Better treatment, better outcome

Can we treat cardiac surgery patients better before their operation so that the outcome afterwards improves?

Every year, thousands of Dutch cardiac surgery patients enter the operating room with an untreated iron deficiency anemia. The guidelines are clear: treat the anemia. The Boost the Blood Initiative (BTBI) works to put this into practice, together with cardiac surgery centres in the Netherlands.

Preoperative anemia is still structurally left untreated. Every day we see the consequences of anemia and of blood transfusions in our patients. That is why we are taking the initiative.

About the Boost the Blood Initiative

Improving outcomes after surgery

Can we treat cardiac surgery patients better before their operation so that the outcome afterwards improves? That is both the question and the goal of the Boost the Blood Initiative (BTBI), a quality improvement project.

Preoperative anemia turns out, time and again, to be a major risk factor for a poor outcome after cardiac surgery. In the large majority of cases it is caused by iron deficiency.

The problem

Guidelines are not being implemented

International and national guidelines recommend treatment with iron in the case of iron deficiency anemia, in order to improve the postoperative outcome.

So far, however, this does not happen in the large majority of patients. A survey by the cardiac anaesthesiology section of the Dutch Society of Anaesthesiology some years ago found that only one cardiac surgery centre routinely carried out diagnosis and treatment for preoperative anemia.

Our goal

To implement the (inter)national guideline

In this quality improvement project, anaesthesiologists work together with all specialties involved in cardiac surgery to treat as many patients as possible with iron deficiency anemia with iron before their operation, so that they start surgery in the best possible condition.

Specifically, the aim is that in the participating hospitals, additional diagnostic testing is done in the case of preoperative anemia, and that when there is an iron deficiency, treatment with iron is given. The expectation is that this leads to fewer patients with preoperative anemia directly before surgery, fewer red blood cell transfusions and a better postoperative outcome.

The effect becomes visible through the collaboration with the Netherlands Heart Registration

This quality improvement project is made possible by the collaboration with the Netherlands Heart Registration (NHR). The NHR is a quality registry that routinely collects perioperative data on all cardiac surgery patients in the Netherlands. As part of this project, additional data are supplied on top of the regular data delivery from the cardiac surgery hospitals to the NHR. This concerns preoperative medication (including iron treatment) and transfusion data (including the number of red blood cell transfusions). These additional variables have been set out in a dedicated manual, which has been shared with the data managers of all cardiac surgery centres.

Take part

Six-monthly meetings to discuss progress and experiences

The additional data supplied to the NHR are fed back to the participating hospitals periodically. This shows whether treating patients with iron before surgery is succeeding, whether the number of patients with preoperative anemia is falling, and whether this results in fewer red blood cell transfusions. These meetings also give participants the opportunity to share their experiences with implementing preoperative iron treatment and to help one another.

Participating hospitals

Join with your centre

Ten cardiac surgery centres in the Netherlands have now joined this initiative. The more centres take part, the more patients are operated on from an optimised starting position, and the more we learn from each other about implementation.

What your centre does:

  • diagnosis and treatment according to the existing guideline

  • supplying additional variables to the NHR (preoperative iron treatment and number of red blood cell transfusions)

  • joining the online progress meeting twice a year

Guidelines

Follow the guidelines for the diagnosis and treatment of preoperative anaemia

There are several diagnostic and treatment protocols for iron deficiency anemia, but they are very similar. The flowchart from the guideline “Perioperative blood and (anti)coagulation management for cardiac surgery” is particularly helpful.

Two intravenous iron preparations exist: ferric carboxymaltose (Ferinject) and ferric derisomaltose (Monofer). For information on these products, the SmPCs can be consulted. Oral iron treatment appears less suitable for these patients. The main objections are that it takes a long time before the iron stores are replenished (the waiting time before surgery is often short), and that many cardiac surgery patients have low-grade inflammation (for example atherosclerosis, recent myocardial infarction, obesity), which reduces enteral iron uptake.

Guidelines

IV iron saves costs

IV iron as part of patient blood management saves costs. Less anemia before surgery means a higher Hb, fewer blood transfusions and a better outcome.

Safe with the current products

Hypersensitivity reactions occurred regularly with older intravenous iron preparations. With the current products this risk is very low.

Simple to organise

This is straightforward to set up with the laboratory: when anaemia is identified, the iron status is determined automatically. There are clear flowcharts for who does what and when. The treatment itself can be given in day care: 30 minutes for the infusion and 30 minutes for observation, and the patient goes home again.

Supporting literature

Contact

For more information, please contact Dr Thijs Rettig, trettig@amphia.nl, Dr Joachim Bosboom, jbosboom@amphia.nl or Dr Peter Noordzij, p.noordzij@antoniusziekenhuis.nl