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Algorithm for Patient Red Cell Mass Optimisation. (1) Sometimes, specific (megaloblastic, haemolytic) anaemia may need to be addressed; (2) TSAT < 20% indicates absolute iron deficiency, while levels below 25% recommend iron therapy in cases of anaemia associated with iron deficiency and inflammation; (3) Iron deficiency may be present in the absence of anaemia and requires preoperative correction; (4) If iron deficiency has no apparent cause, it should be identified by specialist examination; (5) The need and dosage for iron supplementation and erythropoiesis-stimulating agents (ESA) are to be exclusively determined by a specialist
Source publication
Patients with untreated anaemia or iron deficiency who undergo surgical procedures have an increased risk for mortality and morbidity. Patient Blood Management programmes address this issue worldwide and try to improve patient outcomes through a complex set of measures targeting anaemia correction, minimisation of bleeding and improvement of anaemi...
Context in source publication
Context 1
... WHO defines anaemia as a haemoglobin (Hb) level below 13 g/dl in men and 12 g/dl in women [21]. To diagnose anaemia, a minimum assessment should include a complete blood count (required for diag- nosing anaemia), determining the levels of serum ferritin (indicator of iron stores), serum iron and serum transferrin needed to measure TSAT (an in- dicator of iron available for erythropoiesis and required for iron deficiency assessment) and testing the level of CRP (an indicator of inflammation, required for assessing anaemia of chronic disease) ( Figure 1). Iron deficiency should be detected and corrected by iron administration as follows: ...
Citations
... In Romania, a multidisciplinary initiative group endorsed by the Ministry of Health has developed national recommendations for PBM, aimed at improving patient outcomes and reducing the use of allogeneic blood transfusions, which are a precious but insufficient resource in the elective surgical setting [18,19]. The recommendations cover a range of areas, including the preoperative optimization of haemoglobin (Hb) levels and haemostasis, intraoperative haemostasis management and protocols, and postoperative monitoring and management of anaemia. ...
... As part of the Romanian national pilot programme of PBM [19], we performed a single-centre, retrospective study in a tertiary centre of cardiovascular surgery. Data were recorded using a pre-approved protocol, available in Supplementary Table S1. ...
... This suggests that, had there been a better uptake of the questionnaire (the implementation was for only 75.7% of patients), it is likely to have led to a reduction in PRBC transfusion in the matched "after" cohort. The result is coherent with the aim of the questionnaire [19], which not only triages patients with a potentially undetected bleeding disorder, but also signals to the physician to adequately adjust or discuss with the multidisciplinary team the management of antiplatelet and anticoagulant agents. In other published data, various risk scores and questionnaires have performed differently in cardiac surgery, so there is no consensus on the best risk assessment score [35]. ...
Citation: Stefan, M.; Tomescu, D.; Predoi, C.; Goicea, R.; Perescu, M.; Popescu, M.; Dorobant , u, D.; Droc, G.; Andrei, S , .; Stiru, O.; et al. Less (Transfusion) Is More-Enhancing Recovery through Implementation of Patient Blood Management in Cardiac Surgery. A Retrospective, Single-Centre Study of 1174 Patients. J. Cardiovasc. Dev. Dis. 2023, 10, 266. Abstract: Introduction: The implementation of Patient Blood Management (PBM) in cardiac surgery has been shown to be effective in reducing blood transfusions and associated complications, as well as improving patient outcomes. Despite the potential benefits of PBM in cardiac surgery, there are several barriers to its successful implementation. Objectives: The main objectives of this study were to ascertain the impact of the national Romanian PBM recommendations on allogeneic blood product transfusion in cardiac surgery and identify predictors of perioperative packed red blood cell transfusion. Methods: As part of the Romanian national pilot programme of PBM, we performed a single-centre, retrospective study in a tertiary centre of cardiovascular surgery, including patients from two time periods, before and after the implementation of the national recommendations. Using coarsened exact matching, from a total of 1174 patients, 157 patients from the before group were matched to 169 patients in the after group. Finally, we built a multivariate regression model from the entire cohort to analyse independent predictors of PRBC transfusion in the perioperative period. Results: Although there was a trend towards a lower proportion of patients requiring PRBC transfusion in the "after" group compared to the "before" group (44.9%vs. 50.3%), it was not statistically significant. There was a significant difference between the "after" group and the "before" group in terms of fresh-frozen plasma (FFP) transfusion rates, with a lower percentage of patients requiring FFP transfusion in the "after" group compared to "before" (14.2%, vs. 22.9%, p = 0.04). This difference was also seen in the total perioperative FFP transfusion (mean transfusion 0.7 units in the "before" group, SD 1.73 vs. 0.38 units in the "after" group, SD 1.05, p = 0.04). In the multivariate regression analysis, age > 64 years (OR 1.652, 95% CI 1.17-2.331, p = 0.004), female sex (OR 2.404, 95% CI 1.655-3.492, p < 0.001), surgery time (OR 1.295, 95% CI 1.126-1.488, p < 0.001), Hb < 13 g/dl (OR 3.611, 95% CI 2.528-5.158, p < 0.001), re-exploration for bleeding (OR 3.988, 95% CI 1.248-12.738, p = 0.020), viscoelastic test use (OR 2.18, 95% CI 1.34-3.544, p < 0.001), FFP transfusion (OR 4.023, 95% CI 2.426-6.671, p < 0.001), and use of a standardized pretransfusion checklist (OR 8.875, 95% CI 5.496-14.332, p < 0.001) remained significantly associated with PRBC transfusion. The J. Cardiovasc. Dev. Dis. 2023, 10, 266. https://doi.org/10.3390/jcdd10070266 https://www.mdpi.com/journal/jcdd J. Cardiovasc. Dev. Dis. 2023, 10, 266 2 of 12 use of a preoperative standardized haemostasis questionnaire was independently associated with a decreased risk of perioperative PRBC transfusion (0.565, 95% CI 0.371-0.861, p = 0.008). Conclusions: Implementation of national PBM recommendations led to a reduction in FFP transfusion in a cardiac surgery centre. The use of a preoperative standardized haemostasis questionnaire is an independent predictor of a lower risk for PRBC transfusion in this setting.
... As for transfusions in our ICU, the indications and triggers for administering blood products vary and are left to the interpretation of the caring doctor [38]. The cross-over on the Kaplan Meier curve indicates an uneven hazard rate produced by different physicians which may be improve by more precise protocols. ...
COVID-19 produces cytokine-mediated persistent inflammation and is associated with elevated iron stores and low circulating iron. It is believed that central to the pathophysiological mechanism is interleukin 6 and hepcidin. A state of iron overload, termed hyperferritinemia, and inflammatory anemia take place. Both conditions are linked to a worse result in critically ill patients. Blocking the interleukin 6—hepcidin pathway with Tocilizumab could present favorable outcomes. The aim of this study was to evaluate if Tocilizumab influences survival, the occurrence of sepsis, anemia and transfusions in critically ill patients suffering from COVID-19. This prospective observational study focused on levels of interleukin 6, hepcidin and blood iron parameters in patients treated with Tocilizumab. Data were compared before and after therapy as well as between treated and control groups. Results indicate that there is no difference in terms of survival nor in the rate of anemia or sepsis occurrence. Hepcidin was elevated and anemia ensued after treatment, which could indicate alternative pathways. In conclusion, when the classic interleukin 6—hepcidin pathway is blocked, inflammation seems to use alternative routes. Further understanding of these pathways is required and new pharmacological therapies need to be developed to treat persistent inflammation.
... Anemia was defined by Hb levels below 13 g/dL in males and 12 g/dL in females. Severe anemia requiring transfusions was defined as: (i) Hb < 6 g/dL; (ii) Hb 6-8 g/dL associated with either tachycardia, hypotension, ischemic changes on EKG, lactic acidosis, low central venous oxygen saturation or reduced compensatory reserve (ischemic heart disease, cardiac failure, cerebro-vascular disease); (iii) Hb 8-10 g/dL associated with reduced compensatory reserve [11]. Bacterial supra-infection was defined as the combined presence of clinical features (temperature > 38 • C or <36 • C, imaging describing consolidations, moderate polymorphonuclears on sputum gram staining) and microbiological criteria (pathogen identified at any sites). ...
Inflammation in COVID-19 produces intracellular iron overload with low circulating iron available for metabolic processes. The accumulated intracellular iron generates reactive species of oxygen and results in ferroptosis, a non-programmed cell death. Since no organ is spared, iron dysmetabolism increases the mortality and morbidity. Hepcidin and the mediator interleukin 6 are believed to play a role in the process. Our aim is to evaluate the predictive values of serologic iron and inflammatory parameters in COVID-19 critically ill patients. Hence, 24 patients were included. Hepcidin and interleukin 6, along with routine blood parameters, were determined and outcomes, such as death, multiple organ damage (MOD), anemia, and need for transfusions, were assessed. The results of this pilot study indicate that iron metabolism parameters individually, as well as models consisting of multiple laboratory and clinical variables, may predict the outcomes. Further larger studies are needed to validate the results of this pilot stud. However, this paper identifies a new direction for research.
... Also, there was no observable impact of the wave period on bleeding. Intraoperative PRBC transfusion remained low and did not differ either between pre-pandemic and pandemic levels or in regards to the wave period, suggesting a good adherence to previously issued patient blood management recommendations, for which our institution was a pilot center [16]. ...
Background
Surges of critically ill patients can overwhelm hospitals during pandemic waves and disrupt essential surgical activity. This study aimed to determine whether hospital mortality increased during the COVID-19 pandemic and during pandemic waves.
Material/Methods
This was a retrospective analysis of a prospective, observational, epidemiological database. All patients who underwent surgery from January 1 to December 31, 2020, were included in the analysis. The setting was a large Eastern European Surgical Center referral center of liver transplant and liver surgery, a major center of abdominal surgery.
Results
A total of 1078 patients were analyzed, and this number corresponded to a reduction of surgical activity by 30% during the year 2020 compared with 2019. Despite an increase in surgery complexity during the pandemic, perioperative mortality was not different, and this was maintained during the pandemic wave. The pandemic (OR 1.45 [0.65–3.22], P=0.365) and the wave period (OR 0.897 [0.4–2], P=0.79) were not associated with hospital mortality in univariate analysis. In the multivariate model analysis, only the American Society of Anesthesiology (ASA) score (OR 5.815 [2.9–11.67], P<0.0001), emergency surgery (OR 5.066 [2.24–11.48], P<0.0001), and need for surgical reintervention (OR 5.195 [1.78–15.16], P=0.003) were associated with hospital mortality.
Conclusions
Despite considerable challenges, in this large retrospective cohort, perioperative mortality was similar to that of pre-pandemic practice. Efforts should be made to optimize personnel issues, while maintaining COVID-19-free surgical pathways, to adequately address patients’ surgical needs during the following waves of the pandemic.
... This was proven in clinical trials, and several expert consensus statements suggest that 13 g/dl should be the new standard for both males and females (17)(18)(19). In Romania, based on the experience of a PBM pilot programme led by a multidisciplinary group of physicians, national recommendations have been elaborated (20) and transformed into guidelines endorsed by the Ministry of Health (21). Data from hospitals participating in the programme have previously been published (22). ...
... This could be explained by the increased prevalence of anaemia in the elderly, but age remains significant as a predictor in the multivariate model. Given the significant strain on hospital logistics and perceived increase in short-term costs (33) forms for each unit of PRBC prescribed, either electronic or on paper, on which the attending physician can justify the indication for transfusion, based on Hb value and on other clinical factors, including the functional triggers for transfusion (20). There are important limitations to our study. ...
Background:
Anaemia and blood transfusion are two independent contributing factors to perioperative morbidity in cardiac surgery. While preoperative treatment of anaemia has been shown to improve outcomes, in real life, logistical difficulties remain substantial, even in high-income countries. The adequate trigger for transfusion in this population remains controversial, and there is a wide variability in transfusion rates among centres.
Objectives:
To assess the impact of preoperative anaemia on perioperative transfusion in elective cardiac surgery,todescribe the perioperative trajectory of haemoglobin (Hb), to stratify outcomes based on preoperative presence of anaemia and to identify predictors of perioperative blood transfusion.
Materials:
and Methods: We included a retrospective cohort of consecutive patients who underwent cardiac surgery with cardiopulmonary bypass in a tertiary centre of cardiovascular surgery. Recorded outcomes included hospital and intensive care unit (ICU) length of stay (LOS), surgical re-exploration due to bleeding, packed red blood cell (PRBC) transfusion pre-, intra- and postoperatively. Other record perioperative variables were preoperative chronic kidney disease, duration of surgery, use of rotation thromboelastometry (ROTEM) and cell saver, and fresh frozen plasma (FFP) and platelet (PLT) transfusion. Hb values were recorded at four distinct time points: Hb1 - at hospital admission, Hb2 - last Hb recorded preoperatively, Hb3 - first Hb recorded postoperatively and Hb4 - at hospital discharge. We compared the outcomes between anaemic and non-anaemic patients. Transfusion was decided by the attending physician on a case-by-case basis. Results: Of the 856 patients operated during the selected period, 716 underwent non-emergent surgery and 710 were included in the analysis. Also, 40.5% (n = 288) of patients were anaemic preoperatively (Hb <13 g/dl); 369 patients (52%) were transfused PRBCs, with differences found between anaemic and non-anaemic patients regarding the percentage of transfused patients perioperatively (71.5% vs 38.6%, p < 0.001) and in the total median number of units transfused (2 [IQR 0-2] vs 0 [IQR 0-1], p <0.001). We built a multivariate model, and logistic regression analysis showed that preoperative Hb <13 g/dl (odds ratio [OR] 3.462 [95% CI 1.766-6.787]), female sex (OR 3.224 [95% CI 1.648-6.306]), age (1.024 per year [95% CI 1.0008-1.049]), hospital LOS (OR 1.093 per day of hospitalisation [95% CI 1.037-1.151]) and FFP transfusion (OR 5.110 [95% CI 1.997-13.071]) are associated with PRBC transfusion.
Conclusions:
Untreated preoperative anaemia leads to more transfusion in elective cardiac surgery patients, both as a ratio of transfused patients and as the number of units of PRBCs per patient, and this is associated with an increased use in FFP.
... We consider that the preoperative treatment of anemia by increasing the hemoglobin level to at least 8 g/ dl is important in decreasing the rates of postoperative morbidity. This can be achieved by implementing the Patient Blood Management into the cancer patient perioperative management protocol [20]. Through this protocol in the preoperative stage, the patient should be checked for the level of hemoglobin, ferritin levels, serum iron and total iron binding capacity. ...
... Patient Blood Management protocols and ESPEN guidelines require that patients with certain risk factors be properly evaluated and optimized for surgery [20]. Identification of patients with anemia who are not surgical emergencies or who do not present hemodynamic instability are candidates for the correction of anemia with iron products in the preoperative period. ...
Introduction. Gastric cancer remains among the top three digestive diseases with the highest mortality rates in the world. Treatment of gastric cancer is multidisciplinary, gastric resection being essential for the best result. Anemia is one of the most common comorbidities present in patients diagnosed with gastric cancer. Materials and Methods. This is a retrospective analytical study over a period of 6 years (2014-2019). It is based on 114 consecutive gastric resections for cancer performed by a single team using exclusively resection and reconstruction stapling methods. The study aims to investigate a correlation between the presence of preoperative anemia and the incidence of postoperative morbidity and mortality. Results. Preoperative anemia was found in 70% of patients, with about half of these patients presenting with mild anemia. Most postoperative complications were grade I and II according to the Clavien Dindo scale. Anemia was correlated with an increase in infectious complications, anastomotic leaks and secondary peritoneal abscesses, pancreatic complications after multivisceral resection and length of hospital stay. Conclusions. Preoperative anemia is a risk factor that exposes the cancer patient to an increased incidence of life-threatening postoperative complications. In addition, it also extends the length of hospital stay and costs. Therefore, special attention should be paid to the identification and reduction of anemia before extensive gastric surgery in order to obtain the best possible therapeutic result.
... Correcting iron deficits is especially important in surgical patients whereby reversal of iron deficiency lowers transfusion requirements [40]. This conduct represents the first pillar of all patient blood management programs [41,42]. Iron can be administered enterally or intravenously, with the former being most common [43]. ...
Understanding of how the human organism functions has preoccupied researchers in medicine for a very long time. While most of the mechanisms are well understood and detailed thoroughly, medicine has yet much to discover. Iron (Fe), Copper (Cu), and Zinc (Zn) are elements on which organisms, ranging from simple bacteria all the way to complex ones such as mammals, rely on these divalent ions. Compounded by the continuously evolving biotechnologies, these ions are still relevant today. This review article aims at recapping the mechanisms involved in Fe, Cu, and Zn homeostasis. By applying the knowledge and expanding on future research areas, this article aims to shine new light of existing illness. Thanks to the expanding field of nanotechnology, genetic disorders such as hemochromatosis and thalassemia can be managed today. Nanoparticles (NPs) improve delivery of ions and confer targeting capabilities, with the potential for use in treatment and diagnosis. Iron deficiency, cancer, and sepsis are persisting major issues. While targeted delivery using Fe NPs can be used as food fortifiers, chemotherapeutic agents against cancer cells and microbes have been developed using both Fe and Cu NPs. A fast and accurate means of diagnosis is a major impacting factor on outcome of patients, especially when critically ill. Good quality imaging and bed side diagnostic tools are possible using NPs, which may positively impact outcome.
... Transferrin saturation (TSAT%) was calculated then as the ratio between serum iron (µg/dL) and transferrin concentration (mg/dL) multiplied by a constant of 70.9 11 . TSAT below 20%, transferrin lower than 12 ng/mL and ferritin lower than 100 ng/mL reflect absolute iron deficiency 12,13 . Blood samples were centrifuged at 3000 rotations/minute and serum was stored at -20°C for a maximum of 30 days. ...
Objective:
Patients with digestive neoplasms have both iron deficiency and chronic inflammatory anemia with hepcidin upregulation, which may be aggravated in the postoperative period. Vitamin D impacts hepcidin levels. We aimed to investigate the correlations between vitamin D and iron status vs. hepcidin levels in patients with digestive tumors undergoing open abdominal surgery.
Patients and methods:
This prospective observational study was performed during 2016-2018 in a University teaching hospital. After obtaining the Ethical Approval and the patients' informed consent, 30 adult patients with digestive tumors were included. Hepcidin, vitamin D and iron levels were measured in the first 24 hours after surgery.
Results:
We observed a negligible/weak correlation between serum iron and hepcidin levels in the first 24 hours after surgery, with a correlation coefficient of 0.24 and a weak/low correlation between hepcidin and vitamin D levels, with a correlation coefficient of 0.37.
Conclusions:
The correlations between vitamin D and hepcidin levels, as well as between hepcidin and serum iron levels, are weak. Interindividual variability in iron-hepcidin-vitamin D regulation might be wide and other regulatory mechanisms might also play important roles in inflammatory anemia modulation in the perioperative period.
... The program objectives are to identify patients at risk of transfusion and to provide a managed plan aimed to preserve the own blood for reducing or eliminating the need of RBC transfusion (24). In Romania, the PBM Initiative Group recently published an implementation guide, approved and recommended by the Minister of Health (25). However, specific PBM strategies for oncological surgical patients are insufficiently defined. ...
... The program objectives are to identify patients at risk of transfusion and to provide a managed plan aimed to preserve the own blood for reducing or eliminating the need of RBC transfusion (24). In Romania, the PBM Initiative Group recently published an implementation guide, approved and recommended by the Minister of Health (25). However, specific PBM strategies for oncological surgical patients are insufficiently defined. ...
Background: Both anemia and blood transfusion are now considered independent risk factors for poor outcome in colorectal cancer patients. Severe anemia can increase tumor aggressiveness and blood transfusion may induce immunosuppression and promote cancer recurrence. Specific Patient Blood Management (PBM) strategies for oncological surgical patients are insufficiently defined and recommended. Primary objectives: Evaluation of the perioperative anemia prevalence and transfusion rate in colorectal cancer patients. Secondary objectives: Sub-group analysis of anemic versus non-anemic patients and colon versus rectal cancer patients. Methods: We retrospectively reviewed records from all consecutive surgical oncological patients admitted between January and June 2017. We selected major lower abdominal surgical patients and then colorectal surgical patients. We evaluated the perioperative hemoglobin values dynamics (preoperative=Hb1, postoperative= Hb2, at discharge= Hb3), anemia prevalence and severity and transfusion rate. Statistical analysis used Student t test, Wilcoxon signed-rank and Chi-square tests from SPSS 17. Results: Of the 1284 patients screened, 546 patients were submitted to major lower abdominal surgery and 260 patients to colorectal cancer surgery. The mean age was 65.6 +- 11.1 years, 57.7% males. The perioperative dynamics of hemoglobin was Hb1/Hb2/Hb3 =12/10.6/10.4 g/dL. Anemia prevalence was 52.3/82.3/82.6% preoperatively/postoperatively/at hospital discharge. Global transfusion rate was 23.8%, with pre/intra/postoperative distribution of 2.3/11.9/10.8%. Anemic patients were older (p=0.005), with a higher transfusion rate (p 0.001) and a longer hospital LOS (p=0.04). Colon cancer patients had lower Hb values (p=0.001) and higher prevalence of preoperative anemia (p=0.001) comparing with rectal cancer patients. Conclusions: The analysis of this cohort of colorectal cancer patients identified an increased prevalence of anemia in all perioperative phases. There is an urgent need of PBM program implementation in this selected group of surgical patients. Celsius.
