The Impact of an Algorithm-Guided Management of Preoperative Anemia in Perioperative Hemoglobin Level and Transfusion of Major Orthopedic Surgery Patients
The aim of this study was to evaluate a laboratory-guided therapeutic algorithm of preoperative anemia. 335 patients with elective hip or knee arthroplasty were included in this retrospective before-after study. Group I ( ) underwent conventional preoperative procedures before algorithm implementation. Group II ( ) underwent algorithm-guided preoperative anemia management. A hemoglobin-level of 13？g/dL was the therapeutic cut-off for men and women. Reticulocyte hemoglobin content (CHr) and soluble transferrin receptor (sTfR)/log ferritin ratio were used in the form of the Thomas plot. Iron deficiency (ID) was substituted with 1000？mg iron intravenous (i.v.) and 10000 international units (I.U.) of erythropoiesis-stimulating agent (ESA) subcutaneous (s.c.) or i.v., anemia of chronic disease (ACD) (without functional ID) with 40000 I.U. ESA s.c. or i.v and additionally 200？mg iron i.v. Substituted anemic patients in Group II ( ) showed a distinctly higher preoperative (Hb-median 13 versus 11.95 g/dL) ( ) and postoperative (Hb-median 9.75 versus 9.0？g/dL) ( ) Hb level compared with untreated anemic patients in Group I ( ). In Group II red blood cell (RBC) units (35？units/234 patients) were reduced by 44% compared with Group I (27？units/101 patients). Algorithm-guided preoperative anemia management raises perioperative Hb-level and reduces blood use. 1. Introduction Based on the knowledge of the side effects of allogenic blood transfusions, patient blood management (PBM) evolved into a multidisciplinary clinical discipline. In the case of complications in hospitalized patients, such as lung injuries or nosocomial infections [1, 2], allogenic blood transfusions are known to be a risk factor. Furthermore, transfusion-related immunomodulation is described [3, 4]. Based on these findings, it is generally agreed that allogenic blood transfusion should be avoided, if possible. Thus, patients should undergo accurate clinical investigation before an elective surgical procedure. Preoperative anemia management including laboratory diagnosis and therapy of the various forms of anemia is one essential part of PBM. The prevalence of preoperative anemia is positively correlated with the age of the patient and more often found in elderly patients [2, 5]. Anemia of chronic disease (ACD) and iron deficiency (ID) are the most frequent causes of preoperative anemia [2, 6]. Low preoperative hemoglobin (Hb) levels are well known as major predicting factors in requiring perioperative blood transfusion in orthopedic surgery [7, 8]. Patients with preoperative Hb levels between 10
References
[1]
A. Shander, M. Javidroozi, S. Perelman, T. Puzio, and G. Lobel, “From bloodless surgery to patient blood management,” Mount Sinai Journal of Medicine, vol. 79, pp. 56–65, 2012.
[2]
H. Gombotz, “Patient blood management: a patient-orientated approach to blood replacement with the goal of reducing anemia, blood loss and the need for blood transfusion in elective surgery,” Transfusion Medicine and Hemotherapy, vol. 39, pp. 67–72, 2012.
[3]
A. Shander and L. T. Goodnough, “Why an alternative to blood transfusion?” Critical Care Clinics, vol. 25, no. 2, pp. 261–277, 2009.
[4]
C. Madjdpour, V. Heindl, and D. R. Spahn, “Risks, benefits, alternatives and indications of allogenic blood transfusions,” Minerva Anestesiologica, vol. 72, no. 5, pp. 283–298, 2006.
[5]
T. G. Monk, “Preoperative recombinant human erythropoietin in anemic surgical patients,” Critical Care, vol. 8, no. 2, pp. S45–S48, 2004.
[6]
G. M. T. Hare, J. E. Baker, and K. Pavenski, “Assessment and treatment of preoperative anemia: continuing professional development,” Canadian Journal of Anesthesia, vol. 58, no. 6, pp. 569–581, 2011.
[7]
M. Munoz, J. A. Garcia-Erce, J. Cuenca, E. Bisbe, and E. Naveira, “On the role of iron therapy for reducing allogenic blood transfusion in orthopaedic surgery,” Blood Transfusion, vol. 10, pp. 8–22, 2012.
[8]
M. Mu？oz, C. Breymann, J. A. García-Erce, S. Gómez-Ramírez, J. Comin, and E. Bisbe, “Efficacy and safety of intravenous iron therapy as an alternative/adjunct to allogeneic blood transfusion,” Vox Sanguinis, vol. 94, no. 3, pp. 172–183, 2008.
[9]
D. R. Spahn, “Anemia and patient blood management in hip and knee surgery: a systematic review of the literature,” Anesthesiology, vol. 113, no. 2, pp. 482–495, 2010.
[10]
L. T. Goodnough, A. Maniatis, P. Earnshaw et al., “Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines,” British Journal of Anaesthesia, vol. 106, pp. 13–22, 2011.
[11]
A. Shander, H. Van Aken, M. J. Colomina et al., “Patient blood management in Europe,” British Journal of Anaesthesia, vol. 109, pp. 55–68, 2012.
[12]
L. T. Goodnough, B. Skikne, and C. Brugnara, “Erythropoietin, iron, and erythropoiesis,” Blood, vol. 96, no. 3, pp. 823–833, 2000.
[13]
M. P. G. Leers, J. F. W. Keuren, and W. P. Oosterhuis, “The value of the Thomas-plot in the diagnostic work up of anemic patients referred by general practitioners,” International Journal of Laboratory Hematology, vol. 32, no. 6, pp. 572–581, 2010.
[14]
C. Thomas, A. Kirschbaum, D. Boehm, and L. Thomas, “The diagnostic plot: a concept for identifying different states of iron deficiency and monitoring the response to epoetin therapy,” Medical Oncology, vol. 23, no. 1, pp. 23–36, 2006.
[15]
C. Thomas and L. Thomas, “Biochemical markers and hematologic indices in the diagnosis of functional iron deficiency,” Clinical Chemistry, vol. 48, no. 7, pp. 1066–1076, 2002.
[16]
C. Brugnara, “Iron deficiency and erythropoiesis: new diagnostic approaches,” Clinical Chemistry, vol. 49, no. 10, pp. 1573–1578, 2003.
[17]
A. Kumar, “Perioperative management of anemia: limits of blood transfusion and alternatives to it,” Cleveland Clinic Journal of Medicine, vol. 76, no. 4, pp. S112–S118, 2009.
[18]
L. T. Goodnough and A. Shander, “Patient blood management,” Anesthesiology, vol. 116, pp. 1367–1376, 2012.
[19]
A. Kumar and J. L. Carson, “Perioperative anemia in the elderly,” Clinics in Geriatric Medicine, vol. 24, no. 4, pp. 641–648, 2008.
[20]
O. Mimoz, D. Frasca, A. Medard, L. Soubiron, B. Debaene, and C. Dahyot-Fizelier, “Reliability of the HemoCue hemoglobinometer in critically ill patients: a prospective observational study,” Minerva Anestesiologica, vol. 77, pp. 979–985, 2011.
[21]
S. R. Pasricha, S. C. Flecknoe-Brown, K. J. Allen et al., “Diagnosis and management of iron deficiency anaemia: a clinical update,” Medical Journal of Australia, vol. 193, pp. 525–532, 2010.
[22]
L. T. Goodnough, E. Nemeth, and T. Ganz, “Detection, evaluation, and management of iron-restricted erythropoiesis,” Blood, vol. 116, no. 23, pp. 4754–4761, 2010.
[23]
C. Thomas and L. Thomas, “Anemia of chronic disease: pathophysiology and laboratory diagnosis,” Laboratory Hematology, vol. 11, no. 1, pp. 14–23, 2005.
[24]
R. A. Moore, H. Gaskell, P. Rose, and J. Allan, “Meta-analysis of efficacy and safety of intravenous ferric carboxymaltose (Ferinject) from clinical trial reports and published trial data,” BMC Blood Disorders, vol. 11, p. 4, 2011.
[25]
M. Auerbach, L. T. Goodnough, D. Picard, and A. Maniatis, “The role of intravenous iron in anemia management and transfusion avoidance,” Transfusion, vol. 48, no. 5, pp. 988–1000, 2008.
[26]
A. A. Khalafallah and A. E. Dennis, “Iron deficiency anaemia in pregnancy and postpartum: pathophysiology and effect of oral versus intravenous iron therapy,” Journal of Pregnancy, vol. 2012, Article ID 630519, 10 pages, 2012.
[27]
T. D. Johnson-Wimbley and D. Y. Graham, “Diagnosis and management of iron deficiency anemia in the 21st century,” Therapeutic Advances in Gastroenterology, vol. 4, pp. 177–184, 2011.
[28]
K. Aspuru, C. Villa, F. Bermejo, P. Herrero, and S. G. Lopez, “Optimal management of iron deficiency anemia due to poor dietary intake,” International Journal of General Medicine, vol. 4, pp. 741–750, 2011.
[29]
C. Beghé, A. Wilson, and W. B. Ershler, “Prevalence and outcomes of anemia in geriatrics: a systematic review of the literature,” American Journal of Medicine, vol. 116, no. 7, pp. 3–10, 2004.
[30]
P. Beris, M. Mu？oz, J. A. García-Erce, D. Thomas, A. Maniatis, and P. Van Der Linden, “Perioperative anaemia management: consensus statement on the role of intravenous iron,” British Journal of Anaesthesia, vol. 100, no. 5, pp. 599–604, 2008.
[31]
A. Shander, M. Javidroozi, and L. T. Goodnough, “Anemia screening in elective surgery: definition, significance and patients' interests,” Anesthesia and Analgesia, vol. 103, no. 3, pp. 778–779, 2006.
[32]
E. Saleh, D. B. L. McClelland, A. Hay, D. Semple, and T. S. Walsh, “Prevalence of anaemia before major joint arthroplasty and the potential impact of preoperative investigation and correction on perioperative blood transfusions,” British Journal of Anaesthesia, vol. 99, no. 6, pp. 801–808, 2007.
