Preoperative iron treatment in anaemic patients undergoing elective total hip or knee arthroplasty: a systematic review and meta-analysis

Abstract

ObjectivesPreoperative anaemia is associated with increased risks of postoperative complications, blood transfusion and mortality. This meta-analysis aims to review the best available evidence on the clinical effectiveness of preoperative iron in anaemic patients undergoing elective total hip (THR) or total knee replacement (TKR).DesignElectronic databases and handsearching were used to identify randomised and non-randomised studies of interventions (NRSI) reporting perioperative blood transfusion rates for anaemic participants receiving iron before elective THR or TKR. Searches of CENTRAL, MEDLINE, Embase, PubMed and other databases were conducted on 17 April 2019 and updated on 15 July 2020. Two investigators independently reviewed studies for eligibility and evaluated risk of bias using the Cochrane risk of bias tool for randomised controlled trials (RCTs) and a modified Newcastle-Ottawa scale for NRSIs. Data extraction was performed by ABS and checked by AB. Meta-analysis used the Mantel-Haenszel method and random-effects models.Results807 records were identified: 12 studies met the inclusion criteria, of which 10 were eligible for meta-analyses (one RCT and nine NRSIs). Five of the NRSIs were of high-quality while there were some concerns of bias in the RCT. Meta-analysis of 10 studies (n=2178 participants) showed a 39% reduction in risk of receiving a perioperative blood transfusion with iron compared with no iron (risk ratio 0.61, 95% CI 0.50 to 0.73, p<0.001, I2=0%). There was a significant reduction in the number of red blood cell units transfused with iron compared with no iron (mean difference −0.37units, 95% CI −0.47 to -0.27, p<0.001, I2=40%); six studies (n=1496). Length of stay was significantly reduced with iron, by an average of 2.08 days (95% CI −2.64 to −1.51, p<0.001, I2=40%); five studies (n=1140).ConclusionsPreoperative iron in anaemic, elective THR or TKR patients, significantly reduces the number of patients and number of units transfused and length of stay. However, high-quality, randomised trials are lacking.PROSPERO registration numberCRD42019129035.

Appropriateness of inpatient intravenous iron therapy in a Swiss tertiary care hospital

“…A recent randomized controlled trial, however, concluded that IV iron administration before major surgery did not improve patients' outcome compared to placebo, for patients with preoperative anemia and for a smaller subgroup with ID 41,42 . Furthermore, we emphasize that anemic patients may also benefit from oral iron replacement 43 …”

“…41,42 Furthermore, we emphasize that anemic patients may also benefit from oral iron replacement. 43 Concerning the gynecological patients we observe that the current guideline by the Swiss Association for Gynecology and Obstetrics (SGGG) supports a rather liberal use of IV iron. The authors suggest IV iron for all postpartum patients with an anemia Hb < 95 g/L, claiming that IV iron has been proven superior to oral iron with regards to a faster increase in hemoglobin, an improvement in fatigue and less gastrointestinal side effects compared to oral iron.…”

Hospital transfusion service operations during the SARS‐CoV‐2 pandemic: Lessons learned from the AABB hospital survey in preparation for the next infectious disease outbreak

“…Respondents were not asked to identify surgeries that were impacted explicitly. Yet, this finding could provide insight into the evaluation and treatment of preoperative anemia (another patient blood management program component 23 ), the benefits of which might include decreased blood transfusions, not to mention improved outcomes and shorter length of hospital stay 24–28 . Notably, a recent randomized controlled trial showed that patients receiving iron supplementation were not transfused less blood compared to patients who did not receive iron up to 42 days before major abdominal surgery 29 …”

Scaling up Quality Improvement for Surgical Teams (QIST)—avoiding surgical site infection and anaemia at the time of surgery: a cluster randomised controlled trial of the effectiveness of quality improvement collaboratives to introduce change in the NHS

“…To achieve this, we compared the roll-out of two different preoperative initiatives to improve postoperative outcomes: anaemia screening and treatment (QIST: Anaemia) and MSSA nasal decolonisation (QIST: Infection). Both initiatives are associated with improved postoperative outcomes and are recommended by multiple national and international guidance, including those from the World Health Organisation (WHO) and the National Institute for Health and Care Excellence [ 6 , 7 , 31 – 37 ]. As the initiatives target healthcare teams, a cluster RCT was used.…”