What are the guidelines and ferritin cutoff for iron transfusion prior to major surgery, including abdominal procedures such as hernia repair?

From the Guidelines

Iron transfusions before surgery are typically recommended for patients with iron deficiency anemia, defined as ferritin levels below 100 ng/mL, and preoperative iron therapy should be considered for major surgeries with expected blood loss >500 mL, including cardiac, orthopedic, gynecological, and major abdominal surgeries, as supported by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline 1.

Key Considerations

• Preoperative anemia is associated with increased risk of postoperative complications, increased rate of blood transfusion, and mortality, and may worsen long-term oncology outcomes 1.
• Patients with iron deficiency anemia should receive iron therapy, either oral or intravenous, to reduce blood transfusions and increase hemoglobin levels before elective non-cardiac surgery 1.
• Hernia repair is generally not considered major abdominal surgery unless it's complex or involves extensive dissection, and typically doesn't require preoperative iron therapy unless the patient has significant anemia.

Treatment Recommendations

• For patients requiring iron supplementation, intravenous iron is preferred when surgery is scheduled within 6 weeks, as oral iron takes longer to replenish stores.
• Treatment should begin 2-4 weeks before surgery when possible, with a total iron dose calculated based on hemoglobin deficit and body weight, typically ranging from 1000-1500 mg for most adults.

Benefits of Iron Therapy

• Iron therapy helps optimize oxygen-carrying capacity before surgery, reducing transfusion requirements and improving postoperative recovery, with the greatest benefit in surgeries with significant blood loss 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.
• 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 and reduced the risk of readmission to hospital for complications 1.

From the FDA Drug Label

Inclusion criteria prior to randomization included hemoglobin (Hb) <12 g/dL, ferritin ≤100 ng/mL or ferritin ≤300 ng/mL when transferrin saturation (TSAT) ≤30%. Inclusion criteria included hemoglobin (Hb) ≤11. 5 g/dL, ferritin ≤ 100 ng/mL or ferritin ≤300 ng/mL when transferrin saturation (TSAT) ≤ 30%. Iron deficiency was defined as serum ferritin <100 ng/mL or 100 to 300 ng/mL with TSAT <20%.

The guidelines for iron transfusion prior to surgery are not explicitly stated in the provided drug label. However, the label does provide information on the treatment of iron deficiency anemia, including the following ferritin cutoffs:

• Ferritin ≤100 ng/mL
• Ferritin ≤300 ng/mL when TSAT ≤30%
• Ferritin ≤300 ng/mL when TSAT ≤20% (for patients with heart failure)

The label does not specify which surgeries should have iron transfusion prior to the procedure. Additionally, it does not explicitly state whether hernia repair is considered major abdominal surgery. 2

From the Research

Guidelines for Iron Transfusion Prior to Surgery

• There are no specific guidelines mentioned in the provided studies regarding iron transfusion prior to surgery.
• However, study 3 discusses the efficacy and safety of intravenous ferric carboxymaltose in patients with iron-deficiency anemia, which may be relevant to pre-surgical iron transfusion.

Ferritin Cutoff for Iron Transfusion

• No specific ferritin cutoff values are mentioned in the provided studies for iron transfusion prior to surgery.
• Study 3 mentions the change in ferritin levels as an efficacy measure, but does not provide a specific cutoff value.

Surgeries Requiring Iron Transfusion

• The provided studies do not specifically address which surgeries require iron transfusion prior to surgery.
• However, studies 4, 5, 6, and 7 discuss various aspects of hernia repair surgery, including outcomes, complications, and risk factors.

Hernia Repair as Major Abdominal Surgery

• Study 4 describes the repair of complex incisional hernias as a major challenge, suggesting that hernia repair can be considered a major abdominal surgery.
• Study 5 discusses the postoperative complication rates of open incisional ventral hernia repair, which is a type of major abdominal surgery.
• Study 6 investigates the viability of complex ventral hernia repair in class III morbidly obese patients, which is also a type of major abdominal surgery.
• Study 7 analyzes the risk factors for long-term recurrence after ventral hernia repair, which is a type of major abdominal surgery.