FIGURE 2
Optimising pre-operative anaemia suggested treatment algorithm ( adapted from ref 22 )
Expected > 500ml blood loss or transfusion risk > 10 %
Vitamin B12 and / or folate therapy
Anaemia detection : Hb < 130g / l
Vitamin B12 and / or folate low
Further laboratory testing : serum ferritin , transferrin saturaion , B12 , folate , C-reactive protein , creatinine
Abnormal serum creatinine
|
Ferritin < 30mg / l
Iron deficiency anaemia
|
Ferritin 30-100mg / l + transferrin saturation < 20 % or C-reactive protein > 5mg / l |
Ferritin > 100mg / l + transferrin saturation < 20 % or C-reactive protein > 5mg / l |
Ferritin > 100mg / l + transferrin saturation > 20 % |
Timing of surgery not critical (> 6 weeks ) |
Anaemia of chronic inflammation with iron deficiency |
Anaemia / chronic inflammation |
Abnormal serum creatinine |
Oral iron Check Hb after 4 weeks , if still anaemic ( Hb < 130g / l ) give intravenous iron |
Timing critical or one of the following :
• Poor oral iron tolerance / noncompliance
• Impaired GI absorption
• Haemodialysis
|
Intravenous iron |
Chronic kidney disease
Refer to nephrologist
|
Intravenous iron
Assess for sourceof blood loss and refer as appropriate or refer to GI if no obvious source and :
• Adult male
• Postmenopausal female
• Premenopausal female with GI symptoms
Consider and refer as appropriate Non-haematological cause
• Acute / chronic inflammation
• Chronic infection
• Malignancy
• Liver disease
• Renal failure
Haematological cause
• Haemoglobinopathy , e . g ., Thalassaemia trait
• Sideroblastic anaemia
It is recognised that the surgery waiting lists in the UK already under pressure have been further increased by the COVID-19 pandemic obstructive pulmonary disease care : offer treatment and support to stop smoking ; offer pneumococcal and influenza vaccinations ; offer pulmonary rehabilitation for people with COPD ( if indicated ); co-develop a personalised self-management plan ; and optimise treatment of comorbidities . 16 Postponement of surgery is advisable only after a recent exacerbation . 13
Optimising diabetes control Peri-operative hyperglycaemia , whether the cause is known diabetes , undiagnosed diabetes or stress hyperglycaemia , is a risk factor for harm , increased 17 , 18
length of stay and death .
The Centre for Peri-operative Care ( CPOC ) in the UK has published guidance on the peri-operative care for patients with diabetes mellitus undergoing elective and emergency surgery . 19
Ideally , diabetic patients should be optimised at the time of referral from primary care . 17 In situations where this is not possible , advice from the diabetes team should be sought as soon as possible to facilitate optimisation .
The key recommendations from the CPOC guideline are that pre-operative assessment clinics should refer all patients with a HbA1C of 69mmol / mol and above , an insulin pump or a continuous subcutaneous insulin infusion ( CSII ) to a specialist diabetes team for treatment optimisation . 19
Another recommendation from this document is that preassessment clinics should work where possible , with the pharmacy team to ensure medicines reconciliation prior to admission to reduce medication errors including a system for patients to report changes to their medication between their pre-operative assessment and date of surgery . Ideally , diabetic medication should be pre-prescribed prior to admission and for best practice rescue treatment should also be pre-prescribed for looming hypo- or hyper-glycaemia . 19
Pharmacists can use this vital time adequately to promote lifestyle interventions such as smoking
28 | Issue 99 | 2021 | hospitalpharmacyeurope . com