What are the medical clearance requirements for total shoulder replacement in a patient with anemia (low hemoglobin)?

From the Guidelines

Medical clearance for total shoulder replacement with low hemoglobin should prioritize optimizing the patient's hemoglobin levels before proceeding with surgery to reduce perioperative risks, as recommended by the most recent guidelines 1. The initial approach should include identifying the cause of anemia through laboratory testing, such as complete blood count, iron studies, B12, and folate levels.

• For iron deficiency anemia, oral iron supplementation (ferrous sulfate 325 mg three times daily) should be started 4-6 weeks before surgery, as suggested by previous guidelines 1.
• If time is limited or oral iron is not tolerated, intravenous iron (such as iron sucrose or ferric carboxymaltose) can be administered.
• For severe anemia (hemoglobin <8 g/dL) or symptomatic patients, blood transfusion may be necessary, targeting a hemoglobin of at least 8-10 g/dL before surgery.
• Erythropoietin therapy (40,000 units subcutaneously weekly for 3-4 weeks preoperatively) can be considered for patients with chronic kidney disease or anemia of chronic disease, as recommended by older guidelines 1. Optimizing hemoglobin levels preoperatively is crucial as anemia increases the risk of perioperative blood transfusions, postoperative infections, prolonged hospital stays, and cardiovascular complications, as highlighted in the more recent guidelines 1.
• Additionally, patients should be advised to continue any prescribed cardiac medications and maintain good glycemic control if diabetic, as these factors also impact surgical outcomes.
• Patient pathways and pre-assessment clinics should be established to allow timely and appropriate management, and elective surgery should be delayed if required, as suggested by the guidelines 1.

From the Research

Medical Clearance for Total Shoulder Replacement with Low Hemoglobin

• Total shoulder replacement is a major orthopedic surgery that requires careful preoperative planning, especially in patients with low hemoglobin levels 2, 3.
• Low hemoglobin levels can increase the risk of blood transfusion during or after surgery, which can lead to additional complications 2, 3.
• Several studies have investigated the use of preoperative iron supplementation to improve hemoglobin levels before total joint arthroplasty, including total shoulder replacement 4, 5.
• Preoperative iron supplementation has been shown to increase preoperative hemoglobin levels and reduce the need for blood transfusions 4, 5.
• The use of tranexamic acid (TXA) has also been studied as a way to reduce blood loss during total shoulder arthroplasty and reverse total shoulder arthroplasty 6.
• TXA has been shown to decrease perioperative blood loss, change in hemoglobin and hematocrit, and postoperative drain output in patients undergoing primary shoulder arthroplasty 6.

Predictors of Blood Transfusion

• Several factors have been identified as predictors of blood transfusion in patients undergoing total shoulder replacement, including:
  • Lower preoperative hemoglobin level 2, 3
  • Lower preoperative hematocrit level 2
  • History of anemia 2, 3
  • Hypertension 2
  • Cerebrovascular accident 2
  • Estimated blood loss (EBL) 3

Preoperative Management

• Preoperative management of patients with low hemoglobin levels undergoing total shoulder replacement may include:
  • Iron supplementation to improve hemoglobin levels 4, 5
  • Use of erythropoietin to stimulate red blood cell production 4
  • Optimization of underlying medical conditions, such as hypertension and cerebrovascular accident 2
  • Consideration of the use of TXA to reduce blood loss during surgery 6