Challenges with

Laura McKenzie-Kerr R.N. SHN Patient Blood Management Coordinator/ONTraC for SHN

SHN.ca ONTraC Program at SHN

I am a Registered Nurse and my role is to optimize the elective surgical patient and decrease the need of an allogenic . I have been in this role for 15 years and I have been an employee at SHN for almost 35 years. I am one of 25 ONTraC/Patient Blood Management Coordinators across Ontario. This is a Ministry of Health and Long Term Care funded program.

2 Objectives of my presentation

Increase the awareness and the challenges of anemia specifically • Iron Deficiency Anemia • Anemia of Chronic Disease • Hospital Acquired Anemia

3 Anemia in general … • Anemia should be viewed as a serious and treatable medical condition • Mild pre-operative anemia is an independent risk factor that can increase perioperative morbidity and mortality • Anemia is an independent risk factor for several un-favorable outcomes including: increase risk of hospitalization/or readmission, prolonged hospitalization (LOS), increased risk of a allogenic blood transfusion, decreased quality of life, contributes to postpartum hemorrhage and post partum depression 4 Anemia in general …

- Anemia is an extremely common condition with a disproportionate prevalence in women - Globally it is estimate 1 in 4 human beings is anemic - 30% in non pregnant women - 42% in pregnant women across the world - 24% of black women less than 50 years old are anemic / 3% of white women are anemic

5 Definition of Anemia

• Anemia as defined by the World Health Organization is:

o A of less than 120 g/L for women and a hemoglobin of less than 130 g/L for men

• Keep in mind a surgical procedure with moderate or high blood loss will further aggravate the anemia and already depleted iron stores

6 Common Causes of Anemia

- Iron Deficiency - Anemia of Chronic Disease / Inflammation (2nd most common) - Chronic Kidney Disease - Hospital Acquired Anemia - B12 Deficiency Anemia - - Sickle Cell Anemia

7 Causes of Iron Deficiency Anemia

• Hemorrhage

• Malabsorption

• Decreased dietary intake

• Increased requirements (pregnancy)

• Chronic Hemolysis

8 Signs and Symptoms of Anemia

Exhaustion/fatigue even with sleep / going to bed at 9:30 pm every night Restless legs, shortness of breath, palpitations Foggy feeling/difficulty concentrating/studying for exams can be challenging Cold hands/feet Dizziness especially on sudden movement/black spots PICA-craving or chewing substances with no nutritional value/dirt, coal, baby powder Ice chewing or pagophagia - associated with iron deficiency with or without anemia - cause unclear Dry hair and dry nails 9 Prevalence of Anemia at SHN A snap shot of what is happening across Ontario • Total Knees/Total Hip Replacements – 30% of my patients are anemic. This is a mixture of chronic disease, thalassemia, iron deficiency, chronic kidney disease • Total Abdominal Hysterectomy /Abdominal Myomectomy patients – approximately 90% of my patients have a preop hemoglobin less than 120 g/L • I am referred patients who are newly diagnosed with colon or gastric cancer who required hemoglobin optimization prior to their surgery • I have also been involved with patients who are post gastric bypass surgery who require hemoglobin optimization prior to surgery

10 Prevalence of Anemia at SHN

• Pregnant patients are referred for hemoglobin optimization prior to delivery • The risk of iron deficiency increases in pregnancy due to an increase in maternal iron requirements to accommodate the expansion of the maternal mass, development of the fetus and placenta and the loss of blood with labor and delivery • As a result patients were probably anemic prior to pregnancy or become anemic during the pregnancy • Anemia in pregnancy is defined as a hemoglobin less than 110 g/L 11 Hot off the Press!

- Early prenatal anemia exposure may increase risks during pediatric neurodevelopment

- Children born to mothers who had anemia during the first 30 weeks of pregnancy, but not those whose mothers had anemia after 30 weeks of pregnancy, were more likely to develop intellectual disability, autism spectrum disorder and attention- deficit/hyperactivity disorder, compared with those whose mothers didn't have anemia during pregnancy, according to a Swedish study in JAMA Psychiatry. However, researchers found that fewer than 1% of mothers had anemia during early pregnancy.

12 Anemia and the Pre-op patient Early detection and treatment can reduce or eliminate anemia related risks.

From the ONTraC data, we know that the likelihood of receiving a transfusion increases exponentially when the preoperative hemoglobin is below 130 g/L (considered anemic for males).

It is all about the “drop” of hemoglobin with the surgery being performed and there are many strategies used to decrease the amount of blood loss including early assessment for anemia, type of anesthesia planned, use of tranexamic acid, oral iron, iv iron, use of eprex, cell saver and an appropriate transfusion trigger. 13 Effect of preoperative Hb level on transfusion rate

Hb (g/dL) <10 <11 <12 <13 >13 >14

Pre-op Hb of 100 g/L has a seven-fold higher likelihood of transfusion than Hb 130 g/L

But need to see patients early enough to effectively correct anemia Estimated Blood Loss or the “drop”

Surgery Expected and Estimated Blood Loss

Total Knee Replacement 20-30 g/L

Total Hip Replacement 30-40 g/L

Total Abdominal Hysterectomy/ 20-40 g/L Abdominal Myomectomy

Vaginal Delivery Vaginal Delivery less than 500 mLs

1000-1500 mLs C/Section

15 Dietary Suggestions to consider Non-heme - Cream of Wheat (plain) 25% of your daily iron need - Cream of Wheat (with brown sugar) 35% of your daily iron need - One package of Cream of Wheat = 3 cups of raw spinach or one serving of liver - Prunes/Prune juice - Green Vegetables including spinach, kale, broccoli, - Beans/ Lentils

16 Dietary Suggestions to consider

Heme iron options to consider:

Seal 13.5 to 21.0 mg Moose 4.0 mg Wild Duck 7.5 mg Chicken 1.0 mg Pork 0.5 mg to 1.0 mg Sardines 2.0 mg Beef 1.5 mg to 3.0 mg

17 Anemia Assessment

Patient history provides a lot of useful information Is the patient female, small body size, obese, renal disease, diabetic, GI issues, hematuria, blood in stool, endocrine disorders Menstrual cycle and ask what is the flow like, frequency, quality of the period Diet: any restrictions/issues/concerns/marital status Past surgeries? Gastric bypass? / Stomach issues Surgery: What is it and what is the Estimated Blood Loss Medications: prescribed and over the counter Oral Iron: What type / how often / when / side effects

18 Scenario #1 43 year old female walked into our Emergency Department complaining of feeling tired and weak P 110, BP 125/70 R. 18 She was seen by SHN Physician’s Assistant History taken by SHN PA : She has regular periods / No bleeding noted in stool / urine Diet – no issues discussed/No surgeries On no prescribed medications

19 Scenario #1 CBC reveals a normal WBC Hemoglobin of 54 g/L MCV 70 fL (A typical example of with an MCV less than 80 fL) Ferritin done and pending PA and ER doctor order 3 units of RBC = 9 to 12 hours in the Emergency Department Consultations with Hematology and Gastroenterology SHN Charge Technologist Tina Irwin in Transfusion Medicine contacted me to followup regarding order and number of units – we had just started implementing the OTQIP

20 My discussion with the patient and then the ER Doctor Periods: very heavy for first 1-3 days, large clots, accidents happen frequently, pad & tampon every 1-2 hours/24-48 hours (she had no idea that this wasn’t normal) No blood in stool, urine Diet: she ate once a day – trying to lose weight only vegetables and lots of lettuce Current vital signs are within her normal limits and pulse is slightly elevated I went to the ER doctor and discussed with him my information and my concerns I was able to talk him out of 3 units to 2 units. This would take approximately 6 hours for the patient. 21 My discussion with the ER Doctor

I said, I think she has Iron Deficiency Anemia He was surprised I came up with that diagnosis but he agreed to decrease the transfusion order from 2 to 3 units I went and updated her – she was going to get 2 units of Blood and be in ER for about 6 hours with a repeat CBC. I recommended that she obtain a Gyne referral from her GP as her periods are contributing to her anemia I went back to my desk and about 30 minutes later I checked her labs again and saw that the Ferritin was available Any Ideas? What do you think happened?

22 Lab Investigations - Definitions

Ferritin: is the main protein that stores iron. A ferritin level measures the amount of stored iron. : reflects the average volume of the red blood cell (Hct/RBC). Normal ranges for males and females. MCV is increased in B12 and folate deficiency, reticulocytosis, hyperglycemia, and leukemia. MCV is decreased in iron deficiency anemia. The red blood cell size allows a classification of anemia – microcytic, macrocytic, and normocytic which provides insight to the cause of the anemia

23 Lab Investigations - Definitions

Serum Iron: The concentration of iron that is bound to transferrin. Normally, transferrin is about 1/3 bound to iron

Transferrin: a blood protein that transports iron from the gut to the cells. The body makes transferrin in relationship to the need for iron

TSAT: Percent transferrin saturation = serum iron/TIBC x 100

24 Laboratory Investigations to Review Anemia of Iron Deficiency Chronic Disease Laboratory Test Normal Values Anemia ( IDA) IDA + ACD (ACD) Microcytic Normocytic

Iron 4-30 umol/L Low Low Low

Transferrin 1.93 -3.60 g/L High Low to normal Low

24-336 ug/L - Men Normal to High Ferritin Low Normal to high 11-307 ug/L- > 100 mcg/L Women

TSAT 16.0 -60.0 Low Low Low

MCV/MHC Low Low to normal Low to normal25 Anemia of Chronic Disease: Normocytic Hemoglobin 100-130 g/L

Normocytic: Mean Corpuscle Value: 80-100 fL

Causes of include: o Nutritional deficiency o Renal Insufficiency o Hemolysis (auto/allo) o Primary disorder o Endocrine disorders

26 Patient Scenario #2 - 79 year old woman with a preop hemoglobin of 109 g/L with a normal MCV of 90 fl booked for a knee replacement in 2 weeks - She is diabetic, takes hypertensive medications and is on thyroid replacement - I reviewed her diet and she is alone at home/ poor appetite / in too much pain to stand for too long/ husband has just been placed in a NH - I said I didn’t really like her hemoglobin for her knee replacement / she said the Medical Doctor she just saw didn’t say anything - I then told her what I expected to happen with her hemoglobin postoperatively and how that can affect her recovery

27 Anemia of Chronic Disease

• Typical patients that I see are the patients who have diabetes, thyroid disease and hypertension • Depending on the labs I may recommend oral iron/diet suggestions • For these patients I may recommend Eprex to optimize for surgery to target a hemoglobin of 125 g/L for day of surgery

28 Anemia in the Elderly

- As women continue to age the frequency of anemia increases to the point that after age 85, about 20% have anemia - Non-Hispanic black women are 3 times more likely to be anemic as their white counterparts - Among women residing in nursing homes, approximately 50% are anemic - Anemia in the elderly is associated with frailty, increased mortality, poor cognition, and decreased physical performance - It is a potent comorbidity in heart disease and chronic kidney disease 29

Hemoglobin less than 120 g/L for women and 130 g/L for men MCV > 100 to < 110 mild MCV > 100 marked Causes: Serum B12 deficiency, thyroid disease, alcoholism, hepatic disease Medications: HIV antivirals, Methotrexate (RA), Septra, Hydroxyurea Review B12 and Folate and treat accordingly For Surgery: Eprex is a consideration depending on the patient’s surgery / history 30 Hospital Acquired Anemia

• This is an anemia I see every day • Phlebotomy for diagnostic treatment can result in iatrogenic anemia and RBC transfusion • 74% of hospitalized patients will develop Hospital Acquired Anemia • In a study of critically ill patients, almost half of the variation in the amount of blood transfused was accounted for by diagnostic phlebotomy

31 Hospital Acquired Anemia

• 95% of patients admitted to the ICU develop anemia by Day 3

• Two separate studies noted that the average daily blood samples in ICU = 41 mL/day and that could be possibly higher

• When reviewing blood use in the Intensive Care at our hospital it is very common to see patients who have been in ICU for over 7 days or so requiring a unit of red blood cells and then again in 5-7 days after that/not actively bleeding/maintaining a hemoglobin around 70-75 g/L

32 Hospital Acquired Anemia

Possible strategies to avoid/treat HAA include • Micro-sampling in ICU (has shown to reduce blood loss by 37-47% • Using a device to return the drawback blood has been associated with a 50% reduction in diagnostic blood loss • Order only essential bloodwork and minimize the volume of blood drawn to treat the patient • Point of Care Testing • Avoid ordering routine daily blood work if there hasn’t been a change in the patient’s condition

33 Following my presentation: Oral iron / IV iron options will be discussed by Dr. Allison Collins

34 References

1. Patient Blood Management – A Toolkit Guide for Hospitals written by Dr. John Freedman 2. Bloody Easy 4 3. Iron Deficiency Anemia in Women Across the Life Span written by Dr. A. Friedman, Dr. Chen, Dr. P. Ford, Dr. C. Johnson, Dr. A. Lopez, Dr. A. Shander, Dr. J. Waters.

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