PHARMACOLOGICAL MANAGEMENT OFPHARMACOLOGICAL MANAGEMENT OF
PERIOPERATIVE ANAEMIA:PERIOPERATIVE ANAEMIA:
Our experience wit...
Acknowlegments
Dr. J.A. García Erce
Department of Haematology
University Hospital Miguel Servet, Zaragoza
Dr. J. Cuenca
De...
Where do we use blood?
Stanworth et al. Vox Sang 2002; 83: 352-7
Specialty (Directorate) Hospitals (n: 62) Units issued % ...
Regan y Taylor, BMJ 2002
Shander, Semin Hematol 2004
 Costs are increasingly rising
 Limited resource
Reasons for reduci...
Kleinman et al. Transfusion 2004; 44: 386-90
60%
6779 patients transfused in 1995
Reasons for reducing ABT use
Regan y Taylor, BMJ 2002
Shander, Semin Hematol 2004
Reasons for reducing ABT use
 Costs are increasingly rising
 Limite...
Regan y Taylor, BMJ 2002
Shander, Semin Hematol 2004
Reasons for reducing ABT use
 Legal issues
 Costs are increasingly ...
12. Patients should be informed of the known risks and
benefits of blood transfusion and/or alternative
therapies and have...
Allogeneic Blood Transfusion Alternatives
Correction of
anaemia
Iron, B12, folic
acid, rHuEpo
Reduction of
blood loss
Tran...
Preoperative haemoglobin level is the major independent
transfusional risk factor in elective orthopaedic surgery
• Nuttal...
Orthopaedic surgery
 Non-elective procedure
 Hip fracture repair
 BLOOD LOST
 Capsule
 Fragmentation
 Displacement
 Surgery
 PREVIOUS CHRONIC ANAEMIA
Transfusion rate: 40-90%
HIP FR...
Possible role for IV iron
Muscles
(250 mg)
Bone marrow
(300 mg)
Erythrocytes
(2.000 mg)
Macrophages
(500 mg)
Liver
(1000 m...
IV iron and hip fracture
IV iron and hip fracture
IV iron and hip fracture
IV iron and hip fracture
IV iron and hip fracture
IV iron and hip fracture
Orthopaedic surgery
 Non-elective procedure
 Hip fracture repair
 Elective procedures
 Preoperative period
Preoperative anaemia
Bisbe E, Lamsfus JA. Alteración de los parámetros hematológicos en el preoperatorio de
cirugía ortopé...
Patients and methods: We assessed the requirements for ABT in 156 consecutive patients
undergoing surgery for primary TKR,...
Oral iron and knee surgery
IV iron and orthopaedic surgery
Orthopaedic surgery
 Non-elective procedure
 Hip fracture repair
 Elective procedures
 Preoperative period
 Periopera...
IV iron and knee surgery
Blood saving protocol
• In Group A (n=139), consecutive TKR patients received iron sucrose
intrav...
IV iron and knee surgery
Overall ABT rate:
4.2%
IV iron and knee surgery
Orthopaedic surgery
 Non-elective procedure
 Hip fracture repair
 Elective procedures
 Preoperative period
 Periopera...
Postoperative IV iron and hip surgery
Postoperative IV iron and hip surgery
Postop oral iron and hip/knee surgery
Randomised controlled trials in orthopaedics
 Ferrous sulphate (200 mg/d) 3 weeks
M...
Conclusions
NATA Expert Panel on Intravenous Iron
ANAEMIA MANAGEMENT IN SURGERY –
CONSENSUS STATEMENT ON THE ROLE OF INTRA...
Whenever clinically feasible, patients undergoing orthopaedic elective
surgery with a high risk of severe postoperative an...
 Non-anaemic patients with ferritin <100 ng/mL and scheduled for
surgical procedures with an expected blood loss >1500 mL...
of 35

Ponencia ISBT-SETS MADRID 2007

PHARMACOLOGICAL MANAGEMENT OF PERIOPERATIVE ANAEMIA: OUR EXPERIENCE WITH INTRAVENOUS IRON IN ORTHOPAEDIC SURGERY ISBT CONGRESS 2007 SETS CONGRESO 2007 PATIENT BLOOD MANAGEMENT
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Ponencia ISBT-SETS MADRID 2007

  • 1. PHARMACOLOGICAL MANAGEMENT OFPHARMACOLOGICAL MANAGEMENT OF PERIOPERATIVE ANAEMIA:PERIOPERATIVE ANAEMIA: Our experience with intravenous iron inOur experience with intravenous iron in orthopaedic surgery.orthopaedic surgery. XVII Regional Congress Europe ISBT XVIII National Congress SETS Madrid, June 23 – 27, 2007 Prof. Manuel Muñoz Transfusion Medicine School of Medicine Málaga - Spain
  • 2. Acknowlegments Dr. J.A. García Erce Department of Haematology University Hospital Miguel Servet, Zaragoza Dr. J. Cuenca Department of Orthopaedic Surgery University Hospita Miguel Servet, Zaragoza Dr. E. Bisbe Department of Anaesthesiology University Hospital Mar-Esperança, Barcelona
  • 3. Where do we use blood? Stanworth et al. Vox Sang 2002; 83: 352-7 Specialty (Directorate) Hospitals (n: 62) Units issued % of traced units General Surgery 52 81 011 13·62 General & Orthopaedic Surgery 3 9228 1·55 Orthopaedic Surgery only 53 60 470 10·17 Cardiothoracic Surgery 11 48 148 8·14 Accident and Emergency (A & E) 45 33 256 5·59 A & E and Intensive Therapy 1 1105 0·19 Intensive Therapy 20 7328 1·23 Obstetrics/Gynaecology 53 31 101 5·23 Urology 34 15 093 2·54 Neurosurgery 10 5733 0·96 Vascular Surgery alone 8 5387 0·91 Colorectal Surgery 1 1473 0·25 Ear, Nose & Throat (ENT) 30 1966 0·33 Plastic/Maxillofacial/Burns 17 3220 0·54 Total in surgical specialties 304 519 51·25
  • 4. Regan y Taylor, BMJ 2002 Shander, Semin Hematol 2004  Costs are increasingly rising  Limited resource Reasons for reducing ABT use
  • 5. Kleinman et al. Transfusion 2004; 44: 386-90 60% 6779 patients transfused in 1995 Reasons for reducing ABT use
  • 6. Regan y Taylor, BMJ 2002 Shander, Semin Hematol 2004 Reasons for reducing ABT use  Costs are increasingly rising  Limited resource  Adverse effects  Clerical errors (Wrong blood)  Viral transmission  Inmunological complications (TRALI, GVHD, TRIM)
  • 7. Regan y Taylor, BMJ 2002 Shander, Semin Hematol 2004 Reasons for reducing ABT use  Legal issues  Costs are increasingly rising  Limited resource  Adverse effects  Clerical errors (Wrong blood)  Viral transmission  Inmunological complications (TRALI, GVHD, TRIM)
  • 8. 12. Patients should be informed of the known risks and benefits of blood transfusion and/or alternative therapies and have the right to accept or refuse the procedure. Any valid advance directive should be respected. Principle of patient’s autonomy 15. Genuine clinical need should be the only basis for transfusion therapy. Ethical principles of beneficence and justice Blood transfusion: Ethical balance
  • 9. Allogeneic Blood Transfusion Alternatives Correction of anaemia Iron, B12, folic acid, rHuEpo Reduction of blood loss Tranexamic, EACA, Aprotinin, rFVIIa, … Autologous Blood Preoperative autologous donation Normovolaemic haemodilution Perioperative cell salvage Restrictive transfusion protocol Hb <70-80 g/L Blood saving program
  • 10. Preoperative haemoglobin level is the major independent transfusional risk factor in elective orthopaedic surgery • Nuttall GA et al. Transfusion 1996; 36: 144-149 • Salido JA et al. J Bone Joint Surg 2002; 84-A: 216-220 • Garcia-Erce JA et al. Rev Esp Anestesiol Reanim 2002;49:254-6 As well as in non-elective orthopaedic surgery • García Erce JA, et al. Med Clin (Barc) 2003; 120: 161-166. Anaemia, surgery and transfusion
  • 11. Orthopaedic surgery  Non-elective procedure  Hip fracture repair
  • 12.  BLOOD LOST  Capsule  Fragmentation  Displacement  Surgery  PREVIOUS CHRONIC ANAEMIA Transfusion rate: 40-90% HIP FRACTURE AND ANAEMIA  INFLAMMATION: “hepcidin” The standard solution
  • 13. Possible role for IV iron Muscles (250 mg) Bone marrow (300 mg) Erythrocytes (2.000 mg) Macrophages (500 mg) Liver (1000 mg) Iron absorption (1-2 mg/day) Transferrin (3 mg) Iron loss (1-2 mg/day) 20-30 mg/día Iron sucrose
  • 14. IV iron and hip fracture
  • 15. IV iron and hip fracture
  • 16. IV iron and hip fracture
  • 17. IV iron and hip fracture
  • 18. IV iron and hip fracture
  • 19. IV iron and hip fracture
  • 20. Orthopaedic surgery  Non-elective procedure  Hip fracture repair  Elective procedures  Preoperative period
  • 21. Preoperative anaemia Bisbe E, Lamsfus JA. Alteración de los parámetros hematológicos en el preoperatorio de cirugía ortopédica mayor: prevalencia y tratamiento. In: Muñoz M, Bisbe E, García-Erce JA, Giralt M (eds): Actualización en Anemia y Medicina Transfusional Perioperatoria. Málaga, SPICUM, 2006: 55-62.
  • 22. Patients and methods: We assessed the requirements for ABT in 156 consecutive patients undergoing surgery for primary TKR, who received iron ferrous sulphate (256 mg/day; 80 mg of Fe2+ ), vitamin C (1000 mg/day) and folic acid (5 mg/day) during the 30-45 days preceding surgery, and who were transfused if Hb <80 g/L and/or clinical signs/symptoms of acute anaemia or hypoxemia (Group 2). A previous series of 156 TKR patients serves as a control group (Group 1). Oral iron and knee surgery
  • 23. Oral iron and knee surgery
  • 24. IV iron and orthopaedic surgery
  • 25. Orthopaedic surgery  Non-elective procedure  Hip fracture repair  Elective procedures  Preoperative period  Perioperative period
  • 26. IV iron and knee surgery Blood saving protocol • In Group A (n=139), consecutive TKR patients received iron sucrose intravenously (200 mg), 24 hours before surgery and 24 hours after surgery. Patients with preoperative Hb levels <13 g/dL also received a single dose of rHuEPO (40,000 IU, sc; Eprex) 24 hours before surgery. • This protocol plus was applied to a second series of consecutiveTKR patients who also received postoperative unwashed shed blood (USB) if preoperative Hb levels <13 g/dL (Group B, n=173). • In these two groups, transfusion was indicated when patient’s Hb <8 g/dL or when patient presented symptoms of acute anemia.
  • 27. IV iron and knee surgery Overall ABT rate: 4.2%
  • 28. IV iron and knee surgery
  • 29. Orthopaedic surgery  Non-elective procedure  Hip fracture repair  Elective procedures  Preoperative period  Perioperative period  Postoperative period
  • 30. Postoperative IV iron and hip surgery
  • 31. Postoperative IV iron and hip surgery
  • 32. Postop oral iron and hip/knee surgery Randomised controlled trials in orthopaedics  Ferrous sulphate (200 mg/d) 3 weeks Mundy et al. JBJS 2005; 87-B: 213-7  Ferrous sulphate (200 mg/d) 6 weeks Sutton et al. JBJS 2004; 86-B: 31-3  Ferrous gluconate (325 mg/d) 10 weeks Weatherall et al. ANZ J Surg 2004; 74: 1049-51 Oral iron did not improve haemoglobin levels !!!!
  • 33. Conclusions NATA Expert Panel on Intravenous Iron ANAEMIA MANAGEMENT IN SURGERY – CONSENSUS STATEMENT ON THE ROLE OF INTRAVENOUS IRON Photis Beris, Manuel Muñoz, José A. García-Erce, Dafydd Thomas, Alice Maniatis & Philippe Van der Linden. - Grade of recommendation: . “For patients undergoing orthopaedic surgery expected to develop severe postoperative anaemia we currently suggest IV iron administration during the perioperative period”. For all other surgeries no evidence-based recommendation can be made. We strongly recommend that large prospective randomised controlled trials are undertaken in patients undergoing surgery expected to develop severe post operative anaemia.
  • 34. Whenever clinically feasible, patients undergoing orthopaedic elective surgery with a high risk of severe postoperative anaemia should have haemoglobin level and iron status tested a minimum of 30 days before the scheduled surgical procedure.  Unexplained anemia should always be considered as secondary to some other process and, therefore, elective surgery should be deferred until an appropriate diagnosis has been made  Good practice points Patients at risk of receiving perioperative transfusions should be identified, on the basis of patient’s RBC mass, the transfusion trigger and the expected blood loss (e.g., using Mercuriali’s algorithm) 
  • 35.  Non-anaemic patients with ferritin <100 ng/mL and scheduled for surgical procedures with an expected blood loss >1500 mL (Hb drop 3-5 g/dL) might benefit from preoperative oral or IV iron administration, as they may not have enough stored iron to reconstitute their perioperative Hb loss and keep normal iron stores (ferritin ≥30 ng/mL)  Good practice points Patients with preoperative IDA or ACD might receive preoperative treatment with IV iron, with or without rHuEPO. In addition, IV iron should be given to improve the response to rHuEPO and might allow for a reduction in the total dose of rHuEPO  The administration of IV iron should be avoided in patients with pre- treatment ferritin > 500 ng/mL. Nevertheless, IV iron should no be given to patient with ongoing bacteremia Thank you for your kind attention!

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