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Thorac Cardiovasc Surg
DOI: 10.1055/a-2176-2218
Original Cardiovascular

Implementation of a Short-term Treatment Protocol in Anemic Patients before Cardiac Surgery

Dror B. Leviner    *
1   Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa, Israel
,
Dana Abraham   *
2   Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
,
Maayan Shiner
3   Blood Bank Haifa, Carmel Medical Center, Haifa, Israel
,
Naama Schwartz
4   Research Authority, Carmel Medical Center, Haifa, Israel
,
Ophir Lavon
5   Clinical Pharmacology, Carmel Medical Center, Haifa, Israel
,
Erez Sharoni
1   Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa, Israel
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Abstract

Background We assessed whether implementation of an immediate preoperative treatment in anemic patients could result in fewer perioperative packed red blood cell (PRBC) transfusions and improved outcomes in a real-world setting.

Methods From January 1, 2020, to November 31, 2022, we implemented a perioperative protocol for anemic patients (hemoglobin (Hb) level in women <11.5 g/dL, men <12.5 g/dL), which included subcutaneous erythropoietin α, intravenous Iron, and intramuscular vitamin B12 (all given preoperatively) and per os iron and folic acid given once a day postoperatively. We retrospectively compared all patients receiving the protocol to all eligible patients who were operated upon in the 4 years prior to implementation of the protocol. Primary outcome was amount of PRBC transfusions during surgery and index admission.

Results In the months after protocol implementation, 114 patients who received the treatment protocol were compared with 236 anemic patients in the 4 years prior to who did not receive the protocol. The treatment reduced total PRBC use (control group median 4 [2–7] units vs. treatment 2 [1–3] units, p < 0.0001) and the incidence of postoperative blood products transfusions (treatment group 58 patients, 50.88% vs. control group 177 patients, 75%, p < 0.0001). Hb prior to discharge was higher among the protocol group (treatment median 9 g/dL [8.3–9.5 g/dL] vs. control 8.6 g/dL [8.1–9.1 g/dL], p = 0.0081).

Conclusion Despite some differences compared with previously described protocols, the implementation of a perioperative treatment protocol for anemic patients was associated with a reduction in PRBC transfusion in a real-world setting.

Keywords

anesthesia - blood transfusion - coronary artery bypass graft surgery - outcomes

Authors' Contribution

Both D.B.L. and D.A. contributed equally to the conceptualization, data collection, interpretation of the results, writing and editing the manuscript. Both authors invested the same number of hours and effort in this paper.


* These authors contributed equally.


Supplementary Material



Publication History

Received: 04 June 2023

Accepted: 12 September 2023

Accepted Manuscript online:
14 September 2023

Article published online:
30 October 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Pagano D, Milojevic M, Meesters MI. et al. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2018; 53 (01) 79-111
    CrossrefPubMedSearch in Google Scholar
  • 2 Hogan M, Klein AA, Richards T. The impact of anaemia and intravenous iron replacement therapy on outcomes in cardiac surgery. Eur J Cardiothorac Surg 2015; 47 (02) 218-226
    CrossrefPubMedSearch in Google Scholar
  • 3 Padmanabhan H, Siau K, Curtis J. et al. Preoperative anemia and outcomes in cardiovascular surgery: systematic review and meta-analysis. Ann Thorac Surg 2019; 108 (06) 1840-1848
    CrossrefPubMedSearch in Google Scholar
  • 4 Engoren M, Schwann TA, Habib RH, Neill SN, Vance JL, Likosky DS. The independent effects of anemia and transfusion on mortality after coronary artery bypass. Ann Thorac Surg 2014; 97 (02) 514-520
    CrossrefPubMedSearch in Google Scholar
  • 5 Padmanabhan H, Brookes MJ, Nevill AM, Luckraz H. Association between anemia and blood transfusion with long-term mortality after cardiac surgery. Ann Thorac Surg 2019; 108 (03) 687-692
    CrossrefPubMedSearch in Google Scholar
  • 6 Murphy GJ, Reeves BC, Rogers CA, Rizvi SIA, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007; 116 (22) 2544-2552
    CrossrefPubMedSearch in Google Scholar
  • 7 von Heymann C, Kaufner L, Sander M. et al. Does the severity of preoperative anemia or blood transfusion have a stronger impact on long-term survival after cardiac surgery?. J Thorac Cardiovasc Surg 2016; 152 (05) 1412-1420
    CrossrefPubMedSearch in Google Scholar
  • 8 Paone G, Likosky DS, Brewer R. et al; Membership of the Michigan Society of Thoracic and Cardiovascular Surgeons. Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality. Ann Thorac Surg 2014; 97 (01) 87-93 , discussion 93–94
    CrossrefPubMedSearch in Google Scholar
  • 9 Hendrickson JE, Roubinian NH, Chowdhury D. et al; National Heart, Lung, and Blood Institute (NHLBI) Recipient Epidemiology and Donor Evaluation Study (REDS-III). Incidence of transfusion reactions: a multicenter study utilizing systematic active surveillance and expert adjudication. Transfusion 2016; 56 (10) 2587-2596
    CrossrefPubMedSearch in Google Scholar
  • 10 Xu H, Duan Y, Yuan X, Wu H, Sun H, Ji H. Intravenous iron versus placebo in the management of postoperative functional iron deficiency anemia in patients undergoing cardiac valvular surgery: a prospective, single-blinded, randomized controlled trial. J Cardiothorac Vasc Anesth 2019; 33 (11) 2941-2948
    CrossrefPubMedSearch in Google Scholar
  • 11 WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. . Vitamin and Mineral Nutrition Information System. Geneva: World Health Organization; 2011. (WHO/NMH/NHD/MNM/11.1); available at: http://www.who.int/vmnis/indicators/haemoglobin.pdf
    Search in Google Scholar
  • 12 Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. New Jersey, NJ:: Lawrence Erlbaum Associates;; 1988
    Search in Google Scholar
  • 13 Goodnough LT, Monk TG, Andriole GL. Erythropoietin therapy. N Engl J Med 1997; 336 (13) 933-938
    CrossrefPubMedSearch in Google Scholar
  • 14 Sowade O, Warnke H, Scigalla P. et al. Avoidance of allogeneic blood transfusions by treatment with epoetin beta (recombinant human erythropoietin) in patients undergoing open-heart surgery. Blood 1997; 89 (02) 411-418
    CrossrefPubMedSearch in Google Scholar
  • 15 Cladellas M, Farré N, Comín-Colet J. et al. Effects of preoperative intravenous erythropoietin plus iron on outcome in anemic patients after cardiac valve replacement. Am J Cardiol 2012; 110 (07) 1021-1026
    CrossrefPubMedSearch in Google Scholar
  • 16 Spahn DR, Schoenrath F, Spahn GH. et al. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial. Lancet 2019; 393 (10187): 2201-2212
    CrossrefPubMedSearch in Google Scholar
  • 17 Weltert L, Rondinelli B, Bello R. et al. A single dose of erythropoietin reduces perioperative transfusions in cardiac surgery: results of a prospective single-blind randomized controlled trial. Transfusion 2015; 55 (07) 1644-1654
    CrossrefPubMedSearch in Google Scholar
  • 18 Weltert L, D'Alessandro S, Nardella S. et al. Preoperative very short-term, high-dose erythropoietin administration diminishes blood transfusion rate in off-pump coronary artery bypass: a randomized blind controlled study. J Thorac Cardiovasc Surg 2010; 139 (03) 621-626 , discussion 626–627
    CrossrefPubMedSearch in Google Scholar
  • 19 Yoo Y-C, Shim J-K, Kim J-C, Jo Y-Y, Lee J-H, Kwak Y-L. Effect of single recombinant human erythropoietin injection on transfusion requirements in preoperatively anemic patients undergoing valvular heart surgery. Anesthesiology 2011; 115 (05) 929-937
    CrossrefPubMedSearch in Google Scholar
  • 20 Ohri SK, Benedetto U, Luthra S. et al. Coronary artery bypass surgery in the UK, trends in activity and outcomes from a 15-year complete national series. Eur J Cardiothorac Surg 2022; 61 (02) 449-456
    CrossrefPubMedSearch in Google Scholar
  • 21 Lee R, Li S, Rankin JS. et al; Society of Thoracic Surgeons Adult Cardiac Surgical Database. Fifteen-year outcome trends for valve surgery in North America. Ann Thorac Surg 2011; 91 (03) 677-684 , discussion 684
    CrossrefPubMedSearch in Google Scholar
  • 22 Grant SW, Kendall S, Goodwin AT. et al. Trends and outcomes for cardiac surgery in the United Kingdom from 2002 to 2016. JTCVS Open 2021; 7: 259-269
    CrossrefPubMedSearch in Google Scholar
  • 23 Cheung WK, Goon BL, Guilfoyle MC, Wacholtz MC. Pharmacokinetics and pharmacodynamics of recombinant human erythropoietin after single and multiple subcutaneous doses to healthy subjects. Clin Pharmacol Ther 1998; 64 (04) 412-423
    CrossrefPubMedSearch in Google Scholar
  • 24 Krzyzanski W, Perez-Ruixo JJ. An assessment of recombinant human erythropoietin effect on reticulocyte production rate and lifespan distribution in healthy subjects. Pharm Res 2007; 24 (04) 758-772
    CrossrefPubMedSearch in Google Scholar
  • 25 Major A, Mathez-Loic F, Rohling R, Gautschi K, Brugnara C. The effect of intravenous iron on the reticulocyte response to recombinant human erythropoietin. Br J Haematol 1997; 98 (02) 292-294
    CrossrefPubMedSearch in Google Scholar
  • 26 Mirzaei S, Hershberger PE, DeVon HA. Association between adverse clinical outcomes after coronary artery bypass grafting and perioperative blood transfusions. Crit Care Nurse 2019; 39 (01) 26-35
    CrossrefPubMedSearch in Google Scholar
  • 27 Sultan I, Bianco V, Brown JA. et al. Long-term impact of perioperative red blood cell transfusion on patients undergoing cardiac surgery. Ann Thorac Surg 2021; 112 (02) 546-554
    CrossrefPubMedSearch in Google Scholar
  • 28 Yang J-C, Sun Y, Xu C-X. et al. Correlation between red blood cell transfusion volume and mortality in patients with massive blood transfusion: A large multicenter retrospective study. Exp Ther Med 2015; 9 (01) 137-142
    CrossrefPubMedSearch in Google Scholar
  • 29 Sowade O, Ziemer S, Sowade B. et al. The effect of preoperative recombinant human erythropoietin therapy on platelets and hemostasis in patients undergoing cardiac surgery. J Lab Clin Med 1997; 129 (03) 376-383
    CrossrefPubMedSearch in Google Scholar
  • 30 Auerbach M, Adamson JW. How we diagnose and treat iron deficiency anemia. Am J Hematol 2016; 91 (01) 31-38
    CrossrefPubMedSearch in Google Scholar
  • 31 Blumenstein I, Shanbhag S, Langguth P, Kalra PA, Zoller H, Lim W. Newer formulations of intravenous iron: a review of their chemistry and key safety aspects - hypersensitivity, hypophosphatemia, and cardiovascular safety. Expert Opin Drug Saf 2021; 20 (07) 757-769
    CrossrefPubMedSearch in Google Scholar