https://doi.org/10.4081/acbr.2020.91
Preoperative anaemia in surgical patients: Intravenous iron and erythropoiesis-stimulating agents (ESAs) to the rescue
Submitted: 11 June 2020
Accepted: 29 July 2020
Published: 21 October 2020
Accepted: 29 July 2020
Abstract Views: 294
PDF: 180
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All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
Despite the propensity for allogeneic blood transfusion by clinicians, the space for this therapy is steadily being contracted by limited evidence of benefit from its use in most situations, adverse effects of its use, high cost, limited supply and rejection by some religious faithfuls. Available literature concedes to the high prevalence of preoperative anaemia in diverse surgical settings irrespective of geography and reflects the global burden of anaemia. Beyond the poorer surgical outcome directly attributed to preoperative anaemia, it has also been recognized as the major predictor of allogeneic blood transfusion with attendant morbidity and mortality. The concept of Patient Blood Management (PBM) seeks to minimize exposure of patients to allogeneic blood and is based on three pillars of maximizing total red cell mass, minimizing iatrogenic blood loss and harnessing patient’s physiological tolerance of anemia. Consequently, PBM places great premium on correcting preoperative anaemia in surgical patients. With the limited success of leucodepletion and other measures at addressing the complications of allogeneic blood transfusions new interest is expanding in PBM. Several of these have been evaluated and among them the use of newer formulations of intravenous iron with or without erythropoiesis– stimulating agents has been most studied and credited with substantial success and good safety profile. Insight is also offered on the oversubscribed misconception of iron overload in HbSS patients while elucidating on the basis for iron supplementation in proven cases of iron deficiency. Some prevailing barriers, however, threaten the full realization of the potentials of these therapies.
Sixty-Third World Health Assembly. Availability, safety and quality of blood products. 2010. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R12-en.pdf. Accessed on May 1, 2020.
Isbister JP. The three-pillar matrix of patient blood management--an overview. Best Pract Res Clin Anaesthesiol 2013;27:69‐84.
DOI: https://doi.org/10.1016/j.bpa.2013.02.002
Wu WC, Schifftner TL, Henderson WG, et al. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA 2007;297:2481-8.
Seicean A, Seicean S, Alan N, et al. Preoperative anemia and perioperative outcomes in patients who undergo elective spine surgery. Spine (Phila Pa 1976) 2013;38:1331-41.
DOI: https://doi.org/10.1097/BRS.0b013e3182912c6b
Fowler AJ, Ahmad T, Phull MK, et al. Meta-analysis of the association between preoperative anaemia and mortality after surgery. Br J Surg 2015;102:1314-24.
DOI: https://doi.org/10.1002/bjs.9861
Kotze A, Harris A, Baker C, et al. British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia. Br J Haematol 2015;171:322–31.
DOI: https://doi.org/10.1111/bjh.13623
Goodnough LT, Maniatis A, Earnshaw P, et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth 2011;106:13-22.
DOI: https://doi.org/10.1093/bja/aeq361
Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013;30:270-382.
DOI: https://doi.org/10.1097/EJA.0b013e32835f4d5b
Gombotz H, Rehak PH, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study. Transfusion 2007;47:1468-80.
DOI: https://doi.org/10.1111/j.1537-2995.2007.01286.x
Shander A, Javidroozi M, Ozawa S, Hare GM. What is really dangerous: anaemia or transfusion? Br J Anaesth 2011;107:i41-59.
DOI: https://doi.org/10.1093/bja/aer350
Muñoz M, Laso-Morales MJ, Gómez-Ramírez S, et al. Pre-operative haemoglobin levels and iron status in a large multicentre cohort of patients undergoing major elective surgery. Anaesthesia 2017;72:826-34.
DOI: https://doi.org/10.1111/anae.13840
Kearney B, To J, Southam K, Howie D, To B. Anaemia in elective orthopaedic surgery - Royal Adelaide Hospital, Australia. Intern Med J 2016;46:96-101.
DOI: https://doi.org/10.1111/imj.12945
Kassebaum NJ, Jasrasaria R, Naghavi M, et al. A systematic analysis of global anemia burden from 1990 to 2010. Blood 2014;123:615-24.
DOI: https://doi.org/10.1182/blood-2013-06-508325
Baltussen R, Knai C, Sharan M. Iron fortification and iron supplementation are cost-effective interventions to reduce iron deficiency in four subregions of the world. J Nutr 2004;134:2678-84.
DOI: https://doi.org/10.1093/jn/134.10.2678
World Health Organization. Guidelines on food fortification with micronutrients. Available from: http://apps.who.int/iris/bitstream/10665/43412/1/9241594012_eng.pdf?ua=1. Accessed on May 1, 2020.
Weatherall DJ. The inherited diseases of hemoglobin are an emerging global health burden. Blood 2010;115:4331–6.
DOI: https://doi.org/10.1182/blood-2010-01-251348
Musallam KM, Tamim HM, Richards T, et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 2011;378:1396-407.
DOI: https://doi.org/10.1016/S0140-6736(11)61381-0
Gupta PK, Sundaram A, Mactaggart JN, et al. Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations. Ann Surg 2013;258:1096-102.
DOI: https://doi.org/10.1097/SLA.0b013e318288e957
Amponsah G, Alice Charwudzi A. Preoperative Anaemia and Associated Postoperative Outcomes in Noncardiac Surgery Patients in Central Region of Ghana. Anesthesiol Res Pract 2017; 2017:7410960.
DOI: https://doi.org/10.1155/2017/7410960
Saager L, Turan A, Reynolds LF, et al. The association between preoperative anemia and 30-day mortality and morbidity in noncardiac surgical patients. Anesth Analg 2013;117:909-15.
DOI: https://doi.org/10.1213/ANE.0b013e31828b347d
White MC, Longstaff L, Lai PS. Effect of pre-operative anaemia on post-operative complications in low-resource settings. World J Surg 2017;41:644-9.
DOI: https://doi.org/10.1007/s00268-016-3785-6
Fowler AJ, Ahmad T, Abbott TEF, et al. on behalf of the International Surgical Outcomes Study Group. Association of preoperative anaemia with postoperative morbidity and mortality: an observational cohort study in low-, middle-, and high-income countries. Br J Anaesth 2018;121:1227-35.
DOI: https://doi.org/10.1016/j.bja.2018.08.026
Greenky M, Gandhi K, Pulido L, et al. Preoperative anemia in total joint arthroplasty: is it associated with periprosthetic joint infection? Clin Orthop Relat Res 2012;470:2695-701.
DOI: https://doi.org/10.1007/s11999-012-2435-z
Grosso MJ, Boddapati V, Cooper HJ, et al. The Effect of Preoperative Anemia on Complications After Total Hip Arthroplasty. J Arthroplasty 2020;35:S214-S218.
DOI: https://doi.org/10.1016/j.arth.2020.01.012
Abdullah HR, Sim YE, Hao Y, Lin GY, Liew GHC, Lamoureux EL, et al. Association between preoperative anaemia with length of hospital stay among patients undergoing primary total knee arthroplasty in Singapore: a single-centre retrospective study. BMJ Open 2017;7:e016403.
DOI: https://doi.org/10.1136/bmjopen-2017-016403
Baron DM, Hochrieser H, Posch M, et al. European Surgical Outcomes Study (EuSOS) group for Trials Groups of European Society of Intensive Care Medicine; European Society of Anaesthesiology. Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients. Br J Anaesth 2014;113:416-23.
DOI: https://doi.org/10.1093/bja/aeu098
Bydon M, Abt NB, Macki M, et al. Preoperative anemia increases postoperative morbidity in elective cranial neurosurgery. Surg Neurol Int 2014;5:156.
DOI: https://doi.org/10.4103/2152-7806.143754
Wu WC, Schifftner TL, Henderson WG, et al. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA 2007;297:2481-8.
DOI: https://doi.org/10.1001/jama.297.22.2481
Gabriel RA, Clark AI, Nguyen AP, et al. The association of preoperative hematocrit and transfusion with mortality in patients undergoing elective non-cardiac surgery. World J Surg 2018;42:1939-48.
DOI: https://doi.org/10.1007/s00268-017-4359-y
Padmanabhan H, Brookes MJ, Nevill AM, Luckraz H. Association between anemia and blood transfusion with long-term mortality after cardiac surgery. Ann Thorac Surg 2019;108:687-92.
DOI: https://doi.org/10.1016/j.athoracsur.2019.04.044
Cushner FD, Friedman RJ. Blood loss in total knee arthroplasty. Clin Orthop Relat Res 1991;269:98-101.
Kwon HY, Kim BR, Kim YW. Association of preoperative anemia and perioperative allogenic red blood cell transfusion with oncologic outcomes in patients with nonmetastatic colorectal cancer. Curr Oncol 2019;26:e357-e366.
DOI: https://doi.org/10.3747/co.26.4983
Ristagno G, Beluffi S, Tanzi D, et al. Red blood cell transfusion need for elective primary posterior lumbar fusion in a high-volume center for spine surgery. J Clin Med 2018;7:19.
DOI: https://doi.org/10.3390/jcm7020019
Mufarrih SH, Qureshi NQ, Ali A, et al. Total knee Arthroplasty: risk factors for allogeneic blood transfusions in the South Asian population. BMC Musculoskelet Disord 2017;18:359.
DOI: https://doi.org/10.1186/s12891-017-1728-5
Saleh E, McClelland DBL, Hay A, et al. Prevalence of anaemia before major joint arthroplasty and the potential impact of preoperative investigation and correction on perioperative blood transfusions. Br J Anaesth 2007;99:801–8.
DOI: https://doi.org/10.1093/bja/aem299
Jensen LS, Andersen AJ, Christiansen PM, et al. Postoperative infection and natural killer cell function following blood transfusion in patients undergoing elective colorectal surgery. Br J Surg 1992;79:513-6.
DOI: https://doi.org/10.1002/bjs.1800790613
Qiu L, Wang DR, Zhang XY, et al. Impact of perioperative blood transfusion on immune function and prognosis in colorectal cancer patients. Transfus Apher Sci 2016;54:235-41.
DOI: https://doi.org/10.1016/j.transci.2015.07.004
Richards T, Musallam KM, Nassif J, et al. Impact of preoperative anaemia and blood transfusion on postoperative outcomes in gynaecological surgery. PLoS ONE 2015;10:e0130861.
Koch CG, Li L, Duncan AI, et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med 2006;34:1608-16.
DOI: https://doi.org/10.1097/01.CCM.0000217920.48559.D8
Ferraris VA, Davenport DL, Saha SP, et al. Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Arch Surg 2012;147:49-55.
DOI: https://doi.org/10.1001/archsurg.2011.790
Bower WF, Jin L, Underwood MJ, et al. Peri-operative blood transfusion increases length of hospital stay and number of postoperative complications in non-cardiac surgical patients. Hong Kong Med J 2010;16:116-20.
Wright JG, Einhorn TA, Heckman JD. Grades of recommendation. J Bone Joint Surg Am 2005;87:1909-10.
DOI: https://doi.org/10.2106/00004623-200509000-00001
LaPar DJ, Hawkins RB, McMurry TL, et al. Investigators for the Virginia Cardiac Services Quality Initiative. Preoperative anemia versus blood transfusion: Which is the culprit for worse outcomes in cardiac surgery? J Thorac Cardiovasc Surg 2018;156:66-74.e2.
DOI: https://doi.org/10.1016/j.jtcvs.2018.03.109
Loor G, Rajeswaran J, Li L, et al. The least of 3 evils: exposure to red blood cell transfusion, anemia, or both? J Thorac Cardiovasc Surg 2013;146:1480-7.e6.
DOI: https://doi.org/10.1016/j.jtcvs.2013.06.033
Rajesh K, Harsh S, Amarjit K. Effects of prestorage leukoreduction on the rate of febrile nonhemolytic transfusion reactions to red blood cells in a tertiary care hospital. Ann Med Health Sci Res 2015;5:185-8.
DOI: https://doi.org/10.4103/2141-9248.157498
Paglino JC, Pomper GJ, Fisch GS, et al. Reduction of febrile but not allergic reactions to RBCs and platelets after conversion to universal prestorage leukoreduction. Transfusion 2004;44:16-24.
DOI: https://doi.org/10.1046/j.0041-1132.2004.00608.x
Vamvakas EC. Is white blood cell reduction equivalent to antibody screening in preventing transmission of cytomegalovirus by transfusion? A review of the literature and meta-analysis. Transfus Med Rev 2005;19:181-99.
DOI: https://doi.org/10.1016/j.tmrv.2005.02.002
Simancas-Racines D, Osorio D, Marti-Carvajal A, Arevalo-Rodriguez I. Leukodepleted for the prevention of adverse reactions from allogeneic blood transfusion. Cochrane Database Syst Rev 2015;12:CD009745.
DOI: https://doi.org/10.1002/14651858.CD009745.pub2
Tsantes AE, Kyriakou E, Nikolopoulos GK, et al. Cost-effectiveness of leucoreduction for prevention of febrile non-haemolytic transfusion reactions. Blood Transfus 2014;12:232-7.
Millot S, Delaby C, Moulouel B, et al. Hemolytic anemia repressed hepcidin level without hepatocyte iron overload: lesson from Günther disease model. Haematologica 2017;102:260-70.
DOI: https://doi.org/10.3324/haematol.2016.151621
Embury SH, Vichinsky EP. Sickle cell disease. In: Hoffman R, BenzEJ, Shattil SJ, et al. (eds.) Hematology. Basic principles and practice. New York: Churchill Livingstone; 2000. p 522.
Keikhaei B, Yousefi H, Bahadoram M. Hydroxyurea: clinical and hematological effects in patients with sickle cell anemia. Glob J Health Sci 2015;8:252-6.
DOI: https://doi.org/10.5539/gjhs.v8n3p252
Agrawal RK, Patel RK, Shah V, et al. Hydroxyurea in sickle cell disease: drug review. Indian J Hematol Blood Transfus 2014;30:91-6.
DOI: https://doi.org/10.1007/s12288-013-0261-4
Kassim A, Thabet S, Al-Kabban M, Al-Nihari K. Iron deficiency in Yemeni patients with sickle-cell disease. East Mediterr Health J 2012;18:241–5.
DOI: https://doi.org/10.26719/2012.18.3.241
Mohanty D, Mukherjee MB, Colah RB, et al. Iron deficiency anaemia in sickle cell disorders in India. Indian J Med Res 2008;127:366–9.
Royal College of Obstetricians and Gynaecologists. Management of sickle cell disease in pregnancy. Green–top Guideline 2011;61. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_61.pdf. Accessed on June 8, 2020.
Howard J, Malfroy M, Llewelyn C, et al. The Transfusion Alternatives Preoperatively in Sickle Cell Disease (TAPS) study: a randomised, controlled, multicentre clinical trial. Lancet 2013;381:930-8.
DOI: https://doi.org/10.1016/S0140-6736(12)61726-7
Yawn BP, Buchanan GR, Afenyi-Annan AN, et al. Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. JAMA 2014;312:1033-48.
DOI: https://doi.org/10.1001/jama.2014.10517
Vichinsky EP, Haberkern CM, Neumayr L, et al. A comparison of conservative and aggressive transfusion regimens in the perioperative management of sickle cell disease. The Preoperative Transfusion in Sickle Cell Disease Study Group. N Engl J Med 1995;333:206-13.
DOI: https://doi.org/10.1056/NEJM199507273330402
Davis BA, Allard S, Qureshi A, et al. on behalf of the British Society for Haematology. Guidelines on red cell transfusion in sickle cell disease Part II: indications for transfusion. Br J Haematol 2017;176:192-209.
DOI: https://doi.org/10.1111/bjh.14383
Eisenga MF, Bakker SJ, Gaillard CA. Definition of functional iron deficiency and intravenous iron supplementation. Lancet Haematol 2016;3:e504.
DOI: https://doi.org/10.1016/S2352-3026(16)30152-1
Thomas DW, Hinchliffe RF, Briggs C, et al. British Committee for Standards in Haematology. Guideline for the laboratory diagnosis of functional iron deficiency. Br J Haematol 2013;161:639-48.
DOI: https://doi.org/10.1111/bjh.12311
Goodnough LT, Nemeth E, Ganz T. Detection, evaluation, and management of iron-restricted erythropoiesis. Blood 2010;116:4754-61.
DOI: https://doi.org/10.1182/blood-2010-05-286260
Dillon R, Momoh I, Francis Y, et al. Comparative efficacy of three forms of parenteral Iron. J Blood Transfus 2012; Article ID 473514.
DOI: https://doi.org/10.1155/2012/473514
Qassim A, Mol BW, Grivell RM, Grzeskowiak LE. Safety and efficacy of intravenous iron polymaltose, iron sucrose and ferric carboxymaltose in pregnancy: A systematic review. Aust N Z J Obstet Gynaecol 2018;58:22–39.
DOI: https://doi.org/10.1111/ajo.12695
Bhandari S. Update of a comparative analysis of cost minimization following the introduction of newly available intravenous iron therapies in hospital practice. Ther Clin Risk Manag 2011;7:501-9.
DOI: https://doi.org/10.2147/TCRM.S25882
Grant MD, Piper M, Bohlius J, et al. Epoetin and darbepoetin for managing anemia in patients undergoing cancer treatment: comparative effectiveness update. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Apr. Report No.:13-EHC077-EF.
Wu P, Zhang N, Wang X, et al. The erythropoietin/erythropoietin receptor signaling pathway promotes growth and invasion abilities in human renal carcinoma cells. PLoS One 2012;7:e45122.
DOI: https://doi.org/10.1371/journal.pone.0045122
Leyland-Jones B, Semiglazov V, Pawlicki M, et al. Maintaining normal hemoglobin levels with epoetin alfa in mainly nonanemic patients with metastatic breast cancer receiving first-line chemotherapy: a survival study. J Clin Oncol 2005;23:5960-72.
DOI: https://doi.org/10.1200/JCO.2005.06.150
Bohlius J, Tonia T, Schwarzer G. Twist and shout: one decade of meta-analyses of erythropoiesis-stimulating agents in cancer patients. Acta Haematol 2011;125:55–67.
DOI: https://doi.org/10.1159/000318897
Glaspy J, Crawford J, Vansteenkiste J, et al. Erythropoiesis-stimulating agents in oncology: a study-level meta-analysis of survival and other safety outcomes. Br J Cancer 2010;102:301-15.
DOI: https://doi.org/10.1038/sj.bjc.6605498
Bhavi SB, Jaju PB. Intravenous iron sucrose v/s oral ferrous fumarate for treatment of anemia in pregnancy. A randomized controlled trial. BMC Pregnancy Childbirth 2017;17:137.
DOI: https://doi.org/10.1186/s12884-017-1313-9
Biboulet P, Bringuier S, Smilevitch P, et al. Preoperative epoetin-α with intravenous or oral iron for major orthopedic surgery. A randomized controlled trial. Anesthesiology 2018;129:710-20.
DOI: https://doi.org/10.1097/ALN.0000000000002376
Hourlier H, Fennema P. Surgical prescription of epoetin alfa in contemporary total hip arthroplasty: a prospective comparative study. Int Orthop 2020;44:261–6.
DOI: https://doi.org/10.1007/s00264-019-04399-7
Rosencher N, Poisson D, Albi A, et al. Two injections of erythropoietin correct moderate anemia in most patients awaiting orthopedic surgery. Can J Anesth 2005;52:160–5.
DOI: https://doi.org/10.1007/BF03027722
Yoo Y, Shim J, Kim J, et al. Effect of single recombinant human erythropoietin injection on transfusion requirements in preoperatively anemic patients undergoing valvular heart surgery. Anesthesiology 2011;115:929–37.
DOI: https://doi.org/10.1097/ALN.0b013e318232004b
Kurian D, Guinn NR, Hunting J, et al. Preoperative blood management strategy for elective hip and knee arthroplasty. J Healthc Qual 2019;41:376-83.
DOI: https://doi.org/10.1097/JHQ.0000000000000207
Lachance K, Savoie M, Bernard M, et al. Oral ferrous sulfate does not increase preoperative hemoglobin in patients scheduled for hip or knee arthroplasty. Ann Pharmacother 2011;45:764-70.
DOI: https://doi.org/10.1345/aph.1P757
Simpson JAD, Ng SL, Brookes MJ, Acheson AG. Single Dose Preoperative Administration of Intravenous Iron Corrects Iron Deficiency Anaemia in Colorectal Cancer. J Blood Disord Transfus 2010;1:101.
Keeler BD, Simpson JA, Ng O, et al. Randomized clinical trial of preoperative oral versus intravenous iron in anaemic patients with colorectal cancer. Br J Surg 2017;104:214-21.
DOI: https://doi.org/10.1002/bjs.10328
Muñoz M, García-Erce JA, Díez-Lobo AI, et al. Anaemia Working Group España (AWGE). [Usefulness of the administration of intravenous iron sucrose for the correction of preoperative anemia in major surgery patients]. Med Clin (Barc) 2009;132:303-6.
DOI: https://doi.org/10.1016/j.medcli.2008.04.011
Mhaskar R, Wao H, Miladinovic B, et al. The role of iron in the management of chemotherapy-induced anemia in cancer patients receiving erythropoiesis-stimulating agents. Cochrane Database Syst Rev 2016;2:CD009624.
DOI: https://doi.org/10.1002/14651858.CD009624.pub2
Varlotto J, Stevenson MA. Anemia, tumor hypoxemia, and the cancer patient. Int J Radiat Oncol Biol Phys 2005;63:25-36.
DOI: https://doi.org/10.1016/j.ijrobp.2005.04.049
Campos IC, Tanganelli V, Maues HP, et al. Blood transfusion and increased perioperative risk in coronary artery bypass grafts. Braz J Cardiovasc Surg 2017;32:394-400.
DOI: https://doi.org/10.21470/1678-9741-2017-0034
Richards T, Musallam KM, Nassif J, et al. Impact of preoperative anaemia and blood transfusion on postoperative outcomes in gynaecological surgery. PLoS One 2015;10:e0130861.
DOI: https://doi.org/10.1371/journal.pone.0130861
Eyelade OR, Adesina OA, Adewole IF, Adebowale SA. Blood transfusion requirement during caesarean delivery: risk factors. Ann Ib Postgrad Med 2015;13:29-35.
Wise J. Alarming global rise in caesarean births, figures show. BMJ 2018;363:k4319.
DOI: https://doi.org/10.1136/bmj.k4319
Zhao L, Zhang X, Shen Y, et al. Obesity and iron deficiency: a quantitative meta-analysis. Obes Rev 2015;16:1081-93.
DOI: https://doi.org/10.1111/obr.12323
van der Beek ES, Monpellier VM, Eland I, et al. Nutritional deficiencies in gastric bypass patients; incidence, time of occurrence and implications for post-operative surveillance. Obes Surg 2015;25:818-23.
DOI: https://doi.org/10.1007/s11695-014-1456-y
Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340:409-17.
DOI: https://doi.org/10.1056/NEJM199902113400601
Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop 2008;79:168-7.
DOI: https://doi.org/10.1080/17453670710014941
Kehlet H, Thienpont E. Fast-track knee arthroplasty -- status and future challenges. Knee 2013;20:S29-33.
DOI: https://doi.org/10.1016/S0968-0160(13)70006-1
How to Cite
Nwosu, A. D. . (2020). Preoperative anaemia in surgical patients: Intravenous iron and erythropoiesis-stimulating agents (ESAs) to the rescue. Annals of Clinical and Biomedical Research, 1(1). https://doi.org/10.4081/acbr.2020.91
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