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Preoperative preparation and planning are essential for the safe and optimal management of surgical patients. This principal applies to the management of preoperative anemia in elective surgical patients with anticipated major blood loss.

As the use of autologous predonation continues to fall out of favor due to its ineffectiveness as a blood conservation measure, there is growing interest in proactively addressing anemia in high risk surgical patients. Of all the risk factors for transfusion in surgical procedures, low red cell mass is consistently at the top of the list; more importantly, it is one of the few risk factors that is modifiable. Anemia and transfusion in surgical patients have been associated with a higher incidence of complications, including infection, longer length of stay, and increased perioperative mortality. Early identification of anemia in surgical patients has recently gained national attention as it falls under one of the Joint Commission’s Blood Management Performance Measures, currently being beta tested in 75 hospitals. As such, early recognition of anemia in surgical patients may soon become a requirement rather than a recommendation for hospitals.

In order to successfully establish a preoperative anemia management program, a multidisciplinary, multimodal approach is required. The following are recommended steps to establish such programs:

  1. Develop a multidisciplinary team to lead the initiative (representatives from surgery and anesthesia, administration, nursing, preadmission testing, orthopedic case manager/coordinator, physician liaison, pharmacy and finance)
  2. Identify a physician champion that will help to develop and utilize the protocol
  3. Review the literature and develop a preoperative anemia protocol/order set for the use of epoetin alfa and iron supplementation in elective surgical patients
  4. Develop a strategy for early identification of anemic high risk surgical patients at least one month prior to elective major blood loss surgery
  5. Establish a location where the preoperative patients can be evaluated and treated under the protocol/ order set
  6. Determine where and how the protocol/ order set will be first be rolled out
  7. Prospectively capture outcomes data and financial data (reimbursement) for patients on the protocol to support its continued use.

While the steps described above are fairly straightforward, there are also cultural challenges to address, including ownership and accountability for the protocol. Education about the risks of anemia and transfusion, along with the benefits of better preoperative patient preparation are necessary prerequisites to implementing such protocols. This education should target surgeons as well as their office staff, and patient care guides describing blood management options should also be provided.

Early identification and management of patients at risk of complications is an increasing focus of regulatory agencies and hospital systems, and a number of third party insurers are pushing for financial alignment through non-payment of “never events.” Preoperative anemia management programs present a tremendous opportunity to reduce a modifiable risk for our patients, and I challenge you to join the growing number of hospitals establishing such programs.

Selected References:

  • Dunne JR, Malone D, Tracy JK, et al. Perioperative anemia: an independent risk factor for infection, mortality, and resource utilization in surgery. J Surg Res 2002, 102:237:244.
  • Faris PM, Ritter MA, Abels RI. The effects of recombinant human erythropoietin on perioperative transfusion requirements in patients having a major orthopaedic operation. The American Erythropoietin Study Group. J Bone Joint Surg Am 1996, 78:62-72.
  • Goodnough LT, et al. Detection, Evaluation and Management of Anemia in the Elective Surgical Patient. Anesth Analg 2005;101:1858-61
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