Peri-operative treatment of anaemia in major orthopaedic surgery: a practical approach from Spain

In patients undergoing major orthopaedic surgery, pre-operative anaemia, peri-operative bleeding and a liberal transfusion policy are the main risk factors for requiring red blood cell transfusion (RBCT). The clinical and economic disadvantages of RBCT have led to the development and implementation of multidisciplinary, multimodal, individualised strategies, collectively termed patient blood management, which aim to reduce RBCT and improve patients' clinical outcome and safety. Within a patient blood management programme, low pre-operative haemoglobin is one of the few modifiable risk factors for RBCT. However, a survey among Anaesthesia Departments in Spain revealed that, although pre-operative assessment was performed in the vast majority of hospitals, optimisation of haemoglobin concentration was attempted in <40% of patients who may have benefitted from it, despite there being enough time prior to surgery. This indicates that haemoglobin optimisation takes planning and forethought to be implemented in an effective manner. This review, based on available clinical evidence and our experience, is intended to provide clinicians with a practical tool to optimise pre-operative haemoglobin levels, in order to minimise the risk of patients requiring RBCT. To this purpose, after reviewing the diagnostic value and limitations of available laboratory parameters, we developed an algorithm for the detection, classification and treatment of pre-operative anaemia, with a patient-tailored approach that facilitates decision-making in the pre-operative assessment. We also reviewed the efficacy of the different pharmacological options for pre-operative and post-operative management of anaemia. We consider that such an institutional pathway for anaemia management could be a viable, cost-effective strategy that is beneficial to both patients and healthcare systems

Papel del hierro endovenoso para el manejo de la anemia preoperatoria en cirugía ortopédica mayor dentro de un programa de ahorro de sangre

Objetivo

Recommendations from the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS)

Background: Perioperative anemia has been associated with increased risk of red blood cell transfusion and increased morbidity and mortality following surgery. The optimal approach to the diagnosis and management of perioperative anemia is not fully established. Objective: To develop consensus recommendations for anemia management in surgical patients. Methods: An international expert panel reviewed the current evidence and developed recommendations using modified RAND Delphi methodology. Results: The panel recommends that all patients be screened for anemia prior to surgery. Appropriate therapy for anemia should be guided by an accurate diagnosis of the etiology. The need to proceed with surgery in some patients with anemia is expected to persist. However, early identification and effective treatment of anemia has the potential to reduce the risks associated with surgery and improve clinical outcomes. As with preoperative anemia, postoperative anemia should be treated in the perioperative period. Conclusions: Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients

Foro de debate: seguridad de las alternativas a la transfusión alogénica en el paciente quirúrgico y/o crítico

Estos últimos años han aparecido alertas de seguridad, no siempre bien sustentadas, que cuestionan el uso de algunas alternativas farmacológicas a la transfusión de sangre alogénica y/o lo restringen en indicaciones establecidas. Asistimos también a la preconización de otras alternativas, incluyendo productos hemáticos y fármacos antifibrinolíticos, sin que haya una base científica sólida que lo justifique. Por iniciativa del Grupo de Estudios Multidisciplinares sobre Autotransfusión y del Anemia Working Group Espana¿ se reunió a un panel multidisciplinar de 23 expertos del área de cuidados de la salud en un foro de debate para: 1) analizar las diferentes alertas de seguridad en torno a ciertas alternativas a la transfusión; 2) estudiar los antecedentes que las han propiciado, la evidencia que las sustentan y las consecuencias que conllevan para la práctica clínica, y 3) emitir una valoración argumentada de la seguridad de cada alternativa a la transfusión cuestionada, según el uso clínico de la misma. Los integrantes del foro mantuvieron contactos por vía telemática y una reunión presencial en la que presentaron y discutieron las conclusiones sobre cada uno de los elementos examinados. Se elaboró un primer documento que fue sometido a 4 rondas de revisión y actualización hasta alcanzar un consenso, unánime en la mayoría de los casos. Presentamos la versión final del documento, aprobada por todos los miembros del panel, esperando sea de utilidad para nuestros colegas

2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla

La transfusión de sangre alogénica (TSA) no es inocua, y como consecuencia han surgido múltiples alternativas a la misma (ATSA). Existe variabilidad respecto a las indicaciones y buen uso de las ATSA. Dependiendo de la especialidad de los médicos que tratan a los pacientes, el grado de anemia, la política transfusional, la disponibilidad de las ATSA y el criterio personal, estas se usan de forma variable. Puesto que las ATSA tampoco son inocuas y pueden no cumplir criterios de coste-efectividad, la variabilidad en su uso es inaceptable. Las sociedades españolas de Anestesiología y Reanimación (SEDAR), Hematología y Hemoterapia (SEHH), Farmacia Hospitalaria (SEFH), Medicina Intensiva y Unidades Coronarias (SEMICYUC), Trombosis y Hemostasia (SETH) y Transfusiones Sanguíneas (SETS) han elaborado un documento de consenso para el buen uso de la ATSA. Un panel de expertos de las 6 sociedades ha llevado a cabo una revisión sistemática de la literatura médica y elaborado el 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Solo se contempla las ATSA dirigidas a disminuir la transfusión de concentrado de hematíes. Se definen las ATSA como toda medida farmacológica y no farmacológica encaminada a disminuir la transfusión de concentrado de hematíes, preservando siempre la seguridad del paciente. La cuestión principal que se plantea en cada ítem se formula, en forma positiva o negativa, como: «La ATSA en cuestión reduce/no reduce la tasa transfusional». Para formular el grado de recomendación se ha usado la metodología Grades of Recommendation Assessment, Development and Evaluation (GRADE)

Utilitat del ferro endovenós per al tractament de l’anèmia periquirúrgica en cirurgia ortopèdica

Aquesta tesi, realitzada com a compendi de publicacions, vol demostrar quina es la utilitat del ferro intravenós en el tractament de l’anèmia preoperatòria i postoperatòria en el context d’un pla personalitzat per tal d’evitar la transfusió i millorar l’evolució del pacient de cirurgia ortopèdica major. També valora quines implicacions econòmiques te aquest tractament dins d’un programa integral d’estalvi de sang (Patient blood management). Aquest treball s’inicia al 2009 amb un estudi multicèntric comparant dos ferros endovenosos (ferro sacarosa i carboximaltosa) pel tractament de l’anèmia ferropènica preoperatòria en cirurgia major electiva i que es publica al 2011 al British Journal of anaesthesia. En ell es demostra l’eficàcia i seguretat del tractament en corregir l’anèmia ferropènica en menys d’un mes, en pacients de cirurgia ortopèdica major (artroplàsties de maluc i genoll). L’estudi també demostra que la formulació de ferro carboximaltosa que permet administrar tota la dosi necessària en una o dues visites, millora la confortabilitat del tractament i la relació de cost/eficàcia. Posteriorment es valora en un assaig clínic l’eficàcia del ferro endovenós carboximaltosa (FCM) front el ferro oral, per al tractament de l’anèmia postoperatòria en pròtesis de genoll i el seu paper en la qualitat de vida, que es publica l’abril de 2014, també al British Journal of anaesthesia. En aquest estudi s’observa que els pacients tractats amb FCM corregeixen millor que el ferro oral l’anèmia i la ferropènia als 30 dies de la cirurgia però amb poca repercussió en la qualitat de vida i la capacitat d’esforç. El subgrup de pacients amb dipòsits baixos de ferro o amb anèmia postoperatòria mes greu, incrementen l’hemoglobina als 30 dies de manera més significativa i amb repercussió sobre la qualitat de vida sobretot puntuant millor en les activitats habituals. Finalment es publica en la Revista Española de Anestesiología y Reanimación, un anàlisis del tractament de l’anèmia en el context de l’estalvi de sang, des de una perspectiva econòmica, on es veu que aquest tractament pot estalviar costos tan en sang com escorçant la estada hospitalària i els reingressos. Cada cop hi ha mes evidència de que la transfusió es una terapèutica sobre utilitzada que implica un elevat cost, sobre tot incrementant la morbimortalitat, i el tractament de l’anèmia es el primer pilar per a la prevenció de la transfusió. Aquest treball permet demostrar que en mes del 50% dels casos el ferro intravenós pot tenir un paper fonamental tan en la milloria de l’anèmia periquirúrgica i qualitat de vida, com reduint la transfusió i augmentant la seguretat clínica i els costos.This thesis, conducted as a compendium of publications, wants to prove the utility of intravenous iron for treating pre and postoperative anaemia in the context of a personalized plan to avoid transfusion and improve the outcomes in major orthopaedic surgery patients. It also wants to assess the economic implications of this treatment within a comprehensive Patient Blood Management program (PBM). This work begins in 2009 with a prospective, multicentre study comparing two intravenous irons (iron sucrose and carboximaltose) for the treatment of iron deficiency anaemia in preoperative elective major surgery and in 2011 the results were published in the British Journal of Anaesthesia. We demonstrate the efficacy and safety of this treatment to correct iron deficiency anaemia in less than one month, in major orthopaedic surgery patients (hip and knee arthroplasty). The study also shows that the formulation of iron carboximaltose, that allows you to manage the entire necessary dose in one or two visits, improves the comfort of the treatment and the cost / effectiveness relationship. The second study is a randomized clinical trial to evaluate the efficacy of intravenous iron carboximaltose (FCM) versus oral iron for the treatment of postoperative anaemia in knee replacement surgery and their role in the quality of life, published in April 2014, in the British Journal of Anaesthesia. We found that a postoperative dose of FCM resulted in more frequent correction of postoperative anaemia and iron deficiency, than oral iron. Patients with low preoperative iron stores and/ or with severe anaemia the day after surgery, showed a particular benefit of intravenous over oral iron, due a significantly increase of haemoglobin at day 30 and improving the quality of life test, especially in "usual activities" subcategories. Finally we published in “Revista Española de Anestesiología y Reanimación” an assessment of the perioperative anaemia treatment within a comprehensive Patient Blood Management program from an economic perspective. We showed that anaemia treatment in surgery context can offer substantial savings to health departments by reducing the cost of units transfused, and the morbidity related to transfusion. There is increase evidence that transfusion is an overused treatment that leads to high costs, particularly increasing morbidity and mortality. The anaemia treatment is the first pillar in PBM for preventing transfusion in surgery context. This work would demonstrate that in more than 50% of cases, the intravenous iron may play a key role for the improvement of perioperative anaemia and this could reduce transfusion, improve safety and save costs

Management of Perioperative Iron Deficiency Anemia

Preoperative anemia affects 30–40% of patients undergoing major surgery and is an independent risk factor for perioperative blood transfusion, morbidity, and mortality. Absolute or functional iron deficiency is its leading cause. Nonanemic hematinic deficiencies are also prevalent and may hamper preoperative hemoglobin optimization and/or recovery from postoperative anemia. As modifiable risk factors, anemia and hematinic deficiencies should be detected and corrected prior to major surgical procedures. Postoperative anemia is even more common (up to 80–90%) due to surgery-associated blood loss, inflammation-induced blunted erythropoiesis, and/or preexisting anemia. Preoperative oral iron may have a role in mild-to-moderate anemia, provided there is sufficient time (6–8 weeks) and adequate tolerance of oral preparations. Postoperative oral iron is of little value and rife with gastrointestinal adverse events. Intravenous iron should preferentially be used in cases of moderate-to-severe iron deficiency anemia, concomitant use of erythropoiesis-stimulating agents, short time to surgery or nonelective procedures, and for postoperative anemia management. Minor infusion reactions to intravenous iron are rare, the incidence of severe anaphylactic reactions is extremely low, and there is no increase in infections with intravenous iron. Currently available intravenous iron formulations allowing administration of large single doses are preferred

Recommendations from the international consensus conference on anemia management in surgical patients (ICCAMS)

Data de publicació electrónica: 21-09-2022Background: perioperative anemia has been associated with increased risk of red blood cell transfusion and increased morbidity and mortality following surgery. The optimal approach to the diagnosis and management of perioperative anemia is not fully established. Objective: to develop consensus recommendations for anemia management in surgical patients. Methods: an international expert panel reviewed the current evidence and developed recommendations using modified RAND Delphi methodology. Results: the panel recommends that all patients be screened for anemia prior to surgery. Appropriate therapy for anemia should be guided by an accurate diagnosis of the etiology. The need to proceed with surgery in some patients with anemia is expected to persist. However, early identification and effective treatment of anemia has the potential to reduce the risks associated with surgery and improve clinical outcomes. As with preoperative anemia, postoperative anemia should be treated in the perioperative period. Conclusions: early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients

Utilitat del ferro endovenós per al tractament de l'anèmia periquirúrgica en cirurgia ortopèdica

Aquesta tesi, realitzada com a compendi de publicacions, vol demostrar quina es la utilitat del ferro intravenós en el tractament de l'anèmia preoperatòria i postoperatòria en el context d'un pla personalitzat per tal d'evitar la transfusió i millorar l'evolució del pacient de cirurgia ortopèdica major. També valora quines implicacions econòmiques te aquest tractament dins d'un programa integral d'estalvi de sang (Patient blood management). Aquest treball s'inicia al 2009 amb un estudi multicèntric comparant dos ferros endovenosos (ferro sacarosa i carboximaltosa) pel tractament de l'anèmia ferropènica preoperatòria en cirurgia major electiva i que es publica al 2011 al British Journal of anaesthesia. En ell es demostra l'eficàcia i seguretat del tractament en corregir l'anèmia ferropènica en menys d'un mes, en pacients de cirurgia ortopèdica major (artroplàsties de maluc i genoll). L'estudi també demostra que la formulació de ferro carboximaltosa que permet administrar tota la dosi necessària en una o dues visites, millora la confortabilitat del tractament i la relació de cost/eficàcia. Posteriorment es valora en un assaig clínic l'eficàcia del ferro endovenós carboximaltosa (FCM) front el ferro oral, per al tractament de l'anèmia postoperatòria en pròtesis de genoll i el seu paper en la qualitat de vida, que es publica l'abril de 2014, també al British Journal of anaesthesia. En aquest estudi s'observa que els pacients tractats amb FCM corregeixen millor que el ferro oral l'anèmia i la ferropènia als 30 dies de la cirurgia però amb poca repercussió en la qualitat de vida i la capacitat d'esforç. El subgrup de pacients amb dipòsits baixos de ferro o amb anèmia postoperatòria mes greu, incrementen l'hemoglobina als 30 dies de manera més significativa i amb repercussió sobre la qualitat de vida sobretot puntuant millor en les activitats habituals. Finalment es publica en la Revista Española de Anestesiología y Reanimación, un anàlisis del tractament de l'anèmia en el context de l'estalvi de sang, des de una perspectiva econòmica, on es veu que aquest tractament pot estalviar costos tan en sang com escorçant la estada hospitalària i els reingressos. Cada cop hi ha mes evidència de que la transfusió es una terapèutica sobre utilitzada que implica un elevat cost, sobre tot incrementant la morbimortalitat, i el tractament de l'anèmia es el primer pilar per a la prevenció de la transfusió. Aquest treball permet demostrar que en mes del 50% dels casos el ferro intravenós pot tenir un paper fonamental tan en la milloria de l'anèmia periquirúrgica i qualitat de vida, com reduint la transfusió i augmentant la seguretat clínica i els costosThis thesis, conducted as a compendium of publications, wants to prove the utility of intravenous iron for treating pre and postoperative anaemia in the context of a personalized plan to avoid transfusion and improve the outcomes in major orthopaedic surgery patients. It also wants to assess the economic implications of this treatment within a comprehensive Patient Blood Management program (PBM). This work begins in 2009 with a prospective, multicentre study comparing two intravenous irons (iron sucrose and carboximaltose) for the treatment of iron deficiency anaemia in preoperative elective major surgery and in 2011 the results were published in the British Journal of Anaesthesia. We demonstrate the efficacy and safety of this treatment to correct iron deficiency anaemia in less than one month, in major orthopaedic surgery patients (hip and knee arthroplasty). The study also shows that the formulation of iron carboximaltose, that allows you to manage the entire necessary dose in one or two visits, improves the comfort of the treatment and the cost / effectiveness relationship. The second study is a randomized clinical trial to evaluate the efficacy of intravenous iron carboximaltose (FCM) versus oral iron for the treatment of postoperative anaemia in knee replacement surgery and their role in the quality of life, published in April 2014, in the British Journal of Anaesthesia. We found that a postoperative dose of FCM resulted in more frequent correction of postoperative anaemia and iron deficiency, than oral iron. Patients with low preoperative iron stores and/ or with severe anaemia the day after surgery, showed a particular benefit of intravenous over oral iron, due a significantly increase of haemoglobin at day 30 and improving the quality of life test, especially in "usual activities" subcategories. Finally we published in "Revista Española de Anestesiología y Reanimación" an assessment of the perioperative anaemia treatment within a comprehensive Patient Blood Management program from an economic perspective. We showed that anaemia treatment in surgery context can offer substantial savings to health departments by reducing the cost of units transfused, and the morbidity related to transfusion. There is increase evidence that transfusion is an overused treatment that leads to high costs, particularly increasing morbidity and mortality. The anaemia treatment is the first pillar in PBM for preventing transfusion in surgery context. This work would demonstrate that in more than 50% of cases, the intravenous iron may play a key role for the improvement of perioperative anaemia and this could reduce transfusion, improve safety and save costs