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      An international consensus statement on the management of postoperative anaemia after major surgical procedures

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          Summary

          Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two‐day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best‐practice and evidence‐based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow‐up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large‐scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.

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          Most cited references104

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          Bacterial iron homeostasis.

          Iron is essential to virtually all organisms, but poses problems of toxicity and poor solubility. Bacteria have evolved various mechanisms to counter the problems imposed by their iron dependence, allowing them to achieve effective iron homeostasis under a range of iron regimes. Highly efficient iron acquisition systems are used to scavenge iron from the environment under iron-restricted conditions. In many cases, this involves the secretion and internalisation of extracellular ferric chelators called siderophores. Ferrous iron can also be directly imported by the G protein-like transporter, FeoB. For pathogens, host-iron complexes (transferrin, lactoferrin, haem, haemoglobin) are directly used as iron sources. Bacterial iron storage proteins (ferritin, bacterioferritin) provide intracellular iron reserves for use when external supplies are restricted, and iron detoxification proteins (Dps) are employed to protect the chromosome from iron-induced free radical damage. There is evidence that bacteria control their iron requirements in response to iron availability by down-regulating the expression of iron proteins during iron-restricted growth. And finally, the expression of the iron homeostatic machinery is subject to iron-dependent global control ensuring that iron acquisition, storage and consumption are geared to iron availability and that intracellular levels of free iron do not reach toxic levels.
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            International consensus statement on the peri-operative management of anaemia and iron deficiency.

            Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.
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              Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: First update 2016.

              : The management of perioperative bleeding involves multiple assessments and strategies to ensure appropriate patient care. Initially, it is important to identify those patients with an increased risk of perioperative bleeding. Next, strategies should be employed to correct preoperative anaemia and to stabilise macrocirculation and microcirculation to optimise the patient's tolerance to bleeding. Finally, targeted interventions should be used to reduce intraoperative and postoperative bleeding, and so prevent subsequent morbidity and mortality. The objective of these updated guidelines is to provide healthcare professionals with an overview of the most recent evidence to help ensure improved clinical management of patients. For this update, electronic databases were searched without language restrictions from 2011 or 2012 (depending on the search) until 2015. These searches produced 18 334 articles. All articles were assessed and the existing 2013 guidelines were revised to take account of new evidence. This update includes revisions to existing recommendations with respect to the wording, or changes in the grade of recommendation, and also the addition of new recommendations. The final draft guideline was posted on the European Society of Anaesthesiology website for four weeks for review. All comments were collated and the guidelines were amended as appropriate. This publication reflects the output of this work.
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                Author and article information

                Contributors
                Role: Professormmunoz@uma.es
                Role: Associate Professor
                Role: Consultant
                Role: Research Fellow
                Role: Consultant
                Role: Professor
                Role: Professor
                Role: Professor
                Role: General Director
                Role: Professor
                Role: Consultant
                Role: Professor, Director
                Role: Consultant
                Role: Professor and Chairman, Head of Anaesthesiology
                Role: Consultant
                Journal
                Anaesthesia
                Anaesthesia
                10.1111/(ISSN)1365-2044
                ANAE
                Anaesthesia
                John Wiley and Sons Inc. (Hoboken )
                0003-2409
                1365-2044
                31 July 2018
                November 2018
                : 73
                : 11 ( doiID: 10.1111/anae.2018.73.issue-11 )
                : 1418-1431
                Affiliations
                [ 1 ] Department of Surgical Specialties, Biochemistry and Immunology School of Medicine University of Málaga Málaga Spain
                [ 2 ] Department of Colorectal Surgery Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit Nottingham University Hospitals Nottingham UK
                [ 3 ] Department of Anaesthesia University Hospital Mar‐Esperanza Barcelona Spain
                [ 4 ] Division of Surgery University College London London UK
                [ 5 ] Department of Internal Medicine University Hospital Virgen de la Victoria Málaga Spain
                [ 6 ] Department of Haematology and Medicine Launceston General Hospital Launceston Australia
                [ 7 ] Menzies Institute for Medical Research University of Tasmania Australia
                [ 8 ] Section of Surgical Pathophysiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
                [ 9 ] Department of Anaesthesia and Intensive Care Evangelical Hospital Vienna Austria
                [ 10 ] Italian National Blood Centre National Institute of Health Rome Italy
                [ 11 ] Department of Anaesthesiology Intensive Care Medicine and Pain Therapy University Hospital Frankfurt Frankfurt Germany
                [ 12 ] Department of Anaesthesia Royal Marsden NHS Foundation Trust London UK
                [ 13 ] Anaesthesiology Critical Care and Hyperbaric Medicine Englewood Hospital and Medical Centre Englewood NJ USA
                [ 14 ] TeamHealth Research Institute Englewood NJ USA
                [ 15 ] Department of Transfusion Medicine Sanquin Blood Bank Amsterdam The Netherlands
                [ 16 ] Department of Internal Medicine Groene Hart Hospital Gouda The Netherlands
                [ 17 ] Institute of Anaesthesiology University Hospital of Zurich Zurich Switzerland
                [ 18 ] Intensive Care Medicine and Operating Room Management University Hospital of Zurich Zurich Switzerland
                [ 19 ] Department of Anaesthesia and Intensive Care Royal Papworth Hospital Cambridge UK
                Author notes
                [*] [* ] Correspondence to: M. Muñoz

                Email: mmunoz@ 123456uma.es

                Article
                ANAE14358
                10.1111/anae.14358
                6686161
                30062700
                c081fc79-6648-41d9-b813-dfe26378c655
                © 2018 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

                History
                : 28 April 2018
                Page count
                Figures: 1, Tables: 1, Pages: 14, Words: 9837
                Categories
                Review Article
                Review Article
                Custom metadata
                2.0
                anae14358
                November 2018
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.7 mode:remove_FC converted:08.08.2019

                Anesthesiology & Pain management
                anaemia,erythropoiesis stimulating agents,iron deficiency,iron supplementation,postoperative period,transfusion

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