Management of perioperative anemia in
Major orthopedic surgery: practical approach
Nadia Rosencher
Anesthesiology and Intensive care department
Cochin Hospital, Paris Descartes University
75014 Paris France
Belgrade 2011
Disclosure
1.
2.
3.
4.
5.
6.
7.
Belgrade 2011
Abbott,
Air Liquide
Astra-Zeneca,
Bayer,
Bristol Meyer Squibb,
B-Braun,
Boëringher-Ingelheim,
8. General Electric,
9. Glaxo-Smith-Klein,
10. Janssen
11. LFB
12. Pfizer
13. Sanofi-Aventis
14. Vifor
Perioperative anemia Outline
1. Incidence and cause of preoperative anemia
and related mortality
2. International Recommendations : NATA
3. Preoperative assessment: IRON and ESA
4. Postoperative anemia and mortality
5. How to managed Postoperative anemia:
6. Kinetic of bleeding and anticipation
7. Conclusion
Belgrade 2011
Incidence of Preoperative Anemia
in Major orthopedic Surgery
Author/year
Surgery
n
incidence
Saleh 2007
Basora 2006
THR/TKR
1142
THR/TKR
218
20%
39%
THR
225
THR/TKR
2646
HF
HF
HF
844
15%
30%
44%
550
46%
395
46%
Myers 2004
Rosencher 2003
Su 2004
Halm 2004
Gruson 2002
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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
With nutrient deficiency
Iron only
Folate only
B12 only
Iron with folate or B12 or both
n( %)
20/65
12/65 (16.9)
1/65 (1.5)
4/65 (6.1%)
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
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16/65 (24.6)
30.7%
Preoperative Anemia kills me
Belgrade 2011
Preoperative Hematocrit Levels and Postoperative Outcomes
in Older Patients Undergoing Noncardiac Surgery
Wu WC et al, JAMA 2007; 297:2481‒8
• Retrospective cohort study using the VA National
Surgical Quality Improvement Program database.
• 310,311 veterans aged ≥ 65 years who underwent
major noncardiac surgery between 1997 and 2004.
• Increased 30-day mortality in patients with
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
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
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
Belgrade 2011
Preoperative anaemia and postoperative outcomes in noncardiac surgery: a retrospective cohort study
Khaled M Musallam et al,
The Lancet Volume 378, Issue 9800, 15-21 October
2011, Pages 1362-1363
30-day composite morbidity, by anaemia and risk factor status
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 status
Belgrade 2011
Perioperative anemia Outline
1. Incidence and cause of preoperative anemia and
related mortality
2.International Recommendations : NATA
3. Preoperative assessment: IRON and ESA
4. Postoperative anaemia and mortality
5. How to managed Postoperative anemia:
6. Kinetic of bleeding and anticipation
7. Conclusion
Belgrade 2011
Detection, Evaluation and Management
of Preoperative Anemia in the Elective Orthopedic
Surgical Patient—NATA Guidelines
Multidisciplinary panel : 3 orthopedists , 3 hematologists,
6 anesthesiologists, 1 epidemiologist And society
representation :
European Federation of National Associations of
Orthopaedics and Traumatology (EFORT) : G. Benoni
Spine Society of Europe (SSE) : M. Szpalski
European Society of Anaesthesiology (ESA) Y. Ozier
TL Goodnough Br J Anaesth. 2011 Jan;106(1):13-22
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Recommendations―Detection of Anemia
• Recommendation 1: We recommend that
elective surgical patients have a Hb level
determination as close to 28 days before the
scheduled surgical procedure (Grade 1A).
• Recommendation 2: We suggest that the
patient’s target Hb before elective surgery
be within the normal range (normal female ≥
12 g/dL, normal male ≥ 13 g/dL), according to
WHO criteria (Grade 2C).
TL Goodnough Br J Anaesth. 2011 Jan;106(1):13-22
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Recommendations―Evaluation of Anemia
• Recommendation 3: We recommend that laboratory
testing take place to further evaluate for nutritional
deficiencies, chronic renal insufficiency, and/or chronic
inflammatory disease (Grade 1C).
• Recommendation 4: We recommend that nutritional
deficiencies be treated before surgery (Grade 1C).
• Recommendation 5: We suggest that erythropoiesisstimulating 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 females
Hb < 130 g/L for males
Evaluation necessary
Iron status?
Ferritin < 30 μg/L
and/or
TSAT < 15–20%
Ferritin 30–70 μg/L
and/or
TSAT > 20%
Ferritin > 70 μg/L
and/or
TSAT > 20%
Serum creatinine
Glumerular filtration rate
Low
Rule out iron
deficiency
Inflammation/
chronic disease
Normal
Normal
Vitamin B12
and/or folic acid
Low
Chronic kidney
disease (CKD)
Iron deficiency
Referral to
gastroenterologist to rule
out malignancy
Iron therapy
1) Oral iron in divided doses
2) IV iron if patient cannot tolerate oral iron,
intestinal absorption problems, or short timeline
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Referral to
nephrologist
No response
Anemia of
chronic
disease
Erythropoiesisstimulating
agent therapy
Folic acid and/or
Vitamin B12
therapy
Perioperative anemia Outline
1. Incidence and cause of preoperative anemia
and related mortality
2. International Recommendations : NATA
3.Preoperative assessment: ESA and Iron
4. Postoperative anaemia and mortality
5. How to managed Postoperative anemia:
6. Kinetic of bleeding and anticipation
7. Conclusion
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In practice, according to size of RBC
Microcytic
MCV<80fl
Normocytic
MCV 80-96
Macrocytic
MCV >96
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1.
2.
3.
Fe deficiency
Hemoglobinopathy
Anemia of chronic
disease (ACD)
1.
2.
3.
ACD
Acute blood loss
Anaemia of renal
disease
1.
2.
3.
4.
B12, FA deficiency
Chronic liver disease
myelodysplasia
Chemotherapy
IV Iron if
inflammatory
disease + ESA
Referral to
gynecologist and
gastroenterologist
Iron (IV) + ESA
Folic acid and
VitB12 therapy
+ESA + Iron
In preoperative assessment I need as
laboratory testing
•
•
•
•
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Hb level and size of RBC + Platelets
Creatinine serum and creat clearance
CRP (inflammatory disease ?)
Iron status : Transferrin + Tsat
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 Iron
3. 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
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N. Rosencher Transfusion. 2003 Apr;43(4):459-69
Knee and Hip Replacements
100 %
90%
80%
70%
60%
50%
40%
Abnormal bleeding or
female less than 50kg
30%
20%
10%
Baseline Hb g /dL
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Men
Women
16,0
15,0
14,0
13,0
12,0
11,0
10,0
9,0
0%
8,0
Probability of Transfusion
Probability of Allogeneic-Only Transfusion
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.
2.
3.
4.
1. Blood shortage
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Residual an unknown emergent risk
Immuno-modulatory effect
Mistransfusion, bacterial contamination
Hepatitis, VIH….
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 Iron
in 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
rHuEPOa 2400 UI / kg started 3 weeks before surgery.
Hb level (g/dl) (mean)
14
13
12
11
10
9
8
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rHuEPOa 4500 UI / kg during 15 days.
Goldberg M. Semin Hematol 1997;34:41-47.
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
Hb level is
• 3 injections if Hb =11g/dl
accurate only if
• 2 injections if Hb =12g/dl
case of
• 1 injection if Hb = 13g/dl
normovolemia
N Rosencher et al./transfusion clinique et biologique 15 (2008) 294-302
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Risks associated with EPO meta-analysis
De Andrade JR, 1999,Orthopedics, vol 22, p:113-118
8%
8%
7,40%
7%
6%
5,20%
4,80%
5%
Eprex
4%
3,20%
Placebo
3%
2,30%
2%
1%
0%
0,30%
total
DVT
other
0,40%
death
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 IV
2. EPO is indicated if 10 ≤ Hb baseline ≤ 13g/dl
3. 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
–
Belgrade 2011
Or according to Hb baseline (cf table)
Perioperative anemia Outline
1. Incidence and cause of preoperative anemia and
related mortality
2. International Recommendations : NATA
3. Preoperative assessment: IRON and ESA
4.Postoperative anaemia and mortality
5. How to managed Postoperative anaemia:
6. Kinetic of bleeding and anticipation
7. Conclusion
Belgrade 2011
How Anemia kills me?
Belgrade 2011
Frequency of myocardial infarction and death
following primary THR or TKR
US retrospective analysis; N = 10,244
Average mortality = 0.5% after 1 month
MI
%
Death
%
2.5
3
Men
Men
Women
Women
2.0
2
1.5
1.0
1
0.5
0
0.0
< 49
50-59
60-69
Age (years)
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70-79
> 80
< 49
50-59
60-69
Age (years)
Mantilla CB, et al. Anesthesiology. 2002;96:1140-1146.
70-79
> 80
Causes of death in the Norway register
Mortality during the first 60 days after surgery,
1987-1995 (n = 45,767)
Cause of death
deathsa
Number of
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
169
3.69
Bleeding
51
1.11
Sudden death (mors subita)
32
0.70
All non-vascular causes of death
67
1.46
Thromboembolic complications
aCauses
of death according to the death record. The sum of the cause-specific mortality rates therefore
exceeds the all-cause mortality.
Belgrade 2011
Stein A L, Acta Orthop Scand 2002; 73 (4): 392–399
POISE study
P.J. Devereaux et al Ann Intern Med. 2011;154:523-528.
1.
•
•
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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
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
bleeding events
occurred on the day
of surgery1
DVT/PE
Bleeding
Incidence
THR/TKR trial comparing a
ximelagatran/melagtran
regime and enoxaparin 40
mg, both regimens being
initiated preoperatively:
overall, 77% of severe
Surgery
Time
1. Eriksson et al. J Thromb Haemost 2003;1:2490-6
Belgrade 2011
Major bleeding in VTE prevention trials is a
strong predictor of mortality
8
Rate (%)
In VTE prevention
trials in surgical and
medical patients,
major bleeds
increased the risk of
death by 7-fold
OR: 7.0
(95% CI: 4.6 to 10.5;
p<0.001)*
8.6%
6
4
2
0
1.7%
No major bleed
(N=12,771)
Major bleed
(N=314)
*Adjusted for baseline predictors and propensity for bleeding
Eikelboom et al. Circulation 2009;120:2006-11.
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Mechanism’s tree
Among 6 Millions Anaesthesia/year : deaths
totally or partially related to anaesthesia
419
respiratory
centrale
médicament.
VAS
bronche
obstructif
trachée
voies
aériennes
accès
impossible
infection
neurologic
poumons
obstructif rythme
ciment
inhalation
cardiac
cardiaque
cardiolologic
choc
Choc
cardiogénique
métabolique
PE
rythme
A. Lienhart…Anaesthesiology V105, n°6, dec 2006
Belgrade 2011
vascul
vasculaire
infarctus
M.I.
hypoxia
relative
hypovolemia
real
hypovolémie
Hypovolemia
vraie
sepsis
anemia
anémie
39
hemmorhage
hémorragie
49
allergie
sympath.
GA
RA
Perioperative anemia Outline
1. Incidence and cause of preoperative anemia and
related mortality
2. International Recommendations : NATA
3. Preoperative assessment: IRON and ESA
4. Postoperative anaemia and mortality
5.How to decrease Postoperative anaemia:
6. Kinetic of bleeding and anticipation
7. Conclusion
Belgrade 2011
Antifibrinolytics : Mechanism of action
Activator
FIBRINOLYSIS
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Plasminogene
Fibrin
Antifibrinolytics : Mechanism of action
Activator
FIBRINOLYSIS
Belgrade 2011
Plasminogene
Fibrin
Interruption of
sites binding
with LYSINE
when?
Which dose?
How long?
Risks?
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Tranexamic Acid reduces hemorrhage by inhibition of fibrinolysis
activities of plasmine:pharmacokinetic
No sign of overdose reported because
of very wide therapeutic window
• 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)
Belgrade 2011
Allogeneic Transfusion RBC THR+TKR
Tranexamic Ac 20 studies N=1096
Year
Hiippala S
Benoni G
Hiippala S
Jansen A.J
Benoni G
Ellis M
Benoni G
Tanaka N
Engel J.M
Veien M
Husted H
Good L
Zohar E
Lemay E
Johansson T
15 studies
NTT = 3
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1995
1996
1997
1999
2000
2001
2001
2001
2001
2002
2003
2003
2004
2004
2005
N
-0.50
0.00
+0.50 Différence of Risk
28
86
77
42
39
20
40
99
24
30
40
51
60
39
110
-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%]
776
 Tranexamic Acid
-35% [-40% à -29%]
control 
P <0.01
modèle fixe
test d’hétérogénéité p=0.27
P. Zufferey Anesthesiology. 2006;105:1034-46
Allogeneic Transfusion RBC
Tranexamic Acid co variable analysis
-0,50
0,00
+0,50 Risk Difference
design
open
double blind
surgery
THR
TKR
Total dose
< 30 mg/kg
 30 mg/kg
bolus
one bolus
> Many bolus
 Tranexamic Acid
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Heterogeneicity test
Between subgroups
-30% [-43% to –18%]
-36% [-42% to –29%]
p=0.45
-29% [-39% to -19%]
-37% [-43% to -30%]
p=0.21
-30% [-37% to -24%]
-49% [-61% to -38%]
p<0.01
-24% [-35% to -13%]
-38% [-44% to -31%]
p=0.04
control 
P. Zufferey Anesthesiology. 2006;105:1034-46
Tranexamic Ac and arteriel risk
Antifibrinolytic in orthopedic surgery
Aprotinine
n=723
1 acute leg ischaemia
1 Acute Coronary Syndrome
Aminocaproic Ac n=76
3 Acute Coronary Syndromes
Tranexamic Ac
n=575
1 MI
Placebo
n=1057
1 MI + 1 stroke
Zufferey P Anesthesiology 2006: 105; 1034-46
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adverse events
Cardiologic surgery
n=1374
n=883
n=882
n=1295
No adverse vascular effects for TXA
Mangano DT N Engl J Med 2006: 354; 353-65
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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 2011
Duration of postoperative fibrinolysis in
THR
6,000
THR
MedPTH
5,000
MedPTH-
MedPTH-AT
4,000
3,000
2,000
1,000
0
DDE préop
Belgrade 2011
DDE-H0
DDE-H6
DDE-H18
DDE-H24
Blanié A. SFAR 2011
Duration of postoperative fibrinolysis in
TKR
14,000
12,000
TKA
Med PTG
10,000
TKA-TXA
8,000
6,000
4,000
2,000
0
DDE préop
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DDE-H0
DDE-H6
DDE-H18
DDE-H24
Blanié A. SFAR 2011
Now our protocol of TA
Dilution of 1g/100ml physiologic serum / 30 minutes,
because of risk of nausea
TKR or Revision TKR
1. 1g (15mg/kg) 15 min before 1.
deflating tourniquet
2.
2. + 1g (15mg/kg) H + 3
3. 1g (15mg/kg) every 4 or 5
3.
hours during the first
night
THR or Revision THR
1g (15mg/kg) : 15 min before
incision
H + 1: 1g (15mg/kg) /1h during 60
min until end of surgery (RTHR)
1g (15mg/kg) every 4 or 5
hours during the first
night
This procedure is done, but not validated by a important study
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
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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
CRASH-2 trial collaborators, Lancet 2010; 376: 23–32
• 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
Belgrade 2011
TXA.
n=10 060
placebo
n=10 067
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
PE
0.6%
0.7%
0.7%
0.7%
0.86 (0.61-1.23) p=0.42
1.01 (0.73-1.41) p=0.93
DVT
0.4%
0.4%
0.98
RR (IC95%)
(0.63-1.51)
p=0.91
No adverse vascular events with TXA
Belgrade 2011
CRASH-2 trial collaborators, Lancet 2010; 376: 23–
32
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?
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Focus study
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Hb= 9g/dl throughout the study in
restrictive group
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Complications nécessitant transfusion
10% tachycardies+I. Cardiaques
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Threshold Haemoglobin Levels and the Prognosis of
Stable Coronary Disease: Two New Cohorts and a
Systematic Review and Meta-Analysis
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
Conclusions: There is
an association between
low haemoglobin
concentration and
increased mortality.
A large proportion
of patients with
coronary disease have
haemoglobin
concentrations below
the thresholds of risk
defined here.
A D. Shah PLoS Medicine | www.plosmedicine.org 2011 | Vol 8 | Issue 5
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How can we explain that ?
[Hb] (g/dl)
Delay in Blood
supplying
Prescription
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Transfusion Trigger
Time (min)
Perioperative anemia Outline
1. Incidence and cause of preoperative anemia and
related mortality
2. International Recommendations : NATA
3. Preoperative assessment: IRON and ESA
4. Postoperative anaemia and mortality
5.How to decrease Postoperative anaemia:
6. Kinetic of bleeding and anticipation
7. 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”
Hb level has
to be
monitored
every 2H
during first
night or
anticipation
if kinetic of
bleeding is
known
Variation of d’Hb (g.dL-1) level
3
2
1
TKR
THR
0
-1
-2
-3
-4
-5
Recovery room and D+1
Before using Tranexamic Acid drop is 2.1 ± 1.5 g/dl
And with Tranexamic acid drop of Hb is only 1.2 ±1.1g/dl
G. de Saint Maurice SFAR 2003
Belgrade 2011
Anemia
+ bleeding
postoperative
preoperative
Cardiovascular and ischemic
events
death
Belgrade 2011
Rehabilitation is
difficult
Transfusion
± delay
Conclusions
• Anemia should be viewed as a serious and
treatable medical condition rather than as an
abnormal laboratory value.
• Preoperative anemia management in elective
orthopedic surgery patients improves
outcomes.
• New paradigm : no anemia, no transfusion and
mortality should decrease
• Moreover, if you see patient 1 month before
elective surgery, you don’t need to postpone
surgery (stopping VKA, clopidogrel…..)
Belgrade 2011