequency and greater volume of blood transfusions as well as with a longer stay in the hospital. Timely diagnosis and correction of iron deficiency, regardless of the presence of anemia, are mandatory at the stage of preoperative preparation. The use of oral iron medicines is limited by their low efficacy in this category of patients and a high risk of adverse events. Intravenous iron medicines have a high potential for correcting iron deficiency, and their efficacy and safety have been previously demonstrated. Administration of ferric carboxymaltose has proved beneficial in studies on iron deficiency correction in cardiological and cardio-surgical patients. In these patients, ferric carboxymaltose improved the dynamics of ferritin and hemoglobin, reduced the risk of blood transfusion, and decreased the duration of stay in the hospital. Preoperative intravenous administration of ferric carboxymaltose to cardio-surgical patients can improve clinical outcomes and the cost effectiveness of cardiac surgery.
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Affiliation(s)
- A A Garganeeva
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences
| | - O V Tukish
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences
| | - E A Kuzheleva
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences
| | | | - B N Kozlov
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences
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4
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Rammell J, Perre D, Boylan L, Prentis J, Nesbitt C, Elmallah A, Nandhra S. The adverse impact of pre-operative anaemia on survival following major lower limb amputation. Vascular 2023; 31:379-386. [PMID: 35238256 DOI: 10.1177/17085381211065622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Approximately 5000 major lower-limb amputations (MLLA) for PAD occur per-annum in the UK with clinical outcomes being poor for this high-risk cohort of patients. Existing evidence suggests that anaemic surgical patients have an increased 30-day mortality, but this has not been explored in the context of MLLA. Recent prioritization processes suggested that MLLAs are a target area for research into outcome improvement. This cohort study evaluates the impact of anaemia on the outcome of MLLA to understand if optimization might improve outcomes. METHODS All PAD patients undergoing MLLA during 2015-2018 at a tertiary vascular centre were reviewed. Patients were stratified into groups; non-anaemia (>12 g/dL), mild-anaemia (12-10 g/dL) and severe-anaemia (<10 g/dL) by pre-operative haemoglobin (Hb). Primary outcome was overall survival by Kaplan-Meier. Secondary outcomes included length of stay (LOS), post-operative blood-transfusion, surgical-site infection (SSI) and myocardial infarction (MI). Cox-proportional-hazard and receiver-operator characteristics (ROC) analyses were conducted. RESULTS 345 patients were followed up over (mean) 23 months. 105 were non-anaemic, 111 mildly anaemic and 129 severely anaemic. Patients with severe-anaemia had a higher incidence of heart and renal failure (p = 0.003) than those with non- or mild-anaemia. Overall survival worsened significantly with increasing anaemia (p = 0.001). LOS was significantly longer in mild-anaemia which is 26 (16-43) days, (p = 0.006) and severe-anaemia of 28 days (17-40), (p < 0.001) compared to non-anaemia of 18 (10-30) days. Post-operative blood-transfusion (RBC) was required more frequently in 70.5% of severely anaemic patients (p < 0.001), compared to mildly anaemic (24.3%) and non-anaemic (7.6%) patients, with those receiving RBCs having a significantly worse survival. There was no difference in MI, SSI or wound dehiscence. Anaemia was significantly associated with mortality; (HR 1.7 (1.04-2.78), p = 0.03). A minimum-Hb of 10.4 g/L (by ROC) was identified as a cutoff Hb for an increased risk of mortality. CONCLUSION Pre-operative anaemia is associated with worse outcome following MLLA, with increasing severity of anaemia associated with increasing mortality and RBC transfusion being potentially detrimental. More work is required to prospectively evaluate this relationship in this complex and multi-morbid cohort of patients.
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Affiliation(s)
- James Rammell
- Northern Vascular Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Daniel Perre
- Northern Vascular Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Luke Boylan
- Northern Vascular Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - James Prentis
- Department of Anaesthesia, the Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle Upon Tyne, NE7 7DN UK
| | - Craig Nesbitt
- Northern Vascular Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Ahmed Elmallah
- Associate Professor of Vascular Surgery, Faculty of Medicine, El Menoufia University, El Menoufia, Egypt
| | - Sandip Nandhra
- Northern Vascular Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle-upon-Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Réhabilitation améliorée après chirurgie cardiaque adulte sous CEC ou à cœur battant 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Mertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, Chatel D, Cholley B, Curtil A, Grimaud JP, Houel R, Kattou F, Fellahi JL, Guidon C, Guinot PG, Lebreton G, Marguerite S, Ouattara A, Provenchère Fruithiot S, Rozec B, Verhoye JP, Vincentelli A, Charbonneau H. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med 2022; 41:101059. [PMID: 35504126 DOI: 10.1016/j.accpm.2022.101059] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. METHODS Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. CONCLUSIONS Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Julien Amour
- Institut de Perfusion, de Réanimation, d'Anesthésie de Chirurgie Cardiaque Paris Sud, IPRA, Hôpital Privé Jacques Cartier, Massy, France
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France; MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Lionel Camilleri
- Department of Cardiovascular Surgery, CHU Clermont-Ferrand, T.G.I, I.P., CNRS, SIGMA, UCA, UMR 6602, Clermont-Ferrand, France
| | - Thierry Caus
- Department of Cardiac Surgery, UPJV, Amiens University Hospital, Amiens Picardy University Hospital, Amiens, France
| | - Didier Chatel
- Department of Cardiac Surgery (D.C.), Institut du Coeur Saint-Gatien, Nouvelle Clinique Tours Plus, Tours, France
| | - Bernard Cholley
- Anaesthesiology and Intensive Care Medicine, Hôpital Européen Georges-Pompidou, AP-HP, Université de Paris, INSERM, IThEM, Paris, France
| | - Alain Curtil
- Department of Cardiac Surgery, Clinique de la Sauvegarde, Lyon, France
| | | | - Rémi Houel
- Department of Cardiac Surgery, Saint Joseph Hospital, Marseille, France
| | - Fehmi Kattou
- Department of Anaesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France; Faculté de Médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Intensive Care, Dijon University Hospital, Dijon, France; University of Bourgogne and Franche-Comté, LNC UMR1231, Dijon, France; INSERM, LNC UMR1231, Dijon, France; FCS Bourgogne-Franche Comté, LipSTIC LabEx, Dijon, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, Unité mixte de recherche CardioMetabolisme et Nutrition, ICAN, AP-HP, Hôpital Pitié-Salpétrière, Paris, France
| | - Sandrine Marguerite
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, UMR 1034, Biology of Cardiovascular Diseases, F-33600 Pessac, France
| | - Sophie Provenchère Fruithiot
- Department of Anaesthesia, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France; Centre d'Investigation Clinique 1425, INSERM, Université de Paris, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laennec, CHU Nantes, Nantes, France; Université de Nantes, CHU Nantes, CNRS, INSERM, Institut duDu Thorax, Nantes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - André Vincentelli
- Department of Cardiac Surgery, University of Lille, CHU Lille, Lille, France
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Esteban C, Hernández-Rodríguez I. Peripheral arterial disease and anaemia. A review. Med Clin (Barc) 2021; 158:221-228. [PMID: 34602211 DOI: 10.1016/j.medcli.2021.07.010] [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: 03/24/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 12/24/2022]
Abstract
Iron deficiency anaemia is highly prevalent worldwide. In the surgical patient, anaemia of any cause implies higher morbidity and mortality in the post-operative period. This is especially important in patients with peripheral artery disease, as they have very high rates of anaemia due to iron deficiency or other causes. In intermittent claudication, anaemia is a predictor of death in the medium term. Patients with critical ischaemia have higher prevalence of anaemia and it is an indicator of amputation and death in the medium term. Specific protocols need to be developed for these patients since the natural history of their disease does not allow for the correction of anaemia before surgery.
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Affiliation(s)
- Carlos Esteban
- Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Inés Hernández-Rodríguez
- Servicio de Hematología, ICO-Hospital Universitari Germans Trias i Pujol, Institute de Investigación contra la Leucemia Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Barcelona, España.
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8
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Clinical Impact of Preoperative Anemia in Patients Undergoing Peripheral Vascular Interventions: A Systematic Review. SURGERIES 2021. [DOI: 10.3390/surgeries2030027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: This systematic review aims to summarize the existing evidence relating to preoperative anemia and clinical outcomes in peripheral vascular surgery patients. Methods: The following databases were searched—PubMed, COCHRANE, LILACS, and Science Research—from 1 January 2010 up to 8 May 2020, with the last search performed on 1 January 2021. An additional manual search for potential primary studies was conducted on major journals (e.g., Anesthesiology, the British Journal of Anesthesia and the European Journal of Anaesthesiology) and reference lists of included studies. Google Scholar was also checked for additional eligible studies. Reviewers independently screened potentially eligible articles and extracted data from included studies on populations, interventions, comparisons, and outcomes. This review was registered at PROSPERO as CRD 180954. Results: In total, 6 observational studies with a combined total of 87,327 participants were analyzed. Data collected in this review suggest that preoperative anemia, especially when hemoglobin is <10 g/dL, is associated with an increased risk of red blood cell transfusions (OR: 7.5; 95% CI 6.3–8.9, p < 0.0001), limb amputation (OR: 5.2; 95% CI 3.1–8.6, p < 0.0001), and death (p < 0.0031). Conclusions: These data suggest an association between preoperative anemia, blood transfusion requirements, and other adverse clinical outcomes among patients subjected to peripheral vascular interventions. However, further investigations, particularly randomized controlled trials, are warranted to better understand the association between preoperative anemia and patients’ prognosis.
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Perelman SI, Shander A, Mabry C, Ferraris VA. Preoperative anemia management in the coronavirus disease (COVID-19) era. JTCVS OPEN 2021; 5:85-94. [PMID: 34173552 PMCID: PMC7836783 DOI: 10.1016/j.xjon.2020.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/30/2020] [Indexed: 01/28/2023]
Affiliation(s)
- Seth I. Perelman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Aryeh Shander
- TeamHealth Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, NJ
| | - Christian Mabry
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Victor A. Ferraris
- Department of Cardiothoracic Surgery, Lexington VA Medical Center, University of Kentucky, Lexington, Ky
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Charbonneau H, Pasquié M, Berthoumieu P, Savy N, Autones G, Anglès O, Berthelot AL, Croute-Bayle M, Decramer I, Duterque D, Gabiache Y, Julien V, Mallet L, M'rini M, Quedreux JF, Richard B, Sidobre L, Taillefer L, Soula P, Garcia O, Abouliatim I, Vahdat O, Bousquet M, Ferradou JM, Jansou Y, Brunel P, Breil C, Mayeur N. Patient blood management in elective bypass cardiac surgery: A 2-step single-centre interventional trial to analyse the impact of an educational programme and erythropoiesis stimulation on red blood cell transfusion. Contemp Clin Trials Commun 2020; 19:100617. [PMID: 32695923 PMCID: PMC7365967 DOI: 10.1016/j.conctc.2020.100617] [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: 03/03/2020] [Revised: 06/20/2020] [Accepted: 07/12/2020] [Indexed: 12/22/2022] Open
Abstract
Anaemia and iron deficiency are frequent in patients scheduled for cardiac surgery. Perioperative patient blood management (PBM) is widely recommended in current practice guidelines. The aim of this protocol is to analyse the effect of a global perioperative PBM programme on the red blood cell (RBC) transfusion ratio, morbidities and rehabilitation score in elective cardiac surgery. This study is a prospective, single-centre trial with a 2-step protocol, A and B, as follows: A: non-drug intervention: the caregiver is given a blood management educational programme; B: drug intervention: systematic correction of perioperative iron, vitamin deficiencies, and anaemia. This study was designed to enrol 900 patients (500 in group A and 400 in group B) in a rolling period starting at anaesthesia consultation and ending 3 months after surgery. The primary objective was a 20% reduction in RBC transfusion after implementation of PBM programmes (protocol A + B) when compared to our previous transfusion ratio in the first half of 2018 (30.4% vs 38%). The secondary objectives were to evaluate the impact for each step of the study on the RBC transfusion rate, morbidity and the quality of postoperative rehabilitation. The strength of this study is its evaluation of the effect of a global PBM programme on RBC transfusion in cardiac surgery through a 2-step protocol. We aim to assess for the first time the impact of non-drug and drug interventions on RBC transfusion, comorbidities and delayed rehabilitation parameters. Trials registrations ClinicalTrials.gov, NCT04040023: registered 29 July 2019.
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Affiliation(s)
- Hélène Charbonneau
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Marie Pasquié
- Clinical Research Associate, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076, Toulouse Cedex 03, France
| | - Pierre Berthoumieu
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076, Toulouse Cedex 03, France
| | - Nicolas Savy
- Toulouse Institute of Mathematics, UMR5219 - University of Toulouse, CNRS - UPS IMT, F-31062, Toulouse Cedex 9, France
| | - Gérard Autones
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Olivier Anglès
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Anne Laure Berthelot
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Madeleine Croute-Bayle
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Isabelle Decramer
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - David Duterque
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Yannick Gabiache
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Valérie Julien
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Laurent Mallet
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Mimoun M'rini
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Jean François Quedreux
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Benoit Richard
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Laurent Sidobre
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Laurence Taillefer
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
| | - Philippe Soula
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076, Toulouse Cedex 03, France
| | - Olivier Garcia
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076, Toulouse Cedex 03, France
| | - Issam Abouliatim
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076, Toulouse Cedex 03, France
| | - Olivier Vahdat
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076, Toulouse Cedex 03, France
| | - Marc Bousquet
- Department of Cardio-vascular Rehabilitation, Clinique Saint Orens ELSAN, 12 Avenue de Revel, 31650, Saint-Orens-de-Gameville, France
| | - Jean Marc Ferradou
- Department of Cardio-vascular Rehabilitation "Midi-Gascogne" Cardiovascular Rehabilitation, 1487 Avenue du Languedoc, 82500, Beaumont-de-Lomagne, France
| | - Yves Jansou
- Department of Cardio-vascular Rehabilitation, Cinique du Sud ELSAN, ZAC Route de Montredon, Chemin de la Madeleine, 11000, Carcassonne, France
| | - Pierre Brunel
- Perfusionist Group, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076, Toulouse Cedex 03, France
| | - Claude Breil
- Perfusionist Group, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076, Toulouse Cedex 03, France
| | - Nicolas Mayeur
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, 45 avenue de Lombez BP27617, 31076 Toulouse Cedex 03, France
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11
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The Influence of Preoperative Anemia on Clinical Outcomes After Infrainguinal Bypass Surgery. Ann Vasc Surg 2020; 66:586-594. [DOI: 10.1016/j.avsg.2019.11.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 11/19/2022]
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Complex relationship between low albumin level and poor outcome after lower extremity procedures for peripheral artery disease. J Vasc Surg 2020; 73:200-209. [PMID: 32470524 DOI: 10.1016/j.jvs.2020.04.524] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/30/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A low albumin level has been associated with poor outcome, including death, in surgical patients. The mechanistic relationship, however, is more complex than simply nutritional. As studies are scant in the vascular population, we sought to examine the association of low albumin level with outcomes in patients undergoing open and endovascular lower extremity procedures for peripheral artery disease. METHODS Patients with peripheral artery disease undergoing lower extremity procedures (2008-2015) were selected from Cerner Health Facts database (Cerner Corporation, Kansas City, Mo) using International Classification of Diseases, Ninth Revision diagnosis and procedure codes. Age, sex, disease severity, and other comorbidities were captured. Outcomes were identified using codes and encounter data. A χ2analysis and multivariable logistic regression were performed. RESULTS There were 6170 patients evaluated; 4562 (74%) underwent endovascular procedures and 1608 (26%) underwent open surgery. Low albumin level (<3.5 g/dL) was associated with age ≥80 years (23.1% vs 16.3% normal; P < .0001), black race (21% vs 11.6% normal; P < .0001), tissue loss (38% vs 16.4% normal; P < .0001), and higher Charlson index (mean, 3.1 vs 2.2 in the normal group; P < .0001). Low albumin level was also associated with longer length of stay (4.9 vs 2.2 days normal; P < .0001), higher in-hospital mortality (1.9% vs 0.3% normal; P < .0001), and higher 30-day readmission (15% vs 12.7% normal; P = .02). Multivariable analysis demonstrated that low albumin level was strongly associated with in-hospital death (odds ratio [OR], 5.23; 95% confidence interval [CI], 2.00-13.70), infection (OR, 2.51; 95% CI, 1.96-3.22), renal failure (OR, 2.61; 95% CI, 1.79-3.79), and cardiac complications (OR, 2.59; 95% CI, 1.69-3.96). After multivariable adjustment, there was no association between albumin level and 30-day readmission. CONCLUSIONS Low preoperative albumin levels are associated with in-hospital death, prolonged length of stay, and severe morbidity after open and endovascular lower extremity procedures. As the majority of lower extremity procedures are elective, serious consideration should be given to deferring elective procedures until albumin levels have been optimized. Because of the pleiotropic effects of albumin, including antiplatelet and inflammatory function, study of this complex relationship may offer insights into how best to integrate this novel biomarker into vascular surgery decision-making.
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Meybohm P, Westphal S, Ravn HB, Ranucci M, Agarwal S, Choorapoikayil S, Spahn DR, Ahmed AB, Froessler B, Zacharowski K. Perioperative Anemia Management as Part of PBM in Cardiac Surgery – A Narrative Updated Review. J Cardiothorac Vasc Anesth 2020; 34:1060-1073. [DOI: 10.1053/j.jvca.2019.06.047] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/18/2019] [Accepted: 06/29/2019] [Indexed: 12/18/2022]
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14
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Esteban Gracia C. Reply. Med Clin (Barc) 2019; 153:473. [PMID: 31277881 DOI: 10.1016/j.medcli.2019.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 03/28/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Carlos Esteban Gracia
- Servicio de Angiología y Cirugía Vascular, Hospital Germans Trias i Pujol, Badalona, Barcelona, España.
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15
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Esteban C, Rodríguez P, Escudero JR, Clarà A, Fernández A, Fernández S, Agúndez I. Anaemia in patients who underwent vascular surgery: a significant predictor of amputation and death. Med Clin (Barc) 2019; 152:6-12. [PMID: 29650265 DOI: 10.1016/j.medcli.2018.01.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/04/2018] [Accepted: 01/11/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND OBJECTIVE In patients with peripheral artery disease requiring surgery, anaemia has been found to independently predict short and medium term higher morbidity and mortality. PATIENTS AND METHODS We retrospectively studied all patients undergoing surgery, consecutively during 2months in 12 vascular surgery units. We analysed cardiovascular risk factors and preoperative haemoglobin. Statistical analysis was done with Kaplan-Meier for survival and logistic regression modelling to identify predictors of mortality. RESULTS 518 patients were consecutively operated on in our vascular units, the mortality rate was 21% the first year and 34% for cardiovascular events. Preoperative anaemia was present in 63% of the ischemic patients and in 23% of the patients requiring aneurysm repair, one year after surgery it increased to 68% and 50% respectively. When preoperative anaemia was superior to 10mg/dl, one year survival increased (96% vs. 90%), fewer cardiovascular events occurred and there were fewer amputations (24% vs. 68%). CONCLUSIONS On multivariable analysis: age, renal failure, chronic lung disease, coronary artery disease, postoperative complications and previous cardiovascular events were associated with an increased risk mortality rate. Preoperative haemoglobin influenced proportionally such that for every 1mg /dl increase, the probability of mortality decreases by 0.81. Preoperative anaemia, especially when haemoglobin is inferior to 10mg/dl, is associated with an increased risk of death and amputation.
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Affiliation(s)
- Carlos Esteban
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, España.
| | - Patricia Rodríguez
- Servicio de Angiología y Cirugía Vascular, Hospital Josep Trueta, Gerona, España
| | - José Román Escudero
- Servicio de Angiología y Cirugía Vascular, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Albert Clarà
- Servicio de Angiología y Cirugía Vascular, Hospital del Mar, Barcelona, España
| | - Alvaro Fernández
- Servicio de Angiología y Cirugía Vascular, Hospital La Paz, Madrid, España
| | - Sebastián Fernández
- Servicio de Angiología y Cirugía Vascular, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
| | - Ignacio Agúndez
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Burgos, Burgos, España
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16
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Abstract
PURPOSE OF REVIEW Anemia can contribute negatively to a patient's morbidity and mortality. Which treatment options do exist and what role do anesthesiologists play in management of perioperative anemia treatment? This review gives an overview about recent findings. RECENT FINDINGS Patient Blood Management and standards for the management and treatment of anemia have been established worldwide. Various logistic settings and approaches are possible. With a special focus on cardiovascular anesthesia, intravenous iron is a therapeutic option in the preoperative setting. Autologous blood salvage is a standard procedure during surgery. Restrictive transfusion triggers in adult cardiac surgery have been shown to be beneficial in the majority of studies. Elderly patients and defined comorbidities might require higher transfusion triggers. Both, intravenous and oral iron increase hemoglobin values when given prior to surgery. Oral iron is effective when given several weeks prior to elective surgery. Erythropoietin is a treatment decision individualized to each patient. SUMMARY Within the previous 18 months, important publications have demonstrated the established role of anesthesiologists in managing perioperative anemia. A substantial pillar for anemia treatment is the implementation of Patient Blood Management worldwide.
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17
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Valentine EA, Zhou EY, Gordon EK, Ochroch EA. The Year in Vascular Anesthesia: Selected Highlights From 2017. J Cardiothorac Vasc Anesth 2018; 32:2043-2053. [PMID: 29784496 DOI: 10.1053/j.jvca.2018.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Elizabeth A Valentine
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Elizabeth Y Zhou
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Emily K Gordon
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
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