Perioperative Quality Initiative and Enhanced Recovery After Surgery-Cardiac Society Consensus Statement on the Management of Preoperative Anemia and Iron Deficiency in Adult Cardiac Surgery Patients

Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.

[1]  N. Guinn,et al.  Treatment through a preoperative anemia clinic is associated with a reduction in perioperative red blood cell transfusion in patients undergoing orthopedic and gynecologic surgery , 2022, Transfusion.

[2]  M. Mamas,et al.  Derivation and validation of a clinical model to predict death or cardiac hospitalizations while on the cardiac surgery waitlist , 2021, Canadian Medical Association Journal.

[3]  Peter A. Knight,et al.  Preoperative anemia management program reduces blood transfusion in elective cardiac surgical patients, improving outcomes and decreasing hospital length of stay , 2021, Transfusion.

[4]  C. Mazer,et al.  STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. , 2021, Journal of Cardiothoracic and Vascular Anesthesia.

[5]  L. Resar,et al.  Perioperative Management of Patients for Whom Transfusion Is Not an Option , 2021, Anesthesiology.

[6]  S. Goobie,et al.  Preoperative Anemia Screening and Treatment: Is It Worth the Return on Investment? , 2021, Anesthesia and analgesia.

[7]  D. Faraoni,et al.  Management of Perioperative Iron Deficiency in Cardiac Surgery: A Modified RAND Delphi Study. , 2020, The Annals of thoracic surgery.

[8]  A. Buser,et al.  Controversies in the Clinical Practice of Patient Blood Management. , 2020, Journal of cardiothoracic and vascular anesthesia.

[9]  J. Hamdorf,et al.  Associations of a Preoperative Anemia and Suboptimal Iron Stores Screening and Management Clinic in Colorectal Surgery With Hospital Cost, Reimbursement, and Length of Stay: A Net Cost Analysis. , 2020, Anesthesia and analgesia.

[10]  J. Browne,et al.  Preoperative intravenous iron to treat anaemia before major abdominal surgery (PREVENTT): a randomised, double-blind, controlled trial , 2020, The Lancet.

[11]  F. Sanfilippo,et al.  Screening and treating pre‐operative anaemia and suboptimal iron stores in elective colorectal surgery: a cost effectiveness analysis , 2020, Anaesthesia.

[12]  J. Hardy,et al.  Preoperative Anemia Screening and Treatment Practices in Patients Having Total Joint Replacement Surgery: A Retrospective, Observational Audit , 2020, Journal of blood medicine.

[13]  M. Refaai,et al.  Preoperative Anemia Management: What’s New in 2020? , 2020, Current Anesthesiology Reports.

[14]  P. Meybohm,et al.  Perioperative Anemia Management as Part of PBM in Cardiac Surgery - A Narrative Updated Review. , 2020, Journal of cardiothoracic and vascular anesthesia.

[15]  M. Avram,et al.  An Effective and Efficient Testing Protocol for Diagnosing Iron-deficiency Anemia Preoperatively , 2020, Anesthesiology.

[16]  Sephalie Y. Patel,et al.  Perioperative Anemia: Prevention, Diagnosis, and Management Throughout the Spectrum of Perioperative Care , 2020, Anesthesia and analgesia.

[17]  M. Cappellini,et al.  Iron deficiency anaemia revisited , 2020, Journal of internal medicine.

[18]  J. Hardy,et al.  Overcoming barriers to evidence-based patient blood management: a restricted review , 2020, Implementation science : IS.

[19]  M. Zeller,et al.  Management of iron deficiency. , 2019, Hematology. American Society of Hematology. Education Program.

[20]  D. Spahn,et al.  Impact of a Patient Blood Management monitoring and feedback programme on allogeneic blood transfusions and related costs , 2019, Anaesthesia.

[21]  H. Luckraz,et al.  Preoperative anemia and outcomes in cardiovascular surgery: systematic review and meta-analysis. , 2019, The Annals of thoracic surgery.

[22]  R. Engelman,et al.  Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. , 2019, JAMA surgery.

[23]  G. Bouzillé,et al.  Impact of Preoperative Iron Deficiency on Blood Transfusion in Elective Cardiac Surgery. , 2019, Journal of cardiothoracic and vascular anesthesia.

[24]  B. Seifert,et al.  Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial , 2019, The Lancet.

[25]  G. Wells,et al.  The Effect of Preoperative Anemia on Patients Undergoing Cardiac Surgery: A Propensity-Matched Analysis. , 2019, Seminars in thoracic and cardiovascular surgery.

[26]  E. Wood,et al.  Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference , 2019, JAMA.

[27]  J. Freedman,et al.  Hemoglobin Optimization for Coronary Bypass: A 10-Year Canadian Multicenter Experience. , 2019, The Annals of thoracic surgery.

[28]  C. Camaschella Iron deficiency. , 2019, Blood.

[29]  C. Norris,et al.  Variables Associated With Cardiac Surgical Waitlist Mortality From a Population-Based Cohort. , 2019, The Canadian journal of cardiology.

[30]  T. Ueland,et al.  Prevalence and prognostic implication of iron deficiency and anaemia in patients with severe aortic stenosis , 2018, Open Heart.

[31]  R. Weiskopf,et al.  Severe anemia associated with increased risk of death and myocardial ischemia in patients declining blood transfusion , 2018, Transfusion.

[32]  S. Bagshaw,et al.  Six‐Month Outcomes after Restrictive or Liberal Transfusion for Cardiac Surgery , 2018, The New England journal of medicine.

[33]  R. Hawkins,et al.  Preoperative anemia versus blood transfusion: Which is the culprit for worse outcomes in cardiac surgery? , 2018, The Journal of thoracic and cardiovascular surgery.

[34]  L. Feldman,et al.  From Preoperative Assessment to Preoperative Optimization of Frailty. , 2018, JAMA surgery.

[35]  S. Bhandari,et al.  The safety of available treatment options for iron-deficiency anemia , 2018, Expert opinion on drug safety.

[36]  A. Steinbicker,et al.  Intravenous Iron for Treatment of Anemia in the 3 Perisurgical Phases: A Review and Analysis of the Current Literature. , 2017, Anesthesia and analgesia.

[37]  S. Bagshaw,et al.  Restrictive or Liberal Red‐Cell Transfusion for Cardiac Surgery , 2017, The New England journal of medicine.

[38]  D. Swinkels,et al.  Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing in iron-depleted women: two open-label, randomised controlled trials. , 2017, The Lancet. Haematology.

[39]  J. Hamdorf,et al.  Improved outcomes and reduced costs associated with a health‐system–wide patient blood management program: a retrospective observational study in four major adult tertiary‐care hospitals , 2017, Transfusion.

[40]  H. Kehlet,et al.  International consensus statement on the peri‐operative management of anaemia and iron deficiency , 2017, Anaesthesia.

[41]  T. Gan,et al.  Evidence-Based Perioperative Medicine comes of age: the Perioperative Quality Initiative (POQI) , 2016, Perioperative Medicine.

[42]  I. Robertson,et al.  Intravenous ferric carboxymaltose versus standard care in the management of postoperative anaemia: a prospective, open-label, randomised controlled trial. , 2016, The Lancet. Haematology.

[43]  P. Austin,et al.  Preprocedure Anemia Management Decreases Transfusion Rates in Patients Undergoing Transcatheter Aortic Valve Implantation. , 2016, The Canadian journal of cardiology.

[44]  S. Aronson,et al.  How do we develop and implement a preoperative anemia clinic designed to improve perioperative outcomes and reduce cost? , 2016, Transfusion.

[45]  M. Grocott,et al.  Perioperative Medicine: The Value Proposition for Anesthesia?: A UK Perspective on Delivering Value from Anesthesiology. , 2015, Anesthesiology clinics.

[46]  M. Cappellini,et al.  Anemia in Clinical Practice-Definition and Classification: Does Hemoglobin Change With Aging? , 2015, Seminars in hematology.

[47]  L. Pierelli,et al.  A single dose of erythropoietin reduces perioperative transfusions in cardiac surgery: results of a prospective single‐blind randomized controlled trial , 2015, Transfusion.

[48]  A. Xing,et al.  Intravenous Iron Sucrose versus Oral Iron in the Treatment of Pregnancy with Iron Deficiency Anaemia: A Systematic Review , 2015, Gynecologic and Obstetric Investigation.

[49]  G. Angelini,et al.  Liberal or restrictive transfusion after cardiac surgery. , 2015, The New England journal of medicine.

[50]  J. Powell,et al.  Ferrous Sulfate Supplementation Causes Significant Gastrointestinal Side-Effects in Adults: A Systematic Review and Meta-Analysis , 2015, PloS one.

[51]  J. Kellum,et al.  The 12th consensus conference of the Acute Dialysis Quality Initiative (ADQI XII). , 2014, British journal of anaesthesia.

[52]  K. Ho,et al.  Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials , 2013, BMJ.

[53]  E. Andrès,et al.  Anemia in elderly patients: New insight into an old disorder , 2013, Geriatrics & gerontology international.

[54]  P. Austin,et al.  Surgical outcomes and transfusion of minimal amounts of blood in the operating room. , 2012, Archives of surgery.

[55]  B. Chaitman,et al.  Liberal or restrictive transfusion in high-risk patients after hip surgery. , 2011, The New England journal of medicine.

[56]  T. Ganz,et al.  Detection, evaluation, and management of iron-restricted erythropoiesis. , 2010, Blood.

[57]  E. Wood,et al.  Diagnosis and management of iron deficiency anaemia: a clinical update , 2010, The Medical journal of Australia.

[58]  G. Guyatt,et al.  Going from evidence to recommendations , 2008, BMJ : British Medical Journal.

[59]  Gordon H Guyatt,et al.  GrADe : what is “ quality of evidence ” and why is it important to clinicians ? rATING quALITY of evIDeNCe AND STreNGTH of reCommeNDATIoNS , 2022 .

[60]  G. Guyatt,et al.  GRADE: an emerging consensus on rating quality of evidence and strength of recommendations , 2008, BMJ : British Medical Journal.

[61]  D. Wijeysundera,et al.  Risk Associated With Preoperative Anemia in Cardiac Surgery: A Multicenter Cohort Study , 2008, Circulation.

[62]  J. Wish Assessing iron status: beyond serum ferritin and transferrin saturation. , 2006, Clinical journal of the American Society of Nephrology : CJASN.

[63]  J. Légaré,et al.  Assessing the risk of waiting for coronary artery bypass graft surgery among patients with stenosis of the left main coronary artery , 2005, Canadian Medical Association Journal.

[64]  N. Rosencher,et al.  Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe * , 2003, Transfusion.

[65]  K. Buth,et al.  Waiting for Cardiac Surgery: Results of a Risk-Stratified Queuing Process , 2001, Circulation.

[66]  B. Skikne,et al.  Erythropoietin, iron, and erythropoiesis. , 2000, Blood.

[67]  G. Wells,et al.  A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. , 1999, The New England journal of medicine.

[68]  M. Carnes,et al.  Detecting iron deficiency in anemic patients with concomitant medical problems , 1998, Journal of General Internal Medicine.

[69]  Ganzoni Am,et al.  [Intravenous iron-dextran: therapeutic and experimental possibilities]. , 1970, Schweizerische medizinische Wochenschrift.

[70]  S. Frank,et al.  Impact of Preoperative Erythropoietin on Allogeneic Blood Transfusions in Surgical Patients: Results From a Systematic Review and Meta-analysis , 2019, Anesthesia and analgesia.

[71]  B. Seifert,et al.  Iron deficiency is associated with higher mortality in patients undergoing cardiac surgery: a prospective study. , 2019, British journal of anaesthesia.

[72]  J. Légaré,et al.  How established wait time benchmarks significantly underestimate total wait times for cardiac surgery. , 2010, The Canadian journal of cardiology.

[73]  C. Brighton Orthopedic surgery. , 1976, Surgery, gynecology & obstetrics.