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Grandone E, Tiscia GL, Ostuni A, Marongiu F, Barcellona D. Navigating anemia and anticoagulation in elderly patients undergoing orthopedic surgery: strategies for preventing complications and implementing treatments. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2024; 22:450-458. [PMID: 38814879 PMCID: PMC11390616 DOI: 10.2450/bloodtransfus.640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/21/2023] [Indexed: 06/01/2024]
Abstract
BACKGROUND Elderly populations face an increased risk of anemia, leading to elevated transfusion requirements during surgery, especially major orthopedic procedures. Anemia itself increases the risk of thromboembolic events, thus compounding complications in elderly individuals. Polypharmacy and the prevalent use of oral anticoagulants (OAC), particularly for atrial fibrillation, contribute to bleeding risks in this population. Data available in the literature on the peri-operative management of anemia in patients taking OAC is limited and often heterogeneous. MATERIALS AND METHODS This narrative case-based review focuses on the peri-operative management of elderly patients on OAC undergoing major orthopedic surgery. PubMed/Medline was used to search for relevant literature. RESULTS With reference to two cases, we critically evaluate the literature, and focus on risk factors, and preventive and therapeutic strategies as fundamental tools to reduce bleeding and correct anemia as soon as possible in elderly patients undergoing major orthopedic surgery. DISCUSSION Peri-operative management of these patients, especially those on OAC, requires a balanced approach considering bleeding and thrombotic risks. Intravenous iron therapy and tranexamic acid emerge as valuable strategies in minimizing transfusion requirements and optimizing patients' outcomes.
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Affiliation(s)
- Elvira Grandone
- Obstetrics and Gynaecology Department, University of Foggia, Foggia, Italy
- Thrombosis and Hemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
- Department of Obstetrics Gynaecology and Perinatal Medicine, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Giovanni L Tiscia
- Thrombosis and Hemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
| | - Angelo Ostuni
- Immunohematology and Transfusion Medicine Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Francesco Marongiu
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Cagliari, Italy
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2
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Bartoszko J, Miles S, Ansari S, Grewal D, Li M, Callum J, McCluskey SA, Lin Y, Karkouti K. Postoperative intravenous iron to treat iron-deficiency anaemia in patients undergoing cardiac surgery: a protocol for a pilot, multicentre, placebo-controlled randomized trial (the POAM trial). BJA OPEN 2024; 11:100303. [PMID: 39161801 PMCID: PMC11332809 DOI: 10.1016/j.bjao.2024.100303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/01/2024] [Indexed: 08/21/2024]
Abstract
Background Iron-deficiency anaemia, occurring in 30-40% of patients undergoing cardiac surgery, is an independent risk factor for adverse outcomes. Our long-term goal is to assess if postoperative i.v. iron therapy improves clinical outcomes in patients with preoperative iron-deficiency anaemia undergoing cardiac surgery. Before conducting a definitive RCT, we first propose a multicentre pilot trial to establish the feasibility of the definitive trial. Methods This internal pilot, double-blinded, RCT will include three centres. Sixty adults with preoperative iron-deficiency anaemia undergoing non-emergency cardiac surgery will be randomised on postoperative day 2 or 3 to receive either blinded i.v. iron (1000 mg ferric derisomaltose) or placebo. Six weeks after surgery, patients who remain iron deficient will receive a second blinded dose of i.v. iron according to their assigned treatment arm. Patients will be followed for 12 months. Clinical practice will not be otherwise modified. For the pilot study, feasibility will be assessed through rates of enrolment, protocol deviations, and loss to follow up. For the definitive study, the primary outcome will be the number of days alive and out of hospital at 90 days after surgery. Ethics and dissemination The trial has been approved by the University Health Network Research Ethics Board (REB # 22-5685; approved by Clinical Trials Ontario funding on 22 December 2023) and will be conducted in accordance with the Declaration of Helsinki, Good Clinical Practices guidelines, and regulatory requirements. Clinical trial registration NCT06287619.
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Affiliation(s)
- Justyna Bartoszko
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
| | - Sarah Miles
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Saba Ansari
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Deep Grewal
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle Li
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Jeannie Callum
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, ON, Canada
| | - Stuart A. McCluskey
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Yulia Lin
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Arya S, Howell A, Vernich L, Lin Y, Pavenski K, Freedman J. Re-evaluating treatment thresholds in patient blood management: Female patients experience more perioperative anaemia and higher transfusion rates in major elective surgery. Vox Sang 2024. [PMID: 39048294 DOI: 10.1111/vox.13717] [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: 03/11/2024] [Revised: 05/24/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND AND OBJECTIVES By optimizing erythropoiesis, patient blood management (PBM) programmes can reduce transfusions, lower mortality and provide cost-effective care. While definitions of anaemia have historically varied by sex, for the purposes of PBM, anaemia is defined as a haemoglobin <130 g/L. Our objective was to describe whether perioperative anaemia and transfusion rates in the PBM setting vary by sex. MATERIALS AND METHODS We conducted a retrospective study of the Ontario Nurse Transfusion Coordinators Program (ONTraC) database from 2018 to 2022. ONTraC collects data from 25 Ontario hospitals which together account for >70% of Ontario's provincial blood use (~400,000 units per year). We collected data on patients undergoing elective isolated coronary artery bypass graft surgery (CABG), open heart valve replacement, CABG plus valve replacement, single-knee arthroplasty and single-hip arthroplasty. RESULTS From 2018 to 2022, 17,700 patients were included in the ONTraC program; 47% were females (N = 8376). Across almost all years and procedures, females were found to have a significantly lower pre-operative, nadir and discharge haemoglobin as compared with males, irrespective of PBM interventions. Transfusion rates were significantly higher for females; this was most pronounced in cardiac surgery. CONCLUSION Females experienced more perioperative anaemia and higher transfusion rates. Historic sex-specific definitions of anaemia may contribute to a greater tolerance of anaemia in females. Prioritizing females for multimodal PBM and consistently achieving a pre-operative haemoglobin >130 g/L may reduce the amount of red blood cell (RBC) transfusions that female patients receive.
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Affiliation(s)
- Sumedha Arya
- Canadian Blood Services, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Alanna Howell
- Ontario Nurse Transfusion Coordinators Program (ONTraC), Toronto, Ontario, Canada
- Department of Laboratory Medicine, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
| | - Lee Vernich
- Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Division of Transfusion Medicine & Tissue Bank, Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
| | - John Freedman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Ontario Nurse Transfusion Coordinators Program (ONTraC), Toronto, Ontario, Canada
- Department of Laboratory Medicine, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
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4
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Kang KW. Preoperative consultation for determining the appropriate transfusion strategy. Blood Res 2024; 59:21. [PMID: 38847904 PMCID: PMC11161442 DOI: 10.1007/s44313-024-00021-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/31/2024] [Indexed: 06/10/2024] Open
Abstract
Surgical patients are at risk of postoperative complications and mortality, necessitating preoperative patient optimization through the identification and correction of modifiable risk factors. Although preoperative platelet transfusions aim to reduce the risk of bleeding, their efficacy remains uncertain. Similarly, red blood cell transfusion in patients with anemia does not reduce the risk of postoperative mortality and may exacerbate complications. Therefore, developing individualized strategies that focus on correcting preoperative complete blood count abnormalities and minimizing transfusion requirements are essential. This review aimed to examine complete blood count abnormalities and appropriate transfusion strategies to minimize postoperative complications.
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Affiliation(s)
- Ka-Won Kang
- Department of Internal Medicine, Division of Hematology-Oncology, Korea University College of Medicine, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841, the Republic of Korea.
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5
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Connelly NR, Adler AC, Vanderberg LE, Conlin F, Mitchell JD, Goldstein S, Haspel RL. Anesthesiology Resident Knowledge of Transfusion Medicine: Results From the Anesthesiology Transfusion Education Study. Anesth Analg 2024; 138:655-663. [PMID: 36729772 DOI: 10.1213/ane.0000000000006327] [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: 02/03/2023]
Abstract
BACKGROUND Transfusion of blood products is a common practice in anesthesiology. Inadequate transfusion medicine knowledge may lead to inappropriate transfusion practices and patient risk. Using a validated assessment tool modified for anesthesiology, we conducted a survey of anesthesiology residents in the United States to assess transfusion medicine knowledge. METHODS A validated transfusion medicine examination and accompanying survey were forwarded by program directors to residents for anonymous completion on May 5 and closed on June 30, 2021. The outcome of interest was the mean examination score. Secondary areas of interest were performance by year of training and previous educational experience in transfusion reported by the trainees. Rasch analysis was performed on the examination quality and individual question performance. Kruskal-Wallis H tests were used to identify differences between mean scores. Post hoc comparisons were used to assess specific pairwise differences between mean test scores by survey variable. RESULTS Four hundred twenty-three anesthesiology residents in 37 programs completed the examination. The mean score was 45.5% ± 12.6%. There was a significant difference in mean cumulative examination scores between different resident training levels ( P < 0.001). There was a significant difference in scores between clinical anesthesia (CA)-1 and CA-2 residents ( P = 0.011) and CA-1 and CA-3 residents ( P = 0.012). No significant difference in examination scores was observed between CA-2 and CA-3 residents ( P = 0.95). All these subgroups scored below 50% on the examination. Significant differences between the residency training programs and cumulative scores were identified ( P < 0.001). CONCLUSIONS This examination highlights gaps in transfusion medicine knowledge within US anesthesiology residents. Targeted education may improve knowledge in this area and patient care.
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Affiliation(s)
- Neil Roy Connelly
- From the Department of Anesthesiology, UMass Chan Medical School-Baystate, Baystate Medical Center, Springfield, Massachusetts
| | - Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children's Hospital, Houston, Texas
- Baylor College of Medicine, Houston, Texas
| | | | - Frederick Conlin
- From the Department of Anesthesiology, UMass Chan Medical School-Baystate, Baystate Medical Center, Springfield, Massachusetts
| | - John D Mitchell
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts
| | - Sheldon Goldstein
- Department of Anesthesiology, Montefiore Medical Center, New York, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Richard L Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center, and Harvard Medical School Boston, Massachusetts
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Arynov A, Kaidarova D, Kabon B. Alternative blood transfusion triggers: a narrative review. BMC Anesthesiol 2024; 24:71. [PMID: 38395758 PMCID: PMC10885388 DOI: 10.1186/s12871-024-02447-3] [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: 09/13/2023] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Anemia, characterized by low hemoglobin levels, is a global public health concern. Anemia is an independent factor worsening outcomes in various patient groups. Blood transfusion has been the traditional treatment for anemia; its triggers, primarily based on hemoglobin levels; however, hemoglobin level is not always an ideal trigger for blood transfusion. Additionally, blood transfusion worsens clinical outcomes in certain patient groups. This narrative review explores alternative triggers for red blood cell transfusion and their physiological basis. MAIN TEXT The review delves into the physiology of oxygen transport and highlights the limitations of using hemoglobin levels alone as transfusion trigger. The main aim of blood transfusion is to optimize oxygen delivery, necessitating an individualized approach based on clinical signs of anemia and the balance between oxygen delivery and consumption, reflected by the oxygen extraction rate. The narrative review covers different alternative triggers. It presents insights into their diagnostic value and clinical applications, emphasizing the need for personalized transfusion strategies. CONCLUSION Anemia and blood transfusion are significant factors affecting patient outcomes. While restrictive transfusion strategies are widely recommended, they may not account for the nuances of specific patient populations. The search for alternative transfusion triggers is essential to tailor transfusion therapy effectively, especially in patients with comorbidities or unique clinical profiles. Investigating alternative triggers not only enhances patient care by identifying more precise indicators but also minimizes transfusion-related risks, optimizes blood product utilization, and ensures availability when needed. Personalized transfusion strategies based on alternative triggers hold the potential to improve outcomes in various clinical scenarios, addressing anemia's complex challenges in healthcare. Further research and evidence are needed to refine these alternative triggers and guide their implementation in clinical practice.
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Affiliation(s)
- Ardak Arynov
- Department of Anesthesiology and Intensive Care, Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan.
| | - Dilyara Kaidarova
- Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Medicine and Pain Medicine Medical, University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Wang Z, Liu M, Men H, Lyu C, Zheng N. Association between preoperative hemoglobin with length of hospital stay among non-cardiac and non-obstetric surgery patients: a secondary analysis of a retrospective cohort study. J Cardiothorac Surg 2024; 19:97. [PMID: 38365787 PMCID: PMC10870523 DOI: 10.1186/s13019-024-02566-5] [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: 07/05/2023] [Accepted: 01/30/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Previous studies concerning the association between preoperative Hemoglobin (HB) level and the Length Of hospital Stay (LOS) in patients with non-cardiac surgery and non-obstetric surgery remain inconclusive. Herein, the objective of this study was to analyze whether and to what extent the preoperative HB level was connected with the LOS in non-cardiac and non-obstetric surgery patients. METHODS This retrospective cohort study was performed at a single institution, involving patients who underwent elective non-cardiac, non-obstetric surgery from April 2007 to September 2013. Clinical characteristics of patients such as demographics, comorbidities, preoperative HB level, LOS, mortality, procedure length, and pulmonary hypertension (PHTN) Severity Class data were collected. A univariate analysis was used to determine the association between clinical characteristics and LOS. Multivariate regression analysis was conducted to investigate the relationship between preoperative HB level and LOS. RESULTS AND DISCUSSION In this study, 311 patients were included. We observed that compared with the LOS > 7 days group, the average HB level of patients in the LOS ≤ 7 days group was higher (12.04 ± 2.20 g/dl vs. 10.92 ± 2.22 g/dl, p < 0.001). In addition, there were fewer patients with moderate-to-severe anemia in LOS ≤ 7 days group than the LOS > 7 days group (32.74% vs 58.82%, p < 0.001). In addition, we found that patients with LOS ≤ 7 days were accompanied with lower mortality (0.44% vs. 7.06%, p < 0.001) and lower mean combined pulmonary artery systolic pressure (PASP) and right ventricular systolic pressure (RVSP) than that in patients with LOS > 7 days (42.56 ± 11.97 vs. 46.00 ± 12.37, p < 0.05). After controlling for relevant confounders, we discovered a nonlinear association between preoperative HB level and LOS as well as a threshold effect based on LOS. Specifically, when preoperative HB level was less than 11.9 g/dL, LOS decreased by 2 days for each 1 g/dL increase in HB level. However, LOS did not alter substantially with the rise of preoperative HB level when it was higher than 11.9 g/dL. CONCLUSION Our study showed a close non-linear association between preoperative HB level and LOS in patients with non-cardiac surgery and non-obstetric surgery. In particular, for patients with preoperative HB less than 11.9 g/dL, increasing the preoperative HB level can help shorten the LOS after operation.
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Affiliation(s)
- Zhaopeng Wang
- Department of General Medicine, Tianjin Beichen Hospital, Beichen District, Tianjin, 300400, China
| | - Min Liu
- Department of Clinical Laboratory, Tianjin Beichen Hospital, Beichen District, Tianjin, 300400, China
| | - Hengtong Men
- Department of General Medicine, Tianjin Beichen Hospital, Beichen District, Tianjin, 300400, China
| | - Chunfeng Lyu
- Department of General Medicine, Tianjin Beichen Hospital, Beichen District, Tianjin, 300400, China
| | - Ning Zheng
- Department of General Medicine, Tianjin Beichen Hospital, Beichen District, Tianjin, 300400, China.
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George A, Shastry S, Mohan G, Belurkar S. Evaluating patient blood management practices using PBM metrics in a tertiary care center. Transfus Clin Biol 2024; 31:26-30. [PMID: 38110075 DOI: 10.1016/j.tracli.2023.12.002] [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: 09/26/2023] [Revised: 12/10/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND PBM metrics play a crucial role in assessing and monitoring the effectiveness of PBM programs in healthcare settings. The present study aimed to assess the indicators to achieve effective enforcement of PBM at a tertiary care referral hospital. SUBJECTS AND METHOD A prospective observational study was conducted on patients admitted for elective surgery at a tertiary care referral centre. PBM metrics were developed and assessed for various parameters, including documentation, patient evaluation, blood ordering schedule, and appropriateness. Experts in transfusion medicine and haematology checked content validity. Eleven different parameters were analysed, and a score was assigned based on the performance. The outcome was categorized as poor, satisfactory, or good. RESULTS The study included 612 patients meeting the inclusion criteria and recruited from Orthopaedics, General Surgery, OBG, Urology, and ENT departments. All departments completed pre-operative anaemia tests, with General Surgery and Orthopaedics conducting the most red cell transfusions. During the study, all of the blood units were used, and there was no waste. The C/T ratio was greater in the Departments of General Surgery, Urology, and Otorhinolaryngology. Pre-operative anaemia was found in 44.12% of patients, 44 patients had red cell transfusions, with 65% getting single-unit PRBC transfusions. All departments received a PBM score between 17-19, showing adequate PBM but with room for improvement. CONCLUSION The current study utilized Patient Blood Management (PBM) metrics to critically assess the existing practices and identify the key gaps and areas for improvement in a tertiary care centre.
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Affiliation(s)
- Ashna George
- Department of Immunohematology and Blood Transfusion, 2 - Department of Pathology Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shamee Shastry
- Department of Immunohematology and Blood Transfusion, 2 - Department of Pathology Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India.
| | - Ganesh Mohan
- Department of Immunohematology and Blood Transfusion, 2 - Department of Pathology Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sushma Belurkar
- Department of Pathology Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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9
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Hourlier H, Fennema P. An observational study of an adjusted patient blood management protocol intended to lower rates of transfusion following total knee arthroplasty in patients with preoperative anemia. J Orthop Surg Res 2023; 18:918. [PMID: 38041115 PMCID: PMC10693030 DOI: 10.1186/s13018-023-04404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/24/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Patients with preoperative anemia have a higher risk of requiring blood transfusion after major orthopedic surgery due to increased blood loss and closer transfusion thresholds. Various patient blood management (PBM) policies aim to reduce transfusion rates. This observational study aimed to investigate blood loss and evaluate the effectiveness of an adjusted surgical PBM protocol in patients with anemic chronic disease (ACD) undergoing elective total knee arthroplasty (TKA). METHODS A consecutive cohort of patients underwent elective unilateral TKA with an adjusted PBM protocol. The protocol consisted of epoetin (EPO) alfa therapy prescribed by the surgeon, routine administration of tranexamic acid (TXA), and standardized postoperative pharmacologic prophylaxis for thromboembolism. The performance of this PBM protocol was analyzed in patients with a baseline hemoglobin level of less than 12 g/dl. Hemoglobin levels were controlled at admission, on postoperative day (POD) 1, and on POD 7 ± 1. A bleeding index (BI-7) was used as an estimate of blood loss up until POD 7. Multiple linear regression was used to assess whether there were any differences in BI-7 between ACD- and ACD + patients. RESULTS A total of 751 patients with complete hemoglobin monitoring were included in the study. Of these patients, 68 (9.1%) had a baseline hemoglobin concentration of less than 12 g/dl (ACD group). In this group, 28 patients (41.2%) received preoperative EPO therapy. The mean adjusted BI-7 for the study population was 3.0 (95% CI, 2.9 to 3.0) g/dl in the ACD- group and 2.3 (95% CI, 2.0-2.6) g/dl in the ACD + group. The difference in BI-7 was statistically significant (difference, 0.6 [95% CI: 0.3 to 0.9] g/dl, p < 0.001). No major complications occurred in the ACD + group, whereas there were three complications in the ACD- group (p = 1.00). CONCLUSIONS ACD patients undergoing TKA did not have an increased risk of bleeding or bleeding complications with the use of the adjusted PBM protocol. None of ACD patients required transfusion. ACD patients undergoing TKA experienced significantly less blood loss than patients with no preoperative anemia with the use of the adjusted PBM. We now consider the use of EPO in ACD patients with no nutritional deficiencies undergoing TKA at a baseline hemoglobin level of 11 g/dl. However, this should be validated in larger cohorts with a higher prevalence of ACD patients.
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Affiliation(s)
- Hervé Hourlier
- Department of Orthopaedic Surgery, Polyclinique de La Thiérache, Rue du Dr Koral, 59212, Wignehies, France.
- Centre Hospitalier de Fourmies, 59610, Fourmies, France.
| | - Peter Fennema
- AMR Advanced Medical Research GmbH, Männedorf, Switzerland
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10
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Cavalli LB, Pearse BL, Craswell A, Anstey CM, Naidoo R, Rapchuk IL, Perel J, Hobson K, Wang M, Fung YL. Determining sex-specific preoperative haemoglobin levels associated with intraoperative red blood cell transfusion in cardiac surgery: a retrospective cohort study. Br J Anaesth 2023; 131:653-663. [PMID: 37718096 DOI: 10.1016/j.bja.2023.06.062] [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: 12/01/2022] [Revised: 06/07/2023] [Accepted: 06/16/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Anaemic cardiac surgery patients are at greater risk of intraoperative red blood cell transfusion. This study questions the application of the World Health Organization population-based anaemia thresholds (haemoglobin <120 g L-1 in non-pregnant females and <130 g L-1 in males) as appropriate preoperative optimisation targets for cardiac surgery. METHODS A retrospective cohort study was conducted on adults ≥18 yr old undergoing cardiopulmonary bypass surgery. Logistic regression was applied to define sex-specific preoperative haemoglobin concentrations with reduced probability of intraoperative red blood cell transfusion for cardiac surgery patients. RESULTS Data on 4384 male and 1676 female patients were analysed. Binarily stratified multivariable logistic regression odds of receiving intraoperative red blood cell transfusion increased in cardiac surgery patients >45 yr old (odds ratio [OR] 1.84; 95% confidence interval [CI] 1.33-2.55), surgery urgency <30 days (OR 2.03; 95% CI 1.66-2.48), combined coronary artery bypass grafting and valve surgery, or other surgery types (OR 2.24; 95% CI 1.87-2.67), and female sex (OR 1.92; 95% CI 1.62-2.28). The odds decreased by 8.4% with each 1 g L-1 increase in preoperative haemoglobin (OR 0.92; 95% CI 0.91-0.92). Logistic regression predicted females required a preoperative haemoglobin concentration of 133 g L-1 and males 127 g L-1 to have a 15% probability of intraoperative transfusion. CONCLUSIONS The World Health Organization female anaemia threshold of haemoglobin <120 g L-1 disproportionately disadvantages female cardiac surgery patients. A preoperative haemoglobin concentration ≥130 g L-1 in adult cardiac surgery patients would minimise their overall probability of intraoperative red blood cell transfusion to <15%.
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Affiliation(s)
- Leonardo B Cavalli
- School of Health, University of the Sunshine Coast, Birtinya, QLD, Australia; School of Science, Technology and Engineering, University of the Sunshine Coast, Sippy Downs, QLD, Australia; Sunshine Coast Health Institute, Birtinya, QLD, Australia.
| | - Bronwyn L Pearse
- Blood Management, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Alison Craswell
- School of Health, University of the Sunshine Coast, Birtinya, QLD, Australia; Sunshine Coast Health Institute, Birtinya, QLD, Australia
| | - Christopher M Anstey
- School of Medicine, Sunshine Coast Campus, Griffith University, Birtinya, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Rishendran Naidoo
- Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Ivan L Rapchuk
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Anaesthesia and Perfusion Department, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Joanne Perel
- Pathology Queensland, Queensland Health, Brisbane, QLD, Australia
| | - Kylie Hobson
- Blood Management, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Mingzhong Wang
- School of Science, Technology and Engineering, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Yoke-Lin Fung
- School of Health, University of the Sunshine Coast, Sippy Downs, QLD, Australia
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Cançado RD. Iron deficiency anemia in women: pathophysiological, diagnosis, and practical management. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023S112. [PMID: 37556631 DOI: 10.1590/1806-9282.2023s112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/20/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Rodolfo Delfini Cançado
- Faculdade de Ciências Médicas da Santa Casa de São Paulo - São Paulo (SP), Brazil
- Hospital Samaritano-Higienópolis - São Paulo (SP), Brazil
- Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular - São Paulo (SP), Brazil
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12
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Arya S, Xiang T, Tang GH, Pavenski K. Including the patient in patient blood management: Development and assessment of an educational animation tool. Transfusion 2023; 63:1488-1494. [PMID: 37317645 DOI: 10.1111/trf.17458] [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: 02/23/2023] [Revised: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Patient blood management (PBM) programs are effective at reducing transfusion-associated mortality and morbidity; however, patient engagement within the realm of PBM remains relatively unstudied. Our objectives were to develop a novel educational tool utilizing animation to educate preoperative patients about anemia and to evaluate the effectiveness of this intervention. STUDY DESIGN AND METHODS We created a patient-facing animation for preoperative surgical patients. The animation addressed characters' health journeys from diagnosis to treatment, addressing the role of PBM. We utilized the concept of patient activation as a means to empower patients, and developed the animation to be as accessible as possible. Post-viewing, patients provided feedback utilizing an electronic survey. RESULTS A final version of the animation can be found here: https://vimeo.com/495857315. A total of 51 participants viewed our animation, the majority of whom were planned to undergo joint replacement or cardiac surgery. Almost all (94%, N = 4) agreed that taking an active role in their health was the most important factor in determining their ability to function. The video was felt to be easy to understand (96%, N = 49), and 92% (N = 47) agreed that they had a better understanding of anemia and its treatment. After watching the animation, patients felt more certain that they could follow through with their PBM plan (98%, N = 50). DISCUSSION To the best of our knowledge, there are no other PBM-specific patient education animations. Patients enjoyed learning about PBM though animation, and patient education may lead to better uptake of PBM interventions. We hope that other hospitals will be inspired to pursue this approach.
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Affiliation(s)
- Sumedha Arya
- Department of Medicine, Canadian Blood Services, Medical Affairs and Innovation, University of Toronto, Toronto, Ontario, Canada
| | - Tracy Xiang
- Biomedical Communications, Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Grace H Tang
- Hematology-Oncology Clinical Research Group, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Katerina Pavenski
- Department of Medicine and Laboratory Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine and Laboratory Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Pathobiology, University of Toronto, Toronto, Ontario, Canada
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Wijma AG, Eisenga MF, Nijkamp MW, Hoogwater FJH, Klaase JM. Treatment of iron deficiency in patients scheduled for pancreatic surgery: implications for daily prehabilitation practice in pancreatic surgery. Perioper Med (Lond) 2023; 12:36. [PMID: 37434251 DOI: 10.1186/s13741-023-00323-1] [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: 01/16/2023] [Accepted: 06/30/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Preoperative anemia is a frequent complication in pancreatic surgical patients, and it adversely affects morbidity, mortality, and postoperative red blood cell (RBC) transfusion rates. Iron deficiency (ID) is often the underlying cause of anemia and constitutes a modifiable risk factor. METHODS Single-center, longitudinal prospective cohort study conducted between May 2019 and August 2022 at the University Medical Center Groningen in the Netherlands. Patients scheduled for pancreatic surgery were referred to the outpatient prehabilitation clinic for preoperative optimization of patient-related risk factors. Patients were screened for anemia (< 12.0 g/dL in women and < 13.0 g/dL in men) and ID (either absolute [ferritin < 30 µg/L] or functional [ferritin ≥ 30 µg/L + transferrin saturation < 20% + C-reactive protein > 5 mg/L]). Intravenous iron supplementation (IVIS) (1,000 mg ferric carboxymaltose) was administered to patients with ID at the discretion of the consulting internist. Pre- and postoperative hemoglobin (Hb) levels were assessed, and perioperative outcomes were compared between patients receiving IVIS (IVIS-group) or standard care (SC-group). RESULTS From 164 screened patients, preoperative anemia was observed in 55 (33.5%) patients, and in 23 (41.8%) of these patients, ID was the underlying cause. In 21 patients, ID was present without concomitant anemia. Preoperative IVIS was administered to 25 patients, out of 44 patients with ID. Initial differences in mean Hb levels (g/dL) between the IVIS-group and SC-group at the outpatient clinic and one day prior to surgery (10.8 versus 13.2, p < 0.001, and 11.8 versus 13.4, p < 0.001, respectively) did not exist at discharge (10.6 versus 11.1, p = 0.13). Preoperative IVIS led to a significant increase in mean Hb levels (from 10.8 to 11.8, p = 0.03). Fewer SSI were observed in the IVIS-group (4% versus 25.9% in the SC-group, p = 0.02), which remained significant in multivariable regression analysis (OR 7.01 (1.68 - 49.75), p = 0.02). CONCLUSION ID is prevalent in patients scheduled for pancreatic surgery and is amendable to preoperative correction. Preoperative IVIS increased Hb levels effectively and reduced postoperative SSI. Screening and correction of ID is an important element of preoperative care and should be a standard item in daily prehabilitation practice.
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Affiliation(s)
- Allard G Wijma
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, PO Box 30.001, 9700, RB, Groningen, The Netherlands.
| | - Michele F Eisenga
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, PO Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Maarten W Nijkamp
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, PO Box 30.001, 9700, RB, Groningen, The Netherlands
| | - Frederik J H Hoogwater
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, PO Box 30.001, 9700, RB, Groningen, The Netherlands
| | - Joost M Klaase
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, PO Box 30.001, 9700, RB, Groningen, The Netherlands
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14
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Duarte GDC, Ribeiro GN, Moschen M, Toledo RSM, Bordin JO, Langhi DM. Targeting patient blood management's first pillar: A multicentric retrospective study on preoperative anemia. Hematol Transfus Cell Ther 2023; 45:338-341. [PMID: 35882618 PMCID: PMC10499570 DOI: 10.1016/j.htct.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/04/2022] [Accepted: 06/07/2022] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Anemia is a common issue in surgical patients and has been associated with worse clinical outcomes, such as a higher probability of transfusions and longer hospital stay. Therefore, Patient Blood Management programs are actively aiming to achieve early identification and treatment of anemia, previous to the surgery. METHODS AND MATERIALS In this study, preoperative hemoglobin within the Blood Order Schedule (BOS) at 16 blood centers in several Brazilian regions were retrospectively evaluated. Data regarding hemoglobin, age, gender and Brazilian regions were further analyzed. RESULTS From the 20,201 BOSs evaluated, the mean age was 55.65 ± 23.52 years old, with an overall prevalence of preoperative anemia of 60.9%. Women had a lower mean preoperative hemoglobin (11.74 ± 2.84 for women and 12.27 ± 3.06 for men) and higher prevalence of anemia than men (66% of females and 52.2% of males). The individuals over 65 years old and under 18 were the most affected by preoperative anemia. All regions had a high prevalence of preoperative anemia, without any direct association with the Human Development Index. CONCLUSION In summary, upon evaluating the BOS, our study showed a high prevalence of preoperative anemia in all Brazilian regions, regardless of the gender and age group, but that women and individuals less than 18 or over 65 years old have an even higher prevalence of preoperative anemia. This information can identify the institutions in which preoperative anemia is a critical issue and in which new strategies, such as preoperative screening clinics, might be helpful.
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15
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Rozental O, Cushing MM, Shander A, Isbister JP, Lasocki S, Meybohm P, Muñoz M, Spahn DR, Weiniger CF, Trentino KM, Girardi NI. Penny-wise and pound-foolish: the challenges of preoperative anaemia management. Br J Anaesth 2023:S0007-0912(23)00231-3. [PMID: 37244835 DOI: 10.1016/j.bja.2023.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/15/2023] [Accepted: 04/20/2023] [Indexed: 05/29/2023] Open
Abstract
The timely correction of anaemia before major surgery is important for optimising perioperative patient outcomes. However, multiple barriers have precluded the global expansion of preoperative anaemia treatment programmes, including misconceptions about the true cost/benefit ratio for patient care and health system economics. Institutional investment and buy-in from stakeholders could lead to significant cost savings through avoided complications of anaemia and red blood cell transfusions, and through containment of direct and variable costs of blood bank laboratories. In some health systems, billing for iron infusions could generate revenue and promote growth of treatment programmes. The aim of this work is to galvanise integrated health systems worldwide to diagnose and treat anaemia before major surgery.
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Affiliation(s)
- Olga Rozental
- Department of Anesthesiology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Melissa M Cushing
- Department of Pathology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA.
| | - Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, TeamHealth, Englewood Health, Englewood, NJ, USA
| | - James P Isbister
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Sigismond Lasocki
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Angers, Université d'Angers, Angers, France
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Manuel Muñoz
- Peri-operative Transfusion Medicine, Department of Surgical Specialties, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
| | - Donat R Spahn
- Institute of Anesthesiology, University Hospital of Zurich, Zurich, Switzerland
| | - Carolyn F Weiniger
- Department of Anesthesia, Intensive Care and Pain, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kevin M Trentino
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Natalia I Girardi
- Department of Anesthesiology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
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16
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Lynch KT, Hassinger TE. Preoperative Identification and Management of Anemia in the Colorectal Surgery Patient. Clin Colon Rectal Surg 2023; 36:161-166. [PMID: 37113284 PMCID: PMC10125282 DOI: 10.1055/s-0043-1760868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Preoperative anemia is a common finding in patients undergoing colorectal surgery, particularly those with cancer. While often multifactorial, iron deficiency anemia remains the most common cause of anemia in this patient population. Although seemingly innocuous, preoperative anemia is associated with an increased risk of perioperative complications and need for allogenic blood transfusions, both of which may worsen cancer-specific survival. Preoperative correction of anemia and iron deficiency is thus necessary to diminish these risks. Current literature supports preoperative screening for anemia and iron deficiency in patients slated to undergo colorectal surgery for malignancy or for benign conditions with associated patient- or procedure-related risk factors. Accepted treatment regimens include iron supplementation-either oral or intravenous-as well as erythropoietin therapy. Autologous blood transfusion should not be utilized as a treatment for preoperative anemia when there is time to implement other corrective strategies. Additional study is still needed to better standardize preoperative screening and optimize treatment regimens.
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Affiliation(s)
- Kevin T. Lynch
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Taryn E. Hassinger
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
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17
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Hornedo-González KD, Jacob AK, Burt JM, Higgins AA, Engel EM, Hanson AC, Belch L, Kor DJ, Warner MA. Non-invasive hemoglobin estimation for preoperative anemia screening. Transfusion 2023; 63:315-322. [PMID: 36605019 PMCID: PMC9898154 DOI: 10.1111/trf.17237] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/03/2022] [Accepted: 11/22/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Preoperative anemia is common and associated with adverse postoperative outcomes. Assessment of hemoglobin concentrations may facilitate optimization prior to surgery. However, phlebotomy-based hemoglobin measurement may contribute to patient discomfort and iatrogenic blood loss, which makes non-invasive hemoglobin estimation attractive in this setting. STUDY DESIGN AND METHODS This is a prospective study of adult patients presenting for preoperative evaluation before elective surgery at a tertiary care medical center. The Masimo Pronto Pulse CO-Oximeter was utilized to estimate blood hemoglobin concentrations (SpHb), which were then compared with hemoglobin concentrations obtained via complete blood count. Receiver operating curves were used to identify SpHb values maximizing specificity for anemia detection while meeting a minimum sensitivity of 80%. RESULTS A total of 122 patients were recruited with a median (interquartile range) age of 66 (58, 72) years. SpHb measurements were obtained in 112 patients (92%). SpHb generally overestimated hemoglobin with a mean (± 1.96 × standard deviation) difference of 0.8 (-2.2, 3.9) g/dL. Preoperative anemia, defined by hemoglobin <12.0 g/dL in accordance with institutional protocol, was present in 22 patients (20%). The optimal SpHb cut-point to identify anemia was 13.5 g/dL: sensitivity 86%, specificity 81%, negative predictive value 96%, and positive predictive value 53%. Utilizing this cut-point, 60% (73/122) of patients could have avoided phlebotomy-based hemoglobin assessment, while an anemia diagnosis would have been missed in <3% (3/122). CONCLUSION The use of SpHb devices for anemia screening in surgical patients is feasible with the potential to reliably rule-out anemia despite limited accuracy.
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Affiliation(s)
- Kevin D Hornedo-González
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
- School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
| | - Adam K Jacob
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Preoperative Evaluation Clinic, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer M Burt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Patient Blood Management Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew A Higgins
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Patient Blood Management Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth M Engel
- Preoperative Evaluation Clinic, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Hanson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa Belch
- Preoperative Evaluation Clinic, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Patient Blood Management Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Patient Blood Management Program, Mayo Clinic, Rochester, Minnesota, USA
- Division of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Dahmen AS, Phuoc VH, Cohen JB, Sexton WJ, Patel SY. Bloodless surgery in urologic oncology: A review of hematologic, anesthetic, and surgical considerations. Urol Oncol 2022; 41:192-203. [PMID: 36470804 DOI: 10.1016/j.urolonc.2022.11.010] [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: 09/12/2022] [Revised: 11/01/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
The urologic oncology patient who refuses blood transfusion can present unique challenges in perioperative blood management. Since blood loss and associated transfusion can be expected in many complex urologic oncology surgeries, a multidisciplinary approach may be required for optimal outcomes. Through collaboration with the hematologist, anesthesiologist, and urologist, various techniques can be employed in the perioperative phases to minimize blood loss and the need for transfusion. We review the risks and benefits of these techniques and offer recommendations specific to the urologic oncology patient.
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Affiliation(s)
- Aaron S Dahmen
- Department of Urology, University of Chicago, Chicago, IL
| | - Vania H Phuoc
- Department of Medical Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jonathan B Cohen
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Sephalie Y Patel
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL.
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Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews. J Clin Med 2022; 11:jcm11195628. [PMID: 36233497 PMCID: PMC9572852 DOI: 10.3390/jcm11195628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022] Open
Abstract
The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.
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20
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Affiliation(s)
- Samir Kendale
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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21
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Anesthesia preoperative clinics: redefining the value proposition. Int Anesthesiol Clin 2021; 59:59-72. [PMID: 34433183 DOI: 10.1097/aia.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Peel JK, Trudeau J, Tano R, Jadunandan S, Callum J, Moussa F, Lin Y. Determining Optimal Treatment to Correct Preoperative Anemia and Reduce Perioperative Allogeneic Blood Transfusions in Cardiac Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:2631-2639. [PMID: 33483268 DOI: 10.1053/j.jvca.2020.12.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/24/2020] [Accepted: 12/28/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Preoperative anemia management reduces red blood cell (RBC) transfusion and adverse outcomes, but how best to optimize the patient's hemoglobin (Hgb) before cardiac surgery remains unclear. The authors sought to determine the optimal treatment of anemia using iron and epoetin alfa before cardiac surgery. DESIGN Retrospective cohort study. SETTING Sunnybrook Health Sciences Centre, University of Toronto. PARTICIPANTS The study comprised 532 consecutive patients referred to the outpatient Blood Conservation Clinic and who underwent cardiac surgery between 2008 and 2018. INTERVENTIONS Of the 532 patients, 207 received oral iron, 84 received intravenous (IV) iron, 71 received epoetin alfa, 92 received combination therapy, and 78 received no treatment. MEASUREMENTS AND MAIN RESULTS Multivariate linear, logistic, and Poisson regressions modelled preoperative Hgb, the change from referral to preoperative Hgb (∆Hgb), the odds of transfusion, and the number of RBC units transfused, while accounting for baseline covariates. Higher ∆Hgb was associated with IV iron >600 mg (9.80 g/L [6.17-13.42]), epoetin alfa >80,000 U (5.80 g/L [2.20-9.40]), and higher referral Hgb (1.91 g/L [1.09-2.74] per 10 g/L). Higher preoperative Hgb (odds ratio 0.76 [0.64-0.90]; count ratio 0.84 [0.77-0.93] per 10 g/L) corresponded to a lower likelihood of being transfused and transfusion of fewer RBC units. CONCLUSIONS Preoperative IV iron >600 mg and epoetin alfa >80,000 U each was associated with significant increases in Hgb. Higher preoperative Hgb was associated with a lower likelihood of transfusion and transfusion of fewer RBC units. The authors recommend that cumulative preoperative doses of IV iron >600 mg and epoetin alfa >80,000 U be used for treatment of anemia before cardiac surgery.
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Affiliation(s)
- John K Peel
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jacqueline Trudeau
- Department of Anesthesia, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ruby Tano
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Saudia Jadunandan
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Quality in Utilization, Education and Safety Research Program, University of Toronto, Toronto, Ontario, Canada
| | - Fuad Moussa
- Department of Cardiac Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Quality in Utilization, Education and Safety Research Program, University of Toronto, Toronto, Ontario, Canada.
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23
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Kattini R, Poirier J, Minty L, LaJuenesse D, Kelly L, Madden S, Minty R, Larsen S, Hummelen R. Intravenous iron therapy in a rural hospital: A retrospective chart review. CANADIAN JOURNAL OF RURAL MEDICINE 2021; 26:123-127. [PMID: 34259226 DOI: 10.4103/cjrm.cjrm_4_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Intravenous iron infusion therapy is commonly delivered in rural hospitals, but there are no common guidelines for dosing or choice of agent. The objective of the study was to understand present practice and alternate therapies and develop practical recommendations for small hospital use. Methods This was a retrospective chart review of all non-dialysis patients aged 15 years or older who received iron replacement therapy at Sioux Lookout Meno Ya Win Health Centre from May 2013 to May 2019 and a literature review of available iron preparations. Results Of the 147 patients who received intravenous iron replacement, 75 were administered a single dose of 200 mg or 500 mg iron sucrose. Commonly used in pregnant patients, an increase in haemoglobin by an average of 9.2 g/L followed a 200 mg dose and 12.5 g/L after 500 mg. The 3-h infusion time for the 500 mg dose consumed considerably more nursing resources. Non-pregnant patients can be transfused more effectively with iron maltoside which can efficiently deliver larger doses of iron. Conclusion We recommend iron maltoside for efficient intravenous iron replacement in non-pregnant patients and single or multiple doses of 200 mg iron sucrose during pregnancy.
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Affiliation(s)
- Ribal Kattini
- Sioux Lookout Local Education Group, Sioux Lookout, ON, Canada
| | - Jenna Poirier
- Sioux Lookout Local Education Group, Sioux Lookout, ON, Canada
| | - Lauren Minty
- Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | | | - Len Kelly
- Sioux Lookout Meno Ya Win He-alth Centre, Sioux Lookout, ON, Canada
| | - Sharen Madden
- Division of Clinical Sciences, Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Robert Minty
- Division of Clinical Sciences, Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Sydney Larsen
- Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Ruben Hummelen
- Division of Clinical Sciences, Northern Ontario School of Medicine, Thunder Bay, ON, Canada
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Houston BL, Fergusson DA, Falk J, Krupka E, Perelman I, Breau RH, McIsaac DI, Rimmer E, Houston DS, Garland A, Ariano RE, Tinmouth A, Balshaw R, Turgeon AF, Jacobsohn E, Park J, Buduhan G, Johnson M, Koulack J, Zarychanski R. Evaluation of Transfusion Practices in Noncardiac Surgeries at High Risk for Red Blood Cell Transfusion: A Retrospective Cohort Study. Transfus Med Rev 2020; 35:16-21. [PMID: 32994103 DOI: 10.1016/j.tmrv.2020.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/17/2020] [Accepted: 08/21/2020] [Indexed: 01/28/2023]
Abstract
Perioperative bleeding is a major indication for red blood cell (RBC) transfusion, yet transfusion data in many major noncardiac surgeries are lacking and do not reflect recent blood conservation efforts. We aim to describe transfusion practices in noncardiac surgeries at high risk for RBC transfusion. We completed a retrospective cohort study to evaluate adult patients undergoing major noncardiac surgery at 5 Canadian hospitals between January 2014 and December 2016. We used Canadian Classification of Health Interventions procedure codes within the Discharge Abstract Database, which we linked to transfusion and laboratory databases. We studied all patients undergoing a major noncardiac surgery at ≥5% risk of perioperative RBC transfusion. For each surgery, we characterized the percentage of patients exposed to an RBC transfusion, the mean/median number of RBC units transfused, and platelet and plasma exposure. We identified 85 noncardiac surgeries with an RBC transfusion rate ≥5%, representing 25,607 patient admissions. The baseline RBC transfusion rate was 16%, ranging from 5% to 49% among individual surgeries. Of those transfused, the median (Q1, Q3) number of RBCs transfused was 2 U (1, 3 U); 39% received 1 U RBC, 36% received 2 U RBC, and 8% were transfused ≥5 U RBC. Platelet and plasma transfusions were overall low. In the era of blood conservation, we described transfusion practices in major noncardiac surgeries at high risk for RBC transfusion, which has implications for patient consent, preoperative surgical planning, and blood bank inventory management.
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Affiliation(s)
- Brett L Houston
- Department of Medical Oncology and Haematology, CancerCare Manitoba and Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jamie Falk
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emily Krupka
- Faculty of Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Iris Perelman
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Rodney H Breau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada; Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada; Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Emily Rimmer
- Department of Medical Oncology and Haematology, CancerCare Manitoba and Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Donald S Houston
- Department of Medical Oncology and Haematology, CancerCare Manitoba and Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allan Garland
- Departments of Medicine and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert E Ariano
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Robert Balshaw
- George & Fay Yee Center for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada; CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Eric Jacobsohn
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jason Park
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gordon Buduhan
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Michael Johnson
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joshua Koulack
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ryan Zarychanski
- Department of Medical Oncology and Haematology, CancerCare Manitoba and Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
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25
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The changing landscape of iron deficiency. Mol Aspects Med 2020; 75:100861. [PMID: 32418671 DOI: 10.1016/j.mam.2020.100861] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 12/25/2022]
Abstract
Iron deficiency (ID) with or without anemia is common worldwide. ID is a broad definition encompassing decreased total body iron (absolute deficiency) as well as reduced iron supply to erythropoietic and/or other organs with preserved stores (functional iron deficiency, FID), as it occurs in inflammation. Increased iron needs unbalanced by iron supply, low iron intake, reduced absorption and chronic blood loss, often in combination, are the main causes of absolute ID, easily diagnosed by low ferritin levels. In all these cases hepcidin synthesis is repressed, while in FID is augmented by inflammatory cytokines, causing iron sequestration in stores. Because of increased ferritin levels diagnosis of ID in the latter condition may be tricky: global clinical evaluation, accepted threshold of iron tests together with response to iron treatment may be of help. Search and removal of the responsible cause(s) is as important as diagnosing ID or FID. The response to oral iron treatment is suboptimal when hepcidin levels are high. Future research is needed to establish/validate markers for improved diagnosis of complex cases and to test the therapeutic value of drugs under development aimed at interfering with the altered iron trafficking.
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26
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Ning S, Zeller MP. Management of iron deficiency. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:315-322. [PMID: 31808874 PMCID: PMC6913441 DOI: 10.1182/hematology.2019000034] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Iron deficiency (ID) affects billions of people worldwide and remains the leading cause of anemia with significant negative impacts on health. Our approach to ID and iron deficiency anemia (IDA) involves three steps (I3): (1) identification of ID/IDA, (2) investigation of and management of the underlying etiology of ID, and (3) iron repletion. Iron repletion options include oral and intravenous (IV) iron formulations. Oral iron remains a therapeutic option for the treatment of ID in stable patients, but there are many populations for whom IV iron is more effective. Therefore, IV iron should be considered when there are no contraindications, when poor response to oral iron is anticipated, when rapid hematologic responses are desired, and/or when there is availability of and accessibility to the product. Judicious use of red cell blood transfusion is recommended and should be considered only for severe, symptomatic IDA with hemodynamic instability. Identification and management of ID and IDA is a central pillar in patient blood management.
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Affiliation(s)
- Shuoyan Ning
- Division of Hematology and Thromboembolism and
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada; and
| | - Michelle P Zeller
- Division of Hematology and Thromboembolism and
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada; and
- Canadian Blood Services, Ancaster, ON, Canada
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