BEST PRACTICES
Preoperative Assessment
A. Evaluate and assess patient if possible 3-4 weeks before surgery.
B. If predicted blood loss is over 150 ml (EBL), the following points apply:
1. Consult blood conservation/management department
a. Does the patient have a need to avoid blood transfusion under any circumstance?
1) Yes = a specified Advance Directive should be drafted specifying their unique
requests. Notify patient they need to have dialogue with surgeon and
anesthesiologist if this has not already taken place.
2) No = proceed with steps below.
b. Obtain CBC with platelets, GFR, Creat, (fasting) serum iron, transferring, iron
saturation, ferritin, and non cardiac CRP.
1) If 3 or more of any of the following apply, administer IV iron:
Transferrin over 250
Serum iron under 35
Iron saturation under 25%
Hgb under 13
MCH 28 or below
MCV under 85
Ferritin under 200 (consider ferritin not useful if crp elevated)
c. If hemoglobin <13 and patient is scheduled for orthopedic surgery, consider the
use of ESA’s in conjunction with iron replacement.
d. If hgb is under 11.0 and gfr is under 60, consider ESA’s in conjunction with iron
replacement.
C. Arrange IV iron and/or ESA’s through infusion center after counseling patient on need.
D. Ask patient to stop all nutritional supplements immediately.
Surgery
1.
2.
3.
4.
5.
6.
7.
8.
Cellsaver indicated
Minimal Invasive surgery (laparoscopic/robotic)
Hemostatic agents
Volume expanders
Minimal discards with central lines
Safe sets- (re-infuse discards from arterial lines)
ANH Acute normal volemic hemodilution
Aquamantys
Postoperative
A. If preoperative assessment and treatment was administered on patient:
1. On first postop day, review EBL in addition to first morning lab postop results.
a. If there has been a perioperative blood loss of 500 or more ml, consider IV iron
therapy at half dose regardless if IV iron or ESA was given in the preop setting.
b. If under 500 ml ebl, just monitor daily labs.
B. If no preoperative assessment was done and no treatment was administered at that time:
1. If there has been a perioperative blood loss of 500 or more ml, consider IV iron
therapy.
2. If under 500 ml ebl, just monitor daily labs.
C. Encourage reduced frequency and size of lab draws on all patients
D. Maintain and/or continue pre-natal vitamins
E. Folic acid, vitamin C, and B12