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Guidance needed to manage preoperative, as well as postoperative anemia in elective surgery
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Lately, increased attention has been paid to anemia among orthopaedic patients who undergo major planned elective surgery, such as lower limb joint reconstruction or spine surgery, since recent publications have documented these patients more frequently require postoperative blood transfusions. Because we see more elderly patients today and they lead more active lifestyles than in the past, more are referred for reconstructive surgery. Therefore, we will need clear guidelines for anemia to assist both orthopaedic surgeons and anesthetists.
There are several issues. One concerns the initial level of hemoglobin (Hb) at which a patient scheduled for surgery is considered anemic. Some investigators propose 130 g/L Hb as the level for anemia. If that is an accepted level, by some accounts 35% of the U.S. population would have anemia. Other researchers discuss the fact that Hb less than 100 g/L always needs attention, while other reports say it is acceptable for Hb to decrease to 80 g/L before anything needs to be done. However, still other studies report different Hb levels are acceptable for men and women, and even the levels for women vary depending on whether the woman is premenopausal or postmenopausal.
There needs to be a clear consensus on the definition of anemia, if for no other reason than there are so many different definitions of the condition.
Once anemia has been properly diagnosed preoperatively, physicians should know what to do to manage it. I think we all know what to do when severe anemia is diagnosed, such as less than 50 g/L Hb. In my clinic, these patients are referred to the general practitioner for a detailed examination and treatment. Elderly patients with severe anemia most frequently have an iron deficiency and can easily have this corrected within weeks. However, gastrointestinal cancer may be the actual reason for the anemia and that must be ruled out.
Milder anemia in elderly and younger patients proves more challenging. The main question is whether we should proceed with surgery if we, as the surgeon, feel the patient is healthy enough or screen him or her to learn the extent of the anemia and treat it preoperatively. Clear guidelines for this scenario are lacking.
Finally, probably the most discussed and controversial issue is what the Hb level should be after surgery and at what point we should consider blood transfusion in patients with symptoms, such as dizziness, nausea, low blood pressure and tachycardia. This is a daily debate in a department like mine in which we have many patients who undergo short-stay total joint replacement. The medical staff and patients would prefer a quick and non-complicated recovery, but this demands a relatively liberal blood transfusion policy. However, transfusions are known to increase morbidity.
When it comes to anemia, a distinction is needed between healthy and younger patients and elderly patients with recognized comorbidities. Some physicians believe about 50 g/L Hb can be acceptable for a healthy young patient, even one who is symptomatic, but there are no hard and fast guidelines that say such an Hb level is acceptable. More guidance is needed.
I encourage further discussions concerning anemia management among orthopaedic surgeons and anesthetists. The more we can come to a consensus in this area, the better it will be for our patients.
- For more information:
- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Rd., Thorofare, NJ 08086, USA; email: orthopaedics@healio.com.
Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.