Anemia, Surgery Patient Blood Management, Iron deficit, Iron deficiency Anaemia Choosing Wisely

1. “PATIENT BLOOD MANAGEMENT”
Strategies and protocols to optimize
hemoglobin levels
Dr José Antonio García-Erce
GIEMSA. AWGE. NATA. Investigador del IACS y IdiPAz 49
Coordinador Grupo de Trabajo de la SETS “Hemoterapia basada en
el sentido común”
Servicio Hematología y Hemoterapia. H San Jorge (Huesca).

2. Conflicts of Interest
External Assesor
- AMGEN Oncología 2010/2012
- Roche Anemia 2009
- Ditassa-Ferrer 2004
Speach/Talks, investigations trials, grants, collaborations
-Vifor-Uriach/Ferralinze/Zambon
-Janssen-Cilag/Braun
-Astra-Tech de Aztra Zeneca/Well-Health?/GSK
-Sanofi Aventis/Esteve/Novartis/Octapharma
-Cobe-Caridian/Roche Oncología/AMGEN Oncologia
Member CAT 2002-2005
Member Documento de Sevilla “Alternativas a la Transfusión”
Member Documento LatinoAmericano de la Anemia
Member GIEMSA/AWGE/SETS/AEHH/NATA
Scientific Committe NATA
SEHH representative in ONT (Organización Nacional de Transplante)
Coordinator of Working Group “Hemoterapia con sentido común”

3. Prof. Manolo Muñoz Gómez
GIEMSA. Facultad de Medicina. Universidad de Málaga
Dr. Jorge Cuenca Espiérrez
Trauma and Orthopaedic Surgery. Aragón.
Prof. Antonio Herrera Rodríguez
Cátedra Department of Orthopaedic Surgery. Zaragoza
Dr Manuel Quintana Díaz
Unidad Cuidados Intensivos y Quemados. Hospital Universitario La Paz. Madrid. IDI-PAZ 49
Dra Ana I Peral García
Servicio de Anestesiología y Reanimación. Hospital Univeritario Puerta de Hierro. Majadahonda
Dra Dª Elvira Bisbe Vives
Servicio de Anestesiología y Reanimación. Hospital de La Esperanza, Barcelona
Dra Dª Mendaza
ExJefa de Servicio. Farmacia Hospitalaria. University Hospital Miguel Servet, Zaragoza
Acknowledgements

5. WHY?
ANAEMIA “EPIDEMIA”
« PATIENT BLOOD MANAGEMENT »

6. 25%
Incidence/Prevalence of Anaemia
Cortestía/Modifiicada Prof. M. Muñoz

7. Cortesy/Modificated from Prof M Muñoz. / Kassebaum NJ et al. Blood 2014; 123: 615-624
Data from 187 countries (1990 – 2010)
1990 2010
HombresMujeres
1990 2010
50
40
30
20
10
BLEEDING
Malaria
Anquilostoma
Esquistosoma
HbS/ falciform A
Talasemias
CKD Diabetes
CKD HipertensiOn
Another CKDs
IRON DEFICIT
Incidence/Prevalence and etiology of Anaemia

8. POSTGRADO UNIVERSITARIO EN BLOOD MANAGEMENT
Wen-Chih Wu et al. JAMA 2007; 297: 2481 – 2488
Haematocrit < 39%
Procedure Patients (n) n %
General surgery 106 340 45 478 42.8
Urology 59 157 21 408 36.2
Orthopaedics 57 636 25 131 43.6
Periferic vascular 47 734 24 865 52.1
Thoracic 14 051 6 780 48.3
Others 25 393 9 308 36.7
Overall 310 311 132 970 42.8
Cortestía/Modifiicada Prof. M. Muñoz
Prevalence of Preoperative Anaemia

9. POSTGRADO UNIVERSITARIO EN BLOOD MANAGEMENTCortestía/Modifiicada Prof. M. Muñoz
Shander et al. 2004
Prevalence of Peri-operative Anaemia

10. García-Erce JA, Laso-Morales MJ, Gómez-Ramírez, Núñez-Matas MJ, Muñoz M. Analysis of
the prevalence and causes of low preoperative haemoglobin levels in a large multicentre
cohort of patients undergoing major non-cardiac surgery. Transfusion Medicine 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 cancer 379 35 (9)
Overall 2699 947 (35)
* As defined by Hb <13 g/dL for both genders

11. 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
García-Erce JA, Laso-Morales MJ, Gómez-Ramírez, Núñez-Matas MJ, Muñoz M. Analysis of
the prevalence and causes of low preoperative haemoglobin levels in a large multicentre
cohort of patients undergoing major non-cardiac surgery. Transfusion Medicine 2016

12. García-Erce JA, Laso-Morales MJ, Gómez-Ramírez, Núñez-Matas MJ, Muñoz M. Analysis of
the prevalence and causes of low preoperative haemoglobin levels in a large multicentre
cohort of patients undergoing major non-cardiac surgery. Transfusion Medicine 2016
WOMEN 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
* 692/1773 (38%) of all women

14. WHY?
ANAEMIA EPIDEMIA
ANAEMIA´S RISKS
« PATIENT BLOOD MANAGEMENT »

15. Blood loss (mL)
ι
0
ι
500
ι
1000
ι
1500
ι
2000
ι
2500
ι
3000
Acute Anaemia
Transfusion
Haemoglobin(g/dL)
9 –
11 –
13 –
7 –
5 –
15 –
Haemoglobin lost
(IRON)
Bleeding
25% 45%
Erythrocyte mass
Major surgical procedures
(orthopedics, trauma, cardiac, cancer, etc)
Modificada /Cortesía Prof. M. Muñoz
Risks of preoperative anaemia

16. Rosencher et al. OSTHEO study. Transfusion 2003.
Transfusionprobability(%)
Women
Men
1680 THA, TKA
↑10% ABT per ↓1 g/dL Hb
Haemoglobin (g/dL)
8 9 10 11 12 13 14 15 16
31.2%
Patients(%)
Haemoglobin (g/dL)
© Prof. M. Muñoz- Modified/Cortesy Prof Muñoz
Risks of preoperative anaemia

17. POSTGRADO UNIVERSITARIO EN BLOOD MANAGEMENT
AumentodelriesgoINCREASEOFRISK
© Prof. M. Muñoz- Modified/Cortesy Prof Muñoz

18. POSTGRADO UNIVERSITARIO EN BLOOD MANAGEMENT
Anaemia* Patients
N (%)
Mortality
OR (CI 95%)
Morbildity**
OR (CI 95%)
No-anaemics 158196 (69.4) 1 1
Anaemics 69229 (30.4) 1.42 (1.31 – 1.54) 1.35 (1.30 – 1.40)
• Slight 57870 (25.4) 1.41 (1.30 – 1.53) 1.31 (1.26 – 1.36)
• Moderate - severe 11359 (5.0) 1.44 (1.29 – 1.60) 1.56 (1.47 – 1.66)
Total: 227425 patientes
* Slight anaemia: Hto >29% – <36/39%; Moderated-severe anaemia: Hto ≤29%.
** One o more cardiac, respiratory, renal, neurologic or surgical wound complications,
sepsis or deep venous thrombosis (30d postOP).
© Prof. M. Muñoz

19. POSTGRADO UNIVERSITARIO EN BLOOD MANAGEMENT

20. POSTGRADO UNIVERSITARIO EN BLOOD MANAGEMENT
Anaemia OR ajusted [CI 95%] p
Allogenic Transfusion 4.7 [3.8 – 5.8] <0.001
Hospital stay >5 days 2.5 [1.9 – 3.4] <0.001
Readmission 90 days 1.4 [1.1 – 1.9] <0.005
5165 knee and hip arthroplasties
6 fast-track danish centers (January 2010 – December 2011)
662 anaemics (13%) (OMS criteria)
Cortestía/Modifiicada Prof. M. Muñoz
Risks of preoperative anaemia

21. Risks of preoperative anaemia

23. POSTGRADO UNIVERSITARIO EN BLOOD MANAGEMENT
Colorectal resections performed from 2001 to 2013 in New York State
125,160 cases met inclusion criteria. There were 3481 surgeons and 210 hospitals that
performed at least 1 elec-tive colorectal resection.
RESULTS: the overall rate of perioperative blood transfusion for the study
cohort was 13.9%. the unadjusted blood transfusion rates ranged from 2.4% to
58.7% for individual surgeons and 2.9% to 32.8% for individual hospitals.
Receipt of a blood transfusion was also independently associated with
pneumonia (OR = 3.23), surgical site infection (OR = 2.27), intra-abdominal
abscess (OR = 2.72), and sepsis (OR = 4.51).
Risks of preoperative anaemia

24. Cortestía/Modifiicada Prof. M. Muñoz
?
Risks of preoperative anaemia

25. Risks of preoperative anaemia

27. WHY?
ANAEMIA EPIDEMIA
ANAEMIA´S RISKS
LEGISLATION
« PATIENT BLOOD MANAGEMENT »

28. NEED OF A « PATIENT BLOOD MANAGEMENT »
12. Patients should be informed of the known risks and
benefits of blood transfusion and/or alternative therapies
and have the right to accept or refuse the procedure. Any
valid advance directive should be respected.
Principle of patient’s autonomy
15. Genuine clinical need should be the only basis for
transfusion therapy.
Ethical principles of beneficence and justice
Addapted Prof Muñoz

29. The outcome, optimal use of blood is defined as:
The safe, clinically effective and efficient use of
donated human blood
2010
Safe: No adverse reactions or infections
Clinically effective: Benefits the patient
Efficient: No unnecessary transfusions.
Transfusion at the time the patient needs it
NEED OF A « PATIENT BLOOD MANAGEMENT »

30. It is necessary to reduce the unnecessary transfusions. This can be achieved
through the appropriate clinical use of blood, avoiding the needs for transfusion
and use of alternatives to transfusion.
The commitment of the health authorities, health care providers and clinicians
are important in prevention, early diagnosis and treatment of diseases/
conditions that could lead to the need for blood transfusion.
http://www.who.int/bloodsafety/clinical_use/en/
Blood transfusion is an essential part of modern health care. Used correctly, it
can save life and improve health. However, as with any therapeutic intervention,
it may result in acute or delayed complications and carries the risk of
transmission of infectious agents.
WHA 63.12 (resolution). Availability, safety and quality of blood products, 2010.
Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R12-en.pdf.
NEED OF A « PATIENT BLOOD MANAGEMENT »

31. Perioperative
Optimization of
erithropoiesis
Minimitation of
blood loss and
perioperative
coagulopathy
Optimization of
perioperative
anaemia tolerance
and blood
recovery
The national health systems, health authorities, health care
providers must stablish
MULTIMODAL MULTIDISCIPLINAR PERIOPERATIVE PROGRAMS
to improve the perioperative manage of patient based on:
WHA 63.12 (resolution). Availability, safety and quality of blood products, 2010.
Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R12-en.pdf.
Addapted Prof Muñoz
NEED OF A « PATIENT BLOOD MANAGEMENT »

33. WHY?
ANAEMIA EPIDEMIA
ANAEMIA´S RISKS
LEGISLATION
RECOMENDATIONS/EVIDENCE
NEED OF A « PATIENT BLOOD MANAGEMENT »

34. "Whenever clinically feasible, patients undergoing elective surgery
with a high risk of severe postoperative anaemia should have their
haemoglobin level and iron status tested, preferably at least 28
days before the surgical procedure. For patients >60 yr old,
vitamin B12 and folic acid should also be measured".
NEED OF A « PATIENT BLOOD MANAGEMENT »

35. sibility of guideline implementation.
5 External stakeholders areidentified and given theopportu-
nity to comment. In this case, comment wasreceived from
the Association of Anaesthetists of Great Britain and Ire-
Secretary, British Society for Haematology,
London N1 9PF, UK.
uk
6 September 2015
3
ª 2015 John Wiley & Sons Ltd
British Journal of Haematology, 2015, 171, 322–331
Recommendation
- To avoid causing unnecessary delay to patients, anaemia screening
should take place when referral for surgery is first made, in order to
allow investigation and correction if appropriate (Grade 1C).
- Where surgery is urgent, whatever time is available before operation should still
be used for anaemia investigation and treatment initiation (Grade 1C).
NEED OF A « PATIENT BLOOD MANAGEMENT »

37. Spanish Consensus Statement on alternatives to allogeneic blood
transfusion: the 2013 update of the "Seville Document“. Blood Transfus.
2013 Jun 17:1-25.

38. Iron supplementation’s evidence
Orthopaedic, gynaecologic, colo-rectal.
 Preoperative IV iron (Grade 2B)
Orthopaedic, gynaecologic, cardiac (±
rHuEPO).
 Perioperative IV iron (Grade 2B)
ID or low iron stores (ferritin <100
ng/mL), if there is enough time.
 Preoperative oral iron (Grade 2B)
No recommended.
 Postoperative oral iron (Grade – 1B)
Seville Document Update. Blood Transfusion 2013.© Prof. M. Muñoz/Cortesy Prof Muñoz

39. POSTGRADO UNIVERSITARIO EN BLOOD MANAGEMENT
European Society of Anesthesia’s Guidelines 2013
Management of severe perioperative bleeding ESA
Preoperative correction of anaemia
- We recommend that patients at risk of bleeding are assessed for
anaemia 4–8 weeks before surgery. 1C
- If anaemia is present, we recommend identifying the cause (iron
deficiency, renal deficiency or inflammation). 1C
- We recommend treating iron deficiency with iron
supplementation (oral or intravenous). 1B
- If iron deficiency has been ruled out, we suggest treating anaemic patients
with erythropoietin-stimulating agents. 2A
- If autologous blood donation is performed, we suggest treatment with
erythropoietin-stimulating agents in order to avoid preoperative anaemia and
increased overall transfusion rates. 2B

42. WHY?
ANAEMIA EPIDEMIA
ANAEMIA´S RISKS
LEGISLATION
RECOMENDATIONS
HOW?
NEED OF A « PATIENT BLOOD MANAGEMENT »

43. Pre-operative

44.  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.
• Hastening the recovery from postoperative anaemia.
Goodnough et al. NATA guidelines. BJA 2011;106:13-22.
Seville Document Update. Blood Transfusion 2013.
The "ORTHODOX " approach
© Prof. M. Muñoz/Cortesy Prfo Muñoz

45. Transfus Med, 1997; 7:281 – 286
Iron pre-load for major joint replacement
C.M. Andrews, D.W. Lane, and J.G. Bradley
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
Anaemic Control Iron
Hbfall(g/dl)
Postoperative fall in Hb
with 95% confidence limits
P=0·008
Table 4. Homologous blood transfused
Mean units
transfused
Transfusion
rate
Anaemic 2·8 4/16 (25.0%)
Control 1·8 3/40 (7.5%)
Iron 1·7 0/35 (0.0%)
Anaemic ferrous sulphate 200 mg b.d. 4-weeks
Iron: ferrous sulphate 200 mg b.d. 4-weeks
Control: no treatment
Non anaemic

46. Patients and methods: We assessed the requirements for ABT in 156 consecutive
patients undergoing surgery for primary TKR, who received iron ferrous sulphate
(256 mg/day; 80 mg of Fe2+), vitamin C (1000 mg/day) and folic acid (5 mg/day)
during the 30-45 days preceding surgery, and who were transfused if Hb <80 g/L
and/or clinical signs/symptoms of acute anaemia or hypoxemia (Group 2).
A previous series of 156 TKR patients serves as a control group (Group 1).

47. Preoperative oral iron

49. POSTGRADO UNIVERSITARIO EN BLOOD MANAGEMENT
Okuyama M, Ikeda K, Shibata T, Tsukahara Y, Kitada M, Shimano T. Preoperative Iron
Supplementation an Intraoperative Transfusion During Colorectal Cancer Surgery. Surg Today
(2005) 35: 36-40
ABT intra OP 27,4% vs 9,4%
Iron supplementation was given for at
least 2 weeks preoperatively to 32
patients whose Hb level at first
presentation was 10.0 g/ dl (group A).
The iron preparation was sodium ferrous
citrate (200 mg/day), given orally after
meals in the morning and evening.

50. Tasa transfusional: 8 %

51. Muñoz M et al. WJG 2014

52. Post-operative

54. WHY?
ANAEMIA EPIDEMIA
ANAEMIA´S RISKS
LEGISLATION
RECOMENDATIONS
HOW
CONCLUSIONS
NEED OF A « PATIENT BLOOD MANAGEMENT »

55. WHA 63.12 (resolution). Availability, safety and quality of blood products, 2010.
Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R12-en.pdf.
Optimización
perioperatoria
eritropoyesis
Minimización
del sangrado/
coagulopatía
Tolerancia
a la anemia
postoperatoria
Mejor
resultado
clínico
Cortesía Prof Muñoz

56. PREPARAR AL PACIENTE

57. PREPARAR AL PACIENTE

58. Multidisciplinar Work Team
We can not do it alone!
Cortesía Prof Muñoz

59. Gerencia
Hospital
Apoyo
Organización
Compromiso Anestesiólogos GeneralistasHematólogosCirujanos
Liderazgo Coordinador del programa de PBM
Conocimiento Sangrado Alternativas CostesTransfusiónAnemia
Autoridades
Sanitarias
Fondos
Legislación
Sociedades
Medicas
Guías de
práctica
clínica
Consejo
Planificación Implementación Evaluación
Cortesía Prof Muñoz We can not do it alone!
Multidisciplinar Work Team

61. “The safest blood transfusión is….the one don´t given”
Please!, DO SOMETHING! TREAT THE ANAEMIA WISE AND NICELY!

64. “PATIENT BLOOD MANAGEMENT”
MUCHAS GRACIAS POR SU ATENCIÓNA
Dr José Antonio García-Erce
GIEMSA. AWGE. NATA. Investigador del IACS y IdiPAz 49
Coordinador Grupo de Trabajo de la SETS “Hemoterapia basada en
el sentido común”
Servicio Hematología y Hemoterapia. H San Jorge (Huesca).