Anemia in the Preoperative Patient

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Anemia is commonly encountered in the preoperative patient. Determination of the cause of the anemia can affect perioperative surgical and medical management and outcome. Red blood cell transfusions are often administered during the perioperative time period in patients with preoperative anemia, although evidence to support the optimal transfusion threshold is limited. The authors review the evaluation of anemia and evidence regarding perioperative blood transfusions. Recommendations on the treatment of anemia, including perioperative blood transfusions, are outlined.

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

References (49)

  • S.S. Cook et al.

    Transfusion practice in central Virginia

    Transfusion

    (1991)
  • E.A. Friedman et al.

    A study of national trends in transfusion practice

    (1980)
  • A.W. Wells et al.

    Where does blood go? Prospective observational study of red cell transfusion in north England

    BMJ

    (2002)
  • J.L. Carson et al.

    Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion

    Transfusion

    (2002)
  • J.M. Leung et al.

    Electrocardiographic ST-segment changes during acute, severe isovolemic hemodilution in humans

    Anesthesiology

    (2000)
  • P. Toy et al.

    Fatigue during acute isovolemic anemia in healthy, resting humans

    Transfusion

    (2000)
  • R.B. Weiskopf et al.

    Acute severe isovolemic anemia impairs cognitive function and memory in humans

    Anesthesiology

    (2000)
  • R.B. Weiskopf et al.

    Human cardiovascular and metabolic response to acute, severe isovolemic anemia

    JAMA

    (1998)
  • D.R. Spahn et al.

    Hemodilution tolerance in elderly patients without known cardiac disease

    Anesth Analg

    (1996)
  • D.R. Spahn et al.

    Hemodilution tolerance in patients with coronary artery disease who are receiving chronic β-adrenergic blocker therapy

    Anesth Analg

    (1996)
  • C. Madjdpour et al.

    Anemia and perioperative red blood cell transfusion: a matter of tolerance

    Crit Care Med

    (2006)
  • W.C. Wu et al.

    Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery

    JAMA

    (2007)
  • A. Shander et al.

    Do preoperative anemia and polycythemia affect clinical outcome in patients undergoing major surgery?

    Nat Clin Pract Cardiovasc Med

    (2008)
  • P.E. Marik et al.

    Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature

    Crit Care Med

    (2008)
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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.

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