Preoperative Anemia Management Research Articles

84 A PROSPECTIVE AUDIT OF THE MANAGEMENT OF POSTOPERATIVE ANAEMIA IN PATIENTS AFTER OPERATIVE MANAGEMENT OF NECK OF FEMUR FRACTURES

Abstract Background There is limited evidence available to guide the diagnosis and management of anaemia and iron deficiency in post operative patients. Numerous guidelines from professional associations exist for the management of pre-operative anaemia. We identified an international consensus statement that provided guidance on patient care with respect to postoperative anaemia and iron deficiency. Our aim was to determine if our practice was consistent with the best practice recommendations of this document. Methods We conducted a prospective audit on a convenience sample of patients over the age of 60 with neck of femur fractures who underwent operative management between January and April 2022. We collected data on pre and post operative haematological indices including haemoglobin, serum iron, ferritin and transferrin saturation as well as data on patients who received IV iron and red cell transfusions. Results We included 50 patients with neck of femur fractures who underwent hip replacement. All patients had post-op haemoglobin levels performed. Fifteen (30%) patients fulfilled the criteria for diagnosis of postoperative iron deficiency. Only 4/15 of these patients received IV iron postoperatively. Four patients who did not fulfil criteria for post-op iron deficiency received IV iron. Two patients had a post-op haemoglobin between 7-8g/dL and appropriately received red cell transfusions. Four patients received red cell transfusions despite having post-op haemoglobin levels >8g/dL. Conclusion Our findings indicated approximately 1/3 of patients fulfilled criteria for post operative iron deficiency while only a small proportion were treated for this. More data is required to establish the impact of post-op anaemia management strategies on functional recovery and quality of life as well as laboratory and interventional endpoints. A local protocol for the management of post operative iron deficiency with and without anaemia will be developed.

Perioperative Quality Initiative and Enhanced Recovery After Surgery-Cardiac Society Consensus Statement on the Management of Preoperative Anemia and Iron Deficiency in Adult Cardiac Surgery Patients.

Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.

An Observational Study of Paediatric Preoperative Transfusion Practice in a Resource-Limited Setting

BackgroundPaediatric anaemia is highly prevalent in low–middle-income countries and can negatively impact postoperative outcomes. Currently, there are no guidelines for the management of paediatric preoperative anaemia. To ensure optimal care in resource-limited settings: balancing the risks of anaemia and using resources such as blood transfusion, we first need to understand current practices. To address this, a joint UK–Bangladesh team conducted an observational study at a paediatric surgical centre in Bangladesh.MethodsA total of 464 patients ≤16 years who underwent elective and emergency surgery were categorised into major (351/464), moderate (92/464) and minor (21/464) surgery groups according to anticipated blood loss. Preoperative anaemia testing and transfusion was assessed retrospectively through patient notes.ResultsMedian age was 4 years and 73% were male. 32.5% (151/464) patients had preoperative blood testing for anaemia. 17.5% (81/464) children were transfused preoperatively. Of those children transfused, 40.7% (33/81) underwent transfusion solely based on visible signs of anaemia on clinical examination. Seventy-five percentage (36/48) of children who underwent transfusion after blood testing had haemoglobin ≥80 g/L. Major surgery category had the highest proportion of children who were transfused and tested for anaemia.ConclusionA liberal transfusion approach is evident here. Discussion with local clinicians revealed that this was due to limitations in obtaining timely blood results and reduction in laboratory costs incurred by families when clinical suspicion of anaemia was high. Further research is needed to analyse the potential of using bedside haemoglobin testers in conjunction with patient blood management strategies to limit blood transfusions and its associated risks.

EP.TU.269Management of preoperative anemia with Iron Therapy in colorectal cancer patients- a Systematic Review and Meta-Analysis

Abstract Background Nearly half of colorectal cancer (CRC) patients are diagnosed with anemia at the initial assessment (Ferlay et al., 2015). Anemic patients require blood transfusion, which increases cancer recurrence (Acheson et al., 2012). Hence iron therapy for anemia correction reduces postoperative morbidity and mortality. Aims To review randomized controlled trials on iron therapy for preoperative anemia in CRC patients. Methodology Includes formulating a review question, analyzing, quantifying the inclusion and exclusion criteria, literature search, quality assessment, data extraction and data synthesis, bias rectification, results interpretation and summarizing the evidence. Cochrane Handbook of Systematic Reviews and acronym PICO has been used for formulating review questions and study design (O’Connor et al., 2011). Selection Criteria Systematic reviews and RCTs with higher level of evidence were included in this review Data Extraction Quality assessment and data collection were done using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta- Analysis) checklist. Data extraction and analysis done by REVMAN Manager (Higgins et al., 2011). Results Two trials reported that iron therapy reduces the need for blood transfusion, but with insignificant result. All three studies showed that hemoglobin rise occurs with iron therapy postoperatively. None of the studies analyzed the quality of life. Recommendations RCTs with larger sample size to be done for more relevant and accurate reports, aiming at the primary and secondary outcomes like morbidity, mortality and quality of life. Oral iron with fewer side effects has to be experimented for best efficacy.

Complication Risk in Ventral Skull Base Surgery Based on Preoperative Hematocrit.

Preoperative anemia has been shown to be a predictor of complications in different surgeries. This has not been exclusively studied in skull base surgery. This study investigates the impact of preoperative hematocrit on complications following ventral skull base (VSB) surgery. Retrospective database review. The National Surgical Quality Improvement Program was queried for all cases of VSB surgery from 2005 to 2015. Univariate and multivariate analyses were performed to investigate the impact of preoperative anemia on complications following VSB procedures. 3,053 patients meeting inclusion criteria were identified. On univariate analysis, low hematocrit was found in 39.7% of patients and was associated with increased mean age (55.71 vs. 53.25 years), male gender (63.6% vs. 36.4%), and Black race (18.5% vs. 10.9%). Preoperative anemia was also associated with increased incidences of postoperative pneumonia, blood transfusions, sepsis, medical complications, surgical complications, extended length of hospital stay (LOS), and mortality. On multivariate analysis, associations between low preoperative hematocrit and perioperative transfusions (odds ratio [OR] 2.57, 95% confidence interval [CI] 1.88-3.50, P < .001), total surgical complications (OR 2.12, 95% CI 1.60-2.80, P < .001), and extended LOS (OR 1.29, 95% CI 1.05-1.57, P=.013) remained significant. Low preoperative hematocrit is associated with increased risk of postoperative complications and extended LOS in patients undergoing VSB surgery. This study highlights the importance of careful preoperative assessment and management of anemia in these patients. 3 Laryngoscope, 132:1707-1713, 2022.

1037 Early Detection and Management of Preoperative Anaemia in An Elective Vascular Surgery Cohort

Abstract Introduction Iron deficiency anaemia is the most common cause of anaemia in the surgical population. Patients receiving transfusions during major surgery encounter more adverse outcomes compared to those that do not, indicating the early management of pre-operative anemia is likely to reduce major surgical patient morbidity and mortality. Previous studies have demonstrated that 33% of patients undergoing major vascular surgery operations are anaemic (haemaglobin, Hb, &amp;lt;130g/L). Aim We aim to reduce the proportion of anaemic patients undergoing major vascular surgery by 50%. Method A point-of-care HemoCue machine was used to measure Hb in patients who were referred for elective major surgery in 11 vascular clinics. Patients with Hb &amp;lt; 130g/L were prescribed a 1-month course of Ferrous Sulfate (200mg TDS), and a letter was sent to their GP requesting iron function tests. Post-intervention Hb levels were rechecked following the preoperative anaesthetics review. Results 11 patients were referred for major surgery, of which 4 were identified as anaemic (36%). The mean Hb concentration was 121.3g/L, which increased to 137.3g/L following oral iron therapy. The mean duration of follow up was 36 days (range 0-94 days). Conclusions The implementation of a HemoCue machine to identify and manage preoperative anaemia was successful in our pilot study. Further work should include full integration of our pathway into current vascular clinics without student support. This will enable evaluation of the impact of our intervention on a wider scale.

Demonstration of a U.S. nationwide reduction in transfusion in general surgery and a review of published transfusion reduction methodologies.

Red blood cell transfusions in surgical procedures can be lifesaving. However, recent studies show transfusions are associated with a dose-dependent increase in postoperative morbidity and mortality; hospitals and physicians have attempted to reduce them. We sought to determine the success of these efforts and review and summarize published reduction methods employed. An analysis of transfusion data from ACS-NSQIP public use files of general surgical procedures for 2012 and 2018; a retrospective review of the literature surrounding general surgical transfusion reduction from 2008 to 2018. The rate of general surgical transfusion in the NSQIP dataset decreased from 5.5% in 2012 to 4.0% in 2018, a 27% relative reduction in transfusion. After extensive multivariable adjustment for patient risk and operative complexity, this effect remained (Odds ratio 0.65, 95% CI 0.63-0.67, p< .001). Furthermore, there was a positive correlation between specific procedure decreases in transfusion and decreases in 30-day morbidity (rho =0.41, p= .003) and mortality (rho=0.37, p= .007). There were 866 published studies matching our search term "red blood cell transfusion reduction." Forty-four were relevant to general surgery. Seven dominant strategies for transfusion reduction by descending frequency of report included restrictive transfusion thresholds, management of preoperative anemia, perioperative interventions, educational programs, electronic clinical decision support, waste reduction, and audits of transfusion practices. Our study demonstrates a 27% decrease in general surgery transfusion between 2012 and 2018 with associated reductions in morbidity and mortality, suggesting published employed strategies have been successful and safely implemented.

Need for preoperative anemia management clinics in Japan: initiatives at a university hospital in the USA.

Untreated preoperative anemia increases the risk of morbidity and mortality and there is increasing evidence that early intervention for preoperative anemia improves outcomes after major surgery. Accordingly, anemia management clinics have been established in various institutions in the USA. As an example, the University of Iowa Hospitals and Clinics outpatient clinic treats pre-surgical anemic patients, who undergo major surgery with anticipated blood loss of more than 500mL, by providing effective standardized care in a timely manner. This standardized care is an integral part of patient blood management to reduce perioperative blood transfusion and improve patient outcomes. The importance of preoperative anemia management has not yet been sufficiently recognized in Japan. Timely intervention for preoperative anemia should be incorporated into routine pre-surgical patient care in Japan.

Clinical Outcome and Risk Factors of Red Blood Cell Transfusion in Patients Undergoing Elective Primary Meningioma Resection.

Simple SummaryThe transfusion of red blood cells (RBC) in patients undergoing major elective cranial surgery is associated with increased morbidity and mortality. This study sought to identify the clinical outcome of RBC transfusions in skull base and non-skull base meningioma patients including the identification of risk factors for RBC transfusion. Data underline that preoperative anaemia rate was significantly higher in transfused patients (17.7%) compared to patients without RBC transfusion (6.2%). We could further show that RBC transfusion was associated with increased postoperative complications and increased hospital length of stay. After multivariate analyses, risk factors for RBC transfusion were preoperative American Society of Anaesthesiologists (ASA) physical status score, tumor size, surgical time, and intraoperative blood loss. We concluded that blood loss due to large tumors or localization near large vessels are the main triggers for RBC transfusion in meningioma patients paired with a potential preselection that masks the effect of preoperative anaemia in multivariate analysis. So far, this has not been investigated in a large cohort (n = 423) of skull base and non-skull base meningioma patients.Transfusion of red blood cells (RBC) in patients undergoing major elective cranial surgery is associated with increased morbidity, mortality and prolonged hospital length of stay (LOS). This retrospective single center study aims to identify the clinical outcome of RBC transfusions on skull base and non-skull base meningioma patients including the identification of risk factors for RBC transfusion. Between October 2009 and October 2016, 423 patients underwent primary meningioma resection. Of these, 68 (16.1%) received RBC transfusion and 355 (83.9%) did not receive RBC units. Preoperative anaemia rate was significantly higher in transfused patients (17.7%) compared to patients without RBC transfusion (6.2%; p = 0.0015). In transfused patients, postoperative complications as well as hospital LOS was significantly higher (p < 0.0001) compared to non-transfused patients. After multivariate analyses, risk factors for RBC transfusion were preoperative American Society of Anaesthesiologists (ASA) physical status score (p = 0.0247), tumor size (p = 0.0006), surgical time (p = 0.0018) and intraoperative blood loss (p < 0.0001). Kaplan-Meier curves revealed significant influence on overall survival by preoperative anaemia, RBC transfusion, smoking, cardiovascular disease, preoperative KPS ≤ 60% and age (elderly ≥ 75 years). We concluded that blood loss due to large tumors or localization near large vessels are the main triggers for RBC transfusion in meningioma patients paired with a potential preselection that masks the effect of preoperative anaemia in multivariate analysis. Further studies evaluating the impact of preoperative anaemia management for reduction of RBC transfusion are needed to improve the clinical outcome of meningioma patients.

Preoperative anemia management program reduces blood transfusion in elective cardiac surgical patients, improving outcomes and decreasing hospital length of stay.

Anemia is an independent risk factor for hospitalization, readmission, prolonged length of stay (LOS), diminished quality of life, and mortality. A multidisciplinary program was implemented to manage anemia preoperatively as a patient blood management (PBM) initiative. From March 2016 to August 2018, 240 patients were screened for anemia during their preoperative cardiovascular visit. About 52/240 (22%) were found to be anemic and met out inclusion criteria. Also, 45/52 (87%) had iron deficiency anemia and 7 (13%) had anemia without iron deficiency. A similar historical cohort of patients undergoing elective cardiovascular surgery with hemoglobin (Hb) < 12 g/dl from September 2014 to February /2016 (n=52) served as control group. The primary outcome was perioperative red blood cell (RBC) transfusion. Secondary outcomes were date-of-surgery Hb, intensive care unit (ICU) and hospital LOS, complication rates, and transfusion cost. The two most common treatments were IV iron ± folate (n=36/45; 80%) and oral iron (n=9/45; 20%). As compared to historical patients, study patients had significantly higher day-of-surgery Hb (10.6 ± 1.4 vs. 9.8 ± 1.3g/dl, p < .001), lower utilization of RBC transfusion (0.86 ± 1.4 vs. 2.78 ± 2.4, p < .001), fewer days in the ICU (2.1 ± 2.0 vs. 4.0 ± 3.5, p=.002), and shorter total LOS (6.9 ± 4.8 vs. 12.9 ± 6.8, p < .0001). Study patients also showed lower overall complication rates (p < .0001). Analysis of RBC acquisition cost and transfusion cost also showed significant saving of 69% ($293 vs. $945 and $656 vs. $2116, respectively). When corrected for type of procedures and surgeon, our pilot anemia program in elective cardiovascular surgeries showed higher day-of-surgery Hb and significant reduction in RBC transfusion rates, ICU and hospital LOS, and overall complication rates.

Preoperative Preparation of Patients with Anemia before Shoulder Replacement

The preoperative anemia in patients increases the risk of perioperative blood transfusion, myocardial infarction, ischemic stroke, acute kidney injury, and higher nosocomial and 30-day mortality, lengthens the duration of treatment, and increases the risk of re-hospitalization.The objective: to improve treatment results of patients after revision shoulder replacement through management of preoperative anemia.Subjects and methods. 170 medical files of patients who underwent revision shoulder replacement from 2014 to 2021 were retrospectively analyzed. On the day when they were examined by the physician, all patients had blood hemoglobin level below 130 g/l. The patients were divided into two groups that were comparable in their characteristics. Patients of the Main Group (n = 90) received preoperative preparation with iron carboxymaltate in combination with recombinant human erythropoietin 4 weeks before the expected date of surgery. Patients of the Control Group (n = 80) did not have any specific preparation.Results. The data obtained showed that the volume of intraoperative and postoperative drainage blood loss did not differ statistically between the groups; hemoglobin blood level in patients from the Main Group was statistically significantly higher both before the surgery and on the first day after it, and no hemotransfusion was indicated. In the Control Group, a statistically significantly greater decrease in hemoglobin level was observed in the postoperative period; 3 (3.8%) patients in the Control Group required RBC-transfusion. Complications in the early postoperative period (myocardial infarction, pulmonary embolism, and cardiac arrhythmia) were significantly less frequent in the Main Group versus the Control one (4.5% of cases vs. 8.8%; p &lt; 0.05).Conclusion. The use of iron carboxymaltate at the dose of 1,000 mg once and, if necessary, repeatedly in 14 days in combination with recombinant human erythropoietin at the dose of 150 IU/kg allows preparing patients for revision shoulder replacement within the period from two weeks to one month. Preoperative management of anemia until the hemoglobin concentration reaches 130 g/l using the proposed regimen can significantly reduce the need for blood transfusion and frequency of somatic complications in the early postoperative period.

New trend in transfusion medicine – Patient blood management

Abstract Transfusion is often part of hospital care, the indication being in constant change as an effect of latest multicentric studies’ result. Although transfusion-related complications decreased significantly, the intervention still involves risks, that are worth assuming if only the anemia of patient cannot be managed with other, safer methods. Management of patients declining transfusion or of those unsuitable for transfusion has brought instructive results in assessment of hemoglobin concentration conditioning the necessity of the intervention. Further development of these findings led to development of Patient Blood Management concept, aiming the optimization of blood product usage while improving morbidity and mortality of patient care. Patient Blood Management applies guides helping to avoid transfusions that are not definitely necessary for patients. Using restrictive transfusion principles, preoperative anemia management, tight hemostasis monitoring and treatment, is not only safer but also cost-effective. The objective of our paper is the brief report of some Patient Blood Management guidelines, and to promote and facilitate the application of the new approach.

73 An Audit Evaluating the Management of Pre-Operative Anaemia in Elective Bowel Resections at Frimley Park Hospital

Abstract Introduction Pre-operative anaemia is common within the surgical population, particularly those scheduled for elective bowel resections. National and local guidelines recommend the treatment of pre-operative anaemia, as it is an independent risk factor for poor post-operative outcomes, including length of stay in hospital. Method A retrospective study of all NHS patients over the age of 18 scheduled for an elective bowel resection at Frimley Park Hospital between 1st May-31st October 2019. Results 85 patients met the inclusion criteria, with 29 recorded as anaemic. Of these patients, 55% (n = 16) received iron replacement, all of which were intravenous and did not include mildly anaemic patients. The median rise in haemoglobin post-infusion was 14g/L, with only one patient achieving a normal haemoglobin. The median length of stay for patients with a normal haemoglobin was six days, which increased to eight for those with anaemia of any severity. A statistically significant relationship was found between severity of anaemia and increased length of stay, particularly in the female population. Conclusions Pre-operative anaemia was linked to increased length of stay in hospital. The findings support the intravenous treatment of all severities of anaemia pre-operatively and therefore suggest treating mild anaemia patients, as normalising their haemoglobin will improve outcomes.

Blood Conservation and Hemostasis in Cardiac Surgery: A Survey of Practice Variation and Adoption of Evidence-Based Guidelines.

Blood conservation and hemostasis are integral parts of reducing avoidable blood transfusions and the associated morbidity and mortality. Despite the publication of blood conservation guidelines for cardiac surgery, evidence suggests persistent variability in practice patterns. Members of the Society of Cardiovascular Anesthesiologists (SCA) created a survey to audit conformance to existing guidelines and use the results to help narrow the evidence-to-practice gap. Members of the SCA and its Continuous Practice Improvement (CPI)- Blood Conservation Work Group developed a 48-item Blood Conservation and Hemostasis in Cardiac Surgery (BCHCS) survey. The questionnaire included the components of the Anesthesia Quality Institute's (AQI) composite measure AQI49. The survey was distributed to the entire SCA membership by e-mail via the Research Electronic Data Capture (REDCap) Consortium between the fall of 2017 and early 2018. Of 3152 SCA members, 536 returned surveys for a response rate of 17%. Most responders worked at academic institutions. The median transfusion trigger after cardiopulmonary bypass was hemoglobin (Hgb) 7.0 to 8.0 g/dL. There are 4 components to AQI49, and the composite conformance to all of them was low due to 1 specific component: the use of transfusion algorithms supplemented with point-of-care (POC) testing. There was good conformance to the other 3 components of AQI49: use of antifibrinolytics, minimization of hemodilution and use of red cell salvage. Overall, practices with a multidisciplinary patient blood management (PBM) team were the most successful in meeting all 4 AQI49 criteria. The survey demonstrated widespread adoption of several best practices, including the tolerance of lower hemoglobin transfusion triggers, use of antifibrinolytics, minimization of hemodilution, and use of red cell salvage. The survey also confirms that gaps remain in preoperative anemia management and the use of transfusion algorithms supplemented with POC hemostasis testing. Serial use of this survey can be used to identify barriers to implementation and audit the effectiveness of interventions described in this article. This instrument could also help harmonize local, regional, and national efforts and become an essential component of an implementation strategy for PBM in cardiac surgery.

Perioperative Management of Patients for Whom Transfusion Is Not an Option

This article reviews the management of patients requesting or requiring surgery without transfusion, including patient identification and informed consent, determining preoperative target hemoglobin and anemia management, and intraoperative and postoperative blood conservation techniques.

Patient blood management – recommendations from the International Consensus Conference, Frankfurt/Main, Germany

An International Consensus Conference (ICC) on PBM was held in 2018 to develop evidence‐based clinical and research recommendations for preoperative anaemia, red blood cell (RBC) transfusion thresholds for adults and implementation of PBM programmes. An international scientific committee (SC) defined 17 Population‐Intervention‐Comparison‐Outcome (PICO) questions for the three topics preoperative anaemia, red blood cell (RBC) transfusion thresholds for adults and PBM implementation. Based on these questions, an extensive literature search was conducted in four biomedical databases. The GRADE framework (= grading of recommendations, assessment, development and evaluation) was used to develop a systematic approach to the presentation of evidence summaries and for making clinical recommendations. Three expert panels (EP) consisting of clinicians, scientists, nurses, patient representatives and methodologists were established and used these methods to develop recommendations driven by published evidence. Out of more than 17 500 literature citations, data from 145 studies were incorporated. The expert panel for preoperative anaemia developed 4 clinical and 3 research recommendations. A strong recommendation advices early detection and management of preoperative anaemia before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations have been formulated. Two strong clinical recommendations for RBC transfusion thresholds comprise a haemoglobin concentration of &lt;7 g/dl for critically ill, but clinical stable adult intensive care patients independent of septic shock and &lt;7·5 g/dl for adults undergoing cardiac surgery. For the implementation of PBM programmes, 2 clinical and 3 research recommendations were developed. Research recommendations were formulated as encouragement of new studies to answer open questions. Due to the relative paucity of strong evidence‐based answers in current publications to the 17 PICO questions, additional research, an international consensus for accepted definitions and Hb thresholds as well as clinically meaningful end‐points for clinical studies are necessary. The 2018 PBM ICC defined the current status of PBM evidence and established 10 clinical and 12 research recommendations for preoperative anaemia, RBC transfusion thresholds for adults and implementation of PBM programmes.

Current concepts in the evaluation and management of preoperative anemia.

In the past years, patient blood management (PBM) has evolved to improve patient's care and safety. Anemia is one of the most common medical diseases in the world and is an independent risk factor for morbidity and mortality. Iron deficiency is the main cause for anemia and constitutes a potentially preventable condition with a great impact on surgical outcome. However, preoperative anemia management is not yet established in most hospitals. Changing workflows and re-thinking is challenging. Numerous published studies confirmed the positive effect of preoperative anemia diagnosis and treatment recently. Iron supplementation in iron-deficient anemic (IDA) patients reduce the need for allogenic blood transfusion thereby improving perioperative outcome. Since the introduction of PBM programs, important movements towards early detection and therapy of preoperative anemia have been observed. However, preoperative anemia management is not implemented on a large scale as many healthcare professionals are not aware of the most recent findings in the field. Preoperative anemia management, particularly iron supplementation in IDA patients, has proven to be highly effective and has a tremendous effect on patient safety and outcome.

Retrospective evaluation of preoperative anaemia management at a Melbourne metropolitan hospital: a framework for quality improvement

AbstractBackgroundThere is a strong evidence base supporting the implementation of patient blood management systems to treat preoperative anaemia and reduce perioperative transfusions, yet implementation of these systems remains limited. The patient blood management practices at Northern Health are currently under review. This study evaluates the prevalence of anaemia in the Northern Health surgical cohort and determines the current blood management practices of each surgical unit to create recommendations for a hospital‐wide implementation strategy that can be used as a framework for quality improvement in similar metropolitan hospitals.MethodsPreadmission and perioperative data were collected for adults undergoing elective major surgery from orthopaedics, gynaecology, urology, colorectal and hepatobiliary units between April 2018 and March 2019. Data were analysed using the Shapiro–Wilk, the Kruskal–Wallis and Fisher’s exact tests.ResultsA total of 697 patient files were analysed. 14·2% of patients were anaemic at preadmission clinic with 37% of these attributable to iron deficiency. Anaemic patients had a higher rate of transfusion (P &lt; 0·05), length of stay (P &lt; 0·05) and complications (P &lt; 0·05) when compared to non‐anaemic patients. The orthopaedic unit was the best performing in key areas of patient blood management. The orthopaedic unit successfully treated 44% of patients with anaemia, which was more than urology (33%; P &lt; 0·05), colorectal (25%; P &lt; 0·05) and hepatobiliary (0%; P &lt; 0·05).ConclusionThe orthopaedic unit has the most effective method for treating preoperative anaemia. We recommend that a hospital‐wide patient blood management system be modelled from the current orthopaedic system and address specific barriers identified within each unit.

Perioperative Blood Management of Preoperative Anemia Determines Long-Term Outcome in Patients with Pancreatic Surgery

Background/PurposeAnemia affects the postoperative course of patients undergoing a major surgical procedure. However, it remains unclear whether anemia has a different impact on the long-term outcome of patients with malignant or benign pancreatic disease. MethodsA retrospective analysis of patients undergoing pancreatic surgery for pancreatic malignancies or chronic pancreatitis was conducted between January 2012 and June 2018 at the University Hospital Dresden, Germany. The occurrence of preoperative anemia and the administration of pre-, intra-, and postoperative blood transfusions were correlated with postoperative complications and survival data by uni- and multivariate analysis. ResultsA total of 682 patients were included with 482 (70.7%) undergoing surgical procedures for pancreatic malignancies. Univariate regression analysis confirmed preoperative anemia as a risk factor for postoperative complications > grade 2 according to the Clavien-Dindo classification. Multivariate regression analyses indicated postoperative blood transfusion as an independent risk factor for postoperative complications in patients with a benign (OR 20.5; p value < 0.001) and a malignant pancreatic lesion (OR 4.7; p value < 0.01). Univariate and multivariate analysis revealed preoperative anemia and pre-, intra-, and postoperative blood transfusions as independent prognostic factors for shorter overall survival in benign and malignant patients (p value < 0.001–0.01). ConclusionPreoperative anemia is a prevalent, independent, and adjustable factor in pancreatic surgery, which poses a significant risk for postoperative complications irrespective of the entity of the underlying disease. It should therefore be understood as an adjustable factor rather than an indicator of underlying disease severity.

Evaluation of Red Blood Cell Transfusion Practice and Knowledge Among Cancer Surgeons

BackgroundTransfusion of blood products has a negative impact on surgical and cancer outcomes. The objective of the current study was to evaluate surgeons’ practice and knowledge of red blood cell transfusion for surgical patients. MethodsA survey of residents, fellows, and faculty surgeons at the Ohio State University Wexner Medical Center and surgeons who identified as taking care of cancer patients nationally was conducted. Four domains were addressed including perceived preoperative assessment and management of anemia, perceived use of transfusion alternatives, perceived use of and factors influencing packed red blood cell administration, and transfusion practice knowledge. ResultsAmong 158 respondents, 87 (64.5%) were surgeons on faculty at an academic medical center, 26 (19%) were surgeons in private practice, and 24 (15.2%) were surgical residents or fellows. The majority of respondents were surgical oncologists or hepatobiliary surgeons (N = 83, 62.0%) and had been in practice > 10 years (> 10–15 N = 28, 20.6%) and > 15 years N = 59, 43.4%). Only thirteen (N = 13, 8.2%) surgeons reported that they routinely complete a preoperative anemia workup. The majority of providers reported that they rarely or never use alternatives to transfusion such as erythropoietin (N = 135, 91.8%), tranexamic acid (N = 140, 94.6%), autologous blood transfusion (N = 141, 95.3%), or cell saver for benign (N = 107, 72.3%) or malignant cases (N = 133, 90.4%). Provider transfusion knowledge was variable. ConclusionsSurgeons varied widely in their transfusion practice and knowledge. Further education of surgeons regarding transfusion medicine and practice, as well as use of transfusion alternatives, could lead to improved patient outcomes. Patient blood management programs may help inform individual surgeon practices.