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

Hemodynamic, ventilatory and gas exchange responses to exercise using a cycle ergometer and the incremental shuttle walk test in pregnant women

BACKGROUND

Cardiovascular disease, including hypertension, in pregnant women is a leading cause of morbidity and mortality globally. The development of reference intervals for cardiovascular responses using exercising testing to measure oxygen utilisation (V̇O2) with cardiopulmonary exercise testing (CPET), and distances walked using the incremental shuttle walk test (ISWT), may be promising methods to assess and stratify pregnant women regarding their risk of adverse pregnancy outcomes, to encourage exercise during pregnancy, and to improve exercise prescriptions during pregnancy. We aimed to determine the reference intervals for V̇O2 at rest, anaerobic threshold (AT), and submaximal exercise using CPET, and the reference interval for the ISWT, to develop a correlation equitation that predicts submaximal V̇O2 from the distance walked in the ISWT, and to explore the relationship between hemoglobin (Hb) and ferritin concentration and V̇O2 at AT in women in second trimester.

METHODS

After prospective IRB approval (HREC 15/23) and clinical trials registration (ANZCTR ACTRN12615000964516), and informed written consent, we conducted CPET and the ISWT according to international guidelines in a university associated tertiary referral obstetric and adult medicine hospital, in healthy pregnant women in second trimester (14 to 27 gestational weeks). Hemoglobin and ferritin concentrations were recorded from pathology results in the participants' medical records at the time of exercise testing. Adverse events were recorded.

RESULTS

About 90 participants undertook CPET, 28 of which also completed the ISWT. The mean ± SD age and body mass index (BMI) were 32 ± 3.2 years, and 25 ± 2.7 kg/m2. Median (IQR) gestation was 23 (22-24) weeks. One in 4 women were 24 weeks or greater gestation. The reference intervals for V̇O2 at rest, AT, and submaximal exercise were 2.9 to 5.3, 8.1 to 20.7, and 14.1 to 30.5 mL/kg/min respectively. The reference interval for the ISWT was 218 to 1058 meters. The correlation equation to predict submaximal V̇O2 from the distance walked in the ISWT was submaximal V̇O2 (mL/kg/min) = 0.012*distance walked in ISWT (m) + 14.7 (95%CI slope 0.005-0.070, Pearson r = 0.5426 95%CI 0.2126-0.7615, P = .0029). Hemoglobin concentration was positively correlated with V̇O2 at AT (AT V̇O2 (mL/kg/min) = 0.08*Hb (g/L) + 4.9 (95%CI slope 0.0791-0.143, Pearson r = 0.2538 95%CI 0.049-0.438, P = .016). There was no linear association between ferritin and submaximal V̇O2 (Pearson r = 0.431 P = .697). There were no maternal or fetal complications.

CONCLUSIONS

CPET and ISWT are safe and feasible in women in second trimester including those at or beyond 24 weeks gestation. We have established the reference interval for V̇O2 at rest, AT, and submaximal exercise by CPET, the reference interval for the distance walked for the ISWT, and a correlation equation to predict submaximal V̇O2 for use in clinical practice and research. Hemoglobin rather than ferritin is likely correlated with exercise capacity in pregnancy suggesting vigilance to correct lower hemoglobin levels may positively impact maternal health.

CLINICAL TRIALS REGISTRY

The study was prospectively registered with the Australian and New Zealand Clinical Date of registration - 15/9/2015; Date of initial participant enrolment - 4/11/2015; Clinical trial identification number; ACTRN12615000964516; URL of the registration site - https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369216.

The incidence and factors associated with anemia in elective surgical patients admitted to a surgical intensive care unit: a retrospective cohort study

BACKGROUND

Anemia is a frequently reported and commonly documented issue in intensive care units. In surgical intensive care units, more than 90% of patients are found to be anemic. It is a hematologic factor that contributes to extended mechanical ventilation, sepsis, organ failure, longer hospitalizations in critical care units, and higher mortality. Thus, this study aimed to determine the incidence and identify factors associated with anemia in elective surgical patients admitted to the surgical intensive care unit.

METHODS

A retrospective follow-up study involving 422 hospitalized patients was carried out between December 2019 and December 2022 in the surgical intensive care unit after elective surgery at Tikur-Anbessa Specialized Hospital, Addis Ababa, Ethiopia. Data were gathered from the patients' charts, and study participants were chosen using methods of systematic random sampling. SPSS 26 (the statistical software for social science, version 26) was used to analyze the data. Bivariable and multivariable binary logistic regression were used to examine associations between variables.

RESULTS

The incidence of anemia in elective surgical patients admitted to the intensive care unit was 69.9% (95% CI 65.4-74.5%). American Society of Anesthesiologists' class III (ASA III) [AOR: 8.53, 95% CI 1.92-13.8], renal failure [AOR:2.53, 95% CI (1.91-5.81)], malignancy [AOR: 2.59, 95% CI (1.31-5.09)], thoracic surgery [AOR: 4.07, 95% CI (2.11-7.87)], urologic surgery [AOR: 6.22, 95% CI (2.80-13.80)], and neurosurgery [AOR: 4.51, 95% CI (2.53-8.03)] were significantly associated with anemia in surgical patients admitted to the intensive care unit.

CONCLUSION

More than two-thirds of the intensive care unit-admitted surgical patients experienced anemia. An American Society of Anesthesiologists' (ASA III score), renal failure, malignancy, thoracic surgery, urologic surgery, and neurosurgery were significantly associated with this condition. Early identification helps to institute preventive and therapeutic measures.

Over the Past Decade, Preoperative Anemia Has Become a Greater Predictor of Transfusions After Total Knee Arthroplasty

BACKGROUND

With advancements in perioperative blood management and the use of tranexamic acid, the rate of transfusions after total knee arthroplasty (TKA) has substantially decreased. As these principles are refined, other modifiable risk factors, such as preoperative anemia, may play an increasingly important role in transfusion risk for patients undergoing TKA.

METHODS

A multicenter, national database was utilized to identify patients undergoing TKA from 2010 to 2021. Anemia was defined by World Health Organization definitions as < 12 g/dL for women and < 13 g/dL for men. A predictive model was created using backwards elimination logistic regression to predict transfusion risk, controlling for demographic and medical covariates. The coefficient of anemia was then analyzed for each year. The trend over time was fitted with a best-fit linear regression equation.

RESULTS

There were 509,117 patients who underwent TKA, and had a mean age of 67 years (range, 18 to 89). There were 57,716 (11%) patients who were anemic preoperatively, and 15,426 (3%) of patients required a transfusion. Rate of transfusion decreased from 10.6% in 2010 to 0.6% in 2021. The odds ratio associated with anemia as a predictor of transfusion increased from 3.1 (95% confidence interval: 2.1 to 4.6) in 2010 to 14.0 (95% confidence interval: 8.9 to 24) in 2021.

CONCLUSIONS

The results of this study demonstrate that the importance of preoperative anemia as a predictor of transfusion has increased over the past decade as rates of transfusion have decreased. As perioperative blood management protocols improve, preoperative anemia should be considered an important focus of intervention to reduce the risk of transfusion prior to TKA.

LEVEL OF EVIDENCE

III.

Management of peri-surgical anemia in elective surgery. Conclusions and recommendations according to Delphi-UCLA methodology

INTRODUCTION

Preoperative anemia affects approximately one third of surgical patients. It increases the risk of blood transfusion and influences short- and medium-term functional outcomes, increases comorbidities, complications and costs. The "Patient Blood Management" (PBM) programs, for integrated and multidisciplinary management of patients, are considered as paradigms of quality care and have as one of the fundamental objectives to correct perioperative anemia. PBM has been incorporated into the schemes for intensified recovery of surgical patients: the recent Enhanced Recovery After Surgery 2021 pathway (in Spanish RICA 2021) includes almost 30 indirect recommendations for PBM.

OBJECTIVE

To make a consensus document with RAND/UCLA Delphi methodology to increase the penetration and priority of the RICA 2021 recommendations on PBM in daily clinical practice.

MATERIAL AND METHODS

A coordinating group composed of 6 specialists from Hematology-Hemotherapy, Anesthesiology and Internal Medicine with expertise in anemia and PBM was formed. A survey was elaborated using Delphi RAND/UCLA methodology to reach a consensus on the key areas and priority professional actions to be developed at the present time to improve the management of perioperative anemia. The survey questions were extracted from the PBM recommendations contained in the RICA 2021 pathway. The development of the electronic survey (Google Platform) and the management of the responses was the responsibility of an expert in quality of care and clinical safety. Participants were selected by invitation from speakers at AWGE-GIEMSA scientific meetings and national representatives of PBM-related working groups (Seville Document, SEDAR HTF section and RICA 2021 pathway participants). In the first round of the survey, the anonymized online questionnaire had 28 questions: 20 of them were about PBM concepts included in ERAS guidelines (2 about general PBM organization, 10 on diagnosis and treatment of preoperative anemia, 3 on management of postoperative anemia, 5 on transfusion criteria) and 8 on pending aspects of research. Responses were organized according to a 10-point Likter scale (0: strongly disagree to 10: strongly agree). Any additional contributions that the participants considered appropriate were allowed. They were considered consensual because all the questions obtained an average score of more than 9 points, except one (question 14). The second round of the survey consisted of 37 questions, resulting from the reformulation of the questions of the first round and the incorporation of the participants' comments. It consisted of 2 questions about general organization of PBM programme, 15 questions on the diagnosis and treatment of preoperative anemia; 3 on the management of postoperative anemia, 6 on transfusional criteria and finally 11 questions on aspects pending od future investigations. Statistical treatment: tabulation of mean, median and interquartiles 25-75 of the value of each survey question (Tables 1, 2 and 3).

RESULTS

Except for one, all the recommendations were accepted. Except for three, all above 8, and most with an average score of 9 or higher. They are grouped into: 1.- "It is important and necessary to detect and etiologically diagnose any preoperative anemia state in ALL patients who are candidates for surgical procedures with potential bleeding risk, including pregnant patients". 2.- "The preoperative treatment of anemia should be initiated sufficiently in advance and with all the necessary hematinic contributions to correct this condition". 3.- "There is NO justification for transfusing any unit of packed red blood cells preoperatively in stable patients with moderate anemia Hb 8-10g/dL who are candidates for potentially bleeding surgery that cannot be delayed." 4.- "It is recommended to universalize restrictive criteria for red blood cell transfusion in surgical and obstetric patients." 5.- "Postoperative anemia should be treated to improve postoperative results and accelerate postoperative recovery in the short and medium term".

CONCLUSIONS

There was a large consensus, with maximum acceptance,strong level of evidence and high recommendation in most of the questions asked. Our work helps to identify initiatives and performances who can be suitables for the implementation of PBM programs at each hospital and for all patients.

Executive summary of the consensus document on the management of perioperative anemia in Spain

Perioperative anemia is an independent risk factor for postoperative morbidity and mortality. However, conceptual, logistical and administrative barriers persist that hinder the widespread implementation of protocols for their management. The project coordinator convened a multidisciplinary group of 8 experienced professionals to develop perioperative anemia management algorithms, based on a series of key points (KPs) related to its prevalence, consequences, diagnosis and treatment. These KPs were assessed using a 5-point Likert scale, from "strongly disagree [1]" to "strongly agree [5]". For each KP, consensus was reached when receiving a score of 4 or 5 from at least 7 participants (>75%). Based on the 36 KPs agreed upon, diagnostic-therapeutic algorithms were developed that we believe can facilitate the implementation of programs for early identification and adequate management of perioperative anemia, adapted to the characteristics of the different institutions in our country.

Incidence, risk factors and impact of anemia after elective neurosurgery: A retrospective cohort study

Objectives

Anemia after surgery is common and is associated with adverse clinical outcomes. Understanding the incidence and risk factors for postoperative anemia is important to reduce anemia-related complications and blood transfusion. There is lack of data regarding postoperative anemia and its contributing factors in neurosurgery. This study evaluates the incidence and risk factors of postoperative anemia, and its impact on clinical outcomes.

Methods

This was a single centre, retrospective study of patients who underwent elective neurosurgery over seven months. Data regarding age, gender, body mass index, American Society of Anesthesiologists (ASA) physical status, diagnosis, surgery, preoperative hemoglobin, surgery duration, intraoperative blood loss and red blood cell (RBC) transfusion, dose of tranexamic acid, intraoperative fluid balance, years of surgeon's experience, postoperative hemoglobin, postoperative RBC transfusion, Glasgow Coma Scale (GCS) score at hospital discharge, and duration of postoperative intensive care unit and hospital stay were collected. Logistic regression was used to identify predictors of postoperative anemia.

Results

The incidence of postoperative anemia was 11.3% (116/1025). On univariate analysis; age, preoperative hemoglobin, surgery duration, gender, ASA grade, surgery type, and surgeon's experience were associated with postoperative anemia. Lower preoperative hemoglobin (p<0.001) and non-tumor surgery (p<0.001) were predictive of postoperative anemia on multivariate analysis. Postoperative anemia resulted in increased RBC transfusion (p<0.001) and lower GCS score at discharge (p=0.012).

Conclusions

Atleast one in ten patients undergoing elective neurosurgery develop postoperative anemia. Lower preoperative hemoglobin and non-tumor surgery predict anemia. Anemia results in increased RBC transfusion and lower discharge GCS score.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Assessment and management of postoperative anemia

Postoperative anemia is a complex clinical issue that requires attention due to its ramifications on the patient's recovery and prognosis. Originating from multiple determinants, such as intraoperative blood loss, hemolysis, nutritional deficiencies, systemic inflammation and impact on the bone marrow, postoperative anemia has varied and often challenging presentations. Patients undergoing major surgical procedures, in particular, are susceptible to developing anemia due to the considerable associated blood loss. Accurate diagnosis plays a crucial role in the approach, requiring meticulous hematological analysis, including hemoglobin, hematocrit and reticulocyte count, as well as an in-depth investigation of the underlying causes. An additional challenge arises in the form of the excessive practice of phlebotomy during hospitalization for clinical monitoring. Although it is essential to assess the progression of anemia, frequent removal of blood may contribute to iatrogenic anemia, further delaying recovery and possibly increasing susceptibility to infection.

Postoperative anemia in cardiac surgery patients: a narrative review

PURPOSE

Anemia reduces the blood's ability to carry and deliver oxygen. Following cardiac surgery, anemia is very common and affects up to 90% of patients. Nevertheless, there is a paucity of data examining the prognostic value of postoperative anemia. In this narrative review, we present findings from the relevant literature on postoperative anemia in cardiac surgery patients, focusing on the incidence, risk factors, and prognostic value of postoperative anemia. We also explore the potential utility of postoperative anemia as a therapeutic target to improve clinical outcomes.

SOURCE

We conducted a targeted search of MEDLINE, Embase, and the Cochrane Database of Systematic Reviews up to September 2022, using a combination of search terms including postoperative (post-operative), perioperative (peri-operative), anemia (anaemia), and cardiac surgery.

PRINCIPAL FINDINGS

The reported incidence of postoperative anemia varied from 29% to 94% across the studies, likely because of variations in patient inclusion criteria and classification of postoperative anemia. Nonetheless, the weight of the evidence suggests that postoperative anemia is common and is an independent risk factor for adverse postoperative outcomes such as acute kidney injury, stroke, mortality, and functional outcomes.

CONCLUSIONS

In cardiac surgery patients, postoperative anemia is a common and prognostically important risk factor for postoperative morbidity and mortality. Nevertheless, there is a lack of data on whether active management of postoperative anemia is feasible or effective in improving patient outcomes.

Changes in Practices After Implementation of a Patient Blood Management Program in French Surgical Departments: The National Multicenter Observational PERIOPES Study

BACKGROUND

Patient blood management (PBM) is an evidence-based approach recommended to improve patient outcomes. Change in practices is often challenging. We report here data from French surgical departments before and after a standardized implementation of a PBM program.

METHODS

This was a national, multicenter, observational study in surgical centers ("expert" centers with an already established protocol for preoperative anemia or "pilot" centers). Data from consecutive surgical patients of different specialties were retrieved before and after the implementation of a PBM program. Primary outcome variables (preoperative anemia treatment rates, transfusion rates, and length of hospital stay) before and after the implementation of a PBM program were analyzed with segmented regression adjusted on confounders (American Society of Anesthesiologists [ASA] scores and centers).

RESULTS

A total of 1618 patients (ASA physical status III and IV, 38% in the first period and 45% in the second period) were included in expert (N = 454) or pilot (N = 1164) centers during the first period (January 2017-August 2022) and 1542 (N = 440 and N = 1102, respectively) during the second period (January 2020-February 2023). After implementation of the PBM program, the rate of preoperative anemia treatment increased (odds ratio, 2.37; 95% confidence interval [CI], 1.20-4.74; P = .0136) and length of hospital stay in days decreased (estimate, -0.11; 95% CI, -0.21 to -0.02; P = .0186). Transfusion rate significantly decreased only in expert centers (odds ratio, 0.17; 95% CI, 0.03-0.88; P = .0354).

CONCLUSIONS

PBM practices in various surgical specialties improved significantly after the implementation of a PBM program. However, too many patients with preoperative anemia remained untreated.

Baseline haemoglobin variability by measurement technique in pregnant people on the day of childbirth

Point-of-care haemoglobin measurement devices may play an important role in the antenatal detection of anaemia in pregnant people and may be useful in guiding blood transfusion during resuscitation in obstetric haemorrhage. We compared baseline haemoglobin variability of venous and capillary HemoCue® haemoglobin, and Masimo® Rad-67 Pulse CO-Oximeter haemoglobin with laboratory haemoglobin in people on the day of their planned vaginal birth. A total of 180 people undergoing planned vaginal birth were enrolled in this prospective observational study. Laboratory haemoglobin was compared with HemoCue and Masimo Rad-67 Pulse CO-Oximeter measurements using Bland-Altman analysis, calculating mean difference (bias) and limits of agreement. Five (2.8%) people had anaemia (haemoglobin < 110 g.l-1 ). Laboratory haemoglobin and HemoCue venous haemoglobin comparison showed an acceptable bias (SD) 0.7 (7.54) g.l-1 (95%CI -0.43-1.79), with limits of agreement -14.10-15.46 g.l-1 and acceptable agreement range of 29.6 g.l-1 . Laboratory and HemoCue capillary haemoglobin comparison showed an unacceptable bias (SD) 13.3 (14.12) g.l-1 (95%CI 11.17-15.34), with limits of agreement - 14.42-40.93 g.l-1 and unacceptable agreement range of 55.3 g.l-1 . Laboratory and Masimo haemoglobin comparison showed an unacceptable bias (SD) -14.0 (11.15) g.l-1 (95%CI -15.63 to -12.34), with limits of agreement to -35.85 to 7.87 g.l-1 and acceptable agreement range of 43.7 g.l-1 . Venous HemoCue, with its acceptable bias and limits of agreement, should be applied more widely in the antenatal setting to detect, manage and risk stratify pregnant people with anaemia. HemoCue capillary measurement under-estimated haemoglobin and Masimo haemoglobin measurement over-estimated, limiting their clinical use. Serial studies are needed to determine if the accuracy of venous HemoCue haemoglobin measurement is sustained in other obstetric settings.

Effects of ferric derisomaltose on postoperative anaemia in adult spinal deformity surgery: a study protocol for a randomised controlled trial

INTRODUCTION

Postoperative anaemia is prevalent in adult spinal deformity (ASD) surgery in association with unfavourable outcomes. Ferric derisomaltose, a novel iron supplement, offers a promising solution in rapidly treating postoperative anaemia. However, the clinical evidence of its effect on patients receiving spinal surgery remains inadequate. This randomised controlled trial aims to evaluate the safety and efficacy of ferric derisomaltose on postoperative anaemia in ASD patients.

METHODS AND ANALYSIS

This single-centre, phase 4, randomised controlled trial will be conducted at Department of Orthopaedics at Peking Union Medical College Hospital and aims to recruit adult patients who received ASD surgery with postoperative anaemia. Eligible participants will be randomly assigned to receive ferric derisomaltose infusion or oral ferrous succinate. The primary outcome is the change in haemoglobin concentrations from postoperative days 1-14. Secondary outcomes include changes in iron parameters, reticulocyte parameters, postoperative complications, allogeneic red blood cell infusion rates, length of hospital stay, functional assessment and quality-of-life evaluation.

ETHICS AND DISSEMINATION

This study has been approved by the Research Ethics Committee of Peking Union Medical College Hospital and registered at ClinicalTrials.gov. Informed consent will be obtained from all participants prior to enrolment and the study will be conducted in accordance with the principles of the Declaration of Helsinki. The results of this study are expected to be disseminated through peer-reviewed journals and academic conferences.

TRIAL REGISTRATION NUMBER

NCT05714007.

Anemia diagnosis and therapy in malignant diseases: implementation of guidelines-a representative study

PURPOSE

Anemia in cancer should be diagnosed and treated according to guideline recommendations. The implementation of ESMO and German guidelines and their effect on anemia correction was analyzed.

METHODS

This retrospective epidemiological study, representative for Germany, analyzed data on anemia management of cancer patients with anemia ≥ grade 2. The Guideline Adherence Score (GLAD) for diagnosis (GLAD-D) and therapy (GLAD-T) was defined as follows: 2 points for complete, 1 point for partial, 0 point for no adherence.

RESULTS

Data were analyzed for 1046 patients. Hb levels at diagnosis of anemia were 8-10 g/dL in 899 (85.9%) patients, 7-8 g/dL in 92 (8.7%), and < 7 g/dL (5.0%) in 52. Transferrin saturation was determined in 19% of patients. Four hundred fifty-six patients received RBC (43.6%), 198 (18.9%) iron replacement, 106 (10.1%) ESA, and 60 (5.7%) vitamin B12 replacement. 60.6% of patients receiving iron replacement were treated intravenously and 39.4% were treated orally. Two hundred eighty-eight (36.6%) of 785 patients receiving transfusions had no guideline-directed indication. GLAD-D was 2 in 310 patients (29.6%), 1 in 168 (16.1%), and 0 in 568 (54.3%). GLAD-T was 2 in 270 patients (25.8%), 1 in 320 patients (30.6%), and 0 in 456 patients (43.6%). Higher GLAD-D significantly correlated with higher GLAD-T (τB = 0.176, p < 0.001). GLAD-T 2 was significantly associated with greater Hb increase than GLAD-T 0/1 (p < 0.001) at 28 days (10.2 vs. 9.7 g/dL) and at 2 months (10.4 vs. 9.9 g/dL).

CONCLUSIONS

Anemia assessment is inadequate, transfusion rates too high, and iron and ESA therapy too infrequent.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05190263, date: 2022-01-13.

The effectiveness of fibrin sealants in head and neck surgery: a systematic review protocol

OBJECTIVE

This review will investigate the effectiveness of fibrin sealants in adult patients who underwent head and neck surgery.

INTRODUCTION

Controlling bleeding is important in head and neck surgery. Complications involving nearby vital structures increase the risk of morbidity and mortality. Surgical tissue adhesives are used in addition to other traditional hemostatic methods to reduce surgical site bleeding. Fibrin sealants have shown some success compared with other tissue adhesives, but individual studies have been inconclusive.

INCLUSION CRITERIA

We will include studies comparing fibrin sealants with placebo or usual care in patients 18 years or older who have undergone soft tissue surgery of the head and neck with drain placement. Primary outcomes include wound complications and time to surgical drain removal. Secondary outcomes include length of hospital stay, drain volume output, surgical management of postoperative hematoma, rate of blood transfusions, and adverse reactions.

METHODS

We will search electronic databases (PubMed, Embase, Cochrane Database of Controlled Trials) for studies published from 1975 onwards. Titles, abstracts, and full-text papers will be assessed against the inclusion criteria by 2 independent reviewers. Study screening and selection will be performed, and critical appraisal conducted using the standardized JBI appraisal tools. Data will be extracted by 2 independent reviewers. Meta-analysis will be conducted for all outcomes where appropriate, with weighted mean differences for continuous data. Risk ratios will be used for dichotomous data. Certainty will be reported using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

REVIEW REGISTRATION

PROSPERO CRD42023412820.

Effect of recombinant human erythropoietin combined with iron sucrose on postoperative hemoglobin in patients undergoing artificial joint replacement

With the aging of the population, an increasing number of elderly patients are opting for artificial joint replacement, leading to the exploration of various rapid rehabilitation programs in the perioperative period. In this study, we aimed to investigate the effectiveness of combining recombinant human erythropoietin and iron sucrose in altering the range and trend of postoperative hemoglobin in patients undergoing arthroplasty. Specifically, we will examine whether this combination can effectively alter the rise and fall of postoperative haemoglobin, identify the inflection point of haemoglobin change or recovery after arthroplasty, and assess the effect of treatment on serum iron in postoperative blood. We conducted a retrospective study of 138 patients who underwent unilateral total joint arthroplasty by the same surgeon in the same hospital before July 2022. The results of this study may provide valuable insights for the development of effective rehabilitation programs for patients undergoing arthroplasty.

The effect of postoperative intravenous iron in anaemic, older cardiac surgery patients on disability-free survival (AGE ANEMIA study): study protocol for a multi-centre, double-blind, randomized, placebo-controlled trial

BACKGROUND

Postoperative anaemia is common in older cardiac surgery patients and often caused by iron deficiency. Anaemia may negatively affect recovery after cardiac surgery. This study aims to determine the efficacy of treatment of postoperative iron deficiency anaemia (IDA) with intravenous iron (IVI) on disability 90 days after cardiac surgery in older patients.

METHODS

This is a randomized placebo-controlled double-blind multi-centre trial. In total, 310 patients aged ≥ 70 years with moderate IDA on postoperative day 1 (haemoglobin 85-110 g/L and ferritin concentration < 100 μg/L or iron saturation < 20%) after uncomplicated elective cardiac surgery (aortic valve repair or coronary artery bypass graft surgery) will be included. Patients will be randomly allocated to receive either IVI (ferric derisomaltose) or placebo (sodium chloride 0.9%) on postoperative day 1 in a 1:1 ratio, stratified by centre and type of cardiac surgery. The primary outcome is disability measured by the 12-item World Health Organization Disability Assessment score 2.0 after 90 days. Secondary outcome measures are the number of postoperative red blood cell (RBC) transfusions, change in reticulocyte haemoglobin content (pg) from randomization to hospital discharge, Hb levels at discharge, hospital complications, dyspnoea (assessed with the Rose Dyspnoea Scale) and health-related quality of life (HRQL) (assessed with The Older Persons and Informal Caregivers-Short Form (TOPICS-SF) questionnaire) after 90 days and days alive and out of hospital after 90 days. Lastly, the functional outcomes (e.g. steep ramp or 6-min walk test) and Hb level after 90 days will be assessed as an exploratory endpoint.

DISCUSSION

The results of this study will demonstrate whether early treatment of postoperative IDA with IVI improves disability at 90 days in older cardiac surgery patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04913649. Registered on June 4, 2021.

Perioperative Management of Heart Transplantation: A Clinical Review

In this clinical review, the authors summarize the perioperative management of heart transplant patients with a focus on hemodynamics, immunosuppressive strategies, hemostasis and hemorrage, and the prevention and treatment of infectious complications.

Appropriateness of inpatient intravenous iron therapy in a Swiss tertiary care hospital

INTRODUCTION

Intravenous (IV) iron replacement is an established treatment for iron deficiency and is recommended in various medical guidelines, but cheaper oral iron formulations remain first-line therapy in several instances. Data on adherence to current prescription standards are lacking in Switzerland.

METHODS

Retrospective single center quality control study evaluating the appropriateness of IV iron replacement in 400 inpatients during 2019 and 2021 at a Swiss tertiary care hospital. Appropriateness of IV iron was assessed by expert chart review according to national and international guidelines.

RESULTS

IV iron prescriptions were assessed as inappropriate in 147 (37%) of cases (indication lacking in 13%, oral route preferred in 24%). Inappropriate prescribing was more common (p < .001) in surgical wards (66%) compared to medical units (48%) and the gynecologic ward (19%). Iron studies were lacking in 29% of inappropriate IV administrations. Insufficient replacement dosages were chosen in 38% of patients with appropriate prescription.

CONCLUSION

Based on current guidelines, inappropriate in-hospital prescription of IV iron was frequently observed. Considerable differences exist between hospital units, which are consistent with conflicting recommendations of professional societies. We recommend increased attention toward the prescription quality to avoid unnecessary, expensive, and potentially harmful use of IV iron.

Perioperative Iron Deficiency in Patients Scheduled for Major Elective Surgeries: A French Prospective Multicenter Cross-Sectional Study

BACKGROUND

The management of perioperative iron deficiency is a component of the concept of patient blood management. The objective of this study was to update French data on the prevalence of iron deficiency in patients scheduled for major surgery.

METHODS

The CARENFER PBM study was a prospective cross-sectional study in 46 centers specialized in orthopedic, cardiac, urologic/abdominal, or gynecological surgery. The primary end point was the prevalence of iron deficiency at the time of surgery (D-1/D0) defined as serum ferritin <100 µg/L and/or transferrin saturation (TSAT) <20%.

RESULTS

A total of 1494 patients (mean age, 65.7 years; women, 49.3%) were included from July 20, 2021 to January 3, 2022. The prevalence of iron deficiency in the 1494 patients at D-1/D0 was 47.0% (95% confidence interval [CI], 44.5-49.5). At 30 days after surgery, the prevalence of iron deficiency was 45.0% (95% CI, 42.0-48.0) in the 1085 patients with available data. The percentage of patients with anemia and/or iron deficiency increased from 53.6% at D-1/D0 to 71.3% at D30 ( P < .0001), mainly due to the increase of patients with both anemia and iron deficiency (from 12.2% at D-1/D0 to 32.4% at D30; P < .0001). However, a treatment of anemia and/or iron deficiency was administered preoperatively to only 7.7% of patients and postoperatively to 21.7% (intravenous iron, 14.2%).

CONCLUSIONS

Iron deficiency was present in half of patients scheduled for major surgery. However, few treatments to correct iron deficiency were implemented preoperatively or postoperatively. There is an urgent need for action to improve these outcomes, including better patient blood management.

[Iron deficiency in cardiac surgery patients and the possibility of its correction at the preoperative stage]

Among cardio-surgical patients, the prevalence of iron deficiency conditions reaches 70 %, and anemia is detected in less than 50% cases. Meanwhile, both anemia and latent iron deficiency are risk factors for adverse outcomes in cardio-surgical patients. These conditions are associated with a high frequency and greater volume of blood transfusions as well as with a longer stay in the hospital. Timely diagnosis and correction of iron deficiency, regardless of the presence of anemia, are mandatory at the stage of preoperative preparation. The use of oral iron medicines is limited by their low efficacy in this category of patients and a high risk of adverse events. Intravenous iron medicines have a high potential for correcting iron deficiency, and their efficacy and safety have been previously demonstrated. Administration of ferric carboxymaltose has proved beneficial in studies on iron deficiency correction in cardiological and cardio-surgical patients. In these patients, ferric carboxymaltose improved the dynamics of ferritin and hemoglobin, reduced the risk of blood transfusion, and decreased the duration of stay in the hospital. Preoperative intravenous administration of ferric carboxymaltose to cardio-surgical patients can improve clinical outcomes and the cost effectiveness of cardiac surgery.

Intravenous iron and erythropoietin therapy for postoperative anemia among orthopedic surgery patients

BACKGROUND

Postoperative anemia is a risk factor for adverse surgical outcomes. Our study aimed to assess the role of intravenous iron and erythropoietin therapy for the rapid correction of anemia following orthopedic surgery.

METHODS

Patients undergoing elective orthopedic surgery were prospectively enrolled and randomly divided into three groups: Control (placebo), Group 1 (IV iron monotherapy), and Group 2 [combined IV iron and recombinant human erythropoietin (rHuEPO) therapy]. Blood tests were performed preoperative (baseline) and on postoperative days (PODs) 1, 3, and 7.

RESULTS

All groups demonstrated significantly lower hemoglobin (Hb) concentrations compared to baseline, with no significant inter-group differences in postoperative Hb concentrations (p > 0.05). Serum erythropoietin, ferritin, and vitamin B₁₂ levels, and reticulocyte count increased beyond normal ranges in all groups. Significantly lower serum iron levels were observed postoperatively in all groups (p < 0.05). No significant inter-group differences in hepcidin level were observed (p > 0.05).

CONCLUSION

Postoperative treatment with combined intravenous iron and rHuEPO was ineffective in correcting postoperative anemia among orthopedic surgery patients, besides achieving higher reticulocyte counts in the first week of surgery. No improvement in mobilization of storage iron was achieved with rHuEPO. We further suggest against vitamin B₁₂ administration during the early postoperative period.

Clinical effects of tourniquet use for non-traumatic major lower limb amputation: a two-centre retrospective cohort study

OBJECTIVE

To investigate the effect of tourniquet use on outcomes after major lower limb amputation (MLLA) due to peripheral arterial disease (PAD) or complications from diabetes mellitus.

METHODS

In this two-centre retrospective observational study, vascular patients who underwent MLLA between 01/01/2016-31/12/2020 at two UK hospitals were identified using operating theatre databases. Hospital databases were used to access medical records, operation notes and laboratory reports. The use of a tourniquet in each MLLA was noted. The primary outcome was postoperative haemoglobin (Hb) drop (g/L). Secondary outcomes were units of allogeneic blood transfused perioperatively, 90-day revision rates, 90-day wound breakdown rates, surgical site infection (SSI) rates (at 30 days) and 90-day mortality. A follow-up index (a measure of follow-up completeness) was calculated for all 30- and 90- day outcomes.

RESULTS

472 patients underwent MLLA, of which 124 had a tourniquet applied. The median postoperative Hb drop was significantly lower in the tourniquet group compared to the non-tourniquet group (13 [IQR 5-22] g/L vs. 20 [IQR 11-28] g/L; p=<.001). 33.1% (41) of tourniquet patients received a blood transfusion perioperatively, compared to 35.6% (124) of non-tourniquet patients (p=.82). Sixteen percent (76) of patients required surgical revision within 90 days, with no significant difference between the tourniquet and non-tourniquet group (20.2% tourniquet vs 14.7% no tourniquet; p=.15). SSI rates (12.0% tourniquet vs. 10.6% no tourniquet, p=.66) and 90-day mortality (6.5% tourniquet vs 10.1% no tourniquet; p=.23) were similar. Multivariable regression demonstrated that tourniquet use was independently associated with a reduced haemoglobin drop (β= -4.671, 95%CI -7.51 to -1.83, p=<.001), but was not associated with wound breakdown, revision surgery or SSI. Hypertension, SSI and below knee amputation using the skew flap technique were all significant predictors of revision surgery. All follow up-indices were ≥0.97.

CONCLUSION

Tourniquet use in MLLA was associated with a significantly lower fall in postoperative Hb without evidence of harm in terms of SSI, wound breakdown/revision rates or mortality.

Sucrosomial® Iron: An Updated Review of Its Clinical Efficacy for the Treatment of Iron Deficiency

Iron deficiency (ID) and iron deficiency anemia (IDA) are highly prevalent worldwide. Oral iron salts, especially ferrous sulfate, are commonly used for the treatment of iron deficiency (ID). However, its use is associated with gastrointestinal side effects, thus compromising treatment compliance. Intravenous iron administration is a more costly and logistically complex alternative and is not risk-free, as infusion and hypersensitivity reactions may occur. Sucrosomial^® iron is an oral formulation consisting of ferric pyrophosphate conveyed by a phospholipid and sucrester matrix (sucrosome^®). Intestinal Sucrosomial^® iron absorption is mediated by enterocytes and M cells, through the paracellular and transcellular routes, and occurs mostly as intact particles. These pharmacokinetic properties of Sucrosomial^® iron result in higher iron intestinal absorption and excellent gastrointestinal tolerance compared to oral iron salts. The evidence derived from clinical studies supports the use of Sucrosomial^® iron as a valid first option for the treatment of ID and IDA, especially for subjects who are intolerant or refractory to conventional iron salts. Newer evidence also demonstrates the effectiveness of Sucrosomial^® iron, with a lower cost and fewer side effects, in certain conditions usually treated with IV iron in current clinical practice.

Antimicrobial Peptides: Challenging Journey to the Pharmaceutical, Biomedical, and Cosmeceutical Use

Antimicrobial peptides (AMPs), or host defence peptides, are short proteins in various life forms. Here we discuss AMPs, which may become a promising substitute or adjuvant in pharmaceutical, biomedical, and cosmeceutical uses. Their pharmacological potential has been investigated intensively, especially as antibacterial and antifungal drugs and as promising antiviral and anticancer agents. AMPs exhibit many properties, and some of these have attracted the attention of the cosmetic industry. AMPs are being developed as novel antibiotics to combat multidrug-resistant pathogens and as potential treatments for various diseases, including cancer, inflammatory disorders, and viral infections. In biomedicine, AMPs are being developed as wound-healing agents because they promote cell growth and tissue repair. The immunomodulatory effects of AMPs could be helpful in the treatment of autoimmune diseases. In the cosmeceutical industry, AMPs are being investigated as potential ingredients in skincare products due to their antioxidant properties (anti-ageing effects) and antibacterial activity, which allows the killing of bacteria that contribute to acne and other skin conditions. The promising benefits of AMPs make them a thrilling area of research, and studies are underway to overcome obstacles and fully harness their therapeutic potential. This review presents the structure, mechanisms of action, possible applications, production methods, and market for AMPs.

Post-Embolization Hemoglobin Changes: When to Consider Re-intervention

PURPOSE

Decline in hemoglobin (Hgb) levels is common post-embolization, but there is no consensus on the classification of patients based on risk for re-bleeding or re-intervention. The current study evaluated post-embolization Hgb level trends with the goal of understanding the factors predictive of re-bleeding and re-intervention.

MATERIALS AND METHODS

All patients who underwent embolization for gastrointestinal (GI), genitourinary, peripheral, or thoracic arterial hemorrhage from 01/2017 to 01/2022 were reviewed. Data included demographics, periprocedural pRBC transfusion (TF) or pressor requirements, and outcome. Lab data consisted of Hgb values pre-embolization, immediately post-embolization, and daily values on days 1-10 after embolization. Hgb trends were compared between patients across TF and re-bleeding outcomes. Regression model was used to examine factors predictive of re-bleeding and magnitude of Hgb reduction post-embolization.

RESULTS

A total of 199 patients were embolized for active arterial hemorrhage. Perioperative Hgb level trends were similar for all sites and between TF + and TF- patients, showing a decline reaching a nadir within 6 days post-embolization followed by an upward trend. Maximum Hgb drift was predicted by GI embolization (p = 0.018), TF before embolization (p = 0.001), and use of vasopressor (p = 0.000). Patients with Hgb drop  > 15% within the first two days post-embolization had a higher chance of having a re-bleeding episode (p = 0.04).

CONCLUSION

Perioperative Hgb trends showed a consistent downward drift followed by an upward shift, irrespective of TF requirement status or site of embolization. Using a cut-off value of 15% Hgb reduction within the first two days post-embolization may be helpful to assess re-bleeding risk.

Hidden Blood Loss and Its Possible Risk Factors in Full Endoscopic Lumbar Interbody Fusion

BACKGROUND

Full endoscopic lumbar interbody fusion (Endo-LIF) is a representative recent emerging minimally invasive operation. The hidden blood loss (HBL) in an Endo-LIF procedure and its possible risk factors are still unclear.

METHODS

The blood loss (TBL) was calculated by Gross formula. Sex, age, BMI, hypertension, diabetes, ASA classification, fusion levels, surgical approach type, surgery time, preoperative RBC, HGB, Hct, PT, INR, APTT, Fg, postoperative mean arterial pressure, postoperative heart rate, Intraoperative blood loss (IBL), patient blood volume were included to investigate the possible risk factors by correlation analysis and multiple linear regression between variables and HBL.

RESULTS

Ninety-six patients (23 males, 73 females) who underwent Endo-LIF were retrospective analyzed in this study. The HBL was 240.11 (65.51, 460.31) mL (median [interquartile range]). Fusion levels (p = 0.002), age (p = 0.003), hypertension (p = 0.000), IBL (p = 0.012), PT (p = 0.016), preoperative HBG (p = 0.037) were the possible risk factors.

CONCLUSION

Fusion levels, younger age, hypertension, prolonged PT, preoperative HBG are possible risk factors of HBL in an Endo-LIF procedure. More attention should be paid especially in multi-level minimally invasive surgery. The increase of fusion levels will lead to a considerable HBL.

Clinical outcomes and prediction nomogram model for postoperative hemoglobin < 80 g/L in patients following primary lumbar interbody fusion surgery

OBJECTIVE

To analyze the association between different postoperative hemoglobin (Hb) levels and postoperative outcomes in patients who have undergone primary lumbar interbody fusion, and to investigate the risk factors and establish a predictive nomogram mode for postoperative Hb < 80 g/L.

METHODS

We retrospectively analyzed 726 cases who underwent primary lumbar interbody fusion surgery between January 2018 and December 2021in our hospital. All patients were divided into three groups according to the postoperative Hb levels (< 70 g/L, 70-79 g/L, ≥ 80 g/L). The postoperative outcomes among the three groups were compared, and the risk factors for postoperative Hb < 80 g/L were identified by univariate and multivariable logistic regression analysis. Based on these independent predictors, a nomogram model was developed. Predictive discriminative and accuracy ability of the predicting model was assessed using the concordance index (C-index) and calibration plot. Clinical application was validated using decision curve analysis. Internal validation was performed using the bootstrapping validation.

RESULTS

Patients with postoperative Hb < 80 g/L had higher rates of postoperative blood transfusion, a greater length of stay, higher rates of wound complications, and higher hospitalization costs than those with postoperative Hb ≥ 80 g/L. Preoperative Hb, preoperative platelets, fusion segments, body mass index, operation time, and intraoperative blood loss independently were associated with postoperative Hb < 80 g/L. Intraoperative blood salvage was found to be a negative predictor for postoperative Hb < 80 g/L (OR, 0.21 [95% CI 0.09-0.50]). The area under the curve of the nomogram model was 0.950. After internal validations, the C-index of the model was 0.939. The DCA and calibration curve suggested that the nomogram model had a good consistency and clinical utility.

CONCLUSIONS

Postoperative Hb < 80 g/L in patients following primary lumbar interbody fusion surgery increased blood transfusions requirement and was independently associated with poor outcomes. A novel nomogram model was established and could conveniently predict the risk of postoperative Hb < 80 g/L in patients after this type of surgery.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

[Implementation of Patient Blood Management as Standard-of-Care]

Anaemia is among the most common co-morbidity in surgical patients. However, it often remains unrecognized and untreated, which results in an increased requirement for allogeneic blood products and complications. Patient Blood Management offers patient-centred and evidence-based therapies and preventive measures for anaemia. Patient Blood Management is composed of 3 main pillars: pre-operative anaemia management, blood loss reduction and the rational use of allogeneic blood products. The World Health Organization demands the implementation of Patient Blood Management measures since 2010. However, a comprehensive implementation of Patient Blood Management as a standard-of-care is still not achieved. Here, we describe the need for a comprehensive Patient Blood Management implementation and highlight several specific Patient Blood Management measures.

Perioperative Tracking of Intravenous Iron in Patients Undergoing On-Pump Cardiac Surgery: A Prospective, Single-Center Pilot Trial

BACKGROUND

Preoperative intravenous iron administration is a frequently used patient blood management procedure. If the timeframe of intravenous iron administration before surgery is short, (1) the concentration of the intravenous iron compound might still be high in patients' plasma when undergoing surgery and (2) this iron in patients' plasma is at risk to be lost due to blood loss. The aim of the current study was, therefore, to track the iron compound ferric carboxymaltose (FCM) before, during, and after cardiac surgery requiring cardiopulmonary bypass, with an emphasis on intraoperative iron losses in shed blood and potential recovery through autologous cell salvage.

METHODS

Concentrations of FCM were analyzed in patients' blood using a hyphenation of liquid chromatography and inductively coupled plasma-mass spectrometry to distinguish between pharmaceutical compound FCM and serum iron. In this prospective, single-center pilot trial, 13 anemic and 10 control patients were included. Anemic patients with hemoglobin levels ≤12/13 g/dL in women and men were treated with 500 milligrams (mg) intravenous FCM 12 to 96 hours before elective on-pump cardiac surgery. Patients' blood samples were collected before surgery and at days 0, 1, 3, and 7 after surgery. One sample each was taken of the cardiopulmonary bypass, the autologous red blood cell concentrate generated by cell salvage, and the cell salvage disposal bag.

RESULTS

Patients who had received FCM <48 hours before surgery had higher FCM serum levels (median [Q1-Q3], 52.9 [13.0-91.6]) compared to ≥48 hours (2.1 [0.7-5.1] µg/mL, P = .008). Of 500-mg FCM administered <48 hours, 327.37 (257.96-402.48) mg were incorporated compared to administration ≥48 hours with 493.60 (487.78-496.70) mg. After surgery, patients' plasma FCM concentration in the FCM <48 hours group was decreased (-27.1 [-30 to -5.9] µg/mL). Little FCM was found in the cell salvage disposal bag (<48 hours, 4.2 [3.0-25.8] µg/mL, equivalent to 29.0 [19.0-40.7] mg total; equivalent to 5.8% or 1/17th of the 500 mg FCM initially administered), almost none in the autologous red blood cell concentrate (<48 hours, 0.1 [0.0-0.43] µg/mL).

CONCLUSIONS

The data generate the hypotheses that nearly all FCM is incorporated into iron stores with administration ≥48 hours before surgery. When FCM is given <48 hours of surgery, the majority is incorporated into iron stores by the time of surgery, although a small amount may be lost during surgical bleeding with limited recovery by cell salvage.

Centre for Perioperative Care anaemia guideline: implications for anaesthesia

The Centre for Perioperative Care (CPOC) has published in September 2022 guidance addressing perioperative anaemia. This editorial addresses the definition of anaemia for women and management of borderline anaemia in women. We also address implications of the CPOC guidance for anaesthetists and the future direction of anaemia research and management.

Early Saphenous Vein Graft Aneurysm Rupture: A Not So-Late Complication. Case Report and Comprehensive Literature Review

BACKGROUND AND OBJECTIVES

Saphenous vein graft (SVG) is a cardiac surgical practice used to create a cardiac bypass in cases of coronary artery obstruction. It consists of a surgical procedure that involves the creation of an aorto-coronary communication by a venous conduit (saphenous vein) to bypass coronary stenosis and allow cardiac revascularization. This practice can be affected by early and late complications. The most feared complication is graft aneurysm or pseudoaneurysm degeneration and rupture which are considered late complications. This paper presents a rare case of SVG aneurysmal rupture that occurred 24 h after surgery and a review of the literature to provide a general look at the state of knowledge.

MATERIALS AND METHODS

The systematic review was carried out using the guidelines according to the PRISMA method.

RESULTS

Cases of aneurysmal rupture have never been described prior to one month after surgery. The male sex and subjects under 45 are the most affected by this complication. Death occurs in less than half of the cases, being more frequent in young people. Performing a CT or angio-CT examination led to the diagnosis.

CONCLUSIONS

It is impossible to estimate the implanted vessel's quality, so postoperative follow-up is fundamental. Transesophageal ultrasound can be useful, and hematochemical tests are valuable early diagnostic tools, whrease CT and angio-CT can be useful even months after surgery. Forensic analysis should always perform an autopsy and graft histological examination.

Implementation of a patient blood management in an Italian City Hospital: is it effective in reducing the use of red blood cells?

To evaluate the effect of patient blood management (PBM) since its introduction, we analyzed the need for transfusion and the outcomes in patients undergoing abdominal surgery for different types of tumor pre- and post-PBM. Patients undergoing elective gastric, liver, pancreatic, and colorectal surgery between 2017 and 2020 were included. The implementation of the PBM program was completed on May 1, 2018. The patients were grouped as follows: those who underwent surgery before the implementation of the program (pre-PBM) versus after the implementation (post-PBM). A total of 1302 patients were included in the analysis (445 pre-PBM vs. 857 post-PBM). The number of transfused patients per year decreased significantly after the introduction of PBM. A strong tendency for a decreased incidence of transfusion was evident in gastric and pancreatic surgery and a similar decrease was statistically significant in liver surgery. With regard to gastric surgery, a single-unit transfusion scheme was used more frequently in the post-PBM group (7.7% vs. 55% after PBM; p = 0.049); this was similar in liver surgery (17.6% vs. 58.3% after PBM; p = 0.04). Within the subgroup of patients undergoing liver surgery, a significant reduction in the use of blood transfusion (20.5% vs. 6.7%; p = 0.002) and a decrease in the Hb trigger for transfusion (8.5, 8.2-9.5 vs. 8.2, 7.7-8.4 g/dl; p = 0.039) was reported after the PBM introduction. After the implementation of a PBM protocol, a significant reduction in the number of patients receiving blood transfusion was demonstrated, with a strong tendency to minimize the use of blood products for most types of oncologic surgery.

The management of peri-operative anaemia in patients undergoing major abdominal surgery in Australia and New Zealand: a prospective cohort study

OBJECTIVES

To assess the prevalence and management of anaemia in patients undergoing major abdominal surgery, and the influence of guideline adherence on patient outcomes.

DESIGN

Prospective observational cohort study.

SETTING

56 hospitals in Australia and New Zealand.

PARTICIPANTS

People aged 18 years or more who underwent major abdominal surgery during two 2-week periods in July 2021.

MAIN OUTCOME MEASURES

Proportions of patients managed according to Australian National Blood Authority patient blood management guidelines.

SECONDARY OUTCOMES

anaemia prevalence, post-operative complications, length of hospital stay, re-admission within 30 days of discharge.

RESULTS

Data were available for 2730 eligible patients (mean age, 56.7 years; SD, 17.3 years), including 1558 women (57.1%). Haemoglobin levels prior to surgery were documented for 2461 of 2727 patients (90.2%), 689 of whom had anaemia (28.0%). Pre-operative anaemia assessment and management were associated with lower likelihood of intra-operative (adjusted odds ratio [aOR], 0.33; 95% CI, 0.19-0.57) and post-operative blood transfusion (aOR, 0.36; 95% CI, 0.25-0.53), and of post-operative complications (aOR, 0.79; 95% CI, 0.63-0.99). Tranexamic acid was administered during 128 of 2728 procedures (4.7%); a restrictive transfusion strategy was followed for 96 of the 167 patients who received post-operative blood transfusions (58%). Post-operative anaemia was identified in 1227 of 2069 patients (59.3%) in whom haemoglobin was assessed prior to discharge. The proportion of people re-admitted to hospital within 30 days was larger for patients with anaemia at discharge (169 of 1207 patients followed up, 14.0% v 61 of 825, 7.4%). Haemoglobin assessments were recorded by 30 days after discharge for only 288 patients with post-operative anaemia (24.3%).

CONCLUSIONS

The management of peri-operative anaemia differs between hospitals in Australia and New Zealand, with consequences for patient outcomes. Patients are often discharged after surgery with anaemia, which is therefore a potential therapeutic target.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12621001517864 (retrospective).

The Efficacy of Bone Wax in Reduction of Perioperative Blood Loss in Total Hip Arthroplasty via Direct Anterior Approach: A Prospective Randomized Clinical Trial

BACKGROUND

Perioperative blood management in total hip arthroplasty (THA) has become a prime focus of research. Given the morbidity, delayed recovery, and prolonged hospital stay associated with postoperative anemia, various measures have been proposed to reduce perioperative blood loss (PBL). In this trial, we studied the efficacy of bone wax application on the distal cut surface of the femoral neck in reducing PBL during THA through the direct anterior approach.

METHODS

In a randomized controlled clinical trial, 152 patients underwent THA through the direct anterior approach with use of bone wax (n = 75) or without bone wax (control) (n = 77). The study was triple-blinded. The primary outcomes were apparent PBL (blood in sponges and suction canister) and total PBL on postoperative days (PODs) 3 and 5 (as calculated with the Good and Nadler methods). Transfusion and complications were the secondary outcomes.

RESULTS

No significant difference was found between the 2 groups in terms of age, sex, body mass index, American Society of Anesthesiologists score, etiology, preoperative hematologic/coagulation profile, anesthesia, intraoperative mean arterial pressure, or operative time. Apparent PBL, total PBL on POD3, and total PBL, in milliliters, on POD5 were significantly lower in the wax group, with median values of 200 (interquartile range [IQR]: 115 to 310) versus 370 (IQR: 195 to 513.7), 505.2 (IQR: 409.2 to 637.6) versus 747 (IQR: 494.6 to 955.4), and 536.7 (IQR: 430.9 to 689.3) versus 767.8 (IQR: 537.8 to 1,021.9) in the wax and control groups, respectively (p < 0.001). No significant differences in the rates of transfusion and complications were found.

CONCLUSIONS

Bone wax on the cut surface of femoral neck can significantly reduce PBL during THA through the direct anterior approach. Bone wax is accessible and inexpensive and can be considered a routine part of the surgical technique in THA through the direct anterior approach. This intervention has no impact on complication or transfusion rates.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

A novel model forecasting perioperative red blood cell transfusion

We aimed to establish a predictive model assessing perioperative blood transfusion risk using a nomogram. Clinical data for 97,443 surgery patients were abstracted from the DATADRYAD website; approximately 75% of these patients were enrolled in the derivation cohort, while approximately 25% were enrolled in the validation cohort. Multivariate logical regression was used to identify predictive factors for transfusion. Receiver operating characteristic (ROC) curves, calibration plots, and decision curves were used to assess the model performance. In total, 5888 patients received > 1 unit of red blood cells; the total transfusion rate was 6.04%. Eight variables including age, race, American Society of Anesthesiologists' Physical Status Classification (ASA-PS), grade of kidney disease, type of anaesthesia, priority of surgery, surgery risk, and an 18-level variable were included. The nomogram achieved good concordance indices of 0.870 and 0.865 in the derivation and validation cohorts, respectively. The Youden index identified an optimal cut-off predicted probability of 0.163 with a sensitivity of 0.821 and a specificity of 0.744. Decision curve (DCA) showed patients had a standardized net benefit in the range of a 5–60% likelihood of transfusion risk. In conclusion, a nomogram model was established to be used for risk stratification of patients undergoing surgery at risk for blood transfusion. The URLs of web calculators for our model are as follows: http://www.empowerstats.net/pmodel/?m=11633_transfusionpreiction.

Postoperative anaemia and patient-centred outcomes after major abdominal surgery: a retrospective cohort study

BACKGROUND

Compared with anaemia before surgery, the underlying pathogenesis and implications of postoperative anaemia are largely unknown.

METHODS

This retrospective cohort study analysed prospective data obtained from 2983 adult patients across 47 centres enrolled in a clinical trial evaluating restrictive and liberal intravenous fluids. The primary endpoint was persistent disability or death up to 90 days after surgery. Secondary endpoints included major septic complications, hospital stay, and patient quality of recovery using a 15-item quality of recovery (QoR-15) score, hospital re-admissions, and disability-free survival up to 12 months after surgery. Anaemia and disability were defined according to the WHO definitions. Multivariable regression was used to adjust for baseline risk and surgery.

RESULTS

A total of 2983 patients met inclusion criteria for this study, of which 78.5% (95% confidence interval [CI], 76.7-80.1%) had postoperative anaemia. Patients with postoperative anaemia had a higher adjusted risk of death or disability up to 90 days after surgery when compared with those without anaemia: 18.2% vs 9.2% (risk ratio [RR]=1.51; 95% CI, 1.10-2.07, P=0.011); lower QoR-15 scores on Day 3 and Day 30, 105 (95% CI, 87-119) vs 114 (95% CI, 99-128; P<0.001), and 130 (95% CI, 112-140) vs 139 (95% CI, 121-144; P<0.011), respectively; higher adjusted risk of a composite of mortality/septic complications, 2.01 (95% CI, 1.55-42.67; P<0.001); unplanned admission to ICU (RR=2.65; 95% CI, 1.65-4.23; P<0.001); and longer median (inter-quartile range [IQR]) hospital stays, 6.6 (4.4-12.4) vs 3.7 (2.5-6.5) days (P<0.001).

CONCLUSIONS

Postoperative anaemia is common and is independently associated with poor outcomes after surgery. Optimal prevention and treatment strategies need to be investigated.

CLINICAL TRIAL REGISTRATION

NCT04978285 (ClinicalTrials.gov).

Perioperative inappropriate red blood cell transfusions significantly increase total costs in elective surgical patients, representing an important economic burden for hospitals

Background

Red blood cell (RBC) transfusions in surgical patients are associated with increased morbidity a hospital stay. However, little is known about how clinical and economic outcomes differ between appropriately and inappropriately transfused patients. We hypothesized that inappropriate RBC transfusions in elective surgical patients would significantly increase hospital cost. The aim of this study was to quantify the economic burden associated with inappropriate RBC transfusions.

Methods

We retrospectively included all adult patients admitted for elective non-cardiac surgery between January 2014 and March 2020. Patients were divided into three groups (not transfused, appropriately transfused and inappropriately transfused). The primary outcome was the excess in hospital cost in patients inappropriately transfused compared to non-transfused patients. Costs were calculated using a bottom–up approach and involving cost calculation on a granular level. According to international guidelines, transfusions were considered appropriate if administered with an ASA score of 1–2 and the last hemoglobin level measured before transfusion < 70 g/L, or with an ASA score ≥ 3 and the last hemoglobin level < 80 g/L. Cases where RBC transfusions were deemed necessary regardless of the Hb levels were reviewed by the patient blood management (PBM) board and classified accordingly. Secondary outcomes included total transfusion rate, transfusion index, and length of hospital stay. Statistical analysis was carried out by multivariable regression models.

Results

During the study period there were 54,922 consecutive surgical admissions, of these 1,997 received an RBC transfusion, with 1,125 considered inappropriate. The adjusted cost of each inappropriate RBC transfusions was estimated in United States dollars (USD) 9,779 (95% CI, 9,358 – 10,199; p < 0.001) and totaled USD 11,001,410 in our series. Inappropriately transfused patients stayed 1.6 times (95% CI, 1.5–1.6; p < 0.001) longer in hospital (10.6 days vs. 6.7 days) than non-transfused patients and a mean 2.35 RBC units per patient were administered.

Conclusion

Inappropriate RBC transfusions in elective surgical patients seem to be common and may represent a significant economic burden. In our experience, inappropriate transfusions significantly increased hospital costs by an average of USD 9,779 compared to non-transfused patients. Through specific PBM policy, hospitals may improve cost-effectiveness of their elective surgical activity by lowering inappropriate transfusions.

The prevalence of perioperative iron deficiency anaemia in women undergoing caesarean section-a retrospective cohort study

Background

Caesarean section is a common surgery, with almost 23 million procedures performed globally each year. Postpartum haemorrhage, in association with caesarean section surgery, is a leading global cause of maternal morbidity and mortality. Perioperative iron deficiency anaemia is a risk factor for intraoperative bleeding. Therefore, anaemia is an important and modifiable risk factor for bleeding during caesarean section surgery. Recent recommendations advise that all preoperative patients with anaemia (defined as haemoglobin concentration (Hb) < 130 g/L), regardless of sex, be assessed and treated to normalise haemoglobin levels. It is unclear how this recommendation translates to pregnant women where the World Health Organization (WHO) defines anaemia at a much lower threshold (Hb < 110 g/L). We aimed to determine the prevalence, and characterization, of Hb levels < 130 g/L perioperatively in women undergoing caesarean section.

Method

We conducted a retrospective cohort study of 489 consecutive women who underwent caesarean section over a 12-week period, in a single-centre tertiary referral maternity unit in Australia. We calculated the proportion of women who were anaemic (Hb < 130 g/L) at four time points—first hospital appointment, third trimester, preoperatively and on discharge from hospital. The proportion of women who were iron deficient (ferritin level < 30 μg/L) at their first hospital appointment was determined.

Results

Haemoglobin was measured in 479 women. Ferritin was measured in 437 of these women. The mean (SD) Hb at the first hospital appointment, third trimester, preoperatively, and postoperatively on discharge was 126.7 (11.4) g/L, 114.6 (10.6) g/L, 124.1 (12.4) g/L, and 108.0 (13.6) g/L respectively. Iron deficiency was present in 148 (33.9%) women at their first hospital appointment; 107 of 248 (43.1%) women with anaemia and 41 of 189 (21.7%) with no anaemia. 29 women were found to have moderate anaemia (Hb 80−109 g/L) with 18 of these 29 (62.1%) women having iron deficiency. Only 68 (45.9%) women with iron deficiency at their first hospital appointment received treatment. The prevalence of anaemia classified as Hb < 130 g/L versus the WHO classification of Hb < 110 g/L from all causes was 57.4% versus 6.1% at first hospital appointment, 94% versus 26.1% in third trimester, and 66.0% versus 12.2% preoperatively. Postoperatively at least 40% of women had Hb < 130 g/L on hospital discharge versus at least 23% of women using WHO definition of Hb < 110 g/L. Of the 112 women with hospital discharge Hb < 110 g/L, 35 (31.3%) women were iron deficient at their first hospital appointment.

Conclusion

Over one in three women were iron deficient at their first hospital appointment. 62% of women with moderate anaemia (Hb 80–109 g/L) also had iron deficiency. At least four in 10 women were anaemic (Hb < 130 g/L) on hospital discharge. Less than half of the women with anaemia were treated. Our data suggests that 30% of postoperative anaemia may be prevented with intensive treatment of iron deficiency in early pregnancy. Large prospective studies, are needed to determine outcomes after caesarean section in women, stratified by preoperative Hb and ferritin levels. The prevalence of anaemia in our data suggests it is a moderate public health problem.

Surgical Outcomes and Analysis of Quality of Life Following Knee Arthroplasty in Very Elderly Patients

In an aging population, the incidence of severe knee osteoarthritis in very elderly patients increases, leading to functional impairment and loss of independence. Knee replacement could be an effective treatment but is often denied due to fear of increased complication rate with advanced age. The objective of this study was to investigate complication rate, mortality, clinical outcome, and quality-adjusted life years (QALYs) of primary knee replacement in very elderly patients, defined as 83 years or older. Medical records of 85 cases, receiving a primary total (total knee arthroplasty [TKA]) or unicompartmental (unicompartmental knee arthroplasty [UKA]) knee replacement, aged 83 years or older at the time of surgery, were retrospectively reviewed for surgical and medical complications as well as survivorship. Functional outcome was obtained by Oxford Knee Score (OKS) and QALY. At a mean follow-up of 21 months (TKA) and 24 months (UKA), surgical and medical complication rates were 9.7 and 8.1% for TKA and 4.3 and 4.3% for UKA, respectively. One-year survival rate was 98.4% in TKA and 98.8% in UKA, the 5-year survival rate was 83.1 and 86.6%, respectively. OKS improved from 19 to 41 points in TKA and 23 to 40 points in UKA. Mean QALYs were 4.1 years for TKA and 3.9 years for UKA. TKA and UKA are safe and reliable surgical procedures in treating end-stage osteoarthritis in very elderly patients. Patients might benefit from improved pain, function, and quality of life. The mortality rate and overall complication rate were low, although slightly higher than reported in cohorts with younger patients. If the patient is suitable, UKA might be preferred over TKA, as the complication rate was significantly lower. Patients should not be excluded from knee replacement based on their age alone, but careful patient selection, peri- and postoperative optimization, and awareness for complications are quintessential for successful treatment.

The LRINEC Score-An Indicator for the Course and Prognosis of Necrotizing Fasciitis?

Background: The Laboratory Risk Indicator for Necrotizing Fasciitis score (LRINEC) is a simple tool used to support early diagnosis of Necrotizing Fasciitis (NF). The aim of this study was to investigate whether the LRINEC is suitable as a progression and prognosis parameter in patients with NF. Methods: In this retrospective study, laboratory data of 70 patients with NF were analyzed. The LRINEC was calculated for every patient at the time of hospital admission and postoperatively after surgical interventions. Furthermore, the LRINEC was examined as a prognostic factor for survival. Results: The overall lethality of our series was 20 out of 70 (28.6%). A highly significant LRINEC decrease was found for serial debridements. The largest decrease was observed after the first debridement. There was a significant difference between the initial LRINEC of deceased and surviving patients. A cut off value of >6.5 (7 LRINEC points) resulted in an optimal constellation of sensitivity (70%) and specificity (60%) to predict lethality in patients with NF. Conclusions: The LRINEC significantly decreases after surgical debridement. An initial LRINEC equal or greater than seven is an independent prognostic marker for lethality and can help to identify high-risk patients.

Short-term treatment of iron deficiency anemia after cardiac surgery

Iron deficiency anemia (IDA) is frequent after cardiac surgery and is associated with increased morbidity and mortality. In a retrospective study, we analyzed 106 patients with IDA (hemoglobin [Hb] ≤ 12 g/dl in women and ≤ 13 g/dl in men, transferrin saturation [TSAT] ≤ 20%) on admission to a Cardiac Rehabilitation Unit after cardiac surgery. The patients were divided into two groups, one was treated with oral sucrosomial iron (SI) and the other with intravenous ferric carboxymaltose (FCM). Patients received a single 1000 mg dose of FCM from the day after admission to rehabilitation (T1), or a 120 mg/day dose of SI from T1 until discharge (T2); after discharge, SI was reduced to 30 mg/day until the end of follow-up (T3). Hb was evaluated at T1, T2 and T3; the other hematological parameters at T1 and T3; natriuretic peptides at T1, T2 and T3; 6-minute walk test (6MWT) at T1 and T2. Folate, vitamin B12 and reticulocytes were sampled on admission. Folate deficiency was documented in 60.4% of patients. Hb increased in both groups with no significant differences between the two treatments (p = 0.397). The other iron metabolism parameters (sideremia, transferrin, TSAT) displayed similar behavior, showing a significant increase at T3 (p < 0.001) with both therapies, although the increase was faster with FCM. Ferritin – high on admission – decreased at T3 in the SI group and rose significantly in the FCM group (SI 219.5 vs. FCM 689 ng/ml p < 0.0001). The 6MWT increased significantly at T2, with an overlap between SI and FCM. In conclusion, the results of this study show that SI and FCM exhibit the same effectiveness on IDA; the response time to therapy of both treatments is also equally fast. SI and FCM induce a similar increase in functional capacity. The study shows that SI can be a viable alternative to FCM after cardiac surgery in terms of effectiveness and tolerability.

The impact of timing of intravenous iron supplementation on preoperative haemoglobin in patients scheduled for major surgery

BACKGROUND

Anaemia is frequent and an independent risk factor for morbidity and mortality in patients undergoing surgery. Iron deficiency (ID) is the main cause for anaemia and can be corrected by intravenous (IV) iron. The aim of this study was to investigate the timing of preoperative IV iron supplementation on preoperative haemoglobin (Hb) level.

MATERIALS AND METHODS

Surgical patients were screened for the presence of anaemia and ID from November 2015 to January 2020. In case of ID or iron deficiency anaemia (IDA), patients received IV iron supplementation. The timing of IV iron supplementation on preoperative Hb level was analysed by days and time frames clustered by 5 days before surgery.

RESULTS

In total, 404 patients with IV iron supplementation were analysed. In all patients, IV iron was administered with a median (interquartile range [IQR]) of 3.0 (1.0; 9.0) days before surgery. Preoperative Hb level increased steadily starting from 6 days (0.13 [±1.2] g/dL) until 16 days before surgery (1.75 [±1.1] g/dL). Group comparison revealed a median preoperative Hb change of -0.2 (-0.5; 0.2) g/dL for days 1-5, 0.2 (0.0; 0.7) g/dL for days 6-10, 0.7 (0.2; 1.1) g/dL for days 11-15, 0.7 (0.2; 1.8) g/dL for days 16-20, 0.9 (0.3; 1.7) g/dL for days 21-25, 1.5 (0.4; 2.6) g/dL for days 26-30, and 0.6 (0.0; 1.7) g/dL for >31 days. Three patients received multiple administrations of IV iron which resulted in an increase in Hb of >4 g/dL.

DISCUSSION

Supplementation of IV iron to increase Hb concentration preoperatively may be most effective if administered at least ten days before surgery.

Intravenous iron therapy to treat burn anaemia: A retrospective cohort study

PURPOSE

Intravenous iron is an effective treatment for anaemia in many populations but has not been evaluated in those with burn anaemia. This study aimed to evaluate the efficacy and safety of intravenous iron to manage burn anaemia.

METHODOLOGY

This was a retrospective cohort study of patients admitted to the Royal Brisbane and Women's Hospital with burns to at least 15% total body surface area (TBSA). Data collected from patient records included demographics, treatment details, and outcomes including length of stay, blood transfusions, and serum haemoglobin concentrations. Linear mixed effects regression models were used to assess the effect of treatment with intravenous iron on haemoglobin over time.

RESULTS

Sixty patients met inclusion criteria, with 11 (18%) treated using intravenous iron. Those treated with intravenous iron had higher TBSA burns (median 39% vs 18%, P = 0.0005), more operations (3 vs 1, P = 0.0012), and more blood transfusions (median 8 units vs 0 units, P = 0.0002). One patient (9%) experienced a minor adverse drug reaction from intravenous iron. When examining the change in modelled haemoglobin levels over the first 14 days following the last major operation, the change in the intravenous iron group (11.22 g/L) was 14.56 g/L greater than the change in the group not receiving intravenous iron (-3.34 g/L, P = 0.0282).

CONCLUSION

This exploratory study provides preliminary evidence of benefit and safety of intravenous iron treatment on burn anaemia recovery.

Iron status in patients with burn anaemia

PURPOSE

The iron status of burn patients is poorly understood, limited by difficulty interpreting conventional iron studies in the context of the acute phase response triggered by critical illness. The aim of this study was to evaluate the iron status of patients with burn anaemia using recent post-operative guidelines.

METHODOLOGY

This retrospective cohort study utilised data collected from records for adult patients admitted to the Royal Brisbane and Women's Hospital with burns to at least 15% TBSA. Rates of iron deficiency, defined as ferritin< 100 µg/L or ferritin 100-300 µg/L with transferrin saturation< 20%, and low iron availability, defined as transferrin saturation< 20%, were calculated.

RESULTS

Of 60 included patients (90% male), 16 (27%) underwent iron studies. 11 (18%) were treated with intravenous iron. Iron studies showed that five (31%) patients had evidence of iron deficiency, and ten out of 12 (83%) had evidence of reduced iron availability. Two patients (40%) with evidence of iron deficiency were not treated with intravenous iron.

CONCLUSION

Application of recent guidelines for interpretation of conventional iron studies in patients with inflammatory states may improve the identification of iron deficiency in burn patients. Iron deficiency may be an under-recognised and under-treated contributor to burn anaemia.

Impact on blood loss and transfusion rates following administration of tranexamic acid in major oncological abdominal and pelvic surgery: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Major bleeding and receiving blood products in cancer surgery are associated with increased postoperative complications and worse outcomes. Tranexamic acid (TXA) reduces blood loss and improves outcomes in various surgical specialities. We performed a systematic review and meta-analysis to investigate TXA use on blood loss in elective abdominal and pelvic cancer surgery.

METHODS

A literature search was performed for studies comparing intravenous TXA versus placebo/no TXA in patients undergoing major elective abdominal or pelvic cancer surgery.

RESULTS

Twelve articles met the inclusion criteria, consisting of 723 patients who received TXA and 659 controls. Patients receiving TXA were less likely to receive a red blood cell (RBC) transfusion (p < 0.001, OR 0.4 95% CI [0.25, 0.63]) and experienced less blood loss (p < 0.001, MD -197.8 ml, 95% CI [-275.69, -119.84]). The TXA group experienced a smaller reduction in haemoglobin (p = 0.001, MD -0.45 mmol/L, 95% CI [-0.73, -0.18]). There was no difference in venous thromboembolism (VTE) rates (p = 0.95, OR 0.98, 95% CI [0.46, 2.08]).

CONCLUSIONS

TXA use reduced blood loss and RBC transfusion requirements perioperatively, with no significant increased risk of VTE. However, further studies are required to assess its benefit for cancer surgery in some sub-specialities.

Polymeric Coatings and Antimicrobial Peptides as Efficient Systems for Treating Implantable Medical Devices Associated-Infections

Many infections are associated with the use of implantable medical devices. The excessive utilization of antibiotic treatment has resulted in the development of antimicrobial resistance. Consequently, scientists have recently focused on conceiving new ways for treating infections with a longer duration of action and minimum environmental toxicity. One approach in infection control is based on the development of antimicrobial coatings based on polymers and antimicrobial peptides, also termed as “natural antibiotics”.

Non-erythropoiesis-stimulating agent, non-iron therapies for the management of anaemia: protocol for a scoping review

INTRODUCTION

Preoperative anaemia is associated with poor postoperative outcomes and is the strongest predictor of allogenic blood transfusion, which contributes further to patient morbidity. Emphasis has been placed on correcting anaemia prior to surgery to mitigate these outcomes. Conflicting evidence exists regarding the benefit of currently recommended interventions. With greater understanding of iron haemostasis and erythropoiesis, novel therapies have been identified. These are at varying stages of development with some demonstrating promising results in patients with chronic kidney disease. It is not known how these agents have been studied outside this population, particularly in the perioperative context. To address this, we will conduct a scoping review of the published literature to chart the evidence.

METHODS AND ANALYSIS

The scoping review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews framework. The electronic database search will include Scopus, MEDLINE (Ovid) and Excerpta Medica database (Ovid), with no language restrictions, and will include all publications since 1 January 2010. This review will have three objectives: (1) to describe the mechanisms of action for novel agents, (2) to describe the level of evidence and stage of development of novel agents in a perioperative setting, and (3) to determine the potential agents suitable for prospective controlled trials in a preoperative or postoperative patient cohort and aiming to improve patient-centred outcomes. The review process will involve two reviewers with a third reviewer resolving disagreements. Data will be extracted and organised with subsequent analysis.

ETHICS AND DISSEMINATION

This scoping review does not require research ethics approval. The results will be published in a peer-reviewed journal and inform the development of future prospective trials based on established evidence from potential therapeutic agents.

TRIAL REGISTRATION NUMBER

This protocol has been registered prospectively on the Open Science Framework registry (DOI:10.17605/OSF.IO/SM3UH, https://osf.io/sm3uh/?view_only=39876ccf7a4348dfbd566535b957a7db).Cite Now.