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“Evidence-based therapeutic options should be weighed before, during, and after surgical procedures in order to effectively manage perioperative anemia.” Lawrence T. Goodnough, MD

The 3 pillars of anemia management for the surgical population may be divided into 3 phases: preoperative, intraoperative, and postoperative. To keep blood loss at a minimum in this population, it is important to identify anemia preoperatively, plan surgical techniques and strategies to reduce blood loss intraoperatively, and prevent complications postoperatively.

According to recommendations of the Society for the Advancement of Blood Management, it is prudent to plan and test patients well in advance for surgery (eg, 30 days prior) to allow sufficient time for therapeutic interventions, including administration of iron, vitamin B12, and erythropoietin, agents that increase red blood cell mass. Other strategies include restricting diagnostic phlebotomy and carefully managing anticoagulation. Anticoagulation can be addressed by discontinuing agents that can adversely affect clotting. Preoperative autologous donation (PAD) is another technique for use in this patient population, although it has become less popular as a blood-saving strategy.

Meticulous hemostasis and careful surgical dissection are among those intraoperative strategies that are critical for reducing blood loss. Additionally, preservation of the patient’s blood through acute normovolemic hemodilution is a low-cost option that can significantly reduce loss of red cell mass in surgical cases with a high-expected blood loss. Autotransfusion, or autologous blood cell salvage, is an appropriate option when religious objections exclude the use of allogeneic blood or when massive amounts of blood are lost. This method involves reinfusing recovered blood into the patient after it has been surgically extracted from a surgical wound, washed, or filtered.

Postoperatively, relevant methods of anemia management include close surveillance for bleeding, adequate oxygenation, restricted phlebotomy for diagnostic tests, postoperative cell salvage, pharmacologic enhancement of hemostasis, avoidance of hypertension, tolerance of normovolemic anemia, and meticulous management of anticoagulants and antiplatelet agents.

Ultimately, the goal is to limit the amount of blood withdrawn before, during, and after surgery. If the patient’s blood management strategy is effectively customized to address unique deficiencies, then management of perioperative anemia is achieved.


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