Transfusión de productos hemáticos en paciente crítico con hemorragia. Indica...José Antonio García Erce
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Actualización del manejo del paciente con anemia perioperatoria. Dr García Erce. Curso Ahorro SAngre. Hospital Universtiarios La Paz Madrid
1. V Curso Medicina Transfusional
Ahorro de sangre en cirugía
ACTUALIZACIÓN DEL MANEJO DEL PACIENTE CON
ANEMIA PERIOPERATORIA
Universidad Autónoma de Madrid, 26 de noviembre 2012
Dr José Antonio García Erce.
GIEMSA-AWGE; SEHH; SETS; NATA
Servicio de Urgencias Generales
Hospital Universitario La Paz, Madrid
2.
3. Agradecimientos
Dr. Manuel Quintana Díaz
Servicio Urgencias HULP. Universidad Autónoma de Madrid
Prof. Manolo Muñoz Gómez
GIEMSA. Facultad de Medicina. Universidad de Málaga
Dr. Jorge Cuenca Espiérrez
Department of Orthopaedic Surgery
University Hospital Miguel Servet, Zaragoza
Prof. Antonio Herrera Rodríguez
Cátedra Department of Orthopaedic Surgery
University Hospital Miguel Servet, Zaragoza
Dra. Elvira Bisbe
Department of Anaesthesiology. University Hospital Mar-Esperança,
Barcelona
4. www.awge.org
Declaración de Conflicto de intereses
Asesor externo
- AMGEN Oncología 2010/2012
- Roche Anemia 2009
- Ditassa-Ferrer 2004
Charlas, estudios investigación y ayudas a congresos
-Vifor-Uriach/Ferralinze
-Janssen-Cilag
-Astra-Tech de Aztra Zeneca/GSK
-Sanofi Aventis/Esteve/Novartis
-Cobe-Caridian/Roche Oncología
Miembro del CAT 2002-2005
Miembro del Documento de Sevilla “Alternativas a la Transfusión”
Miembro del Documento LatinoAmericano de la Anemia
Miembro de GIEMSA/ Secretario AWGE/Socio SETS/AEHH/NATA
Editor Asociado Revista ANEMIA www.revistaanemia.org
Miembro Comité Científico NATA y TATM
TRANSFUSIÓN DE COMPONENTES SANGUÍNEOS
7. ACTUALIZACIÓN DEL MANEJO DEL
PACIENTE CON ANEMIA
PERIOPERATORIA
www.awge.org
INTRODUCCIÓN
JUSTIFICACIÓN
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8. It is necessary to reduce the unnecessary transfusions. This
can be achieved through the appropriate clinical use of blood,
avoiding the needs for transfusion and use of alternatives to
transfusion.
The commitment of the health authorities, health care providers
and clinicians are important in prevention, early diagnosis
and treatment of diseases/ conditions that could lead to the
need for blood transfusion.
http://www.who.int/bloodsafety/clinical_use/en/
Blood transfusion is an essential part of modern health care.
Used correctly, it can save life and improve health. However, as
with any therapeutic intervention, it may result in acute or
delayed complications and carries the risk of transmission of
infectious agents.
10. To promote improvements in the quality of the clinical
transfusion process, which is defined as:
Transfusion of the right unit of blood to the right
patient at the right time, and in the right
condition and according to appropriate
guidelines.
A chain of integrated events that begins with a correct
decision that the patient needs blood and ends with an
assessment of the clinical outcome of the transfusion. Its
goal is to achieve optimal use of blood.
2010
V Curso Medicina Transfusional
11. The outcome, optimal use of blood is defined as:
The safe, clinically effective and efficient use of
donated human blood
Safe: No adverse reactions or infections
Clinically effective: Benefits the patient
Efficient: No unnecessary transfusions.
Transfusion at the time the patient needs it
2010
V Curso Medicina Transfusional
14. “Primun non noccere”
No deberíamos administrar tratamiento alguno que
no vaya a obtener un beneficio esperado y objetivable
Deberíamos realizar aquella práctica clínica que
tenga la máxima evidencia cíentífica/recomendación
Deberíamos aplicar aquella terapia o acción más
eficiente y con el máximo coste-beneficio.
V Curso Medicina Transfusional
MANEJO DE LA ANEMIA PERIOPERATORIA
15. “Primun non noccere”
“Even though blood transfusion has been used
for over 100 years there is little evidence of it’s
efficacy in many clinical situations.
Blood transfusion should only be prescribed to
increase the oxygen consumption, and there are
many reasons supporting this statement”
V Curso Medicina Transfusional
MANEJO DE LA ANEMIA PERIOPERATORIA
22. Prevalencia de anemia preoperatoria
Puntos clave:
• Entre el 20% y el 75% de los pacientes quirúrgicos pueden
presentar anemia preoperatoria debido a su patología quirúrgica
o a otras patologías.
25. Data for 227 425 patients, of whom 69 229 (30,44%) had
preoperative anaemia.
After adjustment, postoperative mortality at 30 days was
higher in patients with anaemia than in those without
anaemia (OR 1·42, 95% CI 1·31–1·54)
27. Primer signo de una enfermedad más grave
LA ANEMIALA ANEMIA
PUEDE SER EL PRIMERPUEDE SER EL PRIMER
SIGNO de un paciente conSIGNO de un paciente con::
- ÚLCERA
- MIOMA
- CELAQUIA
- CÁNCER
- INSUFICIENCIA RENAL
- INSUFICIENCIA CARDÍACA
- APLASIA MÉDULA
- INFECCIÓN
- INTOXICACIÓN
28. Anemia
Pérdidas
de sangre
Menor vida
media de los
eritrocitos
Baja producción
de eritropoyetina
Resistencia
a la
eritropoyetina
Baja
disponibilidad de
hierro
Aumento
de pérdidas
Disminución de
la eritropoyesis
“Vampirismo”
Falta
nutrientes
Fisiopatología de la anemia
29. 20-30
mg/día
Músculo
(250 mg)
Médula ósea
(300 mg)
Eritrocitos
(2.000 mg)
Macrófagos SRE
(500 mg)
Hígado
(1000 mg)
Absorción intestinal de hierro
(1-2 mg/día)
Transferrina
(3 mg)
Pérdidas de hierro
(1-2 mg/día)
Fisiopatología de la anemia ferropénica
30. 20-30
mg/día
Músculo
(250 mg)
Médula ósea
(300 mg)
Eritrocitos
(2.000 mg)
Macrófagos SRE
(500 mg)
Hígado
(1000 mg)
Absorción intestinal de hierro
(1-2 mg/día)
Transferrina
(3 mg)
Pérdidas de hierro
(1-2 mg/día)
Fisiopatología de la anemia mixta
35. Anemia ferropénica
Datos epidemiológicos
• Prevalencia:
– Anemia ferropénica: ¼ población mundial (2.000 millones en todo
mundo)
– Déficit de hierro: 1/3 población mundial
– 2-5 % chicas adolescentes en EEUU anemia ferropénica.
– > 10% mujeres españolas (Cataluña) con ferropenia
• Etiología de la anemia ferropénica
– Mujer fértil causa más frecuente: ginecológica.
– Causa más frecuente global: pérdida hemática digestiva.
** Hasta 1/3 de pacientes con Enfermedad de Crohn,
tienen anemia (mala tolerancia a hierro oral).
39. Nutrient deficiencies in non-anaemic patients
referred to the preoperative autologous blood donation
program at University Hospital “Miguel Servet” (2003-2008)
Prosta-
tectomy
Liver
MTX
Adult
Orthop.
Scoliosis
Patients (n) 328 120 1488 96
Tf Sat <20% (%) 20 36 16 23
Ferritin < 30 mg/L (%) 8 15 12 16
Ferritin < 100 mg/L
+ CRP >10 mg/L (%)
21 30 21 9
Vit B12 < 270 pg/mL (%) 29 20 9 6
Folate < 3 ng/mL (%) 6 5 3 6
CRP > 10 mg/L (%) 63 53 37 11
Prevalencia de déficit férrico
en el cirugía programada
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ACTUALIZACIÓN DEL MANEJO DEL
PACIENTE CON ANEMIA
PERIOPERATORIA
RIESGOS DE LA ANEMIA
41. Prevalencia de anemia preoperatoria
Puntos clave:
• Entre el 20% y el 75% de los pacientes quirúrgicos pueden presentar
anemia preoperatoria debido a su patología quirúrgica o a otras
patologías.
• En el paciente quirúrgico, la anemia preoperatoria se asocia con
un mayor riesgo de TSA (La Hb es el principal factor predictor de
la necesidad de TSA)
42. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
TRANSFUSIÓN
Hb<120 G/L Hb 120-140 G/L Hb> 140 G/L
García-Erce JA, Solano VM, Cuenca J, Ortega P. “LA HEMOGLOBINA
PREOPERATORIA COMO ÚNICO FACTOR PREDICTOR DE LAS
NECESIDADES TRANSFUSIONALES EN LA ARTROPLASTIA DE
RODILLA”. Rev Esp Anestesiol Reanim 2002; 49: 131-5
NIVEL DE HEMOGLOBINA Y RIESGO TRANSFUSIONAL
FACTORES DE RIESGO TRANSFUSIONAL
43. Hb 130-140 g/l
100
75
62
46
25
0 20 40 60 80 100
%TRANSFUSION
Hb < 110 g/l Hb 110-120 g/l Hb 120-130 g/l
Hb > 140 g/l
García Erce JA, et al. FACTORES PREDICTIVOS DE LA NECESIDAD DE
TRANSFUSION EN LA FRACTURA SUBCAPITAL DE CADERA EN
PACIENTES DE MÁS DE 65 AÑOS. Med Clin (Barc) 2003;120(5):161-6.
NIVEL DE HEMOGLOBINA Y RIESGO TRANSFUSIONAL
FACTORES DE RIESGO TRANSFUSIONAL
46. Data for 227 425 patients, of whom 69 229 (30,44%) had
preoperative anaemia.
After adjustment, postoperative mortality at 30 days was
higher in patients with anaemia than in those without
anaemia (OR 1·42, 95% CI 1·31–1·54)
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ACTUALIZACIÓN DEL MANEJO DEL
PACIENTE CON ANEMIA
PERIOPERATORIA
¿CÓMO TRATAR LA ANEMIA?
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ACTUALIZACIÓN DEL MANEJO DEL
PACIENTE CON ANEMIA
PERIOPERATORIA
¿POR QUÉ SE TRANSFUNDE?
¿POR QUÉ SE DEBERÍA TRANSFUNDIR?
51. Criterios generales de indicación
Uso adecuado:
•Presencia de signos o síntomas de hipoxia
tisular
•Ausencia de tratamiento específico de la
anemia
•Refractariedad al tratamiento específico
•La situación clínica del paciente precisa
una reposición inmediata de la masa
eritrocitaria
Tratamiento transfusional
52. Criterios generales de indicación
Uso adecuado:
•Presencia de signos o síntomas de hipoxia
tisular
•Ausencia de tratamiento específico de la
anemia
•Refractariedad al tratamiento específico
•La situación clínica del paciente precisa
una reposición inmediata de la masa
eritrocitaria
Tratamiento transfusional
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ACTUALIZACIÓN DEL MANEJO DEL
PACIENTE CON ANEMIA
PERIOPERATORIA
¿MANEJO DIAGNÓSTICO?
54. “Lo primero que debemos hacer con un paciente
quirúrgico es detectar la presencia de anemia y
determinar su causas con la suficiente antelación
como para poder hacer algo con ella”
Goodnough LT et al . Anesth Analg 2005; 101: 1858-61
El tratamiento de la anemia preoperatoria ha demostrado
ser eficaz para reducir los requerimientos transfusionales
y mejorar la evolución postoperatoria y la calidad de vida
de los pacientes quirúrgicos.
Shander A et al. Am J Med 2004; 116 (suppl 7A): 58S-69S.
Manejo de la anemia preoperatoria
AUMENTO DE MASA ERITROCITARIA
55. Manejo de la anemia perioperatoria
“Siempre que sea clínicamente factible, en los pacientes programados
para una cirugía con alto riesgo de desarrollar anemia postoperatoria
grave, se debería determinar la hemoglobina y el status férrico, al
menos 30 días antes de la intervención. En los pacientes >60 años,
se deberían determinar también los niveles de vitamina B12 y folatos”.
56. Recommendation 1: We recommend that elective surgical
patients have an Hb level determination as close to 28 days
before the scheduled surgical procedure as possible (G1C).
Recommendation 3: We recommend that laboratory
testing be performed to further evaluate anaemia for
nutritional deficiencies, chronic renal insufficiency, and/or
chronic inflammatory disease (G1C).
57.
58.
59.
60.
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ACTUALIZACIÓN DEL MANEJO DEL
PACIENTE CON ANEMIA
PERIOPERATORIA
¿MANEJO TERAPÉUTICO?
63. Spanish Consensus Statement on
Alternatives to Allogeneic Blood Transfusions
“An update of Seville’s Document”
11th
Annual Symposium
Barcelone, Spain. April 8 - 9 , 2010
H
S E
H H
S E
H H
S E
H
64. AABT
Sangre autóloga
• Donacion preoperatoria
• Hemodilución
• Recuperación perioperatoria
Criterio restrictivo
de transfusión
Hb <70-80 g/L
Reducción del
sangrado
• Aprotinina
• Antifibrinoliticos
• Desmopresina
• rFVIIa
Estimulación de la
eritropoyesis
• Vitamina B12
• Acido Fólico
• rHuEpo
• Hierro
Alternativas
a la TSA
Alternativas a la
Transfusión Alogénica
65. Estimulación de la eritropoyesis
- Hierro (enteral o parenteral)(oral y ev)
- Agentes Estimulantes de la Eritropoyesis (rHuEpo
y darbopetina) (ESAs)
- Vitamina B12
- Acido Fólico
- Otras vitaminas
- Andrógenos
AUMENTO DE MASA ERITROCITARIA
66. Transferrin saturation <20%
1. Gastrointestinal or gynaecological evaluation
2. Reticulocyte counts, creatinine level, CRP
IDA1
Ferritin <30 µg/L
+ MCH <27 pg
ACD + ID3
Ferritin
30-100 µg/L
ACD2
Ferritin
>100 µg/L
3. sTfR/log Ft, hypochromic RBC, CHr
Hb <12-13
Treatment with
oral or IV iron
Hb <12 g/dL♀ - <13 g/dL ♂
Evaluate for comordibity and medication
Treatment with
ESAs
AUMENTO DE MASA ERITROCITARIA
67. Diagnóstico
1. Evaluación GI y/o ginecológica
2. Reticulocitos, creatinina, PCR
Hb <13 g/dL
Tto con
B12 / Folato
Sat. transferrina <20% Sat. transferrina >20%
AF1
Ferritina <30 µg/L
+ HCM <27 pg
ATC + F3
Ferritina
30-100 µg/L
ATC2
Ferritina
>100 µg/L
Vitamina B12 y Folato
Bajo
VCM >100 fL
Anemia
Macrocitica4
Normal
AI SMD4
3. sTfR/log Ft >2, hipocromos, CHr
4. Evaluación hematológica (Alcoholismo?)
Hb <13 g/dL
Tratamiento con
hierro oral o IV
Hb 10-13 g/dL
Evaluar sangrado estimado y comorbilidad
Tratamiento
con AEEs
1. Evaluación GI y/o ginecológica
2. Reticulocitos, creatinina, PCR
Hb <13 g/dL
Tto con
B12 / Folato
Sat. transferrina <20% Sat. transferrina >20%Sat. transferrina <20% Sat. transferrina >20%
AF1
Ferritina <30 µg/L
+ HCM <27 pg
ATC + F3
Ferritina
30-100 µg/L
ATC2
Ferritina
>100 µg/L
ATC2
Ferritina
>100 µg/L
Vitamina B12 y Folato
Bajo
VCM >100 fL
Anemia
Macrocitica4
Normal
AI SMD4
3. sTfR/log Ft >2, hipocromos, CHr
4. Evaluación hematológica (Alcoholismo?)
Hb <13 g/dL
Tratamiento con
hierro oral o IV
Hb 10-13 g/dL
Evaluar sangrado estimado y comorbilidad
Tratamiento
con AEEs
68.
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ACTUALIZACIÓN DEL MANEJO DEL
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PERIOPERATORIA
HIERRO
70. Estimulación de la eritropoyesis
- Hierro (enteral o parenteral)(oral y ev)
- Agentes Estimulantes de la Eritropoyesis (rHuEpo y
darbopetina) (ESAs)
- Vitamina B12
- Acido Fólico
- Otras vitaminas
- Andrógenos
AUMENTO DE MASA ERITROCITARIA
72. Este es un proceso que consume mucho tiempo:
• Una persona de 70 kg de peso con una Hb de 8.5 g/dL presenta un
déficit de hierro corporal de alrededor de 1400 - 1500 mg.
• Déficit Fe = [(14 – Hb) x 2.4 x Peso] + 500
• Incluso en presencia de este grado de anemia, la máxima absorción
de hierro sería de solo 10 mg/dia
• Por lo que se necesitarían unos 6 meses de terapia con hierro oral
para corregir el déficit de hierro de este paciente.
Unos cálculos matemáticos simples!!!:
si 1 g/dL Hb = 165 mg hierro,
ante una pérdida de 3–5 g/dL de Hb,
la pérdida de hierro será = 495 – 825 mg
y podríamos administrar hasta 600 mg de hierro sacarosa por semana
¡PERIODO INACEPTABLE EN ESTA CIRUGÍA!
Administración diaria de hierro oral?
AUMENTO DE MASA ERITROCITARIA
73. Hierro oral postoperatorioHierro oral postoperatorio
Administración de hierro oral
¡El hierro oral postoperatorio no aumenta la Hb!
Sulfato ferroso (200 mg/d) 3 semanas
Mundy et al. JBJS 2005; 87-B: 213-7
Sulfato ferroso (200 mg/d) 6 semanas
Sutton et al. JBJS 2004; 86-B: 31-3
Gluconato ferroso (325 mg/d) 10 semanas
Weatherall et al. ANZ J Surg 2004; 74: 1049-51
Sulfato ferroso (200 mg/d) 2 meses
Crosby et al. Heart Lung 1994; 23: 493-9
Sulfato ferroso (200 mg/3xd) 4 semanas (+0.76g/dl)
Prasad et al. Injury 2009;
40:1073-6 Sulfato ferroso (200 mg/2xd) 6 semanas
Parker. JBJS Am 2010; 92: 265-9
✔
AUMENTO DE MASA ERITROCITARIA
75. Esta indicación tiene en cuenta varios factores, como:
Intolerancia ó contraindicación al hierro oral (eg, EII).
Poco tiempo antes de la cirugía.
Anemia preoperatoria grave.
Uso de estimuladores de la eritropoyesis
Estado inflamatorio del paciente.
Sangrado perioperatorio estimado.
¿Cúal es el papel del hierro EV?
AUMENTO DE MASA ERITROCITARIA
76. Enfermedad Inflamatoria Intestinal (E. Chrön, Colitis Ulcerosa)
Cirugía Gastro-intestinal (Obesidad mórbida, gastrectomía, etc)
Ulcus péptico, hemorragia activa
Anemia perioperatoria (ginecológica, cáncer colon, urológica, etc)
Programas de autotransfusión predepósito
Anemia en paciente nefrológico
Anemia asociada a neoplasias o a quimioterapia
Anemia durante el embarazo ó el puerperio
Anemia e insuficiencia cardíaca
Síndrome de anemia cardiorrenal
Síndrome de piernas inquietas
Indicaciones del hierro EV?
Administración de FE EV
77.
78.
79. Nuevas preparaciones de hierro IV
Hierro
sacarosa
Hierro
dextrano de
bajo peso
molecular
(LMWID)
Carboxymaltosa
de hierro
Hierro
isomaltoside
1000
Nombre comercial Venofer® Cosmofer®
INFeD®
Ferinject®
Injectafer®
Monofer®
Tipo de complejo Tipo II Tipo I Tipo I Tipo I
Peso molecular (kD) 30-60 165 150 150
Volumen distribución inicial (L) 3.4 3.5 3.5 3.4
Semi-vida plasmática (h) 6 20 16 20
Liberación hierro lábil ± - - -
Donación directa a transferrina
(% dosis inyectada)
4-5 1-2 1-2 <1
Necesidad de dosis test SI/NO (1) SI NO NO
Dosis individual máxima (mg) 200 20 mg/kg 15 mg/kg
(max 1000 mg)
20 mg/kg
(max 2000 mg)
Efectos adversos graves
(x10
6
dosis)
0.6 3.3 (2) --- ---
Mortalidad (x10
6
dosis) 0.11 0.75 (2) --- ---
(1) La administración de dosis test sólo es necesaria en algunos países de Europa.
(2) Estas cifras han sido repetidamente criticadas ya que no en muchas de las comunicaciones de efectos adversos graves o
mortalidad no estuvo claro el compuesto utilizado (LMWID o HMWID).
80. Efectos tóxicos por hierro libre
Inmunogenicidad
Seguridad
alta
Hierro
gluconato
Seguridad
alta
Hierro
sacarosa
Hierro
dextrano
Necesidades
médicas
no cubiertas
Dosis limitadas
Dosis test
Administración lenta
Alta toxicidad
Sobresaturación Tf
Necrosis hepática Dosis altas
Dosis test
Administración lenta
Reacciones
anafilácticas
Dosis limitadas
Dosis test
Administración lenta
pH muy alcalino
Hierro
carboximaltosa
Dosis altas
No dosis test
Administración
rápida
No reacciones
anafilácticas
Algunas formulaciones de FEEV
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ACTUALIZACIÓN DEL MANEJO DEL
PACIENTE CON ANEMIA
PERIOPERATORIA
HIERRO EV
PREOPERATORIO
85. A multicentre comparative study on the efficacy of intravenous
ferric carboxymaltose and iron sucrose for correcting preoperative
anaemia in patients undergoing major elective surgery. 2011
86.
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ACTUALIZACIÓN DEL MANEJO DEL
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PERIOPERATORIA
HIERRO EV
PERI-OPERATORIO
89. - Grade of recommendation: .
“For patients undergoing orthopaedic surgery expected to develop
severe postoperative anaemia we currently suggest IV iron
administration during the perioperative period”.
For all other surgeries no evidence-based recommendation can be
made. We strongly recommend that large prospective randomised
controlled trials are undertaken in patients undergoing surgery expected
to develop severe post operative anaemia.
Tratamiento perioperatorio
90.
91.
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ACTUALIZACIÓN DEL MANEJO DEL
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HIERRO EV
POST-OPERATORIO
94. Br J Anaesth. 2012 Mar;108(3):532-
Effects of postoperative intravenous iron on transfusion
requirements after lower limbarthroplasty.
Muñoz M, Naveira E, Seara J, Cordero J.
95.
96. Documento de Consenso:
Anemia en el paciente quirúrgico o crítico
Tratamiento farmacológico: hierro
• Igualmente sugerimos tratar los déficits de B12 y fólico, aún sin anemia.
En pacientes programados para ser sometidos a un
procedimiento de cirugía mayor (especialmente ortopédico o
traumatológico) con alta probabilidad de desarrollar anemia
postoperatoria moderada o grave sugerimos la administración de
hierro endovenoso durante el período perioperatorio o
postoperatorio inmediato para disminuir el porcentaje de
pacientes expuestos a la TSA, y conseguir una más rápida
corrección de la anemia.
2B
AUMENTO DE MASA ERITROCITARIA
97. Conclusions:
The substantial Hb increase and stabilisation at 11–12 g/dl
in FCM-treated patients suggest a role for i.v. iron alone in
anaemia correction in cancer patients.
98.
99.
100.
101. Los hierros ev aumentan las
infecciones
Errores, falacias y otras leyendas urbanas
102. Se ha estudiado a 286 pacientes, de los que el 26,1% desarrolló IN, siendo
la infección urinaria la más frecuente. Los valores descendidos de Hb o
ferritina al ingresar, así como los valores elevados de ASA, se asociaron a
un mayor riesgo de desarrollo de IN. El número de concentrados de
hematíes transfundidos también se asoció a un aumento del riesgo de
infección. No se encontró relación entre la administración de hierro
intravenoso y la IN.
CONCLUSIONES: La hemoglobinemia, la ferropenia y la TSA son
factores asociados al riesgo de IN en fracturas de cadera.
104. Autor, año N Tipo de
Fractura
Hierro IV
(mg)
Transfusión,
n (%)
Infección,
n (%)
Mortalidad 30d,
n (%)
Control
Cuenca, 2004 102 FPC --- 57 (55.9) 34 (33.3) 17 (16.7)
Cuenca, 2004 57 FSC --- 21 (36.8) 19 (33.3) 11 (19.3)
García-Erce, 2005 41 FPC, FSC --- 29 (70.7) 13 (31.4) 6 (14.6)
TOTAL 200 107 (53.5) 68 (34) 34 (17.0)
Hierro sacarosa
Cuenca, 2004 23 #
FPC 100 9 (39.1) 6 (26.1)* 3 (13.0)
Cuenca, 2004 55 #
FPC 200 – 300 24 (43.6) 9 (16.4)* 5 (8.9)
Cuenca, 2004 20 FSC 200 – 300 3 (15.0) 3 (15.0)* 0 (0.0)*
García-Erce, 2005 83 FPC, FSC 600##
20 (24.1)* 10 (12.5)* 6 (7.2)
TOTAL 181 56 (30.9)* 27 (14.9)* 14 (7.7)
RR [IC95%]
(p)
0,58 [0,45-0,74]
(p<0,001)
0,44 [0,29-0,65]
P<,001
0,45 [0,25-0,82]
(p:0,0065)
0
10
20
30
40
50
60
Control
Hierro sacarosa
*P<0.05
Pacientes(%)
*
*
*
Seguridad del hierro sacarosa: Meta-analisis: El análisis revela un
descenso significativo en la tasa de transfusión, de infección y de mortalidad
105. E. Naveira1
, S. Gómez2
, J. Seara3
, J. Cordero3
, F. Martos4
, M. Muñoz5
1
Cuidados Postoperatorios, 3
Cirugía Ortopédica y 4
Anestesiología, Clínica Santa Elena,
Torremolinos, Málaga; 2
Medicina Interna, HCU Virgen de la Victoria, Málaga;
5
Medicina Transfusional, Facultad de Medicina, Málaga.
Infección nosocomial tras cirugía protésicaInfección nosocomial tras cirugía protésica
del miembro inferior:del miembro inferior:
Posible efecto protector de la administraciónPosible efecto protector de la administración
postoperatoria de hierro intravenoso.postoperatoria de hierro intravenoso.
106. Br J Anaesth. 2012 Mar;108(3):532-
Effects of postoperative intravenous iron on transfusion
requirements after lower limbarthroplasty.
Muñoz M, Naveira E, Seara J, Cordero J.
107. Clinical investigation
Very short term perioperative intravenous iron
administration and postoperative outcome in major
orthopaedic surgery: a pooled analysis of
observational data from 2547 patients.
Susana Gómez-Ramírez1, Jorge Cuenca2, José Antonio García-Erce3, Daniel
Ariza4, Enrique Naveira5, Manuel Muñoz6.
• Methods.
• Perioperative data from 2547 patients, undergoing lower
limb arthroplasty (n=1186) or hip fracture repair (n=1361)
at four different centres were pooled in two databases.
Patients received very short term perioperative IV iron
(200-600 mg; n=1538), with or without recombinant
erythropoietin (40,000 IU), or standard treatment
(n=1009), and data on ABT, PNI, 30d mortality and
length of hospital stay (LHS) were comparatively
analyzed.
108. Very short term perioperative intravenous iron
administration and postoperative outcome in major
orthopaedic surgery: a pooled analysis of
observational data from 2547 patients.
Total patients
(n=2633)
• Patientsexcluded(Hb<10 g/d)l: 86
109. Very short term perioperative intravenous iron
administration and postoperative outcome in major
orthopaedic surgery: a pooled analysis of
observational data from 2547 patients.
• Results:
• Compared to standard therapy, perioperative IV
iron reduced rates of ABT (48.8% vs. 32.4%;
p=0.001), PNI (26.9% vs. 10.7%; p=0.001)
and 30d mortality (9.4% vs. 4.8%; p=0.003),
and the length of hospital stay (LHS; 13.4 days
vs. 11.9 days; p=0.001) in hip fracture patients.
110.
111. Interpretation:
Iron supplementation should be considered for women with
unexplained fatigue who have ferritin levels below 50 μg/L.
We suggest assessing the efficiency using blood markers
after six weeks of treatment.
Trial registration no. EudraCT 2006–000478–56.
113. www.awge.org
Evitar la trasfusión: una opción con criterio
V Curso Medicina Transfusional
ACTUALIZACIÓN DEL MANEJO DEL
PACIENTE CON ANEMIA
PERIOPERATORIA
ERITROPOYETINA
114. Estimulación de la eritropoyesis
- Hierro (enteral o parenteral)(oral y ev)
- Agentes Estimulantes de la Eritropoyesis (rHuEpo
y darbopetina) (ESAs)
- Vitamina B12
- Acido Fólico
- Otras vitaminas
- Andrógenos
AUMENTO DE MASA ERITROCITARIA
115. 208 patients undergoing elective primary or revision hip arthroplasty
were randomised to 3 groups. All received daily sc injections of
either EPO or placebo starting 10 days before surgery. Group 1 (78
patients) received 14 days of placebo, group 2 (77 patients) received
14 days of erythropoietin (300 units/kg to a maximum of 30 000
units), and group 3 (53 patients) received placebo for days 10 to 6
before surgery and EPO for the next 9 days.
A primary outcome event (any transfusion or a Hb < 80 g/L) occurred
in 46% of patients in group 1, 23% in group 2, and 32% in group 3
(p<0,003). The mean number of transfusions was 1,4 in group 1, 0,52
in group 2 y 0,70 in group 3.
AUMENTO DE MASA ERITROCITARIA
116. Tratamiento
rHuEPO en cirugía ortopédica programada
Estudio multicéntrico aleatorizado y controlado (Hb 10 – 13 g/dL)
• Grupo 1 (n = 458): rHuEPO 4 × 40 000 IU sc + hierro oral
• Grupo 2 (n = 235): placebo + hierro oral
Weber et al. Eur J Anaesth 2005; 22: 249-57
TRANSFUSIÓN ALOGÉNICAEVOLUCIÓN HEMOGLOBINA
12.2* 45.5
120. www.awge.org
Evitar la trasfusión: una opción con criterio
V Curso Medicina Transfusional
ACTUALIZACIÓN DEL MANEJO DEL
PACIENTE CON ANEMIA
PERIOPERATORIA
ERITROPOYETINA
¿DUDAS?
121. Tratamiento
rHuEPO en cirugía ortopédica programada
Fegan et al. Ann Int Med 2000; 133: 845-854
● Control
■ EPO 20.000 UI/semana
▲ EPO 40.000 UI/semana
Evolución del nivel de hemoglobina
122. Tratamiento
rHuEPO en cirugía ortopédica programada
Evolución del nivel de hematocrito
Tto: rHuEPO (40.000 U/semana) + hierro oral (200 mg/dia)
Rosencher et al. Can J Anesth 2005; 52:160-5
123. 20-30
mg/día
Músculo
(250 mg)
Médula ósea
(300 mg)
Eritrocitos
(2.000 mg)
Macrófagos SRE
(500 mg)
Hígado
(1000 mg)
Absorción intestinal de hierro
(1-2 mg/día)
Transferrina
(3 mg)
Pérdidas de hierro
(1-2 mg/día)
Hierro EV
AUMENTO DE MASA ERITROCITARIA
130. Actualización Documento Sevilla
ATSA Tratamiento de la anemia perioperatoria
Siempre que sea clínicamente factible, en los pacientes
programados para cirugía recomendamos investigar la
presencia de anemia preoperatoria, preferiblemente al menos
30 días antes de la intervención, para realizar su diagnóstico
diferencial e instaurar el tratamiento adecuado, si procede.
1C
• Obviamente, aunque esta recomendación no es aplicable al paciente
sometido a cirugía no electiva ni al paciente crítico, la detección de la
anemia y su posterior diagnóstico diferencial deberían realizarse lo
más precozmente posible
Diagnóstico
131. Actualización Documento Sevilla
ATSA Tratamiento de la anemia perioperatoria
En pacientes programados para cirugía electiva sugerimos la
administración preoperatoria de hierro oral para mejorar el
nivel de hemoglobina preoperatoria y reducir el porcentaje de
pacientes que reciben TSA.
Tratamiento farmacológico: hierro
2B
No recomendamos la administración de hierro oral como
tratamiento de la anemia postoperatoria en pacientes sin
anemia ferropénica o ferropenia previas a la intervención.
1B
132. Actualización Documento Sevilla
ATSA Tratamiento de la anemia perioperatoria
Tratamiento farmacológico: hierro
En pacientes anémicos programados para cirugía mayor,
sugerimos la administración preoperatoria de hierro
intravenoso para reducir la tasa transfusional
2B
• Intolerancia a o contraindicación para hierro oral.
• Poco tiempo antes de la cirugía.
• Anemia preoperatoria moderada-grave.
• Uso de estimuladores de la eritropoyesis.
• Estado inflamatorio del paciente.
• Sangrado perioperatorio estimado moderado-alto.
133. Actualización Documento Sevilla
ATSA Tratamiento de la anemia perioperatoria
Tratamiento farmacológico: hierro
• Este tratamiento puede conseguir una más rápida corrección de
la anemia postoperatoria.
• Igualmente sugerimos tratar los déficits de vitamina B12 y ácido
fólico, aún sin anemia.
En pacientes de cirugía mayor con alta probabilidad de
desarrollar anemia postoperatoria moderada o grave
sugerimos la administración de hierro endovenoso durante el
período perioperatorio o postoperatorio inmediato para
disminuir el porcentaje de pacientes expuestos a la TSA.
2B
134. Actualización Documento Sevilla
ATSA Tratamiento de la anemia perioperatoria
Tratamiento farmacológico: hierro
Recomendamos el tratamiento con Fe IV para la corrección
de la anemia y la disminución de la tasa transfusional en
pacientes con anemia postparto moderada ó grave,
enfermedad inflamatoria intestinal y en pacientes
oncológicos que reciben quimioterapia/radioterapia
1B
La evidencia disponible no permite hacer recomendaciones
sobre el uso de hierro en pacientes críticos, siendo urgente
la realización de estudios sobre el uso de hierro oral y
parenteral en este colectivo de pacientes.
0
135. Actualización Documento Sevilla
ATSA Tratamiento de la anemia perioperatoria
Tratamiento farmacológico: Eritropoyetina
Recomendamos la administración de rHuEPO como coad-
yuvante de la donación autóloga en pacientes a los que se
les solicita un predepósito de ≥3 unidades.
1A
Recomendamos la administración preoperatoria o
periperatoria de eritropoyetina recombinante humana
(rHuEPO) en los pacientes de cirugía ortopédica programada
con anemia (Hb entre 10 y 13 g/dL) y sangrado moderado-
alto para reducir la exposición a TSA.
1A
136. Actualización Documento Sevilla
ATSA Tratamiento de la anemia perioperatoria
Tratamiento farmacológico: Eritropoyetina
Sugerimos el uso de rHuEPO en pacientes quirurgicos no
ortopédicos (e.g., cirugía cardíaca, cáncer de colon), para
reducir la tasa transfusional.
2A
• No obstante, hay que recordar que se trataría de un uso "off-label" de la
rHuEPO
• Algunos autores han cuestionado su seguridad en estos pacientes a pesar
de ser una terapia a corto plazo.
No recomendamos el uso de rHuEPO para el tratamiento de
la anemia en pacientes críticos que no tengan una indicación
previa para éste fármaco (e.g., insuficiencia renal crónica),
con la posible excepción de los pacientes ingresados por
traumatismos, especialmente con TCE grave.
1A
Notas del editor
Even though blood transfusion has been used for over 100 years there is little evidence of it’s efficacy in many clinical situations. Blood transfusion should only be prescribed to increase the oxygen consumption, and there are many reasons supporting this statement
The Spanish version of the consensus was published in 2006
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
&lt;number&gt;
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
&lt;number&gt;
&lt;number&gt;
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
&lt;number&gt;
Destacar que la anemia ferropénica es un problema de salud muy importante; Datos de la OMS afirman que ¼ de la población mundial sufre anemia ferropénica y hasta 1/3, déficit de hierro. Por ejemplo, en 1997 se cifró la prevalencia de la anemia ferropénica en adolescentes americanas en torno al 2-5 %.
En cuanto a la etiología, excepto en las mujeres en edad fértil, en las que la causa ginecológica es la más frecuente, en el resto de la población, la causa más habitual son las pérdidas por vía digestiva. Además, y muy importante para nosotros los digestólogos, hay un grupo especial de enfermos, aquellos afectos de EICI, en los que la anemia es muy frecuente y tienen como particularidad, una especial mala tolerancia al hierro oral, incluso puede precipitar brotes de la enfermedad.
La anemia influye muy negativamente en la calidad de vida de los pacientes aunque está demostrado que el médico (al menos el Digestólogo) infravalora este hecho.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Even though blood transfusion has been used for over 100 years there is little evidence of it’s efficacy in many clinical situations. Blood transfusion should only be prescribed to increase the oxygen consumption, and there are many reasons supporting this statement
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
&lt;number&gt;
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
The Spanish version of the consensus was published in 2006
Even though blood transfusion has been used for over 100 years there is little evidence of it’s efficacy in many clinical situations. Blood transfusion should only be prescribed to increase the oxygen consumption, and there are many reasons supporting this statement
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
&lt;number&gt;
The Spanish version of the consensus was published in 2006
&lt;number&gt;
&lt;number&gt;
The Spanish version of the consensus was published in 2006
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
The Spanish version of the consensus was published in 2006
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006
The Spanish version of the consensus was published in 2006