PREOPERATIVE HEMOGLOBIN

Below a hemoglobin concentration of 7 g/dL, the resting cardiac output increases to

maintain a normal oxygen delivery. An increased hemoglobin concentration may be
appropriate for older and sicker patients with cardiac or pulmonary disease,
particularly when there is clinical evidence (eg, a reduced mixed venous oxygen
saturation and a persisting tachycardia) that transfusion would be useful.
transfusions are not recommended until the hematocrit decreases to 24% or lower
(hemoglobin <8.0 g/dL), but it is necessary to take into account the rate of blood loss
and comorbid conditions (eg, cardiac disease)

Morgan Clinical Anesthesiology, 5th 2013

The American Society of Anesthesiologists Task Force on Perioperative Blood
Transfusion noted in its recommendations that transfusion of RBCs should usually be
administered when the hemoglobin concentration is low (e.g., <6 g/dL in a young,
healthy patient), especially when the anemia is acute. RBCs are usually unnecessary
when the hemoglobin concentration is more than 10 g/dL

Stoelting's Pharmacology and Physiology in Anesthetic Practice, 5th Edition, 2015

COMPLETE BLOOD COUNT AND
HEMOGLOBIN CONCENTRATION
A preoperative hemoglobin value has been suggested as the only test necessary in
many patients prior to elective surgery; however, even this minimal standard has been
questioned
The standard regarding the lowest acceptable perioperative hematocrit and
indication for a preoperative transfusion has changed during the past decade. The
current recommendations of the National Blood Resource Education Committee are
that a hemoglobin level of 7 g/dL is acceptable in patients without systemic disease.
In patients with systemic disease, signs of inadequate systemic oxygen delivery
(tachycardia, tachypnea) are an indication for transfusion (barash)

Clinical Anesthesia, 7th ed. (Barash et al, 2013)

Transfusion is rarely indicated when the hemoglobin level is higher than 10 g/dL and
is almost always needed when hemoglobin is less than 6 g/dL
A randomized trial found no advantage of routinely transfusing older patients who
were undergoing hip fracture repair to a hemoglobin concentration of 10 g/dL as
opposed to 8 g/dL.

Miller's Anesthesia, 2-Volume Set, 8th ed. (2015)

GUIDELINES FOR PERIOPERATIVE
MANAGEMENT OF INFANTS AND CHILDREN
WITH ANEMIA
In infants older than 3 months, hemoglobin levels of 8 g/dL or higher may be
acceptable
In infants younger than 2 months (or in preterm infants, 50 to 52 weeks'
postconceptual age), a hemoglobin level of 9.5 to 10 g/dL is probably the absolute
minimum
In infants in their first week of life, infants weighing less than 1500 g, and infants with
cardiac or pulmonary disease, a preoperative hemoglobin level of 12 g/dL or higher
is advisable

Smith Anesthesia for Infants & Children 7Ed 2005

RED CELL TRANSFUSION GUIDELINES
The old adage of transfusing red cells such that the hemoglobin is greater than 10
g/dL and the hematocrit is more than 30% prior to operations no longer applies.
The evidence to date suggests that a more conservative threshold for transfusion can
be used in most patients.
Recently updated guidelines from the American Society of Anesthesiology recommend
transfusion if hemoglobin level is less than 6 g/dL and that transfusion is rarely
necessary when the level is more than 10 g/dL
When hemoglobin concentrations fall between 6 and 10 g/dL, the guidelines state
that transfusion decisions should be based on indication of organ ischemia, risk of or
ongoing bleeding, intravascular volume status, and susceptibility to complications of
inadequate oxygenation
Med Clin North Am. 2009 September, Anemia in the Preoperative
Patient, Manish S. Patel, MDa and Jeffrey L. Carson, MD
CLINICAL PRACTICE GUIDELINES FROM
THE AABB NOVEMBER 2016
AABB guidelines include the following recommendations for hemodynamically stable patients
without active bleeding:
●Hemoglobin <6 g/dL – Transfusion recommended except in exceptional circumstances.
●Hemoglobin 6 to 7 g/dL – Transfusion generally likely to be indicated.
●Hemoglobin 7 to 8 g/dL – Transfusion may be appropriate in patients undergoing
orthopedic surgery or cardiac surgery, and in those with stable cardiovascular disease, after
evaluating the patient’s clinical status.
●Hemoglobin 8 to 10 g/dL – Transfusion generally not indicated, but should be considered for
some populations (eg, those with symptomatic anemia, ongoing bleeding, acute coronary
syndrome with ischemia, and hematology/oncology patients with severe thrombocytopenia
who are at risk of bleeding).
●Hemoglobin >10 g/dL – Transfusion generally not indicated except in exceptional
circumstances.
SYMPTOMATIC PATIENT
symptomatic anemia should be treated with transfusion in all patients with
hemoglobin <10 g/dL, regardless of the hemoglobin level, provided that the
symptoms are severe enough and are clearly related to the anemia rather than the
underlying condition.
Symptoms of anemia include symptoms of myocardial ischemia, orthostatic
hypotension or tachycardia unresponsive to fluid replacement
Chronic anemia can present with symptoms such as irritability, weakness, and exercise
intolerance. These symptoms of anemia are nonspecific and often not considered
sufficient indications for transfusion.
Some patients will not manifest typical anemia symptoms for a variety of reasons (eg,
altered mental status, diabetic neuropathy, analgesic therapy). Thus, surrogate
measures (eg, ECG changes) may be useful in some situations. When transfusion is
used in a symptomatic patient, it is important to determine whether symptoms have
improved following the transfusion, because this may guide further decision-making
TERIMA KASIH BANYAK
MOHON ASUPAN