Pre-operative assessment
of anemia in women
undergoing hysterectomy
Michael Suen, Ciara Stevenson, Suzannah Wojcik, Cairina
Frank, Sukhbir Singh, Elianna Saidenberg
12th Annual TOH Patient Safety Conference
Oct 27, 2016
No conflicts of interest to disclose
“ A pint of sweat will save a
gallon of blood.
George S. Patton
”
Patient Blood Management (PBM)
 Evidence-based
 Optimize
 Avoid
approach
patient care
transfusions
Gynecology
Patient Blood
Management
Peri-operative Patient Blood Management
 Reduced
transfusions
 Improved
health outcomes
Kotze et al Br J Anesthesia 2012; 108:943-52
Moskowitz et al Ann Thorac Surg 2010; 90:451-8
Outpatient Clinics
Heavy
Bleeding
Posttreatment
follow-up
Consult
Medical
Surgical
> 1 year
> 3 months
Chronic anemia
Quality of life
Under the Microscope

Retrospective chart review

n = 376, 4 years

Hysterectomy within a tertiary level academic center (fellowship
trained surgeon)

Outcomes:

Pre-operative hemoglobin

Hemoglobin level

Ferritin
Pre-operative Hemoglobin
4%
96%
Yes
No
Pre-operative Hb (g/L)
9.00%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
<80
80 - 99
100 - 114
Referrals for Heavy Menstrual Bleeding
 24%
ferritin
 Median:
 36%
30 ug/L
iron supplementation
Patient Blood Management Guidelines, Australian
National Blood Authority, available at www.nba.gov.au
Muñoz et al. Blood Transfus. 2015 Jul; 13(3): 370–379
Why does it even matter?
Analysis
Odds ratio (95% CI)
Anemia vs. no anemia
30-day postoperative mortality
Mild anemia vs. no anemia
Mod-severe anemia vs. no anemia
Anemia vs. no anemia
Composite post-operative
morbidity*
Mild anemia vs. no anemia
Mod-severe anemia vs. no anemia
1.42
(1.31 – 1.54)
1.41
(1.30 – 1.53)
1.44
(1.29 – 1.60)
1.35
(1.30 – 1.40)
1.31
(1.26 – 1.36)
1.56
(1.47 – 1.66)
Adapted from Musallam KM, et al. Lancet 2011; 378:1396–407.
The Future
Heavy
Bleeding
Posttreatment
follow-up
Consult
Medical
Surgical
> 1 year
> 3 months
Farmer et al. Best Pract Res Clin Anaesthesiol. 2013 Mar;27(1):43-58
Farmer et al. Best Pract Res Clin Anaesthesiol. 2013 Mar;27(1):43-58
Heavy
Bleeding
Posttreatment
follow-up
• CBC, Ferritin
• Iron supplementation
Consult
•
•
•
•
Repeat labwork
Adjust iron PRN
Hematology consult PRN
Menstrual suppression
Medical
Surgical
Reassess while awaiting surgery
Summary
 Opportunities
for multidisciplinary care
 Opportunities
for improvement
 Share
lessons for patient care
Thank you!
Questions?
Ottawa Minimally Invasive Gynecology Group
Patient Blood
Management
Guidelines, Australian
National Blood Authority,
available at
www.nba.gov.au
Medical options

Non-steroidal anti-inflammatories

Anti-fibrinolytics


Tranexamic acid
Combined hormonal contraceptives

Oral contraceptive pills

Transdermal patch

Selective Progesterone Receptor Modulators

Intrauterine systems

Gonadotropin-releasing hormone agonists