An international consensus statement on the management of postoperative anaemia after major surgical procedures

Abstract

Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.

Keywords: anaemia; erythropoiesis stimulating agents; iron deficiency; iron supplementation; postoperative period; transfusion.

Figure 1

Postoperative anaemia management. (a) Whenever possible, assess iron status within 24 h postoperatively, if it has not been already performed in the pre‐operative assessment. Monitor haemoglobin for 3–4 days postoperatively. (b) According to WHO classification. (c) Appropriate treatment should be considered. (d) Postoperative ferritin < 100 μg.l⁻¹, ferritin < 300 μg.l⁻¹ and transferrin saturation < 20% or reticulocyte haemoglobin content < 28 pg. (e) Due to pre‐operative anaemia or heavy surgical bleeding, irrespective of iron status. (f) Total iron deficiency = (target haemoglobin − actual haemoglobin) × weight (kg) × 0.24. Add another 10 mg.kg⁻¹ for replenishing iron stores, especially in patients with pre‐operative iron deficiency. Consider adding recombinant human erythropoietin (40,000 IU) for patients with severe anaemia or declining transfusion. For i.v. iron dosing schedule, see Table 1. (i) Transfuse one red blood cell unit at the time, with post‐transfusion re‐assessment of further needs. Consider i.v. iron supplementation after transfusion, using post‐transfusion haemoglobin as actual haemoglobin for total iron deficiency calculation.