The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial.

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 µg.l-1 ; functional iron deficiency as ferritin 30-100 µg.l-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

An international consensus statement on the management of postoperative anaemia after major surgical procedures.

Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.

International consensus statement on the peri-operative management of anaemia and iron deficiency.

Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.

Preoperative anaemia is associated with increased allogeneic pack red cell transfusion in revision hip and knee joint arthroplasty: a retrospective analysis of 5387 patients over a 10-year period at a single high volume centre.

OBJECTIVES: To estimate the prevalence of preoperative World Health Organization (WHO) defined anaemia in patients presenting for revision hip and knee arthroplasty and its association with transfusion of allogeneic packed red blood cells (PRBC). BACKGROUND: Studies have mainly investigated the prevalence of preoperative anaemia in primary and not revision hip and knee joint arthroplasty. METHODS: An analysis of a prospectively collected patient data for 5387 patients having revision hip or knee arthroplasty over a 10-year period at a single high volume centre was conducted. Logistic regression was used to assess whether the presence of WHO defined preoperative anaemia as well as other risk factors were associated with inpatient allogeneic PRBC transfusion. RESULTS: There were 5387 patients assessed of which 3021 (56·01%) patients had revision total hip replacements and 2366 (43·09%) had revision total knee arthroplasty. Of these patients 1956 (36·03%) had preoperative WHO defined anaemia. A total of 2034 (37·08%) patients received at least one unit of allogeneic PRBC during their primary hospital admission. In the final model preoperative WHO defined anaemia was independently associated with allogeneic PRBC transfusion in hip and knee revision surgery OR 4·042 (4·012-4·072 95% CI) CONCLUSIONS: Preoperative anaemia is common in patients presenting for revision hip and knee arthroplasty and independently associated with transfusion of allogeneic PRBC.

AAGBI guidelines: the use of blood components and their alternatives 2016.

Blood transfusion can be life-saving. Anaesthetists regularly request and administer blood components to their patients. All anaesthetists must be familiar with indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematology specialists and their local blood sciences laboratory is encouraged. Considerable changes in approaches to optimal use of blood components, together with the use of alternative products, have become apparent over the past decade, leading to a need to update previous guidelines and adapt them for the use of anaesthetists working throughout the hospital system.

Thromboelastography (TEG®) compared with total platelet count in thrombocytopenia haematological malignancy patients with bleeding: a pilot observational study.

BACKGROUND: There has been no reported use of Thromboelastography(®) (TEG(®) ) in assessing thrombocytopenic haematological malignancy (HM) patients experiencing bleeding. OBJECTIVES: To assess whether there are differences in TEG(®) variables in thrombocytopenic HM patients experiencing clinically significant bleeding compared with those not experiencing bleeding. METHODS: Thirty adult patients with HM and a total platelet count (TPC) of ≤ 30 × 10(9) L(-1) were observed for greater than or equal to grade two World Health Organisation (WHO) bleeding episodes for 72 h. They had TPC, TEG(®) parameters [maximal amplitude (MA), reaction time (R-time), alpha (α-angle) and functional fibrinogen (FF) levels], activated partial thromboplastin time (APTT) and prothrombin time (PT) measured at inclusion, 24 and 48 h. RESULTS: Five patients had nine significant bleeding episodes. Patients bleeding (n) were all more hypocoaguable when measured by TEG(®) than patients not bleeding at inclusion n = 4 (MA: 16.9 vs 31.8 mm, P < 0.01; R-time: 10.1 vs 7.5 min, P = 0.02; α-angle: 18.8 vs 28.4, P < 0.01; FF: 182.4 vs 204 mg dL(-1), P < 0.01), at 24 h n = 3 (MA 18 vs 29.4 mm, P = 0.02; R-time: 9.4 vs 7.4 mins, P = 0.02; α-angle: 21.6 vs 26.5, P = 0.04 and FF: 168 vs 201 mg dL(-1) P = 0.01) and at 48 h n = 2 (MA: 29.7 vs 23.0, P = 0.02; R-time: 8.1 vs 6.7 mins, P = 0.05; α-angle: 22.6 vs 26.5, P = 0.04; FF: 170 vs 208 mg dL(-1), P = 0.01). There were no significant differences in TPC, APTT or PT between patients that bled and those that did not at each time point. CONCLUSIONS: Thrombocytopenic HM patients experiencing bleeding are hypocoaguable on TEG(®).