Perioperative Anaemia in Elective Joint Replacements Neil Brown, Jacqui Howes, Marian MacKinnon Department of Anaesthesia, Raigmore Hospital, Inverness Introduction Anaemia is known to be an independent risk factor for complications.1 Blood transfusion is an expensive therapy associated with significant morbidity.2 A recently published consensus statement provides new recommendations for best clinical practice in this area.3 The elective joint replacement service presents a large population of purely elective patients undergoing major surgery, with potential for intervention to optimise preoperative condition. Preoperative anaemia is common, and time spent on the waiting list could be used to investigate and correct any
iron deficiency and/or anaemia before surgery. Given that this population accounts for significant blood usage, we wanted to investigate the prevalence of preoperative anaemia, the use of blood products and any association with outcome. Methods Data were collected retrospectively for all elective hip and joint replacements during 2015. Demographics, operation details, length of stay, pre- and haemoglobin (Hb) and details of any transfusion were recorded. For the purposes of this project anaemia was defined as haemoglobin of less than 120 g/l. Results Hip (n=310) Knee (n=293) Female, n (%) 179 (58%) 164 (56%) Age mean, median, (range) 67.5, 69 (31-90) 69, 69 ASA 1-2, n (%) 239 (83.5%) 229 (83%) ASA 3-4, n (%) 47 (16.3%) 46 (16.6%) Preop Hb mean, median, (range) 135.5, 135 (96-180) 138, 138 (92-171) Preop anaemia, n (%) 41 (13.2%) 27 (9.2%) Received n (%) 25 (8.1%) 10 (3.4%) A total of 603 cases were reviewed, of which 68 patients (11.3%) were anaemic. Thirty-five patients (5.8%) were transfused a combined total of 80 units of red cells. Preoperative anaemia (Hb <120) was present in 13.2% of elective hip and 9.2% of elective knee replacements. Preoperative anaemia was associated with longer inpatient stay – particularly in ASA3 patients, mean length of stay was increased from 5.8 days to 10.6 days if preoperative anaemia was present. Joint replacement surgery was found to consistently drop haemoglobin by ~20 g/l from baseline. Two thirds of patients who received blood transfusion were anaemic preoperatively. Conclusion/next steps This project quantified the rate of red cell transfusion in this purely elective of patients to be 5.8%, with an estimated cost of over £13,000 per year4 and potential for morbidity from transfusion. It was interesting to note that the majority of patients who
received blood transfusion were anaemic preoperatively, and also that preoperative anaemia was associated with an increased length of stay. We have introduced a protocol to investigate patients with preoperative anaemia by checking ferritin and protein (CRP) levels. In cases consistent with iron deficiency, a letter will be forwarded to the patient’s GP and they will be commenced on iron supplementation. If anaemia of chronic disease is suspected, patients will be given intravenous iron and reviewed on admission. Data are being collected on an ongoing basis following the introduction of this protocol to review any impact on transfusion rates, length of stay and any associated benefits from treating and prompting investigation of preoperative anaemia. References Preoperative anaemia. Hans GA, Jones N 2013 Continuing Education in Anaesthesia, Critical Care & Pain The 2015 Annual SHOT Report PHB Bolton-Maggs (Ed) D Poles et al. on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group 2016 Available at International consensus statement on the peri-operative management of anaemia and iron deficiency. Munoz M, Acheson A et al 2017 Anaesthesia Costing statement: blood transfusion NICE 2015 Preoperative risk scoring; Uptake and correlation with postoperative course in a tertiary teaching hospital R Foye, S Dwyer, A Baker Elizabeth University Hospital, Glasgow Introduction With the ever increasing demand for critical care and downstream acute beds nationally,1 methods to estimate the length of stay for patients undergoing major surgery and to allow appropriate planning could be a valuable bed management resource. Furthermore, with recent further emphasis regarding the importance of patient consent,2 being able to offer objective measures of perioperative risk seems appropriate where possible. One such method, the Surgical Outcome Risk Tool (SORT) scoring system, may prove worthwhile in our institution for these issues; it takes into account the patients’ ASA, age, urgency and nature of the procedure, and provides a predicted 30 day mortality.3 We sought to assess how widely risk scoring was being used at our institution, and how well it correlated with length of stay in critical care, acute hospital stay and rate of postoperative complications. Methods Beginning May 2016, we followed one hundred consecutive patients undergoing colorectal and