Perioperative Anaemia and Anticoagulation Management:

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The following case is intended to stimulate discussion regarding the investigation and management of perioperative anaemia and perioperative anticoagulation strategies.

Mr FF is an 80 year old man living with minimal assistance in country South Australia. He was reviewed prior to a total hip replacement.

•Past Medical History

1.

1. Mixed mitral valve disease.  Minimally invasive mitral valve repair in August 2010.  Post operative echocardiogram shows persisting moderate regurgitation but normal left ventricular function.
2. Atrial fibrillation. 
3. COAD
4. Osteoporosis
5. Gout
6. Chronic Renal Failure
7. Septic arthritis right knee. September 2010 ;3 months of IV antibiotic therapy.  Admission complicated by ATN and a right groin collection requiring incision and drainage.

•Medication list:

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• Risedronate/Calcium 1 tablet weekly 
• Colchicine 0.5mg daily 
• Warfarin 2mg daily 
• Frusemide 40mg daily 
• Ferrogradumet 1 tablet daily
• Oxycontin 40mg bd 
• Ezetimibe/Simvastatin 10mg/40mg daily–
• Seretide 50/500 1 puff bd 
• Tiotropium 1 puff daily

Mr F describes ongoing right knee pain as well as progressively worsening right hip pain. He has lost over 20kg of weight in the last year and has had poor appetite. This is associated with variable bowel habit with periods of alternating loose stools and constipation. He has never noted any frank blood or melaena bowel actions. He has been increasingly fatigued in the last three months but denies shortness of breath as he is unable to walk far due to hip and knee pain. Relevant examination findings include : mild pallor , marked pitting oedema but no other signs of cardiac failure. Chest auscultation was unremarkable and there was no organomegaly. His right knee had restricted range of movement , there was ongoing swelling which the patient reports as unchanged but no erythema or warmth. Urinalysis was unremarkable. 

CBE: Showed a microcytic anaemia : Hb 81 (progressively falling) MCV 75

Biochemical abnormalities included hypoalbuminaemia (Alb 20-25) , persistently elevated creatinine since his previous admission (150-170).

His inflammatory markers were also persistently elevated: CRP consistently 100

Iron studies :

Could you make some comments primarily regarding how you would manage the following:

- His anaemia and interpretation of his iron studies

- His anticoagulation strategy
- Other issues you would like to discuss (of which there are many)