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.

Background: Cell salvage (CS) is an integral part of patient blood management (PBM) and aims to reduce allogeneic red blood cell (RBC) transfusion. Methods: This observational study analysed patients scheduled for elective cardiac surgery requiring cardiopulmonary bypass (CPB) between November 2015 and October 2018. Patients were divided into a CS group (patients receiving CS) and a control group (no CS). Primary endpoints were the number of patients exposed to allogeneic RBC transfusions and the number of RBC units transfused per patient. Results: A total of 704 patients undergoing cardiac surgery were analysed, of whom 338 underwent surgery with CS (CS group) and 366 were without CS (control group). Intraoperatively, 152 patients (45%) were exposed to allogeneic RBC transfusions in the CS group and 93 patients (25%) in the control group (P < 0.001). Considering the amount of intraoperative blood loss, regression analysis revealed a significant association between blood loss and increased use of RBC units in patients of the control compared to the CS group (1000 mL: 1.0 vs. 0.6 RBC units; 2000 mL: 2.2 vs. 1.1 RBC units; 3000 mL: 3.4 vs. 1.6 RBC units). Thus, CS was significantly associated with a reduced number of allogeneic RBCs by 40% for 1000 mL, 49% for 2000 mL, and 52% for 3000 mL of blood loss compared to patients without CS. Conclusions: Cell salvage was significantly associated with a reduced number of allogeneic RBC transfusions. It supports the beneficial effect of CS in cardiac surgical patients as an individual measure in a comprehensive PBM program.

Objective: To evaluate the effectiveness of routine intravenous iron in surgical patients with iron deficiency anemia (IDA). Background: Anemia is the most common medical disease in the world and is an independent risk factor for morbidity and mortality. Iron deficiency (ID) is the main cause for anemia and constitutes a potentially preventable condition with great impact on surgical outcome. Methods: In this prospective single-center observational study, surgical patients were screened for the presence of anemia and ID. Patients were assigned to 1 of 4 study groups: A(-) (no anemia); A(-), ID+, T+ (no anemia, iron-deficient, iron supplementation); A(+) (anemia); and A(+), ID+, T+ (anemia, iron-deficient, iron supplementation) according to hemoglobin level, iron status, and supplementation with iron. Results: Among 1728 patients, 1028 were assigned to A(-); 55 to A(-), ID+, T+; 461 to A(+); and 184 to A(+), ID+, T+. While all iron-supplemented IDA patients required less red blood cell (RBC) transfusion during the postoperative period (A(+) 42.5% vs A(+), ID+, T+ 31.5%), a reduced intraoperative transfusion rate was observed for ID and IDA patients only if iron was supplemented >7 days before surgery. Hospital stay was significantly reduced by 2.8 days in iron-supplemented patients (P < 0.01 comparing 13.9 +/- 0.8 days for A(+), ID+, T+ vs. 16.7 +/- 0.7 days for A(+)). Conclusion: Preoperative IDA management with intravenous iron is effective in improving hemoglobin level, thereby reducing intraoperative RBC transfusion rate particular if iron is administrated >7 days before surgery. Hospital length of stay was reduced in all preoperatively iron-supplemented IDA patients.

BACKGROUNDApproximately every third surgical patient is anemic. The most common form, iron deficiency anemia, results from persisting iron‐deficient erythropoiesis (IDE). Zinc protoporphyrin (ZnPP) is a promising parameter for diagnosing IDE, hitherto requiring blood drawing and laboratory workup.STUDY DESIGN AND METHODSNoninvasive ZnPP (ZnPP‐NI) measurements are compared to ZnPP reference determination of the ZnPP/heme ratio by high‐performance liquid chromatography (ZnPP‐HPLC) and the analytical performance in detecting IDE is evaluated against traditional iron status parameters (ferritin, transferrin saturation [TSAT], soluble transferrin receptor–ferritin index [sTfR‐F], soluble transferrin receptor [sTfR]), likewise measured in blood. The study was conducted at the University Hospitals of Frankfurt and Zurich.RESULTSLimits of agreement between ZnPP‐NI and ZnPP‐HPLC measurements for 584 cardiac and noncardiac surgical patients equaled 19.7 μmol/mol heme (95% confidence interval, 18.0–21.3; acceptance criteria, 23.2 μmol/mol heme; absolute bias, 0 μmol/mol heme). Analytical performance for detecting IDE (inferred from area under the curve receiver operating characteristics) of parameters measured in blood was: ZnPP‐HPLC (0.95), sTfR (0.92), sTfR‐F (0.89), TSAT (0.87), and ferritin (0.67). Noninvasively measured ZnPP‐NI yielded results of 0.90.CONCLUSIONZnPP‐NI appears well suited for an initial IDE screening, informing on the state of erythropoiesis at the point of care without blood drawing and laboratory analysis. Comparison with a multiparameter IDE test revealed that ZnPP‐NI values of 40 μmol/mol heme or less allows exclusion of IDE, whereas for 65 μmol/mol heme or greater, IDE is very likely if other causes of increased values are excluded. In these cases (77% of our patients) ZnPP‐NI may suffice for a diagnosis, while values in between require analyses of additional iron status parameters.

Anaemia is associated with a reduced blood oxygen carrying capacity; it is defined by the WHO as a haemoglobin (Hb) concentration of <12 and <13 g dl−1 for women and men, respectively. Recent data highlight anaemia as an independent risk factor for morbidity and mortality.1Musallam K.M. Tamim H.M. Richards T. et al.Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study.Lancet. 2011; 378: 1396-1407Abstract Full Text Full Text PDF PubMed Scopus (762) Google Scholar Despite potential risks, transfusion with allogeneic blood products has been considered the mainstay to correct severe anaemia.2Whitlock E.L. Kim H. Auerbach A.D. Harms associated with single unit perioperative transfusion: retrospective population based analysis.BMJ (Clin Res Ed). 2015; 350: h3037Crossref PubMed Scopus (75) Google Scholar Patient blood management (PBM) evolved from the urgent need for adeqaute anaemia management and encompasses more than 100 measures to date.3Meybohm P. Richards T. Isbister J. et al.Patient blood management bundles to facilitate implementation.Transfus Med Rev. 2017; 31: 62-71Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 4Baron D.M. Metnitz P.G. Fellinger T. Metnitz B. Rhodes A. Kozek-Langenecker S.A. Evaluation of clinical practice in perioperative patient blood management.Br J Anaesth. 2016; 117: 610-616Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar A Hb concentration of <6 g dl−1, however, all too frequently results in an immediate transfusion without considering the alternatives. This is beyond discussion for patients with massive haemorrhage, but might be precipitous for the non-bleeding, non-surgical severely anaemic patient whose risk/benefit ratio might differ. In fact, the decision to transfuse should not be based exclusively on Hb levels, but also on physiological status, haemodynamic and respiratory parameters, volume status, and dynamics of bleeding. This is illustrated by the recent case of a 73-yr-old male with suspected iron deficiency anaemia (IDA) [Hb, 4.5 g dl−1; haematocrit (Hct), 17%] seen in our anaemia walk-in clinic5Meybohm P. Goehring M.H. Choorapoikayil S. et al.Feasibility and efficiency of a preoperative anaemia walk-in clinic: secondary data from a prospective observational trial.Br J Anaesth. 2017; 118: 625-626Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar without signs of active bleeding, with pale skin who was awake, able to walk, alert, and oriented to person, place, time, and events. No dyspnoea was observed, but he complained of overall tiredness. His body weight had been stable for the last 10 yr (BMI, 18 kg m−2). In 2016, he was diagnosed with anaemia by his general practitioner (Hb, 6.2 g dl−1; Hct, 17%) and referred for further diagnosis and treatment, with two hospitals both suggesting treatment with red blood cell (RBC) transfusion,6(BÄK) GMA Cross-sectional guidelines for therapy with blood components and plasma derivatives.2011http://www.bundesaerztekammer.de/fileadmin/user_upload/downloads/Querschnittsleitlinie_Gesamtdokument-englisch_07032011.pdfDate accessed: January 11, 2018Google Scholar which was refused by the patient along with any other treatment. His medical history revealed multiple allergies, chronic fatigue syndrome, right inguinal hernia, slightly enlarged liver, coeliac disease, latent hyperthyroidism, and immunoglobulin G deficiency. He denied regular intake of medications, reported a strict gluten-free diet and reduced consumption of meat, and denied any further medical examinations. Laboratory testing revealed severe iron deficiency (transferrin saturation, 2.33%; ferritin, 3 ng ml−1), indicating low iron stores as the underlying cause of the anaemia. Inflammatory markers, kidney and liver function tests, and vitamin B12 and folic acid concentrations were within normal ranges (Table 1). Abnormal laboratory parameters were confirmed by a second test.Table 1Patient blood values assessed externally (12 September 2016) and in our anaemia walk-in clinic (18 August 2017 and 11 September 2017). Transferrin saturation was calculated as: [Iron (μg dl−1)/transferrin (mg dl−1)]×70.9 = transferrin saturation (%). On dates marked with an asterisk (*), the patient received treatment with 1000 mg ferric carboxymaltose i.v. CRP, C-reactive protein; IDA, iron deficiency anaemia; GGT, gamma-glutamyltransferase; GOT, glutamic-oxaloacetic transaminase; GPT, glutamic-pyruvic transaminase; Hb, haemoglobin; MCH, mean corpuscular haemoglobin; MCV, mean corpuscular volumeDate12/09/201618/08/2017*11/09/2017*Normal valuesIDA cut-off valuesHb (g dl−1)6.24.58.713.5–17.5Ferritin (ng ml−1)5.35369<100Transferrin saturation (%)2.335.83<20MCV (fl)56.556.171.0<80MCH (pg)15.414.920.0<27CRP (mg dl−1)0.070.030.01<0.5Haematocrit (%)22.717.030.839.6–50.6Leucocytes (1000 μl−1)45006140Creatinine (mg dl−1)0.720.690.7–1.2Urea (mg dl−1)383318–55Bilirubin (mg dl−1)0.20.2<1.4GOT (U L−1)1824<40GPT (U L−1)713<50GGT (U L−1)3558<60Phosphatase alkaline (U L−1)556340–130Vitamin B12 (pg ml−1)476.8197–771Folic acid (ng ml−1)5.842.0–9.1 Open table in a new tab The patient received i.v. iron (1000 mg ferric carboxymaltose in 200 ml NaCl 0.9%) over a period of 30 min under constant monitoring. Dosing was based on the patient's iron status and Hb concentration. He refused in-hospital admission, but agreed to a follow up 1 week later. His status and quality of life determined by regular phone calls using a 5-point scale (bad, not too bad, OK, good, very good) showed that after the first week, he still felt tired (bad) and overall weak (bad), and refused the scheduled follow up. Two to three weeks after infusion his health-related quality of life improved incrementally [after the second week: tiredness (OK), overall condition (OK); third week: tiredness (very good) and overall condition (very good)]. Laboratory testing revealed an increase of Hb from 4.5 to 8.7 g dl−1 (Hct 30.8%), but with persisting roin deficiency anaemia (transferrin saturation (5.83%), ferritin (69 ng ml−1)) (Table 1). The patient received a second bolus of 1000 mg ferric carboxymaltose. As an additional follow-up was refused by the patient, we forwarded all information to his general practitioner to investigate the cause of iron deficiency anaemia, which might be related to his known coeliac disease. Reticulocyte Hb content is a valuable tool to monitor the effectiveness of erythropoiesis, and thus to diagnose recurrence of iron deficiency anaemia, as reticulocytes have a much quicker turnover than RBCs (3–4 vs 120 days), decreasing faster when iron stores are decreasing. In this case report, administering a single dose of i.v. iron nearly doubled the Hb concentration of a severely anaemic 73-yr-old patient from 4.5 to 8.7 g dl−1 within 3 weeks. Patients have survived even lower Hb concentrations, for example in cadaveric liver transplantation (Hb, 0. 6 g dl−1)7Kariya T. Ito N. Kitamura T. et al.Recovery from extreme hemodilution (hemoglobin level of 0.6 g/dL) in cadaveric liver transplantation.AA Case Rep. 2015; 4: 132-136Crossref PubMed Scopus (7) Google Scholar or spine surgery with renal cell carcinoma (Hb, 1.1 g dl−1),8Zollinger A. Hager P. Singer T. et al.Extreme hemodilution due to massive blood loss in tumor surgery.Anesthesiology. 1997; 87: 985-987Crossref PubMed Scopus (53) Google Scholar yet none of these patients was exposed to chronic anaemia. The human body is able to compensate for chronic anaemia by increasing cardiac output, changing Hb affinity for oxygen, and decreasing blood viscosity to increase blood flow and fluid retention. Such compensatory mechanisms can enable patients to cope with the consequences of longstanding anaemia, potentially allowing for more cause-directed treatments. As for any pharmaceutical, i.v. iron is associated with side-effects of which allergic reactions are the most serious. However, these are extremely rare with newer formulation.9Auerbach M. Deloughery T. Single-dose intravenous iron for iron deficiency: a new paradigm.Hematol Am Soc Hematol Educ Program. 2016; 2016: 57-66PubMed Google Scholar Other less serious side-effects are non-allergic infusion reactions such as skin rush, dizziness, and palpitations. Allogeneic blood transfusions can also cause allergic reactions, but are additionally associated with acute or delayed haemolytic transfusion reactions, transfusion-associated circulatory overload, transfusion-related acute lung injury, and transfusion-related immunomodulation.10Delaney M. Wendel S. Bercovitz R.S. et al.Transfusion reactions: prevention, diagnosis, and treatment.Lancet (London, England). 2016; 388: 2825-2836Abstract Full Text Full Text PDF PubMed Scopus (225) Google Scholar Correction of iron deficiency anaemia with oral iron was excluded considering the underlying coeliac disease likely resulting in limited gastrointestinal absorption and long treatment intervals of up to 6 months. As a single unit of RBCs (500 ml) increases Hb ideally by 1 g dl−1 (3% change in Hct), at least 4 units would have been required to achieve a similar result.11Elzik M.E. Dirschl D.R. Dahners L.E. Correlation of transfusion volume to change in hematocrit.Am J Hematol. 2006; 81: 145-146Crossref PubMed Scopus (49) Google Scholar Not only would this increase the likelihood of RBC side-effects, for a patient with compensated chronic severe anaemia, RBC transfusion could be extremely detrimental if ventricular architecture had changed. Furthermore, RBC transfusion would not have refilled iron stores, which is essential for erythrocyte production; therefore, anaemia would have only been reversed temporarily. As this case illustrates, a single dose of 1000 mg iron can increase Hb by 4 g dl−1 in a patient with iron deficiency anaemia by haematopoiesis. Intravenous iron is an alternative low-risk approach to treat severe iron deficiency anaemia in non-bleeding patients with relatively mild symptoms, and therefore worth routine consideration. Data collection: C.T., P.G. Data analysis and drafting of the manuscript: C.F., C.T., P.G., A.Z., K.Z., P.M., S.C. The authors thank all people involved in establishing the anaemia walk-in clinic at the University Hospital Frankfurt. Furthermore, we thank the patient who gave us permission to report the case. Special thanks to S. Isik, our anaemia nurse, who collected data and provided care for the patient. PM and KZ received grants by B. Braun Melsungen, CSL Behring, Fresenius Kabi and Vifor Pharma for the implementation of Frankfurt‘s Patient Blood Management Program; honoraria for scientific lectures from B. Braun Melsungen, Vifor Pharma, Ferring, CSL Behring, and Pharmacosmos. All other authors have no conflicts. Departmental funding.