Anesthesiology Manual:
Best Practices and Case Management

Intravenous (IV) iron therapy is an effective and generally safe treatment for iron deficiency and iron-deficiency anemia (IDA). Yet concerns about adverse reactions continue to limit its use, potentially leaving patients with inadequately treated anemia. A new international consensus paper published in the British Journal of Anaesthesia (BJA) in July 2026 aims to address these concerns by translating current evidence into practical recommendations for clinicians. Developed by experts from the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), the publication provides guidance on selecting IV iron formulations, recognising adverse events, preventing complications and managing reactions safely. The central message is reassuring: serious hypersensitivity reactions are rare, most infusion-related events are manageable, and appropriate monitoring and formulation selection can substantially improve treatment safety. However, the recommendations also highlight an important and sometimes overlooked complication: formulation-dependent hypophosphatemia, particularly following ferric carboxymaltose administration. Key findings at a glance Serious hypersensitivity reactions are uncommon: Severe reactions occur in only a small proportion of patients receiving modern IV iron formulations. Not every infusion reaction is anaphylaxis: Mild, transient reactions can often be managed by temporarily interrupting the infusion. Hypophosphatemia varies substantially between formulations: A meta-analysis reported an incidence of 47% with ferric carboxymaltose versus 4% with ferric derisomaltose. Extravasation can cause permanent skin staining: Careful cannula placement, saline flushing and regular inspection are essential. Infection risk remains uncertain: Most large randomised trials have not demonstrated a clinically important increase in infection risk, although treatment is generally deferred during active, uncontrolled infections. Routine prolonged observation is not always necessary: NATA suggests that mandatory 30-minute postinfusion observation is generally unnecessary, while emphasising close monitoring during administration. Treatment should be individualised: Patient characteristics, cumulative iron exposure, infusion convenience and formulation-specific adverse effects should guide clinical decisions. Why intravenous iron safety matters Iron deficiency and […]

A large European multicentre study has found that 95% of patients undergoing elective procedures fasted from clear liquids for more than four hours before anesthesia, despite international guidelines recommending that healthy adults should be encouraged to drink clear liquids until two hours before their procedure. Published in the European Journal of Anaesthesiology, the prospective observational Thirst study included 5,100 adult patients from 46 centres across 12 European countries. The researchers reported a median preoperative liquid fasting duration of 12 hours, six times the recommended two-hour interval. These findings highlight persistent challenges in implementing evidence-based fasting guidelines and raise concerns about unnecessary patient discomfort, dehydration and perioperative physiological stress. Key findings at a glance Median liquid fasting duration: 12 hours, with an interquartile range of 10 to 14.6 hours. Patients fasting for more than four hours: 95.2% (4,862 patients). Patients fasting between two and four hours: 3.9% (199 patients). Patients drinking within two hours before anesthesia: 0.8% (39 patients). Study population: 5,100 adults undergoing elective surgery or interventional procedures. Participating centres: 46 hospitals and clinical centres across 12 European countries. The findings demonstrate that prolonged preoperative liquid fasting remains widespread despite established international recommendations. Why is preoperative fasting necessary? Preoperative fasting is an important safety measure intended to reduce the risk of regurgitation and pulmonary aspiration of gastric contents during anesthesia. Pulmonary aspiration can cause serious respiratory complications, including aspiration pneumonitis and pneumonia. However, modern fasting guidelines distinguish between solid food and clear liquids. For healthy adults undergoing elective procedures, international recommendations generally permit clear liquids until two hours before anesthesia. Clear liquids empty relatively rapidly from the stomach. Evidence reviewed in the study indicates that consuming clear liquids two hours before anesthesia does not increase aspiration risk compared with longer fasting periods in appropriately selected patients. Prolonged fluid restriction, therefore, […]