British Journal of Anaesthesia 106 (1): 13–22 (2011) doi:10.1093/bja/aeq361


Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines

L. T. Goodnough1*, A. Maniatis 2, P. Earnshaw3, G. Benoni4, P. Beris 5, E. Bisbe 6, D. A. Fergusson7, H. Gombotz8, O. Habler9, T. G. Monk10, Y. Ozier 11, R. Slappendel 12 and M. Szpalski 13

1 Department of Pathology and Medicine, Stanford University School of Medicine, Pasteur Dr., Room H-1402, 5626, Stanford, CA 94305, USA

2 Hematology Division, Henry Dunant Hospital, Athens, Greece

3 Department of Orthopaedics, Guy’s and St Thomas’ Hospital, London, UK

4 Department of Orthopedics, Malmo¨ University Hospital, Malmo¨ , Sweden

5 Department of Hematology, Geneva University Hospital, Geneva, Switzerland

6 Department of Anesthesiology, University Hospital Mar-Esperanc¸a, Barcelona, Spain

7 University of Ottawa Centre for Transfusion Research, Ottawa, Ontario, Canada

8 Department of Anesthesiology and Intensive Care, General Hospital Linz, Linz, Austria

9 Department of Anesthesiology, Surgical Intensive Care and Pain Control, Krankenhaus Nordwest GmbH, Frankfurt am Main, Germany

10 Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA

11 Department of Anesthesiology and Intensive Care, Cochin Hospital, Paris Descartes University, Paris, France

12 Perioperative Medicine Consultancy, Nijmegen, The Netherlands

13 Department of Orthopedics, IRIS South Teaching Hospitals, Free University of Brussels, Brussels, Belgium

* Corresponding author. E-mail:



Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. A standardized approach for the detection, evaluation, and management of anaemia in this setting has been identified as an unmet medical need. A multidisciplinary panel of physicians was convened by the Network for Advancement of Transfusion Alternatives (NATA) with the aim of developing practice guidelines for the detection, evaluation, and management of preoperative anaemia in elective orthopaedic surgery. A systematic literature review and critical evaluation of the evidence was performed, and recommendations were formulated according to the method proposed by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. We recommend that elective orthopaedic surgical patients have a haemoglobin (Hb) level determination 28 days before the scheduled surgical procedure if possible (Grade 1C). We suggest that the patient’s target Hb before elective surgery be within the normal range, according to the World Health Organization criteria (Grade 2C). We recommend further laboratory testing to evaluate anaemia for nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C). We recommend that nutritional deficiencies be treated (Grade 1C). We suggest that erythropoiesis-stimulating agents be used for anaemic patients in whom nutritional deficiencies have been ruled out, corrected, or both (Grade 2A). Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value. Implementation of anaemia management in the elective orthopaedic surgery setting will improve patient outcomes.

Keywords: anaemia; blood transfusion; orthopaedic surgery; preoperative assessment; preoperative preparation


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