Is medical clearance indicated for total shoulder replacement in a patient with anemia (low hemoglobin)?

From the Guidelines

Medical clearance for a total shoulder replacement with a hemoglobin level of 9.1 g/dL should be approached cautiously, and the patient should be evaluated for the cause of anemia and treated accordingly before surgery. The patient's low hemoglobin level increases the risk of postoperative complications, and correcting the anemia preoperatively is crucial to reduce this risk 1.

Causes and Treatment of Anemia

• The cause of anemia should be investigated, and iron deficiency anemia should be treated with oral or intravenous iron supplementation 1.
• Intravenous iron has been shown to be more effective than oral iron in restoring hemoglobin concentrations in patients with iron deficiency anemia and anemia of chronic disease 1.
• A 2021 systematic review found that preoperative IV iron supplementation decreased blood transfusion by 16% and was not associated with increased incidence of any adverse effects 1.

Management and Monitoring

• The patient should be optimized nutritionally with adequate protein intake and vitamin supplementation, including B12 and folate.
• Blood transfusion may be necessary if hemoglobin falls below 8 g/dL during the perioperative period, as recommended by the American College of Physicians 1.
• Postoperatively, continued iron supplementation and close monitoring of hemoglobin levels are essential to prevent further complications.

Collaboration and Decision-Making

• The final clearance decision should involve collaboration between the surgeon, anesthesiologist, and primary care physician, weighing the risks of proceeding against the risks of delaying surgery.
• The patient's overall health, including the presence of cardiovascular disease, should be taken into consideration when making the decision to proceed with surgery 1.

From the Research

Medical Clearance for Total Shoulder Replacement with Low Hemoglobin

• A hemoglobin level of 9.1 is considered low and may require medical clearance before undergoing total shoulder replacement surgery.
• According to 2, a hemoglobin level below 11 g/dl is a significant independent prognostic factor associated with shorter survival in cancer patients, however, this may not be directly applicable to total shoulder replacement surgery.
• In patients with low hemoglobin levels, iron supplementation can improve hematopoietic response, reduce the need for red blood cell transfusions, and increase hemoglobin levels 3.
• For patients who decline blood transfusion, a comprehensive set of strategies called "Bloodless Medicine and Surgery" (BMS) can be used to optimize hematopoietic capacity, minimize blood loss, and improve hemostasis 4.
• A systematic approach should be used to determine the diagnosis of low hemoglobin level, including patient history and laboratory values 5.
• Iron deficiency anemia can be treated with ferrous sulfate, which has a high bioavailability and can reduce side effects with a sustained iron release dosage form 6.
• It is essential to note that the provided studies may not directly address the specific question of medical clearance for total shoulder replacement with low hemoglobin, and further research may be necessary to provide a definitive answer.