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Non-treatment of preoperative anaemia is substandard clinical practice

2015; Elsevier BV; Volume: 115; Issue: 1 Linguagem: Inglês

10.1093/bja/aev099

1471-6771

Donat R. Spahn, Kai Zacharowski,

Cardiac, Anesthesia and Surgical Outcomes

It is well known that preoperative anaemia is frequent and associated with increased mortality and morbidity, even if only mild anaemia is present.1Musallam KM Tamim HM 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 (757) Google Scholar, 2Baron DM Hochrieser H Posch M et al.Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients.Br J Anaesth. 2014; 113: 416-423Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar In addition, preoperative anaemia is one of the most significant risk factors in subsequent red blood cell transfusion,3Gombotz H Rehak PH Shander A Hofmann A Blood use in elective surgery: the Austrian benchmark study.Transfusion. 2007; 47: 1468-1480Crossref PubMed Scopus (231) Google Scholar which in itself has adverse effects on mortality and morbidity.4Spahn DR Goodnough LT Alternatives to blood transfusion.Lancet. 2013; 381: 1855-1865Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar Therefore, unmanaged preoperative anaemia is a contraindication for elective surgery.4Spahn DR Goodnough LT Alternatives to blood transfusion.Lancet. 2013; 381: 1855-1865Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar In this edition of the British Journal of Anaesthesia, Muñoz and colleagues5Muñoz M Gómez-Ramírez S Kozek-Langenecker S et al.'Fit to fly': overcoming the barriers to preoperative haemoglobin optimization in surgical patients.Br J Anaesth. 2015; 115: 15-24Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar rightly alerted the medical community, reporting that preoperative anaemia is often left untreated. The paradox of known negative consequences of untreated anaemia and current practice is explained by the presentation of 10 widely held misconceptions. Moreover, we identified two additional reasons why physicians are still hesitating to treat preoperative anaemia systematically. First, the World Health Organization's definition of anaemia with a haemoglobin concentration of <120 g litre−1 in women and <130 g litre−1 in men is not sufficiently known by the majority of physicians. Furthermore, the notion that very mild forms of anaemia (haemoglobin values between 100–120 and 100–130 g litre−1, respectively) result in adverse clinical outcomes, such as increased mortality and a long list of complications,1Musallam KM Tamim HM 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 (757) Google Scholar, 2Baron DM Hochrieser H Posch M et al.Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients.Br J Anaesth. 2014; 113: 416-423Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar is also not well known. Second, there may be reluctance by some physicians to treat preoperative anaemia actively, because of the fact that they themselves will be held responsible for any adverse events occurring thereafter. In contrast, a perioperative transfusion in a patient who is anaemic before surgery is considered by most an inevitable event, for which medical staff cannot be held responsible. Therefore, some physicians prefer not to be involved in treating preoperative anaemia. We hope that the refuting by Muñoz and colleagues5Muñoz M Gómez-Ramírez S Kozek-Langenecker S et al.'Fit to fly': overcoming the barriers to preoperative haemoglobin optimization in surgical patients.Br J Anaesth. 2015; 115: 15-24Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar of 10 widely held misconceptions helps pave the way to widespread treatment of preoperative anaemia. A consortium of four large German University Hospitals (Frankfurt, Münster, Bonn, and Kiel) is engaged in the concept of patient blood management (PBM). The Frankfurt group has shown how to target and implement treatment of preoperative anaemia (ClinicalTrials.gov Identifiers: NCT01820949 and NCT02147795). Their investigation clearly highlights five key success factors (Table 1) for implementing a comprehensive preoperative anaemia treatment programme. The first factor, which is clearly the most important, was establishing a dedicated interdisciplinary PBM steering committee, with preoperative anaemia treatment being the first pillar of PBM.4Spahn DR Goodnough LT Alternatives to blood transfusion.Lancet. 2013; 381: 1855-1865Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar Second, the inclusion and support of senior hospital management is of utmost importance. Only with this support can the necessary reorganization of the preclinical procedures and structures be implemented. Additionally, the understanding of surgical and medical disciplines is crucial to the management and treatment of preoperative anaemia. Last, but not least, focusing our efforts on the knowledge of how operations are regularly performed in anaemic patients, who frequently require allogeneic red blood cell transfusions, is also essential (www.patientbloodmanagement.eu). Such favourable hospital conditions and improvements can be achieved only by continuous education over years and through the coordination of a dedicated interdisciplinary PBM steering committee. Should your hospital not yet have the aforementioned structure, then becoming a leader in PBM and establishing a steering committee is the way forwards.Table 1Key success factors for the large-scale implementation of preoperative anaemia treatment 1.Dedicated, interdisciplinary patient blood management steering committee2.Support from senior hospital management3.Commitment from surgical and medical disciplines4.Knowledge of patient blood management background (anaemia, transfusion, alternatives to transfusion)5.Knowledge of clinical and preclinical management: •Surgical procedures associated with frequent preoperative anaemia and considerable blood loss•Structure and processes of preclinical evaluation to be reorganized and optimized Open table in a new tab Other centres have also succeeded in implementing treatment of preoperative anaemia. Theusinger and colleagues6Theusinger OM Kind SL Seifert B Borgeat L Gerber C Spahn DR Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland.Blood Transfus. 2014; 12: 195-203PubMed Google Scholar contacted the primary physician of each patient found to be anaemic before surgery. These patients were to undergo major orthopaedic surgery (n=8871), with suggested treatment of anaemia using erythropoietin α, i.v. iron, vitamin B12 and folic acid. Despite the fact that not all patients who were anaemic before surgery were treated, the incidence of anaemia on the day of operation decreased from 15 to 10% (P<0.01) and total allogeneic transfusion rate reduced from 20 to 10% (P<0.01). Short-term treatment of preoperative anaemia with erythropoietin and i.v. iron has also been shown to be successful in orthopaedic7Na HS Shin SY Hwang JY Jeon YT Kim CS Do SH Effects of intravenous iron combined with low-dose recombinant human erythropoietin on transfusion requirements in iron-deficient patients undergoing bilateral total knee replacement arthroplasty.Transfusion. 2011; 51: 118-124Crossref PubMed Scopus (81) Google Scholar and cardiac surgery.8Yoo YC Shim JK Kim JC Jo YY Lee JH Kwak YL Effect of single recombinant human erythropoietin injection on transfusion requirements in preoperatively anemic patients undergoing valvular heart surgery.Anesthesiology. 2011; 115: 929-937Crossref PubMed Scopus (137) Google Scholar Likewise, a group of four Spanish hospitals recently published their success in short-term preoperative treatment of anaemia with erythropoietin and i.v. iron in 2547 patients undergoing hip and knee arthroplasty or surgery for hip fracture.9Muñoz M Gómez-Ramírez S Cuenca J et al.Very-short-term perioperative intravenous iron administration and postoperative outcome in major orthopedic surgery: a pooled analysis of observational data from 2547 patients.Transfusion. 2014; 54: 289-299PubMed Google Scholar They could decrease the allogeneic transfusion rate from 37 to 24% (P<0.01), the postoperative infection rate from 12 to 8% (P<0.01), and the length of hospital stay from 12 to 11 days (P<0.01). In patients undergoing surgery for hip fracture, the 30 day mortality was reduced from 9 to 5% (P<0.01). Through sound scientific evidence, they disproved 10 misconceptions of perioperative anaemia treatment. Moreover, this medical need can be met with successful treatment options. Therefore, we conclude that there is no reason why treatment of preoperative anaemia anaemia should not be widely practised. Untreated preoperative anaemia is indeed a contraindication for elective surgery, and failure to treat preoperative anaemia is substandard clinical practice. D.R.S.'s academic department is receiving grant support from the Swiss National Science Foundation, Berne, Switzerland; the Ministry of Health (Gesundheitsdirektion) of the Canton of Zurich, Switzerland for Highly Specialized Medicine; the Swiss Society of Anesthesiology and Reanimation (SGAR), Berne, Switzerland; the Swiss Foundation for Anesthesia Research, Zurich, Switzerland; Bundesprogramm Chancengleichheit, Berne, Switzerland; CSL Behring, Berne, Switzerland; and Vifor SA, Villars-sur-Glâne, Switzerland. D.R.S. was the chairman of the ABC Faculty and is the co-chairman of the ABC-Trauma Faculty, both of which are managed by Physicians World Europe GmbH, Mannheim, Germany and sponsored by unrestricted educational grants from Novo Nordisk Health Care AG, Zurich, Switzerland; CSL Behring GmbH, Marburg, Germany; and LFB Biomédicaments, Courtaboeuf Cedex, France. In the past 5 years, D.R.S. has received honoraria or travel support for consulting or lecturing from the following companies: Abbott AG, Baar, Switzerland; AMGEN GmbH, Munich, Germany; AstraZeneca AG, Zug, Switzerland; Bayer (Schweiz) AG, Zürich, Switzerland; Baxter AG, Volketswil, Switzerland; Baxter S.p.A., Roma, Italy; B. Braun Melsungen AG, Melsungen, Germany; BoehringerIngelheim (Schweiz) GmbH, Basel, Switzerland; Bristol-Myers-Squibb, Rueil-Malmaison Cedex, France and Baar, Switzerland; CSL Behring GmbH, Hattersheim am Main, Germany and Berne, Switzerland; Curacyte AG, Munich, Germany; Ethicon Biosurgery, Sommerville, NJ, USA, Fresenius SE, Bad Homburg v.d.H., Germany; Galenica AG, Bern, Switzerland (including Vifor SA, Villars-sur-Glâne, Switzerland); GlaxoSmithKline GmbH & Co. KG, Hamburg, Germany; Janssen-Cilag AG, Baar, Switzerland; Janssen-Cilag EMEA, Beerse, Belgium; Merck Sharp & Dohme AG, Luzern, Switzerland; Novo Nordisk A/S, Bagsvärd, Denmark; Octapharma AG, Lachen, Switzerland; Organon AG, Pfäffikon/SZ, Switzerland; Oxygen Biotherapeutics, Costa Mesa, CA, USA; Photonics Healthcare GmbH, Munich, Germany; ratiopharm Arzneimittel Vertriebs-GmbH, Vienna, Austria; Roche Diagnostics International Ltd, Reinach, Switzerland; Roche Pharma (Schweiz) AG, Reinach, Switzerland; Schering-Plough International, Inc., Kenilworth, NJ, USA; Tem International GmbH, Munich, Germany; Verum Diagnostica GmbH, Munich, Germany; ViforPharma Deutschland GmbH, Munich, Germany; ViforPharma Österreich GmbH, Vienna, Austria; and Vifor (International) AG, St Gallen, Switzerland. K.Z.'s department is receiving unrestricted educational grants from B. Braun Melsungen AG, Fresenius Kabi GmbH, CSL Behring GmbH, and ViforPharma GmbH. In the past 3 years, K.Z. has received honoraria or travel support for consulting or lecturing from the following companies: Abbott GmbH & Co. KG, Aesculap Akademie GmbH, AQAI GmbH, Astellas Pharma GmbH, AstraZeneca GmbH, Aventis Pharma GmbH, B. Braun Melsungen AG, Baxter Deutschland GmbH, Biosyn GmbH, Biotest AG, Bristol-Myers Squibb GmbH, CSL Behring GmbH, Dr. F. Köhler Chemie GmbH, Dräger Medical GmbH, Essex Pharma GmbH, Fresenius Kabi GmbH, Fresenius Medical Care, Gambro Hospal GmbH, Gilead, GlaxoSmithKline GmbH, Grünenthal GmbH, Hamilton Medical AG, HCCM Consulting GmbH, Heinen+Löwenstein GmbH, Janssen-Cilag GmbH, med Update GmbH, Medivance EU B.V., MSD Sharp&Dohme GmbH, Novartis Pharma GmbH, Novo Nordisk Pharma GmbH, P. J. Dahlhausen & Co. GmbH, Pfizer Pharma GmbH, Pulsion Medical Systems S.E., Siemens Healthcare, Teflex Medical GmbH, Teva GmbH, TopMed Medizintechnik GmbH, Verathon Medical, and ViforPharma GmbH. 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