Abstract
BackgroundGuidelines to treat anaemia with intravenous (IV) iron have focused on elective surgical patients with little attention paid to those undergoing non-elective/emergency surgery. Whilst these patients may experience poor outcomes because of their presenting illness, observational data suggests that untreated anaemia may also be a contributing factor to poor outcomes. We conducted a systematic review to investigate the safety and efficacy of IV iron in patients undergoing non-elective surgery.MethodsWe followed a pre-defined review protocol and included randomised controlled trials (RCTs) in patients undergoing non-elective surgery who received IV iron. Primary outcomes were all-cause infection and mean difference in haemoglobin (Hb) at follow-up. Secondary outcomes included transfusion requirements, hospital length of stay (LOS), health-related quality of life (HRQoL), mortality and adverse events.ResultsThree RCTs (605 participants) were included in this systematic review of which two, in both hip fracture (HF) patients, provided data for meta-analysis. Both of these RCTs were at low risk of bias. We found no evidence of a difference in the risk of infection (RR 0.99, 95% CI 0.55 to 1.80, I2 = 9%) or in the Hb concentration at ‘short-term’ (≤ 7 days) follow-up (mean difference − 0.32 g/L, 95% CI − 3.28 to 2.64, I2 = 37%). IV iron did not reduce the risk of requiring a blood transfusion (RR 0.90, 95% CI 0.73 to 1.11, p = 0.46, I2 = 0%), and we observed no difference in mortality, LOS or adverse events. One RCT reported on HRQoL and found no difference between treatment arms.ConclusionWe found no conclusive evidence of an effect of IV iron on clinically important outcomes in patients undergoing non-elective surgery. Further adequately powered trials to evaluate its benefit in emergency surgical specialties with a high burden of anaemia are warranted.Trial registrationThis systematic review was registered on PROSPERO (CRD42018096288)
Highlights
Guidelines to treat anaemia with intravenous (IV) iron have focused on elective surgical patients with little attention paid to those undergoing non-elective/emergency surgery
The principles of patient blood management (PBM), which emphasise early diagnosis and treatment of anaemia, have been predominantly applied to patients undergoing elective surgery (‘Practice Guidelines for Perioperative Blood Management An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*’ 2015; Kotze et al 2015; Munoz et al 2018) with little attention paid to patients undergoing non-elective or emergency surgery
We found no evidence of an effect of IV iron on infection, haemoglobin or transfusion requirements in patients undergoing non-elective surgery
Summary
Guidelines to treat anaemia with intravenous (IV) iron have focused on elective surgical patients with little attention paid to those undergoing non-elective/emergency surgery. Whilst these patients may experience poor outcomes because of their presenting illness, observational data suggests that untreated anaemia may be a contributing factor to poor outcomes. The principles of patient blood management (PBM), which emphasise early diagnosis and treatment of anaemia, have been predominantly applied to patients undergoing elective surgery (‘Practice Guidelines for Perioperative Blood Management An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*’ 2015; Kotze et al 2015; Munoz et al 2018) with little attention paid to patients undergoing non-elective or emergency surgery. Observational data from the hip fracture population suggests that anaemia impedes functional recovery and increases length of stay (LOS) and re-admission rates (Halm et al 2004; Foss et al 2008)
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