Belgrade 2011

Management of perioperative anemia in Major orthopedic surgery: practical

approach

Nadia Rosencher Anesthesiology and Intensive care department

Cochin Hospital, Paris Descartes University75014 Paris France

Belgrade 2011

Disclosure

1. Abbott, 2. Air Liquide3. Astra-Zeneca,4. Bayer,5. Bristol Meyer Squibb,6. B-Braun,7. Boëringher-Ingelheim,

8. General Electric,9. Glaxo-Smith-Klein, 10.Janssen11. LFB12. Pfizer13. Sanofi-Aventis14. Vifor

Belgrade 2011

Perioperative anemia Outline

1.Incidence and cause of preoperative anemia and related mortality

2.International Recommendations : NATA3.Preoperative assessment: IRON and ESA4.Postoperative anemia and mortality5.How to managed Postoperative anemia: 6.Kinetic of bleeding and anticipation7.Conclusion

Belgrade 2011

Author/year Surgery n incidence

Saleh 2007 THR/TKR 1142 20%

Basora 2006 THR/TKR 218 39%

Myers 2004 THR 225 15%

Rosencher 2003 THR/TKR 2646 30%

Su 2004 HF 844 44%

Halm 2004 HF 550 46%

Gruson 2002 HF 395 46%

Incidence of Preoperative Anemia in Major orthopedic Surgery

Incidence of Preoperative Anemia in Major orthopedic Surgery

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Prevalence of preoperative anaemia and haematinic deficiencies in patients

scheduled for elective orthopaedic surgery (Elvira Bisbe et al, TATM 2008;10:166-73)

Type of Anemia n( %)

With nutrient deficiency 20/65

Iron only 12/65 (16.9)

Folate only 1/65 (1.5)

B12 only 4/65 (6.1%)

Iron with folate or B12 or both 3/65 (4.6)

Without nutrient deficiency

Renal insufficiency only 2/65 (3.1)

ACI, no renal insufficiency 19/65 (29)

Renal insufficiency and ACI 6/65 (9.3)

UA 16/65 (24.6)

30.7%

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Preoperative Anemia kills me

Belgrade 2011

Preoperative Hematocrit Levels and Postoperative Preoperative Hematocrit Levels and Postoperative Outcomes in Older Patients Undergoing Noncardiac Outcomes in Older Patients Undergoing Noncardiac

SurgerySurgery

Wu WC et al, Wu WC et al, JAMAJAMA 2007; 2007; 297:2481‒8 297:2481‒8

• Retrospective cohort study using the VA National Retrospective cohort study using the VA National Surgical Quality Improvement Program database.Surgical Quality Improvement Program database.

• 310,311310,311 veterans aged ≥ 65 years who veterans aged ≥ 65 years who underwent major noncardiac surgery between underwent major noncardiac surgery between 1997 and 2004.1997 and 2004.

• Increased 30-day mortality in patients with Increased 30-day mortality in patients with preoperative preoperative Hct < 39% (Hb < 13 g/dL)..

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WC Wu et al. JAMA 2007;297:2481-8

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• We obtained data for 227 425 patients, of whom 69 229 (30.44%) had preoperative anaemia.

• postoperative mortality at 30 days was higher in patients with anaemia than in those without anaemia (odds ratio [OR] 1.42,; this difference was consistent in mild anaemia 1.41, and moderate-to-severe anaemia (1.44, ) Composite postoperative morbidity at 30 days was also higher in patients with anaemia than in those without anaemia

• When compared with patients without anaemia or a defined risk factor, patients with anaemia and most risk factors had a higher adjusted OR for 30-day mortality and morbidity than did patients with either anaemia or the risk factor alone.

• Conclusion : Preoperative anaemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery

Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study

Khaled M Musallam et al,  The Lancet Volume 378, Issue 9800, 15-21 October 2011, Pages 1362-

1363

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30-day composite morbidity, by anaemia and risk factor status 30-day composite morbidity, by anaemia and risk factor status

Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study

Khaled M Musallam et al,  The Lancet Volume 378, Issue 9800, 15-21

October 2011, Pages 1362-1363

Belgrade 2011

Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study

Khaled M Musallam et al,  The Lancet Volume 378, Issue 9800, 15-21 October 2011, Pages 1362-

1363

•

Figure 1.  30-day mortality, by anaemia and risk factor statusFigure 1.  30-day mortality, by anaemia and risk factor status

Belgrade 2011

Perioperative anemia Outline

1.Incidence and cause of preoperative anemia and related mortality

2.International Recommendations : NATA3.Preoperative assessment: IRON and ESA4.Postoperative anaemia and mortality5.How to managed Postoperative anemia: 6.Kinetic of bleeding and anticipation7.Conclusion

Belgrade 2011

Detection, Evaluation and ManagementDetection, Evaluation and Managementof Preoperative Anemia in the Elective Orthopedic of Preoperative Anemia in the Elective Orthopedic

Surgical Patient—NATA GuidelinesSurgical Patient—NATA Guidelines

TL Goodnough Br J Anaesth. 2011 Jan;106(1):13-22

Multidisciplinary panel : 3 orthopedists , 3 hematologists, 6 anesthesiologists, 1 epidemiologist And society representation :

European Federation of National Associations of Orthopaedics and Traumatology (EFORT) : G. BenoniSpine Society of Europe (SSE) : M. Szpalski

European Society of Anaesthesiology (ESA) Y. Ozier

Multidisciplinary panel : 3 orthopedists , 3 hematologists, 6 anesthesiologists, 1 epidemiologist And society representation :

European Federation of National Associations of Orthopaedics and Traumatology (EFORT) : G. BenoniSpine Society of Europe (SSE) : M. Szpalski

European Society of Anaesthesiology (ESA) Y. Ozier

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Recommendations―Detection of Recommendations―Detection of AnemiaAnemia

• Recommendation 1: Recommendation 1: We recommend thatWe recommend that eelective surgical patients have a Hb level lective surgical patients have a Hb level determination as close to determination as close to 28 days before the 28 days before the scheduled surgical procedure (Grade 1A).scheduled surgical procedure (Grade 1A).

• Recommendation 2: Recommendation 2: We suggest thatWe suggest that t the he patientpatient’’s target Hb before elective surgery s target Hb before elective surgery be within the normal range be within the normal range (normal female (normal female ≥ 12 g/dL, normal male ≥ 13 g/dL), ≥ 12 g/dL, normal male ≥ 13 g/dL), according to WHO criteria (Grade 2C).according to WHO criteria (Grade 2C).

TL Goodnough Br J Anaesth. 2011 Jan;106(1):13-22

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Recommendations―Evaluation of Recommendations―Evaluation of AnemiaAnemia

• Recommendation 3Recommendation 3: : We recommend thatWe recommend that l laboratory testing take place to further evaluate for nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C).

• Recommendation 4:Recommendation 4: We recommend thatWe recommend that nutritional deficiencies be treated before surgery (Grade 1C).

• Recommendation 5:Recommendation 5: We suggest thatWe suggest that eerythropoiesis-stimulating agent (ESA) therapy be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected. (Grade 2A).

TL Goodnough Br J Anaesth. 2011 Jan;106(1):13-22

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Hb < 120 g/L for femalesHb < 130 g/L for males

Ferritin < 30 μg/L and/or TSAT < 15–20%

Ferritin 30–70 μg/Land/orTSAT > 20%

Normal

Iron status?

Serum creatinineGlumerular filtration rate

Anemia of chronic disease

LowVitamin B12

and/or folic acid

Ferritin > 70 μg/Land/or TSAT > 20%

Normal

Chronic kidney disease (CKD)

Low

Rule out iron deficiency Inflammation/ chronic disease

Iron deficiency Referral to gastroenterologist to rule out malignancy

Folic acid and/orVitamin B12

therapy

Erythropoiesis-stimulating agent therapy

Iron therapy1) Oral iron in divided doses 2) IV iron if patient cannot tolerate oral iron, intestinal absorption problems, or short timeline

Referral to nephrologist

No response

Evaluation necessary

Belgrade 2011

Perioperative anemia Outline

1.Incidence and cause of preoperative anemia and related mortality

2.International Recommendations : NATA3.Preoperative assessment: ESA and

Iron4.Postoperative anaemia and mortality5.How to managed Postoperative anemia: 6.Kinetic of bleeding and anticipation7.Conclusion

Belgrade 2011

In practice, according to size of RBC

Microcytic MCV<80fl

1. Fe deficiency 2. Hemoglobinopathy3. Anemia of chronic

disease (ACD)

IV Iron if inflammatory disease + ESA

Normocytic MCV 80-96

1. ACD 2. Acute blood loss 3. Anaemia of renal

disease

Referral to gynecologist

and gastroenterolog

ist Iron (IV) + ESA

Macrocytic MCV >96

1. B12, FA deficiency 2. Chronic liver

disease3. myelodysplasia4. Chemotherapy

Folic acid and VitB12 therapy

+ESA + Iron

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In preoperative assessment I need as In preoperative assessment I need as llaboratory testing

• Hb level and size of RBC + Platelets • Creatinine serum and creat

clearance• CRP (inflammatory disease ?)• Iron status : Transferrin + Tsat

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To sum up: at preoperative assessment

1. To increase Hb in this short delay (28 days), I need ESA

2. Because of ESA therapy, I need Iron3. The choice of IV Iron is based on CRP,

if oral is not tolerated, if drug interaction (thyroxin…), if renal impairment..

4. In case of macrocytic RBC, I add Folic acid and Vitamin B12

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Probability of Allogeneic-Only TransfusionKnee and Hip Replacements

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%8,

0

9,0

10,0

11,0

12,0

13,0

14,0

15,0

16,0

Baseline Hb g /dL

Pro

bab

ilit

y o

f Tra

nsfu

sio

n

Men Women

N. Rosencher Transfusion. 2003 Apr;43(4):459-69

Abnormal bleeding or female less than 50kg

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Preoperative EPO : «  a first class technique….. »

If Hb increases before surgical procedure:• Blood loss tolerated without any

transfusion increases and thus we avoid any transfusion (autologous and allogeneic)

• We can solve all the problems of the controversy or close the debate about

1. Blood shortage

1. Residual an unknown emergent risk2. Immuno-modulatory effect3. Mistransfusion, bacterial contamination4. Hepatitis, VIH….

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Why do we always need to associate Iron to ESA

1. Erythropoiesis stimulation increases need of Iron,

2. Iron fixed to transferrin disappears rapidly and Iron from ferritin serum should be mobilized

3. Mobilisation is done very slowly even if ferritin serum level is normal

4. Iron should be quickly delivered to respond to demand of erythropoiesis stimulated by EPO

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Iron deficiency leads to bad response to ESA

• If anemia cannot be corrected by ESA, it means that Iron is deficient or not well absorbed (inflammatory disease…)

• Functional Iron deficiency = decrease of TSAT < 20%

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In practice : How to prescribe Ironin preoperative period ?

• If oral 200 à 300 mg/day • 1 h before meals• If IV between 500mg /each injection of

EPO, according to Iron status• Drug interactions with oral Iron are

not well known (Thyroxin, cycline, fluoroquinolone, diphosphonates…)

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Combined effect of Delay and dose

D-21

D-14

D-10

D-7 D0 D1 D2 D3 D4 D5

8

9

10

11

12

13

14

Hb

le

ve

l (g

/dl)

(m

ea

n)

rHuEPO2400 UI / kg started 3 weeks before surgery.

rHuEPO4500 UI / kg during 15 days.

Goldberg M. Semin Hematol 1997;34:41-47.

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Optimizing EPO use

1. Iron therapy added (200 to 300 mg/day if oral medication) and 200-500mg/week if IV

2. Start first injection between 21 and 30 days before surgery

3. Number of EPO injections should be related to Hb baseline

• 4 injections if Hb =10g/dl• 3 injections if Hb =11g/dl• 2 injections if Hb =12g/dl• 1 injection if Hb = 13g/dl

N Rosencher et al./transfusion clinique et biologique 15 (2008) 294-302

Hb level is accurate only if case of normovolemia

Hb level is accurate only if case of normovolemia

Risks associated with EPO meta-analysis De Andrade JR, 1999,Orthopedics, vol 22, p:113-118

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EPO Contraindications

• Recent stroke • Recent MI• Non controlled Hypertension• All arterial thrombosis or risk of

thrombosis event• Iron deficiency

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Take this message home

1. EPO efficacy increases with • dose (600 UI /kg/week)• delay between first injection and surgery• Iron therapy is necessary :200mg/Day (if

oral) and 500mg/week if IV2. EPO is indicated if 10 ≤ Hb baseline ≤ 13g/dl3. Contraindications are all recent artery

diseases (MI, Stroke, severe HyperTension, arteritis…..)

4. Suggestion : The number of injections should be related to Hb baseline

N Rosencher et al./transfusion clinique et biologique 15 (2008) 294-302

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How to use IV IRON

1. In postoperative period, because inflammatory disease: IV Iron : 500 and 1000 mg in 15 minutes but no more than 15mg/kg/week

2. In preoperative period, in case of inflammatory disease or renal impairment

3. If EPO: 500mg/injection– Or according to Hb baseline (cf table)

Belgrade 2011

Perioperative anemia Outline

1.Incidence and cause of preoperative anemia and related mortality

2.International Recommendations : NATA3.Preoperative assessment: IRON and ESA4.Postoperative anaemia and mortality5.How to managed Postoperative anaemia: 6.Kinetic of bleeding and anticipation7.Conclusion

Belgrade 2011

How Anemia kills me?

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MI Death

US retrospective analysis; N = 10,244Average mortality = 0.5% after 1 month

Frequency of myocardial infarction and death following primary THR or TKR

Mantilla CB, et al. Anesthesiology. 2002;96:1140-1146.

% %

0.0

0.5

1.0

1.5

2.0

2.5

< 49 50-59 60-69 70-79 > 80

Men

Women

Age (years)

0

1

2

3

< 49 50-59 60-69 70-79 > 80

Men

Women

Age (years)

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Causes of death in the Norway register

Cause of death Number of deathsa Mortality/1000

THRa

All deaths before 31 December 1995 360 7.87

All vascular causes of death 274 5.99 Ischemic heart disease 145 3.17

PE and infarction 42 0.92

Cerebrovascular disease 55 1.20

DVT 13 0.28

Thromboembolic complications 169 3.69

Bleeding 51 1.11

Sudden death (mors subita) 32 0.70

All non-vascular causes of death 67 1.46

Mortality during the first 60 days after surgery,1987-1995 (n = 45,767)

aCauses of death according to the death record. The sum of the cause-specific mortality rates therefore exceeds the all-cause mortality.

Stein A L, Acta Orthop Scand 2002; 73 (4): 392–399

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1. Within 30 days of random assignment, 415 patients (5.0%) had a perioperative MI. Most MIs (74.1%) occurred within 48 hours of surgery; 65.3% of patients did not experience ischemic symptoms.

• The 30-day mortality rate was 11.6% (48 of 415 patients) among patients who had a perioperative MI and 2.2% (178 of 7936 patients) among those who did not (P 0.001).

• Among patients with a perioperative MI, mortality rates were elevated and similar between those with (9.7%; adjusted odds ratio, 4.76 [95% CI, 2.68 to 8.43]) and without (12.5%; adjusted odds ratio, 4.00 [CI, 2.65 to 6.06]) ischemic symptoms

P.J. Devereaux et al Ann Intern Med. 2011;154:523-528.

POISE study

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Independent Predictors of Perioperative MI.

Devereaux P et al. Ann Intern Med 2011;154:523-528

©2011 by American College of Physicians

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In THR and TKR, vast majority of bleeding events occur peri-operatively

BleedingDVT/PE

Time

Inci

den

ce

Surgery

THR/TKR trial comparing a ximelagatran/melagtran regime and enoxaparin 40 mg, both regimens being initiated preoperatively:

overall, 77% of severe bleeding events occurred on the day of surgery1

1. Eriksson et al. J Thromb Haemost 2003;1:2490-6

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Major bleeding in VTE prevention trials is a strong predictor of mortality

*Adjusted for baseline predictors and propensity for bleeding

Eikelboom et al. Circulation 2009;120:2006-11.

In VTE prevention trials in surgical and

medical patients, major bleeds

increased the risk of death by 7-fold

0 No major bleed

(N=12,771)

Major bleed

(N=314)

8

4R

ate

(%

)

8.6%

1.7%2

6

OR: 7.0(95% CI: 4.6 to 10.5;

p<0.001)*

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Mechanism’s treeAmong 6 Millions Anaesthesia/year : deaths

totally or partially related to anaesthesia

métabolique

PE

ciment

choccardiogénique

anémiehypoxiarythme

infarctus

obstructifcentrale

voiesaériennes

poumons

obstructif accèsimpossible

VAS bronche trachée

médicament.

infection inhalation

cardiaque neurologic

hypovolémievraie

sepsis allergie sympath.

hémorragie

relative hypovolemia

GA RA

vasculairerespiratory

rythme

419

real Hypovolemia

hemmorhage

vascul

4939

anemia

M.I.

cardiac

cardiolologic Choc

A. Lienhart…Anaesthesiology V105, n°6, dec 2006

Belgrade 2011

Perioperative anemia Outline

1.Incidence and cause of preoperative anemia and related mortality

2.International Recommendations : NATA3.Preoperative assessment: IRON and ESA4.Postoperative anaemia and mortality5.How to decrease Postoperative

anaemia: 6.Kinetic of bleeding and anticipation7.Conclusion

Belgrade 2011

Antifibrinolytics : Mechanism of actionAntifibrinolytics : Mechanism of action

ActivatorActivator PlasminogenePlasminogene

FibrinFibrinFIBRINOLYSISFIBRINOLYSIS

Belgrade 2011

Antifibrinolytics : Mechanism of actionAntifibrinolytics : Mechanism of action

ActivatorActivator PlasminogenePlasminogene

FibrinFibrinFIBRINOLYSISFIBRINOLYSIS

Interruption Interruption of sites of sites

binding with binding with LYSINELYSINE

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when?Which dose?How long?Risks?

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Tranexamic Acid reduces hemorrhage by inhibition of fibrinolysis activities of plasmine:pharmacokinetic

• Half life = 3 hours• Renal excretion: delay between 2

injections has to be increased if moderate Renal Impairment (30 ml/min<creatinin clearance <60ml/min)

• Maximum concentration is reached immediately after perfusion (at least 30min to avoid nausea)

No sign of overdose reported becauseof very wide therapeutic window

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Allogeneic Transfusion RBC THR+TKRTranexamic Ac 20 studies N=1096

Différence of Risk

Hiippala SBenoni G Hiippala SJansen A.JBenoni G Ellis M Benoni G Tanaka NEngel J.M Veien MHusted HGood L Zohar E Lemay EJohansson T

Year

199519961997199920002001200120012001200220032003200420042005

-26% [-54% à +2%]

-37% [-56% à -18%]

-46% [-64% à -28%]

-52% [-77% à -28%]

-33% [-63% à -4%]

-60% [-94% à -26%]

-20% [-48% à +8%]

-34% [-46% à -22%]

-23% [-49% à +3%]

-13% [-32% à +7%]

-25% [-50% à 0%]

-47% [-70% à -24%]

-48% [-71% à -24%]

-40% [-63% à -17%]

-26% [-44% à -9%]

Tranexamic Acid control

-0.50 0.00 +0.50

NTT = 3

-35% [-40% à -29%] P <0.01

modèle fixe test d’hétérogénéité p=0.27

N

2886774239204099243040516039

110

15 studies 776

P. Zufferey Anesthesiology. 2006;105:1034-46

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surgery

Total dose

bolus

design-30% [-43% to –18%]

-36% [-42% to –29%]

opendouble blind

p=0.45

-0,50 0,00 +0,50 Risk DifferenceHeterogeneicity test Between subgroups

Tranexamic Acid control

-29% [-39% to -19%]

-37% [-43% to -30%]

THRTKR p=0.21

< 30 mg/kg 30 mg/kg

-30% [-37% to -24%]

-49% [-61% to -38%]p<0.01

one bolus> Many bolus

-24% [-35% to -13%]

-38% [-44% to -31%]p=0.04

Allogeneic Transfusion RBCTranexamic Acid co variable analysis

P. Zufferey Anesthesiology. 2006;105:1034-46

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Tranexamic Ac and arteriel risk

Zufferey P Anesthesiology 2006: 105; 1034-46

Tranexamic Ac n=575 1 MI

Placebo n=1057 1 MI + 1 stroke

Aprotinine n=723 1 acute leg ischaemia 1 Acute Coronary

Syndrome

Aminocaproic Ac n=76 3 Acute Coronary Syndromes

Antifibrinolytic in orthopedic surgery

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adverse events Cardiologic surgery

Mangano DT N Engl J Med 2006: 354; 353-65

No adverse vascular effects for TXA

n=882 n=1295n=883n=1374

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Contrindications of Tranexamic Acid

• Severe Hypertension• Arteritis, or severe arterial disease• MI, Stroke • carotid Stenosis• Severe Renal Insufficiency (creatinine

clearance <30ml/min)• Pulmonary Embolism• Epilepsy

Belgrade 2011Blanié A. SFAR 2011

Duration of postoperative fibrinolysis in THR

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Duration of postoperative fibrinolysis in TKR

Blanié A. SFAR 2011

Belgrade 2011

Now our protocol of TA

This procedure is done, but not validated by a important study

TKR or Revision TKR1. 1g (15mg/kg) 15 min

before deflating tourniquet

2. + 1g (15mg/kg) H + 33. 1g (15mg/kg) every 4 or 5

hours during the first night

THR or Revision THR1. 1g (15mg/kg) : 15 min

before incision2. H + 1: 1g (15mg/kg) /1h during

60 min until end of surgery (RTHR)

3. 1g (15mg/kg) every 4 or 5 hours during the first night

Dilution of 1g/100ml physiologic serum / 30 minutes, because of risk of nausea

N Rosencher et al./transfusion clinique et biologique 15 (2008) 294-302

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PTG : acide tranexamique vs placebo

PTG : Récupération périop inutile si acide tranexamique

Belgrade 2011

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Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage a randomised, placebo-controlled trial

• Méthode : 274 centres (44 pays) = 20201 patients à risque hémorragique dans les premieres heures

• Randomisation : Ac Tranex 1g/30min puis 1 g 8h après vs placebo

CRASH-2 trial collaborators, Lancet 2010; 376: 23–32

Belgrade 2011

CRASH-2 trial collaborators, Lancet 2010; 376: 23–32

TXA.n=10 060

placebon=10 067 RR (IC95%)

mortality 14.5% 16% 0.91 (0.85-0.97) p<0.01

Any vasc Thrombosis 1.7% 2.0% 0.84 (0.68-1.02) p=0.08

MI 0.3% 0.5% 0.64 (0.42-0.97) p=0.04

Stroke 0.6% 0.7% 0.86 (0.61-1.23) p=0.42PE 0.7% 0.7% 1.01 (0.73-1.41) p=0.93

DVT 0.4% 0.4% 0.98 (0.63-1.51) p=0.91

No adverse vascular events with TXA

Belgrade 2011

Take this message Home

1. TA reduces bleeding and transfusion after THR, TKR and spinal surgery

2. Important doses (≥30mg.kg-1 …) and many bolus are more efficient

3. Good safety, but no important study (>1000 patients) Nausea are possible if perfusion is too fast (less than 30 min)

4. Cost /effective (1€/1g)

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How to explain the difference between registers and randomized studies?

Belgrade 2011

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Focus study

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Hb= 9g/dl throughout the study in restrictive group

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Complications nécessitant transfusion10% tachycardies+I. Cardiaques

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Threshold Haemoglobin Levels and the Prognosis ofStable Coronary Disease: Two New Cohorts and a

Systematic Review and Meta-Analysis

A D. Shah PLoS Medicine | www.plosmedicine.org 2011 | Vol 8 | Issue 5

Conclusions: There is an association between low haemoglobin concentration and increased mortality. A large proportionof patients with coronary disease have haemoglobin concentrations below the thresholds of risk defined here.

20,131 people with a new diagnosis of stable angina and no previous acute coronary syndrome, and 14,171 people with first MI who survived for at least 7 days were followed up for a mean of 3.2 years

Belgrade 2011

How can we explain that ?

Transfusion Trigger

[Hb] (g/dl)

Time (min)

Delay in Blood supplying

Prescription

Belgrade 2011

Perioperative anemia Outline

1.Incidence and cause of preoperative anemia and related mortality

2.International Recommendations : NATA3.Preoperative assessment: IRON and ESA4.Postoperative anaemia and mortality5.How to decrease Postoperative

anaemia: 6.Kinetic of bleeding and anticipation7.Conclusion

Belgrade 2011

Postoperative drop of Hemoglobin level after Knee and Hip Replacement : between

recovery room discharge and on morning of the day one

TRANSFUSION DE GLOBULES ROUGES HOMOLOGUES : PRODUITS, INDICATIONS,

ALTERNATIVES

RECOMMANDATIONS

Août 2002

«  transfusion has to be adapted to

kinetic of bleeding to maintain [Hb] level threshold”

Var

iatio

n of

dV

aria

tion

of d

’’ Hb

(g.d

LH

b (g

.dL-1-1

) le

vel

) le

vel

Recovery room and D+1

3

-5

-4

-3

-2

-1

0

1

2

THR

TKR

G. de Saint Maurice SFAR 2003

Before using Tranexamic Acid drop is 2.1 ± 1.5 g/dlAnd with Tranexamic acid drop of Hb is only 1.2 ±1.1g/dlBefore using Tranexamic Acid drop is 2.1 ± 1.5 g/dlAnd with Tranexamic acid drop of Hb is only 1.2 ±1.1g/dl

Hb level has to be monitored every 2H during first night or anticipation if kinetic of bleeding is known

Hb level has to be monitored every 2H during first night or anticipation if kinetic of bleeding is known

Belgrade 2011

death

Cardiovascular and ischemic events

Rehabilitation is difficult

Transfusion ± delay

Anemia

preoperative postoperative+ bleeding

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ConclusionsConclusions• Anemia should be viewed as a serious and Anemia should be viewed as a serious and

treatable medical condition rather than as an treatable medical condition rather than as an abnormal laboratory value. abnormal laboratory value.

• Preoperative anemia management in elective Preoperative anemia management in elective orthopedic surgery patients improves orthopedic surgery patients improves outcomes.outcomes.

• New paradigm : no anemia, no transfusion and New paradigm : no anemia, no transfusion and mortality should decreasemortality should decrease

• Moreover, if you see patient 1 month before Moreover, if you see patient 1 month before elective surgery, you don’t need to postpone elective surgery, you don’t need to postpone surgery (stopping VKA, clopidogrel…..)surgery (stopping VKA, clopidogrel…..)