Perioperative Iron Deficiency in Patients Scheduled for Major Elective Surgeries: A French Prospective Multicenter Cross-Sectional Study

BACKGROUND

The management of perioperative iron deficiency is a component of the concept of patient blood management. The objective of this study was to update French data on the prevalence of iron deficiency in patients scheduled for major surgery.

METHODS

The CARENFER PBM study was a prospective cross-sectional study in 46 centers specialized in orthopedic, cardiac, urologic/abdominal, or gynecological surgery. The primary end point was the prevalence of iron deficiency at the time of surgery (D-1/D0) defined as serum ferritin <100 µg/L and/or transferrin saturation (TSAT) <20%.

RESULTS

A total of 1494 patients (mean age, 65.7 years; women, 49.3%) were included from July 20, 2021 to January 3, 2022. The prevalence of iron deficiency in the 1494 patients at D-1/D0 was 47.0% (95% confidence interval [CI], 44.5-49.5). At 30 days after surgery, the prevalence of iron deficiency was 45.0% (95% CI, 42.0-48.0) in the 1085 patients with available data. The percentage of patients with anemia and/or iron deficiency increased from 53.6% at D-1/D0 to 71.3% at D30 ( P < .0001), mainly due to the increase of patients with both anemia and iron deficiency (from 12.2% at D-1/D0 to 32.4% at D30; P < .0001). However, a treatment of anemia and/or iron deficiency was administered preoperatively to only 7.7% of patients and postoperatively to 21.7% (intravenous iron, 14.2%).

CONCLUSIONS

Iron deficiency was present in half of patients scheduled for major surgery. However, few treatments to correct iron deficiency were implemented preoperatively or postoperatively. There is an urgent need for action to improve these outcomes, including better patient blood management.

Transfusion-Related Renal Dysfunction After Cardiac Surgery

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Following cardiac surgery, 20% of patients will present with AKI, which is associated with increased mortality, and transfusion increases the risk of AKI.

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The main objective was to determine whether the composition of transfusion was associated with AKI.

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In this study, AKI patients received higher amount of MRP_14 through transfusion vs non-AKI.

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MRP_14 has been reported to activate and enhance neutrophil transmigration into damaged tissues. In a murine model of ischemia-reperfusion, MRP_14 increased renal damage and enhanced neutrophil influx into the kidney. MRP_14 also increased neutrophilic-trogocytosis toward tubular cells.

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The sex of the donor and the method of preparation of the blood determined the concentration of MRP_14 in packed red blood cells.

Transfusion is a specific cause of acute kidney injury (AKI) after cardiac surgery. Whether there is an association between the composition of blood products and the onset of AKI is unknown. The present study suggests that the transfusion of packed red blood cells containing a high amount of myeloid-related protein 14 (MRP_14) could increase the incidence of AKI after cardiac surgery. In a mouse model, MRP_14 increased the influx of neutrophils in the kidney after ischemia-reperfusion and their ability to damage tubular cells. Higher concentrations of MRP_14 were found in packed red blood cells from female donors or prepared by whole blood filtration.

Evaluation of the impact of HMS Plus on postoperative blood loss compared with ACT Plus in cardiac surgery

BACKGROUND

The standardized management of anticoagulation during the cardiopulmonary bypass seems inaccurate because of patients and surgeries variability. This study evaluates if an individualized management of heparin and protamine guided by the HMS Plus system during cardiopulmonary bypass could reduce postoperative blood loss.

METHODS

We conducted a prospective, controlled, unblinded, single-center study. 188 patients operated for cardiac surgery were included. Patients were divided in ACT Plus group (standardized approach) and HMS Plus group (individualized approach). The primary outcome was blood-loss volume during the first 24 postoperative hours. The main secondary outcomes were the need for allogeneic blood transfusions and the final protamine/heparin ratio.

RESULTS

There was no difference between the two groups for baseline characteristics. Medium bloodloss volume (±DS) in the ACT Plus group was 522 mL ±260 mL vs. 527 mL ±255 mL in the HMS Plus group (P = 0.58). The final protamine/heparin ratio (±DS) in the ACT Plus group was 0.94 ±0.1 vs. 0.58 ± 0.1 in the HMS Plus group (P < 0.0001). The transfusion rate during surgery in the ACT Plus group was 25% vs. 14% in the HMS Plus group (P = 0.09).

CONCLUSIONS

HMS Plus did not reduce the mean blood-loss volume during the first 24 postoperative hours compared with ACT Plus. Its utility for potential transfusion rate reduction remains to be proven.

Programmes for the management of preoperative anaemia: audit in ten European hospitals within the PaBloE (Patient Blood Management in Europe) Working Group

BACKGROUND AND OBJECTIVES

Preoperative anaemia is an independent risk factor for a higher morbidity and mortality, a longer hospitalization and increased perioperative transfusion rates. Managing preoperative anaemia is the first of three pillars of Patient Blood Management (PBM), a multidisciplinary concept to improve patient safety. While various studies provide medical information on (successful) anaemia treatment pathways, knowledge of organizational details of diagnosis and management of preoperative anaemia across Europe is scarce.

MATERIALS AND METHODS

To gain information on various aspects of preoperative anaemia management including organization, financing, diagnostics and treatment, we conducted a survey (74 questions) in ten hospitals from seven European nations within the PaBloE (Patient Blood Management in Europe) working group covering the year 2016.

RESULTS

Organization and activity in the field of preoperative anaemia management were heterogeneous in the participating hospitals. Almost all hospitals had pathways for managing preoperative anaemia in place, however, only two nations had national guidelines. In six of the ten participating hospitals, preoperative anaemia management was organized by anaesthetists. Diagnostics and treatment focused on iron deficiency anaemia which, in most hospitals, was corrected with intravenous iron.

CONCLUSION

Implementation and approaches of preoperative anaemia management vary across Europe with a primary focus on treating iron deficiency anaemia. Findings of this survey motivated the hospitals involved to critically evaluate their practice and may also help other hospitals interested in PBM to develop action plans for diagnosis and management of preoperative anaemia.

Cost-effectiveness of point-of-care viscoelastic haemostatic assays in the management of bleeding during cardiac surgery: protocol for a prospective multicentre pragmatic study with stepped-wedge cluster randomised controlled design and 1-year follow-up (the IMOTEC study)

INTRODUCTION

During cardiac surgery-associated bleeding, the early detection of coagulopathy is crucial. However, owing to time constraints or lack of suitable laboratory tests, transfusion of haemostatic products is often inappropriately triggered, either too late (exposing to prolonged bleeding and thus to avoidable administration of blood products) or blindly to the coagulation status (exposing to unnecessary haemostatic products administration in patients with no coagulopathy). Undue exposition to transfusion risks and additional healthcare costs may arise. With the perspective of secondary care-related costs, the IMOTEC study (Intérêt MédicO-économique de la Thrombo-Elastographie, dans le management transfusionnel des hémorragies péri-opératoires de chirurgies Cardiaques sous circulation extracorporelle) aims at assessing the cost-effectiveness of a point-of-care viscoelastic haemostatic assay (VHA: RoTem or TEG)-guided management of bleeding. Among several outcome measures, particular emphasis will be put on quality of life with a 1-year follow-up.

METHODS AND ANALYSIS

This is a multicentre, prospective, pragmatic study with stepped-wedge cluster randomised controlled design. Over a 36-month period (24 months of enrolment and 12 months of follow-up), 1000 adult patients undergoing cardiac surgery with cardiopulmonary bypass will be included if a periprocedural significant bleeding occurs. The primary outcome is the cost-effectiveness of a VHA-guided algorithm over a 1-year follow-up, including patients' quality of life. Secondary outcomes are the cost-effectiveness of the VHA-guided algorithm with regard to the rate of surgical reexploration and 1-year mortality, its cost per-patient, its effectiveness with regard to haemorrhagic, infectious, renal, neurological, cardiac, circulatory, thrombotic, embolic complications, transfusion requirements, mechanical ventilation free-days, duration of intensive care unit and in-hospital stay and mortality.

ETHICS AND DISSEMINATION

The study was registered at Clinicaltrials.gov and was approved by the Committee for the Protection of Persons of Nantes University Hospital, The French Advisory Board on Medical Research Data Processing and the French Personal Data Protection Authority. A publication of the results in a peer-reviewed journal is planned.

TRIAL REGISTRATION NUMBER

NCT02972684; Pre-results.

Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study

RATIONALE

Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence.

OBJECTIVES

To determine whether early HVHF decreases all-cause mortality 30 days after randomization.

METHODS

This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury.

MEASUREMENTS AND MAIN RESULTS

On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia.

CONCLUSIONS

For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury. Clinical trial registered with www.clinicaltrials.gov (NCT 01077349).

[Body mass index and albuminemia in patients under mechanical circulatory assistance before cardiac transplantation]

OBJECTIVE

To evaluate the prognostic influence of peri-implantation nutritional status of patients under mechanical circulatory assist (MCA) prior to cardiac transplantation (CT).

STUDY DESIGN

Retrospective analysis of patients with cardiogenic shock included from June 1997 to December 2002.

PATIENTS AND METHODS

Evaluation at MCA's implantation, at day (D) 30 and at CT or patient's death (D) of body mass index (BMI=body weight (kg)/size (m(2)), albuminemia (Alb g/l), expressed as median values (med) and range (min-max). Odds ratio (OR) and CI 95%) were calculated. A multivariate analysis was performed to determine variables related to D or CT success.

RESULTS

Thirty-four patients (30 men), median age 40.5 years (10-63), were included. MCA types were cardiac pumps (N=3); pneumatic (N=18) or electric (N=5) ventricular assist devices and artificial heart (N=8). Global mortality was 56% (19 over 34 patients) and at implantation in the global population (N=34) BMI was 19.4 (9.3-28.1) and Alb 24.6 g/l (15-37.5). At MCA's implantation and D30 respectively, 38 and 42% of the patients had a severe hypoAlb (Alb<30 g/l) and a BMI<19 attesting of a seriously deteriorated nutritional status. No significant statistical difference was observed on median BMI of transplanted patients T (N=15) and expired patients D (N=19). Alb was significantly different (p<10(-4)) between T and D patients: median Alb: 30 g/l (20-37.5) in T patients, 20 g/l (15-31) in D patients. HypoAlb<21 g/l was an independent prognostic factor of death (p=0.004; OR: 0.541; IC95% : 0.36-0.82) and Alb>33 g/l an independent prognostic factor of CT success (p=0.003; OR:1.38; IC95% : 1.12-1.71).

CONCLUSION

These results seem to demonstrate that at MCA implantation, a seriously deteriorated albuminemia level (<30 g/l) negatively impacts patients overall survival after CT.

[Effects of plasma substitutes on hemostasis]

OBJECTIVE

Data synthesis on haemostasis effects of cristalloids and colloids and clinical implications for their use for plasma volume replacement.

DATA SOURCES

Data were searched in the Medline database from 1954 to 2000 using the following key-words: cristalloids, colloids, albumin, gelatin, dextran, hydroxyethyl starch, haemostasis, von Willebrand disease, haemodilution.

DATA EXTRACTION

Publications from 1954 to 1990 were selected depending on the quality of their methodology. Most of articles published after 1990 and all types including case report were accepted.

DATA SYNTHESIS

Cristalloids induces a moderate hypercoagulable state with 10 to 30% haemodilution. Hypocoagulation is observed above 50% haemodilution. Albumin does not impair hemostasis except with a 50% or more haemodilution where hypocoagulation is observed. Dextran dramatically impairs haemostasis and fibrinolysis. With increasing dose, a progressive decrease of all von Willebrand multimers, mostly the largest, is observed. Till 50% haemodilution, gelatin has a moderate impact on hemostasis, but platelet aggregation is moderately modified. However this moderate impairment of haemostasis may potentiate the haemostatic effect of other colloids when used in association with gelatin. More than 30% haemodilution with hydroxyethyl starch (HES) has a serious effect in vitro on platelet function and fibrinoformation. In most studies in human, less than 20 ml.kg-1 plasma volume replacement has no clinical impact, but in some evaluations postoperative bleeding is more important with HES, particularly HES 450, in comparison to other colloids. With HES 450 and HES 200 highly substituted (0.6 of degree of substitution) intravascular cumulation of large molecules leads to type I von Willebrand syndrome when doses overtake 80 ml.kg-1. Dextran and HES are prohibited in patients with impaired haemostasis due to congenital disease (haemophilia and von Willebrand disease) or acquired defect (thrombocytopenia). Caution is required in patients with renal failure or receiving antithrombotic or non-steroidal anti-inflammatory agents. Patients without a haemorrhagic diathesis must not received more than 1.5 g.kg-1.j-1 of dextran and restrictive conditions of use must be respected with HES.

CONCLUSION

Except isotonic cristalloids, all colloids induce haemostastic changes particularly for haemodilution over 30%. Effects are more pronounced with HES and dextran.

[Hyperchloremic acidosis druing plasma volume replacement]

OBJECTIVES

Review of the physiological and clinical consequences of hyperchloraemic acidosis observed during plasma volume replacement using crystalloids and colloids.

DATA SOURCES

Data were searched in the Medline database after 1990 using the following key words: metabolic acidosis, crystalloids, colloids, albumin, gelatin, hydroxyethyl starch.

DATA EXTRACTION

Publications before 1990 were selected for their historical value. Most of articles published after 1990 and all types including case report were accepted.

DATA SYNTHESIS

Large volume infusion of isotonic solution can cause hyperchloraemic acidosis. Colloid plasma substitutes using saline solvent may be responsible for the same kind of acidosis with acidaemia. The anion gap is not modified in this case because of chloride increase. Physiological mechanism may be described using the Henderson-Hasselbach equation or the strong ion difference decrease (Stewart concept). Excessive chloride infusion is a major factor in this acid-base disorder and the term hyperchloraemic acidosis should be preferred to dilutional acidosis. When perioperative acidosis occurs, careful and complete analysis of acid-base disturbance should be made. The association of a normal anion gap, normal lactatemia, hyperchloraemia and acidaemia does not need specific treatment. Acidosis corrects spontaneously and slowly following chloride normalization. But any factor that may increase acidosis should be avoided.

CONCLUSION

The use of balanced solution like lactated-Ringer solution instead of isotonic saline solution for fluid resuscitation, except for specific contra-indication as intracranial hypertension, may avoid hyperchloraemic acidosis. Potential risk of this acidosis led to the conception of a new colloid using balanced crystalloids solution as the solvent (Hextend).

Postoperative analgesia by epidural methylprednisolone after posterolateral thoracotomy

The aim of this study was to evaluate the potential analgesic effect of epidural methylprednisolone (MP) after posterolateral thoracotomy (PLT). Adult male patients undergoing PLT for lung surgery were included in a prospective, randomized, double blind study. Peroperative analgesia (bupivacaine plus sufentanil) was given by a thoracic epidural catheter associated with general anaesthesia. After surgery, patients received either MP 1 mg kg(-1) followed by a continuous epidural infusion of MP 1.5 mg kg(-1) during 48 h (MP group) or 0.9% saline as a bolus injection and continuous epidural infusion (P group). Additional morphine analgesia was administered by i.v. patient-controlled analgesia. Pain was assessed at rest and with mobilization every 4 h after operation during 48 h with a visual analogue scale (VAS). The primary end-point was the total morphine requirements during the 48 first postoperative hour. Twenty-four patients were allocated to MP (n=12) and P (n=12) groups. Characteristics of the two groups were similar. There were no differences between groups for morphine requirements (median and interquartile range) during the 48 h: 59 mg (40-78) in MP group vs 65 mg (59-93) in P group. There were no differences between groups for morphine requirements every 4 h during the 48 h and VAS for pain at rest and evoked pain. No side effects were reported. It was concluded in this small study that these results did not support the use of epidural steroids for postoperative analgesia after PLT.

Transesophageal echocardiography diagnosis of tricuspid obstruction by a vena cava tumour

PURPOSE

To present the anesthetic management for excision of a primary tumour of the inferior vena cava.

CLINICAL FEATURES

Resection of a primary tumour of the inferior vena cava without extension to the right atrium was scheduled without extra-corporeal circulation (ECC). The operation consisted of tumour excision with transtumoral clamping. During the immediate postoperative period, tricuspid obstruction was suspected when a "cannon a wave" was recorded from the right atrial pressure curve. Transesophageal echocardiography confirmed the diagnosis of tumour obstruction of the tricuspid valve.

CONCLUSION

Tricuspid obstruction due to postoperative mobilization of a primary tumour of the inferior vena cava was diagnosed by transesophageal echocardiography. Perioperative management particularities of the primary tumour of the vena cava are discussed.

[Post-traumatic hematoma of the esophagus]

A 20-year-old man was admitted after a traffic accident for a closed chest trauma. Initial evaluation showed a sternal fracture with a minor pneumomediastinum. Twenty-four hours later be experienced an acute respiratory failure, due to total left pulmonary atelectasis from indirect compression of the left main stem bronchus. Mediastinal widening at the postero-superior level was visualized by CT scan. The aortogram was normal. Thoracotomy showed a moderate left haemothorax, associated with an intramural haematoma of the low thoracic oesophagus which was respected. The time course was uneventful, except repetitive atelectases treated by fibrescopic aspiration. Oesophageal haematoma secondary to chest trauma is a rare injury, with around 10 cases reported in the literature. Compression of tracheobronchial axis is exceptional. Because of the delayed occurrence of such a complication after chest trauma, with sternal fracture, close clinical surveillance and CT scans are essential.