‘Fit to fly’: overcoming barriers to preoperative haemoglobin optimization in surgical patients

Abstract

In major surgery, the implementation of multidisciplinary, multimodal and individualized strategies, collectively termed Patient Blood Management, aims to identify modifiable risks and optimise patients' own physiology with the ultimate goal of improving outcomes. Among the various strategies utilized in Patient Blood Management, timely detection and management of preoperative anaemia is most important, as it is in itself a risk factor for worse clinical outcome, but also one of the strongest predisposing factors for perioperative allogeneic blood transfusion, which in turn increases postoperative morbidity, mortality and costs. However, preoperative anaemia is still frequently ignored, with indiscriminate allogeneic blood transfusion used as a 'quick fix'. Consistent with reported evidence from other medical specialties, this imprudent practice continues to be endorsed by non-evidence based misconceptions, which constitute serious barriers for a wider implementation of preoperative haemoglobin optimisation. We have reviewed a number of these misconceptions, which we unanimously consider should be promptly abandoned by health care providers and replaced by evidence-based strategies such as detection, diagnosis and proper treatment of preoperative anaemia. We believe that this approach to preoperative anaemia management may be a viable, cost-effective strategy that is beneficial both for patients, with improved clinical outcomes, and for health systems, with more efficient use of finite health care resources.

Management of Perioperative Iron Deficiency Anemia

“…The WHO criteria for the definition of anemia may not be reliable for the classification of nonpregnant women undergoing surgical procedures with expected moderate-to-high blood loss [4, 5]. Recently, a study of 1,388 women who underwent cardiac surgery revealed that “borderline” Hb concentrations (12.0–12.9 g/dL) were associated with increased red blood cell transfusion (RBCT) requirements and prolonged hospital stay compared to no anemia (Hb ≥13 g/dL) [6].…”

“…Recently, a study of 1,388 women who underwent cardiac surgery revealed that “borderline” Hb concentrations (12.0–12.9 g/dL) were associated with increased red blood cell transfusion (RBCT) requirements and prolonged hospital stay compared to no anemia (Hb ≥13 g/dL) [6]. Irrespective of gender, in patients scheduled for a major surgical procedure, a preoperative Hb <13 g/dL should be considered as suboptimal [4, 5]. …”

Nutrition in peri-operative esophageal cancer management

“…Preoperative anemia is common in esophageal cancer and is a risk factor in itself for a worse clinical outcome, as well as a strong predisposing factor for perioperative blood transfusion, which in turn increases morbidity, mortality, and costs [70][71][72]. Detection, diagnosis, and proper treatment of anemia are central in the concept of preoperative blood management in surgical patients [70].…”

“…Detection, diagnosis, and proper treatment of anemia are central in the concept of preoperative blood management in surgical patients [70]. At present, preoperative iron therapy is recommended for iron-deficiency anemia [17].…”

The Relationship Between Preoperative Hemoglobin Concentration, Use of Hospital Resources, and Outcomes in Cardiac Surgery

“…Reasons why pre -operative hemoglobin concentration may be a more useful marker than anemia status include that anemia, as defined by WHO criteria, is a late marker of iron deficiency. It has also been argued that it may be inappropriate to define anemia by different values with respect to gender in a surgical population where blood loss has a proportionately greater effect on circulating blood volume in females (17). It is tempting to speculate whether treatment will lead to an improvement in post-operative outcomes.…”