BACKGROUND: Anemia is common in patients presenting for elective orthopedic surgery and is associated with increased risk of perioperative blood transfusion, which in turn carries risks of increased morbidity and mortality from hemolysis, lung injury, and anaphylaxis. Elective hip and knee arthroplasty are procedures associated with substantial blood loss, and rank among the top ten surgeries for greatest transfusion frequency. Blood transfusion also represents a financial burden to the health system. When preoperative anemia is treated, reduced cost of care with improved outcomes has been demonstrated. The Duke University Hospital Preoperative Anemia Clinic (PAC) is an initiative launched to medically optimize patients prior to undergoing procedures with a known high risk of transfusion. Here we present data following the first year of this initiative, including preoperative referral rates of orthopedic patients to PAC, treatment modalities utilized, and proportion of patients referred to PAC who received therapeutic intervention and ultimately underwent surgery. Of the 14 patients who completed treatment and subsequently underwent surgery, 4 received both IV Iron and erythropoietin (EPO), 7 received IV iron only, 2 received oral iron only and 1 received EPO only. Only 2 of these patients received transfusion during hospitalization, one in the setting of abbreviated therapy due to delayed PAC referral, and the other related to complex surgical repair.
METHODS: Following IRB approval, a retrospective cross-sectional analysis was preformed of patient records at a single institution. Information was collected on medical record screening date, hemoglobin, iron, and B12 values, procedure type, referring provider, and therapy type. Figure 1 outlines the algorithm used to identify an anemic threshold for therapy based on point-of-care hemoglobin (POC) testing (Hemocue, Ängelholm, Sweden).
RESULTS: From September 2014 to December 2015, 250 patients were screened for anemia at our joint replacement orthopedic surgery clinic. Of three possible referring surgeons, one surgeon generated 87.2% of referrals. During that time 36 patients (14.4%) were referred to PAC for further management. Of these, 14 (39%) completed treatment and subsequently underwent surgery, 4 (11%) completed treatment and were awaiting surgery at the time of analysis, and 2 (5.5%) had surgery cancelled due to uncontrolled medical co-morbidities. 16 patients (44.4%) referred to the PAC were excluded from further treatment due to discrepancy between POC hemoglobin value and venipuncture sample (9 patients), anemia managed by nephrologist for end-stage renal disease (2 patients), anemia managed by hematologist/oncologist for cancer (3 patients), or other cause (2 patients).
DISCUSSION: PAC appears to be an effective tool for evaluation and medical optimization of anemic patients undergoing orthopedic surgery with a high risk of transfusion. Barriers to identification of anemic patients include adaptation and compliance with an accurate and reliable screening process.
