Perioperative Anemia Management without Transfusion

Abstract

Introduction: Preoperative anemia increases postoperative morbidity. Iron supplementation and erythropoiesis-stimulating agents (ESAs) are alternatives to transfusion. This review evaluates efficacy.
Methods: Literature review (2015–2024) of RCTs and meta-analyses of intravenous (IV) iron ± ESAs vs. placebo or oral iron in anemic (Hb <12 g/dL) adults undergoing elective surgery. Primary outcome: Hb increase preoperatively. Secondary: transfusion rate.
Results: Fifteen studies (n=3,450) showed IV iron increased Hb by 1.1 g/dL vs. 0.5 g/dL for oral iron (p=0.004) over 4 weeks. IV iron + ESA increased Hb by 2.0 g/dL and reduced transfusion rate (OR 0.54). Adverse events (hypersensitivity) were rare (0.6%).
Discussion: IV iron corrects anemia faster than oral iron due to better absorption. ESAs add benefit but increase cost and thrombotic risk. Ferric carboxymaltose has rapid response.
Conclusions: Preoperative IV iron at least 4 weeks before surgery effectively raises Hb and reduces transfusions. ESAs reserved for severe anemia or patient refusal of blood.