In patients undergoing major surgical procedures, preoperative anaemia and perioperative allogeneic blood transfusion (ABT) have been linked to increased postoperative morbidity and mortality, as well as longer hospital stays. A multidisciplinary, multimodal, individualised strategy – collectively termed patient blood management – used to minimise or eliminate ABT is indicated to improve outcomes. This new standard of care relies on detection and treatment of perioperative anaemia (Pillar 1) and reduction of surgical blood loss and perioperative coagulopathy (Pillar 2) to harness and optimise physiological tolerance of anaemia (Pillar 3), thus allowing the use of restrictive transfusion criteria. Normalisation of preoperative hemoglobin levels is a World Heath Organization recommendation. Iron repletion should be routinely ordered when indicated. Preoperative oral iron is time-consuming and poorly tolerated with low adherence in published trials. Postoperative oral iron has been proven to be inefficacious and is no longer recommended. Preoperative and perioperative intravenous iron, with or without erythropoiesis stimulating agents, is safe and effective at reducing ABT rate and hastening the recovery from postoperative anaemia. Intravenous iron does not seem to increase the risk for postoperative thromboembolism, infection, or mortality. Newer intravenous iron formulations demonstrate potentially much lower immunogenic activity, allow complete replacement dosing in 15 to 60 minutes, markedly facilitating care, and may be cost-effective in many clinical settings.
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