Haemoglobin concentration and mass as determinants of exercise performance and of surgical outcome

The ability of the cardiorespiratory system (heart, lungs, blood) to deliver oxygen to exercising skeletal muscle constrains maximum oxygen consumption V˙O2max, with cardiac output and the concentration of oxygen-carrying haemoglobin ([Hb]) being key limiting parameters. Total blood volume (BV) is the sum of the plasma volume (PV) and the total red cell volume. The measured [Hb] is dependent upon the total circulating mass of haemoglobin (tHb-mass) and plasma volume (PV). While the proportion of oxygen carried in plasma is trivial (0.3 mL of oxygen per 100 mL of plasma), each gram of Hb, contained in red blood cells, binds 1.39 mL of oxygen. As a result, the relationship between V˙O2max and tHb-mass is stronger than that observed between V˙O2max and [Hb] or BV. The glycoprotein hormone erythropoietin drives red cell synthesis and, like simple transfusion of packed red blood cells, can increase tHb-mass. An iron-containing haem group lies at the centre of the Hb molecule and, in situations of actual or functional iron deficiency, tHb-mass will also rise following iron administration. However achieved, an increase in tHb-mass also increases circulating oxygen-carrying capacity, and thus the capacity for aerobic phosphorylation. It is for such reasons that alterations in V˙O2max and exercise performance are proportional to those in arterial oxygen content and systemic oxygen transport, a change in tHb-mass of 1 g being associated with a 4 mL · min-1 change in V˙O2max. Similarly, V˙O2max increases by approximately 1% for each 3 g · L-1 increase in [Hb] over the [Hb] range (120 to 170 g · L-1). Surgery, like exercise, places substantial metabolic demands on the patient. Whilst subject to debate, oxygen supply at a rate inadequate to prevent muscle anaerobiosis may underpin the occurrence of the anaerobic threshold (AT), an important submaximal marker of cardiorespiratory fitness. Preoperatively, cardiopulmonary exercise testing (CPET) can be used to determine AT and peak exertional oxygen uptake (V˙O2 peak) as measures of ability to meet increasing oxygen demands. The degree of surgical insult and the ability to meet the resulting additional postoperative oxygen demand appear to be fundamental determinants of surgical outcome: individuals in whom such ability is impaired (and thus those with reduced V˙O2 peak and AT) are at greater risk of adverse surgical outcome. This review provides an overview of the relationships between [Hb], tHb-mass, exercise capacity, and surgical outcome and discusses the potential value of assessing tHb-mass over [Hb].