Domenico Girelli: Why Hemoglobin Alone Is Not Enough Before Surgery
Domenico Girelli, Full Professor of Internal Medicine and Head of the Department of Medicine at University of Verona, shared a post on LinkedIn about a recent article he and his colleagues co-authored, published in Anesthesia and Analgesia, adding:
“Are we missing the full picture by focusing only on hemoglobin (Hb) before surgery?
In perioperative care, Patient Blood Management (PBM) has rightly focused on detecting and treating preoperative #anemia. However, looking at Hb alone can overlook a crucial earlier stage: Nonanemic Iron Deficiency (NAID).
We suggest that characterizing a patient’s iron status prior to major elective surgery is essential, even when Hb is normal.
Key insights:
- Iron is much more than a substrate for Hb: it is vital for cellular energy, mitochondrial oxidative phosphorylation, skeletal/cardiac muscle function, and immune health.
- Preoperative reserve matters: patients with depleted iron stores face higher risks of post-operative anemia and impaired functional recovery following expected surgical blood loss and inflammatory stress.
Diagnostic evaluation requires context—interpreting ferritin alongside TSAT and inflammatory markers (i.e. CRP) to distinguish absolute from functional iron deficiency.
NAID is not an automatic indication for universal iron therapy in every patient, but recognizing it as a modifiable dimension of perioperative reserve enables targeted, individualized optimization before surgery.
Ignoring iron stores while focusing strictly on Hb means missing a key window to prevent postoperative complications and optimize patient recovery.”
Title: Beyond Hemoglobin: The Clinical Imperative for Managing Nonanemic Iron Deficiency in Perioperative Care—A Perspective
Authors: Manuel Muñoz, Ioav Cabantchik, Rodolfo D. Cançado, Caroline Evans, Domenico Girelli, Vernon Louw, Patrick Meybohm, Sherri Ozawa, Joshua Ozawa-Morriello, Dorine W. Swinkels, Donat R. Spahn, Aryeh Shander
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