Prevalence of iron deficiency and red blood cell transfusions in surgical patients

Abstract Background: Patient blood management (PBM) programs aim to implement best practices and encourage blood stewardship. Judicious use of red blood cell transfusions improves patient safety, decreases hospital length of stay (LOS) and reduces cost. A 2010 World Health Organization statement asserted "…before surgery every reasonable measure should be taken to optimize the patient's own blood volume, minimize the patient's blood loss and to harness and optimize physiological tolerance of anemia…". A comprehensive PBM program includes a preoperative anemia clinic to facilitate these goals. At our institution, 21% of surgical patients are anemic prior to their elective surgery and these patients consume approximately 67% of our transfused operating room blood. Our aim was to reduce red blood cell transfusions in elective orthopedic surgical patients by 25% and decrease hospital LOS through the implementation of a preoperative anemia clinic. Methods: After enlisting the support of hospital leadership, a preoperative anemia clinic referral/consult order was added the electronic medical record. Appropriate patients for referral were undergoing elective orthopedic surgery and had anemia defined as a Hgb <11.0 g/dl. Additional non-anemic patients with extenuating circumstances such as religious objection to transfusion were also referred. Every effort was made to see patients at least 2 weeks prior to the date of scheduled surgery or within 48 hours if the referral was not placed that far in advance. Work-up of anemia was individualized based on a patient's laboratory abnormality and medical profile. Interventions were targeted at treating the underlying cause of anemia and included but were not limited to parenteral iron, erythropoietin receptor agonists, and vitamin B12 injections. The primary measures assessed were the average LOS from day of surgery to discharge and the number of red blood cell units transfused during that stay. Findings: Early data since implementing our preoperative anemia clinic has demonstrated a reduction in LOS from 5.5 days for anemic patients undergoing elective surgery without a referral versus 3.5 days for those with a referral. A relative decrease in LOS of 36%. Reductions in hospital LOS were observed across the spectrum of all elective surgical procedures. The overall red blood cell transfusion rate in patients without referral versus with referral was 1.5% and 1.2% respectively; and of those requiring a transfusion, the mean red blood cell units transfused in the perioperative period was 2.31 units versus 1.19 units, resulting in a relative reduction of 48%. Additionally, 2 patients were diagnosed with a gastric ulcer and 2 patients with multiple myeloma during work-up and referred appropriately for treatment. Discussion: Expansion of the PBM program at our institution to include a preoperative anemia clinic has led to significant reductions in both red blood cell transfusions and hospital LOS in elective orthopedic surgical patients. Early results indicate a near doubling of our goal of a 25% reduction in red blood cells transfused. This has positively impacted our patients and led to both direct and indirect financial savings at our institution. Given the initial success, we hope to expand our preoperative anemia clinic to include all surgical specialties and streamline workflow. To facilitate growth additional staffing will be required. We have created patient education videos about the benefits of correcting their anemia prior to an elective surgery and hope to further engage primary care practitioners to refer patients earlier in their surgical evaluation. We conclude that the creation of a preoperative anemia clinic at our institution is a valuable resource and has led to a decreased use of red blood cell transfusions, a decreased average hospital LOS, improved patient safety and considerable financial savings. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

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A Single Institution Registry of Hereditary Hemorrhagic Telangiectasia

Blood ◽

10.1182/blood.v124.21.5004.5004 ◽

2014 ◽

Vol 124 (21) ◽

pp. 5004-5004

Author(s):

Naushin Shareef ◽

Philip Kuriakose

Keyword(s):

Iron Deficiency ◽

Blood Cell ◽

Gene Mutation ◽

Red Blood Cell ◽

Arteriovenous Malformations ◽

Systemic Treatment ◽

Deficiency Anemia ◽

Single Institution ◽

Excessive Bleeding ◽

Red Blood Cell Transfusions

Abstract Background: Herediatry Hemorrhagic Telangiectasia (HHT), is also known as Osler-Weber-Rendu syndrome is an inherited familial disorder of vascular dysplasia with a variety of clinical manifestations including arteriovenous malformations of hepatic, pulmonary, cerebral circulation and with characteristic mucocutaneous telangiectasias. The underlying arteriovenous malformation may lead to recurrent and sometimes severe bleeding, of which epistaxis is the the most common. Excessive bleeding may in turn contribute to the development of severe iron deficiency anemia. Current management of excessive bleeding can be local therapy such as nasal cauterization versus systemic treatment in the form of iron infusions, red blood cell transfusions and angiogenesis inhibitors. Currently, there is no cure for HHT. Despite screening measures, most patients with HHT are unaware of their diagnosis. The incidence of HHT has also been subject to under-reporting. Currently, the United States lacks a formal registry for pateints with HHT. Other countries have initiated a registry to understand HHT in their institution. Given the significant morbidity associated with HHT, the purpose of this single institution, multidisciplinary study is to understand the prevelance and clinical characteristics of HHT and thus facilitate better treatment measures and continuity of care for patients with HHT. Methods: A retrospective study was made of all patients diagnosed with HHT at our institution from 2008 to 2014. Epidemilogical data, presence or absence of first degree relatives with HHT, visceral involvement, severity of epistaxis using a validated epistaxis severity scoring system, genetic testing for ENG or ACVRL1 gene mutation, and current local or systemic treatment were evaluated. Results: 27 patients ranging from age of 11 to 78 years were diagnosed as HHT. Median age was 52. 15 patients were male and 12 patients were female. 6 pateints had ENG gene mutation and 1 patient had ACVRL1 gene mutation. 3 out of 6 patients with ENG gene mutation did not have significant iron deficiency anemia. 11 patients had more than one first degree relative with HHT. All patients had symptoms of epistaxis. 8 patients had more than 1 visceral involvement with gastrointestinal and pulmonary manifestations being the most common. 11 patients had pulmonary arteriovenous malformations, 4 had cerebral arteriovenous malformations, and 8 had gastrointestinal manifestaions. Majority of patients had nasal cauterization to control their nasal bleeding. Of the local treatments, 1 patient used intranasal bevacizumab. Of the systemic treatments, 1 patient used estrogen and 1 used tamoxifen and 1 used thalidomide. 8 patients received intravenous iron therapy with significant improvement in their symptoms. 7 patients has multiple red blood cell transfusions. The most common discipline to evaluate patients with HHT was otolaryngology, hematology and genetics department. Conclusion: This is the first single institution, multidisciplinary registry created to decribe the occurrence of HHT in our institution and to identify and understand the clinical presentation of HHT. This data will help improve better screening measures, diagnosis, treatment options and improve clinical care and outcomes for patients with HHT in our institution and also help facilitate a future multicenter registry. Disclosures No relevant conflicts of interest to declare.

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