What are the consensus practice guidelines for patients with anemia undergoing surgery?

From the Guidelines

Consensus practice guidelines for patients with anemia having surgery recommend preoperative optimization of hemoglobin levels whenever possible, with a focus on treating iron deficiency anemia with intravenous iron supplementation to reduce the need for blood transfusions and improve outcomes. For elective surgeries, patients should be screened for anemia at least 4 weeks before the procedure, with a target hemoglobin of at least 13 g/dL for men and 12 g/dL for women 1. Iron deficiency anemia should be treated with iron supplementation, preferably intravenous iron (such as iron sucrose 200 mg or ferric carboxymaltose 500-1000 mg) for faster correction, especially when surgery is scheduled within 2-4 weeks 1.

Key Considerations

• Preoperative anemia is associated with an increased risk of postoperative complications, increased rate of blood transfusion, and mortality, and may worsen long-term oncology outcomes 1
• The recent PREVENTT trial showed that the use of intravenous iron in patients with all types of anemia before major open elective abdominal surgery increased hemoglobin concentrations before surgery but did not reduce the frequency of blood transfusion, mortality, in-hospital complications, length of stay, or quality of life relative to a placebo 1
• A 2021 systematic review showed that preoperative IV iron supplementation decreased blood transfusion by 16% and was not associated with increased incidence of any adverse effects across the groups 1
• All patients should have their hemoglobin concentration measured before listing for major elective surgery, and where blood transfusion is anticipated, this and alternatives to transfusion should be discussed with the patient before surgery, and their consent should be documented according to local protocols 1

Treatment Approaches

• Oral iron (ferrous sulfate 325 mg daily) can be used when time permits, typically 6-8 weeks before surgery
• For patients with other types of anemia, treatment should target the underlying cause
• Erythropoiesis-stimulating agents like epoetin alfa (300-600 IU/kg three times weekly) may be considered for patients with anemia of chronic disease
• Blood transfusions should be reserved for patients with severe anemia (hemoglobin <7-8 g/dL) or those with symptomatic anemia and cardiovascular risk factors

Intraoperative and Postoperative Strategies

• Minimizing blood loss through meticulous surgical technique
• Cell salvage
• Antifibrinolytics like tranexamic acid (10-15 mg/kg IV)
• Restrictive transfusion thresholds These approaches aim to reduce transfusion requirements, decrease complication rates, shorten hospital stays, and improve surgical outcomes by ensuring adequate oxygen delivery to tissues during the perioperative period.

From the Research

Consensus Practice Guidelines for Patients with Anemia Having Surgery

• The consensus practice guidelines for patients with anemia having surgery involve the optimization of pre-operative anemia to reduce morbidity and mortality rates 2.
• Patients undergoing major surgery should be optimized if their haemoglobin concentration is less than 130 g.l-1 on screening, with detection of anemia following listing for surgery as soon as possible to allow enough time for optimization 2.
• The most common cause of pre-operative anemia is iron deficiency, which can be treated with iron therapy, and iron clinics should be set up in either primary or secondary care to allow for optimal treatment 2.

Treatment Strategies for Anemic Patients Before Surgery

• Patient blood management programs have been developed to reduce the need for blood transfusion during surgery and improve patient outcomes, with a primary focus on the identification, diagnosis, and treatment of preoperative anemia 3.
• Timely detection and definition of the etiology of anemia before elective surgery are crucial to accurately correct preoperative anemia 3.
• Preoperative iron substitution in patients with iron deficiency is recommended, although the evidence of its effectiveness is limited 3.
• Combined therapy with erythropoiesis-stimulating agents and intravenous iron is recommended for patients with non-pure iron deficiency anemia, which may effectively reduce the need for red blood cell transfusion 3.

Prevention, Diagnosis, and Management of Perioperative Anemia

• Anemia is common in the perioperative period and is associated with poor patient outcomes, and should be actively addressed throughout the perioperative spectrum of patient care 4.
• Evidence-based recommendations for the prevention, diagnosis, and treatment of anemia include the utility of iron supplementation and erythropoiesis-stimulating agents (ESAs) 4.
• The preoperative administration of iron monotherapy may not result in a reduced number of patients or units transfused, although iron supplementation in addition to ESAs probably results in a reduced red blood cell utilization 5.

Efficacy and Safety of Erythropoietin and Iron Therapy

• The optimal treatment strategy for anemia remains to be established, although treatment of anemia includes oral and intravenous iron and erythropoiesis stimulating agents (ESAs) 6.
• Erythropoiesis stimulating agents and iron therapy reduced red blood cell transfusion relative to iron therapy, without any change in mortality, stroke, myocardial infarction, renal dysfunction, pulmonary embolism, or deep vein thrombosis 6.
• Administration of ESA and iron therapy reduced the risk for red blood cell transfusion compared with iron therapy alone in patients undergoing cardiac and non-cardiac surgery, although publication bias and heterogeneity reduces the confidence of the finding 6.