Effects of postoperative intravenous iron on transfusion requirements after lower limb arthroplasty.

Br J Anaesth.
Muñoz M, Naveira E, Seara J, Cordero J.
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Preoperative anaemia is one of the major predictive
factors for allogeneic blood transfusion (ABT) in surgical procedures with moderate-to-high perioperative blood loss.
Therefore, in major elective surgery, preoperative identification and evaluation of anaemia must be made early
enough to implement the appropriate treatment.1 In thisregard, preoperative i.v. iron has been shown to rapidly increase
haemoglobin levels and reduce ABT requirements,
without serious side-effects.2 Similarly, perioperative i.v.
iron, with or without erythropoietin, plus a restrictive
transfusion protocol has been shown to reduce ABT requirements
after elective and non-elective orthopaedic
surgery.3–5 Data on the efficacy of postoperative i.v. iron in
orthopaedic surgical patients are, however, contradictory.6 7
This and other evidence has been analysed in a consensus
statement which suggests the perioperative administration
of i.v. iron in patients undergoing orthopaedic surgery with
high risk for developing severe postoperative anaemia.8
We, therefore, read with great interest the report by
Ho¨nemann and colleagues9 on the successful use of i.v.
ferric carboxymaltose (FCM) for treating severe anaemia,
after volume therapy and surgery, in a young trauma
patient who refused ABT. However, patients who are older
and/or present with less severe postoperative anaemia may
also benefit from postoperative i.v. iron therapy, and we
present here our experience in 114 consecutive patients
who underwent total lower limb arthroplasty and were at
risk for ABT (Hb,10 g dl21 on postoperative day 1).
All patients were operated on by the same surgical team,
using the same implants, and received the same antibiotic
and antithrombotic prophylaxis and postoperative management.
Patients received 100 mg day21 i.v. iron sucrose for
three consecutive days (300 mg) (n¼32), 200 mg day21 i.v.
iron sucrose for three consecutive days (600 mg) (n¼56),
600 mg i.v. FCM on postoperative day 1 (n¼7), or no iron
(control, n¼19). The limited physiological reserve and the
higher prevalence of unrecognized cardiovascular disease
may render this elderly patient population more vulnerable
to acute postoperative anaemia and, therefore, ABT was
given if postoperative Hb was ,8 g dl21 or there were clinical symptoms of acute anaemia (Hb ,9 g dl21 for patients with active cardiac disease). There were no differences between groups regarding age, gender distribution, co-morbidity, or surgical procedure, but preoperative Hb was slightly lower in the 300 mg i.v. iron group (Table 1). Overall, patients receiving 600 mg i.v. iron showed lower ABT rate and index (without differences in pre-ABT Hb levels) (Table 1). No differences in perioperative data were observed between patients receiving 600 mg iron sucrose or 600 mg FCM (data not shown). In addition, patients receiving 600 mg also had
lower postoperative infection rate and shorter length of hospital stay, suggesting that i.v. iron may have direct effects on body physical and functional performance, beyond those on erythropoiesis.10 No clinically meaningful adverse side effects of i.v. iron were noted.
In conclusion, postoperative administration of 600 mg of
i.v. iron seems to be safe, and more effective than that of
300 mg to reduce ABT requirements in patients at risk. A randomized controlled trial to confirm the efficacy of postoperative FCM in orthopaedic patients is currently ongoing(EudraCT 2010-023038-22).