Prevalence and causes of preoperative anaemia in elective major surgery patients

Blood transfusion in older surgical patients: the only option or is there a better approach?

Anemia is a common clinical condition that can significantly affect patient outcomes, particularly in those undergoing surgery. In older adults, the presence of anemia combined with cardiovascular disease can increase surgical morbidity and mortality, influencing surgical decisions and creating a cascade of complications that may negatively impact recovery. Blood transfusion remains the primary response to anemia in the perioperative setting, despite evidence suggesting potential adverse effects on survival and recovery. However, older adults present unique challenges due to age-related physiological changes anda reduced tolerance to anemia and blood loss. The debate between restrictive and liberal blood transfusion strategies in this population remains unresolved. Patient Blood Management (PBM) protocols have been developed to systematically address perioperative anemia. This review emphasizes the need for a nuanced approach to transfusion in older adults, suggesting that while a restrictive strategy may not be universally applicable, decisions should be guided by thorough clinical evaluations. These assessments should prioritize not only hemoglobin levels but also patient-specific factors, including life expectancy, comorbidities, and patient preferences, with the involvement of a multidisciplinary team to tailor the best approach for everyone.

Magnitude and associated factors of preoperative anemia among adult elective surgical patients at Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia, 2024

Background

Preoperative anemia is a common hematologic public health problem among elective surgical patients. Preoperative anemia complications independently increase the risk of perioperative complications and mortality rate. Despite this complication, there is a scarcity of evidence on the prevalence and associated factors of preoperative anemia among adult elective surgical patients in Ethiopia. Therefore, this study aimed to investigate the magnitude and associated factors of preoperative anemia among adult elective surgical patients at Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.

Methods

An institution-based cross-sectional study was conducted from January 1 to 30, 2024 at Saint Paul's Hospital Millennium Medical College. A consecutive sampling technique was used to select eligible study participants. Chart review and a structured, pretested, and interviewer-administered questionnaire were employed. Kobo toolbox was used to collect the data and exported to SPSS version 25 software for data cleaning, coding, and analysis. Binary logistic regression model was fitted to identify factors associated with preoperative anemia. An adjusted odds ratio (AOR) with its 95% CI and a p-value of ≤0.05 was used to declare a statistical association.

Results

A total of 247 study participants were included in the analysis, giving a response rate of 98.8%. Majority (68%) of the participants were from urban areas. The median age of the patient was 38 (IQR ± 32) years. The magnitude of preoperative anemia was found to be 27.1% (95% CI: 21.9, 33.1). Being female (AOR = 3.44; 95%CI: 1.53, 7.73), being overweight (AOR = 0.26; 95%CI: 0.10, 0.88), and having infection and injury/trauma as indications for surgery (AOR = 4.59; 95%CI: 1.62, 12.96) and (AOR = 3.58; 95%CI: 1.35, 9.49) were significantly associated with preoperative anemia.

Conclusion

In this study, more than one-fourth of the study participants had preoperative anemia. To decrease this public health problem, it is better to screen at risk patients, specifically females and trauma patients during the preoperative visit and disseminate information about a healthy diet and the prevention and treatment of anemia through health education.

Optimizing the transfusion strategy in surgical patients in a Lebanese university hospital

BACKGROUND AND PURPOSE

Our aim was to analyze factors that influence transfusion requirements in surgical patients in order to achieve a transfusion-saving strategy.

METHODS

Data was collected from patient's files at the Notre Dame de Secours-Jbeil University Hospital Center between January 2017 and June 2019. Selection was made for 400 patients who had undergone surgery and required transfusion. The studied variables were age, sex, and type of surgery whether planned or urgent with its expected level of bleeding. The presence of chronic anemia, coronary artery disease, values of hemoglobin and hematocrit before and after transfusion, iron status preoperatively, and post-operation complications were also noted.

RESULTS

The analysis of 400 transfused surgical patients showed that the mean age was 62 ± 18 years with 52.5% women and 47.5% men. In 82.3% of patients, surgical bleeding was expected, 77.8% of surgeries were scheduled, and 22.3% were urgent. Fifty-two percent of patients were known to have coronary artery disease. Orthopedic (35%) and cardiothoracic (29.5%) surgeries had the highest transfusion rate. Among all patients, only 106 patients (26.5%) underwent a preoperative iron workup. The pre-transfusion levels of hemoglobin were 9.9 ± 0.6 and hematocrit of 29.7 ± 1.9. 26.3% of patients had a post-transfusion complication. On the other hand, 19.5% of women and 20% of men were already anemic when admitted to the hospital. Anemic women required 7.6 times more transfusions than non-anemic, while anemic men required 12.38 times more transfusions than non-anemic men. Age, presence of coronary artery disease, and chronic anemia have been found to be factors increasing the risk of post-transfusion complications. Finally, urgent and unplanned surgeries are 2.9 times more likely to cause post-transfusion complications.

CONCLUSION

This study therefore confirms that anemic patients are more likely to receive perioperative blood transfusions. Consequently, in order to reduce blood transfusion and its complications, it would be beneficial primarily to diagnose and treat anemia preoperatively. Other transfusion-saving strategies could also be useful in the setting of surgical bleeding, such as the use of tranexamic acid and different autologous transfusion methods like the cell saver.

Prevalence and risk factors of preoperative anemia in patients undergoing elective orthopedic procedures in Northwest Ethiopia: a multicenter prospective observational cohort study

BACKGROUND

Preoperative anemia is a common hematologic problem in major orthopedic surgery in developing countries. It is a condition in which the number and size of red blood cells are insufficient to meet the body's physiologic needs, consequently impairing the capacity of the blood to transport oxygen to the body. Preoperative anemia is common in elective orthopedic surgical patients and is an independent risk factor for perioperative morbidity and mortality. This study aimed to assess preoperative anemia prevalence and risk factors in patients undergoing elective orthopedic procedures.

METHOD

A multicenter prospective observational cohort study was conducted from June 01 to August 30, 2022. A systematic random sampling technique was used to select the study unit. Data were collected using a structured questionnaire. Descriptive statistics were expressed in percentages and presented with tables and figures. Binary logistic regression was used to see the association between independent and dependent variables. A P-value < 0.05 was considered statistically significant.

RESULT

Preoperative anemia's prevalence and risk factors in patients undergoing elective orthopedic procedures was 24.1[95%CI= (18.2-30.6)]. Multivariable logistic analyses showed that low monthly income level [AOR:5,95%CI:(1.36-7.98)], patient with cancer [AOR:3.4,95%CI:(3.7-8.84)], patient with malaria infectious [AOR: 3.2,95%CI:( 1.13-8.91)], patient with anti-retroviral therapy [AOR: 5.2,95%CI:( 1.8-11.04)], and previous history of surgery [AOR:1,95%CI(1.43-2.4)], were factors significantly associated with preoperative anemia.

CONCLUSION

The prevalence of preoperative anemia among adult patients who underwent elective orthopedics procedures was high. Low Monthly income, patients with cancer, patient with malaria infection, and patients with anti-retroviral therapy, previous histories of surgery were found significantly associated with preoperative anemia. So, we recommend to health professional's early identification, diagnosis and treatment of preoperative anemia should be done to reduce the risks of anemia and related adverse outcomes.

Preoperative Anemia Is a Predictor of Worse Postoperative Outcomes Following Open Pancreatoduodenectomy: A Propensity Score-Based Analysis

Background

Preoperative anemia is a common clinical situation proved to be associated with severe outcomes in major surgeries, but not in pancreatic surgery. We aim to study the impact of preoperative anemia on morbidity and mortality in patients undergoing open pancreatoduodenectomy and use propensity score matching (PSM) to balance the basal data and reduce bias.

Methods

We analyzed the data of consecutive patients undergoing open pancreatoduodenectomy with a complete record of preoperative hemoglobin, at two pancreatic centers in China between 2015 and 2019. Anemia is defined as hemoglobin less than 12 g/dl for male and 11 g/dl for female, following Chinese criteria. We compared clinical and economic outcomes before and after PSM and used logistic regression analysis to assess the correlation between variables and anemia.

Results

The unmatched initial cohort consisted of 517 patients. A total of 148 cases (28.6%) were diagnosed with anemia at admission, and no case received a preoperative blood transfusion or anti-anemia therapy. After PSM, there were 126 cases in each group. The rate of severe postoperative complications was significantly higher in the anemia group than in the normal group (43.7% vs. 27.0%, p = 0.006), among which the differences in prevalence of clinically relevant postoperative pancreatic fistula (CR-POPF) (31.0% vs. 15.9%, p = 0.005) and cardiac and cerebrovascular events (4.0% vs. 0.0%, p = 0.024) were the most significant. The costs involved were more in the anemia group (26958.2 ± 21671.9 vs. 20987.7 ± 10237.9 USD, p = 0.013). Among anemic patients, receiver operating characteristic (ROC) curve analysis shows the cut-off value of hemoglobin, below which, patients are prone to suffer from major complications (104.5 g/l in male and 90.5 g/l in female). Among all patients, multivariate analysis showed that preoperative obstructive jaundice [odds ratio (OR) = 1.813, 95% confidence interval (CI) (1.206–2.725), p = 0.004] and pancreatic ductal adenocarcinoma [OR = 1.861, 95% CI (1.178–2.939), p = 0.008] were predictors of anemia. Among paired patients, preoperative anemia [OR = 2.593, 95% CI (1.481–5.541), p = 0.001] and malignant pathology [OR = 4.266, 95% CI (1.597–11.395), p = 0.004] were predictors of postoperative severe complications.

Conclusion

Preoperative anemia is a predictor of worse postoperative outcomes following open pancreatoduodenectomy and needs to be identified and treated.

Prevalence and factors associated with preoperative anemia among adult patients scheduled for major elective surgery at University hospital in Northwest Ethiopia; a cross-sectional study

BACKGROUND

Anemia is the most common hematological finding in surgical patients. One-third of surgical patients were anemic during preoperative assessment. The presence of preoperative anemia was found to be related with increased morbidity, mortality, length of hospital stay, intensive care unit admissions and postoperative infections.

OBJECTIVE

To determine the prevalence and factors associated with preoperative anemia among adult patients scheduled for major elective surgery at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2020.

METHODS

After obtaining an ethical approval, hospital-based cross-sectional quantitative study was conducted from June to August 2020 in University of Gondar Hospital. Full blood count within two weeks of preoperative period was considered valid if there were no any factors that affect the hematologic system Descriptive statistics, cross-tabulations and binary logistic regression analysis were performed to identify factors associated withpreoperative anemia. The strength of the association was presented using AOR with 95% confidence interval and p-value < 0.05 was considered as statistically significant.

RESULT

A total of 185 patients enrolled with 100% response rate. We observed preoperative anemia in 36.8% patients. The multi-variable binary logistic analysis showed that ASA II and III [AOR: 3.8, CI: 1.6-9.2], recent prior surgery [AOR: 3.3, CI: 1.3-8.5], history of malignancy [AOR: 9.4, CI: 2.0-43.4], orthopedic procedure [AOR: 11.2, CI: 4.0-31.6] and gynecologic procedure [AOR: 5.2, CI: 1.7-14.5] were significantly associated with preoperative anemia.

CONCLUSION

The prevalence of preoperative anemia was high and ASA ≥2, recent prior surgery, history of malignancy, orthopedic surgery and gynecologic procedure were significantly associated with preoperative anemia. We recommend to clinicians to aim prevention, early detection and treatment of preoperative anemia among adult patients scheduled for major elective surgery to reduce risk of anemia and related adverse outcomes.

Hematinic and Iron Optimization in Peri-operative Anemia and Iron Deficiency

Purpose of Review

Preoperative anemia is independently associated with worse postoperative outcomes following cardiac and noncardiac surgery. This article explores the current understanding of perioperative anemia and iron deficiency with reference to definition, diagnosis, and treatment.

Recent Findings

Iron deficiency is the most common cause of anemia. It can arise from reduced iron intake, poor absorption, or excess iron loss. Inflammation throughout the preoperative period can drive iron sequestration, leading to a functional deficiency of iron and the development of what was referred to until recently as the “anemia of chronic disease.” Current best practice guidance supports the routine administration of preoperative intravenous iron to treat anemia despite limited evidence. This “one size fits all” approach has been called into question following results from a recent large, randomized trial (the PREVENTT trial) that assessed the use of a single dose of intravenous iron compared to placebo 10–42 days before major abdominal surgery. Although there were no improvements in patient-centered outcomes apparent during the initial hospital stay, secondary endpoints of this trial suggested there may be some late benefit after discharge from the hospital (8 weeks postoperatively). This trial raises questions on (1) the mechanisms of iron deficiency in the perioperative patient; (2) the need to reassess our opinions on generic anemia management; and (3) the need to address patient outcomes after discharge from hospital.

Summary

Despite the known associations between preoperative anemia (particularly iron deficiency anemia) and poor postoperative outcome, recent evidence suggests that administering intravenous iron relatively close to surgery does not yield a tangible short-term benefit. This is made more complex by the interplay between iron and innate immunity. Iron deficiency irrespective of hemoglobin concentration may also impact postoperative outcomes. Therefore, further research into associations between iron deficiency and postoperative outcomes, and between postoperative anemia, delayed outcomes (hospital readmission), and the efficacy of postoperative intravenous iron is required.

Perioperative anemia: clinical practice update

Perioperative medicine is an evolving area of medicine in which collaboration between internists, hospitalists, surgeons and anesthesiologists is the key to delivering high-quality care. Research in all areas of perioperative medicine, including perioperative anemia, is constantly evolving. Perioperative anemia is a major contributor to mortality and morbidity in the perioperative period. It is associated with an increased likelihood of postoperative wound complications, infections, delirium, increased length of stay and increased risk of readmissions. However, there is a lack of comprehensive guidelines for management of perioperative anemia. We performed an exhaustive review of contemporary literature on perioperative anemia and present evaluation and management recommendations that have the potential to impact clinical practice in the perioperative period.

Real-world results of the implementation of preoperative anaemia clinic with intravenous iron therapy for treating iron-deficiency anaemia: a propensity-matched case-control study

Background

Preoperative anaemia is associated with blood transfusion and longer hospital length of stay. Preoperative iron deficiency anaemia (IDA) can be treated with oral or intravenous (IV) iron. IV iron can raise haemoglobin faster compared with oral iron. However, its ability to reduce blood transfusion and length of stay in clinical trials is inconclusive. This study aims to compare blood transfusion and hospital length of stay between anemic patients who received preoperative IV iron versus standard care, after implementation of a protocol in 2017 to screen patients for preoperative IDA, and its treatment with IV iron.

Methods

Retrospective before-after cohort study comparing 89 patients who received IV iron preoperatively in 2017, with historic patients who received oral iron therapy (selected by propensity score matching (PSM) from historic cohort of 7,542 patients who underwent surgery in 2016). Propensity score was calculated using ASA status, age, gender, surgical discipline, surgical risk and preoperative haemoglobin concentration. Both 1:1 and 1:2 matching were performed as sensitivity analysis.

Results

After PSM, there was no statistically significant difference in distribution of preoperative clinical variables. There was no significant difference in proportion of cases requiring transfusion nor a difference in average units transfused per patient. IV iron cohort stayed in hospital on average 8.0 days compared to non-IV iron cohort 14.1–15.1 days (P=0.006, P=0.013 respectively). Average time from IV iron therapy to surgery was 10.5 days.

Conclusions

Preoperative IV iron therapy for patients with IDA undergoing elective surgery may not reduce perioperative blood transfusion, but this could be due to the short time between therapy and surgery. Implementation of IV iron therapy may reduce hospital length of stay compared to standard care for anemic patients, although this may be enhanced by concomitant improvement in perioperative care.

Preoperative Anemia Screening and Treatment Practices in Patients Having Total Joint Replacement Surgery: A Retrospective, Observational Audit

Background

Surgical patients with preoperative anemia are more likely to experience adverse outcomes. Patient blood management (PBM) guidelines recommend screening and treating patients for anemia preoperatively to enable optimisation before surgery. This study investigates compliance with PBM guidelines and reports the association between length of stay and transfusion risk in patients with preoperative anemia.

Study Design and Methods

A retrospective, observational, chart audit that included all patients having primary, total hip and knee replacement surgery between July-December 2018 at a tertiary, metropolitan healthcare facility.

Results

Six hundred and seven patients patients were included, 96% (n = 583) patients had blood tests available (full blood count), and 8.1% (n = 49) had iron studies. Most patients 53% (n = 324) were screened between 2 and 6 days before surgery; 14.6% (n = 85) were anaemic preoperatively and only 5.9% (n = 5) of anaemic patients received treatment. Patients who had anemia preoperatively were more likely to receive a blood transfusion (odds ratio 8.65 [95% CI 3.98-18.76]) and stayed longer in hospital (median difference = 1, χ² _LR = 17.2, df=1, p<0.007).

Conclusion

Tests ordered for patients having major surgery should include iron studies, renal function, CRP and full blood count to enable detection and classification of preoperative anemia. Timing of screening relative to surgery needs to be sufficient to allow patient optimisation to occur. Appropriate treatment should be provided to anaemic patients to prevent unnecessary blood transfusions and reduce the length of stay. A standardised preoperative anemia pathway may assist in improving practice.

Managing preoperative anemia: Evolving concepts and strategies for improving patient outcomes

Anemia is the most common hematological disease, and is defined by the World Health Organization as a condition in which the number of red blood cells and consequently oxygen-carrying capacity is insufficient to meet the physiological needs of the body. Anemia can occur throughout the perioperative period and has important clinical consequences. Preoperative anemia is usually regarded as no more than a surrogate marker of a patient's physical status, and it is not always adequately addressed before surgery. Postoperative anemia is a common event and occurs in 80-90% of patients who have undergone major surgery. This manuscript discusses the detection and management of preoperative anemia, the three pillars of patient blood management, perioperative anemia management, and risk stratification for anemia in the surgical setting.

[Diagnostics and treatment of preoperative anemia]

Approximately 14-40% of patients in industrialized countries present with preoperative anemia. Depending on the severity, anemia is associates with increased perioperative morbidity and mortality. One of the most important causes of preoperative anemia is iron deficiency which is usually easy to treat. Implemented in the multimodal concept of patient blood management, the diagnostics and treatment of preoperative anemia are important aspects for improvement of perioperative outcome. Adequate and early diagnostics of the cause of anemia before treatment is important because treatment options, e.g. with iron, erythropoetin, folic acid and vitamin B₁₂, may be expensive, may have severe side effects, and in the case of a wrong indication, will not improve anemia. In addition, an adequate regeneration of the erythrocyte volume requires time. This review article presents important aspects of the epidemiology and prognostic implications of preoperative anemia, the physiology and pathophysiology of anemia as well as diagnostic features and the evidence base for preoperative treatment options.