Sampled reviewed Kumar, A. (2009, November). Perioperative Management of Anemia: Limits of blood transfusion and alternatives to it.

Retrieved October 14, 2013, from Cleveland Clinic Journal of Medicals: www.ccjm.org One of the common disorders that are found in many people nowadays is anemia. Anemia is a condition that develops when blood is lacking of healthy red blood cells or hemoglobin. Hemoglobin is the main part of red blood cells and binds oxygen. If there is too few or abnormal red blood cells, then the hemoglobin is abnormal or low. Thus, the cells in the body will not get enough oxygen. Main symptom of anemia is fatigue due to the organs not functioning properly. If the number of red blood cells or concentrations of haemoglobin are low, a person is said to have anemia. The haemoglobin is a protein (mettalloprotein) inside the red blood cells and contains iron and transport oxygen. Thus, anemia is seen as the most common disorder of the blood and basically can be found in the countries where people suffer from malnutrition. Therefore, there should be more awareness on anemia because the more we know the better precaution can be done in order to have a bigger span of knowledge about this blood disorder. Thus a better management on this anemia and the proper transfusion about it is needed to be known. In the article, Perioprative Management of Anemia; Limits of Blood Transfusion and Alternatives to it written by Ajay Kumar MD retrieved from www.ccjm.org on 14th October 2013; the discussion was done about the limits of transfusion and the better alternatives towards treating anemia. This perioperative anemia is closely referred to the excess of mortality and morbidity. Even though, the transfusion of allogenic blood is a method that has been used for a long time in managing anemia, the blood supply is still seems to be insufficient to meet the needs of the transfusion. In addition to that, there are many other

complications in this transfusion such as infection, renal injury, and acute lung injury. The data also shows that the mortality and length of stay can be worsen with the usage of the transfusion. Thus, there are other alternatives given such as iron supplementation and other stimulating agents. However, these supplements and perioperative transfusion still hold to certain risk especially among the surgical patients. Thus, this article will discuss about the new programme management on the blood management program aimed at reducing allogeniec blood exposure for greater patients. The article will mainly discuss on the anemia as a potent multiplier of mortality and morbidity risk mainly in the perioperative setting. In this article, there will be a discussion on the Joint Commission in planning to implement performance measurement on the blood management. The author also discussed about the risks from transfusion persists including transfusion related to acute lung injury and other infection that emerges despite of the improved safety blood supplies. The article also will be reviewed at a standpoint of the preoperative evaluation in eliciting the history of bleeding tendencies, previous transfusion and the symptoms of anemia. Lastly, the article will also conclude on the usage of the ESAs (the supplements) minimizing the needs of blood transfusion in the surgical patients and risk of thromboembolism in the absence of prophylactic anticoagulation. The article will mainly outline certain important matters. It will review the clinical importance of the perioperative anemia, its role and the shortcoming of the blood transfusion. In addition, it will discuss about the pros and cons of the alternative approaches in managing the perioperative blood products used in the institution of Cleveland Clinic. In order to understand the perioperative anemia, its significant is discussed briefly by the author. The author, Kumar, discussed about the prevalence depending on many other factors. The prevalence depends on the patients disease and comorbidities, the surgical procedure and associated blood loss and the definition of the anemia used among the surgical

patients as it varies widely from 5% to 76%. This shows that different patient has different need according to the variety prevalence it depends upon. Even the gender of the patient is taken into account as the prevalence of preoperative anemia increases with patientage and is higher in women than in men (page 112). In addition, anemia is seen as a multiplier of mortality risk as the presence of it can relate closely to the other chronic diseases such as the kidney disease, heart failure and so on. There is also a proof showing the adverse effects of anemia that have been demonstrated specifically in the perioperative settings. There is a close association of this anemia with the cardiovascular disease and towards the increase in the ris of death and cardiac events. Kumar then discussed about the certainty of whether the option of using the blood transfusion is the best choice. The usage of allogenic blood transfusion in managing anemia and blood loss seems to be the best concept used for many years in treating this disorder and over the years it has gone through certain little changes. There are many challenges on the blood supply and according to Kumar; the main challenge faced because of the blood transfusion is the insufficient blood supply for the transfusion needs. According to the federal governments 2007 National Blood Collection and Utilization Survey Report, 6.89% of US hospitals reported that they cancelled elective surgery on 1 or more days in the prior year because of a lack of blood availability, and 13.5% experienced at least 1 day in which nonsurgical blood needs could not be met. (page 113). This shows that there is a great urgency in increasing the blood donation to meet the needs of the blood transfusion. The article discussed about how the Joint Commission is set to measure blood management and there was a panel set for this whereby 17 performances were measured related to blood conservation and the appropriate transfusion. The author also explained that the measurements are still under development and more result will be seen in future. The safety of the blood supply is also discussed as there are possibilities of viral transmission and this

TRALI persist on the safety of the blood supply which has now improved markedly. The blood supply needed to be really safe for a blood transfusion as many people are declining the transfusion due to the fear of being infected of HIV, hepatitis C virus and hepatitis B virus. However, the transfusion-related acute lung injury (TRALI) has persisted in years and being characterised by acute onset in noncardiogenic pulmonary edema within 6 hours of the blood product transfusion. TRALI acts as the antibodies to human leukocyte antigen develop, inducing leak syndrome and is believed to be immune-mediated. Only those receiving plasma from multiparaous female donors are believed to be affected. Kumar also explained the fact proving that there is evidence that hemovigilance can reduce TRALI risk (page 213). In addition, there should be seriously marked up checkings because not only the public are scared of the existing disease but also concerned about the other new diseases and infections such as the malaria, West Nile virus and others. According to the author, the blood transfusion has never undergone any safety evaluation by the FDA. The Transfusion Requirement in Critical Care (TRICC) trial has been conducted in the 838 criticaly ill patients in intensive care settings. As the TRICC were carried out, they found significantly higher mortality among patients who underwent transfusion compared with those who did, not perform it (page 113). The author described about a few studies that has been conducted on the patients undergoing noncardiac. One of the studies shows that transfusion was the single factor that is reliably associated with the increased of the risk postoperative morbidity. In addition to that, there has been some studies with the findings where the perioperative blood transfusion is associated with the host adverse outcomes including the increased of morbidity and the length of the stay. Thus, it increased the rates of postoperative infection, as well as immunosuppression,the viral transmission, and acute transfusion reactions. The most interesting fact that bothers many people in thinking how blood transfusion happens is the outcomes and duration of the blood

being stored. The relation between transfusion and outcomes is the shelf life of the blood being transfused (page 114). Thus, the author explains that FDA is allowing blood storage for a maximum of 42 days, and there is a recent study that shows that for those patients who received the old blood (the blood stored for more than 14days) had higher rates of sepsis, prolonged intubation, renal failure, and 1 year mortalitity compared to those who receive new blood. Therefore, Kumar discussed that there is an increase in the demand of the new blood supply and there is a slight defect that puts a pressure in the long storage of blood for supply. The author later on discussed about the management of perioperative anemia. Fisrt, Kumar discussed about the perioperative evaluation in anemia. Thus the evaluation should draw out the history of bleeding tendencies, previous transfusions and the symptoms of anemia. In addition, medications in treating the anemia such as the aspirin, clopidogrel and anticoagulants should be able to predispose perioperative anemia. The main symptoms that should be given attention is the shortness of breath and fatigue. Kumar presents his findings by discussing that if anemia is present and is associated with another hematologic abnormality, the patient should be referred to a haematologist for bone marrow examination (page 114). Hence, is there is no existence of hematologic abnormality, the ensuing work up will rely on the red blood cell. The utmost point is to identify which intervention in the short term as possible for anemia in order it is easy for the treatments. The anemia can be because of the chronic disease, iron deficiency, and vitamin B deficiency. By completing these findings, the conditions will be assisted for further evaluation at a preoperative centre. There is a broad overview of the management options that is being discussed by the author in this article. The author discussed that the choice for optimal medical management can only be made once the cause of the anemia is identified. The choices will be either pharmacologic or technological options which include the options of iron supplements and erythripoiessis stimulating agents.

Each option is discussed firmly by the author in this article. The first option is the pharmacologic options are the iron supplements and erythropoiesis-stimulating agents. These irons are available in four preparations which are the ferrous sulphate, ferrous gluconate, ferrous fumarate and iron polysaccharide. However, there is always a limitation in taking these supplements and there are possibilities in having side effects. Therefore the dose and the pills should be decreased to reduce the side effects. The intravenous (IV) preparations have been used for many years and now after years of implementation, it has become safer. The generally used in perioperative setting are the iron sucrose and the iron gluconate. Different from the older IV preparations, the usage of iron sucrose and iron gluconate often requires a second dose. However, the side effect still exists in this type of treatment as well. There are some doubts about the efficacy and safety of iron supplementation. There are evidences discussed by the author about the efficacy and safety of iron supplements as there are proves of patients undergoing colorectal cancer surgey found that among the 116 patients who were anemic, intraoperative transfusion was needed in a significantly lower proportion of those who received 2 weeks of preoperative oral iron supplements (page 115). In addition there is a decrease in the risk of infection and cancer progression on the concern of the IV iron therapy usage. In general, IV iron, especially the newer forms, is a safer alternative to blood transfusion. (page 115). The Erythropoiesis-stimulating agents (ESAs) which include the epoetin alfa (erythropoietin) can improve the treatments of anemia. It is not only approved by FDA but is also used explicitly for the use in patients indergoing major surgeries. Kumar also discussed about the efficacy in reducing transfusions. The epoetin alfa was shown to minimize perioperative exposure to allogenic blood transfusion in patients undergoing orthopaedic or cardiac surgery (page 115). It is efficient given daily or weekly for the patients and the miracle part of it is that it does not increase the risk of thrombotic

events when used among the surgical patients. Kumar also discussed about being concerned over the perioperative thromboembolic risk that made FDA aware. In discussing about the technological options and other strategies, the discussion was on the autologus blood donation. It is a practice in decline where in the cases of elective surgery, the autologus blood donation can be used in protecting against the disease transmission and to overcome the challenge of blood type compatibility. However, due to the high cost of this the demand on it is still lacking. In addition to that, the autologus blood donation increase the likelihood that the patient will be anemic on the day of surgery, so that he or she may still need allogenic blood (page 116) defeating the initial purpose of the use. Despite the limitations of it, the preoperative autologus blood still remains as useful antibodies for blood donors even though it is difficult to be obtained. In addition to that, the cell salvage is another innovative technology that can be used in recovering the patients blood either in the usage of transfusion after filtering and washing. It best suits for the transfusion that involves the massive blood loss. However, Kumar also discussed that the cost of this transfusion is high and it requires technical expertise. The phlebotomy stands for a significant amount of

blood loss for the patients in the intensive care. However, in a transfusion, about 30% of the blood transfused is reported to be lost to phlebotomy. In this article, the author also promoted about being responsible in the blood product used. Due to the reason of the valuable blood supply that is earned, the author defines blood as expensive, Blood is expensive, and in recent years hospitals have experienced increases in the cost of blood and blood products (page 117). Thus, in the Cleveland Clinic, there is a developed multipronged approach that is created in managing the blood. The particular program also is used in increasing the awareness about the risks faced associated with blood and blood transfusion. The aims is to educate the staff physicians and other caregivers about the appropriate use of blood products (page 117). The program also implemented a new

policy to require staff authorisation for the need of blood in nonemergency situations so that the requirement is adherent to an indication based ordering process. As a conclusion, the author defined anemia associated with increased morbidity and mortality in the perioperative setting. (page 117). The author also defines the perioperative blood transfusion as a method in raising haemoglobin levels among the anemic patients ut at the same increasing the perioperative morbidity in the form of acute transfusion reactions. The author also did not define the fact that the blood collection continues to be lagging in demand due to the a few reasons discussed above. However, with a lot of experiments, ideas, and researches, there are always improvement and amendments done for better results. As a reader, I find this article to be very useful and it is pack with informative facts and readings that can help us as readers to understand anemia better. In addition, anemia is a blood disorder that can be found in many people and therefore the reading on it can be a standing point for us to understand better on how to assist it. In addition, by reading this article, there is a great awareness on the concern about the blood transfusion where many are worried if the blood can be infected with the various types of dangerous and risky diseases. Due to that, reading this article decreased my worries as I have a better understanding that the inspection on the blood transfusion has been marked up and FDA is involved in inspecting the proper ways of donating blood and transfusing it. In conclusion, the article, Perioprative Management of Anemia; Limits of Blood Transfusion and Alternatives to it written by Ajay Kumar MD gives us a clearer opportunity in understanding the perioperative management of anemia and ways in handling the safety measurement of it. This article will help the readers to understand better and to handle the blood transfusion in a more appropriate way.