[Perioperative anemia]

Anemia is a frequent finding, particularly in the elderly population, and usually indicative of a serious disease. The main causes of preoperative anemia are acute or chronic hemorrhage, iron deficiency, renal insufficiency, inflammatory and neoplastic diseases. A preexisting mild anemia may be enhanced or unmasked by surgically induced bleeding or repeated diagnostic phlebotomies, and by a postoperative erythropoietic dysfunction caused by the surgical trauma, irrespective of any hemorrhage. Low hemoglobin values are associated with a distinct increase of mortality and morbidity, both in the normal population and perioperatively and in the critically ill patients. The anemia-associated risk is exacerbated by preexisting cardiovascular disease, important intraoperative blood loss and advanced age. In contradiction to established therapeutical concepts, the administration of allogeneic blood beyond hemoglobin levels of 8-10 g/dl has not been found to decrease perioperative or intensive care morbidity or mortality. Rather, in addition to the inherent long-term risks of transfusions, a liberal transfusion strategy seems to increase the incidence of postoperative complications. Thus, current transfusion guidelines tend to be interpreted in an increasingly restrictive manner. Depending on the urgency of the clinical situation, the primary goal should be to diagnose and treat the underlying disease, rather than to focus on the symptom anemia. Time permitting, the patient's cardiovascular and pulmonary status should be optimized preoperatively. Furthermore, iron should be substituted to treat and prevent deficiency. Recombinant human erythropoietin has successfully been used to treat anemia of chronic renal failure and chronic disease, as well as in the perioperative and intensive care setting, and to support the efficiency of autologous programs.