Feature Articles

Anemia and Surgery: From the Preoperative Period to Postoperative Recovery

December 3, 2008

Anemia is an important concern for the surgical patient throughout the entire surgical process, including the preoperative period, the surgery itself, as well as the postoperative recovery period. It is estimated that one-third1 to one-half2 of surgical patients may be anemic preoperatively secondary to the conditions for which they require surgery. After surgery, anemia is even more common, affecting 90% of patients.1,2

“Anemia can affect how patients respond to surgery and how quickly they return to health,” said Dr. Aryeh Shander, Chief of the Department of Anesthesiology and Critical Care Medicine, at Englewood Medical Center in Englewood, NJ. “Unfortunately, testing for anemia is often not a top priority during the preoperative period. Anemia is often one of the easiest conditions to diagnose and to treat when it is recognized early enough before surgery.”

Anemia is commonly unrecognized and overlooked by physicians and surgeons because it often exhibits very non-specific symptoms or no symptoms at all. Detection of anemia is often overshadowed by the myriad of other concerns that need to be addressed when preparing a patient for surgery.

Preoperative Anemia Screening
While hemoglobin screening is included in standard pre-admission testing, it usually occurs only 3-7 days prior to surgery. This precludes the opportunity to effectively evaluate and manage the patient who is found to be anemic, and may result in postponement or cancellation of the surgical procedure. Dr. Shander recommends, “Whenever clinically feasible, elective surgery patients should have their hemoglobin level tested a minimum of 30 days before the scheduled surgical procedure. Preoperative anemia is associated with perioperative risks of blood transfusion, as well as increased perioperative morbidity and mortality.”

Anemia should be viewed as a significant clinical condition, rather than simply an abnormal laboratory value.Causes of Anemia in Surgical Patients
The causes of preoperative anemia are multifactorial and may include acute or chronic blood loss, poor nutrition, renal insufficiency, malignancy or chronic disease.3,4 Additionally, some patients may be more susceptible to perioperative anemia than others. Studies have shown that female patients, those with smaller body surface area, and African American patients are at increased risk.1,5

Untreated bleeding episodes, along with the frequent phlebotomies that are a standard part of postoperative procedure, cause blood loss and can contribute to anemia during surgery and recovery.4 Postoperative inflammatory response can additionally lead to blunted erythropoietic response and diminished iron availability, resulting in anemia.3

Causes of Preoperative Anemia
  • Acute or chronic blood loss
  • Poor nutrition
  • Renal insufficiency
  • Malignancy
  • Chronic disease

Consequences of Anemia
Anemia should be viewed as a significant clinical condition, rather than simply an abnormal laboratory value.6 In surgical patients, anemia has been linked to increased postoperative morbidity and mortality.7 Several studies have shown that patients with preoperative anemia have a higher incidence of allogeneic blood transfusion compounding the problems from anemia which may include a longer hospital stay and an increased likelihood of dealth after surgery.2,7,8 Patients who are transfused after surgery as a result of anemia are more likely to develop postoperative infection, require longer periods of mechanical ventilation, and have a greater risk of mortality.9,10

Strategies for Managing Anemia

Blood Transfusions – In some circumstances, blood transfusion may be a necessary procedure, but concerns about their risk have restricted their use. Blood transfusion has many known adverse effects including potential transmission of infectious diseases, allergic and hemolytic transfusion reactions, and immunomodulation.10,11 Allogeneic blood transfusion should be avoided whenever possible because of these associated risks and also because transfusion has not been proven to improve postoperative outcomes.12

Blood Conservation Techniques – In surgeries with expected high blood loss, strategies to reduce operative blood loss may help prevent postoperative anemia and may decrease or eliminate the need for allogeneic blood transfusions. These strategies include meticulous surgical technique, the use of autologous blood, acute normovolemic hemodilution and cell salvage, to name a few.

Erythropoiesis-Stimulating Agents (ESAs) and Iron – ESA plus iron therapy can be used to correct preoperative anemia and has been shown to reduce the need for blood transfusions. In addition to reducing the need for transfusion, management of anemia with erythropoietin and iron has been shown to accelerate erythropoiesis, Hb recovery, and enhance quality of life and function in surgery patients.13-15

Recognition and treatment of anemia during the preoperative period gives surgeons more options for dealing with the blood lost during surgery. Comprehensive anemia management can reduce or eliminate the need for perioperative allogeneic transfusions, and provide better outcomes. According to Dr. Shander, “Recognizing and treating anemia before any elective surgery is extremely important, and could be a life saving intervention.”

References

  1. Clemens J, Spivak JL. Serum immunoreactive erythropoietin during the perioperative period. Surgery. 1994 Apr;115(4):510-15. Link.
  2. Dunne JR, Malone D, Tracy JK, Gannon C, Napolitano LM. Perioperative anemia: an independent risk factor for infection, mortality, and resource utilization in surgery. J Surg Res. 2002 Feb;102(2):237-44. Link.
  3. Kulier A, Gombotz H. Perioperative anemia. Anaesthesist. 2001 Feb;50(2):73-86. Link.
  4. Eckardt KU. Anemia in critical illness. Wien Klin Wochenschr. 2001 Feb 15;113(3-4):84-89. Link.
  5. DeFoe GR, Ross CS, Olmstead EM, Surgenor SD, Fillinger MP, Groom RC, Forest RJ, Pieroni JW, Warren CS, Bogosian ME, Krumholz CF, Clark C, Clough RA, Weldner PW, Lahey SJ, Leavitt BJ, Marrin CA, Charlesworth DC, Marshall P, O'Connor GT. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg. 2001 Mar;71(3):769-76. Link.
  6. Nissenson AR, Goodnough LT, Dubois RW. Anemia: not just an innocent bystander? Arch Intern Med. 2003 Jun 23;163(12):1400-04. Link.
  7. Carson JL, Duff A, Poses RM, Berlin JA, Spence RK, Trout R, Noveck H, Strom BL. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet. 1996 Oct 19;348(9034):1055-60. Link.
  8. Faris PM, Spence RK, Larholt KM, Sampson AR, Frei D. The predictive power of baseline hemoglobin for transfusion risk in surgery patients. Orthopedics. 1999 Jan;22(1 Suppl):s135-40. Link.
  9. Gruson KI, Aharonoff GB, Egol KA, Zuckerman JD, Koval KJ. The relationship between admission hemoglobin level and outcome after hip fracture. J Orthop Trauma. 2002 Jan;16(1):39-44. Link.
  10. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion medicine. First of two parts--blood transfusion. N Engl J Med. 1999 Feb 11;340(6):438-47. Link.
  11. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion medicine. Second of two parts--blood conservation. N Engl J Med. 1999 Feb 18;340(7):525-33. Link.
  12. Spence RK. Anemia in the patient undergoing surgery and the transfusion decision. A review. Clin Orthop Relat Res. 1998 Dec;(357):19-29. Link.
  13. Atabek U, Alvarez R, Pello MJ, Alexander JB, Camishion RC, Curry C, Spence RK. Erythropoetin accelerates hematocrit recovery in post-surgical anemia. Am Surg. 1995 Jan;61(1):74-77. Link.
  14. Yazicioğlu L, Eryilmaz S, Sirlak M, Inan MB, Aral A, Taşöz R, Eren NT, Kaya B, Akalin H. Recombinant human erythropoietin administration in cardiac surgery. J Thorac Cardiovasc Surg. 2001 Oct;122(4):741-45. Link.
  15. Braga M, Gianotti L, Gentilini O, Vignali A, Corizia L, Di Carlo V. Erythropoiesis after therapy with recombinant human erythropoietin: a dose-response study in anemic cancer surgery patients. Vox Sang. 1999;76(1):38-42. Link.