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Toledo FV, De Carli D, Meletti JFA, Togo HYA, Gomes IP, Sakashita RM, Montes LF, Tiburcio RS, Miranda CDA. Preoperative iron supplementation in non-anemic patients undergoing major surgery: a systematic review and meta-analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2025; 75:844618. [PMID: 40189047 PMCID: PMC12053702 DOI: 10.1016/j.bjane.2025.844618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2024] [Revised: 03/01/2025] [Accepted: 03/09/2025] [Indexed: 04/27/2025]
Abstract
BACKGROUND Blood transfusions are associated with increased morbidity and mortality, and maintaining global blood supplies can be a challenge. This systematic review investigates the impact of preoperative iron supplementation on the risk of blood transfusion among non-anemic patients undergoing major surgeries. METHODS We conducted a systematic search of PubMed, Embase, and Cochrane Central for randomized controlled trials published up to May 2024. Studies involving the use of erythropoietin, or patients already using iron supplementation when trial randomization was conducted were excluded. Outcomes assessed included the number of individuals who received blood transfusions, and mean hemoglobin levels at the first day and by the first postoperative week. RESULTS A total of 1,162 non-anemic patients from 9 studies were included. Of these, 54% received preoperative iron supplementation. The average age was 71 years, and 44% were women. Preoperative iron supplementation was associated with a significantly lower risk of receiving a blood transfusion (OR = 0.54; 95% CI 0.40 to 0.75; p < 0.001). At the first postoperative day, the iron supplementation group had significantly higher mean hemoglobin levels compared to the no-treatment group (MD = 0.22 g.dL-1; 95% CI 0.02 to 0.42; p = 0.03). However, the pooled results could not rule out the null hypothesis for the difference in mean hemoglobin levels throughout the first week (MD = 0.12 g.dL-1; 95% CI -0.12 to 0.35; p = 0.34). CONCLUSION Preoperative intravenous iron supplementation in non-anemic patients undergoing major surgeries, particularly cardiac procedures, significantly reduces transfusion requirements. However, the benefits of oral iron remain uncertain, and further research is warranted to establish standardized perioperative supplementation protocols. PROSPERO IDENTIFIER CRD42024552559.
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Affiliation(s)
- Fabio Vieira Toledo
- Faculdade de Medicina de Jundiaí (FMJ), Departamento de Anestesiologia, Jundiaí, SP, Brazil.
| | - Daniel De Carli
- Faculdade de Medicina de Jundiaí (FMJ), Departamento de Anestesiologia, Jundiaí, SP, Brazil
| | | | | | - Italo Pires Gomes
- Faculdade de Medicina de Jundiaí (FMJ), Departamento de Anestesiologia, Jundiaí, SP, Brazil
| | | | - Lucas Felix Montes
- Faculdade de Medicina de Jundiaí (FMJ), Departamento de Anestesiologia, Jundiaí, SP, Brazil
| | - Rafael Santos Tiburcio
- Faculdade de Medicina de Jundiaí (FMJ), Departamento de Anestesiologia, Jundiaí, SP, Brazil
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Lu J, Weng X, Ma J, Zhang T, Ming H, Ma X. Preventive effects of perioperative drug injection on postoperative delirium after hip fracture surgery: a systematic review and meta-analysis. Am J Transl Res 2025; 17:1538-1553. [PMID: 40225995 PMCID: PMC11982853 DOI: 10.62347/nwpm9551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 11/28/2024] [Indexed: 04/15/2025]
Abstract
OBJECTIVE To systematically evaluate the efficacy of perioperative drug injection in preventing postoperative delirium (POD) following hip fracture (HF) surgeries. METHODS This research scheme was published on the PROSPERO platform (registration number: CRD42024602190). Databases searched included PubMed, Web of Science, Embase, and Cochrane. The search deadline was July 2024. Statistical analyses were conducted using StataSE15.0 software. Paired analysis and network meta-analysis were performed in R Studio, with included drugs ranked using the cumulative ranking probability plot area (SUCRA) for each outcome measure. The incidence, severity, and duration of delirium were analyzed using risk ratios (RR), weighted mean differences (WMD), and their corresponding 95% confidence intervals (CI). RESULTS This meta-analysis included 13 studies: 9 RCTs and 4 cohort studies involving 2,291 patients with HF. The results indicated a significant reduction in the incidence of POD among patients who received perioperative drug injections, with a combined RR of 0.56 [95% CI (0.47, 0.67), P < 0.001]. There was also a significant reduction in the severity of delirium, with a combined WMD of -2.78 [95% CI (-4.38, -1.19), P = 0.01]. However, there were no significant differences in the duration of delirium or the incidence of adverse events, with combined values of [WMD = -1.81, 95% CI (-3.89, 0.27), P = 0.088] and [RR = 1.34, 95% CI (0.78, 2.32), P = 0.294], respectively. Network meta-analysis identified morphine as the most effective drug for preventing delirium, with a SUCRA value of 19.1%. CONCLUSION In patients undergoing surgery for HF, perioperative drug injections significantly reduce the incidence and severity of postoperative delirium, with intrathecal morphine being the most effective option for prevention. These findings provide valuable insights for managing postoperative delirium prevention in HF patients. Further high-quality randomized controlled studies are needed to validate these results.
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Affiliation(s)
- Jin Lu
- Department of Surgical Intensive Care Unit, Tianjin HospitalTianjin 50300, China
| | - Xin Weng
- Department of Surgical Intensive Care Unit, Tianjin HospitalTianjin 50300, China
| | - Jianxiong Ma
- Department of Orthopedic Surgery and Orthopedic Research Institute, Tianjin HospitalTianjin 50300, China
| | - Tao Zhang
- Department of Surgical Intensive Care Unit, Tianjin Huanhu HospitalTianjin 300350, China
| | - Haolang Ming
- Department of Neuro ICU, Tianjin MEDICAL University General HospitalTianjin 300000, China
| | - Xinlong Ma
- Department of Digital Orthopedics, Tianjin HospitalTianjin 50300, China
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Landers AL, Peterson DF, McKibben NS, Hutchison CE, Trapalis T, DeKeyser GJ, Friess DM, Working ZM. Injury-Associated Anemia in Orthopaedic Trauma: A Comprehensive Review. JBJS Rev 2025; 13:01874474-202501000-00005. [PMID: 39836763 DOI: 10.2106/jbjs.rvw.24.00167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2025]
Abstract
» Anemia is a common comorbidity in orthopaedic trauma patients with important clinical consequences, significantly negatively affecting a patient's course following orthopaedic trauma.» Anemia remains relatively understudied in the orthopaedic trauma population with a large amount of current literature focused solely on geriatric hip fracture patients.» Greater investigation into alternatives to blood transfusions such as iron therapy or cell salvaging for treatment of anemia in the orthopaedic trauma population is needed.
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Affiliation(s)
- Andrea L Landers
- Department of Orthopaedics & Rehabilitation, Oregon Health & Sciences University, Portland, Oregon
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Hao J, Pang P, Liu X, Chi W, Luo Z, Cai W, Zhang L. Can the lung ultrasound score predict pulmonary complications after non-thoracic surgery in patients with blunt thoracic trauma: A single-center observational study. J Clin Anesth 2024; 99:111675. [PMID: 39504920 DOI: 10.1016/j.jclinane.2024.111675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 08/09/2024] [Accepted: 10/27/2024] [Indexed: 11/08/2024]
Abstract
STUDY OBJECTIVE Patients with blunt thoracic trauma have a high risk of developing postoperative pulmonary complications (PPCs). In this study, we aimed to identify the risk factors for PPCs after non-thoracic surgery in patients with blunt thoracic trauma and investigate the efficacy of perioperative lung ultrasound scores in predicting PPC occurrence. DESIGN Prospective observational study. SETTING A Chinese tertiary orthopedic hospital. PARTICIPANTS This observational study included 369 patients with blunt thoracic trauma who underwent surgery for pelvic and upper or lower extremity fractures. INTERVENTIONS Lung ultrasonography was performed pre- and postoperatively. MEASUREMENTS Patients were followed up for 1 week to assess PPCs and assigned to the PPC or non-PPC groups. We identified risk factors for PPCs using univariate and multivariate logistic regression analyses. The predictive value of these risk factors was evaluated using receiver operating characteristic (ROC) curves. MAIN RESULTS PPCs incidence was 36.58 %. The two groups differed significantly in Injury Severity Scores, American Society of Anesthesiologists (ASA) classification, chronic obstructive pulmonary disease, hydrothorax, preoperative hypoxemia, lung ultrasound score, preoperative hemoglobin level, intraoperative infusion volume, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) scores (P < 0.05). Independent risk factors for PPCs included ASA classification III, higher postoperative lung ultrasound scores, preoperative anemia, higher intraoperative infusion volume, and higher ARISCAT scores. ROC curve analysis revealed that postoperative lung ultrasound score (area under the curve [AUC]: 0.810, cutoff: 10), preoperative hemoglobin level (AUC: 0.627, cutoff: 97), intraoperative infusion volume (AUC: 0.701, cutoff: 886.51 mL/h) and ARISCAT score (AUC: 0.718, cutoff: 33) predicted postoperative outcomes effectively. CONCLUSIONS Postoperative lung ultrasound scores reliably predicted pulmonary complications after non-thoracic surgery in patients with blunt thoracic trauma. ASA classification III, preoperative anemia, excessive intraoperative fluid infusion, higher ARISCAT, and postoperative lung ultrasound scores were significant risk factors associated with PPCs. TRIAL REGISTRATION Clinical Trial Number: 1900023408. Registered on May 26, 2019.
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Affiliation(s)
- Jianhong Hao
- Department of Anaesthesiology, HongHui Hospital, Xi'an JiaoTong University, Xi'an, Shaanxi Province, China.
| | - Peng Pang
- Department of Anaesthesiology, Binzhou Medical College Affiliated Hospital, Binzhou, Shandong Province, China
| | - Xiaobing Liu
- Department of Anaesthesiology, HongHui Hospital, Xi'an JiaoTong University, Xi'an, Shaanxi Province, China
| | - Wen Chi
- Department of Operating room, HongHui Hospital, Xi'an JiaoTong University, Xi'an, Shaanxi Province, China
| | - Zhenguo Luo
- Department of Anaesthesiology, HongHui Hospital, Xi'an JiaoTong University, Xi'an, Shaanxi Province, China
| | - Wenbo Cai
- Department of Anaesthesiology, HongHui Hospital, Xi'an JiaoTong University, Xi'an, Shaanxi Province, China
| | - Li Zhang
- Department of Anaesthesiology, HongHui Hospital, Xi'an JiaoTong University, Xi'an, Shaanxi Province, China
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Low WX, Friend H, Dulleston J, Heppenstall S, Spacey K, Liew I. Outcomes of perioperative intravenous iron infusion in femoral fracture surgery: A systematic review and meta-analysis of randomised controlled trials. Surgeon 2024; 22:e171-e180. [PMID: 39009491 DOI: 10.1016/j.surge.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 07/04/2024] [Accepted: 07/10/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Patient blood management recommends the use of intravenous (IV) iron infusion to reduce inappropriate blood transfusion perioperatively for anaemic surgical patients. However, evidence regarding its use in urgent femoral fracture surgery is limited. This systematic review aims to collate the current evidence regarding the utilisation of IV iron in femoral fracture surgery. METHOD MEDLINE, Embase, Cochrane CENTRAL, Clinicaltrials.gov, and the WHO ICTRP databases were systematically searched for randomised controlled trials (RCT) comparing the outcomes of perioperative IV iron infusion with placebo in adults requiring surgical management for femoral fractures. Risk ratios (RR) were calculated using the Mantel-Haenszel method for dichotomous outcomes, and mean differences (MD) were calculated with the inverse-variance method for continuous outcomes. RESULTS Six RCTs with 1292 patients were included. No statistically significant difference was found in the proportion of patients receiving red blood cell (RBC) transfusion (RR = 0.87, 95%CI: 0.75; 1.01, p = 0.058) between groups. Statistically significant difference in postoperative haemoglobin concentration was found between groups measured between day 4-7 of admission (MD = 1.93 g/L, 95%CI: 0.48; 3.39, p = 0.024), but not clinically significant. No statistically significant differences were found between groups in mortality rate, length of hospital stay, infection rate, or return to home rate. CONCLUSION Current evidence indicates that IV iron infusion alone does not provide any clinically significant benefit in femoral fracture surgery. Further high-quality RCTs are needed to explore its synergistic potential when used in combination with other perioperative optimisation methods, including tranexamic acid, erythropoietin and cell salvage.
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Affiliation(s)
- Wen Xian Low
- Queen Mary University of London, Garrod Building, Turner St, London, E1 2AD, UK.
| | - Hetta Friend
- Clinical School of Medicine, University of Cambridge, Hill's Rd, Cambridge, CB2 0SP, UK
| | - Joseph Dulleston
- Clinical School of Medicine, University of Cambridge, Hill's Rd, Cambridge, CB2 0SP, UK
| | | | - Kate Spacey
- Norfolk and Norwich University Hospital, Colney Ln, Norwich, NR4 7UY, UK
| | - Ignatius Liew
- Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
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Ganta A, Linker JA, Pettit CJ, Esper GW, Egol KA, Konda SR. Chronic Preinjury Anemia Is Associated With Increased Risk of 1-Year Mortality in Geriatric Hip Fracture Patients. J Am Acad Orthop Surg 2024:00124635-990000000-01107. [PMID: 39348558 DOI: 10.5435/jaaos-d-24-00658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 08/17/2024] [Indexed: 10/02/2024] Open
Abstract
INTRODUCTION To assess whether a diagnosis of preexisting anemia impacts outcomes of geriatric hip fractures. METHODS This is a retrospective comparative study conducted at a single, urban hospital system consisting of an orthopaedic specialty hospital, two level 1 trauma centers, and one university-based tertiary care hospital. Data of patients aged 55 years or older with a femoral neck, intertrochanteric, or subtrochanteric hip fracture (AO/OA 31A, 31B, and 32A-C) at a single hospital center treated from October 2014 to October 2023 were retrieved from an institutional review board-approved database. Patients were included if they had a hemoglobin measurement recorded between 6 and 12 months before hospitalization for their hip fracture. Patients were cohorted based on whether their hemoglobin values recorded anemic or not. Comparative analysis was conducted to analyze 1-year mortality, 30-day mortality, 30-day readmission, 90-day readmission, and inpatient major complications. RESULTS Four hundred ninety-eight patients had hemoglobin values recorded at 6 to 12 months before their surgery in the electronic medical record. Two hundred seventy-three patients (54.8%) were considered anemic at that time, whereas 225 patients (45.2%) were not. Cohorts were markedly different regarding sex, Charlson Comorbidity Index, preinjury ambulatory status, and Score for Trauma Triage in Geriatric and Middle-Aged Patients (STTGMA) score (P < 0.05 for all). Multivariable analysis revealed that chronic preinjury anemia patients had a higher likelihood of 1-year mortality and a higher risk of major inpatient complication and 30- and 90-day readmission (P < 0.05 for all). CONCLUSION Chronic preinjury anemia within 6 to 12 months before a hip fracture is associated with an increased risk of 1-year mortality, inpatient major complications, and 30- and 90-day readmission after hip fracture fixation. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Abhishek Ganta
- From the Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY (Ganta, Linker, Pettit, Esper, Egol, and Konda), and the Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY (Ganta and Konda)
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O'Loughlin E, Chih H, Sivalingam P, Symons J, Godsall G, MacLean B, Richards T. IRON NOF trial: IV iron for anaemic patients with femoral fracture. BJA OPEN 2023; 7:100222. [PMID: 37638076 PMCID: PMC10457485 DOI: 10.1016/j.bjao.2023.100222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/28/2023] [Accepted: 07/21/2023] [Indexed: 08/29/2023]
Abstract
Background Preoperative anaemia is associated with increased use of blood transfusions, a greater risk of postoperative complications, and patient morbidity. The IRON NOF trial aimed to investigate whether the administration of i.v. iron in anaemic patients during hip fracture surgery reduced the need for blood transfusion and improved patient outcomes. Methods This phase III double-blind, randomised, placebo-controlled trial included patients >60 yr old with preoperative anaemia undergoing surgery for femoral neck or subtrochanteric fracture across seven Australian Hospitals. Patients were randomly allocated on a 1:1 basis to receive either i.v. iron carboxymaltose 1000 mg or placebo (saline) at operation. The primary endpoint was blood transfusion use, with secondary endpoints of haemoglobin concentration at 6 weeks, length of hospital stay, rehabilitation duration to discharge, and 6-month mortality. Subgroup analysis compared outcomes in patients <80 yr old and patients >80 yr old. All analyses were performed by intention-to-treat. This trial was terminated early because of jurisdictional changes of more restrictive transfusion practices and changes in consent requirements. Results Participants (n=143) were recruited between February 2013 and May 2017. There was no difference observed in the incidence of blood transfusion between the treatment group (18/70) (26%) compared with the placebo group (27/73) (37%) (odds ratio for transfusion if receiving placebo: 1.70; 95% confidence interval [CI] 0.83-3.47; P=0.15) and there was no overall difference in the median number of blood units transfused between groups (odds ratio 1.52; 95% CI 0.77-3.00; P=0.22). Patients receiving i.v. iron had a higher haemoglobin 6 weeks after intervention compared with the placebo group (Hb 116 g L-1vs 108 g L-1; P=0.01). No difference was observed in length of hospital stay, rehabilitation duration to discharge, or 6-month mortality. However, in younger patients without major bleeding, the use of placebo compared with i.v. iron was associated with an increased number of units of blood transfused (placebo transfusion incidence rate ratio 3.88; 95% CI 1.16-13.0; P=0.03). Conclusions In anaemic patients undergoing surgery for hip fracture, i.v. iron did not reduce the overall proportion of patients receiving blood transfusion. The use of i.v. iron may reduce the amount of blood transfused in younger patients. The use of i.v. iron is associated with increased haemoglobin concentrations 6 weeks after the operation. Clinical trial registration ACTRN12612000448842.
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Affiliation(s)
- Edmond O'Loughlin
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley and Fremantle Hospital Group, Perth, Western Australia, Australia
| | - HuiJun Chih
- School of Population Health, Faculty of Health Sciences, Curtin University, Bentley, Perth, Western Australia, Australia
| | - Pal Sivalingam
- Department of Anaesthetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Joel Symons
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Guy Godsall
- Department of Anaesthesia, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Beth MacLean
- Division of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - Toby Richards
- Division of Surgery, The University of Western Australia, Perth, Western Australia, Australia
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Lewis SR, Pritchard MW, Estcourt LJ, Stanworth SJ, Griffin XL. Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD013737. [PMID: 37294864 PMCID: PMC10249061 DOI: 10.1002/14651858.cd013737.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Following hip fracture, people sustain an acute blood loss caused by the injury and subsequent surgery. Because the majority of hip fractures occur in older adults, blood loss may be compounded by pre-existing anaemia. Allogenic blood transfusions (ABT) may be given before, during, and after surgery to correct chronic anaemia or acute blood loss. However, there is uncertainty about the benefit-risk ratio for ABT. This is a potentially scarce resource, with availability of blood products sometimes uncertain. Other strategies from Patient Blood Management may prevent or minimise blood loss and avoid administration of ABT. OBJECTIVES To summarise the evidence from Cochrane Reviews and other systematic reviews of randomised or quasi-randomised trials evaluating the effects of pharmacological and non-pharmacological interventions, administered perioperatively, on reducing blood loss, anaemia, and the need for ABT in adults undergoing hip fracture surgery. METHODS In January 2022, we searched the Cochrane Library, MEDLINE, Embase, and five other databases for systematic reviews of randomised controlled trials (RCTs) of interventions given to prevent or minimise blood loss, treat the effects of anaemia, and reduce the need for ABT, in adults undergoing hip fracture surgery. We searched for pharmacological interventions (fibrinogen, factor VIIa and factor XIII, desmopressin, antifibrinolytics, fibrin and non-fibrin sealants and glue, agents to reverse the effects of anticoagulants, erythropoiesis agents, iron, vitamin B12, and folate replacement therapy) and non-pharmacological interventions (surgical approaches to reduce or manage blood loss, intraoperative cell salvage and autologous blood transfusion, temperature management, and oxygen therapy). We used Cochrane methodology, and assessed the methodological quality of included reviews using AMSTAR 2. We assessed the degree of overlap of RCTs between reviews. Because overlap was very high, we used a hierarchical approach to select reviews from which to report data; we compared the findings of selected reviews with findings from the other reviews. Outcomes were: number of people requiring ABT, volume of transfused blood (measured as units of packed red blood cells (PRC)), postoperative delirium, adverse events, activities of daily living (ADL), health-related quality of life (HRQoL), and mortality. MAIN RESULTS We found 26 systematic reviews including 36 RCTs (3923 participants), which only evaluated tranexamic acid and iron. We found no reviews of other pharmacological interventions or any non-pharmacological interventions. Tranexamic acid (17 reviews, 29 eligible RCTs) We selected reviews with the most recent search date, and which included data for the most outcomes. The methodological quality of these reviews was low. However, the findings were largely consistent across reviews. One review included 24 RCTs, with participants who had internal fixation or arthroplasty for different types of hip fracture. Tranexamic acid was given intravenously or topically during the perioperative period. In this review, based on a control group risk of 451 people per 1000, 194 fewer people per 1000 probably require ABT after receiving tranexamic acid (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.46 to 0.68; 21 studies, 2148 participants; moderate-certainty evidence). We downgraded the certainty for possible publication bias. Review authors found that there was probably little or no difference in the risks of adverse events, reported as deep vein thrombosis (RR 1.16, 95% CI 0.74 to 1.81; 22 studies), pulmonary embolism (RR 1.01, 95% CI 0.36 to 2.86; 9 studies), myocardial infarction (RR 1.00, 95% CI 0.23 to 4.33; 8 studies), cerebrovascular accident (RR 1.45, 95% CI 0.56 to 3.70; 8 studies), or death (RR 1.01, 95% CI 0.70 to 1.46; 10 studies). We judged evidence from these outcomes to be moderate certainty, downgraded for imprecision. Another review, with a similarly broad inclusion criteria, included 10 studies, and found that tranexamic acid probably reduces the volume of transfused PRC (0.53 fewer units, 95% CI 0.27 to 0.80; 7 studies, 813 participants; moderate-certainty evidence). We downgraded the certainty because of unexplained high levels of statistical heterogeneity. No reviews reported outcomes of postoperative delirium, ADL, or HRQoL. Iron (9 reviews, 7 eligible RCTs) Whilst all reviews included studies in hip fracture populations, most also included other surgical populations. The most current, direct evidence was reported in two RCTs, with 403 participants with hip fracture; iron was given intravenously, starting preoperatively. This review did not include evidence for iron with erythropoietin. The methodological quality of this review was low. In this review, there was low-certainty evidence from two studies (403 participants) that there may be little or no difference according to whether intravenous iron was given in: the number of people who required ABT (RR 0.90, 95% CI 0.73 to 1.11), the volume of transfused blood (MD -0.07 units of PRC, 95% CI -0.31 to 0.17), infection (RR 0.99, 95% CI 0.55 to 1.80), or mortality within 30 days (RR 1.06, 95% CI 0.53 to 2.13). There may be little or no difference in delirium (25 events in the iron group compared to 26 events in control group; 1 study, 303 participants; low-certainty evidence). We are very unsure whether there was any difference in HRQoL, since it was reported without an effect estimate. The findings were largely consistent across reviews. We downgraded the evidence for imprecision, because studies included few participants, and the wide CIs indicated possible benefit and harm. No reviews reported outcomes of cognitive dysfunction, ADL, or HRQoL. AUTHORS' CONCLUSIONS Tranexamic acid probably reduces the need for ABT in adults undergoing hip fracture surgery, and there is probably little or no difference in adverse events. For iron, there may be little or no difference in overall clinical effects, but this finding is limited by evidence from only a few small studies. Reviews of these treatments did not adequately include patient-reported outcome measures (PROMS), and evidence for their effectiveness remains incomplete. We were unable to effectively explore the impact of timing and route of administration between reviews. A lack of systematic reviews for other types of pharmacological or any non-pharmacological interventions to reduce the need for ABT indicates a need for further evidence syntheses to explore this. Methodologically sound evidence syntheses should include PROMS within four months of surgery.
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Affiliation(s)
- Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael W Pritchard
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Simon J Stanworth
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Trauma & Orthopaedics Surgery Group, Blizard Institute, Queen Mary University of London, London, UK
- The Royal London Hospital Barts Health NHS Trust, London, UK
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Jiang Y, Lin X, Wang Y, Li J, Wang G, Meng Y, Li M, Li Y, Luo Y, Gao Z, Yin P, Zhang L, Lyu H, Tang P. Preoperative Anemia and Risk of In-hospital Postoperative Complications in Patients with Hip Fracture. Clin Interv Aging 2023; 18:639-653. [PMID: 37096216 PMCID: PMC10122467 DOI: 10.2147/cia.s404211] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/07/2023] [Indexed: 04/26/2023] Open
Abstract
Purpose To evaluate the impact of preoperative anemia on postoperative complications after hip fracture surgery. Patients and Methods We conducted a retrospective study including hip fracture patients at a teaching hospital between 2005 and 2022. We defined preoperative anemia as the last hemoglobin measurement level before surgery < 130 g/L for men and < 120 g/L for women. The primary outcome was a composite of in-hospital major complications, including pneumonia, respiratory failure, gastrointestinal bleeding, urinary tract infection, incision infection, deep venous thrombosis, pulmonary embolism, angina pectoris, arrhythmia, myocardial infarction, heart failure, stroke, and death. Secondary outcomes were cardiovascular events, infection, pneumonia, and death. We used multivariate negative binomial or logistic regression to evaluate the impact of anemia and its severity, categorized as mild (90-130 g/L for men, 90-120 g/L for women) or moderate-to-severe (< 90 g/L for both) anemia on outcomes. Results Of the 3540 included patients, 1960 had preoperative anemia. 188 anemic patients experienced 324 major complications, while 63 non-anemic patients had 94 major complications. The risk of major complications was 165.3 (95% CI, 149.5-182.4) and 59.5 (95% CI, 48.9-72.3) per 1000 persons in anemic and non-anemic patients, respectively. Anemic patients were more likely to have major complications than non-anemic patients (adjusted incidence rate ratio (aIRR), 1.87; 95% CI, 1.30-2.72), which was consistent in mild (aIRR, 1.77; 95% CI, 1.22-2.59) and moderate-to-severe (aIRR, 2.97; 95% CI, 1.65-5.38) anemia. Preoperative anemia also increased the risk of cardiovascular events (aIRR, 1.96; 95% CI, 1.29-3.01), infection (aIRR, 1.68; 95% CI, 1.01-2.86), pneumonia (adjusted odds ratio (aOR), 1.91; 95% CI, 1.06-3.57), and death (aOR, 3.17; 95% CI, 1.06-11.89). Conclusion Our findings suggest that even mild preoperative anemia is associated with major postoperative complications in hip fracture patients. This finding highlights considering preoperative anemia as a risk factor in surgical decision-making for high-risk patients.
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Affiliation(s)
- Yu Jiang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Xisheng Lin
- Department of Rehabilitation, the Second Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Yilin Wang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Jia Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Guoqi Wang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People’s Republic of China
| | - Yutong Meng
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ming Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Yi Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Yan Luo
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Zefu Gao
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Pengbin Yin
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Licheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
| | - Houchen Lyu
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
- Correspondence: Houchen Lyu; Peifu Tang, Department of Orthopedics, Chinese PLA General Hospital, No. 28, Fuxing Road, Beijing, 100853, People’s Republic of China, Tel +86-13501149301, Email ;
| | - Peifu Tang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, People’s Republic of China
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10
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Cao MM, Chi JY, Zhang YW, Sheng RW, Gao W, Zhao YK, Rui YF. The Efficacy and Safety of Intravenous Iron in Geriatric Hip Fracture Surgeries: A Systematic Review and Meta-Analysis. World J Surg 2022; 46:2595-2606. [PMID: 35947180 DOI: 10.1007/s00268-022-06690-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND With the increasing evidence provided by recent high-quality studies, the intravenous iron appears to be a reliable therapy for blood administration in geriatric patients with hip fractures. Here, this systematic review and meta-analysis were aimed to assess the effectiveness and safety of intravenous iron in geriatric patients sustaining hip fractures. METHODS Potential pertinent literatures evaluating the effects of intravenous iron in the geriatric patients undergoing hip fractures were identified from Web of Science, PubMed, Embase, and Scopus. We performed a pairwise meta-analysis using fixed- and random-effects models, and the pooling of data was carried out by using RevMan 5.1. RESULTS Four randomized controlled trials and four observational studies conform to inclusion criteria. The results of meta-analysis showed that intravenous iron reduced transfusion rates compared to the control group, yet the result did not reach statistical significance. The intravenous iron was related to lower transfusion volumes, shorter length of stay, and a reduced risk of nosocomial infections. And there was no significant difference in terms of the mortality and other complications between the treatment group and the control group. CONCLUSION Current evidence suggests that intravenous iron reduces the transfusion volume, length of hospital stay, and risk of nosocomial infections. It takes about 7 days for intravenous iron to elevate hemoglobin by 1 g/dl and about 1 month for 2 g/dl. The safety profile of intravenous iron is also reassuring, and additional high-quality studies are needed.
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Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, School of Medicine, Zhongda Hospital, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Jia-Yu Chi
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, School of Medicine, Zhongda Hospital, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Ren-Wang Sheng
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Wang Gao
- Department of Orthopaedics, School of Medicine, Zhongda Hospital, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Ya-Kuan Zhao
- Department of Orthopaedics, School of Medicine, Zhongda Hospital, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Yun-Feng Rui
- Department of Orthopaedics, School of Medicine, Zhongda Hospital, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China.
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China.
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China.
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11
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Shah AA, Donovan K, Seeley C, Dickson EA, Palmer AJR, Doree C, Brunskill S, Reid J, Acheson AG, Sugavanam A, Litton E, Stanworth SJ. Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2133935. [PMID: 34767026 PMCID: PMC8590171 DOI: 10.1001/jamanetworkopen.2021.33935] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/13/2021] [Indexed: 12/22/2022] Open
Abstract
Importance Intravenous iron is recommended by many clinical guidelines based largely on its effectiveness in reducing anemia. However, the association with important safety outcomes, such as infection, remains uncertain. Objective To examine the risk of infection associated with intravenous iron compared with oral iron or no iron. Data Sources Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials (RCTs) from 1966 to January 31, 2021. Ongoing trials were sought from ClinicalTrials.gov, CENTRAL, and the World Health Organization International Clinical Trials Search Registry Platform. Study Selection Pairs of reviewers identified RCTs that compared intravenous iron with oral iron or no iron across all patient populations, excluding healthy volunteers. Nonrandomized studies published since January 1, 2007, were also included. A total of 312 full-text articles were assessed for eligibility. Data Extraction and Synthesis Data extraction and risk of bias assessments were performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) and Cochrane recommendations, and the quality of evidence was assessed using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. Two reviewers extracted data independently. A random-effects model was used to synthesize data from RCTs. A narrative synthesis was performed to characterize the reporting of infection. Main Outcomes and Measures The primary outcome was risk of infection. Secondary outcomes included mortality, hospital length of stay, and changes in hemoglobin and red blood cell transfusion requirements. Measures of association were reported as risk ratios (RRs) or mean differences. Results A total of 154 RCTs (32 920 participants) were included in the main analysis. Intravenous iron was associated with an increased risk of infection when compared with oral iron or no iron (RR, 1.17; 95% CI, 1.04-1.31; I2 = 37%; moderate certainty of evidence). Intravenous iron also was associated with an increase in hemoglobin (mean difference, 0.57 g/dL; 95% CI, 0.50-0.64 g/dL; I2 = 94%) and a reduction in the risk of requiring a red blood cell transfusion (RR, 0.93; 95% CI, 0.76-0.89; I2 = 15%) when compared with oral iron or no iron. There was no evidence of an effect on mortality or hospital length of stay. Conclusions and Relevance In this large systematic review and meta-analysis, intravenous iron was associated with an increased risk of infection. Well-designed studies, using standardized definitions of infection, are required to understand the balance between this risk and the potential benefits.
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Affiliation(s)
- Akshay A. Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Killian Donovan
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Claire Seeley
- Department of Anaesthesia, Royal Berkshire Hospitals NHS Foundation Trust, Reading, United Kingdom
| | - Edward A. Dickson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Antony J. R. Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Jack Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Austin G. Acheson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Anita Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Lasocki S, Loupec T, Parot-Schinkel E, Vielle B, Danguy des Déserts M, Roquilly A, Lahlou-Casulli M, Collange V, Desebbe O, Duchalais A, Drugeon B, Bouzat P, Garrigue D, Mounet B, Hamard F, David JS, Leger M, Rineau E. Study protocol for a multicentre, 2×2 factorial, randomised, controlled trial evaluating the interest of intravenous iron and tranexamic acid to reduce blood transfusion in hip fracture patients (the HiFIT study). BMJ Open 2021; 11:e040273. [PMID: 33455926 PMCID: PMC7813351 DOI: 10.1136/bmjopen-2020-040273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Blood transfusion and anaemia are frequent and are associated with poor outcomes in patients with hip fracture (HF). We hypothesised that preoperative intravenous iron and tranexamic acid (TXA) may reduce the transfusion rate in these patients. METHODS AND ANALYSIS The HiFIT study is a multicentre, 2×2 factorial, randomised, double-blinded, controlled trial evaluating the effect of iron isomaltoside (IIM) (20 mg/kg) vs placebo and of TXA (intravenously at inclusion and topically during surgery) versus placebo on transfusion rate during hospitalisation, in patients undergoing emergency surgery for HF and having a preoperative haemoglobin between 95 and 130 g/L. 780 patients are expected. The primary endpoint is the proportion of patients receiving an allogenic blood transfusion of packed red blood cells from the day of surgery until hospital discharge (or until D30 if patient is still hospitalised). Enrolment started on March 2017 in 11 French hospitals. The study was stopped between July 2017 and August 2018 (because of investigation of serious AEs with IIM in Spain) and slowed down since March 2020 (COVID-19 crisis). The expected date of final follow-up is May 2022. Analyses of the intent-to-treat and per-protocol populations are planned. ETHICS AND DISSEMINATION The HiFIT trial protocol has been approved by the Ethics Committee of Comité de Protection des Personnes Ouest II and the French authorities (ANSM). It will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. The HiFIT trial will be the largest study evaluating iron and TXA in patients with HF. TRIAL REGISTRATION NUMBER clinicalTrials.gov identifier: NCT02972294; EudraCT Number 2016-003087-40.
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Affiliation(s)
- Sigismond Lasocki
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Thibault Loupec
- Service d'anesthésie réanimation A, Université de Montpellier, CHU de Montpellier, Montpellier, France
| | - Elsa Parot-Schinkel
- Département de Biostatistiques et Méthodologie, Centre Hospitalier Universitaire d'Angers, Angers, Pays de la Loire, France
| | - Bruno Vielle
- Département de Biostatistiques et Méthodologie, Centre Hospitalier Universitaire d'Angers, Angers, Pays de la Loire, France
| | | | | | | | - Vincent Collange
- Département Anesthésie Réanimation, Medipole Lyon-Villeurbanne, Villeurbanne, France
| | | | - Alexis Duchalais
- Service d'anesthésie reanimation, CHD Vendée, La Roche-sur-Yon, France
| | - Bertrand Drugeon
- Emergency Department and Prehospital Care, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Universite de Poitiers UFR Medecine et Pharmacie, Poitiers, France
| | - Pierre Bouzat
- Département d'Anesthésie Réanimation, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Delphine Garrigue
- Pôle d'Anesthésie Réanimation, Pôle de l'Urgence, CHRU, Lille, Hauts-de-France, France
| | - Benjamin Mounet
- Service d'anesthésie réanimation A, Université de Montpellier, CHU de Montpellier, Montpellier, France
| | - Franck Hamard
- Service d'Anesthésie Réanimation, Clinique de l'Anjou, Angers, France
| | | | - Maxime Leger
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Emmanuel Rineau
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
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