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Introduction: Approximately 7000 total hip arthroplasty (THA) surgeries occur in Ireland each year. A number of preoperative factors have been identified that increase the risk of postoperative blood transfusion after THA, including anaemia. The ability to identify patients at risk may allow preoperative management strategies to reduce blood transfusions. Data from Irish orthopaedic patients is currently lacking. Aim: To investigate if preoperative anaemia and other factors are associated with postoperative blood transfusions in patients who undergo THA. Methods: A retrospective cohort study of all patients who underwent THA in 2019 in SIVUH, Cork, using medical chart review. Results: In total, 350 charts met the inclusion criteria, with 291 charts reviewed. 8.9% of the patients who underwent THA had preoperative anaemia. Among these, 19.2% had a postoperative blood transfusion, compared to 1.5% of patients who were not anaemic preoperatively. The odds of receiving a blood transfusion was 15.5 times greater in the preoperative anaemia group compared to the non-anaemic group. Increasing age and higher ASA scores were associated with preoperative anaemia and postoperative blood transfusions. Length of stay was increased by 2.2 days (p < 0.00016) if blood transfusion was required. Conclusion: Preoperative anaemia was common in an Irish orthopaedic population undergoing THA. Preoperative anaemia predisposes patients to the greatest increased risk of postoperative blood transfusions. The other factors associated with the need for postoperative transfusion were ASA grade 3 or more and age greater than 65 years. Patients who received postoperative blood transfusions had a significantly increased length of hospital stay. [ABSTRACT FROM AUTHOR]

This article highlights a case of high-dose ferric carboxymaltose (Ferinject®) for the treatment of perioperative iron deficiency anaemia in a 39-year-old patient with dysplastic coxarthrosis. The patient was admitted routinely for a total hip replacement of the left hip joint. She had been suffering from pain, lameness, and restriction of movement in her left hip joint for the past several years. The patient was admitted with initial iron deficiency anaemia of a medium severity (Hgb—96.5 g/L, RBC—3.97 × 1012/L). Laboratory tests were taken to determine the iron deficiency, and transfusion readiness was submitted. The patient received ferric carboxymaltose infusion before surgery. The intraoperative blood loss was—100 mL with an operation duration of 50 min. On the first postoperative day, haemoglobin decreased to 86 g/L. No haemoglobin decrease was observed in the postoperative period, and 92 g/L was the amount of haemoglobin at the time of hospital discharge. The optimal dose for the treatment of perioperative anaemia has not been established; some studies recommend ferric carboxymaltose at a dose of 15 to 20 mg/kg and a maximum of 1000 mg once on the first day after surgery. The uniqueness of this case report is that a high dose of ferric carboxymaltose (1340 mg) during the preoperative period was applied. No side effects such as hypophosphatemia were reported. We believe that, in this clinical case, the patient managed to avoid large intraoperative blood loss and transfusions by using high doses of ferric carboxymaltose. [ABSTRACT FROM AUTHOR]

This article is a guideline from the British Society for Haematology on the identification and management of preoperative anaemia in adults. It provides recommendations on diagnosing anaemia, managing iron deficiency, and the appropriate use of erythropoiesis-stimulating agents and preoperative transfusion. The guideline emphasizes the importance of early assessment for anaemia in patients undergoing elective surgery and the need for shared decision-making regarding further management. It also discusses the association of preoperative anaemia with adverse outcomes and the role of primary care in managing these patients. The article includes information on the definition of anaemia, diagnosing iron deficiency, investigating individuals with iron deficiency, and algorithms for anaemia investigation. The guidelines recommend oral iron therapy as the first-line treatment for iron deficiency anemia (IDA), as it is safe, effective, and cost-efficient. Intravenous (IV) iron therapy may be considered for patients who are intolerant to oral iron or who do not respond well to it. However, the guidelines do not recommend IV iron therapy for all patients with anemia. The timing of iron therapy in relation to surgery is not well-defined, and further research is needed in this area. The guidelines also discuss the treatment of vitamin B12 or folate deficiency and the use of erythropoiesis-stimulating agents. Preoperative transfusion should only be considered in very anemic patients when there is an urgency for surgery and other options for managing anemia are not feasible. Further research is needed [Extracted from the article]

Cross-matching of blood components to the patient's blood is mandatory to ensure the safe transfusion of suitable blood components in a timely manner and avoid serious harm to the recipient. This article will outline the validated methods of cross-matching in the laboratory setting. We will also discuss transfusion reactions and consequences of transfusion of inappropriate or mismatched blood components, alongside the principles of patient blood management and preoperative anaemia. [ABSTRACT FROM AUTHOR]

Paediatric-preoperative anaemia management is challenging in settings where clinical judgment is used to diagnose anaemia owing to a lack of timely, affordable preoperative haemoglobin testing. We analysed anaemia management in such a setting after the introduction of point-of-care bedside haemoglobin testers. 1033 children who underwent surgery at a hospital in Bangladesh were included in this study. 569 underwent major surgery, and 464 underwent minor surgery and belonged to predominantly ASA category 1 or 2. 940/1033 children underwent preoperative anaemia testing. Average haemoglobin was 11.7 g/dL. 103/1033 children were deemed clinically anaemic. However, 285 children were found to have anaemia based on bedside testing. Sensitivity of clinical judgement was 33.68% (95 % CI 28.22%–39.49%), and the specificity was 99.08% (95 % CI 98.02%–99.66%). 63/1033 had preoperative anaemia treatment, of whom 60 underwent transfusion. Subgroup analysis of children with haemoglobin <10 g/dL (n = 124) was done to compare conservative vs liberal transfusion strategy. 43/124 of this subset was transfused. Average length of stay for those transfused was 11.7 days, and those who weren't was 9.9 days (p = 0.087). 4 patients in the transfused subgroup required post-op ICU, and only 1 patient in the conservatively managed arm required ICU (p = 0.048). This study demonstrates the positive impact of bedside haemoglobin testers as they have resulted in a significantly higher proportion of children diagnosed with anaemia at a fraction of the cost and logistics involved in laboratory testing. Further research on haemoglobin thresholds is required to understand the safety and long-term impact of restrictive transfusion in the surgical context. 2c (Grading as per the Oxford Centre for Evidence Based Medicine). [ABSTRACT FROM AUTHOR]

This article highlights a case of high-dose ferric carboxymaltose (Ferinject®) for the treatment of perioperative iron deficiency anaemia in a 39-year-old patient with dysplastic coxarthrosis. The patient was admitted routinely for a total hip replacement of the left hip joint. She had been suffering from pain, lameness, and restriction of movement in her left hip joint for the past several years. The patient was admitted with initial iron deficiency anaemia of a medium severity (Hgb—96.5 g/L, RBC—3.97 × 1012/L). Laboratory tests were taken to determine the iron deficiency, and transfusion readiness was submitted. The patient received ferric carboxymaltose infusion before surgery. The intraoperative blood loss was—100 mL with an operation duration of 50 min. On the first postoperative day, haemoglobin decreased to 86 g/L. No haemoglobin decrease was observed in the postoperative period, and 92 g/L was the amount of haemoglobin at the time of hospital discharge. The optimal dose for the treatment of perioperative anaemia has not been established; some studies recommend ferric carboxymaltose at a dose of 15 to 20 mg/kg and a maximum of 1000 mg once on the first day after surgery. The uniqueness of this case report is that a high dose of ferric carboxymaltose (1340 mg) during the preoperative period was applied. No side effects such as hypophosphatemia were reported. We believe that, in this clinical case, the patient managed to avoid large intraoperative blood loss and transfusions by using high doses of ferric carboxymaltose.

The timely correction of anaemia before major surgery is important for optimising perioperative patient outcomes. However, multiple barriers have precluded the global expansion of preoperative anaemia treatment programmes, including misconceptions about the true cost/benefit ratio for patient care and health system economics. Institutional investment and buy-in from stakeholders could lead to significant cost savings through avoided complications of anaemia and red blood cell transfusions, and through containment of direct and variable costs of blood bank laboratories. In some health systems, billing for iron infusions could generate revenue and promote growth of treatment programmes. The aim of this work is to galvanise integrated health systems worldwide to diagnose and treat anaemia before major surgery. [ABSTRACT FROM AUTHOR]

Allogeneic blood transfusion used to be common in spine surgery. Patient blood management has been widely adopted, and it is important to reassess transfusion predictors in contemporary practice. A retrospective study of inpatient spine surgery was performed using National Surgical Quality Improvement Program (NSQIP) data from 2011 to 2019. The primary outcome was perioperative transfusion within 72 h of surgery. Multivariable logistic regression and recursive partitioning were used to assess up to 15 variables including patient and surgical data, surgical specialty (orthopaedic surgery vs neurosurgery), and year of surgery. The study population included 251 971 US surgical patients; 6.9% of these patients received perioperative blood transfusion. Perioperative transfusions declined over time with the steepest decline from 2011 to 2015. The greatest reduction was seen among orthopaedic cases where the transfusion rate declined from 16.0% to 8.7% between 2011 and 2015. Eight variables were predictive factors in a reduced model: operative time, preoperative haemoglobin, vertebral level, number of vertebral levels, older age, surgeon specialty, arthrodesis, and year of surgery (area under the curve [AUC]=0.880; 95% confidence interval [CI], 0.878–0.883). Overall, longer operative time (>144 min) and greater numbers of vertebral levels had greater associations with transfusion than surgical specialty after adjustments. Prevalence of anaemia (15%) has not substantially declined. Perioperative blood transfusion rate in spine surgery has declined over the past decade. The extent and duration of surgery and preoperative haemoglobin level remain important factors associated with increased odds for perioperative blood transfusion. [ABSTRACT FROM AUTHOR]

Abstract Background The aim of this trial was to assess the effectiveness of quality improvement collaboratives to implement large-scale change in the National Health Service (NHS) in the UK, specifically for improving outcomes in patients undergoing primary, elective total hip or knee replacement. Methods We undertook a two-arm, cluster randomised controlled trial comparing the roll-out of two preoperative pathways: methicillin-sensitive Staphylococcus aureus (MSSA) decolonisation (infection arm) and anaemia screening and treatment (anaemia arm). NHS Trusts are public sector organisations that provide healthcare within a geographical area. NHS Trusts (n = 41) in England providing primary, elective total hip and knee replacements, but that did not have a preoperative anaemia screening or MSSA decolonisation pathway in place, were randomised to one of the two parallel collaboratives. Collaboratives took place from May 2018 to November 2019. Twenty-seven Trusts completed the trial (11 anaemia, 16 infection). Outcome data were collected for procedures performed between November 2018 and November 2019. Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infection (SSI) caused by MSSA (within 90 days post-surgery) for the anaemia and infection trial arms, respectively. Secondary outcomes were deep and superficial SSIs (any organism), length of hospital stay, critical care admissions and unplanned readmissions. Process measures included the proportion of eligible patients receiving each preoperative initiative. Results There were 19,254 procedures from 27 NHS Trusts included in the results (6324 from 11 Trusts in the anaemia arm, 12,930 from 16 Trusts in the infection arm). There were no improvements observed for blood transfusion (anaemia arm 183 (2.9%); infection arm 302 (2.3%) transfusions; adjusted odds ratio 1.20, 95% CI 0.52–2.75, p = 0.67) or MSSA deep SSI (anaemia arm 8 (0.13%); infection arm 18 (0.14%); adjusted odds ratio 1.01, 95% CI 0.42–2.46, p = 0.98). There were no significant improvements in any secondary outcome. This is despite process measures showing the preoperative pathways were implemented for 73.7% and 61.1% of eligible procedures in the infection and anaemia arms, respectively. Conclusions Quality improvement collaboratives did not result in improved patient outcomes in this trial; however, there was some evidence they may support successful implementation of new preoperative pathways in the NHS. Trial registration Prospectively registered on 15 February 2018, ISRCTN11085475

Background: The aim of this trial was to assess the effectiveness of quality improvement collaboratives to implement large-scale change in the National Health Service (NHS) in the UK, specifically for improving outcomes in patients undergoing primary, elective total hip or knee replacement.Methods: We undertook a two-arm, cluster randomised controlled trial comparing the roll-out of two preoperative pathways: methicillin-sensitive Staphylococcus aureus (MSSA) decolonisation (infection arm) and anaemia screening and treatment (anaemia arm). NHS Trusts are public sector organisations that provide healthcare within a geographical area. NHS Trusts (n = 41) in England providing primary, elective total hip and knee replacements, but that did not have a preoperative anaemia screening or MSSA decolonisation pathway in place, were randomised to one of the two parallel collaboratives. Collaboratives took place from May 2018 to November 2019. Twenty-seven Trusts completed the trial (11 anaemia, 16 infection). Outcome data were collected for procedures performed between November 2018 and November 2019. Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infection (SSI) caused by MSSA (within 90 days post-surgery) for the anaemia and infection trial arms, respectively. Secondary outcomes were deep and superficial SSIs (any organism), length of hospital stay, critical care admissions and unplanned readmissions. Process measures included the proportion of eligible patients receiving each preoperative initiative.Results: There were 19,254 procedures from 27 NHS Trusts included in the results (6324 from 11 Trusts in the anaemia arm, 12,930 from 16 Trusts in the infection arm). There were no improvements observed for blood transfusion (anaemia arm 183 (2.9%); infection arm 302 (2.3%) transfusions; adjusted odds ratio 1.20, 95% CI 0.52-2.75, p = 0.67) or MSSA deep SSI (anaemia arm 8 (0.13%); infection arm 18 (0.14%); adjusted odds ratio 1.01, 95% CI 0.42-2.46, p = 0.98). There were no significant improvements in any secondary outcome. This is despite process measures showing the preoperative pathways were implemented for 73.7% and 61.1% of eligible procedures in the infection and anaemia arms, respectively.Conclusions: Quality improvement collaboratives did not result in improved patient outcomes in this trial; however, there was some evidence they may support successful implementation of new preoperative pathways in the NHS.Trial Registration: Prospectively registered on 15 February 2018, ISRCTN11085475. [ABSTRACT FROM AUTHOR]

Aurélie Brunet,1 Yohan N’Guyen,1,* Annick Lefebvre,2,* Anne Poncet,3 Ailsa Robbins,1 Odile Bajolet,2 Yves Saade,3 Vito Giovanni Ruggieri,3,* Sylvain Rubin3,* 1Internal Medicine, Infectious Diseases and Clinical Immunology, Robert Debré University Hospital, Reims, France; 2Operational Hygiene Team, Robert Debré University Hospital, Reims, France; 3Thoracic and Cardiovascular Surgery, Robert Debré University Hospital, Reims, France*These authors contributed equally to this workCorrespondence: Yohan N’GuyenInternal Medicine, Infectious Diseases and Clinical Immunology, Robert Debré University Hospital, Avenue du général Koenig, Reims 51092, FranceTel (+33) 3 26 78 94 22Fax (+33) 3 26 78 40 90Email yohan.nguyen@wanadoo.frPurpose: Obesity remains statistically associated with coronary artery disease, for which coronary artery bypass graft surgery (CABG) remains the standard of care. However, obesity is also associated with sternal wound infection (SWI) which is a severe complication of CABG despite advances in surgery and in infection prevention and control. Strategies to reduce the incidence of SWI are still being investigated, and we therefore conducted a retrospective study to revisit factors other than obesity associated with SWI after CABG.Patients and Methods: Data were extracted from the medical records of 182 patients who underwent elective on-pump CABG using one or both pedicled internal mammary artery grafts in Reims University Hospital between May 2015 and May 2016. All preoperative or perioperative variables with a p value< 0.10 in univariate analysis were entered into a stepwise logistic regression model.Results: Among the 182 patients (145 male (79.6%), median age 68.0 [45.0– 87.0] years), 138 (75.8%) underwent CABG using bilateral internal mammary artery grafts. Median BMI was 27.7 [18.7– 50.5] kg/m2, and there were 51 (28.0%) and 79 (43.4%) patients with obesity and overweight, respectively. Twenty-three out of the 182 patients (12.6%) developed SWI. In-hospital mortality was not statistically different between patients with and without SWI but the median length of stay was (6.0 [2.0– 38.0] versus 5.0[3.0– 21.0] days in the intensive care unit, p=0.03, and 26.0 [9.0– 134.0] versus 9.0 [7.0– 51.0] days in hospital, p< 0.0001). Obesity and preoperative anaemia were independently associated with SWI, as was the number of red blood cell (RBC) units transfused (OR 14.61 [2.64– 80.75], OR 4.64 [1.61– 13.34] and OR 1.27 [1.02– 1.58], respectively).Conclusion: The independent association of SWI with the number of RBC units transfused and the existence of preoperative anaemia and obesity suggests a mechanism of thoracic wall ischemia in SWI after CABG, thus leaving insufficient perfusion of the thoracic wall in patients with obesity. Medical strategies are warranted to try to prevent this costly complication.Keywords: obesity, preoperative anaemia, coronary artery bypass graft surgery, internal mammary arteries

Preoperative anemia occurs in at least a third of patients before elective surgery and is a significant and at the same time modifiable risk factor for increased perioperative morbidity and mortality. Treatment in a preoperative anemia clinic may improve outcomes. Patients are evaluated at least 3 weeks before elective surgery to allow time for treatment of iron-deficiency anemia or further testing and follow-up care. [ABSTRACT FROM AUTHOR]

An International Consensus Conference (ICC) on PBM was held in 2018 to develop evidence‐based clinical and research recommendations for preoperative anaemia, red blood cell (RBC) transfusion thresholds for adults and implementation of PBM programmes. An international scientific committee (SC) defined 17 Population‐Intervention‐Comparison‐Outcome (PICO) questions for the three topics preoperative anaemia, red blood cell (RBC) transfusion thresholds for adults and PBM implementation. Based on these questions, an extensive literature search was conducted in four biomedical databases. The GRADE framework (= grading of recommendations, assessment, development and evaluation) was used to develop a systematic approach to the presentation of evidence summaries and for making clinical recommendations. Three expert panels (EP) consisting of clinicians, scientists, nurses, patient representatives and methodologists were established and used these methods to develop recommendations driven by published evidence. Out of more than 17 500 literature citations, data from 145 studies were incorporated. The expert panel for preoperative anaemia developed 4 clinical and 3 research recommendations. A strong recommendation advices early detection and management of preoperative anaemia before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations have been formulated. Two strong clinical recommendations for RBC transfusion thresholds comprise a haemoglobin concentration of <7 g/dl for critically ill, but clinical stable adult intensive care patients independent of septic shock and <7·5 g/dl for adults undergoing cardiac surgery. For the implementation of PBM programmes, 2 clinical and 3 research recommendations were developed. Research recommendations were formulated as encouragement of new studies to answer open questions. Due to the relative paucity of strong evidence‐based answers in current publications to the 17 PICO questions, additional research, an international consensus for accepted definitions and Hb thresholds as well as clinically meaningful end‐points for clinical studies are necessary. The 2018 PBM ICC defined the current status of PBM evidence and established 10 clinical and 12 research recommendations for preoperative anaemia, RBC transfusion thresholds for adults and implementation of PBM programmes. [ABSTRACT FROM AUTHOR]

Cross-matching of blood components to the patient's blood is mandatory to ensure the safe transfusion of suitable blood components in a timely manner and avoid serious harm to the recipient. This article will outline the validated methods of cross-matching in the laboratory setting. We will also discuss transfusion reactions and consequences of transfusion of inappropriate or mismatched blood components, alongside the principles of patient blood management and pre-operative anaemia. [ABSTRACT FROM AUTHOR]

Preoperative anaemia is common. Its prevalence varies according to the population studied and the definition of what constitutes anaemia. Where the widely accepted definition of the World Health Organization is used (haemoglobin concentration <130 g/l in men or <120 g/l in women), between 20% and 60% of surgical patients are found to be anaemic. Anaemia is well known to contribute to increased peri-operative risk. In contrast to the other well-known risk determinants (e.g. age, magnitude of surgery, the presence or absence of a cancer diagnosis, renal failure etc.), anaemia is potentially modifiable. This article will give an overview of the approach to a patient found to be anaemic before surgery. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to quantify the potential epidemiological and health economic benefits of implementing preoperative anaemia measures (PAMs) in clinical practice in the German healthcare system. Methods: An evidence-based health economic model was developed to assess the possible impact of implementing PAMs, the first pillar of patient blood management (PBM), in a German population. The analysis of two risk factors—iron-deficiency anaemia (IDA) and receipt of a red blood cell concentrate (RBC) transfusion during elective surgery—allowed the estimation of relative risks (RRs), average cost per patient, average length of hospital stay, and avoided hospital deaths after the implementation of PAMs. Results: A total of 4,591,060 patients who had undergone elective surgery during 2015 were identified, of which 29,170 (0.64%) were diagnosed with preoperative IDA. These patients had an increased RR of receiving a RBC transfusion during surgery (RR 5.031; 95% confidence interval [CI] 4.928, 5.136) and increased mortality risk (RR 3.630; 95% CI 3.401, 3.874) versus patients without IDA. Patients who received a RBC transfusion during surgery had a 24.6-times higher risk of death than those who did not (RR 24.593; 95% CI 24.121, 25.075). Average cost of treatment was €7883 in patients with IDA, €21,744 in patients with IDA and RBC transfusion, and €4560 in patients without risk factors. The model identified 29,714 patients (0.65%) who had received a RBC transfusion and who potentially had IDA but remained undiagnosed before surgery. Hypothetical implementation of PAMs would have resulted in an estimated annual net hospital direct cost saving of €1029 million (1.58%) of total hospital direct costs of the German healthcare system and 3036 hospital deaths (0.07%) avoided. Conclusions: This model estimated the impact of implementing PAMs for patients with IDA undergoing elective surgery. A significant number of deaths, costly treatments, and hospital days could have been avoided by the introduction of PAMs in routine clinical practice in Germany. [ABSTRACT FROM AUTHOR]

Background Externally generated hospital benchmarking data indicated that the blood transfusion rate within elective surgical orthopaedic and gastrointestinal patients at a metropolitan, tertiary healthcare facility was higher than comparable Australian hospitals. An investigation of transfusion practices was undertaken with the aim of understanding the reasons contributing to this higher incidence. Study Methods A chart audit was undertaken of every major, elective, surgical orthopaedic and gastrointestinal patient who received a blood transfusion between July and December 2017. The audit aimed to ascertain whether patients were screened and treated for preoperative anaemia and measure the clinical appropriateness of transfusions according to the National Blood Authority (NBA) Perioperative Patient Blood Management (PBM) recommendations. The key recommendations include the utilisation of restrictive transfusion thresholds (in conjunction with clinical assessment) and the administration of a single unit followed by clinical reassessment. Results Forty-five patients had 72 transfusion episodes; 40% of episodes were considered inappropriate (n = 29). Of these, 76% (n = 22) did not have evidence of decompensation, and of the remaining that did (24%, n = 7), there was no evidence of clinical reassessment after transfusion. 42% (n = 19) of patients were anaemic preoperatively, of which only 21% (n = 4) had iron studies, and only one patient received intravenous iron preoperatively. Conclusion Opportunities exist to improve the preoperative anaemia screening processes and clinical decision-making in transfusion practice. The baseline results of this audit will inform an improvement plan to develop interventions to enhance practice. [ABSTRACT FROM AUTHOR]

Abstract Cross-matching of blood components to the patient's blood is mandatory to ensure the safe transfusion of suitable blood components in a timely manner and avoid serious harm to the recipient. This article will outline the validated methods of cross-matching in the laboratory setting. We will also discuss transfusion reactions and consequences of transfusion of inappropriate or mismatched blood components, alongside the principles of patient blood management and pre-operative anaemia. [ABSTRACT FROM AUTHOR]

Introduction: Intravenous iron therapy has been shown to be advantageous in treating anaemia and reducing the need for blood transfusions. Iron treatment, however, may also be hazardous by supporting cancer growth. Present clinical study explores, for the first time, the effect of preoperative intravenous iron therapy on tumour prognosis in anaemic colorectal cancer patients. Methods: A retrospective cohort study was performed on consecutive patients who underwent surgery for colorectal cancer between 2010 and 2016 in a single teaching hospital. The primary outcomes were 5-year overall survival (OS) and disease-free survival (DFS). Survival estimates were calculated using the Kaplan-Meier method and patients were matched based on propensity score. Results: 320 (41.0%) of all eligible patients were anaemic, of whom 102 patients received preoperative intravenous iron treatment (31.9%). After propensity score matching 83 patients were included in both intravenous and non-intravenous iron group. The estimated 1-, 3-, and 5-year OS (91.6%, 73.1%, 64.3%, respectively) and DFS (94.5%, 86.7%, 83.4%, respectively) in the intravenous iron group were comparable with the non-intravenous iron group (p = 0.456 and p = 0.240, respectively). In comparing patients with an event (death or recurrence) and no event in the intravenous iron group, a distinct trend was found for decreased transferrin in the event group (median 2.53 g/L vs 2.83 g/L, p = 0.052). Conclusion: The present study illustrates that a dose of 1000-2000 mg preoperative intravenous iron therapy does not have a profound effect on long-term overall and disease-free survival in anaemic colorectal cancer patients. Future randomised trials with sufficient power are required to draw definite conclusions on the safety of intravenous iron therapy. [ABSTRACT FROM AUTHOR]

Preoperative anaemia is affecting at least a third of patients undergoing elective surgery and is a significant and modifiable risk factor for increased perioperative morbidity and mortality. Iron deficiency is the most common cause of preoperative anaemia and should be corrected. Intravenous iron is efficacious and safe and should be used in patients in whom oral iron is not tolerated or if the time before surgery is short. Erythropoiesis-stimulating agents (ESA) might be suggested (after correction of nutritional deficiencies) for anaemic patients with kidney disease or chronic inflammation and elderly patients with anaemia of unknown cause and adequate iron supply should always be ensured. Elective surgery should be postponed until preoperative anaemia has been appropriately treated. An easy-to-follow algorithm for the detection, evaluation, and appropriate treatment of anaemia and iron deficiency in surgical patients should be used. [ABSTRACT FROM AUTHOR]

SUMMARY: Pre‐operative anaemia and perioperative red blood cell transfusion carry significant consequence when it comes to surgical outcomes. The establishment of patient‐centred clinical pathways has been designed to harness and endorse good transfusion practice, termed the three pillars of patient blood management (PBM). These focus on the timely and appropriate management of anaemia, prevention of blood loss and restrictive transfusion where appropriate. This article reviews the current evidence and ongoing research in the field of PBM in surgery. Strategies to implement PBM have shown significant benefits in appropriate transfusion practice, reduced costs and improved length of hospital stay. Recently published national quality standards have recognised the features of the PBM blueprint such as the consideration of alternatives to red blood cell transfusion, the active measures to reduce perioperative blood loss and the appropriate management of post‐operative anaemia. Adopting PBM in surgical patients should be paramount to reduce the risks posed by perioperative anaemia and blood transfusions. The principles of PBM help structure the interventions and decisions relating to anaemia and blood transfusion, but, more importantly, represent a paradigm shift towards a more considered approach to blood transfusion, acknowledging its risks, preventatives and alternatives. [ABSTRACT FROM AUTHOR]

Background: In preoperative blood management of colorectal cancer patients, intravenous iron therapy is increasingly used to treat anaemia and prevent red blood cell transfusions. However, while iron deficiency is the most common cause of anaemia, little is known about the prevalence and namely type of iron deficiency in this population, whereas both types of iron deficiency (i.e. absolute and functional iron deficiency) are recommended to be treated differently by international cancer guidelines. Objective: The aim of present study is to investigate the prevalence and namely type of iron deficiency in colorectal cancer patients, and to assess its clinical relevance. Methods: Preoperative iron status, clinical parameters (i.e. age, ASA classification, tumour location, tumour stage) and postoperative complications were retrospectively collected for all newly diagnosed colorectal cancer patients in our institution over a 3-year period. Results: Iron deficiency was observed in 163 (48.1%) of 339 patients. Of these iron-deficient patients, 3.7% had an isolated absolute iron deficiency (AID) and 15.3% a functional iron deficiency (FID), while the rest had a combination of AID and FID. Anaemia was present in 66.1% of iron-deficient patients. Iron deficiency was significantly associated with an increased postoperative complication rate (univariable OR 1.94, p = 0.03, multivariable OR 1.84, p = 0.07), with right-sided tumours ( p < 0.001), high ASA classification ( p = 0.002), advanced tumour stage ( p = 0.01) and advanced age ( p = 0.04). In comparing clinical parameters between patients with AID and FID, advanced age was significantly associated with FID ( p = 0.03), and the presence of anaemia with AID ( p = 0.02). Conclusion: In preoperative colorectal cancer patients, there is a high prevalence of iron deficiency, including a high percentage of patients with-a component of-functional iron deficiency, associated with the increased postoperative complication rate. As both types of iron deficiency require a different treatment strategy, our results illustrate the therapeutic potential of especially intravenous iron supplementation in patients with severe iron deficiency and stress the urgency of routinely monitoring preoperative iron status and differentiation between types of iron deficiency. As iron therapy may also be potentially harmful in respect to stimulation of tumour growth, future clinical trials assessing the long-term effect of iron therapy are necessary. [ABSTRACT FROM AUTHOR]

Abstract Preoperative anaemia is common. Its prevalence varies according to the population studied and the definition of what constitutes anaemia. Where the widely accepted definition of the World Health Organization is used (haemoglobin concentration <130 g/l in men or <120 g/l in women), between 20% and 60% of surgical patients are found to be anaemic. Anaemia is well known to contribute to increased peri-operative risk. In contrast to the other well-known risk determinants (e.g. age, magnitude of surgery, the presence or absence of a cancer diagnosis, renal failure etc.), anaemia is potentially modifiable. This article will give an overview of the approach to a patient found to be anaemic before surgery. [ABSTRACT FROM AUTHOR]

Background: Optimisation of blood management in total hip (THA) and knee arthroplasty (TKA) is associated with improved patient outcomes. This study aimed to establish the effectiveness of a perioperative blood management programme in improving postoperative haemoglobin (Hb) and reducing the rate of allogenic blood transfusion. Methods: This retrospective before and after study involves 200 consecutive patients undergoing elective TKA and THA before (Usual Care group) and after (Intervention group) the introduction of a blood management programme in an Australian teaching hospital. Patients in the Intervention group underwent preoperative treatment for anaemia and received intraoperative tranexamic acid (15 mg/kg). The primary outcomes were to compare postoperative Hb levels and the rate of blood transfusion. Secondary outcomes included measurements of total amount of allogenic blood transfused, transfusion-related complications, postoperative complications, need for inpatient rehabilitation and duration of hospital stay. Results: There were no differences between baseline characteristics between groups. The mean (SD) preoperative Hb was higher in the Intervention group compared to that in the Usual Care group: 138.7 (13.9) vs. 133.4 (13.9) g/L, p = 0.008, respectively. The postoperative day 1 Hb, lowest postoperative Hb and discharge Hb were all higher in the Intervention group (p < 0.001). Blood transfusion requirements were lower in the Intervention group compared to the Usual Care group (6 vs. 20 %, p = 0.003). There were no differences in any of the secondary outcomes measured. Patients who were anaemic preoperatively and who underwent Hb optimisation had higher Hb levels postoperatively (odds ratio 5.7; 95 % CI 1.3 to 26.5; p = 0.024). Conclusions: The introduction of a perioperative blood optimisation programme improved postoperative Hb levels and reduced the rate of allogenic blood transfusion. [ABSTRACT FROM AUTHOR]

Aim Preoperative anaemia is associated with increased morbidity and mortality. The aim of this systematic review is to evaluate the efficacy of preoperative iron supplementation in the treatment of anaemia, and its effect on the postoperative recovery of patients undergoing surgery for colorectal carcinoma. Method This systematic review was performed using MEDLINE, EMBASE and the Cochrane library to assess current evidence on the role of iron supplementation in the treatment of preoperative anaemia. Our main outcomes were absolute increase in haemoglobin, blood transfusion rate and postoperative morbidity. Main inclusion criteria were: preoperative iron supplementation, presence of colorectal carcinoma and elective surgery. The Downs-Black questionnaire was used for quality assessment of the included studies. Results Of the 605 studies analysed, seven, three randomized controlled trials and four cohort studies, were included. Despite iron supplementation, the three randomized controlled trials showed a decrease in haemoglobin level. This was contrary to the four cohort studies which all showed a significant increase. All studies showed a decreased blood transfusion rate following iron supplementation. None of the included studies assessed postoperative morbidity. Due to heterogeneity in study design, duration of treatment, dosages and variation in iron substrates, we were unable to perform a meta-analysis. Conclusion In anaemic patients who require surgery for colorectal carcinoma, current evidence is of inadequate quality to draw a definitive conclusion on the efficacy of the various measures to treat preoperative anaemia. [ABSTRACT FROM AUTHOR]

Background Preoperative anaemia is a well-established risk factor for use of blood transfusions and postoperative morbidity. Consequently, focus on preoperative evaluation of haemoglobin levels is increasing. In this context, iron deficiency anaemia may be a symptom of undiscovered gastrointestinal ( GI) cancer requiring further investigation. However, the association between preoperative anaemia and cancer 1 year after elective total hip ( THA) and total knee arthroplasty ( TKA) is unknown. We evaluated 1-year cancer diagnoses, particularly GI cancers, in anaemic and non-anaemic THA and TKA patients. Study Design and Methods A prospective database on preoperative patient characteristics from six Danish orthopaedic centres was cross-referenced with the Danish Cancer Registry for information on diagnoses of new cancers 1 year after surgery. Crude cancer risk estimates were calculated using chi-square and Fisher's exact test in the total study cohort. Adjusted risk estimates were obtained using propensity scores and the Mantel-Haenzel statistic. Results Of 5400 procedures, 731 (13·5%) were in anaemic patients. These were older and had more comorbidity than non-anaemic patients. There were 17 (2·3%) and 79 (1·6%) new cancers in anaemic and non-anaemic patients, respectively ( OR: 1·38; 95% CI: 0·81-2·35, P = 0·228). After propensity matching of 661 anaemic and 1305 non-anaemic patients, we found no association between preoperative anaemia and cancer ( OR: 0·94; 95% CI: 0·51-1·73, P = 0·837) or with GI cancers specifically ( OR: 0·80; 95% CI: 0·25-2·56, P = 0·707). Conclusion Preoperative anaemia per se may not be related to being diagnosed with cancer 1 year after THA and TKA. The optimal criteria for preoperative referral of anaemic patients to gastroenterologist in elective THA and TKA need further investigation. [ABSTRACT FROM AUTHOR]

Background: The pre-operative blood haemoglobin concentration may affect the need for post-operative allogenic red blood cell transfusion. The prevalence of anaemia in patients undergoing major surgery is high, and orthopaedic surgeons are usually not aware of it. The aims of this study were to estimate the prevalence of pre-operative anaemia and to assess its impact on post-operative requirements for allogenic red blood cell transfusions (ARBCT) in the post-operative period following primary elective total knee and hip replacement. Material and methods: We performed a retrospective study of consecutive patients who underwent primary knee and hip joint replacement between July 2010 and June 2011 in a tertiary referral centre for knee and hip replacement. According to the WHO, anaemia was defined as blood haemoglobin concentration <13 g/dL for men and <12 g/dL for women. In accordance with the blood transfusion protocol of our hospital, an allogenic red blood cell unit was indicated when blood haemoglobin concentration was <8 g/dL; or <8.5 g/dL in patients with heart disease or older than 70 years; or between 8.5 and 9 g/dL in patients who had poor orthostatic tolerance. The number of patients who received an allogenic red blood cell unit (300 mL) during the post-operative period (from surgery until discharge) was gathered. Results: A total of 276 consecutive patients (28 % males, 72 % females) were included [mean (sd) age 72 years (10)]: 174 knees and 102 hips. The overall prevalence of pre-operative anaemia was 12 % (33/276, 95 % CI 8-16 %): 13 % (23/174, 95 % CI 9-19 %) in the knee group and 10 % (10/102, 95 % CI 5-17 %) in the hip group. The post-operative ARBCT rate was 31 % (85/276, 95 % CI 25-36 %): 22 % in the knee group (38/174, 95 % CI 16-29 %) and 46 % in the hip group (47/102, 95 % CI 36-56 %) ( p < 0.001). Of the 33 pre-operative anaemic patients (23 knees, 10 hips), 22 (67 %, 95 % CI 48-82 %) received ARBCT: 12/23 (52 %) in the knee group and 10/10 (100 %) in the hip group ( p = 0.002). Pre-operative anaemia was the main risk factor for requiring transfusion ( p < 0.001). Conclusion: Pre-operative anaemia has a clear and determinant impact on post-operative requirements for allogenic red blood cell transfusion in total knee and hip replacement. Treatment of pre-operative anaemia in joint replacements might reduce the allogenic red blood cell transfusion rate. Orthopaedic surgeons should be aware of the pre-operative haematological status of those patients who will undergo for an arthroplasty of the lower limb. The protocol was approved by the ethics committee at Hospital de la Santa Creu i Sant Pau (code: IIBSP-ANE-2011-86). [ABSTRACT FROM AUTHOR]

Background. Delay in diagnosis of anaemia during preoperative assessment poses logistic problems, leading to multiple clinic visits, inadequate preoperative management, and unnecessary delay of surgery. Therefore, we tested an instant spectrophotometric haemoglobin (SpHb) measurement technique to facilitate this assessment. Methods. We evaluated portable instant SpHb vs standard laboratory screening of anaemia between March 2012 and December 2013. Paired Hb measurements were performed on 726 patients using SpHb (Pronto-7, Masimo Corporation, Irvine, CA, USA) and Hb measured on the same day using an automated analyser. The results were obtained from a group of 638 patients from the pre-anaesthetic clinic with expected normal Hb values, and 88 patients from the oncology clinic with known low Hb. Results. Median (range) SpHb was 129.5 (67-171) compared with 136 g litre-1 (63-178) Hb measured using the automated system. Identifying Hb below a threshold of 130 g litre-1 for males had a high sensitivity (93%), while identifying a threshold of 120 g litre-1 for females had lower sensitivity (75%). The specificity for males (77%) and females (81%) was similar. Mean measurement bias and agreement: tolerability interval ratio was 28.1 g litre-1 and 2.78 for men and 23.1 g litre-1 and 2.44 for women. Conclusions. SpHb was sensitive as a preliminary screening tool for detecting true low Hb values in males, but less sensitive in females. Instant SpHb measurement may enable prompt routine preoperative anaemia management, but its precision was lower than expected. Clinical trial registration. This study is approved by the Tasmanian Human Ethics Committee, Australia and was registered prospectively in the Australian and New Zealand Clinical Trials Registry (http://www.ANZCTR.org.au/ ACTRN12611001256965) and the World Health Organization Clinical Trials Registry (http://apps.who.int/trialsearch/trial.aspx?trialid= ACTRN12611001256965). [ABSTRACT FROM AUTHOR]

OBJECTIVES The impact of anaemia on patients undergoing aortic valve surgery has not been well studied. We sought to evaluate the effect of anaemia on early outcomes following aortic valve replacement (AVR). METHODS All patients undergoing non-emergent aortic valve surgery (n = 2698) with or without other concomitant procedures between 1997 and 2010 were included. Preoperative anaemia was defined as per World Health Organization guidelines as haemoglobin (Hb) < 130 g/l in men and Hb < 120 g/l in women. Multivariable analyses were used to determine the association between preoperative anaemia and postoperative outcomes. RESULTS The prevalence of preoperative anaemia was 32.2%. Patients with anaemia were older (71 ± 12 vs 66 ± 13 years, P < 0.001), more likely to have urgent surgery, recent MI, higher creatinine level and impaired preoperative left ventricular function. Overall unadjusted mortality was 2.8% in non-anaemic patients vs 8% in anaemic patients. Anaemic patients were more likely to require renal replacement therapy (11 vs 3%, P < 0.0001) and prolonged ventilation (24 vs 10%, P < 0.0001). Following multivariable adjustment, lower preoperative Hb was an independent predictor of mortality (odds ratio 1.19, 95% CI: 1.04–1.34, P = 0.007) and composite morbidity (odds ratio 1.36, 95% CI: 1.05–1.77, P = 0.02) after AVR. Mortality and composite morbidity were significantly higher with lower levels of preoperative Hb. CONCLUSIONS Preoperative anaemia is a common finding in patients undergoing aortic valve surgery and is an important and potentially modifiable risk factor for postoperative morbidity and mortality. [ABSTRACT FROM PUBLISHER]

The impact of anaemia on patients undergoing aortic valve surgery has not been well studied. We sought to evaluate the effect of anaemia on early outcomes following aortic valve replacement (AVR). Methods: All patients undergoing non-emergent aortic valve surgery (n=2698) with or without other concomitant procedures between 1997 and 2010 were included. Preoperative anaemia was defined as per World Health Organization guidelines as haemoglobin (Hb)

Background: Colorectal cancer (CRC) is the second most frequently diagnosed cancer in women and the third in men. Anaemia is a common condition in patients with CRC., Aim: In this study, we aimed to retrospectively analyse the relationship between preoperative anaemia (POA) and postoperative complications in patients with colorectal cancer (CRC) that underwent elective surgery., Patients and Methods: The data of patients who underwent elective curative surgery for CRC between January 2015 and December 2020 and had pathologically-proven cancer were evaluated retrospectively. We examined the effect of demographic characteristics of patients, preoperative haemoglobin, cancer localization (colon/rectum), American Society of Anaesthesiologist (ASA) classification, preoperative co-morbidity, surgical method (laparoscopic/open), stoma status, tumor stage, presence of preoperative anaemia on surgical site infection, pulmonary complications, renal complications, anastomotic leaks, and need for intensive care and re-operation in the postoperative period., Results: Of the 352 patients who underwent curative resection for CRC, 177 (50.3%) were diagnosed with POA. The median haemoglobin value was 10.7 g/dl in POA patients while it was 13.6 g/dl in the non-POA group. Regarding the localization of tumor, the patients with tumors on the right colon were more statistically significant in terms of POA (p < 0.05). Patients with POA had a higher rate of hypertension and coronary artery disease compared to patients without POA (p < 0.05). In patients with POA, surgical site infection and need for intensive care were statistically significant in the postoperative period compared to patients without POA (p < 0.05, P < 0.01, respectively). However, there was no significant difference between the two groups regarding pulmonary complications, renal complications, anastomotic leaks, and need for re-operation in the postoperative period., Conclusion: We believe that POA should be corrected prior to surgery to reduce not only the need for intensive care but also surgical site infection in patients undergoing elective curative surgery for CRC., Competing Interests: None

Preoperative anaemia is common. Its prevalence varies according to the population studied and the definition of what constitutes anaemia. Where the widely accepted definition of the World Health Organization is used (haemoglobin concentration (Hb) <130 g/l in men or <120 g/l in women), between 20% and 60% of surgical patients are found to be anaemic. Anaemia is well known to contribute to increased peri-operative risk. In contrast to the other well-known risk determinants (e.g. age, magnitude of surgery, the presence or absence of a cancer diagnosis, renal failure etc.) anaemia is potentially modifiable. This article will give an overview of the approach to a patient found to be anaemic before surgery. [ABSTRACT FROM AUTHOR]

Iron deficiency anaemia is highly prevalent worldwide. In the surgical patient, anaemia of any cause implies higher morbidity and mortality in the post-operative period. This is especially important in patients with peripheral artery disease, as they have very high rates of anaemia due to iron deficiency or other causes. In intermittent claudication, anaemia is a predictor of death in the medium term. Patients with critical ischaemia have higher prevalence of anaemia and it is an indicator of amputation and death in the medium term. Specific protocols need to be developed for these patients since the natural history of their disease does not allow for the correction of anaemia before surgery., (Copyright © 2021 Elsevier España, S.L.U. All rights reserved.)

Background and Objectives: The "Patient Blood Management" (PBM) programmes have demonstrated their value in the continuous improvement of care practice, due to continuous systematic reviewing of results and their dynamic and multidisciplinary updating in accordance with new clinical evidence. Our goal is to demonstrate the effectiveness of simple protocols, applicable in second level hospitals., Patients and Methods: 702 patients undergoing scheduled arthroplasty from 2011 to 2018 were retrospectively analysed. During this period, the evolution of transfusion rates and anaemia and bleeding management were recorded in the patients' computerised clinical histories., Results: Stages and transfusion rates were: Year 2011-2012, "Universal self-donation programme": 62.4%; year 2013, "Optimization of preoperative haemoglobin and universal self-donation withdrawal", 22.5%; year 2015, "Stopping the use of cell-savers and drains", 13.2%; and year 2017, "Introduction of routine tranexamic acid", 3.6%. A significant reduction in the transfusion rate and volume (P<.001) and the average hospital stay (8 to 6 days) (P<.001) was achieved. In multivariate models, transfused patients have a .5-day stay and there is a trend towards a reduction in complications, being fewer in patients receiving tranexamic acid (OR .44)., Conclusion: A simple progressive and multidisciplinary PBM programme, with continued re-evaluation, has allowed a reduction in transfusion rates and average hospital stay., (Copyright © 2020 Elsevier España, S.L.U. All rights reserved.)

A response from the author of the article "Preoperative anaemia is a risk factor for mortality and morbidity following aortic valve surgery," in the 2013 issue is presented.

A response to the letter to the editor by the authors about their article "Preoperative anaemia is a risk factor for mortality and morbidity following aortic valve surgery" in a 2013 issue is presented.

A letter to the editor is presented in response to the article "Preoperative anaemia is a risk factor for mortality and morbidity following aortic valve surgery" by Elsayed Elmistekawy and colleagues in a 2013 issue.

A response from the authors of the article "Preoperative anaemia is a risk factor for mortality and morbidity following aortic valve surgery" in a 2013 issue is presented.