Anaemia in the Perioperative Pathway

Anaemia is associated with adverse perioperative outcomes and is present in a third of patients having major surgery

Anaemia is associated with adverse outcomes of surgery. The blood loss of surgery or trauma can cause or worsen anaemia. People who have anaemia have a worse result from their operation including poorer wound healing, slower mobilisation and an increased risk of death. Risk ratios in the published literature suggest people with anaemia have two or three times the rate of complications. Anaemia is often associated with other conditions, but as an independent risk factor, anaemia is responsible for around 20% more complications Interventional studies adopting a Patient Blood Management (PBM) approach, including addressing anaemia, lead to reduced blood transfusion, length of stay, complications and hospital costs.

Anaemia is frequently diagnosed late in the work up of patients for surgery. It is increasingly apparent that a pathway approach to care works best. Pathways should be set up that allow a Patient Blood management (PBM) approach: anaemia should be diagnosed early and its cause investigated. Treatment should be given, intraoperative blood loss minimised and the patient’s physiological response optimised. The pathway should anticipate potential problems. .

“Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value.”

This CPOC perioperative anaemia guideline (updated 2025) has been developed using a whole pathway approach. It contains recommendations for patients of all ages undergoing surgery and for health care professionals in both emergency and elective surgical settings and across specialities.

Why is this guideline important?

The aim of this guideline is to ensure that the patient is at the centre of the whole process, and that everyone involved in their care carries out their individual responsibilities to minimise the risk from anaemia. 

Updated Guideline 2025 v2.1

The guideline has been updated in 2025 and v2.1 was published in May 2025. A summary of the changes to the original version can be downloaded for information. 

To make the best of this approach we need to make sure patients and all health care professionals including GPs and multidisciplinary hospital teams work together to:

• identify anaemia early in the pathway
• make the patient aware of this and all actions going forward
• find the cause of the anaemia
• use tried and tested treatments for anaemia before surgery.  This could include advice on changes in diet, oral treatments such as iron supplements and the use intravenous iron when necessary
• make sure the patient has a personalised treatment programme including providing appropriate information about the pros and cons of the different approaches suggested to the patient and how long these should be continued
• communicate clearly between different members of the team so that operations are not cancelled unnecessarily and improve the interface between primary care and hospitals
• talk openly to the patient about the benefits and risks of managing anaemia and the surgery 

Anaemia Guideline Working Group