Letter to the Editor
Treatment of perioperative anemia in hip fracture
Tratamiento de la anemia perioperatoria de la fractura de cadera
José Antonio García Ercea,e,
, Susana Gómez Ramírezb, Jorge Cuenca Espiérrezc,e, Manuel Muñoz Gómezd,e
Corresponding author
a Servicio de Hematología y Hemoterapia, Hospital General San Jorge, Huesca, Spain
b Servicio de Medicina Interna, Hospital Internacional Xanit, Benalmádena, Málaga, Spain
c Cirugía Ortopédica y Traumatología, Clínica Quirón, Zaragoza, Spain
d Medicina Transfusional Perioperatoria, Facultad de Medicina, Málaga, Spain
e GIEMSA, Medicina Transfusional Perioperatoria, Facultad de Medicina, Málaga, Spain
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Therefore, we would like to clarify some of the authors’ statements and provide, from our experience and current scientific evidence, some treatment recommendations that we consider more correct and effective.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Approximately 45–60% patients with hip fracture have preoperative anemia, prevalence up to 90% in the postoperative period. Depending on the type of fracture or surgical procedure, 95% of fractures have perioperative bleeding, ranging from 500 to 1500<span class="elsevierStyleHsp" style=""></span>ml, in addition to bleeding the days before the surgery, which results in an average decreased Hb by 4<span class="elsevierStyleHsp" style=""></span>gdl.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Assuming about 200<span class="elsevierStyleHsp" style=""></span>mg iron are required to increase Hb by 1<span class="elsevierStyleHsp" style=""></span>g/dl, then 600–1000<span class="elsevierStyleHsp" style=""></span>mg iron would be required to compensate for the red cells lost. Therefore, the <span class="elsevierStyleItalic">Libro azul</span> (Blue Book) of the Spanish Society of Osteoporotic Fracture recommends prophylactic FeIV administration, from admission, plus administration of rHuEPO sc if Hb levels are below 13<span class="elsevierStyleHsp" style=""></span>g/dl, along with the application of “restrictive” transfusional treatment.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> This recommendation has been shown to decrease transfusion rate in patients with Hb <13<span class="elsevierStyleHsp" style=""></span>g/dl before fracture.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–6</span></a> We also recommend indicating blood transfusion based on clinical criteria, adjusted for cardiovascular risk factors and with the administration of the lowest effective dose: one unit of red blood cell concentrate can be sufficient.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Our group has recently published<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> an analysis of pooled data from over 1300 patients with pertrochanteric or subcapital hip fracture treated with FeIV (200–600<span class="elsevierStyleHsp" style=""></span>mg) from admission with or without rHuEPO (40,000<span class="elsevierStyleHsp" style=""></span>IU). In this analysis, there is a significant reduction in blood transfusion, in the incidence of postoperative infection, in mortality at 30 days and in the length of hospital stay, without increased risk of thrombosis or strokes. The major benefit was reported in patients with pertrochanteric fracture, with Hb <13<span class="elsevierStyleHsp" style=""></span>g/dl treated with FeIV and rHuEPO.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Therefore, it is surprising that the Hb cutoff values selected for the various treatments are <<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>g/dl for FeIV administration and <10<span class="elsevierStyleHsp" style=""></span>g/dl for rHuEPO.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Particularly, because the literature reviewed states that the inflection points for transfusional risk and effectiveness of FeIV, without erythropoietin coadjuvant treatment, are consistent with Hb levels of 13 and 12<span class="elsevierStyleHsp" style=""></span>g/dl, respectively.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–6,9</span></a> Based on the data previously shown, we believe that if no contraindications, all patients with hip fracture should receive FeIV from admission (at least 600<span class="elsevierStyleHsp" style=""></span>mg), and those with Hb levels <<span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>g/dl during hospital admission, should also receive preoperative administration of at least one rHuEPO dose of 40,000<span class="elsevierStyleHsp" style=""></span>IU.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Finally, the authors state that “due to the increasing transfusional restriction recommendation and the proven relationship with postoperative infection resulting from transfusion immunomodulation, alternative therapies will be promoted for anemia treatment.” We believe that the implementation of these therapies, such as treatment of perioperative anemia, reducing bleeding and/or the application of restrictive transfusion criteria should not be focused merely on “transfusional savings” or even economical savings.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> On the contrary, they should be included within the concept of patient blood management (PBM), recently recognized by WHO and whose approach accounts for a paradigm shift. The PBM approach is multidisciplinary and multimodal, and is focused on identifying and providing for the necessary care for continuity of patient care, where communication and coordination among the various disciplines might reduce not only the likelihood of requiring transfusion, but improve clinical outcome and reduce therapy costs.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García Erce JA, Gómez Ramírez S, Cuenca Espiérrez J, Muñoz Gómez M. Tratamiento de la anemia perioperatoria de la fractura de cadera. Med Clin (Barc). 2015;145:554–555.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative medical treatment of old patients admitted with hip fracture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Pareja Sierra" 1 => "J. Rodriguez Solis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2014" "volumen" => "143" "paginaInicial" => "455" "paginaFinal" => "460" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "García-Erce JA, Cassinello Ogea C, Díaz Curiel M. Tratamiento con precursores hematínicos. 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