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Belgrade 2011
Management of perioperative anemia in Major orthopedic surgery: practical
approach
Nadia Rosencher Anesthesiology and Intensive care department
Cochin Hospital, Paris Descartes University75014 Paris France
Belgrade 2011
Disclosure
1. Abbott, 2. Air Liquide3. Astra-Zeneca,4. Bayer,5. Bristol Meyer Squibb,6. B-Braun,7. Boëringher-Ingelheim,
8. General Electric,9. Glaxo-Smith-Klein, 10.Janssen11. LFB12. Pfizer13. Sanofi-Aventis14. Vifor
Belgrade 2011
Perioperative anemia Outline
1.Incidence and cause of preoperative anemia and related mortality
2.International Recommendations : NATA3.Preoperative assessment: IRON and ESA4.Postoperative anemia and mortality5.How to managed Postoperative anemia: 6.Kinetic of bleeding and anticipation7.Conclusion
Belgrade 2011
Author/year Surgery n incidence
Saleh 2007 THR/TKR 1142 20%
Basora 2006 THR/TKR 218 39%
Myers 2004 THR 225 15%
Rosencher 2003 THR/TKR 2646 30%
Su 2004 HF 844 44%
Halm 2004 HF 550 46%
Gruson 2002 HF 395 46%
Incidence of Preoperative Anemia in Major orthopedic Surgery
Incidence of Preoperative Anemia in Major orthopedic Surgery
Belgrade 2011
Prevalence of preoperative anaemia and haematinic deficiencies in patients
scheduled for elective orthopaedic surgery (Elvira Bisbe et al, TATM 2008;10:166-73)
Type of Anemia n( %)
With nutrient deficiency 20/65
Iron only 12/65 (16.9)
Folate only 1/65 (1.5)
B12 only 4/65 (6.1%)
Iron with folate or B12 or both 3/65 (4.6)
Without nutrient deficiency
Renal insufficiency only 2/65 (3.1)
ACI, no renal insufficiency 19/65 (29)
Renal insufficiency and ACI 6/65 (9.3)
UA 16/65 (24.6)
30.7%
Belgrade 2011
Preoperative Anemia kills me
Belgrade 2011
Preoperative Hematocrit Levels and Postoperative Preoperative Hematocrit Levels and Postoperative Outcomes in Older Patients Undergoing Noncardiac Outcomes in Older Patients Undergoing Noncardiac
SurgerySurgery
Wu WC et al, Wu WC et al, JAMAJAMA 2007; 2007; 297:2481‒8 297:2481‒8
• Retrospective cohort study using the VA National Retrospective cohort study using the VA National Surgical Quality Improvement Program database.Surgical Quality Improvement Program database.
• 310,311310,311 veterans aged ≥ 65 years who veterans aged ≥ 65 years who underwent major noncardiac surgery between underwent major noncardiac surgery between 1997 and 2004.1997 and 2004.
• Increased 30-day mortality in patients with Increased 30-day mortality in patients with preoperative preoperative Hct < 39% (Hb < 13 g/dL)..
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WC Wu et al. JAMA 2007;297:2481-8
Belgrade 2011
Belgrade 2011
Belgrade 2011
• We obtained data for 227 425 patients, of whom 69 229 (30.44%) had preoperative anaemia.
• postoperative mortality at 30 days was higher in patients with anaemia than in those without anaemia (odds ratio [OR] 1.42,; this difference was consistent in mild anaemia 1.41, and moderate-to-severe anaemia (1.44, ) Composite postoperative morbidity at 30 days was also higher in patients with anaemia than in those without anaemia
• When compared with patients without anaemia or a defined risk factor, patients with anaemia and most risk factors had a higher adjusted OR for 30-day mortality and morbidity than did patients with either anaemia or the risk factor alone.
• Conclusion : Preoperative anaemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery
Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study
Khaled M Musallam et al, The Lancet Volume 378, Issue 9800, 15-21 October 2011, Pages 1362-
1363
Belgrade 2011
30-day composite morbidity, by anaemia and risk factor status 30-day composite morbidity, by anaemia and risk factor status
Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study
Khaled M Musallam et al, The Lancet Volume 378, Issue 9800, 15-21
October 2011, Pages 1362-1363
Belgrade 2011
Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study
Khaled M Musallam et al, The Lancet Volume 378, Issue 9800, 15-21 October 2011, Pages 1362-
1363
•
Figure 1. 30-day mortality, by anaemia and risk factor statusFigure 1. 30-day mortality, by anaemia and risk factor status
Belgrade 2011
Perioperative anemia Outline
1.Incidence and cause of preoperative anemia and related mortality
2.International Recommendations : NATA3.Preoperative assessment: IRON and ESA4.Postoperative anaemia and mortality5.How to managed Postoperative anemia: 6.Kinetic of bleeding and anticipation7.Conclusion
Belgrade 2011
Detection, Evaluation and ManagementDetection, Evaluation and Managementof Preoperative Anemia in the Elective Orthopedic of Preoperative Anemia in the Elective Orthopedic
Surgical Patient—NATA GuidelinesSurgical Patient—NATA Guidelines
TL Goodnough Br J Anaesth. 2011 Jan;106(1):13-22
Multidisciplinary panel : 3 orthopedists , 3 hematologists, 6 anesthesiologists, 1 epidemiologist And society representation :
European Federation of National Associations of Orthopaedics and Traumatology (EFORT) : G. BenoniSpine Society of Europe (SSE) : M. Szpalski
European Society of Anaesthesiology (ESA) Y. Ozier
Multidisciplinary panel : 3 orthopedists , 3 hematologists, 6 anesthesiologists, 1 epidemiologist And society representation :
European Federation of National Associations of Orthopaedics and Traumatology (EFORT) : G. BenoniSpine Society of Europe (SSE) : M. Szpalski
European Society of Anaesthesiology (ESA) Y. Ozier
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Recommendations―Detection of Recommendations―Detection of AnemiaAnemia
• Recommendation 1: Recommendation 1: We recommend thatWe recommend that eelective surgical patients have a Hb level lective surgical patients have a Hb level determination as close to determination as close to 28 days before the 28 days before the scheduled surgical procedure (Grade 1A).scheduled surgical procedure (Grade 1A).
• Recommendation 2: Recommendation 2: We suggest thatWe suggest that t the he patientpatient’’s target Hb before elective surgery s target Hb before elective surgery be within the normal range be within the normal range (normal female (normal female ≥ 12 g/dL, normal male ≥ 13 g/dL), ≥ 12 g/dL, normal male ≥ 13 g/dL), according to WHO criteria (Grade 2C).according to WHO criteria (Grade 2C).
TL Goodnough Br J Anaesth. 2011 Jan;106(1):13-22
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Recommendations―Evaluation of Recommendations―Evaluation of AnemiaAnemia
• Recommendation 3Recommendation 3: : We recommend thatWe recommend that l laboratory testing take place to further evaluate for nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C).
• Recommendation 4:Recommendation 4: We recommend thatWe recommend that nutritional deficiencies be treated before surgery (Grade 1C).
• Recommendation 5:Recommendation 5: We suggest thatWe suggest that eerythropoiesis-stimulating agent (ESA) therapy be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected. (Grade 2A).
TL Goodnough Br J Anaesth. 2011 Jan;106(1):13-22
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Hb < 120 g/L for femalesHb < 130 g/L for males
Ferritin < 30 μg/L and/or TSAT < 15–20%
Ferritin 30–70 μg/Land/orTSAT > 20%
Normal
Iron status?
Serum creatinineGlumerular filtration rate
Anemia of chronic disease
LowVitamin B12
and/or folic acid
Ferritin > 70 μg/Land/or TSAT > 20%
Normal
Chronic kidney disease (CKD)
Low
Rule out iron deficiency Inflammation/ chronic disease
Iron deficiency Referral to gastroenterologist to rule out malignancy
Folic acid and/orVitamin B12
therapy
Erythropoiesis-stimulating agent therapy
Iron therapy1) Oral iron in divided doses 2) IV iron if patient cannot tolerate oral iron, intestinal absorption problems, or short timeline
Referral to nephrologist
No response
Evaluation necessary
Belgrade 2011
Perioperative anemia Outline
1.Incidence and cause of preoperative anemia and related mortality
2.International Recommendations : NATA3.Preoperative assessment: ESA and
Iron4.Postoperative anaemia and mortality5.How to managed Postoperative anemia: 6.Kinetic of bleeding and anticipation7.Conclusion
Belgrade 2011
In practice, according to size of RBC
Microcytic MCV<80fl
1. Fe deficiency 2. Hemoglobinopathy3. Anemia of chronic
disease (ACD)
IV Iron if inflammatory disease + ESA
Normocytic MCV 80-96
1. ACD 2. Acute blood loss 3. Anaemia of renal
disease
Referral to gynecologist
and gastroenterolog
ist Iron (IV) + ESA
Macrocytic MCV >96
1. B12, FA deficiency 2. Chronic liver
disease3. myelodysplasia4. Chemotherapy
Folic acid and VitB12 therapy
+ESA + Iron
Belgrade 2011
In preoperative assessment I need as In preoperative assessment I need as llaboratory testing
• Hb level and size of RBC + Platelets • Creatinine serum and creat
clearance• CRP (inflammatory disease ?)• Iron status : Transferrin + Tsat
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To sum up: at preoperative assessment
1. To increase Hb in this short delay (28 days), I need ESA
2. Because of ESA therapy, I need Iron3. The choice of IV Iron is based on CRP,
if oral is not tolerated, if drug interaction (thyroxin…), if renal impairment..
4. In case of macrocytic RBC, I add Folic acid and Vitamin B12
Belgrade 2011
Probability of Allogeneic-Only TransfusionKnee and Hip Replacements
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%8,
0
9,0
10,0
11,0
12,0
13,0
14,0
15,0
16,0
Baseline Hb g /dL
Pro
bab
ilit
y o
f Tra
nsfu
sio
n
Men Women
N. Rosencher Transfusion. 2003 Apr;43(4):459-69
Abnormal bleeding or female less than 50kg
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Preoperative EPO : « a first class technique….. »
If Hb increases before surgical procedure:• Blood loss tolerated without any
transfusion increases and thus we avoid any transfusion (autologous and allogeneic)
• We can solve all the problems of the controversy or close the debate about
1. Blood shortage
1. Residual an unknown emergent risk2. Immuno-modulatory effect3. Mistransfusion, bacterial contamination4. Hepatitis, VIH….
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Why do we always need to associate Iron to ESA
1. Erythropoiesis stimulation increases need of Iron,
2. Iron fixed to transferrin disappears rapidly and Iron from ferritin serum should be mobilized
3. Mobilisation is done very slowly even if ferritin serum level is normal
4. Iron should be quickly delivered to respond to demand of erythropoiesis stimulated by EPO
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Iron deficiency leads to bad response to ESA
• If anemia cannot be corrected by ESA, it means that Iron is deficient or not well absorbed (inflammatory disease…)
• Functional Iron deficiency = decrease of TSAT < 20%
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In practice : How to prescribe Ironin preoperative period ?
• If oral 200 à 300 mg/day • 1 h before meals• If IV between 500mg /each injection of
EPO, according to Iron status• Drug interactions with oral Iron are
not well known (Thyroxin, cycline, fluoroquinolone, diphosphonates…)
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Combined effect of Delay and dose
D-21
D-14
D-10
D-7 D0 D1 D2 D3 D4 D5
8
9
10
11
12
13
14
Hb
le
ve
l (g
/dl)
(m
ea
n)
rHuEPO2400 UI / kg started 3 weeks before surgery.
rHuEPO4500 UI / kg during 15 days.
Goldberg M. Semin Hematol 1997;34:41-47.
Belgrade 2011
Optimizing EPO use
1. Iron therapy added (200 to 300 mg/day if oral medication) and 200-500mg/week if IV
2. Start first injection between 21 and 30 days before surgery
3. Number of EPO injections should be related to Hb baseline
• 4 injections if Hb =10g/dl• 3 injections if Hb =11g/dl• 2 injections if Hb =12g/dl• 1 injection if Hb = 13g/dl
N Rosencher et al./transfusion clinique et biologique 15 (2008) 294-302
Hb level is accurate only if case of normovolemia
Hb level is accurate only if case of normovolemia
Risks associated with EPO meta-analysis De Andrade JR, 1999,Orthopedics, vol 22, p:113-118
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EPO Contraindications
• Recent stroke • Recent MI• Non controlled Hypertension• All arterial thrombosis or risk of
thrombosis event• Iron deficiency
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Take this message home
1. EPO efficacy increases with • dose (600 UI /kg/week)• delay between first injection and surgery• Iron therapy is necessary :200mg/Day (if
oral) and 500mg/week if IV2. EPO is indicated if 10 ≤ Hb baseline ≤ 13g/dl3. Contraindications are all recent artery
diseases (MI, Stroke, severe HyperTension, arteritis…..)
4. Suggestion : The number of injections should be related to Hb baseline
N Rosencher et al./transfusion clinique et biologique 15 (2008) 294-302
Belgrade 2011
How to use IV IRON
1. In postoperative period, because inflammatory disease: IV Iron : 500 and 1000 mg in 15 minutes but no more than 15mg/kg/week
2. In preoperative period, in case of inflammatory disease or renal impairment
3. If EPO: 500mg/injection– Or according to Hb baseline (cf table)
Belgrade 2011
Perioperative anemia Outline
1.Incidence and cause of preoperative anemia and related mortality
2.International Recommendations : NATA3.Preoperative assessment: IRON and ESA4.Postoperative anaemia and mortality5.How to managed Postoperative anaemia: 6.Kinetic of bleeding and anticipation7.Conclusion
Belgrade 2011
How Anemia kills me?
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MI Death
US retrospective analysis; N = 10,244Average mortality = 0.5% after 1 month
Frequency of myocardial infarction and death following primary THR or TKR
Mantilla CB, et al. Anesthesiology. 2002;96:1140-1146.
% %
0.0
0.5
1.0
1.5
2.0
2.5
< 49 50-59 60-69 70-79 > 80
Men
Women
Age (years)
0
1
2
3
< 49 50-59 60-69 70-79 > 80
Men
Women
Age (years)
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Causes of death in the Norway register
Cause of death Number of deathsa Mortality/1000
THRa
All deaths before 31 December 1995 360 7.87
All vascular causes of death 274 5.99 Ischemic heart disease 145 3.17
PE and infarction 42 0.92
Cerebrovascular disease 55 1.20
DVT 13 0.28
Thromboembolic complications 169 3.69
Bleeding 51 1.11
Sudden death (mors subita) 32 0.70
All non-vascular causes of death 67 1.46
Mortality during the first 60 days after surgery,1987-1995 (n = 45,767)
aCauses of death according to the death record. The sum of the cause-specific mortality rates therefore exceeds the all-cause mortality.
Stein A L, Acta Orthop Scand 2002; 73 (4): 392–399
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1. Within 30 days of random assignment, 415 patients (5.0%) had a perioperative MI. Most MIs (74.1%) occurred within 48 hours of surgery; 65.3% of patients did not experience ischemic symptoms.
• The 30-day mortality rate was 11.6% (48 of 415 patients) among patients who had a perioperative MI and 2.2% (178 of 7936 patients) among those who did not (P 0.001).
• Among patients with a perioperative MI, mortality rates were elevated and similar between those with (9.7%; adjusted odds ratio, 4.76 [95% CI, 2.68 to 8.43]) and without (12.5%; adjusted odds ratio, 4.00 [CI, 2.65 to 6.06]) ischemic symptoms
P.J. Devereaux et al Ann Intern Med. 2011;154:523-528.
POISE study
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Independent Predictors of Perioperative MI.
Devereaux P et al. Ann Intern Med 2011;154:523-528
©2011 by American College of Physicians
Belgrade 2011
In THR and TKR, vast majority of bleeding events occur peri-operatively
BleedingDVT/PE
Time
Inci
den
ce
Surgery
THR/TKR trial comparing a ximelagatran/melagtran regime and enoxaparin 40 mg, both regimens being initiated preoperatively:
overall, 77% of severe bleeding events occurred on the day of surgery1
1. Eriksson et al. J Thromb Haemost 2003;1:2490-6
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Major bleeding in VTE prevention trials is a strong predictor of mortality
*Adjusted for baseline predictors and propensity for bleeding
Eikelboom et al. Circulation 2009;120:2006-11.
In VTE prevention trials in surgical and
medical patients, major bleeds
increased the risk of death by 7-fold
0 No major bleed
(N=12,771)
Major bleed
(N=314)
8
4R
ate
(%
)
8.6%
1.7%2
6
OR: 7.0(95% CI: 4.6 to 10.5;
p<0.001)*
Belgrade 2011
Mechanism’s treeAmong 6 Millions Anaesthesia/year : deaths
totally or partially related to anaesthesia
métabolique
PE
ciment
choccardiogénique
anémiehypoxiarythme
infarctus
obstructifcentrale
voiesaériennes
poumons
obstructif accèsimpossible
VAS bronche trachée
médicament.
infection inhalation
cardiaque neurologic
hypovolémievraie
sepsis allergie sympath.
hémorragie
relative hypovolemia
GA RA
vasculairerespiratory
rythme
419
real Hypovolemia
hemmorhage
vascul
4939
anemia
M.I.
cardiac
cardiolologic Choc
A. Lienhart…Anaesthesiology V105, n°6, dec 2006
Belgrade 2011
Perioperative anemia Outline
1.Incidence and cause of preoperative anemia and related mortality
2.International Recommendations : NATA3.Preoperative assessment: IRON and ESA4.Postoperative anaemia and mortality5.How to decrease Postoperative
anaemia: 6.Kinetic of bleeding and anticipation7.Conclusion
Belgrade 2011
Antifibrinolytics : Mechanism of actionAntifibrinolytics : Mechanism of action
ActivatorActivator PlasminogenePlasminogene
FibrinFibrinFIBRINOLYSISFIBRINOLYSIS
Belgrade 2011
Antifibrinolytics : Mechanism of actionAntifibrinolytics : Mechanism of action
ActivatorActivator PlasminogenePlasminogene
FibrinFibrinFIBRINOLYSISFIBRINOLYSIS
Interruption Interruption of sites of sites
binding with binding with LYSINELYSINE
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when?Which dose?How long?Risks?
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Tranexamic Acid reduces hemorrhage by inhibition of fibrinolysis activities of plasmine:pharmacokinetic
• Half life = 3 hours• Renal excretion: delay between 2
injections has to be increased if moderate Renal Impairment (30 ml/min<creatinin clearance <60ml/min)
• Maximum concentration is reached immediately after perfusion (at least 30min to avoid nausea)
No sign of overdose reported becauseof very wide therapeutic window
Belgrade 2011
Allogeneic Transfusion RBC THR+TKRTranexamic Ac 20 studies N=1096
Différence of Risk
Hiippala SBenoni G Hiippala SJansen A.JBenoni G Ellis M Benoni G Tanaka NEngel J.M Veien MHusted HGood L Zohar E Lemay EJohansson T
Year
199519961997199920002001200120012001200220032003200420042005
-26% [-54% à +2%]
-37% [-56% à -18%]
-46% [-64% à -28%]
-52% [-77% à -28%]
-33% [-63% à -4%]
-60% [-94% à -26%]
-20% [-48% à +8%]
-34% [-46% à -22%]
-23% [-49% à +3%]
-13% [-32% à +7%]
-25% [-50% à 0%]
-47% [-70% à -24%]
-48% [-71% à -24%]
-40% [-63% à -17%]
-26% [-44% à -9%]
Tranexamic Acid control
-0.50 0.00 +0.50
NTT = 3
-35% [-40% à -29%] P <0.01
modèle fixe test d’hétérogénéité p=0.27
N
2886774239204099243040516039
110
15 studies 776
P. Zufferey Anesthesiology. 2006;105:1034-46
Belgrade 2011
surgery
Total dose
bolus
design-30% [-43% to –18%]
-36% [-42% to –29%]
opendouble blind
p=0.45
-0,50 0,00 +0,50 Risk DifferenceHeterogeneicity test Between subgroups
Tranexamic Acid control
-29% [-39% to -19%]
-37% [-43% to -30%]
THRTKR p=0.21
< 30 mg/kg 30 mg/kg
-30% [-37% to -24%]
-49% [-61% to -38%]p<0.01
one bolus> Many bolus
-24% [-35% to -13%]
-38% [-44% to -31%]p=0.04
Allogeneic Transfusion RBCTranexamic Acid co variable analysis
P. Zufferey Anesthesiology. 2006;105:1034-46
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Tranexamic Ac and arteriel risk
Zufferey P Anesthesiology 2006: 105; 1034-46
Tranexamic Ac n=575 1 MI
Placebo n=1057 1 MI + 1 stroke
Aprotinine n=723 1 acute leg ischaemia 1 Acute Coronary
Syndrome
Aminocaproic Ac n=76 3 Acute Coronary Syndromes
Antifibrinolytic in orthopedic surgery
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adverse events Cardiologic surgery
Mangano DT N Engl J Med 2006: 354; 353-65
No adverse vascular effects for TXA
n=882 n=1295n=883n=1374
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Contrindications of Tranexamic Acid
• Severe Hypertension• Arteritis, or severe arterial disease• MI, Stroke • carotid Stenosis• Severe Renal Insufficiency (creatinine
clearance <30ml/min)• Pulmonary Embolism• Epilepsy
Belgrade 2011Blanié A. SFAR 2011
Duration of postoperative fibrinolysis in THR
Belgrade 2011
Duration of postoperative fibrinolysis in TKR
Blanié A. SFAR 2011
Belgrade 2011
Now our protocol of TA
This procedure is done, but not validated by a important study
TKR or Revision TKR1. 1g (15mg/kg) 15 min
before deflating tourniquet
2. + 1g (15mg/kg) H + 33. 1g (15mg/kg) every 4 or 5
hours during the first night
THR or Revision THR1. 1g (15mg/kg) : 15 min
before incision2. H + 1: 1g (15mg/kg) /1h during
60 min until end of surgery (RTHR)
3. 1g (15mg/kg) every 4 or 5 hours during the first night
Dilution of 1g/100ml physiologic serum / 30 minutes, because of risk of nausea
N Rosencher et al./transfusion clinique et biologique 15 (2008) 294-302
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PTG : acide tranexamique vs placebo
PTG : Récupération périop inutile si acide tranexamique
Belgrade 2011
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Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage a randomised, placebo-controlled trial
• Méthode : 274 centres (44 pays) = 20201 patients à risque hémorragique dans les premieres heures
• Randomisation : Ac Tranex 1g/30min puis 1 g 8h après vs placebo
CRASH-2 trial collaborators, Lancet 2010; 376: 23–32
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CRASH-2 trial collaborators, Lancet 2010; 376: 23–32
TXA.n=10 060
placebon=10 067 RR (IC95%)
mortality 14.5% 16% 0.91 (0.85-0.97) p<0.01
Any vasc Thrombosis 1.7% 2.0% 0.84 (0.68-1.02) p=0.08
MI 0.3% 0.5% 0.64 (0.42-0.97) p=0.04
Stroke 0.6% 0.7% 0.86 (0.61-1.23) p=0.42PE 0.7% 0.7% 1.01 (0.73-1.41) p=0.93
DVT 0.4% 0.4% 0.98 (0.63-1.51) p=0.91
No adverse vascular events with TXA
Belgrade 2011
Take this message Home
1. TA reduces bleeding and transfusion after THR, TKR and spinal surgery
2. Important doses (≥30mg.kg-1 …) and many bolus are more efficient
3. Good safety, but no important study (>1000 patients) Nausea are possible if perfusion is too fast (less than 30 min)
4. Cost /effective (1€/1g)
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How to explain the difference between registers and randomized studies?
Belgrade 2011
Belgrade 2011
Focus study
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Hb= 9g/dl throughout the study in restrictive group
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Complications nécessitant transfusion10% tachycardies+I. Cardiaques
Belgrade 2011
Threshold Haemoglobin Levels and the Prognosis ofStable Coronary Disease: Two New Cohorts and a
Systematic Review and Meta-Analysis
A D. Shah PLoS Medicine | www.plosmedicine.org 2011 | Vol 8 | Issue 5
Conclusions: There is an association between low haemoglobin concentration and increased mortality. A large proportionof patients with coronary disease have haemoglobin concentrations below the thresholds of risk defined here.
20,131 people with a new diagnosis of stable angina and no previous acute coronary syndrome, and 14,171 people with first MI who survived for at least 7 days were followed up for a mean of 3.2 years
Belgrade 2011
How can we explain that ?
Transfusion Trigger
[Hb] (g/dl)
Time (min)
Delay in Blood supplying
Prescription
Belgrade 2011
Perioperative anemia Outline
1.Incidence and cause of preoperative anemia and related mortality
2.International Recommendations : NATA3.Preoperative assessment: IRON and ESA4.Postoperative anaemia and mortality5.How to decrease Postoperative
anaemia: 6.Kinetic of bleeding and anticipation7.Conclusion
Belgrade 2011
Postoperative drop of Hemoglobin level after Knee and Hip Replacement : between
recovery room discharge and on morning of the day one
TRANSFUSION DE GLOBULES ROUGES HOMOLOGUES : PRODUITS, INDICATIONS,
ALTERNATIVES
RECOMMANDATIONS
Août 2002
« transfusion has to be adapted to
kinetic of bleeding to maintain [Hb] level threshold”
Var
iatio
n of
dV
aria
tion
of d
’’ Hb
(g.d
LH
b (g
.dL-1-1
) le
vel
) le
vel
Recovery room and D+1
3
-5
-4
-3
-2
-1
0
1
2
THR
TKR
G. de Saint Maurice SFAR 2003
Before using Tranexamic Acid drop is 2.1 ± 1.5 g/dlAnd with Tranexamic acid drop of Hb is only 1.2 ±1.1g/dlBefore using Tranexamic Acid drop is 2.1 ± 1.5 g/dlAnd with Tranexamic acid drop of Hb is only 1.2 ±1.1g/dl
Hb level has to be monitored every 2H during first night or anticipation if kinetic of bleeding is known
Hb level has to be monitored every 2H during first night or anticipation if kinetic of bleeding is known
Belgrade 2011
death
Cardiovascular and ischemic events
Rehabilitation is difficult
Transfusion ± delay
Anemia
preoperative postoperative+ bleeding
Belgrade 2011
ConclusionsConclusions• Anemia should be viewed as a serious and Anemia should be viewed as a serious and
treatable medical condition rather than as an treatable medical condition rather than as an abnormal laboratory value. abnormal laboratory value.
• Preoperative anemia management in elective Preoperative anemia management in elective orthopedic surgery patients improves orthopedic surgery patients improves outcomes.outcomes.
• New paradigm : no anemia, no transfusion and New paradigm : no anemia, no transfusion and mortality should decreasemortality should decrease
• Moreover, if you see patient 1 month before Moreover, if you see patient 1 month before elective surgery, you don’t need to postpone elective surgery, you don’t need to postpone surgery (stopping VKA, clopidogrel…..)surgery (stopping VKA, clopidogrel…..)