Perioperative anaemia management
Anaemia is common in patients with colorectal cancer, with 30-76% of patients variably reported as anaemic at diagnosis, depending on the level of haemoglobin used to define anaemia. Iron deficiency is also common in colorectal cancer and associated with poor performance and advanced disease.
Anaemia is associated with adverse perioperative outcomes including increased morbidity, prolonged length of hospital stay, excessive health resource utilisation, as well as reduced disease free survival.
Overview of evidence (non-systematic literature review)[edit source]
No systematic reviews were undertaken for this topic. Practice points were based on selected published evidence. See Guidelines development process.
Perioperative treatment options for patients with anaemia[edit source]
Options for correcting perioperative anemia include allogenic blood transfusion, erythropoiesis stimulating agents (ESAs) and iron supplementation in the setting of demonstrable deficiency.
Blood transfusions in the immediate perioperative period have been utilised to rectify the physiological impact of anaemia during surgery. However, the link between blood transfusion and adverse surgical outcomes, as well as increased colorectal cancer recurrence, is now well documented.
Given the association of erythropoiesis stimulating agents with adverse outcomes, including increased thrombosis and decreased survival in cancer patients, and current prescribing restrictions, their use has been limited in colorectal cancer.
Patients undergoing colorectal cancer surgery should be assessed for anaemia and iron deficiency as early as possible prior to surgery, to allow a window to correct reversible causes, in particular haematinic deficiencies, and to enable restoration of erythropoiesis.
Routine blood tests should include haemoglobin, full blood count, ferritin, transferrin, transferrin saturation, B12, folate, and C-reactive protein (CRP).
The Australian National Blood Authority has easily accessible guidelines on perioperative haemoglobin assessment and optimisation, which are based on a 2010 Australian review with recommendations.
Preoperative management of iron-deficiency anaemia[edit source]
Oral and intravenous (IV) iron have both been shown to correct iron deficiency anaemia. Four studies have evaluated the efficacy of preoperative oral iron prior to colorectal cancer surgery and have shown it to achieve reduced transfusion rates, but not a consistent increase in haemoglobin preoperatively.
Intravenously administered iron is preferential, given the time it takes to restore iron levels orally. IV iron also appears more effective than oral iron in correcting anaemia in gastrointestinal diseases, such as inflammatory bowel disease,, as well as prior to most types of surgery. There is emerging evidence for its use in colorectal cancer patients.
A randomised controlled trial (RCT) trial of patients undergoing resectional surgery with a preoperative diagnosis of colorectal cancer randomised 60 patients presenting with colorectal cancer to two doses of iron sucrose or placebo.. Less than a third of these patients were anaemic, and the dose of intravenous iron was suboptimal, but there was a trend towards decreased transfusion among the treatment group.
One RCT has been recently published which randomised abdominal surgery patients with iron deficiency anaemia to standard care or IV iron carboxymaltose. Seventy per cent of these patients had colorectal cancer. Those in the IV iron group had significantly fewer transfusions, increased haemoglobin at surgery and 4 weeks post surgery, and a decreased length of stay, further supporting the role of IV iron.
Postoperative management of iron-deficiency anaemia[edit source]
If iron deficiency anaemia is not addressed preoperatively and/or the patients lose substantial amounts of blood during surgery, IV iron therapy should be considered after surgery.
A recent Australian study has demonstrated a pragmatic and effective approach to the management of post-operative functional iron deficiency anaemia with intravenous iron carboxymaltose in such patients.
New formulations such as iron carboxymaltose can be given quickly in an outpatient or GP setting and have rare adverse reactions, which improve their acceptability and should increase their use.
Patients undergoing elective surgery for colorectal cancer should be assessed for anaemia and iron deficiency and any deficiencies should be addressed preoperatively.
Intravenous iron should be considered in preference to oral iron preoperatively given its quicker therapeutic effect.
Consideration should also be given to treating postoperative functional iron deficiency anaemia with intravenous iron.
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