Anemia and Patient Blood Management in Hip and Knee Surgery

Institute of Anesthesiology, University Hospital and University of Zurich, Zurich, Switzerland.
Anesthesiology (Impact Factor: 5.88). 08/2010; 113(2):482-95. DOI: 10.1097/ALN.0b013e3181e08e97
Source: PubMed


A systematic search was conducted to determine the characteristics of perioperative anemia, its association with clinical outcomes, and the effects of patient blood management interventions on these outcomes in patients undergoing major orthopedic surgery. In patients undergoing total hip or knee arthroplasty and hip fracture surgery, preoperative anemia was highly prevalent, ranging from 24 +/- 9% to 44 +/- 9%, respectively. Postoperative anemia was even more prevalent (51% and 87 +/- 10%, respectively). Perioperative anemia was associated with a blood transfusion rate of 45 +/- 25% and 44 +/- 15%, postoperative infections, poorer physical functioning and recovery, and increased length of hospital stay and mortality. Treatment of preoperative anemia with iron, with or without erythropoietin, and perioperative cell salvage decreased the need for blood transfusion and may contribute to improved patient outcomes. High-impact prospective studies are necessary to confirm these findings and establish firm clinical guidelines.

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    • "Measuring the incidence of patients with severe anaemia can be viewed as a surrogate marker of cardiovascular complications only. Numerous data exist however in the medical literature showing the clinical impact of post-operative anaemia on patient outcomes [4] [14] [21]. Disappointingly, Figs. "
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    ABSTRACT: To understand the mechanisms related to both the onset and correction of severe anaemia after orthopaedic surgery, we analysed all the full blood counts (FBCs) for patients on one orthopaedic ward during a one-year period in an academic hospital. FBCs were screened and the medical records of those patients for whom a postoperative haemoglobin (Hb) concentration below 8g/dL was recorded at least once were reviewed. The onset of postoperative anaemia was determined by calculating the various time intervals delineated by surgery, the time at which the transfusion threshold was reached and the time at which the lowest Hb level (nadir) and transfusion (if any) occurred. A total of 6573 FBCs drawn from 1255 patients were screened. The medical records of 74 consecutive patients with at least one Hb value<8g/dL were analysed. The postoperative Hb nadir was 7.4 (± 0.6) g/dL (mean - SD). The medians (IQR 25-75) of the calculated intervals were: (surgery - nadir): 72 (48-144) h, (nadir - transfusion): 7 (5-21) h and (transfusion threshold - transfusion): 26 (11-51) h. Delayed transfusion (defined as>12hours between the time at which the transfusion threshold was reached and actual transfusion) was observed in 57% of severely anaemic patients after orthopaedic surgery. Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
    06/2015; DOI:10.1016/j.accpm.2015.02.006
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    • "during pregnancy (Hungary) [129] 24.4% in 11 maternity units (UK) [130] 39.6% from 14 cities (China) [131] 43.7% and 89.8% in registries from the 1970s and 2000s, respectively (Kola, Russia) [132] Hb b10 and b8 g/dL seen in 22% and 3% of deliveries between 1993 and 2008 in an obstetrics department (Germany) [133] Increasing prevalence from first to third trimesters [131] CKD 32.3% in stage 3-5 CKD (anemia defined as Hb b11 g/dL or documented treatment of ESAs) [135] Increased risk of kidney disease progression, hospitalization, and death [135] [136] [137] 41.3% in stage 3-5 CKD (defined as Hb 11-13.5 g/dL in men and Hb 11-12 g/dL in women) [136] 45% in predialysis cases (defined as Hb ≤11 g/dL) [137] 56.9% of nursing home residents with CKD [138] Respiratory disease Increased risk of hospitalization, readmission, and death [85] [87] [140] [142] [143] 7.5%-34% in COPD [139] 9.8%-33% in cases of acute exacerbation of COPD [85] [87] [140] 11.5% in restrictive disease [141] 13.3% in chronic respiratory failure [141] 14.7% in obstructive disease [141] 18% in first-time admissions to ICU requiring mechanical ventilation [140] 33.9% at admission and 62.1% during stay for community-acquired pneumonia [142] Cerebrovascular disease 6.4%-19% [144] [145] [146] Increased risk of short-and long-term mortality and poor functional outcomes [145] [146] [148] IDA in 6.4%, iron deficiency without anemia in 2.1%, and anemia of other etiologies in 6.4% in patients aged N65 years old admitted with TIA or first ischemic stroke [147] Ischemic heart disease 9.1%-38% overall [149] [150] [151] [152] [153] [154] [155] [156] [157] Increased risk of cardiac events (including heart failure and recurrent ischemia); complications; poor health status; and in-hospital, short-and longterm death [149-157,159-164] 18.2% of patients aged N80 y admitted for acute MI [158] 20%-27.4% at admission [159-161] 34.7% at discharge and 19.5% persistent during follow-up [162] 40% at seventh week after admission [159] 46.8% new-onset during admission [161] Hospital-acquired anemia seen at discharge in 45.4% of patients who were admitted with MI and normal Hb [163] Heart failure (hospitalized) 10% in chronic heart failure at age ≥70 y [165] Poor outcome, hospitalization, readmission, and mortality (cardiovascular as well as all cause) [165-177] 29%-57% [166-170] Cardiac surgery 28%-54.4% [178-180] Increased risk of receiving blood transfusions [179,180], major morbidity, acute kidney injury, mortality, prolonged hospital stay [178] [179] [180] [181] [183], and cardiovascular events [182] 41.9% of 80-to 90-year-old patients undergoing CPB [181] 44% had sustained postoperative anemia for N50 d [182] Organ transplant 42% [5] and 53.7% [184] during posttransplant follow-up. Poor graft outcome and death [101] [184] 89.4% at time of transplantation, 49.2% at 1 y, and 44.3% at 2 years after transplantation [185] Critically ill 18.7% had Hb b7 g/dL and 29.5% had Hb levels of 7-9 g/dL [186] Increased risk of allogeneic blood transfusion and in-hospital death [186] Incidence of 46.6% and prevalence of 68% in cancer patients admitted to ICU [187] 98/100 consecutive patients admitted to ICU [188] Cancer 18% of women with stage 0-II breast cancer at diagnosis and 21% during radiotherapy [189] Worse prognosis in 2 reports [192] [193], but not in another study [189] 34.8% with solid tumors at diagnosis and 38.9% during radiotherapy [190] 55.7% of adult patients during systemic chemotherapy or radiotherapy [6] 78.3% of cases undergoing gastrectomy for gastric cancer [191] Orthopedics 16.3% of total hip and knee arthroplasty [194] Increased risk of allogeneic blood transfusion [195], discharge to nursing home and readmission [196], but not increased mortality [196] [197] or diminished quality of life [194] [198] 24%-44% in preoperative and 51%-87% in postoperative period [195] 42.5% in hip fracture surgeries [196] Abbreviations: CPB, cardiopulmonary bypass; ENSANUT, Encuesta Nacional de Salud y Nutricion (Mexican National Health and Nutrition Survey); ICU, intensive care unit; KNHANES, Korean National Health & Nutrition Examination Survey; MI, myocardial infarction; TIA, transient ischemic attack. "
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    ABSTRACT: Despite its high prevalence, anemia often does not receive proper clinical attention and its detection, evaluation, and management of iron deficiency anemia and iron-restricted erythropoiesis can possibly be an unmet medical need. A multidisciplinary panel of clinicians with expertise in anemia management convened and reviewed recent published data on prevalence, etiology, and health implications of anemia as well as current therapeutic options and available guidelines on management of anemia across various patient populations, and made recommendations on the detection, diagnostic approach and management of anemia. The available evidence confirms that the prevalence of anemia is high across all populations, especially in hospitalized patients. Anemia is associated with worse clinical outcomes including longer length of hospital stay, diminished quality of life and increased risk of morbidity and mortality, and it is a modifiable risk factor of allogeneic blood transfusion with its own inherent risks. Iron deficiency is usually present in anemic patients. An algorithm for detection and management of anemia was discussed which incorporated iron study (with primary emphasis on transferrin saturation), serum creatinine and GFR and vitamin B12 and folic acid measurements. Management strategies included iron therapy (oral or intravenous), erythropoiesis stimulating agents and referral as needed.
    Transfusion medicine reviews 07/2014; 28(3). DOI:10.1016/j.tmrv.2014.05.001 · 2.92 Impact Factor
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    • "Patient blood management addresses preoperative anemia and the associated risk of allogeneic transfusion, both of which are independently associated with adverse outcomes including increased postoperative mortality and morbidity. As such, blood management is one of the most modifiable factors that might significantly impact length of stay [14-18]. The current study investigates the impact of patient factors, surgical factors, and blood management on postoperative length of stay in patients who underwent primary total knee arthroplasty. "
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    ABSTRACT: The current study investigates the impact of patient factors, surgical factors, and blood management on postoperative length of stay (LOS) in 516 patients who underwent primary total knee arthroplasty. Age, gender, type of anticoagulation, but not body mass index (BMI) were found to be highly significant predictors of an increased LOS. Allogeneic transfusion and the number of allogeneic units significantly increased LOS, whereas donation and/or transfusion of autologous blood did not. Hemoglobin levels preoperatively until 48 hours postoperatively were negatively correlated with LOS. After adjusting for confounding factors through Poisson regression, age (p = 0.001) and allogeneic blood transfusion (p = 0.002) were the most significant determinants of LOS. Avoiding allogeneic blood plays an essential role in reducing the overall length of stay after primary total knee arthroplasty.
    The Open Orthopaedics Journal 05/2014; 8(1):108-13. DOI:10.2174/1874325001408010108
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