Anemia in the Preoperative Patient
Section snippets
Anemia
Anemia is the most common hematologic problem in the preoperative patient. Often, it is a sign of an underlying disease or condition that could affect the surgical outcome. Consequently, blood transfusions are commonly given perioperatively to anemic patients. In 2006, the supply of allogenic whole blood/red blood cells in the United States was estimated to be more than 15.7 million units, and an estimated 14.6 million units were transfused.1 It has been shown that 40% to 70% of all red cell
History and Physical Examination
The evaluation of the anemic preoperative patient should always begin with a thorough history and physical examination. The history should first attempt to elicit symptoms of bleeding, such as menstrual blood loss, hematochezia, melena, hematemesis, hemoptysis, or hematuria. It is also important to ask about symptoms related to the anemia and the body's compensatory mechanisms, that is, anginal chest pain, dyspnea, fatigue, and palpitations. Any history of or symptoms of underlying illnesses,
Risk for anemia in surgical patients
The risk for anemia in patients can be ascertained from studies involving those who decline blood transfusions. The largest such study was a retrospective cohort study performed on 1958 consecutive surgical patients who refused transfusions based on religious reasons. The overall 30-day risk of mortality increased with decreasing preoperative hemoglobin concentrations, especially in those patients with a hemoglobin level of less than 6 g/dL.6 The risk for death was much greater, however, in
Observational Studies
There have been many observational studies documenting the effect of anemia and red blood cell transfusions on clinical outcomes of patients undergoing surgery, of those with acute coronary syndromes, and of those admitted to intensive care units. A systematic review of the literature identified 45 cohort studies including 272,596 patients.17 With the exception of 3 studies, the risks for transfusion appeared to outweigh the benefits. Transfusion was associated with an increased risk for death,
Reversible Causes
In the case of iron deficiency anemia, the underlying cause, such as blood loss, should be identified and treated. Therefore, a thorough gastrointestinal evaluation is often indicated. The supplementation of iron, however, should also be initiated. Iron is most easily given in the oral form, the least expensive of which is ferrous sulfate. Ferrous sulfate provides 65 mg of elemental iron per 325 mg tablet. It is recommended that adults receive 150 to 200 mg of elemental iron per day in
Summary
Anemia produces a unique set of challenges in the preoperative patient. An efficient evaluation of anemia relies on a detailed history and physical examination and a systematic approach to the diagnostic testing. The presence of anemia and the use of perioperative blood transfusions have potential ramifications on the surgical outcome. Although evidence suggests that a lower transfusion threshold may be appropriate in most preoperative patients, the decision to transfuse must be individualized
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This work was supported by Grant No. U01 HL73958 from the National Heart, Lung and Blood Institute, National Institutes of Health.