 Now this slide you see two important things pre-operative anemia and post-operative anemia and Believe it or not, but we know now that world-wide about a third of patients coming for elective surgery have anemia When they've been admitted to the hospital had their operation everything That up to 90% of these patients have anemia and we know If you have in the hospital anemia and we call it hospital acquired anemia Your lengths of stay increases and also your risk to to attract Infection far higher Okay, because it's not working. I would be nice. Thank you. So I Hope I have convinced you that anemia is a really really Good predictor for bad outcome or the other way around if you really want to harm yourself your family or your patients Let them undergo surgery with anemia. I but I would like to phrase a little bit positive There are a lot of options how to treat anemia and what you see now on this graph is pre-optively When the decision has been made that the patient will be operated on you can do a pre-op patient blood management checkup and The chance that someone has eye deficiency anemia so high Once you have diagnosed that you can treat it very simple with iron in a hospital setting We are up to 100% we prescribed now IV intravenous iron and that can be done even one day before surgery ideally two to four weeks before surgery and Then there's a second option a day After the operation because a lot of patients will have anemia because we call it hospital acquired anemia You can treat again the iron deficiency anemia So nobody can say oh there was not enough time or we didn't know whatever in my personal opinion Anemia is a health risk Especially when you do interventions on patients. So it's not acceptable not to sort out anemia prior any elective interventions Next slide, please so I briefly would like to run through the three columns of patient blood management the first one is management of pre-optive anemia, please next slide and What we have established in Frankfurt is an anemia walking in clinic And you can see we have a lot of beach flags and Advertisement just to make patients and doctors aware of the fact that is existing that we're looking after patients And we have even as you can see the t-shirts everything is according to the subject of anemia needs to be sorted out next slide, please and I would like to Guide you through a small trial which has been done in Australia and published in 2016 it was a randomized controlled trial and these trial were looking after patients undergoing abdominal surgery and Patients had eye deficiency anemia and they were randomized in an iron group and in a control group and Patients received about 10 days prior surgery either iron IV on or nothing and You can see that after the 10 days for the surgical case Hemoglobin was significant significantly increased but really amazing the transfusion of red blood cells was reduced by 75% Hospital lengths of stay from nine days to six days So that was reason enough for the ethical review board to stop the trial because they felt That patients with eye deficiency anemia and not being treated with iron were disadvantaged So the trial was stopped next slide, please We have implemented now patient blood management and anemia and the whole process of Surgical patients because what happens usually the surgical patient is coming to see a surgeon the surgeon Is investigating the patient and finally comes to the conclusion this patient needs an operation Then the patient needs to go through certain procedures. It needs some clinical tests. It needs to be Signed in for a special day, then you need a consentment and so on and so on and we have managed that Anemia the patient blood management Walking in clinic is in particular important and it's been done by every patient in our hospital and our hospital has 1500 beds, so we do an over 30,000 operations each year So that's a main change through the process next slide, please and now I would like to show you what we do with patients and If you have a planted event intervention, so any kind of surgery or cardiology or anything And we have more we have time more than 24 hours if you go to the top we Know for each procedure in our hospital for the past three years How much blood has been given to a particular procedure? so we defined a Wrist of transfusion and we defined ten percent as something which is relevant So it's the wrist of transfusion more than ten percent We would like to know you see here hemoglobin values according to the Guidelines from the WHO and then we do a pre-optive anemia management We do an iron status very simple That's got much money. It can be done very quickly and then knowing the patient's iron status We make decisions whether there will be no iron deficiencies or the patient can be operated immediately Or there is iron deficiencies or the patient Will be administered Iron IV or there are other courses, so we need further diagnostics next slide If the risk of transfusion is higher than ten percent the patient also will be operated on because Sorry lower than ten percent and then the wrist of transfusion lower than ten percent the patient will be operated and emergencies will be operated as well So you can see this standard operating procedure makes a huge difference for patients coming for elective surgery next slide, please So this is to summarize for you what it means to have anemia prior surgical intervention We know now that if you are anemic you have a 20 percent longer hospital stay You have a two-fold increased risk of infection You have a four-fold increased risk of kidney injury a three-fold increased risk of mortality And a five-fold risk increase in transfusion So these data are so so strong. So I'm asking myself why we are still doing nonsense operations elective surgery on patients with anemia and You can phrase it the other way around because you can say well, this is Basically bad practice bad medicine and not good for patients. So it shouldn't be allowed next slide, please Let's quickly talk about intensive care unit next slide This is on my unit and you see the patient there right in the middle of all this equipment And there was a publication some years ago and what you see here now with my mouse on the left side you see the Access these are the hemoglobin levels and Regardless whether you start with a hemoglobin level of 15 16 or with a level of 7 If you end up on intensive care unit, you always will have an hemoglobin of 10 So why is that? There are two things number one Dr. Singh 10 is good There's no proof of this, but it has been published 50 years ago that 10 is good Without any evidence second it tells you These people here have been transfused and these people here what I show you later on they lost their blood Both are unacceptable next slide, please What can we do for patients on intensive care unit? We have to make sure that they are being well prepared I call this nowadays elective intensive care patients because we have elective intensive care patients So you can minimize the blood loss at the beginning and you can do a lot for the hemoglobin and During the intensive care stay you have to make sure that you have no GI bleeding You control that you don't take too much blood from phlebotomy You reduce therapeutic interventions and you keep a really close eye on wound bleeding next slide, please And this is a trial which shows you that you can even treat a day after surgery on the intensive care This is study also being published in the year 2016 They were studying 201 patients one day after surgery also Suffering from iron deficiency anemia again They're compared placebo against iron IV and they also found the iron group had a faster recovery the Transfusion of red blood cells was reduced from six to one percent But see the next one post ovative infections from 14 percent to two percent and the hospital lengths of stay from 12 to 8 days To be fairly all the honest ladies and gentlemen if this is not convincing then I don't know what to say next slide So there are a lot of reasons for anemia and let's go to the right side You have certain things which are acquired. I think the most famous one is obviously renal anemia There's some unknown at the bottom. There's some congenital but The most forms of anemia you find on the left side This is iron deficiency vitamin B12 deficiency folic acid Deficiency if you go down Hospital acquired anemia and the main one is through blood loss because of diagnostics, so you can see These are a lot of causes by the most important things on the left side next slide, please and I've shown you this slide before but I would like to get your attention to the bottom now And you see here vascular surgery thoracic surgery trauma urology Obstengine and so on and you see the patients before the surgery their rate of anemia and After surgery and you see numbers 85 to 55 So there's a huge increase and the parents of anemia after surgery telling you that we lose blood And we do things to our patients. We shouldn't do it next slide, please What can we do now in terms of minimizing blood loss and bleeding next slide? And this is a real-life example from my intensive care unit some years ago We had we have we had admitted two patients a young man and an elderly lady Both were suffering from severe pneumonia with beginning sepsis and You see at the top Day one to day seven and this is the amount of blood we have taken one week You see it twice laboratory Three times the blood culture 12 times blood gas analysis and a cross-match and after one week We have taken 643 mil. That's a huge amount of blood and the young man had Added mission hemoglobin of 15 after this week. We've just taken blood samples. He had an hemoglobin of 13 And this is according to WHO definition almost anemic the elder the lady She was anemic already was in hemoglobin of 11 and she ended up with 8.5 next slide The whole story went worse ladies and gentlemen What you can see here now is they're both developed a septic shock With multiple organ dysfunction We were basically with our backs at the wall We have to implement ECMO and renal replacement therapy and again you can see Nine times we have taken blood cultures 14 times laboratories 84 times blood cases once the ECMO clotted and three times the renal replacement clotted This is real life and you can see we have taken from these two humans 1,623 mil of blood in one week and this lady you have any idea how much blood she has she has only 3,000 mils and You can see from a hemoglobin from 15 starting the young man had hemoglobin of 10 He's severe anemic and the lady was 11 went down to 4.8 severe anemic next slide, please So what can we do and what should be known and this is data from the US from a cardiac unit Patients who underwent cardiac surgery after surgery they were bled for a lobotomy just for testing and It's very simple You can just recognize if you're 50 days in hospital You will lose five liters of blood just for diagnostics And that's your whole blood volume You basically have an exchange of your blood Everybody understands that five liters means you will be confused next slide, please So I personally think we doctors here on the left side. We have one pious But we should be like little mosquitoes on the right side. We should be very very careful With patients blood. We should be very careful with patients anyway And we should make sure that we take owning a minimum of blood as Little as possible and what you see here. These are the typical tubes which you know from your own experience and different colors for different testing and We were talking to a company was producing them and we said look can you change? The inner part of the tubing system so that we just need less blood Because nowadays with the new machines in clinical chemistry, you don't need much blood anymore for doing all the testing So they were very helpful that changed it because if you would change the outer side The robots and machines in clinical chemistry wouldn't be able to handle it Next slide and I'll show you what the effect was. I was not there But I'm not tell you the effect was that we was now saving in the University Hospital Frankfurt almost 2,000 liters of blood That's the whole SUV full of blood and then wait The blood we are not taking from our patients and this is a real step forward to reduce Hospital acquired anemia Also, what we have implemented is to be aware of bleeding in a hospital and how to manage and this is just the standard operating procedure for medical doctors to follow if there's bleeding which cannot be controlled and Obviously, whenever you have to make sure that is not surgical bleeding hereafter You have to make sure that you keep physiology a cold patient can't clutch But the pH is not right the blood cannot clot if calcium is not a right blood cannot clot and Then obviously need further information about drug history and there's certain things you can do next slide, please Let's go to the last point restrictive use of blood units next slide, please there are a lot of different guidelines and I'm particularly extremely happy because in Germany since last year It has been implemented that patient blood management is an important part in the hospital to increase patient safety and to improve patient outcome next slide, please and I will tell you a little story if it goes through a lot of guidelines Everything is written in if the hemoglobin is less than six Items are basic saying you can confuse. However, if the hemoglobin is between six and eight You have to be very very sure what you're doing And that means you have to look at your patients. You're treating patients. We are not treating numbers and The doctor has to tick a box to make sure he's doing the right thing and Over a hemoglobin of eight. There's not really any evidence In terms of benefit for the patient next slide, please and I would like to show you another example What happens if the patient loses blood and ECB transfuse? This was a systematic review and meta-analysis on patients undergoing colorectal cancer surgery and There's always two ways to do surgery. You can be very careful You do it in particular. You make sure that is that you do not lose much blood and Stun or you do it very quickly not careful and you transfuse the patient and this meta-analysis It came out that at this group of patients who had been transfused Had a significant higher risk for re-occurrence of colon cancer and that frightens me a lot It frightens me really a lot because it's the poor. It's a potential Disease condition which can be cured if it's done early, but if you transfuse then You have a high risk of re-occurrence. So that tells you we have to be very very careful what we're doing next slide, please So what can be done in a hospital? You need checklists and I'm a huge fan safer surgery is a very good example And we have our PBM checklist where we tick the box pre-optively Inter-optively and post-optively just to make sure the patient is safe and we're doing the right thing next slide, please Just two three examples This was a trial being done in the US and the question was does A restrictive hemoglobin level Has an effect on mortality or mobility in comparison to a more liberal one over 2,000 patients have been enrolled it was a randomized controlled prospective trial As I compared a hemoglobin of 10 versus 8 and These were patients with a high risk cardiac disease undergoing hip surgery and You can see if you had if you were in the restrictive group you haven't had any Disadvantage so there was not a bad the mobility at 30 or 60 days and there was no difference in mortality so to summarize this a Lower hemoglobin is not only safe. It's it has Huge advantages when we're talking about side effects next slide, please a try from Scandinavia Three years ago We're investigating the same question a lower or higher hemoglobin in patients with suffering from septic shock and Again, there was no difference in 90-day mortality or ischemic events if patients were in the lower hemoglobin group Also demonstrating very very clear Sometimes less is more next slide, please And this table just summarized it In the middle of the red with the red digits These were the lower Hemoglobin groups these were the higher ones and then left side to see in Which circumstances the study was done in terms of care unit cardiac surgery Hippoplasment upper GI bleeding had injury Septic shock and cardiac surgery and in all of this trials the lower hemoglobin group had no Disadvantage and some it had even a huge advantage so the new number for Many many patients is not 10. It's a hemoglobin of seven to eight next slide, please This is a particular interesting trial which has been published some months ago in November 13th in the New England These were patients undergoing cardiac surgery and it was a huge number of patients as you can see a restrictive group with 2430 patients the hemoglobin of 7.5 and on the right side the liberal group with 2430 patients with a hemoglobin of 9.5 and The primary composite endpoint was death My card infarction stroke or new onset arena failure with dialysis And you can see the liberal group had significantly less of these endpoints 11.4 percent versus 12.5 So that tells you and tells me We undergo surgery. We do not want to be in the liberal group. We want to be in the restrictive group And if you look at the mortality unbelievable 3% versus 3.6 and the secondary outcome was red blood cell Transfusion 52 versus 72 So this is the biggest trial in this direction and absolutely convincing next slide please So how can we get doctors to do the right thing and I'm a huge fan of training Training training training and we have set up now a web page is called the patient blood manager It's also now available in English. It doesn't cost any money But it's hard work You need a whole day to be able to do four modules the first one is patient blood management The second one is anemia The third one is how to bear blood and the fourth is transfusion next slide and The point is in my department, I have over 130 doctors practicing in my department It is mandatory to do this patient that managed Test if you don't do it, you're not allowed to transfuse blood because it is a very dangerous drug If it's been used in a wrong way So I've told you a lot of little things now. I'm showing you the data of the trial which we have done some years ago you see four centers and Starting 2012 and the four centers were Frankfurt in Germany Keel, Bonn and Münster in Germany next slide and what you can see is that we had a control group control group means business as usual no patient blood management next slide and You can see in this control phase. We included in the trial over 50,000 patients And then we had an implementation phase where we Were teaching doctors nurses health professionals everything about patient blood management that took us three months in Frankfurt alone We we were teaching over 800 health professionals next slide And then we were practicing patient blood management next slide and we included in the trial 75,000 patients next slide and Now I would like to show you the results You don't have to say anything, but I'm just telling you there was before Transfusion and after next slide please and you can see There was a reduction of almost 20 percent over the whole trial in the amount of blood which has been transfused And the last quarter of the trial it was 40 percent 40 percent. Can you imagine next slide? Complications next slide there was no difference when we used patient blood management This was a very important result because it's safe next slide the most surprising data we have obtained from this trial was that we had a Reduction in kidney injury and the patient blood management group by 30 percent next slide So what does it mean if you suffer from kidney injury in the hospital? It's very simple. If you suffer from kidney injury You won't produce any urine anymore and we as doctors do dialysis And then after several days your kidney is working again and everybody's happy. We sent you home But next slide look what happens, but we never looked at in a proper way This is years at the bottom years following discharge and On the left side you see patient survival If you had in the hospital a good kidney injury You are dying far more often than patients who had no acute kidney injury So patient blood management reduces The chance of having a good kidney injury therefore directly saving lives That is an unbelievable amazing result next slide, please Money is also an important issue next slide and I'm telling you if you implement patient blood management In the hospital to save over 10% of the cost So it is basically producing money and at the same time you're doing better medicine next slide So what can you do to motivate hospitals and to motivate doctors? And I feel it's always the same We're all a little bit competitive and we like to have crowns and whatever so we have Founded the idea that we need it bundled so we have Defined over 150 bundles to implement patient blood management, and you can see the more bundles You have Incorporated in your organization You get certificates we start with a basic member of certificate Then you receive bronze silver gold platinum and diamond I'm telling you no one in the world is diamond at the moment. We are in Frankfurt We are one of the leaders we are somewhere here, so there's still room for improvement Next slide. I'm showing you this slide in particular because I'm proud of it And I also would like to motivate you Within Europe we set up a network with Transfusion medicine because we think the whole thing can only work if countries and hospitals are connected We also have received a grant from the European Union and in particular. I'm very proud that in 2017 at the patient safety summit in California We founded the world PPM network and We have been awarded with a German prize for patient safety and the human return award And I'm particularly very proud of this photograph because My personal experiences. He's supporting Everything related to patient safety and he's supporting patient blood management. So thank you mr. President next slide And I just mentioned it the world patient blood management program Which we were lucky and proud to be founded at the patient safety summit and what we're trying to do with this Network is to connect hospitals worldwide to provide some of this information to provide some with help and Finally to collect data and to calculate numbers of life saved And that's the soap in particular important and I'm very proud of it next slide, please and Enclosing two or three more slides We were able last year to get all surgical societies in Germany and the society of anesthesiology intensive care to make a statement a joint recommendation on The subject of patient blood management and we have published it in our two big journals and it's free access in English and in German And this is basically just a summary of three pages and a fourth page with all the literature How important it is to implement patient blood management in the hospital next slide, please and Finally, I would like to show you a clinical trial. We were just running as we speak It's about patients over 70 years undergoing surgery non-cardic surgery and So far we have no data in the literature Caring for these people. We don't know maybe they need a higher hemoglobin. We don't know Maybe they need a lower hemoglobin. We don't know and we are asking ourselves We have transfusion medicines in 70 80 years and no one was looking after this particular group of patients so what we do is what you can see here patients will be Registered in the trial and once they're bleeding and the hemoglobin falls below nine that will be randomized in either a liberal group or in a restrictive group we can see that we separate both groups very clear and The endpoint is after 30 days or hospital discharge A combination of stroke myocardial infarction deaths and some others. So hopefully in two years time We're aiming to have over 2,000 patients Hopefully we can tell you then whether the elderly among us need maybe a different treatment But I personally don't think so. I think we are on the right way Implementing patient blood management also for these patient group next slide Ladies and gentlemen, thank you so much for your attention I know it's not real life when I'm on the phone line You see the slides, but I hope I could convince you that Everybody can contribute to patient blood management And this is a real thing to do because it will if it's done in a proper way save thousands of lives in each hospital Thank you very much Thank you so much Kai even though you aren't here in person and we can't You can feel the passion that you have I hope I speak for everyone who's on the line with us today that We really really appreciate your enthusiasm and you've convinced all of us here that are around the table We're all nodding our heads that this is something that we should all be working on together So I'd love to open it up. We do have 10 minutes for questions and answers So I'll be looking at the chat box online if you're too shy to speak up But at this point if anyone has any questions, please feel free to make yourself aware So we have oh, I see I see the question. I see the question What are the risks of IV iron infusion? Very good point very good question It depends on which iron formulation you're using They're elder. They're old preparations It's never the iron. It's always the co-drug and the some of the older drugs have a sugar transport molecule and There's a high risk of Allergic reactions the newer preparations like carboxyl maltase or so on they have a very low risk they have also the risk of allergic reactions are very low one and obviously if you're not able to Inject it in the vein and you inject it in tissue. It can be very painful and discolorization Thank you. Any other questions out there? Lisa, I see that you In your name, but I wasn't sure if you had a question or not Yes, can you hear me? I can hear you. Yes. Oh, thank you. First of all I just want to say wonderful presentation Kai, you know, I'm a big fan of yours and the work that you do and So I just love the information and I love the results that you're giving as a survivor of multiple hospital acquired infections, you know, I've had 11 Excuse me 11 blood transfusions over the last in years and Oh, you know, one of the things I've noticed is that whenever I am sick whether I had a I had a Stomach virus earlier this year. I just Got back from the summit in London and unfortunately I had bronchitis when I returned because I my immune system has been greatly compromised But I find that Now I am Thrown I can tell in my own body when I am anemic and when my iron is deficient the last time I was in the hospital They kept me an extra day just pumping blood iron through the IV and all of the nutrients in my blood that were missing And so it's it's from a patient perspective This work is so vitally important and I'm glad to see that you carried it out Years later to look at the morbidity and mortality Of it and I wanted to know where there are other side effects or things that you also found As you looked at the long-term results of some of the blood transfusions and the anemia Thank you very much Alicia. It's so wonderful to hear your voice and to know that you feel better now Research has to be said in the long-term effect. There's not much research being done And that's what I don't understand because we transfuse we transfuse humans in 70 or 80 years No one has really looked at the long-term effects that what happened after 10 years No one what we know is with each transfusion the immune system is compromised and people have basically a Paralysis of the immune system and that is the real one of the reasons why Patients will attract easier infection, but also we have there's some evidence It's not one of the same proven, but there's strong indicators for that that if you have Or if you might have Cancer and if it's only a small one no one has detected so far and the immune system goes down the cancer is better chance to multiply and to spread and There are some other things as well which The transfusion goes along because we know that when you get a red blood cell transfusion You also been transfused white blood cells Although nowadays the production of red blood cells is far better the quality is far better And it's obviously life savings in a lot of situation, but you get white blood cells and these white blood cells obviously they are from a donor and these white blood cells Will detect that your cells your own body cells are foreign so you will have a little Explosion in your body because two immune systems are fighting against each other The third thing what we know from transfusion is it is associated with increased risk of myocardial infarction stroke and Some other things and I can tell you a true story for my own family. It happened last week Father Submitted in my hospital two weeks ago. He's living abroad and He had an emergency procedure where I was anesthetizing him and the second one a week later and He was really anemic and I had to transfuse him and after 35 hours after The transfusion he was suffering from a stroke. So we did all the investigation you have to do See suffering from endocarditis has the any edge of fibrillation or any other cause or anything Because we could rule out everything. So now our diagnosis is a Coar chloropathy so coagulation problems related to transfusion because he had an emboli in his brain so it's a lot of things at the moment for all of you, but I Don't want that you think that transfusion overalls is a bad thing Transfusion is saving life and that is important to know but the wrong transfusion the wrong patient for the wrong indication It can be dangerous Thank you, Kai You're welcome Alicia. I There's a question I can see where can people go for more information or to The recent study very simple if you go on the web page patient blood management and and one word dot you for you pin union you find a lot of information you even get to 45 minute minute documentaries the links. They are also been Basically in English and you find a lot of other things Information links and so on it's highly recommendable go to patient blood management dot You for you pin union great Great. Well, we still have three minutes any other questions from those of you On the web don't like that. Everybody's happy. Oh I did hear some voice Well, I since we have some time I have a follow-up question How do you feel about banking blood prior to a surgery? patients banking their own blood in anticipation of the possible need for it or perhaps a family member So that the blood is as close a match as possible Yeah The two things banking your own blood prior a procedure It's not recommended anymore. The reason being is very simple by the time your blood has been taking from you You will lose Blood and for you to Reproduce this blood so that you have a normal blood a red blood cell mess takes time it takes up to two three weeks and The blood you have banked has only a certain amount of time where you can transuse it So that means on one side you take a blood Bank it the other side you're getting anemic is not a very good idea and the third thing is about what had happened quite often That although is your blood you have banked it and you have done everything Sometimes it happened and you can look at a literature people got the wrong blood So there was a chance you received blood from someone else and not the blood you have basically banked for yourself That's unbelievable. So I'm not in favor of this anymore But there's certain exceptions if you have a very rare blood group that could make sense Also that a family member might be able to to provide blood, but these are really Exceptions otherwise nowadays with our knowledge. We know it's not recommended. Okay. Thank you Welcome. I don't know if we have time for one more question, but there's one in the chat room How much iron pre-office efficient? Oh, yes, I can see yeah Thank you for the question that depends a little bit on the iron deficiency anemia the the grade of the amount so Usually 500 milligram up to 1000 milligram is sufficient is really depending on the body weight and Iron status. It's the top of the hour. I really appreciate Everyone getting on the line and on the web today to hear professor Kai Zacharowski speak Kai Thank you so much again. We always enjoy hearing you speak and Inspiring people to make changes that can really make a big impact on patient care We will be sending out a survey to those of you who provided your email so that you can give us some feedback on our Webinars to make them better in the future and we hope that you will join us for our next webinar More information is on our website, but it'll be in June. So thank you so much Have a great rest of your day and we will hopefully see you again soon