Anticipation Key to Tackling Perioperative Anemia

Liam Davenport

April 07, 2022

MANCHESTER, England — About one third of patients who are scheduled for major surgery are anemic. This issue is underrecognized and it requires the involvement of all healthcare professionals to work together to optimize care and maximize outcomes, state the first UK guidelines for perioperative anemia.

Anemia management may include dietary changes, iron supplementation, blood transfusion, perioperative physiological optimization, delay or review of the surgical plan, medication reviews, and greater intraoperative care.

It is quite clear that patients have a better experience if management covers the whole pathway, commented lead author of the guidelines, Scarlett McNally, MD, PhD, East Sussex Healthcare NHS Trust, Eastbourne, UK.

It's much better for the patient "if every individual member of staff knows what's supposed to happen, not just for their bit, but the whole way along," she commented to Medscape Medical News. "Otherwise things go wrong, and people don't anticipate things early enough." 

The new guidelines, to be published in full later this year by the Centre for Perioperative Care, cover emergency and elective surgery for all ages.

It follows the 2021 publication of a guideline for perioperative diabetes management, and a previous document that covered frailty.

McNally was presenting the new guidelines on perioperative anemia here at the British Society for Haematology 62nd Annual Scientific Meeting.

Although perioperative anemia is a "big issue" in clinical management, "some healthcare professionals know a lot about one area," but tend to work in "silos," McNally commented.

The result is clinicians believe that all other areas are "complex" and opaque, and they "don't make the simple decisions" that could have a big impact on patient care.

As an example, she said there are already some excellent guidelines out there, but they are not widely read.

One example of a comprehensive guideline, McNally said, is that issued by the British Society of Gastroenterology. This guideline notes that in cases where a man or a postmenopausal woman has anemia of unknown cause, about 30% of those cases end up having a gastrointestinal cause, and so gastroenterologists are happy to have those patients referred to them.

But McNally said that she personally, as an orthopedic surgeon, wouldn't have known what to do with such a patient, and may have referred that person back to primary care to be investigated.

The new guidelines contain algorithms to help staff plan care. Without those, she said, "a lot is resting on the preassessment nurses, but they are having to think about everything else."

The guidance suggests proactive measures to identify and manage anemia. These include testing for anemia while assessing renal function ahead of a CT scan, or asking patients about their nutrition.

For low risk patients, it may be enough to give general advice about a good diet and exercise to try to get them through the operation.

However, patients who are high risk (defined as likely to lose >500 mL or >10% of blood volume during surgery), need to be identified as such early on, so that early measures can be put in place, as well as a senior review of their care plan.

The guidelines also recommend that operating room staff consider tranexamic acid and other bloodless minimization strategies, and that senior staff give clinical input in cases of functional iron deficiency, a marker of ill health.

To maximize postoperative outcomes, it is suggested that staff work with prehabilitation services and mobilize patients, as symptoms allow.

More importantly, they emphasize the need for shared decision-making about potential surgery, ensuring that the patients understand 'Benefits, Risks, Alternatives, and what if we do Nothing (BRAN).'

No funding was declared. Study author Caroline R. Evans declares relationships with the National Institute for Health Research and Pfizer.

No other relevant financial relationships were declared.

British Society for Haematology 62nd Annual Scientific Meeting: Abstract BSH22-PO119. Presented April 4, 2022.

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