Coloides perioperatorios: de la teoría a la práctica / Perioperative colloids: From theory to practice

Introducción: La administración intravenosa de fluidos constituye un elemento fundamental en la reanimación de pacientes con hipovolemia. Las guías clínicas restringen el uso de coloides en favor de los cristaloides. Actualmente, no conocemos con exactitud cuál es la práctica clínica habitual al respecto durante el periodo perioperatorio. El objetivo del presente estudio es describir el uso perioperatorio de coloides y analizar las posibles causas que motivan su utilización. Material y métodos: Estudio observacional, transversal, multicéntrico. Subanálisis del estudio Fluid Day. Se incluyeron todos los pacientes mayores de 18 años sometidos a cirugía durante las 24h de los 2 días del estudio (18 y 20 de febrero de 2019). Se registraron datos demográficos, comorbilidades, datos referentes al acto anestésico y el procedimiento quirúrgico, fluidos administrados, sangrado perioperatorio y tipo de monitorización utilizado durante el periodo perioperatorio. Resultados: Se analizaron 5.928 casos. Un total de 542 pacientes (9,1%) recibieron algún tipo de coloides, siendo el hidroxietilalmidón el más utilizado (5,1%). Los pacientes que recibieron coloides tuvieron intervenciones más prolongadas (150 [90-255] vs. 75 [45-120] min), fueron intervenidos de urgencia (13,7 vs. 7,5%) y se clasificaron como de alto riesgo (22 vs. 4,8%) más frecuentemente. Su recuperación inmediata mayoritariamente transcurrió en unidades de críticos (45,1 vs.15,8%). Los pacientes que presentaron una hemorragia menor de 500ml recibieron coloides en un 5,9% frente al 45,9% cuando se superó esta cifra. Los pacientes que recibieron coloides presentaban anemia más frecuentemente: 29,4 vs. 16,3%. La administración de coloides supuso un mayor riesgo de transfusión (OR 15,7). La monitorización avanzada también aumentó la probabilidad de administrar coloides (OR 9,43). Conclusiones: En nuestro medio y en condiciones de práctica clínica habitual, la utilización de los coloides es escasa...(AU)

Introduction: Fluid administration is the cornerstone in hypovolemic patient's reanimation. Clinical guidelines restrict colloid administration favouring crystalloids. Currently, we don’t know exactly which is the daily clinical practice during the perioperative period. The objective of this study is to describe perioperative use of colloids analysing possible reasons aiming to use them. Material and Methods: Prospective, cross-section, national, multicentre observational study. Fluid Day sub-study. We enrolled all patient's older than 18 years old who underwent surgery during the 24h of the 2-days study (February, 2019, 18th and 20th). We registered demographic data, comorbidities, anaesthetic and surgical procedure data, fluids administered, perioperative bleeding and monitoring type used during the perioperative period. Results: A total of 5928 cases were analysed and 542 patients (9.1%) received any type of colloids, being hydroxiethyl-starch the most frequently used (5.1%). Patients receiving colloids suffered more longing surgery (150 [90-255] vs. 75 [45-120] min), were urgently operated (13.7 vs. 7.5%) and were more frequent classified as high risk (22 vs. 4.8%). Their recovery was mostly in critical care units (45.1 vs.15.8%). Patients with bleeding less than 500mL received colloids in a percentage of 5.9 versus 45.9% when this figure was overcome. Patients who received colloids were anaemic more frequently: 29.4 vs. 16.3%. Colloids administration had a higher risk for transfusion (OR 15.7). Advanced monitoring also increased the risk for receiving colloids (OR 9.43). Conclusions: In our environment with routine clinical practice, colloids administration is limited and close linked to perioperative bleeding.(AU)

Perioperative colloids: From theory to practice.

INTRODUCTION: Fluid administration is the cornerstone in hypovolemic patient's reanimation. Clinical guidelines restrict colloid administration favouring crystalloids. Currently, we don't know exactly which is the daily clinical practice during the perioperative period. The objective of this study is to describe perioperative use of colloids analysing possible reasons aiming to use them. MATERIAL AND METHODS: Prospective, cross-section, national, multicentre observational study. Fluid Day sub-study. We enrolled all patient's older than 18 years old who underwent surgery during the 24 h of the 2-days study (February, 2019, 18th and 20th). We registered demographic data, comorbidities, anaesthetic and surgical procedure data, fluids administered, perioperative bleeding and monitoring type used during the perioperative period. RESULTS: A total of 5928 cases were analysed and 542 patients (9.1%) received any type of colloids, being hydroxiethyl-starch the most frequently used (5.1%). Patients receiving colloids suffered more longing surgery (150 [90-255] vs. 75 [45-120] min), were urgently operated (13.7 vs. 7.5%) and were more frequent classified as high risk (22 vs. 4.8%). Their recovery was mostly in critical care units (45.1 vs.15.8%). Patients with bleeding less than 500 ml received colloids in a percentage of 5.9 versus 45.9% when this figure was overcome. Patients who received colloids were anaemic more frequently: 29.4 vs. 16.3%. Colloids administration had a higher risk for transfusion (OR 15.7). Advanced monitoring also increased the risk for receiving colloids (OR 9.43). CONCLUSIONS: In our environment with routine clinical practice, colloids administration is limited and close linked to perioperative bleeding.

Bloqueo del plano del erector espinal en L4 en cirugía de artrodesis lumbar: serie de casos / L4 erector spinal plane block after lumbar spine arthrodesi: a case-series

INTRODUCCIÓN: El bloqueo en el plano del erector espinal (erector spinae plane [ESP]) a nivel torácico se ha desarrollado en los últimos años en multitud de procedimientos quirúrgicos, incluido los pacientes tratados mediante artrodesis lumbar. Nos propusimos evaluar el efecto analgésico del ESP realizado a nivel lumbar L4 en el postoperatorio inmediato en pacientes intervenidos por artrodesis lumbar. MÉTODOS Y CASOS CLÍNICOS: Descripción de una serie de 8 casos clínicos intervenidos por artrodesis lumbar a quienes se les realizó un bloqueo del ESP lumbar bilateral en L4 con 20 ml de ropivacaína al 0,2% por lado. Se describió la intensidad del dolor durante las primeras 48 h del postoperatorio mediante escala visual analógica y la analgesia de rescate empleada. El dolor postoperatorio en reposo fue controlado en todos los pacientes (entre 0 y 3), si bien el dolor en movimiento fue considerado entre leve y severo según los pacientes (entre 0 y 8). El consumo de rescate fue entre 1 y 22mg de morfina. CONCLUSIONES: El ESP lumbar parece contribuir al control del dolor postoperatorio inmediato durante las primeras 48 h en pacientes intervenidos por artrodesis lumbar

INTRODUCTION: Thoracic erector spinae plane block is now performed in many different surgical procedures, including lumbar spinal fusion. We evaluated the analgesic effect of lumbar ESP performed at L4 after lumbar spinal fusion surgery. METHODS AND CASE SERIES: Eight patients scheduled for lumbar spinal fusion were included in the case series. Erector spinae plane block was performed at L4 preoperatively, administering 20 ml of 0.2% ropivacaine on each side. We recorded patient-reported pain intensity during the first 48 postoperative hours using a visual analogue scale (VAS) and rescue analgesia requirements. Pain at rest was controlled in all patients (VAS 0 to 3), although pain on movement ranged from mild to severe (VAS 0 to 8). Rescue analgesia consumption ranged from 1 to 22mg morphine. CONCLUSIONS: Lumbar ESP appears to contribute to pain control during the first 48hours after lumbar spinal fusion

L4 erector spinal plane block after lumbar spine arthrodesi: A case-series. / Bloqueo del plano del erector espinal en L4 en cirugía de artrodesis lumbar: serie de casos.

INTRODUCTION: Thoracic erector spinae plane block is now performed in many different surgical procedures, including lumbar spinal fusion. We evaluated the analgesic effect of lumbar ESP performed at L4 after lumbar spinal fusion surgery. METHODS AND CASE SERIES: Eight patients scheduled for lumbar spinal fusion were included in the case series. Erector spinae plane block was performed at L4 preoperatively, administering 20ml of 0.2% ropivacaine on each side. We recorded patient-reported pain intensity during the first 48 postoperative hours using a visual analogue scale (VAS) and rescue analgesia requirements. Pain at rest was controlled in all patients (VAS 0 to 3), although pain on movement ranged from mild to severe (VAS 0 to 8). Rescue analgesia consumption ranged from 1 to 22mg morphine. CONCLUSIONS: Lumbar ESP appears to contribute to pain control during the first 48hours after lumbar spinal fusion.

Foro de debate: seguridad de las alternativas a la transfusión alogénica en el paciente quirúrgico y/o crítico / Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient

Estos últimos años han aparecido alertas de seguridad, no siempre bien sustentadas, que cuestionan el uso de algunas alternativas farmacológicas a la transfusión de sangre alogénica y/o lo restringen en indicaciones establecidas. Asistimos también a la preconización de otras alternativas, incluyendo productos hemáticos y fármacos antifibrinolíticos, sin que haya una base científica sólida que lo justifique. Por iniciativa del Grupo de Estudios Multidisciplinares sobre Autotransfusión y del Anemia Working Group España se reunió a un panel multidisciplinar de 23 expertos del área de cuidados de la salud en un foro de debate para: 1) analizar las diferentes alertas de seguridad en torno a ciertas alternativas a la transfusión; 2) estudiar los antecedentes que las han propiciado, la evidencia que las sustentan y las consecuencias que conllevan para la práctica clínica, y 3) emitir una valoración argumentada de la seguridad de cada alternativa a la transfusión cuestionada, según el uso clínico de la misma. Los integrantes del foro mantuvieron contactos por vía telemática y una reunión presencial en la que presentaron y discutieron las conclusiones sobre cada uno de los elementos examinados. Se elaboró un primer documento que fue sometido a 4 rondas de revisión y actualización hasta alcanzar un consenso, unánime en la mayoría de los casos. Presentamos la versión final del documento, aprobada por todos los miembros del panel, esperando sea de utilidad para nuestros colegas

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues

[Implementation of blood sparing programs in Spain: results of a survey of departments of anesthesiology and resuscitation]. / Implementación de los programas de ahorro de sangre en España: resultados de la encuesta a los servicios de anestesiología y reanimación.

The objective of this article is to determine the availability of a perioperative transfusion management program (Patient Blood Management [PBM]) in various hospitals through a survey that included a description of the preanesthesia visit, the availability and use of the various blood-sparing techniques and the factors limiting their implementation in elective surgery. The survey included 42 questions, directed at the representative departments of anesthesiology of hospitals in Spain (n=91). The survey was conducted from September to November 2012. We analyzed the 82 surveys in which all the questions were answered (90%). Preoperative consultations are routinely performed (>70%) in 87% of the hospitals. The time from the consultation to surgery varied between 1 week and 2 months for 74% of the patients scheduled for orthopedic or trauma surgery, 78% of those scheduled for oncologic surgery and 77% of those scheduled for cardiac surgery. Almost all hospitals (77, 94%) had a transfusion committee, and 90% of them had an anesthesiologist on the committee. Seventy-nine percent of the hospitals had a blood-sparing program, and the most widely used technique was the use of antifibrinolytic agents (75% of hospitals), followed by intraoperative and postoperative blood recovery in equal proportions (67%). Optimization of preoperative hemoglobin was routinely performed with intravenous iron in 39% of the hospitals and with recombinant erythropoietin in 28% of the hospitals. The absence of a well-established circuit and the lack of involvement and collaboration with the surgical team were the main limiting factors in implementing PBM. Currently, the implementation of PBM in Spain could be considered acceptable, but it could also be improved, especially in the treatment of preoperative anemia. The implementation of PBM requires multidisciplinary collaboration among all personnel responsible for perioperative care, including the health authorities.

[The first pillar of patient blood management. Types of anemia and diagnostic parameters]. / Primer pilar del "Patient Blood Management". Tipos de anemia y parámetros diagnósticos.

Patient Blood Management (PBM) is the design of a personalized, multimodal multidisciplinary plan for minimizing transfusion and simultaneously achieving a positive impact on patient outcomes. The first pillar of PBM consists of optimizing the erythrocyte mass. The best chance for this step is offered by preoperative preparation. In most cases, a detailed medical history, physical examination and laboratory tests will identify the cause of anemia. A correct evaluation of parameters that assess the state and function of iron, such as ferritin levels, and the parameters that measure functional iron, such as transferrin saturation and soluble transferrin receptor levels, provide us with essential information for guiding the treatment with iron. The new blood count analyzers that measure hypochromia (% of hypochromic red blood cells and reticulocyte hemoglobin concentrations) provide us useful information for the diagnosis and follow-up of the response to iron treatment. Measuring serum folic acid and vitamin B12 levels is essential for treating deficiencies and thereby achieving better hemoglobin optimization.

[Algorithm for treating preoperative anemia]. / Algoritmo para el tratamiento de la anemia preoperatoria.

Hemoglobin optimization and treatment of preoperative anemia in surgery with a moderate to high risk of surgical bleeding reduces the rate of transfusions and improves hemoglobin levels at discharge and can also improve postoperative outcomes. To this end, we need to schedule preoperative visits sufficiently in advance to treat the anemia. The treatment algorithm we propose comes with a simple checklist to determine whether we should refer the patient to a specialist or if we can treat the patient during the same visit. With the blood count test and additional tests for iron metabolism, inflammation parameter and glomerular filtration rate, we can decide whether to start the treatment with intravenous iron alone or erythropoietin with or without iron. With significant anemia, a visit after 15 days might be necessary to observe the response and supplement the treatment if required. The hemoglobin objective will depend on the type of surgery and the patient's characteristics.

[Optimization of preoperative hemoglobin levels in patients without anemia and/or patients who undergo surgery with high blood loss]. / Optimización de la hemoglobina preoperatoria en pacientes no anémicos y/o sometidos a cirugía de elevada pérdida hemática.

To minimize allogeneic blood transfusions (ABTs) during complex surgery and surgery with considerable blood loss risk, various blood-sparing techniques are needed (multimodal approach). All surgical patients should be assessed with sufficient time to optimize hemoglobin levels and iron reserves so that the established perioperative transfusion strategy is appropriate. Even if the patient does not have anemia, improving hemoglobin levels to reduce the risk of ABT is justified in some cases, especially those in which the patient refuses a transfusion. Treatment with iron and/or erythropoietic agents might also be justified for cases that need a significant autologous blood reserve to minimize ABT during surgery with considerable blood loss.

[Treatment of anemia in patients undergoing bariatric surgery]. / Tratamiento de la anemia en pacientes intervenidos de cirugía bariátrica.

Iron deficiency in patients with morbid obesity can occur before bariatric surgery due to its inflammatory component and after surgery as the result of implementing the malabsorptive techniques. For patients with morbid obesity, micronutrient deficiencies, such as vitamin B12, iron and folate, should be suspected. Iron deficiency and other hematinics should be corrected, even when anemia has not been established. Normal ferritin levels do not allow us to rule out a possible iron deficiency, given that ferritin can increase due to the chronic inflammatory condition of obesity. After bariatric surgery, patients should take iron supplements; however, these supplements are frequently poorly tolerated. Rapid and effective correction of hemoglobin levels might require the intravenous administration of iron preparations.

Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient.

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues.

Optimización del paciente quirúrgico con riesgo de transfusión. «Patient Blood Management»: el nuevo paradigma de la medicina perioperatoria / Optimization of surgical patients at risk of transfusion. Patient blood management: the new paradigm of perioperative medicine

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Implementación de los programas de ahorro de sangre en España: resultados de la encuesta a los servicios de anestesiología y reanimación / Implementation of blood sparing programs in Spain: results of a survey of departments of anesthesiology and resuscitation

El objetivo de este artículo es conocer la disponibilidad de un programa de gestión de la transfusión perioperatoria («Patient Blood Management») en distintos hospitales a través de una encuesta que incluía una descripción de la visita preanestésica, la disponibilidad y utilización de las diferentes técnicas de ahorro de sangre y los factores limitantes de su implementación para cirugía programada. La encuesta constaba de 42 preguntas dirigidas a servicios de anestesiología representativos de los hospitales del territorio español (n = 91), y se realizó durante los meses de septiembre a noviembre de 2012. Fueron analizadas las 82 encuestas que contestaron a todas las preguntas (90%). La consulta preoperatoria se realizó de forma habitual (> 70%) en el 87% de los hospitales. El tiempo desde la consulta hasta la cirugía osciló entre 1 semana y 3 meses en el 74% de pacientes programados para cirugía ortopédica y traumatológica, en el 78% de cirugía oncológica y en el 77% de cirugía cardíaca. Casi la totalidad de hospitales, 77 (94%), disponen de comité de transfusión, con presencia del anestesiólogo en el 90% de ellos. Se dispone de un programa de ahorro de sangre en el 79% de los hospitales y la técnica más frecuentemente utilizada es el uso de antifibrinolíticos en el 75% de los hospitales, seguida de la recuperación de sangre intra y postoperatoria en parecida proporción (67%). La optimización de la hemoglobina preoperatoria se realiza con hierro intravenoso de forma habitual en el 39% de los hospitales y con eritropoyetina recombinante en el 28%. La ausencia de un circuito bien establecido y la falta de implicación y colaboración con el equipo quirúrgico se presentan como los principales factores limitantes de la implantación del «Patient Blood Management». En la actualidad, su aplicación en España se puede considerar aceptable, pero podrían mejorarse aspectos, especialmente en el tratamiento de la anemia preoperatoria. La implementación del «Patient Blood Management» requiere colaboración multidisciplinar de todo el personal responsable de la atención perioperatoria, incluidas las autoridades sanitarias (AU)

The objective of this article is to determine the availability of a perioperative transfusion management program (Patient Blood Management [PBM]) in various hospitals through a survey that included a description of the preanesthesia visit, the availability and use of the various blood-sparing techniques and the factors limiting their implementation in elective surgery. The survey included 42 questions, directed at the representative departments of anesthesiology of hospitals in Spain (n=91). The survey was conducted from September to November 2012. We analyzed the 82 surveys in which all the questions were answered (90%). Preoperative consultations are routinely performed (>70%) in 87% of the hospitals. The time from the consultation to surgery varied between 1 week and 2 months for 74% of the patients scheduled for orthopedic or trauma surgery, 78% of those scheduled for oncologic surgery and 77% of those scheduled for cardiac surgery. Almost all hospitals (77, 94%) had a transfusion committee, and 90% of them had an anesthesiologist on the committee. Seventy-nine percent of the hospitals had a blood-sparing program, and the most widely used technique was the use of antifibrinolytic agents (75% of hospitals), followed by intraoperative and postoperative blood recovery in equal proportions (67%). Optimization of preoperative hemoglobin was routinely performed with intravenous iron in 39% of the hospitals and with recombinant erythropoietin in 28% of the hospitals. The absence of a well-established circuit and the lack of involvement and collaboration with the surgical team were the main limiting factors in implementing PBM. Currently, the implementation of PBM in Spain could be considered acceptable, but it could also be improved, especially in the treatment of preoperative anemia. The implementation of PBM requires multidisciplinary collaboration among all personnel responsible for perioperative care, including the health authorities (AU)

Primer pilar del «Patient Blood Management». Tipos de anemia y parámetros diagnósticos / The first pillar of patient blood management. Types of anemia and diagnostic parameters

Llamamos «Patient Blood Management» al diseño de un plan personalizado multimodal y multidisciplinar para minimizar la transfusión y, al mismo tiempo, conseguir un impacto positivo sobre la evolución de los pacientes. El primer pilar del «Patient Blood Management» incluye la optimización de la masa eritrocitaria, y la mejor oportunidad para esta acción la ofrece la preparación preoperatoria. Una historia clínica detallada, el examen físico y una determinación analítica identificarán, en la mayoría de casos, la causa de la anemia. Una correcta evaluación de los parámetros que valoran el estado y la función del hierro, como la ferritina, y los parámetros que miden el hierro funcional, como la saturación de la transferrina y el receptor soluble de la transferrina, nos aportan una información esencial para guiar el tratamiento con hierro. Los nuevos analizadores de hemograma que determinan la hipocromía (porcentaje de hematíes hipocrómicos y la concentración de hemoglobina reticulocitaria), nos aportan una información útil para el diagnóstico y seguimiento de la respuesta al tratamiento con hierro. La determinación de valores séricos de ácido fólico y vitamina B12 es fundamental para tratar los déficits y conseguir así una mejor optimización de la hemoglobina (AU)

Patient Blood Management (PBM) is the design of a personalized, multimodal multidisciplinary plan for minimizing transfusion and simultaneously achieving a positive impact on patient outcomes. The first pillar of PBM consists of optimizing the erythrocyte mass. The best chance for this step is offered by preoperative preparation. In most cases, a detailed medical history, physical examination and laboratory tests will identify the cause of anemia. A correct evaluation of parameters that assess the state and function of iron, such as ferritin levels, and the parameters that measure functional iron, such as transferrin saturation and soluble transferrin receptor levels, provide us with essential information for guiding the treatment with iron. The new blood count analyzers that measure hypochromia (% of hypochromic red blood cells and reticulocyte hemoglobin concentrations) provide us useful information for the diagnosis and follow-up of the response to iron treatment. Measuring serum folic acid and vitamin B12 levels is essential for treating deficiencies and thereby achieving better hemoglobin optimization (AU)

Algoritmo para el tratamiento de la anemia preoperatoria / Algorithm for treating preoperative anemia

La optimización de la hemoglobina o el tratamiento de la anemia preoperatoria en cirugía con riesgo moderado-alto de sangrado quirúrgico reduce la tasa de transfusión y puede mejorar la evolución postoperatoria, así como la hemoglobina al alta. Para ello se requiere programar una visita preoperatoria con suficiente antelación para poderla corregir. El algoritmo de tratamiento que proponemos se acompaña de un «check list» sencillo para saber si debemos remitir al paciente al especialista o podemos tratarlo en ese mismo momento. Con el hemograma, algún test complementario del metabolismo del hierro, un parámetro de inflamación y la tasa de filtrado glomerular podremos decidir si iniciar el tratamiento con hierro intravenoso solo o asociar eritropoyetina, con o sin hierro. En la anemia importante puede ser necesaria alguna visita de control a los 15 días, para ver la respuesta y complementar el tratamiento, si el paciente lo precisa. La hemoglobina objetivo dependerá del tipo de cirugía y las características del paciente (AU)

Hemoglobin optimization and treatment of preoperative anemia in surgery with a moderate to high risk of surgical bleeding reduces the rate of transfusions and improves hemoglobin levels at discharge and can also improve postoperative outcomes. To this end, we need to schedule preoperative visits sufficiently in advance to treat the anemia. The treatment algorithm we propose comes with a simple checklist to determine whether we should refer the patient to a specialist or if we can treat the patient during the same visit. With the blood count test and additional tests for iron metabolism, inflammation parameter and glomerular filtration rate, we can decide whether to start the treatment with intravenous iron alone or erythropoietin with or without iron. With significant anemia, a visit after 15 days might be necessary to observe the response and supplement the treatment if required. The hemoglobin objective will depend on the type of surgery and the patient’s characteristics (AU)

Optimización de la hemoglobina preoperatoria en pacientes no anémicos y/o sometidos a cirugía de elevada pérdida hemática / Optimization of preoperative hemoglobin levels in patients without anemia and/or patients who undergo surgery with high blood loss

Para minimizar la transfusión de sangre alogénica en cirugía compleja y con gran riesgo de pérdida hemática, es necesario disponer de varias técnicas de ahorro de sangre (abordaje multimodal). Todos los pacientes quirúrgicos deben ser evaluados con el tiempo suficiente para optimizar la hemoglobina y las reservas de hierro, para que la estrategia perioperatoria de transfusión establecida sea adecuada. En algunos casos, aunque el paciente no esté anémico, estará justificado mejorar el valor de hemoglobina para reducir el riesgo de transfusión de sangre alogénica, especialmente en los casos que por alguna razón la rechacen. También puede estar justificado tratar con hierro y/o agentes eritropoyéticos en los casos en que necesitemos una reserva de sangre autóloga importante para minimizar la transfusión de sangre alogénica en la cirugía de gran pérdida hemática (AU)

To minimize allogeneic blood transfusions (ABTs) during complex surgery and surgery with considerable blood loss risk, various blood-sparing techniques are needed (multimodal approach). All surgical patients should be assessed with sufficient time to optimize hemoglobin levels and iron reserves so that the established perioperative transfusion strategy is appropriate. Even if the patient does not have anemia, improving hemoglobin levels to reduce the risk of ABT is justified in some cases, especially those in which the patient refuses a transfusion. Treatment with iron and/or erythropoietic agents might also be justified for cases that need a significant autologous blood reserve to minimize ABT during surgery with considerable blood loss (AU)

Tratamiento de la anemia en pacientes intervenidos de cirugía bariátrica / Treatment of anemia in patients undergoing bariatric surgery

El déficit de hierro en los pacientes con obesidad mórbida puede presentarse tanto antes de la cirugía bariátrica, por su componente inflamatorio, como tras esta, a consecuencia de la realización de las técnicas malabsortivas. En el paciente con obesidad mórbida se debe sospechar deficiencias de micronutrientes, como vitamina B12, hierro y folatos. El déficit de hierro y otros hematínicos debería corregirse, aunque no se haya establecido una anemia. El valor normal de ferritina no permite descartar un posible déficit de hierro, ya que la ferritina puede incrementarse por el estado inflamatorio crónico de la obesidad. Tras la cirugía bariátrica, los pacientes deben recibir suplementos de hierro; sin embargo, estos son frecuentemente mal tolerados. Una corrección rápida y efectiva de los valores de hemoglobina puede requerir la administración de preparados de hierro por vía intravenosa (AU)

Iron deficiency in patients with morbid obesity can occur before bariatric surgery due to its inflammatory component and after surgery as the result of implementing the malabsorptive techniques. For patients with morbid obesity, micronutrient deficiencies, such as vitamin B12, iron and folate, should be suspected. Iron deficiency and other hematinics should be corrected, even when anemia has not been established. Normal ferritin levels do not allow us to rule out a possible iron deficiency, given that ferritin can increase due to the chronic inflammatory condition of obesity. After bariatric surgery, patients should take iron supplements; however, these supplements are frequently poorly tolerated. Rapid and effective correction of hemoglobin levels might require the intravenous administration of iron preparations (AU)