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• W2896902681 abstract "Preoperative anemia is a modifiable disease that remains the strongest predictor of red blood cell (RBC) transfusion.1 It is well known that RBC transfusion can increase the surgical length of stay, increase mortality in surgical patients, and expose patients to the risk of circulatory overload, acute lung injury, and immunosuppression.2–4 Over the past decade, Patient Blood Management (PBM) has transformed from “bloodless surgery” and is now the described approach to countering inappropriate blood transfusions, reducing patient risk, preserving blood reserves, and reducing associated costs. PBM employs 5 concepts to reduce unnecessary transfusions: reducing preoperative phlebotomy, optimizing preoperative hemoglobin, use of autologous donation and cell salvage, minimizing perioperative blood loss, and evidence-based transfusion decisions (Figure).Figure.: Concepts of patient blood management.5In this issue of Anesthesia& Analgesia, Ellermann et al6 provide further evidence on the utility of intravenous iron (IVI) infusions for preoperative optimization of hemoglobin, one of the components within an effective PBM program. In their retrospective evaluation, patients with iron deficiency anemia were transfused with IVI during their preoperative clinic visit if their risk of blood transfusion was >10%. The study primarily evaluated the effect on hemoglobin levels and secondarily the use of RBC transfusion, postoperative infections, and long-term mortality. Ellermann et al6 found that preoperative IVI infusions safely prevented decreases in hemoglobin preoperatively, but only reduced RBC transfusion in one of the study groups. The approach to preoperative anemia by Ellermann et al6 is significant for 2 reasons. One, it shows that preoperative optimization is feasible within a preoperative assessment clinic. Two, it validates a technique that can augment PBM as a whole. We are increasingly seeing the power of protocols. Alone, an iron infusion is unlikely to prevent all blood transfusions. Indeed, only obstetric and gynecological surgeries saw reduced transfusion rates in this study. However, when added to a PBM system, iron infusion may work synergistically with other components to reduce overall transfusions. This study had other successes as well. The study confirmed the alarming prevalence of preoperative anemia that has been cited at 31% for men and 26.5% for women.7 It incidentally identified a lack of efficacy with noninvasive hemoglobin monitors providing useful warnings to the practicing anesthesiologist. The study underscored the importance of early collaboration between surgical and preoperative assessment clinics to allow time for optimization. This study also presented an operational algorithm for treatment and practical means to accomplish the iron transfusion. This study was limited by the fact that a PBM concept had already been established at the author’s institution. Thus, RBC transfusions were already decreased and may have concealed the effect of IVI transfusion alone. The dose of IVI was less than comparable studies (500 vs 1000 mg) and may have reduced the impact of increasing hemoglobin levels but have prevented some side effects.8,9 Nearly 72% of the patients in the study were cardiothoracic and orthopedic surgery patients who traditionally receive higher transfusion rates.10 In this study, patients were assessed in the anesthesia preoperative clinic a median of 3 days before surgery, possibly preventing the full effect of the iron therapy. Evidence suggests that optimal timing for the effect of iron transfusion is 21–28 days.11 Finally, many patients with anemia in this study did not receive iron based on exclusion criteria. Fifty-three percent of the patients with anemia had contraindications to ferric carboxymaltose, and a large percentage of patients were anemic from chronic disease, not iron deficiency. As an active anesthesiologist in the operating room, I welcome efforts toward preoperative hemoglobin optimization. The reassurance of a normal hemoglobin level before surgery is rarely argued. However, as the medical director of a busy preoperative assessment clinic, operationalizing hemoglobin optimization can be daunting. Compounding the dilemma, best “methods” for preoperative optimization are still debatable. Should surgery be delayed for treatment? Should patients receive oral iron, IVI, erythropoiesis stimulants, folate, and B12 or combinations of each? What are the financial implications? Who will order or administer treatments? Finally, is there value in preoperative treatment? One way of determining if a treatment is valuable is to examine its effectiveness, safety, satisfaction to the patient, and cost. Effectiveness: the patient must be assessed with sufficient time to intervene or there must be an agreement with surgeons to delay the procedure if treatable anemia is discovered. Additionally, a risk stratification tool that incorporates predicted surgical blood loss and the patient’s hemoglobin must be developed to guide treatment. This requires a Maximum Surgical Blood Loss Schedule agreed on by anesthesiologists and surgeons and a designed algorithm for anemia testing based on patient history and comorbidity. Appropriate monitoring, space, and training are necessary for safe intravenous administration of iron. This necessitates either treatment space in the preoperative clinic or other community arrangements for IVI transfusion. Clinic staff must also receive specialized training in drug storage and administration. Patient satisfaction: there should be a reasonable expectation for improvement, and the treatment should be easily administered. It should be affordable or covered by health insurance. Treatment also considers the busy personal life of the patient and the impact of time in the preoperative facility before surgery. Cost: managing hemoglobin optimization can be expensive. IVI, erythropoiesis stimulants, and folate/B12 are all potential treatments and have variable coverage by insurance carriers. At my institution, the cost, depending on insurance, for iron infusion is approximately $400 for Feraheme (AMAG Pharmaceuticals, Inc, Waltham, MA) 1000 mg (Ferumoxytol) or $0.40/mg. This Figure matches previously reported costs and accounts for monitoring, intravenous access, and nursing administration.12 The approach by Ellermann et al6 demonstrated value by satisfying many of the variables in the equation. For effectiveness and cost, IVI infusion was carefully selected only for those patients presenting with iron deficiency and who were having a high transfusion risk surgery. Hemoglobin levels did not decline preoperatively for the treatment group, whereas they did for the untreated group (0 vs −0.8 g/dL). For safety and patient satisfaction, patients were evaluated and then treated on the same day by an experienced anesthesiologist in the same clinic with a single dose of IVI. The financial impact of the IVI infusion for the hospital and patient was not discussed. It appears that it is not a lack of value that prevents anemia optimization. “The prevailing problem with preoperative anemia is that, for the most part, we simply choose to ignore it.” Auerbach et al wrote, “Anemia has become a ‘normalized deviation’ with a long tradition of acceptance as a harmless problem that can be ignored in most cases or easily corrected with transfusion.”13 Indeed, the seriousness of untreated preoperative anemia is easily obscured by a hectic surgical schedule. It is a difficult situation. Waiting for a last-minute type and screen frustrates the busy surgeon or forces the anesthesiologist to play clairvoyant on how the patient will tolerate additional blood loss. How then are we to proceed? If we are to harness the power of effective preoperative optimization and heed the warnings of multiple studies demonstrating the negative effects of avoidable blood transfusions, then we must begin to explore each component of PBM. In the example of IVI infusions, preoperative assessment clinics working with institutional leadership must demonstrate the cost savings associated with reduced blood transfusion. In 1 study, the costs of RBC transfusion were estimated at $522–$1183 per unit administered and were often top-line items on institution surgical budgets.14 Next, agreements with surgery clinics or specific surgical service lines should be developed. Identifying surgical procedures with the highest risk for transfusion and creating partnerships with those surgeons focus efforts on patients with the greatest need. Finally, we must educate patients on the benefits of transfusion avoidance. In the study by Ellermann et al6, patients received one 500-mg iron transfusion for preoperative anemia due to iron deficiency. At my institution, this transfusion would have cost the patient approximately $200. Many protocols advocate using higher doses and ≥3 infusions with approximate costs of $1200 to the patient. Possibly the greatest barrier to preoperative anemia optimization may be the patient themselves if they are not willing to pay for this service or not able to be reimbursed by insurance. Many Medicare Administrative Contractors limit payment for IVI infusions for preoperative anemia.13 Institutional leaders should consider preoperative anemia treatment as a value-based metric and negotiate with insurance providers for payment. We are all practicing in the Triple Aim Era of medicine (improved patient experience, reduced cost, and better population health), and anesthesiologists can act as integrators of this philosophy.15 To that end, we must look to optimize conditions that promote the best possible outcomes. Perioperative iron infusion should be considered a viable treatment for patients with iron deficiency anemia. Institutions should actively develop a PBM program because patient benefit is readily demonstrated. Anesthesiologists should take an active role in identifying patients who would benefit from preoperative hemoglobin optimization and coordinate this care. Preoperative assessment clinics should work collaboratively with surgeons and develop protocols for the treatment of anemia in high-risk patients. This scenario is the proverbial “low-hanging fruit.” Preoperative anemia is an easily identifiable, modifiable condition that if treated can potentially prevent negative outcomes and save money. What are we waiting for? We should stop ignoring this problem and learn from others who have initiated successful treatment programs. DISCLOSURES Name: Jeffrey W. Simmons, MD. Contribution: This author analyzed the data and wrote the manuscript. This manuscript was handled by: Marisa B. Marques, MD." @default.
• W2896902681 created "2018-10-26" @default.
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• W2896902681 title "Preoperative Intravenous Iron to Enhance a Blood Management Program" @default.
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