Summary Pre‐operative anaemia is associated with higher rates of transfusion and worse outcomes, including prolonged hospital stay, morbidity and mortality. Iron deficiency is associated with significantly lower haemoglobin levels throughout the peri‐operative period and more frequent blood transfusion. Correction of iron stores before surgery forms part of the first pillar of patient blood management. We established a pre‐operative anaemia clinic to aid identification and treatment of patients with iron deficiency anaemia scheduled for elective cardiac surgery. We present a retrospective observational review of our experience from January 2017 to December 2019. One‐hundred and ninety patients received treatment with intravenous iron, a median of 21 days before cardiac surgery. Of these, 179 had a formal laboratory haemoglobin level measured before surgery, demonstrating a median rise in haemoglobin of 8.0 g.l‐1. Patients treated with i.v. iron demonstrated a significantly higher incidence of transfusion (60%) compared with the non‐anaemic cohort (22%) during the same time period, p < 0.001. Significantly higher rates of new requirement for renal replacement therapy (6.7% vs. 0.6%, p < 0.001) and of stroke (3.7% vs. 1.2%, p = 0.010) were also seen in this group compared with those without anaemia, although there was no significant difference in in‐hospital mortality (1.6% vs. 0.8%, p = 0.230). In patients where the presenting haemoglobin was less than 130 g.l‐1, but there was no intervention or treatment, there was no difference in rates of transfusion or of complications compared with the anaemic group treated with iron. In patients with proven iron deficiency anaemia, supplementation with intravenous iron showed only a modest effect on haemoglobin and this group still had a significantly higher transfusion requirement than the non‐anaemic cohort. Supplementation with intravenous iron did not improve outcomes compared with patients with anaemia who did not receive intravenous iron and did not reduce peri‐operative risk to non‐anaemic levels. Questions remain regarding identification of patients who will receive most benefit, the use of concomitant treatment with other agents, and the optimum time frames for treatment in order to produce benefit in the real‐world setting.

Modified early warning scoring (MEWS) uses abnormalities in routine observations to identify patients at risk of critical illness. Nurses recorded scores at or above the medical response score of 3 on a hospital clinical information system during the first year of introducing MEWS to 10 wards in a university hospital. A total of 619 triggers were recorded in 365 patients. Fifty-nine required intensive care unit (ICU)/high dependency unit (HDU) care; 71 died. Survival was significantly worse for initial scores >4 (35/104 patients died) than for scores 3-4 (P<0.004). Multivariant analysis showed age (P<0.001) and trigger score (P<0.001) but not ward specialty (P=0.1) predicted death. Mean ages of survivors and non-survivors were 64 years (SD 18) and 74 years (SD 17), respectively. Addition of a score for age did not significantly increase the area under a receiver operator characteristic curve for the predictive value of MEWS scores. The study shows that increasing MEWS score is associated with worse outcome across a range of specialties and that nursing staff will use a patient information system to audit MEWS scores.

SummaryThromboelastography is used for assessment of coagulation and to guide administration of blood products peri-operatively. There is currently no method of standardisation in the UK, nor an approved method of proving quality. We investigated the reproducibility of thromboelastography by testing whole blood with no coagulation abnormality in three phases. Where a single operator performed multiple assays on the same blood sample at a single location, we found considerable variation, with 21% of R-and 25% of K-time measurements lying outside a set tolerance range (median AE 20%). Where samples were analysed by different operators in a single location, this finding was repeated. Where blood was transported in a citrated form for simultaneous analysis in multiple locations, results were more consistent, suggesting improved stability. Across all phases of testing there was good reproducibility of the maximum amplitude. Further examination of the results indicated less variation where analysis was performed on blood taken from the same kaolin vial compared with results from different vials. Our preliminary study indicates that R-and Ktimes may be highly variable, which we hypothesise may be due to variable mixing of blood and kaolin. We intend to repeat this study in the context of coagulopathy, where variability in results could potentially impact upon transfusion practice.

Necrotizing fasciitis is a rapidly progressive, life-threatening soft tissue infection which is rapidly fatal unless diagnosed promptly and treated with immediate debridement of necrotic tissue. As early clinical suspicion is paramount to improved survival, this review aims to increase awareness of the condition.

Impact of patient blood management guidelines on blood transfusions and patient outcomes during cardiac surgery.