Good question and challenging answer. If you want a preoperative optimization, you need a good preoperative assessment team, with a muldisciplinary approach. I think the concept of "Patient Based Management" becomes more and more popular and I really advice you to read papers about this or the really interesting book published by A. Shander. I think you need an assessment of iron status in high risk population, then you can replace with at least a 2-3 week oral supplementation or intravenous if your delay is shorter. We have an interesting experience with rhEPO both in adult and children undergoing major surgery. The main advantage of this rhEPO therapy is the "boost" of the medullar response and the increased Hb nadir observed in the perioperative period. In Belgium, rhEPO is used in the perioperative period. We sometimes used (off label) in the peroperative period of cardiac surgery, craniofacial surgery in children, etc. The "ideal" dose scheme is nor well known and further studies are needed to define the benefit-to-risk balance.

The use of tranexamic acid is recommended in several settings, including cardiac surgery, high risk orthopedic surgery, craniofacial surgery. This drug helps decrease blood loss and transfusion requirements.

But I really recommend the implementation of preoperative assessment program using the design of the "patient based management"

In order to minimize perioperative blood loss Aprotinin (Trasylol) may be given. Iron supplements and Erythropoietin may be given to increase the hemoglobin levels.

Aprotinin is not available anymore in most of the countries. But I agree, antifibrinolytic agents should be used. However, the "optimal" dose scheme should be used based on the surgery, the patient, the PK study, etc.

Please, do not forget the iron and vitamins!

Without iron avaible, EPO is not effective!

IV iron i safe and cost-effective!

I can only support the answer of David Faraoni. We are currently performing an observation program for patient blood management in four German hospitals (http://www.patientbloodmanagement.de/en/home). It is important to have all colleagues in your hospital in a dedicated PBM group (anaesthesiologists, surgeons, blood bank, transfusion medicine specialists, nurses, IT department, administrative people, etc.) and the board of directors of your hospital supporting the PBM program. In addition, the regional GPs and specialists in their offices need to be informed or, even better, involved.

The aim of a PBM program is not to save money, but to implement an evidence-based transfusion regimen and therefore, improve patients´ safety. Iron restricted haematopoiesis/anaemia needs iron supplementation (either orally or if impossible due to non compliance, GI complications or time restraints via parenteral application), renal anaemia with low epo levels needs epo, bone marrow failure needs red cell transfusion, etc.

The point is: Diagnostic comes first; dignosis-dependent treatment of preoperative anaemia is the second step.

In addition, perioperative supportive care has to ensure a minimal blood loss and an optimal red cell recovery and marrow function. The anemia tolerance of the patient has to be evaluated and improved. Transfusion triggers have to be restrictive.

The three pilars only work together in pre-, peri- and postoperative supportive treatment. There are a lot of single measures to be implemented, but the whole program has to be supported by the whole clinic.

The colleagues in Australia have published quite some high-level papers here.

Good luck for the implementation of PBM in your hospitals!

Dear Markus

I am agree with you, but the question was: "What is the best practice to optimize preoperative Hb?"

Of course, the main point is: Diagnostic comes first and diagnosis-dependent treatment of preoperative anaemia is the second step.But sometimes, like colon or gastric cancer, myoma, the treatment is the surgical procedure!

Also, the second problem is: you have not time enough to wait the oral iron effect. Using classical calculates, if you have a female with hb 85 g/dL and bleeding myoma, you will need four to six months to hb recovery with only oral iron.

In the swiss and spanish experience iv iron pre and peri operative is not only effective, safe and also cost-effective.

Of course, never a single mesaure must be implemented! and we need multi-disciplinaty teams

The three stone corners are:

a) reduce blleeding

b) treat anemia pre and peri

c) transfuse, if need it, one by one and applying restrictve criteria. We must transfuse a patient not to a figure.

Dear José,

I fully agree with your assessment of oral iron having a longer latency, but in Germany, iv iron has a restricted indication. I also agree with your statement about iv iron beeing safe, but again, this is not translated in a broader indication for iv iron. Most preparations can only be used, when oral iron has shown no or not an adequate effect or intolerable side effects. Only currently, the indications of iv iron broaden.

As to the time until surgery, this is the reason, why GPs and other colleagues have to be included into a PBM program: Elective surgical patients shouldn´t be sent to the hospital only one or a few days before surgery, but at least four weeks in advance to assess preoperative anaemia. Urgent or emergency surgery of course has to be performed without delay and without without further dealing with anaemia other than RBC transfusion if necessary in the individual situation.

Dear Markus

Once again, I am agree with you

For me, it is unmoral that patients allocated in surgical waiting list during several months (and sometimes almost half year) arrive to our hospital the day before or the surgical morning anemic.

We must visit these patients at least 30 days before surgery (see different NATA recommendations or WHO 2010).

But we need to move our concern about preoperative anemia to the family or general doctors. We must change the global conception about anemia. Anemia is not normal. Anemia is not a only frequent condition. It could be an iceberg head of a lot of different illness, including colon, urogenital or gastric cancer.

RBC transfusion must be the last alternative, when all rest mesaures fail or were not avaible!!

I think patient condition is an important point to do make decision according the national guideline.Patient condition is included emergency or elective ,underlying disease , patient age , comorbidities.Transfusion should be considered in emergency condition and life saving .

Dear All,

Thank you for this prosperous discussion.

We are currently in process of establishing a PBM program. Despite the important progress in the recent years in this field, but it seems that it is a raw area!

For example; how you would select your patients? What would be your aim during perop management? What level of preop Hb you would accept? Is there a difference in the outcome between (e.g Iron vs rhEPO)?

We are currently started a big study to highlights the areas that need improvements and help establishing an evidence-base guidelines. I would be happy to collaborate with you (David, Jose, and Markus) and learn from experience!

It is important to know the cause of anemia. I have used both iron & EPO with success.

Dear Markus,

Do you have an English version of the forms that you have in the website?

Thanks

Dear Abdullah

Here is the Australian experience

It is a GREAT job!

I invite all you to read it and enjoy it.

Best regards

JA

Sorry! It is here

And here, I am attaching the Upadte of the Spanish Alternatives Evidence based Document.

Spanish Consensus Statement on alternatives to allogeneic blood transfusion: the 2013 update of the "Seville Document"

Dear Abdullah,

yes, some of the forms we use are in English, but I only have a pdf. I will attach these.

Please tell me, if I can be of further assistance.

Best wishes,

Markus

Sorry, here comes the two forms.

Dear Abdullah, we implanted different strategies to optimize preoperative status, reduce allogeneic blood product requirement, and decrease perioperative blood loss. Would be please to help you and discuss ([email protected]).

David

Hi there,

Thanks all

And special thanks to ResearchGate who give us this apportunisity

Abdullah

I have used iron iv with success but It's important to know the cause of anemia

I am agree with Angela! Anemia is like an iceberg!

Nevertherless, some surgical patients, the anemia could be the consequence and the surgery is the solution, like colon cancer, gastric cancer, bariatric surgery, myoma, urogenital tumor, etc!

IV iron must be used, in case of ferropenia, iron deficiency anemia -associated or not to inflammation- or functional iron deficit, if:

- oral iron intolerance (quite frequent gastro-intestinal side effects)

- lack of compliance

- oral contraindication (like gastric or duodenal ulcers, intestinal inflammatory disease, etc)

- lack or low absorption, like helicobacter pylori infection, gastric atrophy, gastrectomy, high hepcdin levels (inflammation, cancer patients, )

- moderate or severe anaemia (hb level under 105 g/L), because high amount of iron is needed

- short time to surgery

- epo treatment

- "continuous" need, like intestinal angiodisplasia, esophagical varice bleeding, Rendu-Osler-Weber, also NPH

- and, the last but not less important, patient`s preference.

We must have in mind that: two third or three quarters of iron are localized in the haemoglobin! When our patient bleed, iron is loosing. And in the perioperative period, the inflammation blocks the iron reserve (hepcidin mediated); this iron from ferritin and machropaghes could not be mobilized, and iron "functional" deficiency erythropoiesis appears! IV iron could be the solution to "brigde" this blockage.

But the "one million dollars" question, in my modest oppinnion and my best knowledge, is unaswered! Which is it the "ideal" preoperative haemoglobin level?

120 g/L? 130 g/L? 140 g/L? 150 g/L? upper?

I like your "one million dollar" question, and also really appreciate the discussion. I would have taken the question in the other side. What is the lowest preoperative hb level that could be considered as safe? I also agree that the major point is: check your patient, assess hb level and iron status, try to identify the etiology of anemia. In my "non-ideal" world, we have no enough time before the surgery to do all these assessments. Reason why we need an excellent collaboration with other physicians, especially surgeon. It would be great to perform a large survey or large observational study about practices, iron supplementation? iv? Oral? Epo? Safety, efficacy.

Thank you!

I am adding our last review about safety, efective and cost-effective of iv iron perioperative, done with studies from different spanish hospitals.

The survey in Spain is easy! Only few groups are using saving methods. I will glad to collaborate in this study.

Best regards

Very good paper, congratulations and thank you for sharing this paper.

I am sure we could perform a large international survey...

All the best.

David

David,

I'm ready to collaborate

Abdullah,

I have prepared the first 10 €!

Be patient! At the next century...

:)

Jose,

Could you please send me your email?

Thanks

[email protected]

With capital letter

[email protected]

Shu Chien performed many studies in dogs demonstrating little increase in cardiac output at hemoglobin levels greater than 100g/l.

What about the relationship DO2/VO2? In healthy situation, some reports including Jehovah Witnesses described that Hb level as low as 40-50 g/l could maintain satisfactory oxygen supply. However, in the perioperative setting with systemic inflammation and considering the bleeding risk, the benefit-to-risk balance comparing transfusion vs. low Hb level should be considered.

I feel that the intraoperative blood transfusion "trigger" is quite different than that for the regular anemic patients or patients in ICU. I believe the hemodynamic changes along with a personal assessment to the "on going" blood loss will drive the decision in many situations! Yes, we still do frequent ABGs to assess the Hct/Hb but sometimes you don't have time to do that! Thus, I don't think a solid cutoff value can exist intraoperatively, and I don't think the answer for (what was the Hb level when you start transfusing blood?) can always be available.

Obviously, the time to surgery plays a large part in the decision making. In addition, the number and degree of co-morbidities will influence the trigger for treatment. I did a study in the 70's where severely anemic patients given IV iron without EPO doubled the Hgb within 10 days. These were long-standing anemias, so that there was likely considerable erythroid hyperplasia in the marrow and the serum EPO was probably high, driving the marrow response. As Dr. Faraoni notes, the data on isovolemic anemia in Jehovah's Witnesses indicate that the degree of anemia is manageable during surgery in the healthy patient.

Your question make no sense. Anemia is caused by many different mechanisms of which iron deficiency (or reduced erythropoietin) is one cause. If the patient is not iron deficient (and may in fact be iron overloaded) iron makes no sense and may be contraindicated. A full assessment of the cause of anemia must be undertaken before any therapy can be given. If indeed the patient is iron deficient, then intravenous iron would make up the deficiency faster than oral iron. Erythropoietin will not work if there is iron deficiency and one is asked to check for iron deficiency before giving erythropoietin.

The study I referred to was on "severely iron deficient" patients. I should have clarified.

Dr. Cabot raises a good point; not all anemia is iron deficient.

You will be probably interested in a recently published paper by Lin et al. in Tansfusion Medicine Reviews 27 (2013) 221-234.

The conclusions were more or less the following:

1. Patients with preoperative iron deficiency anemia may have an earlier andd more robust hemoglobin recovery with preoperative iron therapy than with oral iron supplementation

2. A short preoperative regimen of EPO, or single dose of EPO plus IV iron in the preoperative or intraoperative period, may significantly reduce transfusion requirements

3. Intravenous iron appears to be as welltolerated as oral iron

4. Erythropoietin may increase the risk of thromboembolism in spinal surgery patients who receive mechanical antithrombotyic prophylaxis in the perioperative period.

Dear Tome

In our experience (thousands of patients treated)

A short course of iv iron plus one unique dose of EPO is:

- effective (reduce transfusion, improve Hb level one month after surgery)

- cost-effective (shorter stays, lower transfused, etc)

- safety (less infection, no more thrombosis, no more death)

From the European perspectve (were low fractionated heparin are universaly administered to orthopedical and trauma patients) short course of EPO treatment (plus iron) in moderate or severe bleeding surgery is safe.

Merry christmass

In Italy the indication to use EPO is not to increase Hb in the preoperative phase.

I think that the first thing to do is to consider the cause of anemia.

Chronic diseases do not achieve a good response to oral iron treatment.

More complications can affort the Hb level: iron deficiency, vitamin deficiency, chronic bleeding, malaborsption, infections....consider that HP infection is more common than expected, and if treated successfully, Hb level increases without any supplementary medication.

In my experience each patient must be treated according to his/her nature of anemia.

It is not possible to give only one answer for such a different scenario.

Happy new year!

We must treat patients, not figures!

An isolated hb level determination is just a figure, a simple "picture"!

We must watch the wholw movie!! The dinamic situation! Also, whe must have in mind, that analytical mistake is possible (it is not unfrequent)

Algorithm or protocol is a helpfull measure for most of patient, must we must individualize to our patient!!

Normovolemic non bleeding anemia is temporally well tolerated.

We must treat the cause and help the erythropoiesis, but with the correct hematinics.

Dear Erika

Alfa-EPO administration is aproved in Europe, including Italy, (and USA) for non iron deficiency anemia present in orhopedical preoperative period.

At the technical file, Alfa-epoetin is indicated for:

• Treatment of anemia due to

- Chronic Kidney Disease (CKD) in patients on dialysis and not on

dialysis

- Zidovudine in HIV-infected patients

- The effects of concomitant myelosuppressive chemotherapy and upon initiation, there is a minimum of two additional months of planned chemotherapy.

• Reduction of allogeneic RBC transfusions in patients undergoing elective, noncardiac, nonvascular surgery.

Its dose in Surgery Patients is 300 Units/kg per day daily for 15 days or 600 Units/kg weekly.

Alfa epoetin is the unique erythropoiesis-stimulating agent (ESA) aproved to treat preoperative anemia in elective non vascular, non cardiac surgery. BetaEpoetin and darboepoetin are not aproved. Their use is under "off labet" indication.

Perioperative hemoglobin optimization depend on patient biases

either elective or emergency, or elective patients should be evaluate 4- 5 weeks preoperatively to optimize the hemoglobin level with pre deposit blood transfusion , blood collection begins 3-5 weeks preoperatively (2-4 units store)

blood transfusion should be considered in emergency cases

with intensive precautions to reduce it , using either acute normovolemic hemodilution or using cell salvage which could be helpfull for eliminating the risk of viral transmission and reducing the risk of immunological recation

Dear Abdullah,

Optimizing preoperative Hb, depends on the subject, the reason of the anemia, and more on the expected blood loss during surgery. I agree with M Mueller for at least 3 weeks for workout; in France we can give IV Iron (if iron deficiency objectively diagnosed only in hospitals and clinics since january 2014 ) or Blood ptransfusion if urgent. EPO still for refractory anemia or renal insufficiency.