Elsevier

Anesthesiology Clinics

Volume 36, Issue 4, December 2018, Pages 701-713
Anesthesiology Clinics

Optimizing Preoperative Anemia to Improve Patient Outcomes

https://doi.org/10.1016/j.anclin.2018.07.017Get rights and content

Section snippets

Key points

  • Several studies have shown that preoperative anemia leads to increased morbidity and mortality following major surgery.

  • The varying degrees of perioperative practice patterns and the health-related impact of preoperative anemia highlight the urgent need to identify new strategies to optimize preoperative anemia.

  • Multiple published protocols recommend testing patients for hemoglobin at least 1 month before surgery, to allow intervention and treatment to take effect before surgery. This initial

Preoperative anemia and postoperative outcomes

The literature on preoperative anemia and postoperative outcomes is discussed here, based on surgical specialty, including cardiac surgery, general surgery, thoracic surgery, spine surgery, orthopedic (eg, joint arthroplasty), and vascular surgery.

Anemia screening in the preoperative assessment clinic

Patient blood management is defined by the Society for the Advancement of Blood Management as the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcome. The 3 pillars include the optimization of red blood cell mass, reduction of blood loss and bleeding, and optimization of the patient’s physiologic tolerance of anemia (Fig. 1).50

In the setting of the preoperative

Treatment of anemia for preoperative optimization

Although professional society guidelines exist for the perioperative management of blood products, including transfusion triggers and cancellation guidance, less clear guidance exists on the perioperative optimization of patient red blood cell volume to improve clinical outcomes.57, 58, 59, 60 Preoperative anemia is clearly associated with worsened outcomes postoperatively. A holistic approach to perioperative blood management focuses on preoperative optimization of red blood cell mass,

Summary

Anemia is a common preoperative finding in surgical populations. With only subtle clinical symptoms except when anemia becomes severe, a systematic approach to the screening and clinical assessment of anemia is needed when performing a preoperative assessment. Given the association between the severity of anemia and increased complication rates, mortality, and hospital length of stay, it is important to identify and optimize these patients. The risk factors associated with transfusion of blood

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      There is no clear strategy for addressing anemia in the current CLTI guidelines.21 Preoperative screening several weeks in advance can expose anemia in time to detect underlying iron and vitamin B12 deficits, which can be corrected and decrease postoperative transfusions.22,23 Intravenous iron supplementation as part of a prehabilitation protocol reduces preoperative anemia and seems safe; however, the effect on mortality remains unclear.24

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      Multiple etiologies can predispose a person to anemia, with the main causes being nutritional deficiency anemia, anemia of chronic disease (ACD), repeated phlebotomies, dilutional anemia and bone marrow suppression due to sulfur drugs, chemotherapy and radiotherapy.5–8 Iron deficiency anemia (IDA) is reported to be the most common cause of anemia in preoperative patients, affecting 33% of the population.9 Moreover, previous research has stated that IDA, ACD and anemia of unexplained origin is amply present among surgical patients, as compared to other etiologies.10,11

    • Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations — Part I: Preoperative and intraoperative management

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      Recombinant human erythropoietin may be considered in impaired erythropoiesis but carries the risk of perioperative thrombotic events. Rarely is preoperative blood transfusion indicated, except in cases of haemoglobinopathies such as sickle cell disease [29,30]. Summary and recommendation: In CRS±HIPEC patients at risk for heavy alcohol consumption, an intensive alcohol cessation programme, including pharmacological intervention ±counselling ±interviews, at least four weeks prior to surgery should be indicated routinely to reduce the risk of surgical complications.

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    Disclosures: None.

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