Does pumping iron bring gains? A review of the role of intravenous iron in perioperative blood management

In recent years, there has been an increased focus on practices that decrease the need for perioperative blood transfusions. Intravenous (IV) iron therapy has globally been instituted as part of perioperative care protocols to potentially decrease the need for blood transfusions in surgical patients who are anaemic or at risk for significant blood loss during the perioperative period. Recommendations for its use are now highlighted to largely have been based on expert opinion as trials investigating the perioperative use of IV iron had been scarce. The PREVENTT trial, published in 2020, was a large multicentre randomised controlled trial (RCT) that provided evidence that does not support routine perioperative IV iron therapy as this intervention was not shown to decrease the need for blood transfusions, or improve morbidity or mortality, despite its associated increase in haemoglobin (Hb) compared to controls. Various aspects of the PREVENTT trial, however, can be criticised, which places into question its validity to impact practice. There is evidence that certain surgical populations may derive more benefit from IV iron therapy than others, with evidence of reduced risk for blood transfusions in orthopaedic populations. The timing of IV iron therapy may also influence its effectiveness with postoperative administration potentially deriving more benefit than preoperative use. It has become evident that there is a need for further studies and higher quality of evidence in these areas.