Patient Blood Management Program Research Articles

Red blood cell transfusion in southern Finland from 2011 to 2016: a quality audit.

The current trends in RBC use and pre- and post-transfusion Hb levels were analysed to improve practice and to provide international comparison. Indications for RBC transfusion have changed with growing scientific evidence. The lowest acceptable haemoglobin (Hb) level has decreased, and transfusing single units instead of pairs has become the new standard. Evidence-based guidelines and patient blood management (PBM) programmes increase clinician awareness of rational RBC use. In Finland, however, no formal PBM programme has been established to date. The study was registry-based, retrospective and observational. All RBC transfusions for adult patients from 2011 to 2016 in the southern region of Finland were analysed. RBC usage decreased from 34·9 to 27·5units per 1000 population (P<0·001). The percentage of single-unit transfusions increased from 57·9 to 66·7%, and the median pre- and post-transfusion Hb levels decreased from 8·4 to 8·2g dL-1 (P<0·001) and 9·9 to 9·6g dL-1 (P<0·001), respectively. The proportion of transfusions with pre-transfusion Hb ≥ 9·0g dL-1 decreased during the study period but remained high, being 29·5% in 2011 and still 25·2% in 2016. Consumption of RBCs has decreased despite aging population and increasing healthcare performance demands. The results indicate more rational and evidence-based RBC use. Nevertheless, the transfusion rate and pre- and post-transfusion Hb are still sufficiently high to enable more restrictive transfusion practice.

Transfusion Strategy the Impact of Oxygen Delivery

Cardiac surgery is associated with high risk of perioperative blood loss leading to hemodynamic instability, which frequently warrants fluid replacement, pharmacological therapy or transfusion. Regardless of an association of as little as 1-2 blood units with a dramatic increase in morbidity and mortality, transfusion is still widely administered. Despite recent guidelines there is still little consensus on blood transfusion thresholds and the implementation of multidisciplinary patient blood management programs, has not led to convincing effects as RBC transfusion is still a frequent option in cardiac surgery.

First trimester ferritin screening for pre-delivery anaemia as a patient blood management strategy

ObjectivesTo determine the optimum approach and timing to screen for iron deficiency in pregnancy. BackgroundThere is a lack of consensus on identifying and treating iron deficiency during pregnancy. Patient blood management programs may be refined by evaluating outcomes. MethodsRetrospective data collection on women delivering prior to and following implementation of patient blood management interventions. Ferritin, transferrin saturation and haemoglobin levels were evaluated in first and second trimesters as predictors of pre-delivery anaemia. The optimum time to screen was determined. Comparison with results following a quality improvement intervention was undertaken. A separate retrospective study was performed to validate the predictive value of ferritin using data extracted from the laboratory information system. ResultsFerritin and transferrin saturation in first trimester detected women who subsequently had anaemia pre-delivery, with ferritin being most discriminatory. Both were superior to haemoglobin concentration. Iron studies in second trimester did not predict pre-delivery anaemia and haemoglobin remained poorly discriminatory. Iron studies lost predictive value when a systematic program ensured treatment of iron depletion during pregnancy. The ability of ferritin to predict pre-delivery anaemia in the first, but not the second, trimester was confirmed on the validation cohort. ConclusionFirst trimester serum ferritin may identify candidates for iron therapy during pregnancy. This strategy may be preferable to haemoglobin screening alone or universal replacement in centres at low risk of anaemia.

Patient Blood Management Program Improves Blood Use and Clinical Outcomes in Orthopedic Surgery.

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopedic surgery patients require a higher hemoglobin transfusion threshold than other patient populations (8 g/dl vs. 7 g/dl). The authors tested the hypothesis in orthopedic patients that implementation of a patient blood management program encouraging a hemoglobin threshold less than 7 g/dl results in decreased blood use with no change in clinical outcomes. After launching a multifaceted patient blood management program, the authors retrospectively evaluated all adult orthopedic patients, comparing transfusion practices and clinical outcomes in the pre- and post-blood management cohorts. Risk adjustment accounted for age, sex, surgical procedure, and case mix index. After patient blood management implementation, the mean hemoglobin threshold decreased from 7.8 ± 1.0 g/dl to 6.8 ± 1.0 g/dl (P < 0.0001). Erythrocyte use decreased by 32.5% (from 338 to 228 erythrocyte units per 1,000 patients; P = 0.0007). Clinical outcomes improved, with decreased morbidity (from 1.3% to 0.54%; P = 0.01), composite morbidity or mortality (from 1.5% to 0.75%; P = 0.035), and 30-day readmissions (from 9.0% to 5.8%; P = 0.0002). Improved outcomes were primarily recognized in patients 65 yr of age and older. After risk adjustment, patient blood management was independently associated with decreased composite morbidity or mortality (odds ratio, 0.44; 95% CI, 0.22 to 0.86; P = 0.016). In a retrospective study, patient blood management was associated with reduced blood use with similar or improved clinical outcomes in orthopedic surgery. A hemoglobin threshold of 7 g/dl appears to be safe for many orthopedic patients.

The Effect on Blood Use after Adopting Single-Unit Policy and Restrictive Transfusion Trigger in a Hematology Unit: The Ensure Study

IntroductionRed blood cell (RBC) transfusion is a frequently performed medical procedure. But it is not without risk. Evidence suggests that restrictive transfusion is safe and effectively lessens the demand for blood components. Nevertheless, there exist considerable variations in transfusion practice among different centers. The hematology unit of Princess Margaret Hospital, a secondary referral center providing inpatient services for patients with various haematological malignancies and autologous stem cell transplantation, adopted a two-phase patient blood management program to reduce the demand for blood transfusions. Firstly, single-unit policy was implemented in Feb 2015 to replace the original protocol of transfusing two units of RBC in every transfusion episode. Secondly, the hemoglobin (Hb) trigger for transfusion decreased from 8g/dL to 7g/dL in asymptomatic and hemodynamically stable patients without cardiovascular disease in Aug 2016. The impact of these strategies to blood use and patient outcomes is evaluated in the present study.MethodThe study periods included 01/01/2014 - 12/31/2014 (Period A), 04/01/2015 - 03/31/2016 (Period B) and 10/01/2016 - 09/30/2017 (Period C). All patients admitted to the center during the study periods were recruited. Demographic data, RBC consumption, length of hospital stay and all-cause inpatient mortality were retrieved from the electronic medical record system. The proportions of single-unit transfusion and the mean Hb level transfusion triggers in different periods were compared with analysis of variance for continuous variables and logistic regressions for categorical variables respectively. Blood use in different periods was expressed in terms of RBC unit transfused per patient-day of hospitalization, and compared by age and sex adjusted incidence rate ratios (IRRs) obtained from zero-inflation negative binomial regression. To study the length of stay, negative binomial regression was performed to determine the age and sex adjusted IRRs for days of hospitalization in different periods. Clustering of data was further adjusted by applying robust standard errors. Generalized estimating equation for logistic regression, controlling for age, sex, days of hospitalization and number of previous admissions, was applied to compare the inpatient mortality in different periods.ResultsA total of 815 patients were recruited in the study, and the total number of admissions was 1,836. The number of patients in Period A was 232 (median age: 61 [IQR 49-71] years, male 54.7%) with 580 admissions, in Period B was 258 (median age: 63 [IQR 49-71] years, male 53.1%) with 566 admissions, and in Period C was 325 (median age: 62 [IQR 52-70] years, male 57.8%) with 690 admissions. The number of transfusion episodes in Periods A to C was 721, 923 and 803 respectively. The proportion of single-unit transfusion increased from 21.8% in Period A to 81.8% in Periods B (p<0.001) and 79.8% in Period C (p<0.001) respectively. The mean transfusion trigger Hb levels were 7.2±1.1 g/dL and 7.2±0.9 g/dL in Periods A and B respectively, and decreased to 6.6±0.9 in Period C (p<0.001 and <0.001). The proportion of transfusions with trigger Hb level >7g/dL decreased from 64.8% and 67.1% in Periods A and B to 17.7% in Period C (p<0.001 and <0.001) (TABLE 1).The total number of RBC transfused in the center was 1,317 units, 1,116 units and 990 units in Periods A to C respectively. RBC transfusion rate per patient-day of hospitalization reduced by 23% in Period B (p<0.001) and by 37% in Period C (p<0.001) respectively. The median length of hospital stay [IQR] was 7 [5-14], 6 [4-16] and 6 [4-13] days in Periods A to C. The in-patient mortality rates were 7.1%, 7.9% and 8.7% in Periods A to C. There was no statistically significant difference in the length of stay and in-patient mortality between different periods (TABLE 2).ConclusionsOur patient blood management program shows that both single-unit policy and lower Hb transfusion trigger are effective measures to reduce RBC use in hematology patients, without compromising the length of stay and inpatient mortality. Subgroup analysis could determine if restrictive transfusion strategies are applicable to all patients. Prospective studies including the occurrence of transfusion incidents and cost-effectiveness as outcome variables are useful to confirm our findings and substantiate the practicability of patient blood management. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Patient Blood Management: Implementation of a Preoperative Anemia Clinic for Elective Orthopedic Surgical Patients

Background: Patient blood management (PBM) programs aim to implement best practices and encourage blood stewardship. Judicious use of red blood cell transfusions improves patient safety, decreases hospital length of stay (LOS) and reduces cost. A 2010 World Health Organization statement asserted “…before surgery every reasonable measure should be taken to optimize the patient's own blood volume, minimize the patient's blood loss and to harness and optimize physiological tolerance of anemia…”. A comprehensive PBM program includes a preoperative anemia clinic to facilitate these goals. At our institution, 21% of surgical patients are anemic prior to their elective surgery and these patients consume approximately 67% of our transfused operating room blood. Our aim was to reduce red blood cell transfusions in elective orthopedic surgical patients by 25% and decrease hospital LOS through the implementation of a preoperative anemia clinic.Methods: After enlisting the support of hospital leadership, a preoperative anemia clinic referral/consult order was added the electronic medical record. Appropriate patients for referral were undergoing elective orthopedic surgery and had anemia defined as a Hgb <11.0 g/dl. Additional non-anemic patients with extenuating circumstances such as religious objection to transfusion were also referred. Every effort was made to see patients at least 2 weeks prior to the date of scheduled surgery or within 48 hours if the referral was not placed that far in advance. Work-up of anemia was individualized based on a patient's laboratory abnormality and medical profile. Interventions were targeted at treating the underlying cause of anemia and included but were not limited to parenteral iron, erythropoietin receptor agonists, and vitamin B12 injections. The primary measures assessed were the average LOS from day of surgery to discharge and the number of red blood cell units transfused during that stay.Findings: Early data since implementing our preoperative anemia clinic has demonstrated a reduction in LOS from 5.5 days for anemic patients undergoing elective surgery without a referral versus 3.5 days for those with a referral. A relative decrease in LOS of 36%. Reductions in hospital LOS were observed across the spectrum of all elective surgical procedures. The overall red blood cell transfusion rate in patients without referral versus with referral was 1.5% and 1.2% respectively; and of those requiring a transfusion, the mean red blood cell units transfused in the perioperative period was 2.31 units versus 1.19 units, resulting in a relative reduction of 48%. Additionally, 2 patients were diagnosed with a gastric ulcer and 2 patients with multiple myeloma during work-up and referred appropriately for treatment.Discussion: Expansion of the PBM program at our institution to include a preoperative anemia clinic has led to significant reductions in both red blood cell transfusions and hospital LOS in elective orthopedic surgical patients. Early results indicate a near doubling of our goal of a 25% reduction in red blood cells transfused. This has positively impacted our patients and led to both direct and indirect financial savings at our institution. Given the initial success, we hope to expand our preoperative anemia clinic to include all surgical specialties and streamline workflow. To facilitate growth additional staffing will be required. We have created patient education videos about the benefits of correcting their anemia prior to an elective surgery and hope to further engage primary care practitioners to refer patients earlier in their surgical evaluation. We conclude that the creation of a preoperative anemia clinic at our institution is a valuable resource and has led to a decreased use of red blood cell transfusions, a decreased average hospital LOS, improved patient safety and considerable financial savings. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Perioperative use of blood products is associated with risk of morbidity and mortality after surgery

BackgroundAdministration of blood products may be associated with increased morbidity and perioperative mortality in surgical patients. MethodsPatients aged 18 + who underwent gastrointestinal surgery at the Ohio State University Wexner Medical Center 9/10/2015-5/9/2018 were identified. Multivariable logistic regression models were used to evaluate impact of blood product use on survival and complications, as well as to identify factors associated with receipt of transfusions. ResultsAmong 10,756 patients, 35,517 units of blood products were transfused. Preoperative nadir hemoglobin was associated with receipt of blood product transfusion (OR 0.55, 95% CI 0.53, 0.68). After adjusting for patient and procedural characteristics, patients undergoing transfusion of blood products had an increased risk of perioperative mortality (OR 7.80, 95% CI 6.02, 10.10). ConclusionsThe use of blood products was associated with increased risk of complication and death. Patient blood management programs should be implemented to provide rational criteria and guidance for the transfusion of blood products.

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.

PHP110 - SUBSTANTIAL HEALTH GAINS FROM HEATH-SYSTEM-WIDE PATIENT BLOOD MANAGEMENT IMPLEMENTATION: ANALYTICS FOR EUROPE

The European Commission has recently published a new guidance to national health authorities and hospitals recommending the implementation of patient blood management (PBM) programs as the new standard of care across European health systems. This research aimed to estimate the potential impact of implementing nationwide PBM programs in 26 different European countries. A mathematical simulation model designated “EU PBM Analytics Tool” was developed based on post-hoc modelling of the relationship between the use of red blood cell (RBC) and its impact on key clinical outcomes (in-hospital mortality, acute myocardial infarctions (AMI)-strokes, hospital length of stay (LOS), 28-day readmissions and hospital acquired infections (HAI)), over a 5-year period, as reported by the Western-Australia PBM program. Data inputs for each country, including RBC use for transfusion, were retrieved from open sources. Results are presented in terms of in-hospital mortality, AMI-strokes, LOS (including re-admissions), HAI, and disability-adjusted life-years (DALY). Across the European countries considered, health-system-wide PBM programs could lower the average annual population-level RBC use rates from 37.9 to 26.1 units per 1,000 inhabitants (avoiding 5.6 million RBC transfusions). For an estimated 125 million emergency or high-complexity elective hospital admissions, over the time period, PBM programs could lead to avoiding 503,552 in-hospital deaths, 128,176 AMI-strokes, reduction of 46 million hospital days and 790,801 HAI. The public health impact can also accumulate to 15 million DALY, avoided on the long-run. The top 5 countries in terms of premature mortality avoidance are: Italy, the United Kingdom, France, Germany and Spain. All together accounting for more than 60% of the PBM implementation benefit, irrespective of the outcome. Implementation of a health-system-wide PBM program in Europe could be associated with unprecedented patient, hospital and public health benefits, antecipating substantial savings to society.

PHP159 - PUBLIC HEALTH AND ECONOMIC VALUE OF A NATIONWIDE PATIENT BLOOD MANAGEMENT PROGRAM

Patient Blood Management (PBM) is an evidence-based, multidisciplinary approach aiming to optimize patients’ own blood in order to improve clinical outcomes and healthcare expenditure. This research set out to assess the public health and economic value of a nationwide PBM program in Portugal. A mathematical decision-model was developed to estimate the impact of a nationwide PBM program over a one-year time horizon. Hospital-attended patients from the following therapeutic areas were considered: surgery (orthopaedic/cardiac/urologic), cardiology, oncology, gastrointestinal bleeding, abnormal uterine bleeding, haemodialysis, inflammatory bowel disease and pregnancy. Model inputs, obtained from Portuguese national health databases and literature review, included effectiveness and cost data on PBM strategies, transfusion utilization, hospitalization, mortality, physician visits and drug use. Model structure and inputs were validated by a national expert panel. For an estimated 384,704 patients eligible for PBM strategies, a reduction in the proportion of red blood cell (RBC) transfused patients of 51.2% could be obtained (-17,202 patients), associated with a reduction in the number of transfused RBC units of 57.3% (-65,214 units). Due to an estimated 8.4% and 37.3% decrease in hospital length of stay and readmissions, respectively, 233,141 in-hospital days could be avoided. Furthermore, in-hospital mortality could reduce by 594 cases, resulting in 1,481 life-years gained. Although an increase in drug use and physician visits would lead to an estimated additional €24.1 million in costs, these would be counterbalanced by €91.9 million in savings, mainly due to €70.4 million in hospitalization costs and €17.6 million in RBC transfusions. Net savings of over €67.7 million could be expected, equivalent to a 6.3% reduction in the public expenditure of this population. The implementation of a nationwide PBM program in Portugal could result in a substantial improvement in public health outcomes with high economic value to the national health system.

Hepcidin as a potential predictor for preoperative anemia treatment with intravenous iron-A retrospective pilot study.

Preoperative anemia occurs in about one third of patients who undergo elective surgery and is associated with an impaired outcome. Therefore, screening of preoperative anemia was established in the context of a multidisciplinary Patient Blood Management (PBM) program at the University Hospital of Muenster, Germany. Anemic patients without contraindications were treated with intravenous (IV) iron (ferric carboxymaltose) to increase their hemoglobin (Hgb) levels and hence to treat anemia prior to surgery. Interestingly, we detected a large variability in the response of Hgb levels after IV iron administration. Systemic iron homeostasis is mainly regulated by the hepatic hormone hepcidin, which regulates the cell surface expression of the sole known iron exporter ferroportin. The objective of this retrospective pilot study was to analyze the potential of hepcidin to predict the response of anemic patients to preoperative IV iron treatment measured as increase in Hgb.Serum samples of non-anemic (n = 48), untreated anemic (n = 64) and anemic patients treated with IV iron (n = 79), in total 191 patients, were collected between October 2014 until June 2016. Serum hepcidin levels were determined and data were analyzed retrospectively.The analysis revealed at first a correlation between serum hepcidin levels and the parameters of the iron status. Second, patients treated with IV iron showed a noticeably higher increase in their delta Hgb level between PBM consultation and surgery (0.45g/dl [0.05, 1.05] compared to patients without IV iron (0.1g/dl [-0.48, 0.73], *p = 0.03). Patients were then grouped into ‘non-responders’, defined as delta Hgb <0.6g/dl and ‘responders’, with delta Hgb ≥0.6g/dl between the day of IV iron treatment and the day of surgery. Within normal ranges and clinically unapparent, a statistically noticeable difference between responders and non-responders was found for CRP and leukocytes. Serum hepcidin levels were higher in the group of non-responders (10.6ng/ml [3.93, 34.77]) compared to responders (2.1ng/ml [0.25, 7.97], *p = 0.04).To conclude, the data of this retrospective pilot study indicate that hepcidin might be a promising biomarker to predict a patient`s responsiveness to IV iron in preoperative anemia treatment. Prospective studies have to investigate serum hepcidin levels as a biomarker to guide physician`s decision on IV iron substitution.

Implementation of a patient blood management program in an Australian private hospital orthopedic unit.

BackgroundPreoperative anemia in surgical patients has been linked to increased rates of allogeneic blood transfusion (ABT) and associated adverse patient outcomes such as prolonged ventilation in intensive care, increased length of hospital stay, and infections. We conducted a multifaceted implementation for orthopedic surgeons to improve preoperative patient assessment of anemia and iron deficiency to reduce perioperative blood transfusions.Materials and methodsUsing a before-and-after study design of independent samples, we recruited a convenience sample of surgeons who performed primary total hip arthroplasty at 1 Australian private hospital. Our implementation intervention consisted of: executive support, interactive education, and peer-to-peer support to encourage adherence to the National Blood Authority’s Patient Blood Management Program (PBMP) guidelines. We also used monthly reminders, e-learning access, and posters. Pre and post medical record audits evaluated preoperative blood tests, preoperative anemia, and number of blood units transfused between day of surgery until discharge. The primary outcome was an increase in the proportion of patients with preoperative blood tests undertaken prior to total hip arthroplasty surgery as recommended by the PBMP guidelines.ResultsAudits from 239 pre- and 263 postimplementation patients from 3 surgeons were conducted. Our primary outcome showed a significantly increased proportion of patients who had all the required preoperative tests postimplementation (0% to 94.6%; P<0.0001). Administration of ABT significantly decreased (pre: 9.2%, n=22; post: 2.3%, n=6; P=0.001) as well as the standard 2 blood units transfused (pre: 73%, n=16; post: 17%, n=1; P=0.022). The time between preoperative tests and day of surgery increased from 16 to 20 days (P<0.0001), allowing more time for physician’s review of test results.ConclusionOur results demonstrated successful implementation of a targeted PBMP to improve preoperative assessment to diagnose and treat anemia and/or iron deficiency prior to orthopedic surgery. This avoided unnecessary ABT and therefore mitigated potential risk to the patient.

Implementing a patient blood management programme in Brazil: challenges and implications for developing countries

BackgroundPatient blood management (PBM) programmes have the intention of promoting the rational use of blood, relying on up‐to‐date medical‐scientific evidence in a multidisciplinary approach, where the patient is the main focus of transfusion decisions. These programmes not only increase patient safety levels, but they also have the potential of lowering hospital costs. The aim of this study was to describe the implementation of a PBM programme at a University hospital in Brazil.Study design and methodsThe discussions regarding this PBM project were initially undertaken among the managers of the hospital's Transfusion Unit. Audits of transfusion practices were carried out, and these indices were presented in meetings with the Transfusion Committee and with other important stakeholders, in order for this information to support the delineation of the programme's work fronts.ResultsThe project was promptly approved by the hospital's Board of Directors due to the relevance of the proposal, which required few financial resources as the project is mainly based on reorganization of workflows. The measures implemented included the following: didactic sessions aimed at the hospital staff, reformulation of the computerized system for the prescription of blood components, elaboration of a protocol for the use of antifibrinolytic drugs during the perioperative period and the institution of an outpatient clinic for evaluation of preoperative anaemia.ConclusionThe benefits and challenges of a PBM project in a country with limited resources are analysed, discussing specificities in the scope of Brazilian Transfusion Medicine in a pioneering way.

Patient blood management program in oncological surgery: A multicenter prospective study.

e18793Background: Patient blood management (PBM) is an evidence-based, multidisciplinary and multimodal approach aiming to optimize the care of patients (pts) who might need blood transfusions.This...

The role of the internist in the patient blood management program

The role of the internist in the patient blood management program

Patient blood management, what does this actually mean for neonates and infants?

Patient blood management (PBM) refers to an evidence-based package of care that aims to improve patient outcomes by optimal use of transfusion therapy, including managing anaemia, preventing blood loss and improving anaemia tolerance in surgical and other patients who may need transfusion. In adults, PBM programmes are well established, yet the definition and implementation of PBM in neonates and children lags behind. Neonates and infants are frequently transfused, yet they are often under-represented in transfusion trials. Adult PBM programmes may not be directly applicable to these populations. We review the literature in neonatal (and applicable paediatric) transfusion medicine and propose specific neonatal PBM definitions and elements.

Intravenous Iron for Treatment of Anemia in the 3 Perisurgical Phases: A Review and Analysis of the Current Literature.

Anemia is a common comorbidity throughout the entire hospital stay. Treatment options include intravenous (IV) iron, oral iron, erythropoietin, and red blood cell (RBC) transfusions. IV iron has gained in popularity with the implementation of patient blood management programs. A variety of studies have been performed to investigate the use of IV iron in preoperative, perioperative, and postoperative settings. An objective review on these studies has yet to be performed. The current narrative review provides an overview of trials investigating IV iron use in the preoperative, perioperative, and postoperative settings. We performed a literature research of English articles published between 1964 and March 2017 in Pubmed including Medline and The Cochrane Library. Only studies with a control group were included. The final review includes 20 randomized controlled trials (RCTs), 7 observational trials, and 5 retrospective studies. Measured outcomes included hemoglobin (Hb) levels, reticulocyte counts, and/or RBC concentrates. Meta-analyses of RCTs using IV iron administration before surgery led to an increase in Hb levels, a reduction of RBC use, and an improvement in patient outcome. Only a few studies investigated the use of IV iron in the perioperative setting. These studies recommended the use of perioperative IV iron in cases of severe anemia in orthopedic surgery but not in all types of surgery. Published RCTs in the postoperative setting have shown positive effects of IV iron on Hb levels, length of hospital stay, and transfusion requirements. Some studies demonstrated an increase of Hb of 0.5-1 g/dL over 4 weeks postoperatively, but the clinical relevance and effect of this increase on an improvement of patient's long-term outcomes are uncertain. To summarize, the evidence to use IV iron is strongest in the preoperative setting, while it remains an individual treatment decision to administer IV iron perioperatively or postoperatively.

Red blood cell transfusion after a global strategy for early detection and treatment of iron deficiency anemia: three-year results of a prospective observational study.

Anemia is the main indication for red blood cell (RBC) transfusion and iron deficiency is the most prevalent, preventable, and treatable cause of anemia worldwide. We aimed to assess the impact of iron deficiency anemia (IDA) on RBC transfusion by means of a program for prevention, early detection, and treatment. A prospective observational study was conducted starting in 2014 after an intervention in clinical practice in Melilla, a peripheral city isolated by 207 km sea distance to nearest continental Spain. Recommendations were proposed for first-step diagnosis of iron deficiency in the laboratory, oral iron prevention and treatment in primary care, and intravenous iron complexes and RBC transfusion for hospital management. Reduction in RBC use for years 2014 to 2016 was the primary outcome, with the period 2010 to 2013 considered as baseline performance for statistical analysis. Compared to baseline, there was a significant (p < 0.05) increase in mean (±SD) yearly reference population (79,748 ± 3265 vs. 85,376 ± 781), ferritin assays (6980 ± 997 vs. 11,794 ± 1567), admissions (6768 ± 239 vs. 7629 ± 191), and subjects exposed to iron therapy (3975 ± 0.0 vs. 4667 ± 21 for oral, 54 ± 7 vs. 257 ± 109 for sucrose, and 128 ± 9 vs.176 ± 15 for carboxymaltose iron). Mean yearly number of RBC units transfused decreased (1622 ± 112 vs. 1434 ± 44; p = 0.043), with a mean reduction of 11.6% from baseline, or 21.4% when estimated by units transfused per 1000 admissions. Management of IDA is a target to avoid RBC transfusion, and awareness of this health problem should be among the first pillars for any patient blood management program.

Five-year trends in perioperative red blood cell transfusion from index cases in five surgical specialties: 2011 to 2015.

Red blood cell (RBC) transfusion can be life-saving; however, the risks of RBC transfusion have been increasingly recognized, and current guidelines recommend restrictive transfusion in most patients. We hypothesized that RBC transfusions are decreasing in surgical patients. A retrospective review of the National Surgical Quality Improvement Program database was performed from 2011 to 2015. Index cases in five surgical specialties were studied: neurosurgery, thoracic surgery, gynecologic surgery, orthopedic surgery, and vascular surgery. Patient characteristics, preoperative laboratory values, and surgery details were compared between years. The study's primary outcome was perioperative RBC transfusion, which was compared over the 5-year period for each specialty. Secondary outcomes were myocardial infarction and renal failure after surgery. In addition, trends in RBC transfusion between low-risk and high-risk patients and between emergency and elective surgery were examined. RBC transfusion decreased in all surgical specialties except for thoracic and gynecologic surgery. RBC transfusion decreased substantially in orthopedic surgery, falling from 22.4% in 2011 to 6.3% in 2015 (p ≤ 0.0001). High-risk patients had greater reductions in the receipt of RBC transfusion than low-risk patients, and there were no increases in myocardial infarction or renal failure after surgery in any specialty. RBC transfusion appears to be decreasing across multiple surgical specialties, with no apparent increase in myocardial infarctions or renal failure. This likely represents an important improvement in patient care. Continued efforts are needed to develop patient blood management programs and further reduce RBC transfusion.

Patient blood management programs: how to spread the word?

Red blood cell (RBC) transfusions save lives and improve health; however, unnecessary transfusion practice exposes patients to immediate and long-term negative consequences. Indirect consequences of unnecessary transfusions are the reduced availability of RBC units for patients who are in need. Accumulating evidence shows that restricting RBC transfusions improves outcomes and current guidelines suggest limiting RBC transfusion to the minimum number of units required to relieve symptoms of anemia or to return the patient to a safe hemoglobin range (7–8 g/dl in stable, non-cardiac inpatients). Still, studies show that there is over-utilization of RBC transfusion, partly due to low level of knowledge of physicians regarding restrictive RBC transfusion policy across a broad range of professions and specialties. Patient blood management (PBM) programs have been developed to promote clear hospital transfusion guidelines, strive for optimization of patient hemoglobin and iron stores and, most importantly, improve education regarding restrictive RBC policy. Understanding what and where the gaps of knowledge are, as was done in the study by Dr. Koren and his colleagues, is an important step for developing effective PBM programs.