Good questions.  I'll give the usual qualified response.

I have a few patients, eg one elderly lady with hereditary haemorrhagic telangiectasia, who need repeat iron top-ups quite often.  I follow these up in the Outpatients myself.  The HHT lady gets 3,000mg of iron almost every 3 months, despite also receiving tranexamic acid.  The others I rely on the GPs to follow and ask them to send them back when their ferritin falls below 50mcg/L, to minimize symptoms.

I worked out Flecknoe-Brown's rough guide to appropriate use of blood transfusion in iron deficiency a few years ago after a few elderly, quite anaemic patients went into pulmonary oedema after receiving the iron polymaltose in 1 litre of saline.  If the haemoglobin concentration in g/L is lower than their age in years, I believe a unit or two of blood before giving IV iron is reasonable.  And I use smaller volumes of saline to infuse the iron polymaltose.

Thanks for this comment - I've been tending to use a lot of 1g doses as most of my patients are frail and elderly, with increases for younger, fitter or more anaemic folk (HB <80) (the ones with HB's <80 almost always end up having a transfusion as well, especially if ED get to them first!) The next question would be - how often? I am aware we top people up with iron infusions when they are in hospital (often for another reason), but then send them home with no plans for another infusion in a few months/year.  Most of my patients will have gastric atrophy or be on PPI's and are unlikely to absorb dietary or oral iron, even if they are no longer bleeding from somewhere. Do any of you bring people in routinely, or simply leave it for the GP to recheck ferritins/Hb over the next few months and refer as necessary?

I also tent to 'round up' the doses of IV iron polymaltose in many cases, based on the principle that iron is avidly held in the reticulo-endothelial system as reserves.  In patients with inflammatory bowel diease, particularly Crohn's disease, I'll often give as much as an extra 1.5 grams for future needs, knowing it will eventually  be needed.  Same for proven angiodysplasia of the small bowel, hereditary haemorrhagic telangiectasia and peri-menopausal women who are intending to 'wait it out' rather than have definitive surgery for menorrhagia.

Calculation of the dose required is based upon the tissue stores plus the haemoglobin deficit.  By the time a patient has a ferritin level below 20 mcg/L, they have totally depleted stores.  A small-bodied woman will need about 400 mg to top up her stores.  A big, muscular athletic male may need as much as 800 mg for stores.  It takes 200 mg of iron to produce one unit of blood.  Your own experience will tell you how many units would be needed to bring the haemoglobin level up to the mid-range, taking into account the patient's size and starting level.  It will usually calculate out at 1-1.5 g (10-15 amps), but you won't do any harm by giving 2-3 more amps while you are there, as above.  The largest quantity I have given was 4,000 mg for a 110 Kg, 2 M tall Tongan footballer with a starting Hb level of 46 g/L. 

I am a general physician and am struggling to institute regular use of iron infusions instead of blood transfusions in my hospital. One main sticking point is the complexity of the protocols for dosing and monitoring. I was pleased to hear about practice and research giving iron polymaltose over 60-90 mins but would like to know other's opinions about dosing. The current dosing schedule is complicated (based on LBW and anaemia), and appears to have been in place since 1970. I would like to propose recommending a dose of 1g or 1.5g for most people. (lower dose for elderly/frail and up to 2g for young and fit) and get away from avoiding iron infusion because it's too complicated or giving a wrong dose because of error during calculation. We have started giving a more 'standardised' dose in a couple of hospitals to ease nursing and junior medical workload.

I agree with Tim, unless there are specific reasons for pre-deposit autologous blood (PAD), eg rare red cell antibodies. A thalassaemia patient who is already anaemic and whose blood may not store well is certainly not a candidate for PAD. I presume the brother also had thal trait. If there is significant blood loss and a strong desire to avoid autologous RBC transfusion, tolerance of anaemia and the use of an erythropoeitin would be a reasonable approach. Increasingly IVI iron is being recommended in this context, even if there is no evidence of iron depletion as functional iron deficiency and inability ro rapidly mobilise iron stores is likely.

When I used to anaesthetise for radical prostate surgery, I found the patients who pre-donated blood inevetibly arrived for surgery somewhat anaemic.  Even if they were taking oral iron, their Hb was always significantly lower than prior to starting the donation. This meant the patients who predonated were much more likely to get transfused.  Autologous transfusion is far from benign (risks from storage lesions, bacterial contamination, wrong blood), therefore I agree that predonation is not indicated. After discussion with the surgeons, we weaned ourselves off the practice!  Regarding the patient with thalasaemia minor, I don't see that the logic is any different.

Had an intersting pre-op clinic patient today.  Booked for a radical prostatectomy - which gets a transfusion about 12% in our hospital.  The patient has Thallasemia Minor, and has a Haemoglobin of  105 which is normal for him.  His brother had the same operation at a different institution recently, and had autologous pre-donation.  My patient is asking about having this as well. My normal advice is not to support autologous blood, but what about here?

Sorry, it is Peter Gibson I was referring to, not David.

Ross, thanks for asking this question.  Consensus on the answer is developing, but it is not helped by the rigors of evidence-based practice.

There is a recent report in the Brit Journal of Surgery which is intersting for what it doesn't say as much as what it does.  It is a small pilot study looking at giving patients having Colorectal Surgery IV Iron sucrose 2-3 weeks preop.  Being small, it showed no benefit BUT the average "anaemic" patient had a HB over 11 as all the seriously anaemic patients had either been given oral iron or transfused!  Another of those studies where a quick glance at the abstract gives a misleading message.  Butit has a good discussion of these issues.  IV Iron seems a good therapy, but it would be good tro get some agreement about what regime to use.  Any ideas?

Edwards T. J., Noble E. J., Durran A., Mellor N,  Hosie K. B. Randomized clinical trial of preoperative intravenous iron sucrose to reduce blood transfusion in anaemic patients after  colorectal cancer surgery  British Journal of Surgery 2009; 96: 1122–1128

The most predictive pre-operative variables for post-op transfusion are type of surgery, surgeon and pre-operative haemoglobin, sex and weight have less impact and are not readily changed! 

I have just looked at our local figures for hip and knee replacements which are remarkably consistent for males and females for both procedures (over 1000 patients for each procedure).  There is an almost linear relationship between pre-op Hb and post op- transfusion rate.  In all groups the transfusion rate is under 10% if the pre-op Hb is >130g/L and 44-63% if the Hb is 110-119g/L - depending on sex and operation. 

The surgeon's influence is also interesting as this will consist of combination of intra-operative technique/length of time for surgery and post-operative transfusion trigger employed. 

Our figures show weight has an influence, transfusion rate doubles as weight reduces from 100kg (10% TKR, 20%THR) to 50kg (20% TKR, 40% THR) , under 50kg the rate double again but the numbers are small.

The influence of sex is related to the females' lower Hb (THR 129 vs 139g/L, TKR 130 vs 140g/L) and weight (13kg THR and 8 kg TKR lower than males).

To reduce the need for blood transfuions and so attendant undesirable effects, addressing pre-operative anaemia is a no brainer.  As to how this is achieved and who drives it will depend on the local organisiation and resources.  It makes sense to use the often extensive waiting times in public systems to investigate/treat anaemia pre-operatively. 

Our inappropriate post-operative transfusions are largely driven by the behaviour of our junior medical staff and nursing staff (who often influence junior medical staff).  This is by no means perfect as our rates demonstrate.  Constant education is required to produce appropriate transfusion behaviour.

There is published data to suggest that many patients go to theatre with anaemia and comonly iron deficiency anaemia, this is often not corrected pre op and the surgery proceeds. Does this increase the risk of requiring a blood transfusion intra op and post op? Why would anaemia not be corrected pre op? Is this the role of the anaesthetist or the surgeon? What is the role of the GP in managing anaemia pre elective surgery?  I would be interested in your views on this.

Regarding Bruce's comment:

Bruce you state that since outcomes are worse if transfusion prior to surgery and it  does not necessarily improve outcome in comparison to the patient that is anemic and has surgery, that we can therefore assume that if we treat the anemia preoperatively with ESA's and epo the outcomes are not necessarily going to be any different.  I want to make sure I understand your comment.

In my clinical practice I have seen great outcomes from ESA and iron but I only usually use it if it is a clear issue of renal insufficiency. If not I usually just use IV iron if there is iron deficiency. 

The biggest abuser I see in the preoperative iron deficient patient is H2 blockers and PPI's that have caused iron deficiency and anemia. Another is recent surgery such as a TJR that has been done within a 6 mo window and now they are being worked up for another. 

My point is this; don't you think that the preoperative transfused patient doesn't do much better than the anemic preoperative patient that goes to surgery due to the immunomodulatory response from the transfusion? I realize that you are referring to preoperative cardiac surgery papers that have sited such outcomes, but I think preoperative optimization even without raising the H&H is a process of improvement.  They can remake those RBC's a lot faster post op if they are preloaded with IV iron.  Just wanting clarity.

This is a great site for open dialogue and Bruce you are always an asset to these discussions.  Trudi

Let me join the discussion.

First: With regards to pre-operative anemia there is a very large literature showing that pre-operative anemia is assocaited with adverse outcomes. That however does not mean that transfusion to improve a Hgb number decreases that relationship. Indeed, anemia is a covariate and a marker for severity of illness or a marker for chronic debilitating illness. In cardiac surgery there is considerable data showing that anemic patients have more renal failure. but when Habib et al. looked at that in 2004 they found that treating the anemia with a transusion actually made the outcomes even worse than if they had simply let the patients be anemic. This last year at the American Association of Blood Bankers meeting Richard Spence presented research from a very large daatabase (>100,000 patients). Anemia by itself was related to adverse outcome, but once again pre-operative transfusion made the outcomes even worse (more mortality). Of interest, the most severely anemic patients did seem to have the least worsening of outcome by transfusion and below about 50gm/L there might be a shift towards an advantage from transfusion. But, if the patient is up above 90gm/l pre-operatively  and they recieve a transfusion the risks of mortality can be increased 4 fold or higher- Wow! 

It therefore does stand to reason that iron therpay, vitamin support and nurtition along with potential judicious use of erythropeotin drugs can boost the native pre-operative hemoglobin. We have just looked at our data in total hip and knee patients. About 20% of our patients have a pre-operative Hgb below 100-110gm/l Hgb and could well benefit from intervention. Hence we are proposing and planning an anemia clinic. Our hospital administration is working onthe business plan for making that happen. I would point out that at least in the United States a new point of care non-invasive pulse oximetry system has just  been FDA approved that allows for non-invasive real time Hgb measurement (Massimo). I have no connection to them, but I would say we think we will use it in our pre-op clinics for quick screening of all elective surgery patients. Each hospital should then decide which patients they think in their practice would benefit from Epo, iorn and advanced nutrition (consultation) etc before being scheduled for surgery.

As for post-operative transfusion and mobility, there is no definitive answer. It is a belief and I underline the word belief that if you are anemic you feel "washed out".  but, to play the devil's advocate, if you have the flu and go to bed for 3-4 days and try to get up out of bed you will become orthostatic. There is nothing in terms of blood transfusion that will increase oxygen supply. There may however be less orthostasis as a higher Hgb causes more viscosity and also changes nitric oxide flux thereby increasing venous and arterial tone. A study about 3 years ago was published in the journal Transfusion and they did study orthopedic patients with and without this practice of topping them up. Indeed subjectively those who recieved the transfusion felt better. In contrast it has been studied in cardiac surgery and it has been shown that "topping them up" before sending them home does not increase return to work, movement around the home or overall recovery. Colleen Koch fromt he Cleveland Clinic has studied patients functionality after heart surgery. Those transfused in the hospital had a much worse funcitonal score, ability to drive, work, take care of themselves etc. than those not transfused. This study was propensity matched and multivariat controlled for covariates. So, I think the argument and old wives tale practice fo giving twounits ot make someone feel better is at best dangerous. It would be good if blood had no risks. for me we need to develop other ways to get people mobilized, but there may be that rare patient who you simply must do it to get them to physical therpay etc. Just don't be folling yourself that you know it works or why!

The question of post-op mobilisation and rehab is an important one and transfusions are commonly recommended by the physios as benefit is often observed. It is my view that blood volume (red cell mass) and support for the macrocirculation is probably the issue here and not actually the oxygen carrying capacity and delivery issues. I suspect that the benefit of transfusion in this setting is attributable to blood volume expansion and prevention of postural hypotension. This is particularly relevent in the elderly (esp females) where blood volume contracts with age and autonomic reflexes are less robust. Interestingly autonomic neuropathy with postural hypotension has been treated with epo on this reasoning.

Pre-operative anaemia is one of the strongest predictors of whether a patient will be transfused in the peri-operative period. This is why autologous pre-deposition is now out of favour: it virtually guaranteed that the patient would be transfused, and autologous blood can still become contaminated by bacteria or mixed up with someone else's.

A male with a Hb less than 120g/L or a female with Hb less than 110g/L should have the anaemia corrected aggressively prior to surgery. It should only take 10 days to achieve this, so it can fit in well with the usual pre-admission clinic or private rooms booking rhythms.

Iron: If the patient has a ferritin level less than 50mcg/L, they will not have enough storage iron to correct the anaemia and cope with operative blood loss. Intravenous iron polymaltose (Ferrosig or Ferrum H) will rapidly correct the anaemia within 10 days and is quite safe. Polymaltose is a different carbohydrate carrier to dextran, so we don't see the allergy problems with iron polymaltose that we used to see with iron dextran (Imferon).

The dose of iron prescribed should be as per the product information for Ferrosig, plus an allowance for the anticipated operative blood loss on the basis of 200mg iron for a unit (450mls) of blood. It can be easily given in the Day Only unit. If given a week or so before surgery, the patient will be churning out fresh young red cells and will have replenished their myocardial iron stores just in time for the operation.

Don't forget that iron deficiency in a male or post-menopausal female implies gastro-intestinal blood loss, so the patient should be referred to a gastro-enterologist for evaluation. This referral need not cause a deferral of the surgery.

EPO: A multi-centre study conducted several years ago demonstrated that pre-operative EPO loading halves the transfusion rates in elective joint replacement surgery. See the MIMS Approved Product Information on Eprex for the details.

The patient must be iron replete (ferritin greater than 100mcg/L) to gain this benefit and, naturally, EPO should not be used in patients with uncontrolled hypertension.

Unfortunately, although this is a TGA-approved indication for Eprex, the Pharmaceutical Benefits Scheme will not reimburse it, and hospital Drug Committees are very nervous about its cost. Perhaps when the true cost of transfusion is fully known, the PBS will change its mind.

If the patient has renal impairment, the PBS will cover EPO under its Section 100 arrangements.

The shot-gun approach: It would be reasonable to add a shot of intramuscular B12 and oral folate 5mg per day to the above measures. Our Area is looking at a standard procedure involving IV iron polymaltose, B12 and folate for all patients found to be anaemic (as defined above) in the pre-admission clinic.

I am almost ashamed to admit this having read some of the comments from the experts, but in my practice which is rural based, the transfusion decision post op is commonly made by the physio who will not get the patient out of bed for rehab unless the Hb is 100 g/L.  The patient's are often dizzy which we are attributing to having a slightly low Hb, so how can I tell in elderly patients what the cause of dizziness and postural hypotension is? They do improve after a two unit tranfusion. I would welcome some expert advice on this.

What thresholds or patient signs clinical and/or laboratory should we be looking for in patients prior to joint replacement surgery which would put them at risk of requiring an intra op or post op transfusion? And further what treatments should we be considering eg is there a role for EPO, iron infusion and/or iron therapy?