An Effective and Efficient Testing Protocol for Diagnosing Iron-deficiency Anemia Preoperatively

Abstract

Background Iron-deficiency anemia is a common perioperative condition and increases perioperative morbidity and mortality. Timely diagnosis and treatment are important. This retrospective cohort study tested the hypothesis that a newly developed preprocedure evaluation protocol diagnoses more patients with iron-deficiency anemia than the traditional practice of obtaining a complete blood count followed by iron studies. Methods The preprocedure anemia evaluation is an order for a complete blood count and reflex anemia testing, which can be completed with a single patient visit. A hemoglobin concentration of 12 g/dl or less with serum ferritin concentration less than 30 ng/ml or transferrin saturation less than 20% defined iron-deficiency anemia. Northwestern Medicine’s database was queried for preoperative clinic patients, age 16 to 89 yr, before (2015 to 2016) and after (2017 to 2018) protocol implementation. The proportion of patients diagnosed with iron-deficiency anemia before and after the preprocedure anemia evaluation implementation was compared. Results Before implementing the protocol, 8,816 patients were screened with a traditional complete blood count. Subsequent iron studies at the providers’ discretion diagnosed 107 (1.2%) patients with iron-deficiency anemia. Some patients were still screened with a complete blood count after implementing the protocol; 154 of 4,629 (3.3%) patients screened with a complete blood count and 738 of 2,828 (26.1%) patients screened with the preprocedure anemia evaluation were diagnosed with iron-deficiency anemia. The preprocedure anemia evaluation identified a far larger proportion of patients with iron-deficiency anemia than did the traditional complete blood count when compared both before (relative risk [95% CI], 21.5 (17.6 to 26.2); P < 0.0001) and after (7.8 [6.6 to 9.3]; P < 0.0001) its implementation. Conclusions The preprocedure anemia evaluation improved identification of iron-deficiency anemia preoperatively. It is more effective and efficient, allowing anemia evaluation with a single patient visit. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Preoperative Intravenous Iron and Erythropoietin to Treat Severe Anemia in Patient With Stage 4 Kidney Disease Before Oncologic Surgery: A Case Report

“…4 Efficient testing protocols to identify patients who can benefit from IV iron preoperatively in 1 clinic visit have been described. 11 Despite its safety and efficacy, recommendations on when to give iron infusions vary. Currently, the American Society of Anesthesiologists Task Force recommends preoperative erythropoietin with or without iron to reduce intraoperative allogeneic blood transfusions and the administration of iron to patients with IDA only if time permits.…”

Intravenous Iron to Treat Anemia becomes an Essential Service to Conserve Blood during the COVID-19 Pandemic

“…However, several studies have shown that blood transfusions are associated with postoperative complications such as infections, need for intensive care and prolonged hospital length of stay [14,15]. In fact, the severity of anemia is directly correlated with worse outcomes, such as the likelihood of readmission ing protocol, the pre-procedure anemia evaluation (PPAE), was implemented in January 2017, and has been shown to effectively and efficiently diagnose anemia including IDA [30], thereby allowing for expedited treatment (Figure 1). The PPAE order set includes reflex anemia testing when a hemoglobin concentration is less than or equal to 12 g/dL on the complete blood count.…”

“…The PPAE order set includes reflex anemia testing when a hemoglobin concentration is less than or equal to 12 g/dL on the complete blood count. Although the World Health Organization defines anemia as a hemoglobin less than 13 g/dL for men and less than 12 g/dL for women [42], we had designed the hemoglobin trigger for reflex testing on our PPAE at 12 g/ dL or lower to simplify the process [30]. The diagnostic tests in the reflex testing evaluate the different etiologies of anemia and include reticulocyte count, serum iron concentration, transferrin saturation, serum ferritin concentration, total iron-binding capacity, thyroid-stimulating hormone concentration, creatinine concentration, estimated glomerular filtration rate and vitamin B 12 concentration.…”

“…Worldwide, iron deficiency is the most common etiology of anemia [7] including in the obstetric population [29]. A recent study showed that 37% of surgical patients had anemia, 70% of which were diagnosed with iron deficiency [30]. Treatment is especially beneficial in the elderly, pregnant patients, those patients having surgeries associated with significant blood loss, patients who refuse blood transfusions, and when perioperative anticoagulation is planned.…”

“…It is important to reiterate that anemia, like any other disease, should be treated. Addressing chronic conditions can improve both perioperative and long-term outcomes [30].…”