Optimisation of pre-operative anaemia in patients before elective major surgery - why, who, when and how?

Anaemia in surgical patients is a common and serious problem; around 40% of patients presenting for major surgery are anaemic. Patients with pre-operative anaemia have significantly higher rates of morbidity and mortality and are likely to be transfused red cells. In addition, red cell transfusions are independently associated with worse outcomes. Pre-optimisation of anaemia in surgical patients leads to higher pre-operative haemoglobin concentrations and less need for transfusion. Patients undergoing major surgery (defined as blood loss > 500 ml expected or possible) should be optimised if their haemoglobin concentration is less than 130 g.l-1 on screening. Detection of anaemia should follow listing for surgery as soon as possible to allow enough time for optimisation. The most common cause of pre-operative anaemia is iron deficiency, which can be treated with iron therapy. Iron clinics should be set up in either primary or secondary care to allow for optimal treatment. In this review, we present literature supporting the optimisation of pre-operative anaemia and propose a treatment algorithm.

The association between borderline pre-operative anaemia in women and outcomes after cardiac surgery: a cohort study.

Anaemia is common before cardiac surgery and is associated with increased morbidity and mortality. The World Health Organization (WHO) definition of anaemia is lower for women than for men by 10 g.l-1 , potentially putting women at a disadvantage compared with men with regard to pre-operative optimisation. Our hypothesis was that women with borderline anaemia (defined by us as haemoglobin concentration 120-129 g.l-1 ) would have a higher rate of red cell transfusion, morbidity and mortality than non-anaemic women (haemoglobin ≥ 130 g.l-1 ). This retrospective observational study included all adult patients admitted for elective cardiac surgery from January 2013 to April 2016. During the study period, 1388 women underwent cardiac surgery. Pre-operatively, 333 (24%) had a haemoglobin level < 120 g.l-1 ; 408 (29%) 120-129 g.l-1 ; and 647 (47%) ≥ 130 g.l-1 . Compared with non-anaemic women, women with borderline anaemia were more likely to be transfused (68.6% vs. 44.5%; RR 1.5, 95%CI 1.4-1.7; p < 0.0001) and were transfused with more units of red cells, mean (SD) 1.8 (2.8) vs. 1.3 (3.0); p < 0.0001. Hospital length of stay was significantly longer in the borderline anaemia group compared with non-anaemic women, median (IQR [range]) 8 (6-12 [3-45]) vs. 7 (6-11 [4-60]); p = 0.0159. Short- and long-term postoperative survival was comparable in both groups. Borderline anaemia is associated with increased red cell transfusion and prolonged hospital stay. Future research should address whether correction of borderline anaemia results in improved outcomes.