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Preoperative Anemia

Preoperative Anemia. Lori Heller, MD Cardiac Anesthesiologist Medical Director, Blood Management Program Swedish Medical Center Seattle, WA. Outline. Anemia/preoperative anemia – Outcomes Evaluation of Anemia Treatment Iron ESA – safety/efficacy. Swedish Medical Center.

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Preoperative Anemia

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  1. Preoperative Anemia Lori Heller, MD Cardiac Anesthesiologist Medical Director, Blood Management Program Swedish Medical Center Seattle, WA

  2. Outline • Anemia/preoperative anemia – Outcomes • Evaluation of Anemia • Treatment • Iron • ESA – safety/efficacy

  3. Swedish Medical Center Private, non-profit organization founded 1910 6 Hospitals 100 Primary and Specialty Care Clinics 2 Ambulatory Care Centers Level II Trauma Residency: Gen Surgery/Family Medicine/Podiatry Fellowships: MFM, Thoracic , Neuro, Robotic, Lap Active Robotic Surgery Program 11,000 employees in Greater Seattle

  4. FH Main Campus Ballard Campus 163 beds 613 beds 385 beds Cherry Hill Campus

  5. Swedish Orthopedic Institute Edmonds Campus 217 beds 84 beds 80175 beds Issaquah Campus 5

  6. Blood Management • Began 1999 as Bloodless Program • Manager • 1.5 FTE RN • 0.7 FTE data assistant • Medical Director – 20 hrs month

  7. % Orthopedic Patients Transfused Ortho transfusion rate decreased 83% over 6 years.

  8. % Patients transfused decreased from 32 to 23 % Hospitalists Patients Transfused

  9. Autologous Blood Utilization

  10. Anemia – it’s prevalent! Estimated 3.5 million US Preoperative – 20-40% (Ortho, lung ca, colorectal, mixed) HCT < 39 – 25-30% HCT < 36 – 34% Elderly – 10-60% Hospitalized men HCT < 39 50-60% women HCT < 36 40% Community - 5-59% • Cardiac Surgery – 26%

  11. Percent CV Pts Anemic Upon Admission 2011-2012

  12. % Orthopedic Patients Anemic

  13. Anemia Higher rates of hospitalization Decreased survival 5 yr survival 48 v. 67% (p<0.001) 8 year survival It’s bad! SaliveJ Am GeriatrSoc 1992;40:489-96 Kikuchi et al J Am Geriatr Soc 2001;49:1226-8 The American Journal of MedicineVolume 119 • Number 4 • April 2006

  14. Anemia Survival Not Anemic Anemic The American Journal of MedicineVolume 119 • Number 4 • April 2006

  15. Preoperative Anemia It’s bad too!

  16. Preoperative Anemia 227,425 pts RC 30 day outcome OR 1.42 mortality Even Mild Anemia Lancet 2011; 378: 1396–407

  17. Preop Anemia 300,000 age > 65 (RC) Increased Mortality and Cardiac Events HCTS < 39 Jama, June 13 2007 Vol 297 (22)

  18. Preop Anemia Retrospective Review 8000 /Non cardiac Surg Prevalence 40% (HCT 36, 39) Adjusted for other RF and Elimination of transfusion or severe anemia OR 2.29 Independently Increased Mortality Anemic Not Anemic Anesthesiology Issue: Volume 110(3), March 2009, pp 574-581

  19. Preop Anemia Anesthesiology Issue: Volume 110(3), March 2009, pp 574-581

  20. Preoperative Evaluation A (reformed) internists perspective: Focused on cardiac status, pulmonary reserve CBC, chemistry, PFT’s, cardiac stress test • “Coronary artery disease – consider beta blockade, perioperative nitrates and placement of Swan Ganzcatheter.”

  21. Confession continued… • Preoperative anemia  ~ 34 • Check Iron studies, trial of oral iron, stool guaiac, send for colon exam “May need perioperative transfusion”

  22. Preoperative Evaluation It’s all relative CAD BE CAREFUL!!!

  23. % Pts Anemic on Admission

  24. Improved Preop Admission Anemia • Managing preop anemia

  25. Improved Preop Admission Anemia • Managing preop anemia • Showing Data • Canceling cases • Make it easy for surgeons

  26. Preoperative Anemia Assessment • 28-30 days in advance • Flexible – finger stick hgb when convenient Prenatal Oral Iron

  27. Limited in Scope • Not for full work up of anemia • Detection and treatment of preoperative anemia to improve surgical outcomes • Always referred back to PMD!

  28. Anemia Decreased Production Increased Destruction Marrow Failure Intrinsic RBC Decreased B12/Folate/ Chemo/Myelodysplastic Decreased HEME Decreased Globin Iron Def Thalassemia Sideroblastic ACD

  29. Anemia Decreased Production Increased Destruction Blood Loss Intravascular Hemolysis Extravascular Hemolysis Vasculitis DIC Prosthetic Valve HGB S, C, E G6PD Immune Hemolysis Hypersplenism

  30. Anemia Blah BlahBlah Blah BlahBlah Blah Blah Blah Blah Decreased B12/Folate/ Myelodysplastic Decreased Blah Blah Decreased Blah Blah Iron Def Thalassemia Sidero something ACD

  31. Surgeon’s View Give Iron Refer to Hematologist

  32. Preoperative Anemia – NATA British Journal of Anaesthesia 106 (1): 13–22 (2011)

  33. Anemia Other Cell lines/abnormal cells? CBC MCV/RDW Retic Count Or normal Iron Studies B12/Folate c/w ACD B12 replacement IM/PO Folate IV Iron ESA + IV iron Thyroid ?ETOH Prenatal B12 500 mcg

  34. Iron • Little use for oral iron as sole replacement • Limited pt compliance • Months to improve stores • Poor absorption – H2 blockers, PPI, inflammation • Chromagen Forte • Vitamin C • B12 • Folate • Prenatal + 500 mcg B12 + Iron

  35. IV Iron • Iron Dextran – “Total dose” replacement - 1500 mg • Risk anaphylaxis • Needs pretreatment • Iron Gluconate/Sucrose • Limited by dosing • 125 mg QD Ferrlicet • 200 mg 2-3 x week Venofer • Ferumoxytol (Feraheme) • 510 mg IV push (watch anaphylaxis x 30 min) • 2 doses 3-8 days apart

  36. Calculating Dose • 150-200 mg Iron for each gm/dl hgb deficit • Plus 500-800 mg to replace true iron stores if • tsat < 10 OR • tsat < 20 + ferritin < 100 ng/dl • Normal hgb+ decreased Ferritin • [100 – ferritin] x 10 • Acute blood loss – mg per cc

  37. FE Deficiency V. ACD

  38. Anemia of Chronic Disease: Role of Hepcidin Andrews J Clin Invest 2004

  39. Anemia Of Chronic Disease • Enteric uptake inhibited • Release from Macrophages Inhibited

  40. Anemia of Chronic Disease- Preoperative Treatment • ESA • IV iron

  41. ESA Use Goodnough Transfusion 34:66-71, 1994 J ThoracCardiovascSurg2001;122:741-745 Sowade Blood 1997 89: 411-418 • Effective • Check CMS guidelines - WA • Elective Hips and Knees HCTS < 39 • All others HCTS < 33 • Not Iron deficient • Give iron with ESA

  42. ASA Statement on Transfusion 2006 Erythropoietin should be administered when possible to reduce the need for allogeneic blood in certain selectedpatient populations (e.g., renalinsufficiency, anemiaof chronic disease, refusal of transfusion).

  43. STS 2011 Guidelines Class IIa. “It is reasonable to use preoperative erythropoietin(EPO) plus iron, given several days before cardiac operation, to increase red cell mass in patients with preoperative anemia, in candidates for operation who refuse transfusion (eg, Jehovah’s Witness), or in patients who are at high risk for postoperative anemia.”

  44. Perioperative ESA’s • Approved for use for pts undergoing autologous donation: • Japan 1993 • Europe 1994 • Canada 1996 • Approved for perisurgical adjuvant therapy w/o auto donation • Canada/USA 1996

  45. Preoperative ESA’s • Canadian, (+2 US studies) – 208 orthopedic pts • 300 u/kg SQ x 14 days, 9 days preoperatively • + oral iron all groups • ½ rate exposure to allogeneic blood • Both groups Hgb > 130 g/L • No adverse events in treatment groups Lancet 341:1227-1232, 1993 De Andrade JR: Am J Orthop 25:533-5421, 1996 Faris: J Bone J Surg 78A:62-72, 1996

  46. Canadian Orthopedic Erythropoietin Study Group – Elective Hips Group 1 placebo 14 days Group 2 300 u/kg EPO 9 days preop/14 days total Group 3 placebo days -10-6 and 300 u/kg EPO next 9 days Lancet 341:1227-1232, 1993

  47. European Epoetin Alfa Surgery Trial • Multicenter trial EPO v routine (6 countries- 700 pts) • Anemic pts – hgb 10-13 g/dl • EPO 40u/ kg/wk x 3 + DOS + iron both groups (oral treatment/iv or oral control) • Results: • higher hgb levels throughout • 12% v. 46% transfusion • No effect post op recovery (time ambulation, d/c, infection rate • Time to ambulation, d/c longer in transfused v. non-transfused • SE comparable Weber, Eur J Anaesthesiol April 2005;22(4): 249-57

  48. European Epoetin Alfa Surgery Trial Weber, Eur J Anaesthesiol April 2005;22(4): 249-57

  49. FDA Orders ESAs Safety Labeling Changes - 2008 • July 30, 2008 – FDA issues Complete Response letters ordering safety labeling changes under FDAAA • Cancer Patients on Chemotherapy • ESAs are not indicated for patients receiving myelosuppressive therapy when the anticipated outcome is cure DOSAGE AND ADMINISTRATION • Therapy should not be initiated at hemoglobin levels ≥10 g/dL, except where the patient is unable to tolerate this degree of anemia due to co-morbid conditions • If the hemoglobin exceeds a level needed to avoid transfusion or exceeds 12 g/dL, withhold dose until the hemoglobin approaches a level where transfusion may be required U.S. Food and Drug Administration. www.fda.gov/medwatch/safety/2008/safety0.8.htm#chronological. Accessed August 7, 2008.

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