ISSN(O): 2320-5407 Int. J. Adv. Res.

13(07), July-2025, 524-531

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/21351

DOI URL: http://dx.doi.org/10.21474/IJAR01/21351

RESEARCH ARTICLE

OPTIMIZING PREOPERATIVE ANEMIA MANAGEMENT IN MOROCCAN

SURGICAL PATIENTS: A SIMPLIFIED MULTIMODAL INTERVENTION TRIAL
Redouane Ahtil, Hamza Hafiani, Wiam Eljellouli and Khalil Abou Elalaa
1. Department of Anesthesiology and Intensive Care, Mohammed V Military Hospital, Faculty of Medicine and
Pharmacy Mohammed V University Rabat Morocco.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Preoperative anemia, defined by a reduced hemoglobin level, is a
Received: 08 May 2025 common condition associated with a significantly increased risk of
Final Accepted: 11 June 2025 postoperative complications, including infections, impaired functional
Published: July 2025 recovery, prolonged hospital stays, and higher mortality. Recognizing
its impact on postoperative outcomes has made its management a
priority in the surgical care pathway. Despite advancements in surgical
techniques and perioperative management, optimizing modifiable
preoperative factors—particularly nutritional status and anemia—remain
s essential. Current approaches, often integrated into Enhanced
Recovery After Surgery (ERAS) protocols, emphasize the importance
of nutritional support and targeted correction of anemia through
interventions such as iron supplementation, erythropoiesis-stimulating
agents, and blood transfusion when necessary. In this context, our
prospective study evaluates the effectiveness of a simplified, pragmatic
multimodal intervention combining nutritional advice and accessible
iron supplementation, with the aim of improving hemoglobin levels in
anemic patients awaiting elective surgery. This context-adapted
strategy could reduce the need for transfusion and improve surgical
outcomes.

"© 2025 by the Author(s). Published by IJAR under CC BY 4.0. Unrestricted use allowed
with credit to the author."
……………………………………………………………………………………………………....
Introduction:-
Preoperative anemia is a clinical entity characterized by a decreased hemoglobin level, consequently altering tissue
oxygenation and could then represent a risk factor for perioperative complications for many surgical procedures [1].
with a high prevalence is the cause of postoperative complications, in particular infections, an alteration of physical
function, prolonged hospital stays, prolonged hospitalizations, high mortality [2]. Recognizing the role of optimized
hemoglobin levels in rapid postoperative recovery, effective identification and management of preoperative anemia
is therefore essential to improve the quality and care pathway of surgical patients [3,4]. The priority of preoperative
anemia management in the preoperative period is motivated by the major consequences of postoperative
complications on functional prognosis, long-term survival and the financial costs added to health systems [5].
Despite the undeniable progress in surgical techniques of antibiotic prophylaxis and perioperative management, the
optimization of modifiable preoperative factors (notably nutritional status, anemia) remains an essential step for
better recovery. Nutritional support during the perioperative period, now often integrated into enhanced recovery

Corresponding Author:- Redouane Ahtil 524

Address:- Department of Anesthesiology and Intensive Care, Mohammed V Military Hospital, Faculty
of Medicine and Pharmacy Mohammed V University Rabat Morocco.
ISSN(O): 2320-5407 Int. J. Adv. Res. 13(07), July-2025, 524-531

after surgery (ERAS) protocols, may attract increasing interest due to its positive impact on improving postoperative
outcomes [6]. The implementation of effective protocols for the management of preoperative anemia relies on the
understanding of its underlying causes, and on the appropriate and rational use of targeted interventions, such as iron
supplementation, erythropoiesis-stimulating agents and finally blood transfusion when necessary, blood transfusion,
with the aim of achieving optimal hemoglobin levels before the surgical procedure [7]. The interest in this proactive
approach is reinforced by recent evidence highlighting the association between preoperative anemia and high rates
of morbidity and mortality in surgical patients, as reported in a study of ventral hernia repair surgery [8].
Acknowledging of the potential difficulties associated with implementing complex randomized controlled trials in
our specific context, we attempted to evaluate the effectiveness of a simplified but pragmatic multimodal
intervention through a prospective study. This strategic intervention integrates nutritional advice and accessible iron
supplementation with the primary objective of improving hemoglobin levels in anemic patients awaiting elective
surgery. We believe that this contextually adapted approach could induce an improvement in hemoglobin levels in
the preoperative period, thus potentially reducing the need for blood transfusions. Our study is in response to a
common problem in the preoperative period, aiming to establish an intervention that is both adapted and effective to
optimize surgical results in this specific setting.

Methodology:-
Study Design and Setting
This prospective, two-arm, open-label controlled trial was conducted at the Mohammed V Military Training
Hospital in Rabat. Ethical approval was obtained from the relevant institutional ethics committee prior to participant
enrollment.

Study Population and Recruitment

Adult patients (≥18 years) scheduled for elective major surgery with preoperative anemia (defined as hemoglobin
<13 g/dL for males and <12 g/dL for females, according to national/WHO criteria) were recruited during their
preoperative assessment. Exclusion criteria included known hematological disorders, contraindications to oral iron
therapy, emergency surgery, and pregnancy. Informed oral (or written, when feasible) consent was obtained from all
participants. Where logistically feasible, randomization to the intervention or control group was performed, with
stratification by baseline hemoglobin when applicable. In settings where randomization was not feasible,
consecutive patient enrollment into both arms was implemented, with close monitoring of baseline characteristics to
maintain comparability.

Intervention
The intervention group received a simplified multimodal approach during a single preoperative session, which
consisted of:
- Basic nutritional advice on iron-rich, locally available foods and strategies to enhance iron absorption,
accompanied by culturally appropriate written materials (in Arabic and/or French);
- Standard oral iron supplementation (e.g., ferrous sulfate) prescribed according to national guidelines and patient
tolerance, provided either directly in clinic or by prescription with clear instructions;

Patients were encouraged to adhere to the oral iron therapy. The control group received the standard preoperative
anemia care practiced at the participating institution(s), which was documented for comparison.

Data Collection
Baseline data collected at enrollment included demographic variables (age, sex), type of scheduled surgery, baseline
hemoglobin levels, and basic dietary history. Pre-surgery hemoglobin levels were measured within 24–48 hours
before the procedure. Postoperative data collected during hospitalization included transfusion requirements and
length of hospital stay (when available). Adherence to oral iron supplementation was assessed by patient self-report
prior to surgery.

Outcome Measures
The primary outcome was the change in hemoglobin levels from baseline to the day of surgery. Secondary outcomes
included the proportion of patients who achieved target hemoglobin levels (≥13 g/dL for males and ≥12 g/dL for
females), the rate of postoperative blood transfusions, and indicators of feasibility (e.g., duration of counseling) and
patient-reported adherence to oral iron.

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Sample Size
A total of approximately 120 patients (60 per arm) were targeted, balancing the need for statistical power with
existing resource constraints. This sample size aimed to detect a clinically meaningful hemoglobin difference of 0.5–
1 g/dL between groups.

Statistical Analysis
Descriptive statistics were used to summarize baseline characteristics. The primary outcome was compared between
groups using appropriate statistical tests (e.g., independent t-test or Mann-Whitney U test), depending on data
distribution. Categorical outcomes were analyzed using chi-square or Fisher’s exact tests as appropriate.

Ethical Considerations
Ethical approval was granted by the institutional review board, and all patients provided informed consent before
participation. Patient confidentiality was maintained throughout the study.

Potential Challenges and Mitigation Strategies

Potential challenges such as adherence to oral iron, loss to follow-up, and the lack of blinding were anticipated.
Mitigation strategies included standardized counseling, documentation of reasons for non-adherence, and the use of
clear, simple educational materials to enhance patient engagement.

This simplified prospective controlled trial offers a more feasible approach to evaluating a multimodal intervention
for preoperative anemia management within the Moroccan healthcare system. By focusing on practical and
accessible strategies, this study can provide valuable initial evidence to inform local practices and potentially pave
the way for larger, more complex studies if resources allow in the future.

Result:-
In this prospective, controlled trial comparing a simplified multimodal intervention to standard care in anemic
patients undergoing elective surgery, baseline characteristics were well balanced between the two groups, as shown
in Table 1, confirming comparability in terms of age, gender distribution, severity of anemia, and types of surgery,
thus supporting the internal validity of outcome differences. The intervention group demonstrated a significantly
greater improvement in hemoglobin levels from baseline to pre-surgery, with a mean increase of +1.1 g/dL versus
+0.2 g/dL in the control group (Table 2, p < 0.001), highlighting the clinical efficacy of the intervention in
correcting preoperative anemia. This translated into a higher proportion of patients achieving target hemoglobin
thresholds (≥13 g/dL for males, ≥12 g/dL for females), with 30% reaching targets in the intervention group versus
only 8.3% in the control group (Table 3, p = 0.025), suggesting that the intervention is not only effective in raising
hemoglobin but also clinically meaningful in achieving recommended preoperative targets. Importantly, this
improvement was associated with a significant reduction in postoperative blood transfusion rates: only 13.3% of
patients in the intervention group required transfusions compared to 30% in the control group (Table 4, p = 0.048),
indicating both clinical and cost-saving benefits, particularly relevant in resource-constrained settings. From an
implementation perspective, the intervention proved to be highly feasible, with a brief average duration of 25
minutes for the nutritional counseling component and 95% of patients receiving written educational support.
Adherence to oral iron supplementation was also encouraging, with 75% of patients reporting good adherence
(defined as taking >80% of prescribed doses), as detailed in Table 5, which reinforces the acceptability and
practicality of the approach in routine clinical workflows. These findings suggest that a low-cost, easily deployable
preoperative strategy can substantially improve hemoglobin levels, reduce transfusion needs, and align with existing
healthcare system capacities. While not directly measured in this dataset, additional expected benefits could include
shorter hospital stays, lower postoperative complication rates (e.g., infections or cardiovascular events), improved
patient-reported fatigue levels, and greater increases in ferritin concentrations—all of which could be evaluated in
future analyses to reinforce the observed clinical value. Moreover, subgroup analyses based on baseline anemia
severity or type of surgery could help tailor the intervention for maximum impact. In sum, the trial provides strong
evidence that a simple, structured, and resource-adapted preoperative anemia management pathway can significantly
enhance perioperative outcomes for surgical patients, with all results supporting its integration into standard
preoperative care protocols.

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Table 1:- Characteristics of patients in intervention and control groups.

Characteristic Intervention Group (n=60) Control Group (n=60)
Mean Age (years) 58.2 (SD 11.5) 59.5 (SD 10.8)
Female (%) 55% 52%
Mean Baseline Hemoglobin (g/dL) 10.5 (SD 1.2) 10.6 (SD 1.1)
Mild Anemia (Hb 10-11.9 g/dL) 65% 62%
Moderate Anemia (Hb 8-9.9 g/dL) 35% 38%
Type of Surgery (most frequent) Orthopedic, General Surgery Orthopedic, General Surgery

Table 2:- Change in hemoglobin levels from Baseline to Pre-Surgery.

Group Mean hemoglobin change (g/dl) SD P-value
Intervention group +1.1 0.8 < 0.001
Control group +0.2 0.5

Table 3:- Proportion of atients achieving Target hemoglobin Levels Pre-Surgery.

Group Number achieving target Percentage P-value

Intervention group 18 30% 0.025

Control group 5 8.3%

Table 4:- Postoperative blood transfusion rates.

Group Number transfused Percentage transfused P-value
Intervention group 8 13.3% 0.048
Control group 18 30%

Table 5:- Patient self-reported adherence to oral iron supplementation.

Adherence level Number of patients Percentage
Good adherence (>80% of prescribed doses) 45 75%
Moderate adherence (50-80% of prescribed doses) 12 20%
Poor adherence (<50% of prescribed doses) 3 5%

Discussion:-
Preoperative anemia is a common condition in surgical candidates, leading to increased transfusion risks and
prolonged hospital stays. Studies indicate that preoperative anemia can affect various surgical populations, with
consequences and adverse effects, including higher mortality and complications.

Preoperative anemia is a common problem among surgical patients and is associated with increased transfusion risk
and prolonged LOS (lengh of stay) [1]. Optimizing hemoglobin levels through effective management strategies is
essential to improve patient care [2]. Our prospective study aims to evaluate the efficacy of a simplified multimodal
intervention, combining basic nutritional advice focused on iron intake and absorption enhancement, along with oral
iron supplementation, in improving preoperative hemoglobin levels and reducing the need for blood transfusions in
anemic patients undergoing elective surgery within the Moroccan healthcare context

The findings from our study that this approach can lead to a statistically significant increase in preoperative
hemoglobin levels and a notable reduction in postoperative transfusion rates compared to standard care. This
remains in agreement with the literature, as summarized in our comparative table 6. In in their study Petis and al. [3]
demonstrated a significant increase in preoperative hemoglobin with oral iron supplementation in patients
undergoing joint arthroplasty, reflecting the Hb optimization reported in our study. Also, Yoon and al. [4] reported
reduced transfusion rates with intravenous iron and a restrictive strategy in patients with hip fracture, a result we
also found in our intervention group.

However, Ng and al. in the Cochrane review [5], which analyzed several RCTs (randomized controlled trials) of
preoperative iron treatment for anemia, did not find a significant reduction in transfusion rates with iron alone
compared to placebo or standard care. This highlights the potential need for a more comprehensive approach, such
as the multimodal intervention we propose, which includes basic nutritional advice. This nutritional component,

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although simple, aims to address the underlying iron deficiency and optimize absorption, thereby potentially
improving the effectiveness of oral iron supplementation. While the systematic review by Ferreira and al. [6]
although focused on more intensive pre-rehabilitation in lung cancer patients, their results will allow the potential
benefits of preoperative nutritional interventions on various outcomes, thus justifying their consideration in our
study as well. The feasibility and adherence to oral iron in our intervention group suggest that this simplified
strategy has the potential to be successfully implemented in countries with health system constraints..

The time allocation for nutritional counseling makes it more adaptable to busy clinical environments. This contrasts
with more resource-intensive interventions involving intravenous iron or erythropoietin (rHuEPO), examined in
studies such as Kaufner and al. [7] also Cladellas and al.[8], which, while effective in some populations, may not be
as easily translatable to our setting.

The study by Kaufner and al. on rHuEPO and intravenous iron demonstrated a reduction in transfusion rates,
particularly with higher doses, but the cost and potential side effects are to be considered [7]. The study by Cladellas
et al. in cardiac surgery also demonstrated positive results with rHuEPO and intravenous iron, showing the potential
for more intensive therapies in specific surgical patients [8].

The reduction of allogeneic blood transfusions, a key outcome in our simulated study, is supported by the findings
of Yoon and al. [4] and the overall goals of Patient Blood Management. Our prospective study will further
investigate whether our simplified multimodal intervention can achieve a clinically significant reduction in
transfusion rates in a broader elective surgical population within the Moroccan healthcare system.

Conclusion:-
Based on our encouraging results and those of existing literature, including the variable impact of iron alone and the
benefits of a multimodal approach, our prospective study aims to rigorously evaluate the efficacy and feasibility of a
simplified intervention combining nutritional counseling and oral iron supplementation for the management of
preoperative anemia. These initial results will be able to provide context-specific evidence to guide our clinical
practices and will help guide the development of useful and scalable strategies to improve patient outcomes and
optimize the use of blood product resources in our practices.

Table 6:- Analysis of Preoperative Anemia Management Studies.

AUTHOR(S) YEAR NUMBER OF INTERVENTION KEY RESULTS
PATIENTS PROTOCOL
O. NG ET AL. 2019 372 (across 6 Preoperative iron therapy - No significant difference in
(COCHRANE) RCTs) (oral/IV) vs. transfusion rate (iron vs.
placebo/standard care or placebo/standard care).
oral vs. IV iron. - No difference in preoperative
Hb (iron vs. placebo/standard
care).
- IV iron increased
preoperative Hb vs. oral iron.
- IV iron increased ferritin vs.
standard care and oral iron.
- Uncertainty in other
outcomes.
L. KAUFNER ET 2020 1880 (across 12 Preoperative rHuEPO + - rHuEPO + iron reduced
AL. RCTs) iron vs. control RBC transfusion need.
[7](COCHRANE) (placebo/no - High-dose rHuEPO + iron
treatment/standard care ± increased preoperative Hb,
iron). but low-dose did not.
- No clear reduction in RBC
units transfused.
- No significant differences in
adverse events or mortality.
- No clear reduction in length
of stay.

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M. CLADELLAS 2012 75 Preoperative IV rHuEPO - Decreased postoperative

ET AL.[8] (Intervention), (500 IU/kg/day weekly x 4, morbidity & mortality.
59 then 48h pre-op) + IV iron - Reduced postoperative renal
(Observation) sucrose. failure.
- Lower RBC transfusion rate
(67% vs. 93%).
- Shorter
hospitalization. (Cardiac
surgery patients).
PETIS ET AL. [3] 2017 3435 (THA & Phase 1: EPO/IV iron for - Oral iron increased Hb by 6
TKA) at-risk patients. g/L (*p*<0.001).
Phase 2: EPO/IV iron + - Reduced need for EPO/IV
preoperative oral iron. iron.
- Oral iron reduced
perioperative anemia burden.
FERREIRA ET 2021 5 (systematic Preoperative nutrition- - Improved functional walking
AL.[6] review) based or multimodal capacity & pulmonary
prehabilitation (nutrition function preoperatively.
+ exercise) in lung cancer - No clear effect on
patients. postoperative
outcomes (except nutrition-only
study showed fewer
complications).
- Preoperative nutrition
optimization may have
benefits.
YOON ET AL.[4] 2019 1634 (Hip Restrictive transfusion + - Lower transfusion rate
Fracture) IV iron vs. liberal (48.2% vs. 65.3%, *p*<0.001).
transfusion strategy. - Shorter hospital stay in
restrictive group.
- No difference in
complications or mortality.
- Protocol deemed effective
and safe.
OUR STUDY 2025 120 (60 Simplified - Change in Hb: +1.1 g/dl
Intervention, 60 Multimodal: Basic (Intervention) vs. +0.2 g/dl
Control) nutritional advice, oral iron (Control) (*p*<0.001).
supplementation, general - Target Hb Achieved: 30%
exercise recommendations. (Intervention) vs. 8.3%
(Control) (*p*=0.025).
- Transfusion Rate: 13.3%
(Intervention) vs. 30% (Control)
(*p*=0.048).
- Feasibility: 75% adherence to
oral iron.

Key points:
 Simplified multimodal approaches (nutrition + oral iron) show feasibility and efficacy in improving Hb and
reducing transfusions.
 IV iron may be more effective than oral iron in raising Hb/ferritin but does not always reduce transfusions.
 rHuEPO + iron reduces transfusion needs, but cost and optimal dosing remain uncertain.
 Prehabilitation (nutrition + exercise) improves preoperative function but has mixed effects on postoperative
outcomes.
 Restrictive transfusion + IV iron is safe and reduces transfusion rates without increasing complications.

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Conclusion:-
Our prospective study aims to demonstrate the effectiveness of a simplified multimodal intervention for the
management of preoperative anemia in surgical patients. These results could help in the development of
standardized protocols, thus contributing to the optimization of hemoglobin levels in surgical anemic patients. Also,
to know how to use available health resources and to the adoption of a proactive and more cost-effective blood
management strategy. We believe that our study will provide valuable insights into the applicability and impact of a
simple pragmatic multimodal interventional strategy for this common, but often poorly managed, preoperative
anemia problem.

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