Perioperative iron administration as an alternative to blood transfusion in major surgery

In the surgical setting, anemia is a common feature and an independent risk factor for blood transfusion, inpatient complications, delayed hospital discharge and poorer functional recovery. Despite adverse side effects and the increasing costs to health systems, allogeneic blood transfusion is the standard of care for anemia. Within this context, NATA (Network for the Advancement of Transfusion Alternatives) guidelines advocate steps towards prevention, diagnosis of anemia and stimulation of erythropoiesis in surgical patients. These include iron – p.o. and i.v. formulations – and recombinant human erythropoietin (rHuEPO) as viable alternatives pre-, peri- and/or postoperatively. The combination of these methods with restrictive transfusion triggers, tranexamic acid and blood salvage techniques may reduce perioperative transfusion rates. The main objective of this article is to briefly review the use of iron in surgical patients, with special focus on orthopedic surgery. From the analyzed information, it can be concluded that, despite the lack of large randomized controlled trials, results indicate that because of the low incidence of serious side effects and the rapid increase of hemoglobin levels, i.v. iron emerges as a safe and effective drug for treating and preventing perioperative anemia. In addition, i.v. iron administration reduces rHuEPO dose requirements. The use of new i.v. iron formulations will allow the administration of large doses in a single session, thus facilitating a more widespread use of this therapeutic option.