Treating anaemia before your surgery

What is this information about?

This information is about what happens if you are found to have anaemia before your operation.  

It explains what anaemia is, and why it is important to treat it before you have your operation. It also explains the different types of treatments you can have, and the risks and benefits of both.  

Why have I been given this information?

You have been given this information because you have been found to have anaemia before your operation. Treating your anaemia now can make complications after your operation less likely to happen.  

Reading this information will help you to understand your treatment options so that you can decide what you would like to do.  

Keep this information in a safe place so you can refer to it when you need to. You can also use it when you are talking to your nurse or doctor about the treatment.

What is anaemia?

Anaemia is when you: 

• do not have enough red blood cells to deliver oxygen around your body  

or

• have red blood cells that cannot carry enough oxygen around your body.  

There are many causes of anaemia. The most common cause is because of a lack of iron. This is called iron deficient anaemia. 

Anaemia in the time before your operation (also called the pre-operative period) is very common. There are different treatments available. Treating your anaemia now may make it less likely that you have problems after your surgery.

Why is treating anaemia important before having surgery?

Compared to people who do not have anaemia before their surgery, people with anaemia:

• are more likely to need a blood transfusion during and after surgery 
• stay longer in hospital  
• may experience a more difficult recovery period.  

University Hospitals Sussex NHS Trust screen people before elective (non-emergency) surgery for anaemia and offer treatment if it is needed. 

What could happen if I do not receive iron?

If you do not wish to have iron replacement, you may become or remain anaemic.  

You may end up needing a blood transfusion to treat your anaemia. Blood transfusions are associated with some side effects and risks, such as possible allergic reactions to the donor blood.

What can I do to help myself?

Many people have anaemia because they do not have enough important nutrients in their diet.  

Improving your diet to increase the amount of iron you take in may help this.  

Sources of iron include: 

• Red meats (beef, lamb and pork). This should not be more than about 70 grams per day.  
• Fish and poultry 
• pulses and legumes (such as beans, peas, and lentils)  
• dark green vegetables (such as spinach, kale and broccoli)  
• nuts and seeds  
• Some foods are fortified with iron. All bread sold in the UK, other than wholemeal, must be fortified and many breakfast cereals are also fortified with iron.  

To help prepare for your surgery and recovery in good time the Centre for Perioperative Care (CPOC) recommends the following:

• increasing your physical activity or exercise 
• stopping smoking 
• preparing psychologically and practically.  

There is more information available here: For Patients | Centre for Perioperative Care 

What treatments are available for anaemia?

The treatment recommended for you depends on your blood results, the type of surgery and the amount of time until your planned surgery. 

Treatment for anaemia can sometimes include a blood transfusion before surgery or blood transfusion and intravenous iron. This will depend on the type of surgery you are having and the type of anaemia that you have. This will be discussed with you by a doctor or nurse looking after you. 

Your anaemia may also be because of low Vitamin B12 or folate levels. This may need treatment with B12 injections (you can have these at your GP surgery) or folate tablets. We will ask your GP to prescribe this.

Treatment with oral iron supplements

If you have more than 6 weeks before your operation, we may advise you to take oral iron tablets (tablets that you swallow).  

4 to 6 weeks before your operation, we will give you a blood test to re-check your haemoglobin levels. Haemoglobin carries oxygen around your body, and iron is important to make haemoglobin.  

If you are told to complete the full course of oral iron it is important to do this. You may need to take oral iron after your surgery for up to 4 months. 

The main types of iron supplements are: 

• Ferrous sulphate  
• Ferrous fumarate 

How do I take oral iron tablets?

• Try to take your tablets at roughly the same time every day, generally first thing in the morning on an empty stomach (for example, one hour before or two hours after eating). This is because your body is not as good at absorbing iron if you take it with food. 
• Avoid taking iron with tea or phytates (found in beans, seeds, nuts or grains) as this also limits absorption.  
• Taking iron tablets with vitamin C does not seem to increase absorption.  
• Some medication also affects absorption of iron from the gut, especially medication which reduces stomach acid (antacids) and certain antibiotics. Always check with your doctor or pharmacist whether any of your other medicines might affect how your iron supplement works.  

What are the potential risks and side effects of oral iron tablets?

You may experience side effects such as

• nausea (sickness)  
• diarrhoea (loose or runny poo)  
• stomach discomfort or constipation (hard or difficult poo). Taking iron on alternate days (missing every other day) may help with this, instead of stopping treatment completely.  
• You may also notice that your stools (poo) become dark while taking iron tablets. This will stop once treatment is completed.  

Please use the details below to contact the Preoperative Anaemia team if the side effects are very bad. There may be another treatment option for you. 

Treatment with iron supplements through the veins (intravenous iron)

We may treat your anaemia with intravenous iron. Intravenous means this is given with an infusion or drip into a vein in your arm.

What are the potential risks and side effects of intravenous iron?

Intravenous iron is a safe and effective therapy. Some of the side effects that have been reported are: 

• Staining of the skin: If your cannula (the part of the drip that goes into your arm) was to move from your vein during treatment, the drug could move into your skin rather than your blood. This could result in a permanent brown stain to the skin. If you notice pain at the injection site during your treatment, please tell the nurse caring for you immediately. Please tell the nurse if the drip comes out or you notice any fluid leaking from the drip site. Avoid rubbing the area.

• Allergy: The risk of having an allergic reaction from intravenous iron is small. But tell the nurse looking after you immediately if you have any of the following during your treatment: 
  • swelling of lips, tongue, face or throat 
  • shortness of breath 
  • itching and rash 
  • feeling hot all over 
  • feeling your heart race 
  • feeling lightheaded or faint.  

• Delayed reaction: it is rare, but some patients may have muscle or joint pains and fever in the days after treatment. It usually lasts two to four days. You can take simple painkillers like paracetamol.  

• Other side effects may include a metallic taste in your mouth (although this disappears quickly). You might feel lightheaded, sick or dizzy.  

Please tell the nurse if you have these symptoms. Nurses will monitor your temperature, pulse and blood pressure throughout the procedure.  

Please ask the nurse looking after you if you can see the patient information leaflet that comes with the intravenous iron. This also has information about the risks of intravenous iron, so it is important to read it.  

What are the expected benefits of treatment with intravenous iron?

Intravenous iron is very good at building up your body’s store of iron. It allows a much larger dose of iron to be given than if you take iron tablets. 

What should I do before I come into hospital for intravenous iron?

Before you receive intravenous iron, if you are taking oral iron tablets, please stop these the day before the iron infusion.  

Your doctor will advise you if and when you should restart these after the iron infusion. You should not start taking your oral iron tablets for at least five days after your last injection of intravenous iron.  

Please be aware that some medicines or remedies that you can buy in a shop or pharmacy (like multivitamins) may contain iron.  

Make sure you tell your doctor or nurse if: 

• you have or feel you may have an infection  
• you have problems with asthma, eczema or problems with allergies or inflammation  
• you have had a reaction to intravenous iron in the past. 

If you are not sure if any of the above applies to you, talk to your doctor or nurse before having the intravenous iron. 

Where will the procedure take place?

You can have iron infusions at different hospitals across the Trust.  We will do our best to arrange the most suitable and convenient location for you.  

Details of the time and place of your appointment will be provided separately. 

How long will I be in hospital?

You will need to come into hospital for a short period of time (about 30 minutes) before the infusion. The infusion usually takes about 15 to 30 minutes.   

If you also need a blood transfusion, you will need to come in the day before to check your bloods, then the following day you will need to come 30 minutes before the infusion. 

You will then be asked to stay in the hospital for about 30 minutes after the infusion.  

Is there anything I should avoid doing once I go home?

Avoid any heavy lifting with the arm that had the treatment for 24 hours. 

Will my iron infusion affect my work or any other activities?

No. Your iron infusion will not affect your usual activities or work. 

Will I have to come back to hospital after the infusion?

You will be asked to return for a blood test 2 to 6 weeks after your infusion. This test helps us see how well the treatment is working.  

We will contact you with the appointment details and tell you if any further infusions are needed.

What if I am not sure about having treatment for my anaemia?

If you are not sure, please ask questions about your treatment. You will speak to a doctor or nurse before your treatment either on the telephone or in person. It may help to think about:

• what are the benefits of having this treatment? 
• What are the risks of having this treatment? 
• What are the alternatives to this treatment? 
• what if I decide not to have this treatment (to do nothing)? 

More information about shared decision making can be found here: https://www.cpoc.org.uk/shared-decision-making 

Even if you decide to have this treatment, you can change your mind at any time and withdraw your consent.  You can talk about this with the team looking after you.

Who can I contact for further information and advice?