Preoperative Anemia Management Research Articles

Multimodal Patient Blood Management Program Based on a Three-pillar Strategy: A Systematic Review and Meta-analysis.

To determine whether a multidisciplinary, multimodal Patient Blood Management (PBM) program for patients undergoing surgery is effective in reducing perioperative complication rate, and thereby is effective in improving clinical outcome. PBM is a medical concept with the focus on a comprehensive anemia management, to minimize iatrogenic (unnecessary) blood loss, and to harness and optimize patient-specific physiological tolerance of anemia. A systematic review and meta-analysis was performed. Eligible studies had to address each of the 3 PBM pillars with at least 1 measure per pillar, for example, preoperative anemia management plus cell salvage plus rational transfusion strategy. The study protocol has been registered with PROSPERO (CRD42017079217). Seventeen studies comprising 235,779 surgical patients were included in this meta-analysis (100,886 pre-PBM group and 134,893 PBM group). Implementation of PBM significantly reduced transfusion rates by 39% [risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55-0.68, P < 0.00001], 0.43 red blood cell units per patient (mean difference -0.43, 95% CI -0.54 to -0.31, P < 0.00001), hospital length of stay (mean difference -0.45, 95% CI -0.65 to -0.25, P < 0,00001), total number of complications (RR 0.80, 95% CI 0.74-0.88, P <0.00001), and mortality rate (RR 0.89, 95% CI 0.80-0.98, P = 0.02). Overall, a comprehensive PBM program addressing all 3 PBM pillars is associated with reduced transfusion need of red blood cell units, lower complication and mortality rate, and thereby improving clinical outcome. Thus, this first meta-analysis investigating a multimodal approach should motivate all executives and health care providers to support further PBM activities.

Korean clinical practice guideline for perioperative red blood cell transfusion from Korean Society of Anesthesiologists.

BackgroundConsidering the functional role of red blood cells (RBC) in maintaining oxygen supply to tissues, RBC transfusion can be a life-saving intervention in situations of severe bleeding or anemia. RBC transfusion is often inevitable to address intraoperative massive bleeding; it is a key component in safe perioperative patient management. Unlike general medical resources, packed RBCs (pRBCs) have limited availability because their supply relies entirely on voluntary donations. Additionally, excessive utilization of pRBCs may aggravate prognosis or increase the risk of developing infectious diseases. Appropriate perioperative RBC transfusion is, therefore, crucial for the management of patient safety and medical resource conservation. These concerns motivated us to develop the present clinical practice guideline for evidence-based efficient and safe perioperative RBC transfusion management considering the current clinical landscape. MethodsThis guideline was obtained after the revision and refinement of exemplary clinical practice guidelines developed in advanced countries. This was followed by rigorous evidence-based reassessment considering the healthcare environment of the country. ResultsThis guideline covers all important aspects of perioperative RBC transfusion, such as preoperative anemia management, appropriate RBC storage period, and leukoreduction (removal of white blood cells using filters), reversal of perioperative bleeding tendency, strategies for perioperative RBC transfusion, appropriate blood management protocols, efforts to reduce blood transfusion requirements, and patient monitoring during a perioperative transfusion. ConclusionsThis guideline will aid decisions related to RBC transfusion in healthcare settings and minimize patient risk associated with unnecessary pRBC transfusion.

Patient blood management for liver resection: consensus statements using Delphi methodology

BackgroundBlood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. MethodsAn expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. ResultsThe 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. ConclusionsPBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.

Anemia Management and Audit Feedback Practices for Reducing Overuse of RBC Transfusion: A Laboratory Medicine Best Practice Systematic Review and Meta-Analysis.

To evaluate the effectiveness of anemia management and audit with feedback practices in reducing overuse of RBC transfusion. This review follows the Centers for Disease Control and Prevention's Laboratory Medicine Best Practice Systematic Review (A-6) method. We searched the literature and solicited unpublished studies on practices to reduce overuse of RBC transfusions as measured by reductions in units transfused and proportion of patients transfused. Thirteen studies on preoperative anemia management and three studies on audit feedback practices met inclusion criteria. Strength of evidence was high to moderate for reducing the number of units and proportion of patients transfused. Preoperative anemia management reduces the proportion of patients transfused and units of RBCs transfused. Audit with feedback across cases, physicians, and/or service areas, as part of a continuous quality improvement practice, reduces the proportion of patients and units of RBCs transfused.

Ask a Pathologist: Preoperative Anemia Management

Ask a Pathologist: Preoperative Anemia Management

Perioperative and Modifiable Risk Factors for Periprosthetic Joint Infections (PJI) and Recommended Guidelines.

Periprosthetic joint infection (PJI) remains a complication that is associated with high morbidity as well as high healthcare expenses. The purpose of this review is to examine patient and perioperative modifiable risk factors that can be altered to help improve rates of PJI. Evidence-based review of literature shows that improved control of post-operative glycemia, appropriate management of obesity, malnutrition, metabolic syndrome, preoperative anemia, and smoking cessation can help minimize risk of PJI. Additionally, use of Staphylococcus aureus screening, preoperative evaluation of vitamin D levels, screening for urinary tract infection, and examination of dental hygiene can help with improving rates of PJI; similarly, appropriate management of perioperative variables such as limiting operating room traffic, appropriate timing, and selection of prophylactic antibiotics and surgical site preparation can help to decrease rates of PJI. In summary, PJI is a morbid complication of total joint arthroplasty. Surgeons should be vigilant of modifiable risk factors that can be improved upon to help minimize the risk of PJI.

Committed to be fit. The value of preoperative care in the perioperative medicine era.

In the era of perioperative medicine, important advances have been made in the perioperative care of patients, usually within those known as enhanced recovery after surgery (ERAS) protocols. These have led to a decrease in postoperative complications and the duration of hospital stays; however, there is still a lack of preoperative care, which could make perioperative medicine more prominent. Elderly patients, malnourished, anemic and ones with a low physical function before surgery are likely to have sub-optimal recovery from surgery. More importantly, a low functional reserve, together with the inherent physiological stress of surgery, reduces the functional capacity of patients in the postoperative period, meaning that they will not reach their preoperative functional capacity. It is well established that both preoperative malnutrition and anemia worsen surgical results, however, for various reasons, their preoperative optimization is complex. Additionally, both are related to the functional capacity of patients. During the last years, prehabilitation has been incorporated into ERAS protocols. Prehabilitation consists of exercise training and nutritional and psychological support, which increases the physiological reserve before surgical stress. The integration of exercise, adequate nutrition, anemia correction and psycho-social components, with multi-modal optimization in the preoperative period leads to an improvement in the functional capacity of the patients undergoing surgery, with the consequent improvement in terms of outcomes. The present article discusses specific aspects of preoperative care which are not well defined in the ERAS protocols and which represent fundamental shifts in surgical practice, including preoperative nutrition, management of preoperative anemia and prehabilitation.

Transfusion Practices Among General Surgeons at a Tertiary Care Center: a Survey Based Study.

Introduction: Blood transfusion practices affect both patient’s outcomes and utilization of institutional resources. Evidence shows that liberal blood transfusion has a detrimental effect on patient’s outcome. A restrictive approach of blood transfusion is recommended by current clinical guidelines. Aim: The aim of this study was to evaluate the attitudes, knowledge, and practices of general surgery (GS) staff and residents regarding peri-operative blood transfusion and anemia management.Material and Methods:A self-administered, web-based questionnaire was developed, and its link was sent to the emails of all general surgeons at King Abdul-Aziz University Hospital (KAUH), Jeddah city, Saudi Arabia. The questionnaire included four parts: 1) background of surgeons; 2) preoperative assessment and management of anemia; 3) post-operative blood transfusion and alternatives; and 4) enablers and barriers.Results:56 surgeons responded to the questionnaire. We found variations in blood transfusion practices, notably the hemoglobin threshold. For stable non-cardiac cases, 7 g/dL was considered the threshold by 50% of respondents. For stable patients with past cardiac disease, a higher threshold was chosen by most (9 g/dL by 43% and 10 gm/dL by 21%). Most respondents believed that transfusion had no effect on the risk of survival (73%) and on the risk of cancer recurrence (55%) after oncologic surgical resection. Recognized facilitators were the availability of scientific evidence (84%), medicolegal concerns (57%), preference (52%), and institutional protocols (50%).Conclusion:Although current clinical guidelines recommend a restrictive transfusion practice, most respondents tended to over-order blood for elective procedures and were not aware of the potential complications of liberal blood transfusion. To implement the restrictive transfusion policies, health institutions should improve the awareness of surgeons and incorporate a strong supporting evidence in formulating local institutional guidelines.

A survey of UK peri-operative medicine: pre-operative care.

The majority of UK hospitals now have a Local Lead for Peri-operative Medicine (n = 115). They were asked to take part in an online survey to identify provision and practice of pre-operative assessment and optimisation in the UK. We received 86 completed questionnaires (response rate 75%). Our results demonstrate strengths in provision of shared decision-making clinics. Fifty-seven (65%, 95%CI 55.8-75.4%) had clinics for high-risk surgical patients. However, 80 (93%, 70.2-87.2%) expressed a desire for support and training in shared decision-making. We asked about management of pre-operative anaemia, and identified that 69 (80%, 71.5-88.1%) had a screening process for anaemia, with 72% and 68% having access to oral and intravenous iron therapy, respectively. A need for peri-operative support in managing frailty and cognitive impairment was identified, as few (24%, 6.5-34.5%) respondents indicated that they had access to specific interventions. Respondents were asked to rank their 'top five' priority topics in Peri-operative Medicine from a list of 22. These were: shared decision-making; peri-operative team development; frailty screening and its management; postoperative morbidity prediction; and primary care collaboration. We found variation in practice across the UK, and propose to further explore this variation by examining barriers and facilitators to improvement, and highlighting examples of good practice.

Outcomes Associated With Transfusion at Time of Hysterectomy [16D

INTRODUCTION: Anemia is a common preoperative diagnosis in patients undergoing hysterectomy. In severe cases, perioperative blood transfusion may be necessary. This study describes perioperative risks associated with transfusion around the time of surgery. METHODS: This is a retrospective cohort study of women undergoing non-emergent hysterectomy between 2012-2014. The primary outcome was a comparison of complications in patients receiving transfusion and those that did not. RESULTS: Among 292 patients who underwent hysterectomy, 30 patients were transfused (10.3%). Factors associated with transfusion were preoperative anemia (10.6 gm/dL in patients requiring transfusion versus 13.0 gm/dL, P &lt; .001), estimated blood loss (425mL vs 200mL, P &lt; .001), and uterine weight (388g vs 100g, P &lt; .001). Patients who received transfusion had a longer length of stay (4 days vs 2 days, P &lt; .001), higher rates of readmission (23.3% vs. 3.4%, P &lt; .001), increased rates of fascial dehiscence (10.0% vs 0.8%, P=.009), more frequent pelvic abscess development (6.7% vs 1.1%, P=.084), more often had venous thromboembolism (6.7% vs 0%, P=.01), and greater need for repeat surgery (13.3% vs 0.8%, P=.001). CONCLUSION: Preoperative anemia places patients undergoing hysterectomy at risk of needing blood transfusion. In this study, blood transfusion was associated with significant perioperative morbidity. Given these findings, aggressive preoperative management of anemia should be strongly considered.

Pre-operative haemoglobin levels and iron status in a large multicentre cohort of patients undergoing major elective surgery.

Pre-operative anaemia in patients undergoing major surgical procedures has been linked to poor outcomes. Therefore, early detection and treatment of pre-operative anaemia is recommended. However, to effectively implement a pre-operative anaemia management protocol, an estimation of its prevalence and main causes is needed. We analysed data from 3342 patients (44.5% female) scheduled for either: elective orthopaedic surgery (n=1286); cardiac surgery (n=691); colorectal cancer resection (n=735); radical prostatectomy (n=362); gynaecological surgery (n=203) or resection of liver metastases (n=122). For both sexes, anaemia was defined by a haemoglobin level < 130g.l-1 ; absolute iron deficiency by ferritin < 30ng.ml-1 (< 100ng.ml-1 , if transferrin saturation < 20% or C-reactive protein >5mg.l-1 ); iron sequestration by transferrin saturation < 20% and ferritin >100ng.ml-1 ; and low iron stores by transferrin saturation > 20% and ferritin 30-100ng.ml-1 . The overall prevalence of anaemia was 36%, with differences according to the type of surgery. Laboratory parameters allowing classification of iron status were available for 2884 patients. Among those with anaemia (n=986), 677 (69%) were women, 608 (62%) presented with absolute iron deficiency, 101 (10%) with iron sequestration; and 150 (5%) with low iron stores. Iron status alterations were similar in women with haemoglobin < 130g.l-1 or < 120g.l-1 . For those who were not anaemic (n=1898), corresponding figures were 656 (35%), 621 (33%), 165 (9%) and 518 (27%), respectively. Anaemia was present in one-third of patients undergoing major elective procedures. Over two-thirds of anaemic patients presented with absolute iron deficiency or iron sequestration. Over half of non-anaemic patients presented with absolute iron deficiency or low iron stores. We consider these data useful for planning pre-operative management of patients scheduled for major elective surgery.

Current practices in perioperative blood management for patients undergoing liver resection: a survey of surgeons and anesthesiologists

Objective: The development of new techniques and blood management strategies in liver resection, and the multidisciplinary nature of perioperative transfusion decision-making, creates an opportunity for practice variation. The aim of this study was to describe the current practices in perioperative blood management, and explore differences between surgeons and anesthesiologists. Methods: A survey was circulated to Canadian liver surgeons and anesthesiologists. The survey focused on management of pre-operative anemia, blood conservation strategies, estimation of blood loss, and transfusion decision-making in a multidisciplinary setting. Results: 198 physicians received the survey, with 117 responding (59.1%). Most responding surgeons (66.7%) perform over 20 liver resections per year, while most responding anesthesiologists (90%) take part in less than 20. The most common blood conservation strategy used is administration of anti-fibrinolytics (63% used them at least occasionally). The most important factor for anesthesiologists when deciding on an intraoperative transfusion was hemoglobin value (47.2%), for surgeons, it was patient hemodynamics (33.4%). Compared to when they started their career, 60.5% of respondents felt they were less likely to transfuse a patient now. Almost 40% of respondents replied that they had no specific management for preoperative anemia, or that someone else managed it. Conclusion: The results of our survey provide insights into current transfusion practice and decision making in liver resection, including a comparison between anesthesiologist and surgeon transfusion behaviour. The findings reflect trends toward restrictive transfusion strategies, and promote the development of improved blood conservation techniques and clinical practice guidelines.

The UK Cardiac and Vascular Surgery Interventional Anaemia Response (CAVIAR) Study: protocol for an observational cohort study to determine the impact and effect of preoperative anaemia management in cardiac and vascular surgical patients

IntroductionPreoperative anaemia is linked to poor postsurgical outcome, longer hospital stays, greater risk of complications and mortality. Currently in the UK, some sites have developed anaemia clinics or pathways that...

Patient Blood Management.

Patient Blood Management is a book that considers a concept that transcends transfusion medicine. It is solely aimed at disease management rather than focusing on a single therapeutic modality, transfusion.The foreword by Denton A. Cooley sums up the essence of patient blood management (PBM) by stating that it is a “compelling concept to preempt anemia, correct bleeding disorders, and minimize blood loss.” He continues by stating that this is an evidence-based approach that has yielded the desired outcomes of improved patient’s health and reduced resource utilization. The preface, written by the three editors, expands on the concept and focuses on the intent of this PBM “book” by addressing the multiprofessional and multidisciplinary approach that spans a multitude of topics from preoperative anemia management to management of patients for whom blood is not an option. Although referred to as a book, this publication is more appropriately described as a “manual” on PBM. Recognizing the burgeoning data on patient outcome associated with a large number of possible interventions (beyond the current single approach—transfusion) applied together or as a single modality, this bundled care includes identification, diagnosis and treatment of anemia, blood conservation both surgical and phlebotomy, and “tolerating” anemia, while therapeutic modalities other than transfusions are implemented effectively. The manual’s content would encourage the reader to explore elsewhere for more detailed data and newer data that are constantly being added to the literature.The editors have gathered a long list of both new and senior contributors to PBM. Although these contributors have been asked to address specific topics, their knowledge of PBM extends far beyond the contributions seen in this manual.Knowing that this publication is an expansion of the original German version of this book, the extensive list of topics is impressive and covers most if not all related PBM topics and issues.To the casual reader, the history and development of PBM and additional material on the future of PBM in the new healthcare milieu would be of value. These items are not included in this book. While they are not necessarily needed in this manual, they would help explain the evolution of PBM and are addressed in other PBM textbooks. Offering the long view in medicine can usually explain the present and help form the future.Each of the chapters is well organized, and for the most part, presents the current thinking in PBM. Although weighted toward transfusion medicine, the editors’ reminder to focus on patients and improved outcome resonates throughout the manual.Despite overall enthusiasm expressed for PBM, some sections of the text offer recommendations that can be challenged since significant controversy exists on these topics. As an example, the sections on pharmacologic agents, parenteral iron, and erythroid-stimulating agents represent conclusions on the basis of old data that have been challenged and are in need of fresh interpretation. Other recommendations ignore the inconsistency of the data used to make a recommendation such as those present in section “transfusion guidelines.” In regard to transfusion indication, the threshold (“trigger”) in patients with coronary artery disease has not been established. Although addressed in the text, table 5.2 appears to present the information in what seems to be a more conclusive manner. Regardless, most of the recommendations are sound and useful.Although open to all disciplines of clinical medicine, the surgical approach to PBM dominates throughout the book. One can extrapolate to other patient populations since PBM is written as disease management of entities such as anemia, coagulation defects, and other hematologic conditions rather than concentrating solely on transfusion as a therapy.Caught between informative and instructive, the manual serves best as an initial overview of each of the topics. It does not lend itself as a guide to therapy nor does it fully expose all of the data and challenges of PBM in an in-depth fashion. The chapters address each topic in a thoughtful and balanced fashion without exposing areas on controversy in any details.There is no question in this reviewer’s mind that the primary audience is anesthesiologists and surgeons followed by internal medicine and others in related fields. Reading through the stimulating chapters and sections, one quickly finds oneself seeking to attain more information—which can be found, for example, in the section on PBM at www.blood.gov.au—to enhance their knowledge and repertoire on PBM. This manual is an essential step in increasing awareness on PBM and helps organize the topic, resulting in easy reading and, in turn, better patient care and outcome.

Correction of iron-deficiency anaemia in colorectal surgery reduces perioperative transfusion rates: A before and after study

BackgroundPreoperative anaemia is a risk factor for poorer postoperative outcomes and many colorectal cancer patients have iron-deficiency anaemia. The aim of this study was to assess if a preoperative iron-deficiency anaemia management protocol for elective colorectal surgery patients helps improve detection and treatment of iron-deficiency, and improve patient outcomes. Materials and methodsRetrospective data was collected from 95 consecutive patients undergoing colorectal cancer surgery to establish baseline anaemia correction rates and perioperative transfusion rates. A new pathway for early detection of iron-deficiency anaemia, and treatment with intravenous iron replacement, for colorectal cancer patients was then developed and implemented. Data from 81 patients was collected prospectively post-implementation to assess the impact of the pathway. ResultsPre-intervention data showed anaemic patients were seventeen times more likely to require perioperative transfusion than non-anaemic patients (95% CI 1.9–151.0, p = 0.011). Post-intervention, fifteen patients with iron-deficiency were treated with either intravenous (n = 8) or oral iron (n = 7). Mean Day 3 postoperative haemoglobin levels were significantly lower in patients with uncorrected anaemia (9.5 g/dL, p = 0.004); those patients whose anaemia was corrected by iron replacement therapy preoperatively had similar postoperative results to non-anaemic patients (10.93 g/dL vs 11.4 g/dL, p = 0.781). Postoperative transfusion rates remained high at 38% in patients with uncorrected anaemia, compared to 0% in corrected anaemia and 3.5% in non-anaemic patients. ConclusionsIntroduction of an iron-deficiency anaemia management pathway has resulted in improved perioperative haemoglobin levels, with a reduction in perioperative transfusion, in elective colorectal patients. Implementation of this pathway could result in similar outcomes across other categories of surgical patients.

International consensus statement on the peri-operative management of anaemia and iron deficiency.

Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.

Implementation of a Preoperative Anemia Management Clinic in a Tertiary Academic Medical Center

Background:Preoperative anemia is commonly encountered with a reported incidence of 5-75% in elective presurgical populations. Anemia is an independent risk factor for perioperative morbidity and mortality and is a strong predictor of perioperative blood transfusion. Approximately 50% of all blood transfusions occur in the perioperative setting and transfusions are a significant financial burden for healthcare institutions. Although preoperative anemia management has been shown to reduce transfusion requirements and improve perioperative outcomes, the optimal delivery model for this service remains unclear. We describe the implementation of a novel preoperative anemia management clinic (AMC) workflow and report patient volume trends since its implementation in Jan 2015 at the University Of Iowa Hospitals & Clinics.Methods:We identified patients undergoing elective high blood loss (HBL) surgical procedures (defined as predicted blood loss >500 cc) with a preoperative hemoglobin (Hb) <12 g/dl as the target population for preoperative anemia management. We identified HBL procedures by ICD codes using information derived from our institutional maximum surgical blood-ordering schedule (MSBOS), intraoperative estimated blood loss (EBL) data from the electronic medical record (EMR) and surgical provider input. In calendar year 2014, 3262 elective HBL surgical patients were identified, out of which 452 (13.9%) received perioperative red cell transfusions. 232 (51.3%) of these patients had a preoperative Hb <12 g/dl. 61 (26%) of these patients were transfused 1 unit PRBCs, 62 (27%) were transfused 2 units and the remaining 109 (47%) patients were transfused > 2 units. Assuming 1- 2 unit transfusions were preventable by preoperative anemia managment, the calculated cost savings to the institution by avoiding these transfusions was estimated to be $200,000/year, not including potential improvement in length of stay. Using these data as baseline, a business plan for an AMC was presented to and approved by our hospital administration. An outpatient clinic was initiated in a temporaray location in early 2015 and later moved to a permanent location with infusion capabilities in August 2015 with two full time staff including a nurse practitioner and a medical assistant supervised by a nurse manager and a medical director. To streamline workflow, a stepwise algorithm for diagnosis and management of anemia was created by a multidisciplinary team that included Hematology, Anesthesiology, Surgery, Internal Medicine, Nursing and Pharmacy. We established referral mechanisms primarily from surgical clinics via automatic EMR alerts for elective HBL procedures linked to case scheduling through the EMR and secondarily through direct outpatient consultations.Results:We observed an overall trend of reduction in the percentage of patients transfused perioperatively in the two quarters following implementation of the preoperative AMC compared with the preceding quarterly intervals since Jan 2014 (Figure). In the same time period we observed a steady increase in number of patient visits to the AMC and number of iron infusions administered. Patient visits and iron infusions more than doubled in the first two quarters of 2016 compared to same time period in 2015 (594 vs 195 and 366 vs 124 respectively). There was a significant reduction in average length of stay (2.78 days) for patients who received transfusions after an AMC visit compared with patients who were not seen in the AMC.Conclusions:Implementation of a structured preoperative anemia management clinic (AMC) with an automatic referral workflow is feasible at a large academic medical center and appears to result in reductions in blood transfusions and hospital length of stay. The heterogeneity of our surgical population and the short timespan since implementation of the AMC are limitations of this analysis. We have ongoing efforts to minimize system errors in our referral mechanisms (ie appropriate EMR alerts to surgeons) and enhance surgical provider education to maximize preoperative anemia management opportunities. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Management of Coagulopathy in Postpartum Hemorrhage.

The purpose of this article is to review the use of blood products and hemostatic agents in the management of coagulopathy at the time of postpartum hemorrhage. Blood product administration strategies are broadly reviewed, including the role of the blood bank, the role of massive transfusion protocols, the role of laboratory monitoring, and the role of anesthesia management. Aspects of patient blood management are discussed. The concept refers to an evidence-based, comprehensive, multidisciplinary approach to optimizing the care of patients who might need transfusion and includes measures to avoid or minimize transfusion such as preoperative anemia management, cell salvage, and the use of hemostatic medication to reduce bleeding. The contributions of individual blood components-red blood cells, plasma, cryoprecipitate, and platelets-are described. Current data regarding the complementary role of hemostatic agents-antifibrinolytic agents and clotting factor concentrates-are presented. Two developments in blood component pathogen reduction are introduced.

Pilares del ahorro transfusional

Allogeneic blood transfusions have played a central role in the development of medicine, mainly as a support therapy in critically ill patients, major surgery, trauma and hematopoietic disorders. However, their use is not without significant adverse effects and associated high costs. Moreover, blood products are a limited resource that should not be wasted.Furthermore, surgery in patients who refuse the use of blood products has shown equal or better results than patients who accept transfusions. This has led to seek an appropriate blood management in all our patients, avoiding unnecessary costs and risks of transfusions, but allowing them when they believe the benefits outweigh the risks.In this paper three essential pillars are presented. The first is the appropriate diagnosis and management of pre-operative anaemia decreasing perioperative risk, since anaemia itself is a factor of morbidity and mortality. The second pillar is formed by various techniques that are available today to minimize bleeding perioperative. Finally, the third pillar is to improve tolerance to anaemia.The joint use of various techniques described in this paper has proven effective in decreasing perioperative bleeding, the need for allogeneic transfusions and blood units used, which may allow better clinical outcomes in our patients.

Efficacy of Ferrous Bisglycinate Chelate for the Management of Preoperative Anaemia in Orthopaedic Surgical Patients: A Prospective Study

Background: Oral iron support in patients (pts) undergoing preoperative autologous blood donation (PABD) programs has been suggested by different authors to improve red blood cell (RBC) production and limit iron depletion. Oral iron therapy, however, is frequently associated with side effects and poor pts compliance. The aim of this study was to evaluate the effectiveness of low doses of ferrous bisglycinate chelate (Tecnofer, Baldacci) a new oral iron preparation characterized by high gastrointestinal absorption and tolerability in the management of preoperative anemia. Material and methods: In our hospital we used a multimodal approach of integrated alternatives strategies after a preliminary clinical evaluation (CE) that provides a supportive iron therapy. We enrolled 60 pts candidate for orthopedic surgery presenting hemoglobin (Hb) levels between 11.5 and 12.5 g/dL in order to evaluate the effectiveness of ferrous bisglycinate chelate for these pts who presented gastrointestinal side effects related to previous oral iron treatment. All pts pre-deposited 1 unit of PABD (400 mL) at day 0. Forty pts (Group A) received 1 tablet/day of ferrous bisglicinate (14 mg/day) for 10 days. No iron was given to 20 pts (Group B). The variation in Hb concentration, percentage of reticulocytes (% RET), serum ferritin (FER) and percentage of transferrin saturation (%SAT) from the day of pre-deposit to ten days after donation were compared between the two groups. Results: The study lasted From October 2014 to December 2014 baseline Hb, RET count, serum FER and transferrin saturation were similar in the 2 groups. Pts receiving iron therapy had a lesser iron depletion, an increased erythropoiesis which in turn limited Hb reduction due to PABD, without showing any side effects. Discussion: Preliminary data of our study seem to indicate that oral administration of low doses of ferrous bisglycinate chelate is an effective and safe therapy to support PABD and to treat iron deficiency in patient’s candidate for major surgery. The high patient’s compliance to this new oral iron therapy seems to be a “Key Factor” in the treatment success.