Perioperative Anaemia Management

Quick Answer

Exam Essentials - ANZCA Final Examination

Definition of Anaemia: WHO criteria: Hb <130 g/L (men), <120 g/L (women), <110 g/L (pregnant). Perioperative significance: Each 10 g/L decrease in preoperative Hb increases transfusion risk and morbidity. [1-3]

Patient Blood Management (PBM) Three Pillars:

1. Optimise erythropoiesis: Iron, B12, folate supplementation; erythropoietin (EPO) in selected patients
2. Minimise blood loss: Antifibrinolytics (TXA), cell salvage, controlled hypotension, minimally invasive techniques
3. Optimise patient tolerance: Restrictive transfusion thresholds, treat underlying disease [4-6]

Transfusion Triggers:

• Restrictive strategy: Hb 70-80 g/L (or 80-100 g/L in high-risk cardiac patients)
• Symptomatic anaemia: Tachycardia, hypotension, dyspnoea, chest pain, syncope despite Hb >70-80 g/L
• Target: Hb 70-90 g/L generally adequate for most patients [7-9]

Iron Deficiency:

• Absolute: Ferritin <30 μg/L, transferrin saturation (TSAT) <20%
• Functional: Ferritin 30-100 μg/L with TSAT <20% (chronic disease/inflammation)
• Treatment: IV iron sucrose or ferric carboxymaltose preferred (faster response than oral) [10-12]

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Populations

Epidemiology of Anaemia:

Aboriginal and Torres Strait Islander populations experience significantly higher rates of anaemia, reflecting broader health disparities:

• Prevalence: 20-30% of Indigenous adults (vs 5-10% non-Indigenous) [13]
• Iron deficiency: Most common cause; multifactorial aetiology
• Chronic disease anaemia: Higher rates of chronic kidney disease, diabetes, inflammatory conditions [14]
• Nutritional factors: Food insecurity, limited access to fresh foods in remote communities [15]

Causes of Anaemia in Indigenous Populations:

Barriers to Optimal Management:

1. Geographic isolation: Limited pathology services in remote communities; delayed results
2. Treatment compliance: Oral iron poorly tolerated; IV iron requires travel to regional centres
3. Follow-up challenges: Monitoring Hb response requires repeated pathology
4. Cultural factors: Traditional diet low in bioavailable iron; shift to Western diet may not improve status
5. Comorbidity burden: Multiple competing health priorities; anaemia may be overlooked [18,19]

Perioperative Considerations:

• Higher baseline anaemia: More likely to require transfusion
• Optimisation time: May need extended preoperative preparation
• Blood availability: Remote/rural hospitals may have limited blood bank resources
• Transfusion consent: Cultural beliefs about blood products may require sensitive discussion
• Cell salvage: Limited availability in remote settings [20,21]

Culturally Safe Care:

• Aboriginal Health Worker involvement: Explain PBM concepts in culturally appropriate ways
• Nutritional counselling: Work with local services to improve iron-rich food access
• Community engagement: Address environmental contributors (overcrowding, parasite control)
• Telemedicine: Specialist haematology consultation for complex cases [22,23]

Māori Populations (Aotearoa New Zealand)

Epidemiological Profile:

Māori experience similar disparities in anaemia prevalence and management:

• Prevalence: 15-25% of Māori adults (vs 5-8% European New Zealanders) [24]
• Iron deficiency: Particularly affects Māori women (menstrual losses, pregnancy, poor nutrition)
• Chronic kidney disease: Higher rates contributing to anaemia of chronic disease [25]

Risk Factors:

• Socioeconomic deprivation limits access to iron-rich foods
• Higher smoking rates (affects vitamin C absorption)
• Increased alcohol consumption (GI bleeding risk)
• Delayed healthcare access [26,27]

Te Tiriti o Waitangi Considerations:

1. Equitable access: Timely investigation and treatment of anaemia
2. Whānau-centred approach: Family involvement in understanding and managing anaemia
3. Māori Health Workers: Supporting patients through optimisation pathways
4. Cultural food preferences: Working within dietary preferences while addressing iron deficiency [28,29]

Rural and Regional Considerations:

• Similar geographic barriers to Australia for remote communities
• Whānau may need to travel with patient for IV iron therapy in main centres
• Community-based services for ongoing monitoring
• Transport assistance for follow-up appointments [30,31]

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Epidemiology and Clinical Significance

Global Burden of Anaemia

Prevalence:

• Global: 1.62 billion people (24.8% world population) [32]
• Developed countries: 5-10% of adults, higher in elderly [33]
• Surgical populations: 20-40% preoperative anaemia depending on procedure [34]
• Obstetric: 40-50% of pregnant women globally [35]

WHO Classification:

Perioperative Impact:

Australian and New Zealand Context:

• National Blood Authority PBM Guidelines: Mandate preoperative optimisation
• Transfusion rates: Declining due to PBM initiatives (10-15% reduction over 10 years)
• Blood shortages: Seasonal and supply challenges; conservation essential
• Cost: Transfusion costs $500-1000 per unit (including administration, testing, overheads) [40,41]

Pathophysiology of Anaemia in Surgical Patients

Decreased Oxygen Delivery:

• DO2 = Cardiac output × Arterial O2 content
• Arterial O2 content = (Hb × 1.34 × SaO2) + (0.003 × PaO2)
• Hb is primary determinant of oxygen-carrying capacity [42,43]

Physiological Compensation:

1. Increased cardiac output (CO increases 2-3× for Hb 50 g/L)
2. Increased 2,3-DPG (right-shift oxyhaemoglobin curve)
3. Tissue capillary recruitment
4. Cellular adaptation (increased mitochondrial density)

Limitations:

• Cardiovascular disease limits compensatory capacity
• Elderly have reduced cardiac reserve
• Tissue hypoxia occurs when Hb <50-70 g/L in most patients [44,45]

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Patient Blood Management (PBM)

Pillar 1: Optimise Erythropoiesis

Preoperative Assessment (Minimum 4 weeks before surgery):

Iron Deficiency Classification:

Iron Supplementation:

IV Iron Protocol:

• Iron sucrose: 200-300 mg IV over 30-60 minutes, 2-3 doses weekly
• Ferric carboxymaltose: 15-20 mg/kg (max 1000 mg) IV over 15-30 minutes
• Monitor: BP, pulse during infusion (anaphylaxis rare but possible)
• Expect: 10-20 g/L Hb rise over 2-4 weeks [54,55]

Erythropoietin (EPO):

Indications:

• Chronic kidney disease (standard of care)
• Preoperative anaemia with insufficient time for iron alone
• Refusal of blood products (Jehovah's Witness)
• High-risk surgery with baseline anaemia [56,57]

Dosing:

• Epoetin alfa: 150-300 units/kg SC 3× weekly × 3-4 weeks preoperatively
• Darbepoetin alfa: 200-300 mcg SC weekly × 3-4 weeks
• Must give with iron supplementation (functional iron deficiency common with EPO) [58,59]

Contraindications/Cautions:

• Active malignancy (theoretical risk of tumour stimulation)
• Uncontrolled hypertension
• History of thrombosis
• Pure red cell aplasia (rare antibody-mediated) [60,61]

Vitamin Supplementation:

• B12 deficiency: 1000 mcg IM monthly or 1000 mcg PO daily
• Folate deficiency: 5 mg PO daily
• Combined deficiencies: Replace B12 before folate (risk of neurological worsening) [62,63]

Pillar 2: Minimise Blood Loss

Surgical Techniques:

• Minimally invasive approaches
• Meticulous haemostasis
• Topical haemostatics (fibrin sealants, oxidised cellulose)
• Controlled hypotension (MAP 60-70 mmHg) where appropriate [64,65]

Pharmacological Agents:

TXA Evidence:

• CRASH-2 (trauma): Reduced mortality (RR 0.91) if given within 3 hours [70]
• POISE-2 (non-cardiac surgery): No clear benefit in low-risk; benefit in high-risk subgroups [71]
• Orthopaedic surgery: Reduced transfusion requirements by 30-50% [72]
• WOMAN (postpartum haemorrhage): Reduced bleeding and hysterectomy [73]

Cell Salvage:

Principles:

• Collect shed blood from surgical field
• Anticoagulate (heparin or citrate)
• Wash, concentrate, filter
• Reinfuse autologous red cells [74,75]

Indications:

• Anticipated blood loss >1000 mL or >20% blood volume
• Jehovah's Witness patients
• Rare blood types/antibodies
• High-risk for transfusion complications [76,77]

Contraindications:

• Malignancy (theoretical risk of tumour cell reinfusion)
• Infection/contamination of surgical field (bowel, pus)
• Sickle cell disease (sickling in circuit)
• Amniotic fluid contamination (caesarean section) [78,79]

Acute Normovolaemic Haemodilution (ANH):

• Remove 1-3 units blood immediately preoperatively
• Replace volume with crystalloid/colloid
• Reinfuse collected blood at end of surgery or if Hb falls below threshold
• Preserves platelets and coagulation factors (fresh blood reinfused) [80,81]

Pillar 3: Optimise Patient Tolerance

Restrictive Transfusion Strategy:

Thresholds:

• Standard patients: Hb 70-80 g/L (restrictive) vs 90-100 g/L (liberal)
• High-risk cardiac: Hb 80-100 g/L
• Symptomatic patients: Transfuse regardless of Hb if evidence of tissue hypoxia [82,83]

Evidence:

• TRICC (1999): Restrictive strategy (Hb 70-90 g/L) safe in critically ill [84]
• TRICS-III (2019): Restrictive (Hb 75 g/L) non-inferior to liberal in cardiac surgery [85]
• FOCUS (2011): Restrictive (Hb 80 g/L or symptoms) safe in high-risk hip fracture [86]
• Cochrane review: Restrictive reduces transfusion 40% without adverse outcomes [87,88]

Target Hb:

• Aim for Hb 70-90 g/L in most patients
• Individualise based on:
  • Age
  • Cardiovascular status
  • Signs of hypoxia
  • Rate of blood loss [89,90]

Single Unit Transfusion Policy:

• Transfuse 1 unit, reassess clinically and with Hb
• Many patients do not need second unit
• Reduces over-transfusion [91,92]

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Transfusion Triggers and Targets

Haemoglobin Thresholds by Patient Group

Clinical Signs of Inadequate Oxygen Delivery

Tissue Hypoxia Indicators:

• Tachycardia (>100 bpm)
• Hypotension (MAP <65 mmHg or SBP <90 mmHg)
• Dyspnoea, chest pain, orthopnoea
• Confusion, agitation, reduced consciousness
• Oliguria (<0.5 mL/kg/hr)
• Cool, clammy extremities
• Lactate elevation (>2 mmol/L)
• Mixed venous oxygen saturation <60% [96,97]

When to Transfuse Despite Higher Hb:

• Active bleeding with haemodynamic instability
• Signs of tissue hypoxia unresponsive to volume
• Acute coronary syndrome with Hb <90-100 g/L
• Severe sepsis with impaired oxygen extraction [98,99]

Transfusion Risks and Complications

Transfusion-Associated Circulatory Overload (TACO):

• Incidence: 1-5% of transfusions
• Risk factors: Elderly, heart failure, renal failure, rapid transfusion, large volumes
• Symptoms: Dyspnoea, hypertension, JVP elevation, pulmonary oedema
• Prevention: Slow transfusion (max 4 hours/unit), diuretics, monitor closely
• Treatment: Diuretics, oxygen, stop transfusion [100,101]

Transfusion-Related Acute Lung Injury (TRALI):

• Incidence: 1:5000-1:10,000 units
• Mechanism: Donor antibodies against recipient WBCs → neutrophil activation → ARDS
• Symptoms: Acute hypoxia, bilateral infiltrates, fever, hypotension (within 6 hours)
• Risk factors: Multiparous female donors (now avoided), plasma-rich products
• Treatment: Supportive (ARDS management); usually resolves 48-96 hours
• Mortality: 5-10% [102,103]

Infectious Risks (Australia/NZ):

• HIV: 1:1-2 million
• Hepatitis B: 1:200,000-400,000
• Hepatitis C: 1:1-2 million
• Bacterial contamination: 1:50,000-100,000
• Prion disease (vCJD): Extremely rare, leukodepletion reduces risk [104,105]

Other Risks:

• Febrile non-haemolytic transfusion reaction (1:200)
• Allergic reaction (1:100)
• Anaphylaxis (1:20,000-50,000)
• Haemolytic transfusion reaction (ABO incompatibility 1:40,000-100,000)
• Delayed haemolytic reaction (1:2000-5000)
• Transfusion-related immunomodulation (TRIM)
• Iron overload (chronic transfusion) [106,107]

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SAQ Practice Questions

SAQ 1: Preoperative Anaemia Optimisation (20 marks)

Scenario: A 68-year-old man is scheduled for elective total hip replacement in 3 weeks. His preoperative Hb is 105 g/L, ferritin 45 μg/L, TSAT 15%, CRP 12 mg/L.

Questions:

a) Classify his iron status and justify your classification. (6 marks)

b) Outline your management strategy to optimise his haemoglobin before surgery. (7 marks)

c) What would you do if surgery could not be delayed and must proceed in 5 days? (7 marks)

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Model Answer:

a) Iron status classification (6 marks):

• Functional iron deficiency (2 marks)
• Justification:
  • Ferritin 45 μg/L (30-100 μg/L range) (1 mark)
  • TSAT 15% (<20%) indicating inadequate iron availability (1 mark)
  • Elevated CRP (12 mg/L) indicating inflammation blocking iron utilisation (2 marks)

b) Management strategy (7 marks):

• IV iron supplementation: Ferric carboxymaltose 1000 mg IV single dose (preferred due to 3-week timeframe) (2 marks)
  • Alternative: Iron sucrose 300 mg IV weekly × 3 doses (1 mark)
• Vitamin optimisation: Check and treat B12/folate if deficient (1 mark)
• EPO consideration: Consider epoetin alfa 300 units/kg SC 3× weekly × 3 weeks if additional response needed (1 mark)
• Monitor: Recheck Hb 1 week post-iron; expect 10-20 g/L rise (1 mark)
• Minimise blood loss: TXA (1 g IV at surgery), cell salvage if available (1 mark)

c) If surgery in 5 days (7 marks):

• IV iron urgently: Ferric carboxymaltose 1000 mg IV immediately (2 marks)
• EPO: Epoetin alfa 300 units/kg SC immediately and on day of surgery (2 marks)
• Iron response: Expect minimal Hb rise in 5 days but improved iron stores for postoperative erythropoiesis (1 mark)
• Transfusion preparation: Crossmatch 2 units; expect may need transfusion given Hb 105 with major surgery (1 mark)
• TXA: Mandatory - 1 g IV at induction + 1 g at closure (1 mark)

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SAQ 2: Transfusion Decision Making (20 marks)

Scenario: A 72-year-old woman with stable coronary artery disease (previous PCI 2 years ago, no recent symptoms) is post-elective right hemicolectomy. She is asymptomatic. Her postoperative day 1 Hb is 78 g/L, down from 125 g/L preoperatively. She is haemodynamically stable with MAP 75 mmHg, HR 82 bpm, SpO2 96% on room air.

Questions:

a) What factors should you consider when deciding whether to transfuse this patient? (6 marks)

b) Based on current evidence, what is your recommendation regarding transfusion? Justify your answer. (7 marks)

c) What are the risks of transfusing this patient? (7 marks)

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Model Answer:

a) Factors to consider (6 marks):

• Symptoms: Asymptomatic (no dyspnoea, chest pain, syncope) (1 mark) | Haemodynamics: Stable (MAP 75, HR 82, no hypotension/tachycardia) (1 mark) | Cardiovascular risk: Stable CAD (not active ischaemia) (1 mark) | Hb level: 78 g/L (above restrictive threshold) (1 mark) | Rate of decline: Likely peaked (post-op day 1) (1 mark) | Bleeding risk: Likely surgical bleeding controlled (1 mark)

b) Recommendation (7 marks):

• Do NOT transfuse (2 marks) | Justification:
  • Restrictive strategy (Hb 70-80 g/L) safe in postoperative patients including those with stable CAD (2 marks)
  • TRICS-III demonstrated non-inferiority of restrictive strategy (Hb 75 g/L) in cardiac surgery patients (2 marks)
  • Patient asymptomatic with stable haemodynamics (1 mark)

c) Risks of transfusion (7 marks):

• TACO: Risk in elderly with cardiac history (2 marks) | TRALI: 1:5000-1:10000 units; potentially fatal (2 marks) | Infection: Hepatitis B, HIV (rare but possible) (1 mark) | Immunological: Allergic reaction, TRIM (1 mark) | Resource: Blood shortage, cost ($500-1000/unit) (1 mark)

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SAQ 3: Massive Transfusion Protocol (20 marks)

Scenario: A 34-year-old trauma patient requires emergency laparotomy for splenic rupture. Estimated blood loss is 3000 mL in 30 minutes. He is tachycardic (HR 128 bpm), hypotensive (MAP 58 mmHg), and confused. The massive transfusion protocol has been activated.

Questions:

a) Outline the principles of massive transfusion. (6 marks)

b) Describe your blood product resuscitation strategy. (7 marks)

c) What adjunctive therapies would you consider? (7 marks)

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Model Answer:

a) Massive transfusion principles (6 marks):

• Definition: Transfusion of >10 units PRBC in 24 hours, or >4 units in 1 hour, or replacement of total blood volume in 24 hours (2 marks) | Goal: Restore oxygen-carrying capacity and correct coagulopathy (1 mark) | Balanced approach: PRBC : plasma : platelets in ratio approximating whole blood (1 mark) | Warm all products: Prevent hypothermia (1 mark) | Monitor: Hb, coagulation, electrolytes, temperature, lactate (1 mark)

b) Blood product strategy (7 marks):

• PRBC: O-negative (if type unknown) or type-specific; aim Hb 80-100 g/L (1 mark) | FFP: 1:1 with PRBC initially (15 mL/kg or 4 units) to correct coagulopathy (2 marks) | Platelets: 1 apheresis unit or 4-6 pooled units if count <50 × 10^9/L (1 mark) | Fibrinogen: Cryoprecipitate (10 units) if fibrinogen <1.5-2.0 g/L (1 mark) | TXA: 1 g IV bolus + 1 g over 8 hours (if within 3 hours of injury per CRASH-2) (1 mark) | Calcium: Monitor and replace (ionised Ca2+ >1.0 mmol/L) (1 mark)

c) Adjunctive therapies (7 marks):

• TXA: 1 g IV bolus + 1 g over 8 hours (reduces mortality if given early) (2 marks) | Recombinant Factor VIIa: If refractory bleeding despite product replacement (1 mark) | Calcium: Replace to maintain ionised Ca2+ >1.0 mmol/L (citrate in FFP chelates calcium) (1 mark) | Magnesium: Monitor and replace if low (1 mark) | Rewarming: Active warming to prevent coagulopathy (hypothermia impairs coagulation) (1 mark) | ROTEM/TEG: Point-of-care testing to guide product replacement (1 mark)

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ANZCA Exam Focus

Viva Voce Preparation

Scenario 1: Preoperative Optimisation

"A patient with Hb 98 g/L is scheduled for major abdominal surgery in 2 weeks. How do you optimise them?"

Key points:

• Iron studies to classify deficiency
• IV iron (ferric carboxymaltose) given timeframe
• Consider EPO if further response needed
• Check B12/folate
• TXA for surgery
• Discuss transfusion threshold

Scenario 2: Transfusion Decision

"A patient post-cardiac surgery has Hb 82 g/L on day 2. They are stable, asymptomatic. Do you transfuse?"

Key points:

• TRICS-III supports restrictive (Hb 75 g/L threshold)
• Asymptomatic + stable = no transfusion
• Monitor for symptoms/tachycardia
• Single unit transfuse if threshold crossed
• Risks of transfusion (TACO especially in cardiac patients)

Scenario 3: Massive Haemorrhage

"You are managing a trauma patient with massive bleeding. Outline your approach."

Key points:

• Activate massive transfusion protocol
• Balanced ratio (1:1:1 PRBC:plasma:platelets)
• TXA early (if <3 hours from injury)
• Calcium monitoring/replacement
• Rewarming
• ROTEM/TEG-guided therapy

Written Exam High-Yield Topics

ANZCA Professional Standards

PS47(G): Guidelines for Perioperative Blood Management

• Preoperative assessment and optimisation requirements
• Restrictive transfusion thresholds
• PBM three pillars

PS06(G): Guidelines for the Management of Massive Haemorrhage

• Massive transfusion protocol activation
• Product ratios
• Adjunctive therapies (TXA, calcium, rewarming)

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This document was created for educational purposes for ANZCA Fellowship examination preparation. All citations are from peer-reviewed literature. Last updated: 2026-02-03