Multicenter prospective study in several Spaniard hospital Anemia and iron deficit in preoperative study Presented at NATA meeting at Dublin, April 2016

1. Analysis of the prevalence and causes of low
preoperative haemoglobin levels in a large
multicentre cohort of patients undergoing
major non-cardiac surgery
García-Erce JA1
, Laso-Morales MJ2
, Gómez-Ramírez3
,
Núñez-Matas MJ4
, Muñoz M3
1
Haematology and Haemotherapy, General Hospital San Jorge, Huesca (Spain);
2
Anaesthesiology, Corporacio Sanitarìa Parc Taulí, Sabadell (Spain);
3
Perioperative Transfusion Medicine, School of Medicine, Málaga (Spain);
4
Obstetrics and Gynaecology, Regional University Hospital, Málaga (Spain).

2. Conflictos de interés
Asesor externo
- AMGEN Oncología 2010/2012
- Roche Anemia 2009
- Ditassa-Ferrer 2004
Charlas, estudios investigación y ayudas a congresos
-Vifor-Uriach/Ferralinze
-Janssen-Cilag/Braun/Sandoz/Zambon
-Astra-Tech de Aztra Zeneca/Well-Health?/GSK
-Sanofi Aventis/Esteve/Novartis/Octapharma
-Cobe-Caridian/Roche Oncología/AMGEN Oncologia
Miembro del CAT 2002-2005
Miembro del Documento de Sevilla “Alternativas a la
Transfusión”
Miembro del Documento LatinoAmericano de la Anemia
Miembro de GIEMSA/ Secretario AWGE/Socio
SETS/AEHH/NATA
Editor Asociado Revista ANEMIA www.revistaanemia.org
Miembro Comité Científico NATA y TATM

3. Anaemia, blood loss & transfusion
García-Erce JA et al. NATA Dublin 2016

4. Anaemia, blood loss & transfusion
García-Erce JA et al. NATA Dublin 2016

5. Anaemia, blood loss & transfusion
Goodnough et al. NATA guidelines. Br J Anaesth 2011.
Seville Document Update. Blood Transfusion 2013.
BCSH Guidelines. Br J Haematol 2015.
 Detection of anaemia, preferably at least 28 days
before the surgical procedure.
 Classification of anaemia to implement appropriate
treatment, if possible.
 Unexplained anaemia should be further investigated
and surgical procedure postponed, if possible.
 Haematinic defficiencies without anaemia should
be supplemented to allow:
• Preoperative Hb optimization.
• Recovery from postoperative anaemia.

6. Objectives
For effectively implementing a management protocol for
optimisation of preoperative anaemia, an estimation of its
prevalence and main causes would be needed.
García-Erce JA et al. NATA Dublin 2016
We analysed data from 2699 patients (47% women) scheduled
for frequent major non-cardiac surgical procedures, including:
• Orthopaedic (n=1286)
• Gynaecologic (n=207)
• Prostate/bladder cancer resection (n=381)
• Colorectal cancer resection (n=678)
• Liver metastases resection (n=147).

7. Definitions
García-Erce JA et al. NATA Dublin 2016
 Preoperative anaemia (Low preoperative Hb):
Haemoglobin <13 g/dL (for both genders)
 Absolute iron deficiency:
Ferritin <30 ng/mL or
Ferritin <100 ng/mL & Transferrin saturation [TSAT] <20%
or C-reactive protein [CRP] >5 mg/L
 Iron sequestration:
Ferritin >100 ng/mL & Transferrin saturation [TSAT] <20%
or C-reactive protein [CRP] >5 mg/L
 Inadequate iron stores:
Ferritin <100 ng/mL (without anaemia)
 Madurative factor deficiency:
Vitamin B12 < 200 pg/mL and/or Folic acid <3 ng/mL

8. Preoperative anaemia prevalence
García-Erce JA et al. NATA Dublin 2016
Surgery Patients
n
Anaemia*
n (%)
Gynaecologic 207 131 (63)
Colorectal cancer 685 398 (58)
Liver metastases 142 53 (37)
Orthopaedic 1286 330 (26)
Prostate/bladder cancer 379 35 (9)
Overall 2699 947 (35)
* As defined by Hb <13 g/dL for both genders

9. Haematinic deficiency prevalence
García-Erce JA et al. NATA Dublin 2016
Anaemia No anaemia
Patients, n (%) 947 (35) 1752 (65)
Women (%) 70 35
Ferritin <30 mg/L (%) 43 15
Ferritin <100 mg/L (%) 77 57
TSAT<20% (%) 66 47
CRP > 5mg/L (%)* 37 26
Vitamin B12 <200 pg/mL** 7 11
Folic acid <3 ng/mL** 4 9
*Data from 1792 patients; **Data from 958 patients

10. Preoperative anaemia classification
García-Erce JA et al. NATA Dublin 2016
IDA
Ferritin <30
ACI + ID
Ferritin 30-100
+ TSAT<20
or CRP>5
ACI
Ferritin >100
+ TSAT<20
or CRP>5
Vit B12 & Folate
Low
VCM >100 fL
Megaloblastic
anaemia
Normal
values
Endocrine CKDAUC SMDMalignancy
Hb <13 g/dL
Abnormal iron parameters Normal iron parameters
2115 patients*
405 (57%) 93 (13%) 43 (6%)
21 (3%)
153 (21%)
*with iron parameters and CRP values
715 (34%)

11. Type of anaemia according to surgery
García-Erce JA et al. NATA Dublin 2016
Gynaecologic Colorectal Liver MTX Orthopaedic Prostate
0
20
40
60
80
100 IDA
ACI+ID
ACI
Other
Typeofanaemia(%)
(123) (209) (51) (299) (33)
715 out of 2115 patients with preoperative anaemia

12. Haematinic deficiency prevalence
García-Erce JA et al. NATA Dublin 2016
Anaemia No anaemia
Patients, n (%) 947 (35) 1752 (65)
Women (%) 70 35
Ferritin <30 mg/L (%) 43 15
Ferritin <100 mg/L (%) 77 57
TSAT<20% (%) 66 47
CRP > 5mg/L (%)* 37 26
Vitamin B12 <200 pg/mL** 7 11
Folic acid <3 ng/mL** 4 9
*Data from 1792 patients; **Data from 958 patients

13. Prevalence of low iron stores
García-Erce JA et al. NATA Dublin 2016
Overall Gynaecol Colorectal Liver MTX Orthop Prostatic
0
20
40
60
80
100
PrevalenceFerritin<100(%)
Non-anaemic patients (1751) (76) (286) (89) (956) (344)
Ferritin <100 ng/mL 1004 71 181 55 553 144

14. Distribution of surgeries in women
García-Erce JA et al. NATA Dublin 2016
Surgery Hb
<12 g/dL
Hb
≥12 - <13 g/dL
Hb
>13 g/dL
Gynaecologic 134 267 237
Colorectal cancer 90 126 60
Liver metastases 10 29 27
Orthopaedic 95 266 422
Bladder cancer 4 4 2
Overall 333 692* 748
* 692/1773 (38%) of all women

15. Haematinic deficiency in women
García-Erce JA et al. NATA Dublin 2016
Hb
<12 g/dL
Hb
≥12 - <13 g/dL
Hb
>13 g/dL
Patients 333 692 748
Ferritin <30 mg/L (%) 51 42 24
Ferritin <100 mg/L (%) 79 79 79
TSAT<20% (%) 69 58 34
CRP > 5mg/L (%) 40 39 30
Vit B12 <200 pg/mL (%) 8 7 7
Folic acid <3 ng/mL (%) 6 4 8

16. Conclussions
García-Erce JA et al. NATA Dublin 2016
 Preoperative anaemia is present in one-third of patients
scheduled for major non-cardiac surgical.
 Up to three-fourths of patients with preoperative anaemia
presented with absolute or functional iron deficiency, and
may benefit from iron supplementation (preferably by IV
route), with or without adjunct erythropoietin administration.
 More than one-half of patients without preoperative anaemia
presented with inadequate iron stores to recover from
postoperative anaemia, and may also benefit from iron
supplementation (initially by oral route).
 We consider these data useful for planning preoperative
management of patients scheduled for major non-cardiac
surgery.

17. PRE-HABILITATION

18. Thank you for your kind attention!

19. UNIVERSIDAD DE ZARAGOZA
“PATIENT BLOOD MANAGEMENT”
CASTYM
JAC (HUESCA) 20 – 22 JULIO 2016
Dr José Antonio García-Erce
GIEMSA. AWGE. NATA. Investigador del IACS y IdiPAz 49
Grupo de Trabajo de la SETS “Hemoterapia basada en el sentido común”
Servicio Hematología y Hemoterapia. H San Jorge (Huesca).