Skip to main content
SpringerLink
Log in

Diagnostik und Behandlung der präoperativen Anämie

Diagnostics and treatment of preoperative anemia

  • Klinische Pharmakologie
  • Published:
Der Anaesthesist Aims and scope Submit manuscript

Zusammenfassung

Die präoperative Anämie findet sich in den industrialisierten Ländern bei 14–40 % der zu operierenden Patienten. Sie geht schweregradabhängig mit erhöhter perioperativer Morbidität und Mortalität einher. Eine der wichtigsten Ursachen ist der gut zu behandelnde Eisenmangel. Im Rahmen des Patient-Blood-Management-Konzepts stellen Diagnostik und Therapie der präoperativen Anämie ein zentrales Element zur Verbesserung des perioperativen Outcome dar.

Eine adäquate und frühzeitige Ursachendiagnostik vor Therapie ist relevant, da die zum Einsatz kommenden Medikamente (Eisen, Erythropoetin, ggf. Folsäure und Vitamin B12) z. T. kostspielig sind, mit relevanten Nebenwirkungen einhergehen können und bei fehlerhafter Indikation zu keiner Verbesserung der Anämie führen. Zum anderen benötigt die adäquate Regeneration des Erythrozytenvolumens Zeit.

Die vorliegende Übersichtsarbeit stellt wichtige Aspekte der Epidemiologie und prognostischen Bedeutung der präoperativen Anämie, der Physiologie und Pathophysiologie der Erythropoese, der Anämiediagnostik und der daraus abgeleiteten Therapieansätze dar und diskutiert die derzeitige Evidenzlage zur präoperativen Therapie.

Abstract

Approximately 14–40% of patients in industrialized countries present with preoperative anemia. Depending on the severity, anemia is associates with increased perioperative morbidity and mortality. One of the most important causes of preoperative anemia is iron deficiency which is usually easy to treat. Implemented in the multimodal concept of patient blood management, the diagnostics and treatment of preoperative anemia are important aspects for improvement of perioperative outcome. Adequate and early diagnostics of the cause of anemia before treatment is important because treatment options, e.g. with iron, erythropoetin, folic acid and vitamin B12, may be expensive, may have severe side effects, and in the case of a wrong indication, will not improve anemia. In addition, an adequate regeneration of the erythrocyte volume requires time. This review article presents important aspects of the epidemiology and prognostic implications of preoperative anemia, the physiology and pathophysiology of anemia as well as diagnostic features and the evidence base for preoperative treatment options.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3

Literatur

  1. Acher PL, Al-Mishlab T, Rahman M et al (2003) Iron deficiency anaemia and delay in the diagnosis of colorectal cancer. Colorectal Dis 5(2):145–148

    Article  CAS  PubMed  Google Scholar 

  2. American Society of Anesthesiologists Task Force on Perioperative Blood Management (2015) Practice guideline for perioperative blood management: An updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology 122(2):241–275

    Article  Google Scholar 

  3. Anand IS (2008) Anemia and chronic heart failure implications and treatment options. J Am Coll Cardiol 52(7):501–511

    Article  PubMed  Google Scholar 

  4. Barnabeu-Wittel M, Romero M, Ollero-Baturone M et al (2016) Ferric carboxymaltose with or without erythropoietin in anemic patients with hip fracture: A randomized clinical trial. Transfusion 56:2199–2211

    Article  CAS  Google Scholar 

  5. Baron DM, Hochrieser H, Posch M et al (2014) European Surgical Outcomes Study (EuSOS) group for Trials Groups of European Society of Intensive Care Medicine; European Society of Anaesthesiology. Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients. Br J Anaesth 113(3):416–423

    Article  CAS  PubMed  Google Scholar 

  6. Basora M, Colomina MJ, Tio M et al (2013) Optimizing preoperative haemoglobin with intravenous iron. Br J Anaesth 110:488–490

    Article  CAS  PubMed  Google Scholar 

  7. Beattie WS, Karkouti K, Wijeysundera DN et al (2009) Risk associated with preoperative anemia in noncardiac surgery: A single-center cohort study. Anesthesiology 110(3):574–581

    Article  PubMed  Google Scholar 

  8. Beck WS (1991) Diagnosis of megaloblastic anemia. Annu Rev Med 42:311–322

    Article  CAS  PubMed  Google Scholar 

  9. Behnisch W, Muckenthaler M, Kulozik A (2016) S1-Leitlinie „Eisenmangelanämie“. AWMF Registernummer 025/021

    Google Scholar 

  10. Bernard AC, Davenport DL, Chang PK et al (2009) Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J Am Coll Surg 208(5):931–932

    Article  PubMed  Google Scholar 

  11. Beru N, McDonald J, Lacombe C et al (1986) Expression of the erythropoietin gene. Mol Cell Biol 6:2571–2575

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Bisbe E, Castillo J, Sáez M et al (2008) Prevalence of preoperative anemia and hematinic deficiencies in patients scheduled for elective major orthopedic surgery. Transfus Altern Transfus Med 10:166–173

    Article  Google Scholar 

  13. Bortslap WAA, Stellingwerf ME, Moollla Z et al (2015) Iron therapy for the treatment of preoperative anaemia in patients with colorectal carcinoma: A systematic review. Colorectal Dis 17:1044–1054

    Article  Google Scholar 

  14. Canet J, Gallart L, Gomar C et al (2010) ARISCAT Group. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology 113(6):1338–1350

    Article  PubMed  Google Scholar 

  15. Dickerhoff R (2015) Hämoglobinkrankheiten. Internist 56:1009–1018

    Article  CAS  PubMed  Google Scholar 

  16. Edwards TJ, Noble EJ, Durran A et al (2009) Randomized clinical trial of preoperative intravenous iron sucrose to reduce blood transfusion in anaemic patients after colorectal cancer surgery. Br J Surg 96:1122–1128

    Article  CAS  PubMed  Google Scholar 

  17. Erslev AJ, Besarab A (1997) Erythropoietin in the pathogenesis and treatment of the anemia of chronic renal failure. Kidney Int 51:622–630

    Article  CAS  PubMed  Google Scholar 

  18. Feagan BG, Wong CJ, Kirkley A et al (2000) Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty: A randomized, controlled trial. Ann Intern Med 133(11):845–854

    Article  CAS  PubMed  Google Scholar 

  19. Gamal M, Abdelhamid B, Zakaria D et al (2018) Evaluation of Noninvasive hemoglobin monitoring in trauma patients with low hemoglobin levels. Shock 49(2):150–153

    Article  CAS  PubMed  Google Scholar 

  20. Glance LG, Dick AW, Mukamel DB et al (2011) Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 114(2):283–292

    Article  PubMed  Google Scholar 

  21. Goodnough LT, Maniatis A, Earnshaw P et al (2011) Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth 106(1):13–22

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Guralnik JM, Eisenstaedt RS, Ferrucci L et al (2004) Prevalence of anemia in persons 65 years and older in the United States: Evidence for a high rate of unexplained anemia. Blood 104(8):2263–2268

    Article  CAS  PubMed  Google Scholar 

  23. Haas JD, Fairchild MW (1989) Summary and conclusions of the International Conference on Iron Deficiency and Behavioral Development, October 10–12, 1988. Am J Clin Nutr 50(3):703–705

    Article  Google Scholar 

  24. Halwachs-Baumann G (2012) Diagnosis of anaemia: Old things rearranged. Wien Med Wochenschr 162:478–488

    Article  PubMed  Google Scholar 

  25. Heil SG, de Jonge R, de Rotte MC et al (2012) Screening for metabolic vitamin B12 deficiency by holotranscobalamin in patients suspected of vitamin B12 deficiency: A multicentre study. Ann Clin Biochem 49:184–189

    Article  CAS  PubMed  Google Scholar 

  26. Hershko C, Karsai A, Eylon L et al (1970) The effect of chronic iron deficiency on some biochemical functions of the human hemopoietic tissue. Blood 36(3):321–329

    CAS  PubMed  Google Scholar 

  27. De Hert S, Staender S, Fritsch G et al (2018) Pre-operative evaluation of adults undergoing elective noncardiac surgery. Eur J Anaesthesiol 35:407–465

    Article  PubMed  Google Scholar 

  28. von Heymann C, Kaufner L, Sander M et al (2016) Does the severity of preoperative anemia or blood transfusion have a stronger impact on long-term survival after cardiac surgery? J Thorac Cardiovasc Surg 152(5):1412–1420

    Article  Google Scholar 

  29. Hiscock R, Kumar D, Simmons SW (2015) Systematic review and meta-analysis of method comparison studies of Masimo pulse co-oximeters (Radical-7™ or Pronto-7™) and HemoCue® absorption spectrometers (B-Hemoglobin or 201+) with laboratory haemoglobin estimation. Anaesth Intensive Care 43(3):341–350

    Article  CAS  PubMed  Google Scholar 

  30. Hoffmann JJ, Urrechaga E, Aguirre U (2015) Discriminant indices for distinguishing thalassemia and iron deficiency in patients with microcytic anemia: A meta-analysis. Clin Chem Lab Med 53(12):1883–1894

    CAS  PubMed  Google Scholar 

  31. Hom J, Dulmovits BM, Mohandas N, Blanc L (2015) The erythroblastic island as an emerging paradigm in the anemia of inflammation. Immunol Res 63:75–89

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Hong FS, Sieradzki N, Pollock C et al (2017) Prevalence and causes of preoperative anaemia in elective major surgery patients. Intern Med J 47(12):1400–1404

    Article  CAS  PubMed  Google Scholar 

  33. Karkouti K, Wijeysundera DN, Beattie WS (2008) Reducing Bleeding in Cardiac Surgery (RBC) Investigators. Risk associated with preoperative anemia in cardiac surgery: A multicenter cohort study. Circulation 117(4):478–484

    Article  PubMed  Google Scholar 

  34. Kassebaum NJ, GBD 2013 Anemia Collaborators (2016) The Global Burden of Anemia. Hematol Oncol Clin North Am 30(2):247–308

    Article  PubMed  Google Scholar 

  35. Kaufner L, von Heymann C (Hrsg) (2018) S3 Leitlinie „Präoperative Anämie“. AWMF Registernummer 001–0024

    Google Scholar 

  36. KDIGO (2012) KDIGO Clinical Practice Guicedeline for Anemia in Chronic Kidney Disease. Kidney International Supplements, Bd. 2

    Google Scholar 

  37. Keeler BD, Simpson JA, Ng O et al (2017) Randomized clinical trial of preoperative oral versus intravenous iron in anaemic patients with colorectal cancer. Br J Surg 104:214–221

    Article  CAS  PubMed  Google Scholar 

  38. Kim A, Nemeth E (2015) New insights into iron regulation and erythropoiesis. Curr Opin Hematol 22(3):199–205

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Kotze A, Harris A, Baker C et al (2015) British Committee for Standards in Hematology guidelines on the identification and management of pre-operative anaemia. Br J Haematol 171:322–331

    Article  PubMed  Google Scholar 

  40. Kozek-Langenecker SA, Ahmed AB, Afshari A et al (2017) Management of severe perioperative bleeding. Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 34:332–395

    Article  PubMed  Google Scholar 

  41. Lasocki S, Krauspe R, von Heymann C et al (2015) PREPARE: the prevalence of perioperative anaemia and need for patient blood management in elective orthopaedic surgery: A multicentre, observational study. Eur J Anaesthesiol 32(3):160–167

    Article  PubMed  Google Scholar 

  42. Lidder PG, Sanders G, Whitehead E et al (2007) Preoperative oral iron supplementation reduces blood transfusion in colorectal surgery. Ann R Coll Surg Engl 89:418–421

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Martinsson A, Andersson C, Andell P et al (2014) Anemia in the general population: Prevalence, clinical correlates and prognostic impact. Eur J Epidemiol 29(7):489–498

    Article  PubMed  Google Scholar 

  44. Metzgeroth G, Hastka J (2015) Eisenmangelanämie und Anämie der chronischen Erkrankungen. Internist 56:978–988

    Article  CAS  PubMed  Google Scholar 

  45. Meybohm P, Herrmann E, Steinbicker AU et al (2016) Patient blood management is associated with a substantial reduction of red blood cell utilization and safe for patient’s outcome: A prospective, multicenter cohort study with a noninferiority design. Ann Surg 264(2):203–211

    Article  PubMed  Google Scholar 

  46. Musallam KM, Tamim HM, Richards T et al (2011) Preoperative anaemia and postoperative outcomes in non-cardiac surgery: A retrospective cohort study. Lancet 378(9800):1396–1407

    Article  PubMed  Google Scholar 

  47. Muñoz M, Acheson AG, Auerbach M et al (2017) International consensus statement on the peri-operative management of anemia and iron deficiency. Anaesthesia 72:233–247

    Article  CAS  PubMed  Google Scholar 

  48. Muñoz M, Garcia-Erce JA, Remacha AF (2011a) Disorders of iron metabolism. Part 1: Molecular basis of iron homoeostasis. J Clin Pathol 64:281–286

    Article  CAS  PubMed  Google Scholar 

  49. Muñoz M, Garcia-Erce JA, Remacha AF (2011b) Disorders of iron metabolism. Part II: Iron deficiency and iron overload. J Clin Pathol 64(4):287–296

    Article  CAS  PubMed  Google Scholar 

  50. Muñoz M, Gómez-Ramírez S, Kozek-Langeneker S (2016) Pre-operative haematological assessment in patients scheduled for major surgery. Anaesthesia 71(Suppl 1):19–28

    Article  PubMed  Google Scholar 

  51. Nemeth E, Ganz T (2014) Anemia of inflammation. Hematol Oncol Clin North Am 28(4):671–681

    Article  PubMed  PubMed Central  Google Scholar 

  52. Ng O, Keeler BD, Simpson A et al (2015) Iron therapy for pre-operative anaemia. Cochrane Database Syst Rev 12:CD11588. https://doi.org/10.1002/14651858.CD011588.pub2

    Article  Google Scholar 

  53. Oberley MJ, Yang DT (2013) Laboratory testing for cobalamin deficiency in megaloblastic anemia. Am J Hematol 88:522–526

    Article  CAS  PubMed  Google Scholar 

  54. Padhi S, Glen J, Pordes BAJ et al (2015) Management of anaemia in chronic kidney disease: Summary of updated NICE guidance. BMJ 350:h2258

    Article  PubMed  Google Scholar 

  55. Palis J (2014) Primitive and definitive erythropoiesis in mammals. Front Physiol 5:3

    Article  PubMed  PubMed Central  Google Scholar 

  56. Pedersen AB, Mehnert F, Overgaard S et al (2009) Allogeneic blood transfusion and prognosis following total hip replacement: A population-based follow up study. BMC Musculoskelet Disord 10(1):167–112

    Article  PubMed  PubMed Central  Google Scholar 

  57. Praetorius K, Madsen CM, Abrahamsen B et al (2016) Low levels of hemoglobin at admission are associated with increased 30-day mortality in patients with hip fracture. Geriatr Orthop Surg Rehabil 7(3):115–120

    Article  PubMed  PubMed Central  Google Scholar 

  58. Qvist N, Boesby S, Wolff B et al (1999) Recombinant human erythropoietin and concentration at operation and during the postoperative period: Reduced need for blood transfusions in patients undergoing colorectal surgery. Prospective double-blind placebo-controlled study. World J Surg 23(1):30–35

    Article  CAS  PubMed  Google Scholar 

  59. Ranucci M, Di Dedda U, Castelvecchio S et al (2012) Surgical and Clinical Outcome Research (SCORE) Group. Impact of preoperative anemia on outcome in adult cardiac surgery: A propensity-matched analysis. Ann Thorac Surg 94(4):1134–1141

    Article  PubMed  Google Scholar 

  60. Richards T, Clevenger B, Keidan J et al (2015) PREVENTT: Preoperative intravenous iron to treat anaemia in major surgery: Study protocol for a randomised controlled trial. Trials 16:254

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  61. Rubiolo C, Piazzolla D, Meissl K et al (2006) A balance between Raf-1 and Fas expression sets the pace of erythroid differentiation. Blood 108:152–159

    Article  CAS  PubMed  Google Scholar 

  62. Sachdev H, Gera T, Nestel P (2005) Effect of iron supplementation on mental and motor development in children: Systematic review of randomised controlled trials. Public Health Nutr 8(2):117–132

    Article  PubMed  Google Scholar 

  63. Semenza GL, Koury ST, Nejfelt MK et al (1991) Cell-type-specific and hypoxia-inducible expression of the human erythropoietin gene in transgenic mice. Proc Natl Acad Sci U S A 88(19):8725–8729

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Shander A, Hofmann A, Isbister J et al (2013) Patient blood management—The new frontier. Best Pract Res Clin Anaesthesiol 27(1):5–10

    Article  PubMed  Google Scholar 

  65. Steinbicker AU, Muckenthaler MU (2013) Out of balance—Systemic iron homeostasis in iron-related disorders. Nutrients 5:3034–3061

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Thomas DW, Hinchliffe RF, Briggs C et al (2013) Guideline for the laboratory diagnosis of functional iron deficiency. Br J Haematol 161:639–648

    Article  CAS  PubMed  Google Scholar 

  67. Tuchscherer A, Chemnitz J (2015) Hämolytische Anämien. Internist 56:1000–1008

    Article  CAS  PubMed  Google Scholar 

  68. Urrechaga E (2008) Discriminant value of % microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. Clin Chem Lab Med 46(12):1752–1758

    Article  CAS  PubMed  Google Scholar 

  69. Williams ML, He X, Rankin JS et al (2013) Preoperative hematocrit is a powerful predictor of adverse outcomes in coronary artery bypass graft surgery: A report from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 96(5):1628–1634 (discussion 1634)

    Article  PubMed  Google Scholar 

  70. Wojchowski DM, Sathyanarayana P, Dev A (2010) Erythropoietin receptor response circuits. Curr Opin Hematol 17:169–176

    CAS  PubMed  PubMed Central  Google Scholar 

  71. Yoder MC (2014) Inducing definitive hematopoiesis in a dish. Nat Biotechnol 32:539–541

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Deutschland

    C. Rosenthal

Authors
  1. C. Rosenthal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. C. von Heymann
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. L. Kaufner
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to C. Rosenthal.

Ethics declarations

Interessenkonflikt

C. Rosenthal hat im Jahr 2018 im Rahmen einer einmaligen Beratertätigkeit zum Thema Patient Blood Management ein Honorar von der Firma Pharmacosmos erhalten. C. von Heymann und L. Kaufner geben an, dass kein Interessenkonflikt zu der Thematik dieses Beitrages besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rosenthal, C., von Heymann, C. & Kaufner, L. Diagnostik und Behandlung der präoperativen Anämie. Anaesthesist 68, 555–567 (2019). https://doi.org/10.1007/s00101-019-0628-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00101-019-0628-5

Schlüsselwörter

Keywords

Search

Navigation