ANAEMIA AND ITS PRE-OPERATIVE MANAGEMENT

Transcription

1 ANAEMIA AND ITS PRE-OPERATIVE MANAGEMENT Julie Sanders, BSc (Hons), RGN, MSc, PhD Head of Research UCL Institute of Human Health and Performance, and UCL Iron Collaboration

2 Plan Definition Prevalence How pre-op anaemia affects recovery from surgery Guidelines for treatment Treatment strategies

3 ANAEMIA Hb concentration level below 13g/dl for men 12g/dl for women (World Health Organisation, 1968; World Health Organisation, 2008)

4 Prevalence Affects 24.8% of the global population (World Health Organisation, 2008). Around 30% (ranging from 11% (Carson, 1996) to 76% (Cappell, 1992) of elective non-cardiac surgical patients are anaemic immediately prior to surgery (Dunne, 2002, Dunkelgrun, 2008, Musallam, 2011), Up to three quarters of those having newly diagnosed anaemia (Bierbaum, 1999). Around 28% (De, 2009) to 54.4% (Hung, 2011) of cardiac surgical patients are pre-operatively anaemic

5 Definition Cause Absolute iron deficiency (AID) Depleted iron stores RBCs are small (microcytic) and pale (hypochromic) Most common for gastro referral (iron deficiency, folate deficiency, vitamin B 12 deficiency,) Anaemia of chronic disease (ACD)/Inflammation (AI) Disruption of iron homeostasis initiated by a cytokine-mediated immune response Infections, cancer, autoimmune, chronic rejection after solid organ transplant, chronic kidney disease and inflammation Symptoms Prevalence Fatigue, tiredness SOBOE Difficulty concentrating 30% of anaemia cases in elective surgical patients (van Straten, 2009). May be mild and may not notice the most common anaemia of chronically ill and hospitalised patients (Weiss, 2002) Most powerful test Decreased ferritin; decreased MCV, Increased transferrin Increased cytokine, Normal to increased ferritin Functional iron deficiency Inadequate iron supply to meet demand despite normal or abundant iron stores Normal or high ferritin levels TSAT <20%

6 Normal amounts of RBCs Anaemic

7 Increase RBC Increase oxygen transport/delivery Increased oxygen more aerobic power (longer and harder body can work before exhausted)

8 Decrease RBC Decrease oxygen transport/delivery Decreased oxygen less aerobic power Increased metabolic demands (increased need to deliver sufficient oxygen) AFFECT RECOVERY FROM SURGERY

9 Vascular surgery: Dunkelgrun, 2008 Retrospective study, n=1,211 Moderate pre-op anaemia: 2.3x more likely to have MACE at 30 day Severe pre-op anaemia: 4.7x more likely to have 30-day MACEs

10 Rectal cancer surgery: van Halteren et al 2004 Registry analysis, n=144

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12 Cardiac surgery: Hospital length of stay (number of days) in anaemic and non-anaemic patients p=0.002 p< p<0.001 Anaemic Non-Anaemic Cladellas et al 2006 Kulier et al 2007 De Santo et al 2009

13 Pre-op Hb and C-POMS summary score (morbidity) Table: Median C-POMS summary score by quntile of Hb Fig: C-POMS summary score by pre-operative anaemia ***p< vs. non-anaemic; boxes show median and inter-quartile range; 95% range shown by bars Lower Hb was independently associated with increased morbidity: 0.38 decrease in C-POMS summary score per 1SD increase in Hb p<0.0001

14 Anaemia associated with increased blood transfusion requirement. Roger et al 2012: Weston Australia PBM system major gynaecological surgery, n=843

15 Cardiac surgery Transfusion rate (%) in anaemic and non-anaemic patients (all p<0.001) Proportion of red blood cell transfusions in preoperatively anaemic and non-anaemic patients ***p< Sanders et al, unpublished

16 Blood transfusions: poorer outcome Bursi et al 2009 Vascular surgery, n=359 Incidence of 30-day death among patients who did and did not receive RBT Malone et al 2003, Trauma patients, n=15,534 Transfusion associated with mortality (OR 2.83, 95%CI , p<0.001), ICU admission (OR 3.27, 95%CI , p=<0.001), ICU LOS (OR 4.37, 95%CI , p<0.001), hospital LOS (OR 6.26, 95%CI , p<0.001)

17 RBC transfusion and total morbidity after cardiac surgery **p< vs not transfused; boxes show median and inter-quartile range; 95% range shown by bars RBC transfusion requirements was independently associated with total morbidity: Transfusion associated with 1.28 increase in C-POMS summary score, p<

18 Approx 30% patients preoperatively anaemic Correction of pre-operative anaemia through nontransfusion Delay surgery if the cause of anaemia is unclear (Goodnough, 2005, Beris, 2008). Pre-op anaemia associated with: increased mortality increased morbidity increased blood transfusion requirement Blood transfusions associated with poorer outcome from surgery

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20 FBC only not recommended in: Minor surgery ASA 1 children <16 yrs and adults <60yrs Grade 2 surgery (intermediate) ASA 1 children <16yrs and adults <40yrs

21 NHS acute Trusts and Primary Care Trusts (PCTs) should ensure that there are adequate arrangements for the preoperative assessment of patients. For planned surgery, the arrangements for preoperative assessment should permit the diagnosis and correction of anaemia in advance of surgery and optimisation of haemostatic function peri-operatively (including discontinuation of anti-platelet drugs and haematological advice for patients on oral anticoagulation).

22 Taken from: Delivering enhanced recovery. Helping patients to get better sooner after surgery. NHS Enhanced Recovery Partnership Programme, 2010.

23 Treatment of anaemia The best therapy for pre-operative anaemia is the treatment of the underlying cause or disease and the restoration of Hb and iron indices to normal (Weiss, 2005, Goddard, 2011). Absolute iron deficiency (AID) Anaemia of chronic disease (ACD)/Inflammation (AI) Definition Cause Depleted iron stores RBCs are small (microcytic) and pale (hypochromic) Most common for gastro referral (iron deficiency, folate deficiency, vitamin B 12 deficiency,) Disruption of iron homeostasis initiated by a cytokine-mediated immune response Infections, cancer, autoimmune, chronic rejection after solid organ transplant, chronic kidney disease and inflammation

24 ACD Treatment of underlying disease For example: Rheumatoid arthritis RBC transfusion for severe or life-threatening anaemia Iron therapy not indicated unless also have true iron deficiency Erythropoietic agents: overcorrection may be harmful NICE guidelines

25 CG114 Anaemia management in people with chronic kidney disease

26 TA142 Epoetin alpha, epoetin beta and darbepoetin alpha for cancer treatmentinduced anaemia

27 IDA Generally considered a safe, cheap and convenient method Pre-operative oral iron supplements taken between 2-5 weeks has been shown to increase pre-operative Hb levels (Okuyama, 2005) Menstrual blood loss GI tract blood loss Malabsorption NSAIDs Initial rise is more rapid than with oral iron, rise in Hb at 12 wks is similar Management < All patients should have iron supplementation both to correct anaemia and replenish body stores (B). < Parenteral iron can be used when oral preparations are not tolerated (C). < Blood transfusions should be reserved for patients with or at risk of cardiovascular instability due to the degree of their anaemia (C). Goddard AF, James MW, McIntyre AS, Scott BB; British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut Oct;60(10): Epub 2011 May 11.

28 Table: Intravenous iron preparations licensed in the United Kingdom IV iron product Preparation Maximum single Duration of Test dose Cost/10mL dose (mg) infusion needed Iron sucrose Complex ferric hydroxide with sucrose containing 2% (20mg/mL) of iron hour Yes Iron dextran Complex of ferric hydroxide with dextran containing 5% (50mg/mL) of iron hours Yes Iron Isomaltoside Complex of ferric iron and isomaltoside containing 10% (100mg/mL) of iron hour No Ferric carboxymaltose Ferric carboxymaltose complex containing 5% (50mg/mL) of iron minutes No 95.50

29 Highest increase occurred 2 weeks after start of iron therapy (Theusinger et al, 2007) IV iron studies in othopaedic, mennorrhagia, abdominal hysterectomy, general surgical patients: Increase Hb Decrease RBC transfusions Increased ferritin levels Range of preparations, doses. Studies small numbers Theusinger et al Treatment of iron deficiency anaemia in orthopaedic surgery with intravenous iron: Efficacy and limits. Anaesthesiology 107; 923-7

30 Comin-Colet et al The effect of intravenous ferric carboxymaltose on health-related quality of life in patients with chronic heart failure and iron deficiency: a sub-analysis of the FAIR-HF study. EJH Advance access published January 31st

31 PREVENTT: (Preoperative intravenous iron to treat anaemia in major surgery) A randomised double-blind controlled phase III study to compare the efficacy and safety of intravenous ferric carboxymaltose with placebo in patients with anaemia undergoing major open abdominal surgery Start recruiting patients: September 2013 Start recruiting sites now

32 Summary Pre-operatively identify anaemia and type: ACD/AI and/or IDA/FID Need to do iron studies Identify and treat cause of anaemia Delay surgery if necessary Treat anaemia Blood transfusion in life-threatening anaemia or at risk of cardiac instability ACD: ESA; iron therapy if also IDA IDA: Iron supplementation to replenish iron stores: oral or IV