ReviewErythropoietin and intravenous iron in PBM
Introduction
Preoperative anemia is common, easy to detect and easy to treat. Its incidence ranges from 11% to 76% depending on the study population and the type of surgery [1]. Studies have shown that it is not only linked to an increased incidence of morbidity and mortality [2], [3] but in addition, it is a major predictor for the use of allogeneic red blood cell (RBC) transfusion in patients undergoing a surgical procedure associated with moderate to high blood loss [4], [5]. Furthermore the increasingly elderly population may be more vulnerable to milder degrees of anemia due to unrecognized cardiovascular disease. The concept of blood management is such that if a patient with anemia can be identified in the pre-operative period, therapeutic modalities can be targeted to that patient who might benefit from such treatment. Management strategies include the optimization of preoperative hemoglobin by maximizing hemopoiesis and RBC mass. This can best be achieved with the use of iron supplementation, either oral or intravenous, with or without the use of erythrocyte stimulating agents (ESAs) such as erythropoietin (rHuEPO).
Section snippets
Intravenous (IV) iron
Iron deficiency is a common cause of preoperative anemia along with anemia of chronic disease. Causes for iron deficiency anemia are listed in Table 1. If time permits (usually requiring up to 2 months for the hemoglobin to return to normal values) oral iron supplementation may be adequate to replace iron stores preoperatively. However in some cases intravenous iron may be required in patients that are intolerant to oral iron, have a decreased intestinal absorption due to previous gastric
Erythropoietin
Similar to receiving red blood cells, the aim of treatment with rHuEPO is to improve the transport of oxygen in the bloodstream, thus avoiding the complications associated with either severe anemia or those of RBC transfusion. This may be of particular importance in patients who refuse blood products for whatever reason (either religious or otherwise.) Reasons for the use of preoperative erythropoietin (rHuEPO) include (1) to correct preoperative anemia and therefore avoid or reduce the number
Patient blood management
In a recent prospective study evaluating the efficacy of an individualized pre-operative blood saving protocol in elective arthroplasty patients, Gonzalez-Porras et al. [19] studied 305 consecutive patients undergoing either total knee or total hip replacement surgery. They compared their patients to a historic group from their database who did not receive any blood saving techniques after matching by age, gender and type of arthroplasty. The primary aim of the study was to obtain a
Conclusion
The selective use of intravenous iron supplementation with or without the use of ESAs is a successful method for the management of preoperative anemia, leading to a reduction in perioperative transfusion requirements in patients undergoing a surgical procedure with associated moderate-high blood loss. With the growing awareness of possible shortages in our blood supply it is behovent of physicians to seek alternatives to RBC transfusions which can be implemented in a timely manner
Disclosures
None.
References (19)
- et al.
Effect of anaemia and cardiovascular disease on surgical mortality and morbidity
Lancet
(1996) - et al.
Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study
Lancet
(2011) - et al.
Review of the clinical practice literature on patient characteristics associated with perioperative allogeneic red blood cell transfusion
Transfus Med Rev
(2003) - et al.
Value of methylprednisolone in prevention of the arthralgia-myalgia syndrome associated with the total dose infusion of iron dextran: a double blind randomized trial
J Lab Clin Med
(1998) - et al.
Sodium ferric gluconate complex in hemodialysis patients. II. Adverse reactions in iron dextran-sensative and dextran-tolerant patients
Kidney Int
(2003) - et al.
Intravenous iron sucrose establishing a safe dose
Am J Kidney Dis
(2001) - et al.
Chronic use of sodium ferric gluconate complex in hemodialysis patients: safety of higher-dose (⩾250mg) administration
Am J Kidney Dis
(2003) - et al.
Intravenous iron in colo-rectal cancer surgery
Semin Hematol
(2006) - et al.
An analysis of blood management in patients having a total hip or knee arthroplasty
J Bone Joint Surg Am
(1999)
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