Evaluating Perioperative Interventions to Improve Patient Outcomes (EPIC-1) Study
Conditions: Anemia, Iron Deficiency, Hyperglycemia
Sponsor: University of Cape Town

Protocol 
An audit of the prevalence of abnormal fasting blood glucose levels in patients 
presenting for elective surgery at a selection of Western Cape government 
hospitals. 
T Biesman-Simons 
Registrar, Department of Anaesthesia and Perioperative Medicine, University of 
Cape Town 
Introduction and study rationale 
Diabetes Mellitus (DM) is a major concern in South Africa, with an estimated prevalence (by 
the International Diabetes Federation [IDF]) of 7% in adults between the ages of 20-79 (IDF, 
2015). A study in the Western Cape showed a crude prevalence of diabetes of 28.2%, with 
undiagnosed type 2 DM (DMII) present in 18.1%.(Erasmus et al., 2012). The true prevalence 
is not known, and undiagnosed DM is a growing burden.  
Poorly controlled DM is known to have an adverse effect on the perioperative clinical course 
with an increase in the length of hospital stay and increased morbidity and mortality (Barker et 
al., 2015, Underwood et al., 2014). As anaesthesiologists and perioperative medicine 
practitioners, perioperative glycaemic control falls within our scope of practice. We know there 
are patients presenting for elective surgery with undiagnosed DMII and impaired fasting 
glucose levels, however, we are not sure of the prevalence rates. The motivation for this study 
was thus, to examine fasting blood glucose levels in elective, non-cardiac, non-obstetric pre-
operative patients at seven hospitals across the Western Cape. The study will be conducted 
over the course of one week, to establish the prevalence of both diagnosed and undiagnosed 
DMII, as well as impaired fasting glucose. 
A fasting blood glucose level (defined as a glucose test taken after eight or more hours of no 
caloric intake) (Sebranek et al., 2013) is a recognised diagnostic test for DMII; patients 
scheduled for elective surgery are starved for a minimum of six hours. However, a large number 
of patients are starved for a greater period of time; therefore the majority will fulfil the criteria 
for a fasting blood glucose test. In this regard, the immediate preoperative period represents an 
ideal time to check blood glucose levels. 

In addition, data will be collected regarding patient comorbidities, as well as evidence of 
diabetic target organ damage. It is hoped that this collected data will help raise the awareness 
regarding the contribution of diabetes to the burden of disease, and may aid in establishing an 
effective perioperative referral system in the screening, diagnosis, and referral for further 
management of DM.  
The aim of this study is to identify the prevalence of abnormal fasting blood glucose levels in 
preoperative patients in the Western Cape. 
Primary outcomes: 
a.     Incidence of DM and intermediate hyperglycaemia. 
Secondary outcomes: 
1.     Establish prevalence of adequate control of DM (HbA1C). 
2.     Establish prevalence of compliance with therapy. 
3.     Establish proportion of patients with complications of diabetes.  
Methods 
Study Design 
This will be a prospective, observational study of adult, non-cardiac, non-obstetric, elective 
surgical patients conducted over a period of one week. 
Study Population 
The study population comprises all adult non-cardiac, non-obstetric patients presenting for 
elective surgery over a period of one week at following sites: Groote Schuur -, Somerset -, 
Paarl -, Victoria -, Mitchell’s Plain -, Worcester - and George Hospital. The study population 
sample size is estimated to be 500 patients, from a recent study on hypertension carried out at 
these hospitals. 
Inclusion criteria: 
• 
Adult patients presenting for non-cardiac, non-obstetric, elective surgery 
 
 

Exclusion criteria: 
• 
Paediatric surgical patients 
• 
Cardiac surgical patients 
• 
Obstetric patients 
• 
Emergency surgery 
Study Methods 
All patients will be assessed as part of the routine preoperative evaluation, usually occurring 
the day before the surgery is scheduled. Informed consent will be obtained by the anaesthetist 
from eligible patients who agree to participate in the study. The patient will be given the option 
to withdraw from the study at any time. If a patient chooses not to participate, surgery will 
proceed as scheduled. Information will be gathered directly from the patient, as well as from 
the folder and documented on the data Case Report Form (CRF).  
At the preoperative assessment, clinical data will be collected and recorded on the CRF. This 
will include whether the patient is a known diabetic or has intermediate hyperglycaemia. In 
addition, patients medications, comorbidities, and the planned surgery will be documented.   
On the day of surgery, before induction of anaesthesia, all patients will have a finger prick 
blood glucose level done by point of care glucometry, if there is not a documented fasting blood 
glucose value in their ward file. In patients of unknown diabetic status, should the preoperative 
value be >7 mmol/l, blood will be drawn when IV access is established, for HbA1C 
measurement.  
 
In known diabetics, a sample will be taken for HbA1C, regardless of the preoperative fasting 
blood glucose level, unless there is an HbA1C measurement in the previous 3 months. 
However, should the patient management have been modified based on the HbA1C result, a 
repeat HbA1C measurement would be performed. These patients will then be stratified into 
four categories (based on the WHO diagnostic criteria) (WHO, 2011): 
• Low fasting glucose level: <2.8 mmol/l 
• Normal fasting glucose level: 2.9-6.0 mmol/l 

• Impaired fasting glucose: 6.1-6.9 mmol/l 
• Diabetic: ≥7.0 mmol/l 
The study protocol can be summarised in the following flow diagram. 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Recent HBA1C (within the previous 3 months). If patient management has been modified in the previous 3 months, a repeat HbA1C 
measurement would be performed 
 
All consenting patients 
No recent HBA1C; 
No ward FBG results 
No recent HBA1C; 
Ward FBG results 
Recent HBA1C* 
HBA1C 
regardless 
HBA1C 
regardless 
No 
HBA1C* 
Diabetic  
Patients 
Unknown status 
No ward FBG 
Ward FBG 
>7 
mmol/L
<7 
mmol/L
>7 
mmol/L
<7 
mmol/L
HBA1C
HBA1C
Finger-prick 
Finger-prick 

Ethical considerations  
This study is a large-scale clinical audit. All data will be recorded by anaesthesia registrars and 
consultants on a separate CRF designed for the purpose of this study, during the in- theatre 
time of the patient. Patient identifying data will not be captured on the CRF, and thereby data 
will be kept confidential. The aforementioned are all documented routinely during the 
anaesthetic, and will not influence patient management or theatre practice, but rather reflects 
current clinical practice. The study is purely observational and therefore no additional 
interventions will take place and no adverse events are anticipated as a result of participation 
in this study. Standard theatre safety precautions and clinical practice will apply.  
DMII is a disease in which the long-term outcomes are very dependent on the management of 
the condition. Therefore, all patients who are identified as having abnormal fasting glucose 
levels (who are not known with diabetes or impaired glucose tolerance), will be referred to 
their local clinic/general practitioner for further workup and management. Furthermore, any 
patient identified with DM will receive further patient education in the form of a patient 
information leaflet (available in English, Afrikaans and Xhosa). 
 
Data management and analysis 
All data will be captured on a CRF and entered into an Excel chart. Data will be collected by 
anaesthesia registrars and specialists. Data will be handled by the research team as described, 
and will be kept anonymous, as no patient- identifying details will be recorded on the CRFs. 
Completed CRFs will be kept in the UCT Department of Anaesthesia and Perioperative 
Medicine (D23, New Groote Schuur Hospital).  
Statistical analysis 
Continuous variables will be described as mean and standard deviation if normally distributed 
or otherwise median and interquartile range (IQR). Comparisons of continuous variables 
between groups will be performed using unpaired t-tests or the Mann Whitney U test as 
appropriate.  With a sample size of approximately 500 patients, and an expected prevalence of 
diabetes of approximately 30%, we expect to be able to determine the prevalence within a 95% 
confidence interval of approximately 9% i.e. 25 to 34%. We believe this study will provide a 
fairly robust estimate of the prevalence of diabetes in the elective surgical population in the 
Western Cape.  

The Statistical Package for the Social Sciences (SPSS) version 24 (SPSS Inc., Chicago, IL, 
USA) will be used for data analysis. 
 
Reporting of results 
Study results will be recorded and submitted in the form of an MMed dissertation to the 
University of Cape Town, for assessment as per postgraduate requirements. These results will 
also be made available to the public and submitted for publication in recognised academic 
journals. Prior to the start of the study, individual institutional approval and provincial approval 
from Western Cape Department of Health will be obtained. DM is a treatable condition that 
contributes significantly to the overall burden of disease in South Africa. Patients participating 
in our study who are diagnosed with DM will be referred to their local clinic or general 
practitioner for further management and education. This will take the form of a letter informing 
the referral physician of the findings.  
 
Conduct of Study 
The collection of data is scheduled to take place from during a week in October. A week before 
commencement, all the medical officers, registrars and specialist in the Department of 
Anaesthesia at participating hospitals will be briefed about the study and their level of 
involvement. The purpose and execution of the study as well as the researchers' expectations 
will be clearly communicated to the various participating hospitals. Posters will be displayed 
in the theatre complex to ensure adherence to the protocol. The elective surgery lists at each 
participating hospital will be collected by the medical officer, registrar or specialist the day 
before scheduled surgery, in order to conduct the preoperative evaluation and recruitment. A 
CRF will be issued for each patient on the elective list to be completed on the preoperative 
round according to the researchers instructions. All the information documented on the data 
form is routinely available in the patients hospital folder. The data from the CRF will be 
transferred to an electronic data sheet which is password protected. No personal information 
will be displayed on this form. 

Upon arrival in theatre on the day of surgery the CRF will be identified in the patients folder. 
Postoperatively, all the completed data forms will be collected in the recovery room by the 
researcher or research assistant.  
Data collection forms from all participating hospitals will be collected by the researchers after 
completion of the study period, and stored in a locked office in the Department of Anaesthesia 
and Perioperative Medicine at Groote Schuur Hospital. 
Resources and costing 
The major costs for the study is the laboratory investigations that will be requested as part of 
the study. The cost of fasting blood glucose determination and HBA1C will be funded by 
Departmental resources. 
 
Reporting of results 
The results of the study will be submitted as an MMed dissertation to the University of Cape 
Town as part of postgraduate study requirements. The results will be submitted for publication 
in a recognised academic journal. 
 
Bibliography: 
BARKER, P., CREASEY, P. E., DHATARIYA, K., LEVY, N., LIPP, A., NATHANSON, M. H., PENFOLD, N., 
WATSON, B. & WOODCOCK, T. 2015. Peri-operative management of the surgical patient with 
diabetes 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia, 70, 
1427-40. 
ERASMUS, R. T., SOITA, D. J., HASSAN, M. S., BLANCO-BLANCO, E., VERGOTINE, Z., KEGNE, A. P. & 
MATSHA, T. E. 2012. High prevalence of diabetes mellitus and metabolic syndrome in a South 
African coloured population: baseline data of a study in Bellville, Cape Town. S Afr Med J, 102, 
841-4. 
IDF. 2015. IDF Diabetes Atlas [Online]. 
SEBRANEK, J. J., LUGLI, A. K. & COURSIN, D. B. 2013. Glycaemic control in the perioperative period. Br 
J Anaesth, 111 Suppl 1, i18-34. 
UNDERWOOD, P., ASKARI, R., HURWITZ, S., CHAMARTHI, B. & GARG, R. 2014. Preoperative A1C and 
clinical outcomes in patients with diabetes undergoing major noncardiac surgical procedures. 
Diabetes Care, 37, 611-6. 
WHO 2011. Use of Glycated Haemoglobin (HbA1c) in the diagnosis of Diabetes Mellitus. In: 
ORGANISATION, W. H. (ed.). World Health Organisation. 
 
 
 

University of Cape Town  
 
Department of Anaesthesia and Perioperative Medicine 
 
EPIC 1 
Evaluating Perioperative Interventions to improve patient outComes 1 
An audit of the prevalence of anaemia in patients presenting for elective surgery 
in selected hospitals in the Western Cape 
 
Research proposal for MMed dissertation in Anaesthesiology and Perioperative 
Medicine 
 
Candidate: 
 
Dr Willem Conradie 
MP 0747076 
CNRWIL003 
 
 
Supervisor: 
Dr Francois Roodt 
Co-Supervisors: 
Prof. Bruce Biccard 
Dr Marcin Nejthardt 

Contents 
Synopsis ................................................................................................................................................ 11 
Study aims and objectives .................................................................................................................... 11 
Background and rationale for the study ............................................................................................... 12 
Methodology ......................................................................................................................................... 14 
Study Design ......................................................................................................................................... 14 
Study Methods ...................................................................................................................................... 15 
Ethical considerations ........................................................................................................................... 15 
Data management and analysis ............................................................................................................ 16 
Statistical analysis ................................................................................................................................. 16 
Reporting of results............................................................................................................................... 16 
Conduct of Study ................................................................................................................................... 17 
Resources and costing .......................................................................................................................... 17 
Reporting of results............................................................................................................................... 18 
 
 
 

Synopsis 
This is a proposal for the study “The prevalence of preoperative anaemia in patients presenting for 
elective surgery.” Preoperative anaemia is considered an independent risk factor for poorer patient 
outcomes, with increases in morbidity and mortality as well as prolonged length of hospital stay 
(Kassebaum et al., 2014, Munoz et al., 2015a). One third of patients presenting for surgery will be 
anaemic, according to the World Health Organization (WHO) criteria (WHO, 1968). However, the 
importance of this finding in the preoperative period is often overlooked and not corrected prior to 
surgery (Munoz et al., 2015a). The leading cause of preoperative anaemia is iron deficiency. Iron 
deficiency anaemia is common in developing countries and results mostly from nutritional deficiency 
(White, 2017). 
Preoperative anaemia is a modifiable risk factor and should be identified early and treated 
appropriately to improve patient outcomes. There are various modalities available for the prevention 
and correction of preoperative anaemia. According to the author’s assessment of the literature, there 
is no published data in South Africa pertaining to the prevalence of preoperative anaemia and the 
association with iron deficiency. 
Study aims and objectives 
The purpose of this observational study is to identify the prevalence of preoperative anaemia among 
patients presenting for elective surgery in the Western Cape. 
Primary outcome: 
a) 
Prevalence of anaemia. 
Secondary outcomes: 
a) 
Prevalence of iron deficiency anaemia. 
b) 
Proportion of patients that have: 
i) 
Blood group and screen for antibodies. 
ii) 
Blood cross-matched. 
iii) 
Blood in operating theatre. 
 
 

Background and rationale for the study 
The WHO defines anaemia as insufficient red blood cell mass, with Haemoglobin (Hb) concentrations 
of <12,0 g/dl in females and <13,0 g/dl in males (WHO, 1968). According to the WHO criteria, the 
global prevalence of anaemia is 32,9% (Kassebaum et al., 2014). 
Preoperative anaemia is an important modifiable risk factor associated with increased postoperative 
morbidity and mortality (Munoz et al., 2015a, Musallam et al., 2011), including an increased risk of 
postoperative complications such as increased hospital length of stay, ICU admissions, wound 
infections and readmission to hospital (Munoz et al., 2015a).  
In patients presenting for surgery, one third will be anaemic at preoperative assessment, with even 
higher rates amongst specific surgical groups, for example colorectal and gynaecological patients 
(Shander, 2014). According to data from the US National Health and Nutritional Examination Survey 
(NHANES), the prevalence is higher in females and increases with age, affecting 1,5%  of males and 
12,2% of females aged 17-49 years, more than 10% in age group >65 years and more than 20% in age 
group >85 years.  
The British Committee for Standards in Haematology guidelines highlight three main reasons to 
identify and treat preoperative anaemia: 1) to identify underlying undiagnosed diseases, for example 
malignancy, 2) to reduce the likelihood of allogeneic blood transfusions (ABT) and 3) to avoid patient 
exposure to unnecessary effects of anaemia and transfusion Audits on transfusion practices is 
scheduled to take place in the United Kingdom. Management of preoperative anemia will be included 
as one of the Key Performance Indicators in these audits (5). 
Preoperative anaemia is a strong predictive factor for perioperative ABT and the associated 
complications. Early detection and treatment of preoperative anaemia is a key intervention in the 
reduction of patient risk due to anaemia-related adverse outcomes after surgery (Munoz et al., 
2015a). A 2017 consensus statement by Muñoz et al. recommends that all patients with planned 
surgery with a transfusion risk of >10% or estimated blood loss >500 ml and a preoperative Hb <13 
g/dl, should receive early workup and treatment. If surgery is elective it should be postponed until the 
Hb is >13 g/dl. This includes obstetric- and gynaecological procedures (Munoz et al., 2011). Minor 
surgery can be performed as scheduled while investigations for anemia are underway (10) (11).   
Although the WHO classification is widely accepted, recent literature suggests that female patients 
should also have a Hb >13 g/dl prior to surgery if moderate to high blood loss is expected (Munoz et 
al., 2017). This is because women have a larger relative red blood cell loss during surgery compared 

to males (Gombotz, 2007). Females with a preoperative Hb of 12 g/dl have a two-fold risk of blood 
transfusion compared to men with an Hb of 13 g/dl.  
Iron deficiency is the leading cause of anaemia worldwide, with the highest incidence in Sub Saharan 
Africa and Asia (Stoltzfus, 2003). These areas account for 85% of the global anaemia burden amongst 
high risk populations, according to the WHO (WHO, 2002).  Iron deficiency anaemia (IDA) is the most 
common cause of preoperative anaemia (Kassebaum et al., 2014, Musallam et al., 2011). In a recent 
multicentre study of patients undergoing major elective surgery reported the same cut off value for 
anaemia (<13 g/dl) were used for males and females. A third of the patients were anaemic, of which 
over two thirds had absolute IDA or iron sequestration (White, 2017). Although South African data on 
IDA is scarce (Nojilana B, 2007), it is a risk factor that contributes significantly to the burden of disease 
in South Africa particularly in the perioperative period. 
The diagnosis of iron deficiency anaemia is based on laboratory testing of Hb, mean corpuscular 
volume (MCV), serum ferritin and transferrin saturation (TSAT). Other tests also exist, but the above 
are most commonly available and affordable tests used for the diagnosis. Ferritin is the main iron 
storage protein in the body and is the most useful test to determine iron status in the absence of 
inflammation (Kotze, 2015). Serum Ferritin has a 92% sensitivity and 98% specificity for absolute iron 
deficiency if the levels are <30 mcg/l (Munoz et al., 2017, Munoz et al., 2011, Musallam et al., 2011).  
Transferrin is the only iron transporter in the body (Munoz et al., 2011). Transferrin saturation (TSAT) 
is measured by serum iron/ total iron binding capacity (TIBC). TSAT< 20% is a reliable indicator of iron 
deficiency and suggests inadequate supply of iron to sustain normal erythropoiesis(9)(12)(17)(14). 
Ferritin and TSAT can indicate whether absolute iron deficiency, iron sequestration, or low iron stores 
for surgery is present (Auerbach and Adamson, 2016, Munoz et al., 2015b).   
 
Despite the morbidity associated with blood transfusions, it remains the most frequently used 
treatment for perioperative anaemia, with up to one third of all transfusions being administered in 
the surgical period (Clevenger and Richards, 2015, Norgaard et al., 2014).  
 
Preoperative iron replacement therapy, especially intravenous iron, has been successfully 
implemented to increase preoperative Hb levels and reduce allogeneic blood transfusions among 
certain patient groups, for example patients undergoing orthopaedic surgery (White, 2017). Early 
recognition and management of preoperative anaemia provides perioperative physicians with an 

opportunity to optimise patients before surgery, thereby reducing ABT and potentially enhancing 
early recovery. Although the prevalence of preoperative anaemia in South Africa is not well known, 
the high prevalence of nutritional deficiencies and chronic diseases such as HIV/AIDS may predispose 
our patients to a high prevalence of preoperative anaemia. 
Methodology: 
Study Design 
This will be a prospective observational study of adult, non-cardiac, elective surgical patients 
conducted over a period of one week. 
Study Population 
The study population comprises all adult non-cardiac patients presenting for elective surgery at 
Groote Schuur-, Somerset-, Paarl-, Victoria-, Mitchell’s Plain-, Worcester-, and George Hospital over a 
period of one week.  
The sample size is based on a recent study (HASS). We expect to recruit 500 patients in 1 week. With 
an estimated incidence of anaemia of 30% we estimate that 150 patients will be investigated for iron 
deficiency as described above.  
Inclusion criteria: 
• 
Adult patients (>18yrs) 
• 
Non-cardiac patients 
• 
Elective surgery 
Exclusion criteria: 
• 
<18 years of age 
• 
Obstetrics patients 
Setting 
Elective surgical patients at Groote Schuur-, Somerset-, Paarl-, Victoria-, Mitchell’s Plain-, Worcester, 
and George Hospital over a period of one week (Monday to Friday, 07:30 to 17:00). 

Study Methods 
All patients will be assessed as part of the routine preoperative evaluation, usually occurring the day 
before the surgery is scheduled. Informed consent will be obtained by the anaesthetist from eligible 
patients who agree to participate in the study. The patient will be given the option to withdraw from 
the study at any time. If a patient chooses not to participate, surgery will proceed as scheduled. 
Information will be gathered directly from the patient as well as from the folder and documented on 
the data collection form. If the patient has had a Hb level measured within the preceding 3 months, 
this value will be documented. If more than one Hb level has been determined during this period, the 
most recent result will be used in the study. If a patient has not had a Hb level documented within this 
period, a finger-prick Hb test prior to inserting the IV line will be done. If this Hb level, or the previously 
documented Hb is low according to the WHO criteria, a blood specimen will be obtained when 
inserting the IV line. If the patient arrives in the operating theatre with a IV line in situ, an additional 
venepuncture will be performed to obtain the blood sample. The collected blood will be sent to NHLS 
for Hb, MCV, serum ferritin and transferrin saturation(TSAT) testing. According to the results each 
patient will be classified as having: i) no anaemia, ii) anaemia without iron deficiency, or iii) iron 
deficiency anaemia. 
 
It will also be documented on the data collection form if the following action has been taken: i) blood 
group and screen for antibodies, ii) blood crossmatch, or iii) blood products ordered for the operating 
theatre. 
Ethical considerations  
This study is a large scale clinical audit. All data will be recorded by anaesthesia registrars and 
consultants on a separate case report form designed for the purpose of this study, during the in- 
theatre time of the patient. Patient identifying data will not be captured on the case report form, and 
thereby data will be kept confidential. The aforementioned are all documented routinely during the 
anaesthetic, and will not influence patient management or theatre practice, but rather reflects current 
clinical practice. The study is purely observational and therefore no additional interventions will take 
place and no adverse events are anticipated as a result of participation in this study. Standard theatre 
safety precautions and clinical practice will apply. Should a patient require further medical care based 
on either of the medical conditions identified, or the severity of the medical conditions, normal clinical 
practice will be followed to ensure adequate medical care of the patient. Furthermore, any patient 

identified with anaemia and or diabetes will receive further patient education in the form of a patient 
information leaflet (available in English, Afrikaans and Xhosa) and referral letter to primary health 
clinic/physician for follow-up and further management. 
Data management and analysis  
All data will be captured on a Case Report Form and entered into an Excel chart. Data will be collected 
by anaesthesia registrars and specialists. Data will be handled by the research team as described, and 
will be kept anonymous, as no patient-identifying details will be recorded on the case report forms. 
Completed Case Report Forms will be kept in the UCT Department of Anaesthesia and Perioperative 
Medicine (D23, New Groote Schuur Hospital).  
Statistical analysis 
Continuous variables will be described as mean and standard deviation if normally distributed or 
otherwise median and interquartile range (IQR). Comparisons of continuous variables between groups 
will be performed using unpaired t-tests or the Mann Whitney U test as appropriate.  With a sample 
size of approximately 500 patients, and an expected prevalence of anaemia of approximately 30%, we 
expect to be able to determine the prevalence within a 95% confidence interval of approximately 9% 
i.e. 25 to 34%. We believe this study will provide a fairly robust estimate of the prevalence of anaemia 
in the elective surgical population in the Western Cape.  
The Statistical Package for the Social Sciences (SPSS) version 24 (SPSS Inc., Chicago, IL, USA) will be 
used for data analysis. 
Reporting of results 
Study results will be recorded and submitted in the form of an MMed dissertation to the University of 
Cape Town, for assessment as per postgraduate requirements. These results will also be made 
available to the public. Prior to the start of the study, institutional approval and provincial approval 
from Western Cape Department of Health will be obtained. 
Anaemia and iron deficiency anaemia are treatable conditions that contribute significantly to the 
overall burden of disease in South Africa. Patients participating in our study who are diagnosed with 
anaemia will be referred to their local clinic or general practitioner for further management and 
education. This will take the form of a letter informing the referral physician of the findings. The most 
common cause of iron deficiency anaemia in developing countries is poor nutritional status. Patients 

will receive a take home pack with information on the prevention of the condition along with a referral 
to the local clinic to receive appropriate nutritional support/supplementation. 
Conduct of Study 
The collection of data is scheduled to take place from 16-20th October, 2017. A week before 
commencement, all the medical officers, registrars and specialist in the Department of Anaesthesia at 
participating hospitals will be briefed about the study and their level of involvement. The purpose and 
execution of the study as well as the researchers' expectations will be clearly communicated to the 
various participating hospitals. Posters will be displayed in the theatre complex to ensure adherence 
to the protocol. 
The elective surgery lists at each participating hospital will be collected by the medical officer, registrar 
or specialist the day before scheduled surgery, in order to conduct the preoperative evaluation and 
recruitment. A Case Report Form (CRF) will be issued for each patient on the elective list to be 
completed on the preoperative round according to the researchers’ instructions. All the information 
documented on the data form is routinely available in the patient’s hospital folder. The data from the 
CRF will be transferred to an electronic data sheet which is password protected. No personal 
information will be displayed on this form. 
Upon arrival in theatre on the day of surgery the CRF will be identified in the patient’s folder. 
Postoperatively, all the completed data forms will be collected in the recovery room by the researcher 
or research assistant.  
Data collection forms from all participating hospitals will be collected by the researchers after 
completion of the study period, and stored in a locked office in the Department of Anaesthesia and 
Perioperative Medicine at Groote Schuur Hospital. 
Resources and costing 
The major costs for the study are the laboratory investigations that will be requested as part of the 
study. The cost of the diagnostic tests, posters and data collection forms will be funded by 
Departmental resources. 

Reporting of results 
The results of the study will be submitted as an MMed dissertation to the University of Cape Town as 
part of postgraduate study requirements. The results will be submitted for publication in a recognised 
academic journal. 
References: 
AUERBACH, M. & ADAMSON, J. W. 2016. How we diagnose and treat iron deficiency anemia. Am J 
Hematol, 91, 31-8. 
BARKER, P., CREASEY, P. E., DHATARIYA, K., LEVY, N., LIPP, A., NATHANSON, M. H., PENFOLD, N., 
WATSON, B. & WOODCOCK, T. 2015. Peri-operative management of the surgical patient with 
diabetes 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia, 70, 
1427-40. 
CLEVENGER, B. & RICHARDS, T. 2015. Pre-operative anaemia. Anaesthesia, 70 Suppl 1, 20-8, e6-8. 
ERASMUS, R. T., SOITA, D. J., HASSAN, M. S., BLANCO-BLANCO, E., VERGOTINE, Z., KEGNE, A. P. & 
MATSHA, T. E. 2012. High prevalence of diabetes mellitus and metabolic syndrome in a South 
African coloured population: baseline data of a study in Bellville, Cape Town. S Afr Med J, 102, 
841-4. 
GOMBOTZ, H., REHAK, P., SHANDER, A., HOFMAN, A. 2007. Blood use in elective surgery: the Austrian 
benchmark study. Transfusion, 47, 12. 
IDF. 2015. IDF Diabetes Atlas [Online].  [Accessed]. 
KASSEBAUM, N. J., JASRASARIA, R., NAGHAVI, M., WULF, S. K., JOHNS, N., LOZANO, R., REGAN, M., 
WEATHERALL, D., CHOU, D. P., EISELE, T. P., FLAXMAN, S. R., PULLAN, R. L., BROOKER, S. J. & 
MURRAY, C. J. 2014. A systematic analysis of global anemia burden from 1990 to 2010. Blood, 
123, 615-24. 
KOTZE, A., HARRIS, A., BAKER, C.,  TARIQ,  I.,  LAVIES, N., RICHARDS,T., RYAN, K.,  TAYLOR, C., DAFYDD, 
T. 2015. British Committee for Standards in Haematology Guidelines on the Identification and 
Management of Pre-Operative Anaemia. Br J Haemotology, 171, 9. 
MUNOZ, M., ACHESON, A. G., AUERBACH, M., BESSER, M., HABLER, O., KEHLET, H., LIUMBRUNO, G. 
M., LASOCKI, S., MEYBOHM, P., RAO BAIKADY, R., RICHARDS, T., SHANDER, A., SO-OSMAN, C., 
SPAHN, D. R. & KLEIN, A. A. 2017. International consensus statement on the peri-operative 
management of anaemia and iron deficiency. Anaesthesia, 72, 233-247. 
MUNOZ, M., GARCIA-ERCE, J. A. & REMACHA, A. F. 2011. Disorders of iron metabolism. Part II: iron 
deficiency and iron overload. J Clin Pathol, 64, 287-96. 
MUNOZ, M., GOMEZ-RAMIREZ, S., CAMPOS, A., RUIZ, J. & LIUMBRUNO, G. M. 2015a. Pre-operative 
anaemia: prevalence, consequences and approaches to management. Blood Transfus, 13, 
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