Anemia in the Presurgical Patient: 
Recognition, Diagnosis and Management

(Content Adapted from Published Brochure)

New Insights and Concepts for the Primary Care Provider

“Anemia is a significant and modifiable risk factor for increased perioperative morbidity and mortality and should be diagnosed and treated before elective surgery.”  Irwin Gross MD, Medical Director, Patient Blood Management, Transfusion Services, Eastern Maine Medical Center, Bangor, ME

What is the Unmet Need in Surgical Patients?

Anemia is epidemic – a common complication of common diseases

  • 30-60% of patients with rheumatoid arthritis
  • 30-80% of patients with inflammatory bowel disease
  • 30-50% of patients with chronic heart failure
  • 20-40% of diabetics without overt renal failure
  • 40-60% of patients with chronic kidney disease

All of these are related to iron absorption and metabolism.

Why Care (More) About Anemia?

Anemia is a significant modifiable risk factor in surgical patients

Prevalence of undiagnosed anemia
At least 1/3 of patients undergoing non-emergent surgical procedures have potentially treatable anemia1

Anemia increases perioperative morbidity and mortality
A large retrospective study of almost 8000 non-cardiac surgical patients found that the prevalence of preoperative anemia was almost 40%. Preoperative anemia was associated with a nearly five-fold increase in the odds of postoperative mortality.2

Even mild preoperative anemia (Hb 10-12 g/dL in women; 10-13 g/dL in men), is independently associated with a 41% increased risk of mortality and a 31% increase in morbidity in patients undergoing major non-cardiac surgery. Perioperative transfusion is associated with an additional increase in morbidity and mortality.3]

Preoperative anemia is the most frequent predictor of perioperative transfusion4
A systematic review of 62 studies shows that preoperative anemia is the most frequent predictor of perioperative transfusion. Other factors include advancing age, female gender, and small body size.

Preoperative anemia diagnosis and treatment improves patient outcomes5-7

  • Improves readiness for surgery
  • Reduces transfusion risk in the perioperative period
  • Reduces anemia and transfusion associated morbidity and mortality
  • Helps identify co-morbidities
  • Effective clinical management of anemia improves patient outcomes in chronic diseases (e.g., chronic heart failure, chronic kidney disease, inflammatory bowel disease, rheumatoid arthritis, etc.).
  • Anemia may be an indicator of an undiagnosed underlying disease process (e.g., iron deficiency suggesting occult malignancy).

What Laboratory Tests are Needed for a Presurgical Anemia Evaluation?

Goals of preoperative anemia laboratory test algorithm

  • Allow diagnosis of common causes of anemia
  • Avoid the need for patients to return for another blood sample
  • Draw CBC and sample for additional testing to “hold” for additional tests if needed
  • Eliminate unnecessary lab studies

First Tier Laboratory Tests

  • Complete Blood Count (CBC)
  • Reticulocyte Count
    • Absolute reticulocyte count
    • Reticulocyte hemoglobin content if available (a functional measure of iron status)
  • Vitamin B12
  • Folate
  • Iron Studies
    • Transferrin Saturation
    • Ferritin
    • Iron
    • Iron Binding Capacity
  • Serum Creatinine

Additional studies predicated on initial test results, or if a diagnosis cannot be made based on initial tests:

Second Tier Laboratory Tests

  • Thyroid Stimulating Hormone (TSH)
  • Direct Antiglobulin Test
  • C-Reactive Protein
  • Soluble Transferrin Receptor
  • Methyl Malonic Acid
  • Erythropoietin
  • Haptoglobin

See Preoperative Anemia Management Algorithm

What Anemia Treatment Strategies Should be Considered for the Anemic Presurgical Patient?

Correct nutritional deficiencies

Iron therapy

  • Choice of therapy is based on:
    • Timescale before surgery
    • Tolerance of oral iron
    • Iron status
  • Consider oral iron if:
    • Adequate time (2-4 months)
    • No ongoing blood loss
    • No inflammatory process or co-morbidity
    • Normal GFR
    • Patient is tolerant

NOTE: Relatively slow iron repletion with a high incidence (30-40%) of gastrointestinal intolerance; co-morbid inflammatory states reduces iron uptake. Need to re-evaluate anemia studies 4 weeks before surgery to determine effectiveness.

  • Intravenous iron is the most common intervention in presurgical anemia
    • Better tolerated and much faster than oral iron
    • Effective—even in inflammation
    • Less expensive than ESAs
  • Vitamin B12
  • Folate
  • Erythropoiesis Stimulating Agents (ESA)
    • When nutritional anemia has been ruled out and/or corrected
    • Use conservatively, lowest dose and shortest administration time
    • Prescribe supplemental iron throughout the course of ESA therapy to optimize presurgical red blood cell production and minimize ESA-induced functional iron deficiency
    • ESA therapy combined with supplemental iron may reduce the subsequent need for blood transfusion.

Treat comorbidities

Delay surgery if necessary to optimize surgical outcome and reduce transfusion risk

NOTE: Expected hemoglobin optimization response to anemia treatment

Most patients can expect to have a hemoglobin rise between 0.5g/dL- 1.0g/dL per week with use of IV iron and or ESA therapy as per prescribing information.

SeeIV Iron Table 

Adopt concept of Patient Blood Management

“The timely application of evidence based medical and surgical concepts designed to manage anemia, optimize hemostasis, and minimize blood loss in order to improve patient outcomes.” – Society for the Advancement of Blood Management

See SABM Foundational Principles of Patient Blood Management.


  1. Shander A, Knight K, Thurer R, Adamson J, Spence R. Prevalence and outcomes of anemia in surgery: a systematic review of the literature. Am J Med. 2004 Apr 5;116 Suppl 7A:58S-69S.
  2. Beattie WS, Karkouti K, Wijeysundera DN, Tait G. Risk associated with preoperative anemia in noncardiac surgery: a single-center cohort study. Anesthesiology. 2009 Mar;110(3):574-81.
  3. Musallam KM, Tamim HM, Richards T, Spahn DR, Rosendaal FR, Habbal A, Khreiss M, Dahdaleh FS, Khavandi K, Sfeir PM, Soweid A, Hoballah JJ, Taher AT, Jamali FR. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet. 2011 Oct 15; 378(9800): 1396-407.
  4. Khanna MP, Hébert PC, Fergusson DA. Review of the clinical practice literature on patient characteristics associated with perioperative allogeneic red blood cell transfusion. Transfus Med Rev. 2003 Apr; 17(2): 110-9.
  5. Cuenca J, García-Erce JA, Muñoz M. Efficacy of intravenous iron sucrose administration for correcting preoperative anemia in patients scheduled for major orthopedic surgery. Anesthesiology. 2008 Jul; 109(1): 151-2
  6. Yoo YC, Shim JK, Kim JC, Jo YY, Lee JH, Kwak YL. Effect of single recombinant human erythropoietin injection on transfusion requirements in preoperatively anemic patients undergoing valvular heart surgery. Anesthesiology. 2011 Nov;115(5):929-37.
  7. Bacuzzi A, Dionigi G, Piffaretti M, Tozzi M et al Preoperative methods to improve erythropoiesis. Transplantation Proceedings 2011; 43(1): 324-326.