A preoperative anemia clinic opened in mid-August to identify and optimize patients with anemia prior to planned surgery as part of UF Health’s ongoing Patient Blood Management Program.
Anemia is a preventable problem that is easily detected during a patient’s evaluation for surgery. The presence of anemia, when combined with the usual anticipated surgical blood loss, increases a patient’s risk of complications, including the need for unnecessary blood transfusions.
Detection and management of anemia in the Anemia Pre-Op Anesthesia Clinic follows an approved algorithm. Ideally, patients are evaluated at least 2 to 3 weeks before planned surgery to allow time for treatment of iron-deficiency anemia or further testing and follow-up care. When surgery cannot be delayed, a dose of intravenous iron might still be administered before surgery if the patient is iron deficient.
The referral-based clinic started small with a focus on patients preparing to undergo major cardiac surgery. The goal is to expand the service to cancer patients undergoing cystectomies, neurosurgical patients, and gynecological patients. Bloodless surgery patients and Jehovah’s Witnesses are also expected to benefit from the clinic in the future.
“There’s pockets of patients in many of our different practices who will really benefit from this,” said Mary Jane Michael, RN, MS, CCRC, Clinical Research Manager. “Our goal is to reduce the tendency to rely on single lab values to drive the transfusion decision of donated human blood products, often given during and after surgery. We aim to improve patient outcomes using multiple evidence-based principles of patient blood management.”
Managing anemia is just one component of patient blood management, an evidence-based, multidisciplinary initiative that seeks to improve patient outcomes. Experts say 40% to 60% of blood transfusions are unnecessary and by introducing a foreign substance into the body, transfusions can put patients at risk for infections and other complications. Anemia is a symptom of some underlying conditions, so if it can be treated and a transfusion can be avoided, patient care is safer, higher quality, and less costly.
“The goals of the preoperative anemia clinic are to identify anemic patients earlier and begin correcting the factors contributing to the anemia, thereby reducing preventable adverse events, reducing unnecessary transfusions, and providing our patients with the care we would want our family members to receive,” said Joshua W. Sappenfield, MD, Associate Professor of Anesthesiology, Chief of the Perioperative Medicine Division, and Medical Director of the Presurgical Clinic.
Major vascular surgery patients, such as patients undergoing aortic aneurysm repairs, seen by Tomas D. Martin, MD, were among the first to be referred for consultation at the clinic. Dr. Martin, a Professor of Surgery in the Division of Thoracic and Cardiovascular Surgery, is a clinical champion for patient blood management and volunteered to be one of the first surgeons to participate in the clinic.
Dr. Martin’s patients are good candidates for the clinic given that this type of high-risk surgery is associated with significant blood loss; however, it was found that in general, surgery for his patients cannot wait 2 to 3 weeks. For two of Dr. Martin’s patients, the anemia clinic attending reached out to the patient’s referring physician to order the necessary lab work outlined in the Anemia Pre-op Anesthesia Clinic algorithm, putting the guidelines in play before the preoperative surgical visit.
Paul Crispen, MD, is another clinical championwho has identified a subset of his patients who routinely have iron-deficiency anemia. Dr. Crispen, an Associate Professor of Urology, plans to send these patients to the clinic prior to their planned, complex surgery.
Currently, the clinic has five on-call attending physicians who are available to review labs and ensure patients are routed to the appropriate treatment: Basma Mohamed, MBChB, Assistant Professor of Anesthesiology; Dr. Sappenfield; Bruce Spiess, MD, Professor of Anesthesiology and Associate Chair of Research; Marc S. Zumberg, MD, Professor in the Department of Hematology; and Senthil Meenrajan, MD, Associate Professor in the Department of Medicine’s Division of General Internal Medicine.
Patients who are having high blood loss surgery, may be having low blood loss surgery but are at high risk for bleeding, have a history of anemia, or have nutritional deficiencies may be appropriate for referral to the Anemia Pre-Op Anesthesia Clinic. Treatments, which include oral or intravenous iron, Vitamin B12 therapy, and Epogen are coordinated and tailored for each patient, taking into consideration age, gender, anticipated surgical blood loss, and preexisting medical conditions. If the patient needs intravenous iron, for instance, they would be sent to the infusion center in Medical Plaza and have the surgery rescheduled.
Going forward, the clinic also plans to collaborate with the Perioperative Cognitive Anesthesia Network, or PeCAN, to offer anemia and cognitive assessments at the same time for the convenience of the patient.
“This type of preoperative collaboration is on the cutting edge of science,” Michael said.