Comprehensive review of physiology and pathophysiology of iron deficiency anemia and its preoperative optimization with parenteral iron. Review of the history of parenteral iron preparation until current practice. At our hospital we optimize iron deficiency anemia preoperatively with intravenous iron to minimize allogeneic blood transfusion intraoperatively and postoperatively, improving patient safety and outcomes and decreasing costs.
Comprehensive review of physiology and pathophysiology of iron deficiency anemia and its preoperative optimization with parenteral iron. Review of the history of parenteral iron preparation until current practice. At our hospital we optimize iron deficiency anemia preoperatively with intravenous iron to minimize allogeneic blood transfusion intraoperatively and postoperatively, improving patient safety and outcomes and decreasing costs.
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Comprehensive review of physiology and pathophysiology of iron deficiency anemia and its preoperative optimization with parenteral iron. Review of the history of parenteral iron preparation until current practice. At our hospital we optimize iron deficiency anemia preoperatively with intravenous iron to minimize allogeneic blood transfusion intraoperatively and postoperatively, improving patient safety and outcomes and decreasing costs.
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Perioperative Management of Perioperative Management of
Iron Deficiency Anemia Iron Deficiency Anemia
Perioperative Management of Perioperative Management of Iron Deficiency Anemia Iron Deficiency Anemia Moises Auron MD FAAP, FACP Moises Auron MD FAAP, FACP HospitaI Medicine HospitaI Medicine DiscIosure of FinanciaI ReIationships DiscIosure of FinanciaI ReIationships Dr. Auron has Dr. Auron has no relationships no relationships with entities with entities producing, marketing, re producing, marketing, re- -selling, or selling, or distributing health care goods or services distributing health care goods or services consumed by, or used on, patients. consumed by, or used on, patients. utIine utIine utIine utIine ron metabolism ron metabolism Diagnosis of DA Diagnosis of DA Calculation of ron deficit Calculation of ron deficit ron preparations ron preparations ron in CKD and ESRD and ACD ron in CKD and ESRD and ACD ron in Surgery ron in Surgery Adverse effects of parenteral iron Adverse effects of parenteral iron CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism Normal body iron content ~ 3 to 4 g. Normal body iron content ~ 3 to 4 g. - - Hemoglobin Hemoglobin ~ 2.5 g ~ 2.5 g - - ron ron- -containing proteins (eg, myoglobin, containing proteins (eg, myoglobin, cytochromes, catalase) ~ 400 mg cytochromes, catalase) ~ 400 mg - - Transferrin Transferrin- -bound ~ 3 to 7 mg bound ~ 3 to 7 mg - - Storage iron (ferritin; hemosiderin) Storage iron (ferritin; hemosiderin) Storage varies according to gender Storage varies according to gender - - Men ~ 1 g (liver, spleen, and bone marrow). Men ~ 1 g (liver, spleen, and bone marrow). - - Women Women depends on physiologic factors depends on physiologic factors (menses, pregnancies, deliveries, lactation, and (menses, pregnancies, deliveries, lactation, and iron intake). iron intake). Muoz M. Vox Sanguinis. 2008; 94: 172183 ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism rythropoiesis in CKD rythropoiesis in CKD rythropoiesis in CKD rythropoiesis in CKD Kalantar-Zadeh K. Adv Chron Kid Dis. 2009; 16(2): 143-151. HemogIobin HemogIobin HemogIobin HemogIobin 64.4 kd tetramer 64.4 kd tetramer 2 pairs of globin polypeptide chains 2 pairs of globin polypeptide chains - - One pair alpha chains One pair alpha chains - - One pair of non One pair of non- -alpha chains alpha chains Heme group Heme group single protoporphyrin X bound to ferrous single protoporphyrin X bound to ferrous (Fe2+) ion (Fe2+) ion linked covalently to each globin chain linked covalently to each globin chain - - f iron is oxidized [ferric state (Fe3+)] f iron is oxidized [ferric state (Fe3+)] metHb metHb Heme iron is linked covalently to histidine Heme iron is linked covalently to histidine Oxygenation and deoxygenation Oxygenation and deoxygenation Hb conformational A Hb conformational A utIine utIine utIine utIine ron metabolism ron metabolism Diagnosis of DA Diagnosis of DA Calculation of ron deficit Calculation of ron deficit ron preparations ron preparations ron in CKD and ESRD and ACD ron in CKD and ESRD and ACD ron in Surgery ron in Surgery Adverse effects of parenteral iron Adverse effects of parenteral iron CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm Diagnostic indicators of IDA Diagnostic indicators of IDA Diagnostic indicators of IDA Diagnostic indicators of IDA Soluble transferrin receptors(sTfRs) Soluble transferrin receptors(sTfRs) sTfR sTfR ferritin index (sTfR ferritin index (sTfR F) F) Zinc protoporphyrin/heme ratio (ZPP/H) Zinc protoporphyrin/heme ratio (ZPP/H) Reticulocyte hemoglobin content (CHr) Reticulocyte hemoglobin content (CHr) Selective endoscopy Selective endoscopy Hepcidin Hepcidin Clark SF. Curr Opin Gastroent. 2009; 25:122128. %ests to assess Iron deficiency %ests to assess Iron deficiency %ests to assess Iron deficiency %ests to assess Iron deficiency Muoz M. Vox Sanguinis. 2008; 94: 172183 $erum %ransferrin Receptor (s%fR) $erum %ransferrin Receptor (s%fR) $erum %ransferrin Receptor (s%fR) $erum %ransferrin Receptor (s%fR) Skikne BS. Am J Hematol. 2008; 83:872875. ndian J Pediatr 2010; 77 (2) : 179-183 Serum TfR/Ferritin Ratio Serum TfR/Ferritin Ratio Serum TfR/Ferritin Ratio Serum TfR/Ferritin Ratio s%fR | as body Fe stores | s%fR | as body Fe stores | %fR/ferritin %fR/ferritin - - vaIuabIe measure of the extent of Fe vaIuabIe measure of the extent of Fe deficiency deficiency %fR/Iog ferritin %fR/Iog ferritin - - superior to the %fR/ferritin ratio, superior to the %fR/ferritin ratio, s%fR or ferritin in correctIy distinguishing IDA vs. s%fR or ferritin in correctIy distinguishing IDA vs. ACD vs. ACD from ACD + IDA (CMBI). ACD vs. ACD from ACD + IDA (CMBI). s%fR had a sensitivity of 71% and specificity of s%fR had a sensitivity of 71% and specificity of 74% for correctIy identifying iron 74% for correctIy identifying iron- -depIeted marrow depIeted marrow Ferritin which had a sensitivity of 25%, but Ferritin which had a sensitivity of 25%, but specificity of 99%. specificity of 99%. Skikne BS. Am J Hematol. 2008; 83:872875. Means RT. Clin. Lab. Haem. 1999; 21:161167 Degree of Iron deficiency Degree of Iron deficiency Degree of Iron deficiency Degree of Iron deficiency Gasche C, et al. nflamm Bowel Dis 2007;13:15451553 MortaIity predictabiIity in CKD MortaIity predictabiIity in CKD MortaIity predictabiIity in CKD MortaIity predictabiIity in CKD Kalantar-Zadeh K. Adv Chron Kid Dis. 2009; 16(2): 143-151. utIine utIine utIine utIine ron metabolism ron metabolism Diagnosis of DA Diagnosis of DA Calculation of ron deficit Calculation of ron deficit ron preparations ron preparations ron in CKD and ESRD and ACD ron in CKD and ESRD and ACD ron in Surgery ron in Surgery Adverse effects of parenteral iron Adverse effects of parenteral iron CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm anzoni's formuIa anzoni's formuIa anzoni's formuIa anzoni's formuIa Total Fe deficit (mg) = [Wt (kg) x Total Fe deficit (mg) = [Wt (kg) x (14 (14 - - actual Hb) x 0.24] + actual Hb) x 0.24] + 500 500 (iron depot) (iron depot) - - Blood volume 70 ml/kg of BW ~7% of body weight Blood volume 70 ml/kg of BW ~7% of body weight - - Fe content of Hb 0.34% Fe content of Hb 0.34% - - Factor 0.24 = 0.0034 x 0.07 x 1000 (g to mg). Factor 0.24 = 0.0034 x 0.07 x 1000 (g to mg). 70 kg; Hb 9 g/dL ~ deficit of 1400 mg. 70 kg; Hb 9 g/dL ~ deficit of 1400 mg. Underestimation of iron depot in males Underestimation of iron depot in males - - ~ 700 ~ 700- -900 mg. 900 mg. Muoz M, et al. World J Gastroenterol 2009; 15(37): 4666-4674 Ganzoni AM. ntravenous iron-dextran: therapeutic and experimental possibilities. Schweiz Med Wochenschr. 1970;100: 301303. CaIcuIation of Iron deficit CaIcuIation of Iron deficit CaIcuIation of Iron deficit CaIcuIation of Iron deficit Blood volume (dL) Blood volume (dL) = 65 (mL/kg) x body weight (kg) = 65 (mL/kg) x body weight (kg) 100 (mL/dL) 100 (mL/dL) Hb deficit (g/dL) Hb deficit (g/dL) = 14.0 = 14.0 [patient Hb] [patient Hb] Hb deficit (g) Hb deficit (g) = = Hb deficit (g/dL) Hb deficit (g/dL) x x Blood volume (dL) Blood volume (dL) ron deficit (mg) ron deficit (mg) = = Hb deficit (g) Hb deficit (g) x 3.3 (mg Fe/g Hb) x 3.3 (mg Fe/g Hb) Volume of parenteral Fe (mL) Volume of parenteral Fe (mL) = = ron deficit (mg) ron deficit (mg) C(mg/mL) C(mg/mL) Schrier SL. Up To Date. Version 18.3 Hemoglobin iron deficit (mg) = BW x (14 Hemoglobin iron deficit (mg) = BW x (14 - - Hgb) x (2.145) Hgb) x (2.145) Volume of product required (mL) = BW x (14 Volume of product required (mL) = BW x (14 - - Hgb) x (2.145) Hgb) x (2.145) C C C = %he concentration of eIementaI iron: C = %he concentration of eIementaI iron: Iron dextran: 50 mg/mL Iron dextran: 50 mg/mL Iron sucrose: 20 mg/mL Iron sucrose: 20 mg/mL Ferric gIuconate: 12.5 mg/mL Ferric gIuconate: 12.5 mg/mL CaIcuIation of Iron deficit CaIcuIation of Iron deficit CaIcuIation of Iron deficit CaIcuIation of Iron deficit Schrier SL. Up To Date. Version 18.3 AIgorithm for IV Iron AIgorithm for IV Iron repIacement repIacement AIgorithm for IV Iron AIgorithm for IV Iron repIacement repIacement Muoz M. Vox Sanguinis. 2008; 94: 172183 utIine utIine utIine utIine ron metabolism ron metabolism Diagnosis of DA Diagnosis of DA Calculation of ron deficit Calculation of ron deficit ron preparations ron preparations ron in CKD and ESRD and ACD ron in CKD and ESRD and ACD ron in Surgery ron in Surgery Adverse effects of parenteral iron Adverse effects of parenteral iron CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm hat about IM iron? hat about IM iron? hat about IM iron? hat about IM iron? Painful Painful Associated with gluteal sarcomas Associated with gluteal sarcomas Permanent discoloration of the skin Permanent discoloration of the skin No evidence of superiority over V No evidence of superiority over V Auerbach M. Am J Hematol. 2008; 83: 580588 ParenteraI Iron ParenteraI Iron ParenteraI Iron ParenteraI Iron Gasche C, et al. nflamm Bowel Dis 2007;13:15451553. http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022180lbl.pdf Name MoIecuIar AnaphyIaxis %est dose [Fe] Max eight (kD) required (mg/mI) Dose Dextran - HM (Dexferrum) 265 Y Y 50 1g - LM (Infed) 165 Y Y 50 1g Fe gIuconate (FerrIecit) < 50 N N 12.5 125mg Fe sucrose (Venofer) 30-100 N N 20 200mg ther iron preparations ther iron preparations ther iron preparations ther iron preparations Ferumoxytol Ferumoxytol (Feraheme ) (Feraheme ) - - semi semi- -synthetic carbohydrate synthetic carbohydrate- -coated coated superparamagnetic iron oxide nanoparticle superparamagnetic iron oxide nanoparticle - - safe and effective when given as a rapid intravenous safe and effective when given as a rapid intravenous infusion of up to 510 mg (infusion rate: up to 30 infusion of up to 510 mg (infusion rate: up to 30 mg/second) in patients with CKD and ESRD mg/second) in patients with CKD and ESRD Safety concerns were hypotension and/or hypersensitivity Safety concerns were hypotension and/or hypersensitivity reactions (anaphylaxis and/or anaphylactoid reactions). reactions (anaphylaxis and/or anaphylactoid reactions). May transiently affect the diagnostic ability of MR May transiently affect the diagnostic ability of MR http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022180lbl.pdf DifficuIt beginnings DifficuIt beginnings DifficuIt beginnings DifficuIt beginnings Self limited arthralgias and myalgias ~ 50% Self limited arthralgias and myalgias ~ 50% - - Only 1 in 87 patients had nonfatal anaphylaxis Only 1 in 87 patients had nonfatal anaphylaxis - - Decreased with methylprednisolone (125 mg) Decreased with methylprednisolone (125 mg) before and after infusion (1998) before and after infusion (1998) - - No relationship with infusion rate No relationship with infusion rate - - Lack of efficacy of ASA and diphenhydramine Lack of efficacy of ASA and diphenhydramine Single case report in Lancet (1983) of meningismus Single case report in Lancet (1983) of meningismus - - Patient with myalgia/arthralgia syndrome Patient with myalgia/arthralgia syndrome Oral iron Oral iron - - inexpensive and effective if tolerated inexpensive and effective if tolerated - - decreased interest in parenteral iron. decreased interest in parenteral iron. Auerbach M. Am J Hematol. 2008; 83: 580588 %he evoIution of iron preparations %he evoIution of iron preparations %he evoIution of iron preparations %he evoIution of iron preparations HMWD (DexFerrum) HMWD (DexFerrum) 11 11- -fold fold serious AE vs. LMWD (nFeD) serious AE vs. LMWD (nFeD) - - Anaphylactic reactions Anaphylactic reactions Non Non- -dextran preparations dextran preparations - - Ferric gluconate Ferric gluconate Patients with reactions Patients with reactions have no tryptase have no tryptase 125 mg V push over 5 125 mg V push over 5 10 min 10 min - - ron sucrose ron sucrose 200 mg V push or 300 mg over 2 hr 200 mg V push or 300 mg over 2 hr LMWD, ferric gluconate, and iron sucrose: LMWD, ferric gluconate, and iron sucrose: similar AE's similar AE's - - Estimated incidence of <1:200,000. Estimated incidence of <1:200,000. Auerbach M. Am J Hematol. 2008; 83: 580588 utIine utIine utIine utIine ron metabolism ron metabolism Diagnosis of DA Diagnosis of DA Calculation of ron deficit Calculation of ron deficit ron preparations ron preparations ron in CKD and ESRD and ACD ron in CKD and ESRD and ACD ron in Surgery ron in Surgery Adverse effects of parenteral iron Adverse effects of parenteral iron CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm Iron in $RD Iron in $RD Iron in $RD Iron in $RD Eschbach (1987) Eschbach (1987) 1g V Fe dextran in dialysis patients failing 1g V Fe dextran in dialysis patients failing to respond to EPO (standard dose of 50 U/kg 3 x wk) despite to respond to EPO (standard dose of 50 U/kg 3 x wk) despite Ferritin > 500 ng/ ml. Ferritin > 500 ng/ ml. Fishbane Fishbane V Fe: V Fe: - - Decreased suboptimal response to EPO: 30 Decreased suboptimal response to EPO: 30 40% to 40% to < 10% < 10% - - | dosing and duration of EPO | dosing and duration of EPO - - Poor compliance and |absorption Poor compliance and |absorption avoid PO Fe avoid PO Fe - - V Fe 1g V Fe 1g rapid improvement of erythropoiesis and rapid improvement of erythropoiesis and replenishment of depleted stores. replenishment of depleted stores. Administered over 10 doses. Administered over 10 doses. Serious AE ~ 0.7% Serious AE ~ 0.7% ~ 0.3% ~ 0.3% - - acute chest and back pain without |BP, RR, acute chest and back pain without |BP, RR, HR, wheezing, stridor, or periorbital edema HR, wheezing, stridor, or periorbital edema Self limited reactions. Self limited reactions. Auerbach M. Am J Hematol. 2008; 83: 580588 Iron and $RD Iron and $RD Iron and $RD Iron and $RD Hoen et al. Hoen et al. - - N = 998 hemodialysis patients N = 998 hemodialysis patients - - No association of ferritin levels or V Fe No association of ferritin levels or V Fe administered with infections. administered with infections. Clin Nephrol. 2002 Jun;57(6):457-61. IDA in Uremia IDA in Uremia IDA in Uremia IDA in Uremia Bacterial overgrowth Bacterial overgrowth G bleeding G bleeding - - Platelet dysfunction Platelet dysfunction - - Anti Anti- -platelets platelets Frequent phlebotomy Frequent phlebotomy Proteinuria Proteinuria Fe utilization (ESA) Fe utilization (ESA) MacDougall C. Curr Med Res & Opin. 2010; 26(2):473482. | Dietary source | Dietary source - - Anorexia Anorexia - - Low protein diet Low protein diet | G absorption | G absorption - - Hepcidin Hepcidin - - PO4 binders, Ca PO4 binders, Ca 2+ 2+ - - Achlorhydria Achlorhydria - - Atrophic gastritis Atrophic gastritis Iron in $RD Iron in $RD Iron in $RD Iron in $RD NKF NKF- -KDOQ KDOQ - - V iron in preference to p.o. iron V iron in preference to p.o. iron - - Serum ferritin >100 ng/ mL Serum ferritin >100 ng/ mL - - Hold Fe if Hold Fe if ferritin > 800 ng/mL ferritin > 800 ng/mL and and Tsat > 50% Tsat > 50% - - V iron can be administered: V iron can be administered: LMWD LMWD total infusion dose or repeated doses total infusion dose or repeated doses Ferric gluconate or iron sucrose Ferric gluconate or iron sucrose repeated doses repeated doses Auerbach M. Am J Hematol. 2008; 83: 580588 IV Iron in Non IV Iron in Non- -diaIysis CKD diaIysis CKD IV Iron in Non IV Iron in Non- -diaIysis CKD diaIysis CKD MacDougall C. Curr Med Res & Opin. 2010; 26(2):473482. Anemia of chronic disease Anemia of chronic disease Anemia of chronic disease Anemia of chronic disease Disturbed iron homeostasis Disturbed iron homeostasis - - | absorption and | Fe recycling from RES | absorption and | Fe recycling from RES - - hypoferremia (low transferrin hypoferremia (low transferrin- -bound iron) bound iron) BD BD - - .V. Fe .V. Fe route of choice route of choice Potential of worsening BD with P.O. Fe Potential of worsening BD with P.O. Fe Auerbach M. Am J Hematol. 2008; 83: 580588 Anemia of cancer and chemotherapy Anemia of cancer and chemotherapy Anemia of cancer and chemotherapy Anemia of cancer and chemotherapy Multiple studies of patients with different type of cancer Multiple studies of patients with different type of cancer on chemoradiation or chemotherapy on ESA on chemoradiation or chemotherapy on ESA - - Randomized to ESA alone, p.o. vs. i.v. ron Randomized to ESA alone, p.o. vs. i.v. ron V iron V iron - - ncrease in Hb > 2 g/dL ncrease in Hb > 2 g/dL - - 45% decrease in allogenic blood transfusions 45% decrease in allogenic blood transfusions - - reduces ESA failure reduces ESA failure - - Oncology Oncology no difference in tumor outcomes vs. ESA no difference in tumor outcomes vs. ESA Auerbach M. Am J Hematol. 2008; 83: 580588 Auerbach M. Am J Hematol. 2008; 83: 580588 utIine utIine utIine utIine ron metabolism ron metabolism Diagnosis of DA Diagnosis of DA Calculation of ron deficit Calculation of ron deficit ron preparations ron preparations ron in CKD and ESRD ron in CKD and ESRD ron in Surgery ron in Surgery Adverse effects of parenteral iron Adverse effects of parenteral iron CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm ParenteraI iron in surgery ParenteraI iron in surgery ParenteraI iron in surgery ParenteraI iron in surgery Efficacy of V ron Efficacy of V ron - - Major elective surgery (N = 84) Major elective surgery (N = 84) 33 CORS, 33 Gynecologic, 21 Ortho 33 CORS, 33 Gynecologic, 21 Ortho - - V iron mean dose 1000 mg V iron mean dose 1000 mg ++ 440 mg 440 mg Hb > 2.0 g/dl Hb > 2.0 g/dl Resolved anemia ~ 58% of cases Resolved anemia ~ 58% of cases No life No life- -threatening AE's threatening AE's Oral vs. V ron Oral vs. V ron - - Gynecologic surgery (N = 76; Hb <9.0 g/dl) Gynecologic surgery (N = 76; Hb <9.0 g/dl) - - V Fe sucrose 3/wk vs. daily PO Fe succinylate V Fe sucrose 3/wk vs. daily PO Fe succinylate Hb (3.0 vs. 0.8 g/dl; Hb (3.0 vs. 0.8 g/dl; p < 0.0001 p < 0.0001) ) Ferritin levels (170.1 vs. 4.1 microg/l; Ferritin levels (170.1 vs. 4.1 microg/l; P<0.0001 P<0.0001) ) Target Hb (76.7% vs. 11.5%; Target Hb (76.7% vs. 11.5%; p < 0.0001 p < 0.0001). ). Muoz M. Med Clin (Barc). 2009 Mar 7;132(8):303-6. Garca-Erce JA. Anemia 2009; 2: 17-27. Kim YH. Acta Haematol. 2009;121(1):37-41. IV Iron IV Iron IV Iron IV Iron Orthopedic surgery Orthopedic surgery - - Meta Meta- -analysis (N = 807) analysis (N = 807) - - transfusion rate [ transfusion rate [RR: 0.60 RR: 0.60, 95% C: 0.50 , 95% C: 0.50- -0.72, P < 0.001] 0.72, P < 0.001] - - infection rate [ infection rate [RR: 0.45 RR: 0.45, 95% C: 0.32 , 95% C: 0.32- -0.63, P < 0.001] 0.63, P < 0.001] Colorectal surgery Colorectal surgery - - 43 colorectal cancer patient 43 colorectal cancer patient Transfusion index 4.0 vs. 1.3 unit/patient Transfusion index 4.0 vs. 1.3 unit/patient V antibiotics (33% vs. 9%) V antibiotics (33% vs. 9%) Garca-Erce JA. Anemia 2009; 2: 17-27. Kim YH. Acta Haematol. 2009;121(1):37-41. Muoz M. Semin Hematol. 2006; 43:S36-8 utIine utIine utIine utIine ron metabolism ron metabolism Diagnosis of DA Diagnosis of DA Calculation of ron deficit Calculation of ron deficit ron preparations ron preparations ron in CKD and ESRD ron in CKD and ESRD ron in Surgery ron in Surgery Adverse effects of parenteral iron Adverse effects of parenteral iron CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm PotentiaI negative effects of PotentiaI negative effects of intravenous iron intravenous iron PotentiaI negative effects of PotentiaI negative effects of intravenous iron intravenous iron Pro Pro- -oxidant oxidant - - might increase oxidative stress, might increase oxidative stress, infections, mortality, tumor growth. infections, mortality, tumor growth. - - p.o. ron p.o. ron - - worsening BD (Fenton reaction) worsening BD (Fenton reaction) Non Non- -ESRD patients ESRD patients nephrotoxicity? nephrotoxicity? - - Transient increase in induced proteinuria and Transient increase in induced proteinuria and albuminuria with iron sucrose. albuminuria with iron sucrose. - - Ferric gluconate showed significant increases in Ferric gluconate showed significant increases in lipid peroxidation. lipid peroxidation. Auerbach M. Am J Hematol. 2008; 83: 580588 Iron and infectious diseases Iron and infectious diseases Iron and infectious diseases Iron and infectious diseases Weinberg ED. Emerg nfect Dis 1999;5:34652. Body iron and disease Body iron and disease Body iron and disease Body iron and disease Weinberg ED. Emerg nfect Dis 1999;5:34652. Iron Adverse drug events Iron Adverse drug events Iron Adverse drug events Iron Adverse drug events FDA (2001 FDA (2001 - - 2003) 2003) - - 30 miIIion doses 30 miIIion doses - - 11 deaths 11 deaths - - 1141 totaI ADs 1141 totaI ADs ron sucrose ron sucrose - - 0.6 per million doses 0.6 per million doses Ferric gluconate Ferric gluconate - - 0.9 per million doses 0.9 per million doses LMWD LMWD - - 3.3 per million doses 3.3 per million doses HMWD HMWD - - 11.3 per million doses 11.3 per million doses Chertow GM. Nephrol Dial Transplant. 2006;21(2):378-82. utIine utIine utIine utIine ron metabolism ron metabolism Diagnosis of DA Diagnosis of DA Calculation of ron deficit Calculation of ron deficit ron preparations ron preparations ron in CKD and ESRD ron in CKD and ESRD ron in Surgery ron in Surgery Adverse effects of parenteral iron Adverse effects of parenteral iron CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm NATA (Network for Advancement of Transfusion Alternatives) NATA (Network for Advancement of Transfusion Alternatives) - - 2 RCT 2 RCT - - 6 Observational studies 6 Observational studies Preoperative Fe therapy Preoperative Fe therapy | 2/3 | 2/3 Blood Transfusion Blood Transfusion V ron: V ron: Ferritin < 100, Tsat < 20%, EBL > 1500 ml Ferritin < 100, Tsat < 20%, EBL > 1500 ml Avoid V ron if Ferritin > 300 ng/ml and Tsat > 50%. Avoid V ron if Ferritin > 300 ng/ml and Tsat > 50%. - - Acute infection. Acute infection. Quality of Evidence is weak Quality of Evidence is weak Recommend large RCT Recommend large RCT Br J Anaesth 2008; 100: 599604. Cost of IV Iron vs. %ransfusion Cost of IV Iron vs. %ransfusion Cost of IV Iron vs. %ransfusion Cost of IV Iron vs. %ransfusion Bieber EJ. OBG Management. 2010;22(2):28-38. Silverstein SB. Am J Hematol. 2004; 76:7478. Shander A. Transfusion. 2010:50:753-65 ron dextran ~ $377 per gram ron dextran ~ $377 per gram ron gluconate ~ $688 per gram ron gluconate ~ $688 per gram ron sucrose ~ $688 per gram ron sucrose ~ $688 per gram Hemoglobin ~ $761 +/ Hemoglobin ~ $761 +/- - 294 per unit (~250 294 per unit (~250 mg) x 4 = mg) x 4 = $ 3044 per gram $ 3044 per gram Recommended Preoperative IV Recommended Preoperative IV Iron repIacement Iron repIacement Recommended Preoperative IV Recommended Preoperative IV Iron repIacement Iron repIacement Venofer (Iron sucrose) 200 mg (10 mI) Venofer (Iron sucrose) 200 mg (10 mI) administered over 10 minutes x 5 administered over 10 minutes x 5 doses. doses. FerrIecit (Ferric gIuconate) 125 mg iv FerrIecit (Ferric gIuconate) 125 mg iv over 1 hour x 8 doses (Inpatient). over 1 hour x 8 doses (Inpatient).