Management of peri-surgical anemia in elective surgery. Conclusions and recommendations according to Delphi-UCLA methodology

INTRODUCTION

Preoperative anemia affects approximately one third of surgical patients. It increases the risk of blood transfusion and influences short- and medium-term functional outcomes, increases comorbidities, complications and costs. The "Patient Blood Management" (PBM) programs, for integrated and multidisciplinary management of patients, are considered as paradigms of quality care and have as one of the fundamental objectives to correct perioperative anemia. PBM has been incorporated into the schemes for intensified recovery of surgical patients: the recent Enhanced Recovery After Surgery 2021 pathway (in Spanish RICA 2021) includes almost 30 indirect recommendations for PBM.

OBJECTIVE

To make a consensus document with RAND/UCLA Delphi methodology to increase the penetration and priority of the RICA 2021 recommendations on PBM in daily clinical practice.

MATERIAL AND METHODS

A coordinating group composed of 6 specialists from Hematology-Hemotherapy, Anesthesiology and Internal Medicine with expertise in anemia and PBM was formed. A survey was elaborated using Delphi RAND/UCLA methodology to reach a consensus on the key areas and priority professional actions to be developed at the present time to improve the management of perioperative anemia. The survey questions were extracted from the PBM recommendations contained in the RICA 2021 pathway. The development of the electronic survey (Google Platform) and the management of the responses was the responsibility of an expert in quality of care and clinical safety. Participants were selected by invitation from speakers at AWGE-GIEMSA scientific meetings and national representatives of PBM-related working groups (Seville Document, SEDAR HTF section and RICA 2021 pathway participants). In the first round of the survey, the anonymized online questionnaire had 28 questions: 20 of them were about PBM concepts included in ERAS guidelines (2 about general PBM organization, 10 on diagnosis and treatment of preoperative anemia, 3 on management of postoperative anemia, 5 on transfusion criteria) and 8 on pending aspects of research. Responses were organized according to a 10-point Likter scale (0: strongly disagree to 10: strongly agree). Any additional contributions that the participants considered appropriate were allowed. They were considered consensual because all the questions obtained an average score of more than 9 points, except one (question 14). The second round of the survey consisted of 37 questions, resulting from the reformulation of the questions of the first round and the incorporation of the participants' comments. It consisted of 2 questions about general organization of PBM programme, 15 questions on the diagnosis and treatment of preoperative anemia; 3 on the management of postoperative anemia, 6 on transfusional criteria and finally 11 questions on aspects pending od future investigations. Statistical treatment: tabulation of mean, median and interquartiles 25-75 of the value of each survey question (Tables 1, 2 and 3).

RESULTS

Except for one, all the recommendations were accepted. Except for three, all above 8, and most with an average score of 9 or higher. They are grouped into: 1.- "It is important and necessary to detect and etiologically diagnose any preoperative anemia state in ALL patients who are candidates for surgical procedures with potential bleeding risk, including pregnant patients". 2.- "The preoperative treatment of anemia should be initiated sufficiently in advance and with all the necessary hematinic contributions to correct this condition". 3.- "There is NO justification for transfusing any unit of packed red blood cells preoperatively in stable patients with moderate anemia Hb 8-10g/dL who are candidates for potentially bleeding surgery that cannot be delayed." 4.- "It is recommended to universalize restrictive criteria for red blood cell transfusion in surgical and obstetric patients." 5.- "Postoperative anemia should be treated to improve postoperative results and accelerate postoperative recovery in the short and medium term".

CONCLUSIONS

There was a large consensus, with maximum acceptance,strong level of evidence and high recommendation in most of the questions asked. Our work helps to identify initiatives and performances who can be suitables for the implementation of PBM programs at each hospital and for all patients.

[Treatment of preoperative anemia in major orthopedic surgery]

The prevalence of preoperative anemia in major orthopedic surgery is high and is the main predictive factor for allogeneic blood transfusion. The scheduling of a preoperative visit with sufficient notice (at least 3 weeks before surgery), with a blood count test and a basic iron metabolism study, enables us to treat the anemia and/or improve preoperative hemoglobin levels, thereby reducing the need for transfusion and the risks associated with transfusions. Intravenous iron and/or erythropoietin are treatments for optimizing preoperative anemia, with good levels of scientific evidence.

[Algorithm for treating preoperative anemia]

Hemoglobin optimization and treatment of preoperative anemia in surgery with a moderate to high risk of surgical bleeding reduces the rate of transfusions and improves hemoglobin levels at discharge and can also improve postoperative outcomes. To this end, we need to schedule preoperative visits sufficiently in advance to treat the anemia. The treatment algorithm we propose comes with a simple checklist to determine whether we should refer the patient to a specialist or if we can treat the patient during the same visit. With the blood count test and additional tests for iron metabolism, inflammation parameter and glomerular filtration rate, we can decide whether to start the treatment with intravenous iron alone or erythropoietin with or without iron. With significant anemia, a visit after 15 days might be necessary to observe the response and supplement the treatment if required. The hemoglobin objective will depend on the type of surgery and the patient's characteristics.

[Implementation of blood sparing programs in Spain: results of a survey of departments of anesthesiology and resuscitation]

The objective of this article is to determine the availability of a perioperative transfusion management program (Patient Blood Management [PBM]) in various hospitals through a survey that included a description of the preanesthesia visit, the availability and use of the various blood-sparing techniques and the factors limiting their implementation in elective surgery. The survey included 42 questions, directed at the representative departments of anesthesiology of hospitals in Spain (n=91). The survey was conducted from September to November 2012. We analyzed the 82 surveys in which all the questions were answered (90%). Preoperative consultations are routinely performed (>70%) in 87% of the hospitals. The time from the consultation to surgery varied between 1 week and 2 months for 74% of the patients scheduled for orthopedic or trauma surgery, 78% of those scheduled for oncologic surgery and 77% of those scheduled for cardiac surgery. Almost all hospitals (77, 94%) had a transfusion committee, and 90% of them had an anesthesiologist on the committee. Seventy-nine percent of the hospitals had a blood-sparing program, and the most widely used technique was the use of antifibrinolytic agents (75% of hospitals), followed by intraoperative and postoperative blood recovery in equal proportions (67%). Optimization of preoperative hemoglobin was routinely performed with intravenous iron in 39% of the hospitals and with recombinant erythropoietin in 28% of the hospitals. The absence of a well-established circuit and the lack of involvement and collaboration with the surgical team were the main limiting factors in implementing PBM. Currently, the implementation of PBM in Spain could be considered acceptable, but it could also be improved, especially in the treatment of preoperative anemia. The implementation of PBM requires multidisciplinary collaboration among all personnel responsible for perioperative care, including the health authorities.

[The first pillar of patient blood management. Types of anemia and diagnostic parameters]

Patient Blood Management (PBM) is the design of a personalized, multimodal multidisciplinary plan for minimizing transfusion and simultaneously achieving a positive impact on patient outcomes. The first pillar of PBM consists of optimizing the erythrocyte mass. The best chance for this step is offered by preoperative preparation. In most cases, a detailed medical history, physical examination and laboratory tests will identify the cause of anemia. A correct evaluation of parameters that assess the state and function of iron, such as ferritin levels, and the parameters that measure functional iron, such as transferrin saturation and soluble transferrin receptor levels, provide us with essential information for guiding the treatment with iron. The new blood count analyzers that measure hypochromia (% of hypochromic red blood cells and reticulocyte hemoglobin concentrations) provide us useful information for the diagnosis and follow-up of the response to iron treatment. Measuring serum folic acid and vitamin B12 levels is essential for treating deficiencies and thereby achieving better hemoglobin optimization.

Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues.

[Therapeutic approach to postoperative anemia]

Postoperative anemia is a common finding in patients who undergo major surgery, and it can affect early rehabilitation and the return to daily activities. Allogeneic blood transfusion is still the most widely used method for restoring hemoglobin levels rapidly and effectively. However, the potential risks of transfusions have led to the review of this practice and to a search for alternative measures for treating postoperative anemia. The early administration of intravenous iron appears to improve the evolution of postoperative hemoglobin levels and reduce allogeneic transfusions, especially in patients with significant iron deficiency or anemia. What is not clear is whether this treatment heavily influences rehabilitation and quality of life. There is a lack of well-designed, sufficiently large, randomized prospective studies to determine whether postoperative or perioperative intravenous iron treatment, with or without recombinant erythropoietin, has a role in the recovery from postoperative anemia, in reducing transfusions and morbidity rates and in improving exercise capacity and quality of life.

[Low-dose aspirin doesn't increase surgical bleeding nor transfusion rate in total knee arthroplasty]

OBJECTIVES

Surgical bleeding. transfusion rate and cardiovascular complications were analized in patients undergoing chronic treatment with low-doses aspirin and scheduled to unilateral primary knee arthroplasty.

PATIENTS AND METHODS

We retrospectively studied 117 patients between 2005 and 2006 scheduled for elective knee replacement that received antiplatelet therapy with aspirin (100mg/day). Aspirin medication was maintained or discontinued preoperatively according to medical criteria. We analyzed the biological, clinical and anesthetic data, blood-saving techniques used, surgical bleeding, allogeneic blood transfusion rate, cardiocirculatory complications (myocardial, cerebral or peripheral ischemia), hospital stay and mortality. This population was compared with 190 patients (control group) who underwent the same operation at the same time interval but did not receive aspirin therapy.

RESULTS

The aspirin-treated group was significantly older, with higher weight and poorer health state (higher incidence of ischemic heart disease, cerebral ischemia and diabetes). The hidden and external surgical bleeding and transfusion rate were similar if the aspirin were interrupted or not, preoperatively. Bleeding and transfusion rates were independent of time of interruption of the aspirin. Hospital mortality was zero in the 2 groups. A acute myocardial infarction and a transient stroke happened in two patients wich aspirin treatment was discontinued.

CONCLUSIONS

Preoperative treatment with low doses of aspirin does not increase surgical bleeding and transfusion rate in total knee arthroplasty. Preoperative discontinuation can cause severe cardiocirculatory complications.

[Epidural analgesia versus femoral or femoral-sciatic nerve block after total knee replacement: comparison of efficacy and safety]

OBJECTIVE

Pain after total knee replacement surgery is intense. The aim of this study was to compare 3 techniques for providing postoperative analgesia (epidural analgesia, femoral nerve block, and a combined femoral-sciatic nerve block) in total knee arthroplasty.

MATERIAL AND METHODS

Observational study of 1550 elective primary unilateral total knee replacement operations. The safety and efficacy of the following 3 techniques were compared: epidural analgesia, femoral nerve block, and femoral-sciatic nerve block. Demographic, anesthetic, and surgical data were recorded. Study variables included pain intensity on a visual analog scale every 4 hours, need for rescue analgesia (morphine), complications and adverse events within 5 postoperative days.

RESULTS

No significant differences were found in demographic, anesthetic, or surgical variables. In the first 24 hours after surgery, pain intensity was significantly less for patients who received a femoral-sciatic nerve block. The mean levels of morphine consumption in the first 96 hours after surgery were similar in the femoral-sciatic nerve block group (3.18 mg) and the epidural analgesia group (3.19 mg); morphine consumption in the femoral block group was significantly higher (4.51 mg). Epidural analgesia was associated with the highest rate of complications (17%).

CONCLUSIONS

A sciatic nerve block combined with a femoral nerve block attenuates pain more effectively and is associated with less postoperative morphine consumption in comparison with a femoral nerve block alone. Peripheral nerve block techniques have fewer adverse side effects than epidural analgesia.