Can This Patient Proceed to Surgery?
Yes, this patient can proceed to surgery, but requires urgent evaluation for iron overload and the underlying cause of their markedly elevated iron saturation (57%) and serum iron (216 μg/dL), as these values suggest possible hemochromatosis or other iron metabolism disorders rather than iron deficiency. 1, 2
Understanding the Laboratory Values
The patient's iron studies reveal a paradoxical pattern that is not consistent with iron deficiency anemia:
- Ferritin 12 ng/mL: Severely low, suggesting depleted iron stores 3
- Serum iron 216 μg/dL: Markedly elevated (normal range typically 60-170 μg/dL)
- Iron saturation 57%: Significantly elevated (normal 20-50%) 2
- TIBC (calculated from "burning 376"): Likely 376 μg/dL, which is normal to slightly elevated
This combination is highly unusual and suggests either:
- Laboratory error or specimen contamination
- Recent iron supplementation or transfusion
- Hemochromatosis with concurrent blood loss
- Thalassemia trait or other hemoglobinopathy 2
Preoperative Assessment Required
Immediate Actions Before Surgery
The surgery should not be delayed solely based on these iron studies, but the following evaluation is essential: 3
- Repeat iron studies to confirm accuracy, as the pattern is internally inconsistent
- Complete blood count (CBC) to assess actual hemoglobin level and mean corpuscular volume 4
- Reticulocyte count to evaluate bone marrow response 3
- C-reactive protein (CRP) to assess for inflammation that might affect ferritin interpretation 2
- Comprehensive metabolic panel including creatinine and GFR to rule out chronic kidney disease 3
Interpretation of Iron Saturation >50%
High transferrin saturation (>50%) typically indicates iron overload conditions rather than deficiency and warrants investigation for:
- Hereditary hemochromatosis
- Secondary iron overload
- Recent iron administration 2
This patient does NOT fit the typical preoperative iron deficiency pattern where ferritin <30 ng/mL would be accompanied by TSAT <20% and low serum iron 3, 1
Decision Algorithm for Surgery
If Hemoglobin is Normal (≥130 g/L):
- Proceed with surgery as scheduled 4
- Complete the diagnostic workup postoperatively
- No iron supplementation needed preoperatively given the elevated iron saturation 1
If Hemoglobin is Low (<130 g/L):
- For elective surgery >4 weeks away: Delay surgery, complete diagnostic evaluation, and treat underlying cause 3, 4
- For elective surgery 2-4 weeks away: Consider brief delay for evaluation; if anemia is mild and patient is otherwise stable, may proceed with close monitoring 4
- For urgent/semi-urgent surgery <2 weeks away: Proceed with surgery but optimize perioperatively 1
Critical Pitfalls to Avoid
Do NOT administer iron supplementation (oral or IV) based solely on the low ferritin without understanding the complete clinical picture, as the elevated iron saturation suggests adequate or excessive circulating iron despite low stores 1, 2
Do NOT assume this is simple iron deficiency anemia - the elevated TSAT and serum iron are inconsistent with this diagnosis and suggest a more complex iron metabolism disorder 2
Do NOT delay necessary surgery for prolonged workup if the patient's hemoglobin is adequate and they are otherwise stable for the planned procedure 3
Recommended Preoperative Management
- Verify hemoglobin level immediately - this is the most critical determinant of surgical risk 4
- Repeat iron studies to confirm the unusual pattern
- Consult hematology if the pattern persists, as this may represent an underlying hemoglobinopathy or iron metabolism disorder 3
- Ensure adequate hydration and optimize other comorbidities 4
- Plan for potential blood conservation strategies intraoperatively if anemia is confirmed 3
The presence of preoperative anemia (if confirmed) is associated with increased morbidity and mortality, but the decision to proceed depends on the urgency of surgery, severity of anemia, and ability to correct it in the available timeframe. 3, 4