British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia

Alwyn Kotze,¹Andrea Harris,²Charles Baker,³Tariq Iqbal,⁴Nick Lavies,⁵Toby Richards,⁶Kate Ryan,⁷Craig Taylor⁸and Dafydd Thomas⁹

Background

Anaemia is most often defined in terms of the criteria established by the World Health Organization (WHO) in 1968 (WHO 2011), namely haemoglobin (Hb) concentration of <130 g/l for men and <120 g/l for women. Pre-operative anaemia is common. Its prevalence varies from 5% to 75% depending on the population studied (Shander et al, 2004). Pre-operative anaemia may significantly affect patient outcomes. Anaemia is an independently predictive risk factor for complications and death (Beattie et al, 2009; Spahn, 2010; Musallam et al, 2011). Co-existing anaemia substantially increases health care costs in medical (Ershler et al, 2005; Nissenson et al, 2005; Dowling, 2007) as well as surgical (M’Koma et al, 2009) patients, with substantial additional cost incurred out of hospital (Ebinger et al, 2004; Ershler et al, 2005). It further predisposes patients to requiring allogeneic blood transfusion (Shander et al, 2004; Beattie et al, 2009; Spahn, 2010; Musallam et al, 2011). (In this guideline, ‘transfusion’ may be taken to mean only allogeneic blood transfusion.) Although these relationships are associative, the body of evidence is large and consistent. The Department of Health, National Blood Transfusion Committee and National Health Service (NHS) Enhanced Recovery Partnership all consequently recommend that anaemia is investigated and treated before planned surgery, but make few recommendations on how this may be achieved (Department of Health 2007, NHS Enhanced Recovery Partnership Programme 2010, National Blood Transfusion Committee 2014). There are three distinct reasons to consider the identification and management of pre-operative anaemia as important:

• Anaemia detected during surgical work-up may be secondary to previously undiagnosed disease, e.g. malignancy.

• To reduce the likelihood of having to resort to transfusion, thus limiting demand on donors and conserving blood supplies for those patients who need it most.

• To avoid unnecessarily exposing surgical patients to potential adverse effects of anaemia, transfusion or both.