Effect of (short-term) intravenous iron supplementation in iron-deficient non-anaemic cardiac surgical patients on perioperative outcome

Effects of Preoperative Intravenous Erythropoietin Plus Iron on Outcome in Anemic Patients After Cardiac Valve Replacement

Feasibility and efficiency of a preoperative anaemia walk-in clinic: secondary data from a prospective observational trial

See article on page 2629–2636, in this issue

16002 Background: Epoetin alfa (EPO) and darbepoetin alfa (DARB) are used to treat cancer-related anemia and to reduce the requirements for blood transfusions. To date, limited information on the relative effectiveness of these agents in the inpatient setting is available. This analysis evaluated red blood cell (RBC) transfusion rates in cancer patients receiving EPO or DARB during hospitalization. Methods: An analysis of electronic inpatient hospital records from the Premier Perspective Comparative Hospital Database was conducted to compare RBC transfusion rates in cancer patients receiving EPO or DARB therapy. Study subjects were identified through hospitalizations recorded between 07/2002 and 03/2005 from over 500 hospitals nationwide. Patients were required to be ≥18 years old, have a primary admitting diagnosis of cancer and be treated with EPO or DARB during hospitalization. Patients who had received renal dialysis were excluded. To minimize effects of outliers, 5% of patients with extreme doses in each group were excluded from the dosing analysis. In addition to descriptive statistics on transfusion requirements, a multivariate logistic model was employed to isolate the effect of an individual erythropoietic agent on the risk of RBC transfusion after controlling for patient demographics, comorbidities, admission characteristics, use of IV or oral iron and hospitalization severity markers. Results: Among the 24,814 EPO and 2,990 DARB study patients, mean age and gender distribution at admission were similar (age: EPO 65.3 years, DARB 64.5 years; %women: EPO 53%, DARB 55%). Mean cumulative dose per inpatient stay was EPO 61,656 ± 50,274 Units and DARB 259 ± 340 mcg. RBC transfusions occurred in 37.9% of EPO patients compared to 39.8% of DARB patients (p=0.0404). Transfused EPO patients received a mean of 2.24 units versus 2.20 units for DARB patients (p=0.2111). After adjusting for covariates, the multivariate model confirmed that DARB treatment was associated with a higher risk of transfusion compared to EPO (odds ratio: 1.2, 95% CI: 1.1–1.3, p=0.0007). Conclusions: This analysis of inpatients with cancer indicates DARB treatment is associated with a higher risk of receiving RBC transfusion compared to treatment with EPO. [Table: see text]

To compare neonatal red blood cell (RBC) transfusion rates in four large Intermountain Healthcare NICUs, all of which adhere to the same RBC transfusion guidelines. This retrospective analysis was part of a transfusion-management quality-improvement project. De-identified data included RBC transfusions, clinical and laboratory findings, the anemia-prevention strategies in place in each NICU, and specific costs and outcomes. Of 2389 NICU RBC transfusions given during the 4-year period studied, 98.9 ± 2.1% (mean ± S.D.) were compliant with our transfusion guidelines, with no difference in compliance between any of the four NICUs. However, RBC transfusion rates varied widely between the four, with averages ranging from 4.6 transfusions/1000 NICU days to 21.7/1000 NICU days (P < 0.00001). Gestational age-adjusted transfusion rates were correspondingly discordant (P < 0.00001). The lower-transfusing NICUs had written anemia-preventing guidelines, such as umbilical cord milking at very low birth weight delivery, use of cord blood for admission laboratory studies, and darbepoetin dosing for selected neonates. Rates of Bell stage ⩾ 2 necrotizing enterocolitis and grade ⩾ 3 intraventricular hemorrhage were lowest in the two lower-transfusing NICUs (P < 0.0002 and P < 0.0016). Average pharmacy costs for darbepoetin were $84/dose, with an average pharmacy cost of $269 per transfusion averted. With a cost of $900/RBC transfusion, the anemia-preventing strategies resulted in an estimated cost savings to Intermountain Healthcare of about $6970 per 1000 NICU days, or about $282,300 annually. Using transfusion guidelines has been shown previously to reduce practice variability, lower transfusion rates and diminish transfusion costs. Based on our present findings, we maintain that even when transfusion guidelines are in place and adhered to rigorously, RBC transfusion rates are reduced further if anemia-preventing strategies are also in place.

Erythropoiesis stimulating agents, blood transfusion, and the practice of medicine

Data on red blood cell (RBC) transfusion in the United States show variation in practice and overprescribing or overdosing is considered to be prevalent. Education or restrictive interventions could modify practice. RBC transfusion and mortality rates were recorded in a single institution over a 15-year period. The first 3 years were used as a baseline. Education measures were used to influence practice for 3 years followed by a 9-year period when questionable RBC orders in nonbleeding inpatients resulted in prospective physician notification for potential modification. Physician notification was done by blood bank technologists with transfusion medicine physician support, if needed. Pretransfusion hemoglobin levels of more than 9 g/dL were recommended for cancellation and levels between 8 and 9 g/dL advised for a single unit, if 2 or more units were requested. RBC transfusion rates were described as inpatient units per 1000 discharges to allow for interyear comparison. A downward trend in RBC transfusion was noted for the intervention period. Comparison of the baseline period with the past 3 years of the intervention period showed an approximate 33% decrease, which was highly significant (508 ± 66 vs. 341 ± 32, p < 0.01). Inpatient mortality rates declined over this period. Physician education in appropriate transfusion practice is desirable but may not greatly impact RBC use. Engagement of physicians who prescribe RBCs that appear inappropriate for indication or dose was associated with a significant decline in RBC use without evidence of a change in mortality.

Impact of Iron Supplementation on Patient Outcomes in Women Undergoing Gynecological Procedures: Systematic Review and Meta-Analysis of Randomized Trials

Pre-bypass acute autologous donation (PAAD) is a method of blood conservation that reduces exposure of blood to the cardiopulmonary bypass (CPB) circuit and may prevent the contact activation of platelets and clotting factors. The purpose of this study was to evaluate the impact of PAAD on product transfusion rates in cardiac surgical patients. This is a retrospective study of patients undergoing cardiac surgery between 2015 and 2017 for either a coronary artery bypass (CABG), valve replacement, or a combined valve/CABG procedure. PAAD was performed by removing blood from the venous line of the bypass circuit immediately before the institution of CPB. The amount of PAAD volume was determined during the surgical time-out. This was based on patient size, baseline hemoglobin, and type of case. Poisson logistic regression was used to determine whether PAAD was a significant predictor for blood product transfusion. After obtaining institutional review board approval, we reviewed 236 records on (n = 154, 65.3%) who received PAAD and (n = 82, 34.7%) with no blood withdrawal before CPB. The median PAAD volume in the PAAD group was 750 mL. Patients undergoing PAAD had a 14.3% red blood cell (RBC) transfusion rate (.27 ± .91 units), and without PAAD, the RBC transfusion rate was 62.2% (1.56 ± 1.79 units). The significant (p &lt; .05) odds ratios (ORs) for RBC transfusion were as follows: baseline hemoglobin .617 (.530–.719), PAAD .998 (.997–.999), CPB time 1.009 (1.003–1.015), age 1.034 (1.013–1.055), and BSA odds ratio (OR) .326 (.124–.857). PAAD could not be used in all patients. However, using the OR in the Poisson logistic regression model, a one-unit reduction in RBC transfusion is predicted for each 500 mL of PAAD. PAAD was also associated with a significant reduction in fresh frozen plasma and platelet transfusion.

Postoperative anemia is a common complication after cardiac surgery, often persisting for months and substantially affecting patient recovery. Despite its prevalence, optimal treatment strategies are lacking. We aimed to evaluate whether early postoperative intravenous (IV) iron is more effective than daily oral iron in correcting anemia after cardiac surgery. This single-center, pragmatic randomized controlled trial enrolled 110 cardiac surgery patients with moderate postoperative anemia (hemoglobin 8-11 g/dL). Participants were randomized 1:1 to receive either a single infusion of 20 mg/kg ferric derisomaltose on postoperative day 1 (IV iron group, n = 57) or 100 mg oral ferrous sulfate twice daily for 4 weeks (oral iron group, n = 53). All outcomes were assessed at 4 weeks postrandomization. The primary composite outcome aimed to measure treatment success, defined as the proportion of participants who were (a) no longer anemic (per World Health Organization criteria) and (b) neither had received allogeneic red blood cell (RBC) transfusions after randomization. Secondary end points included differences in hemoglobin levels, RBC transfusion rates, iron metrics, 6-minute walk test distances, hospital length of stay, and patient-reported outcomes. Primary outcome data were available for 53 participants in the IV iron group and 51 in the oral iron group. The proportion of participants who achieved the primary end point did not differ significantly between groups (28% vs 16%; risk difference 13%, 95% confidence interval [CI], -3% to 28%; P = .121). No statistically significant differences were observed in anemia prevalence (66% vs 82%; P = .058) or RBC transfusion rates (17% vs 33%; P = .054). Mean hemoglobin levels (± standard deviation) were higher in the IV iron group (12.0 ± 1.1 g/dL vs 11.4 ± 1.3 g/dL; P = .013). None of the participants in the IV iron group had ferritin levels <100 µg/L, compared to 26% in the oral iron group (P < .001, accounting for 95% CI for 0 numerators). No significant differences were observed in the 6-minute walk test, hospital length of stay, or patient-reported outcomes. Notably, no serious adverse events related to ferric derisomaltose were reported. Early postoperative IV iron did not demonstrate superiority over oral iron for the primary outcome. However, secondary end points suggest it may improve hemoglobin levels and reduce the prevalence of postoperative iron deficiency. These findings warrant further investigation in larger trials to confirm the clinical effectiveness of early postoperative IV iron.

Red blood cell transfusions for emergency department patients with gastrointestinal bleeding within an integrated health system

BackgroundPreoperative 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.MethodsSingle-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).ResultsFrom 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).ConclusionID 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.

Ravulizumab Effectiveness in the Real World: Evidence from the International PNH Registry

Perioperative anemia is challenging during hospital stay because anemia and red blood cell (RBC) transfusions are associated with an increased morbidity and mortality. With the implementation of patient blood management (PBM), a preanesthesia assessment clinic to screen and treat anemia before elective surgery was institutionalized at Muenster University Hospital, Germany. The main objective of this study was to evaluate the association between treating preoperative anemic patients with intravenous iron (IVI) and (primarily) presurgical hemoglobin levels and (secondarily) use of RBCs and mortality. Between April 1, 2014, and July 4, 2016, patients scheduled for elective surgery with a risk for RBC transfusions >10% in 2013 were screened for preoperative anemia and, if indicated, treated with IVI. Patients' data, time span between visit in the anesthesia/PBM clinic and surgery, demographic data, type of surgery, the difference of hemoglobin levels between visit and surgery, RBC transfusion, infectious-related International Classification of Disease codes during hospital stay, and 1-year survival were determined retrospectively by screening electronic data files. In addition, patients were interviewed about adverse events, health-related events, and infections via telephone 30, 90, and 365 days after visiting the anesthesia/PBM clinic. A total of 1101 patients were seen in the anesthesia/PBM clinic between days -28 and -1 (median [Q1-Q3], -3 days [-1, -9 days]) before elective surgery. Approximately 29% of patients presented with anemia, 46.8% of these anemic patients were treated with ferric carboxymaltose (500-1000 mg).In the primary analysis, hemoglobin levels at median were associated with a reduction between the visit in the anesthesia/PBM clinic and the surgery in all nonanemic patients on beginning of medical treatment (nonanemic patients at median -2.8 g/dL [-4, -0.9 g/dL], while anemic patients without IVI presented with median differences of -0.8 g/dL [-2, 0 g/dL] and anemic patients with IVI of 0 g/dL [-1.0, 0.5 g/dL]). Hemoglobin levels raised best at substitution 22-28 days before surgery (0.95 g/dL [-0.35, 1.18 g/dL]). Due to the selection criteria, transfusion rates were high in the cohort. Overall, there was no association between IVI treatment and the use of RBC transfusions (odds ratio for use of RBCs in anemic patients, no IVI versus IVI: 1.14; 95% confidence interval, 0.72-1.82). Patients treated with or without IVI presented a comparable range of International Classification of Disease codes related to infections. Telephone interviews indicated similar adverse events, health-related events, and infections. Cox regression analysis showed an association between anemia and reduced survival, regardless of IVI. An anemia clinic within the preanesthesia assessment clinic is a feasible and effective approach to treat preoperative anemia. The IVI supplementation was safe but was associated with decreased RBC transfusions in gynecology/obstetric patients only. The conclusions from this retrospective analysis have to be tested in prospective, controlled trials.

More Effective Route of Treatment for Iron Deficiency Anemia in Pregnancy Intravenous Vs Oral Iron