General ways to reduce amount of blood transfused in a surgical patient:
(1) reduce loss
(2) maximize red blood cell production
(3) maximize oxygen delivery
(4) lower threshold level when to transfuse (tolerate lower hemoglobin values)
NOTE: These recommendations assume elective surgery and might not be appropriate for a patient requiring urgent or emergency surgery.
Stages:
(1) preoperative
(2) perioperative
(3) postoperative
Preoperative:
(1) Take a complete history, including tendency to bleed and a description of any previous surgeries.
(2) Perform laboratory screening tests, including a complete blood cell count and coagulation screening tests. If blood loss is expected, submit a specimen to Blood Bank (Type and Hold, Type and Screen or Type and Crossmatch).
(3) Consider autologous blood collection.
(4) Consider erythropoietin to increase red blood cell production.
(5) Treat any iron, folate or vitamin B12 deficiency.
(6) Stop aspirin or other drugs with antiplatelet activity sufficient to remove effect by time of surgery (7 days for aspirin).
(7) Weigh the patient and estimate the blood volume.
(8) If the patient is receiving anticoagulants, develop a plan to reverse prior to surgery.
Perioperative:
(1) Consider acute normovolemic hemodilution.
(2) If available and the surgery appropriate, consider intra-operative red blood cell salvage.
(3) Consider hypotensive surgery if appropriate.
(4) Warm all fluids to avoid hypothermia.
(5) During surgery maintain meticulous hemostasis. Consider use of fibrin glues and sealants.
(6) Use of pharmacologic agents (tranexamic acid, DDAVP, aprotonin) to reduce bleeding.
Postoperative:
(1) Accept a lower postoperative hemoglobin concentration before transfusing.
(2) If transfusion is necessary, limit the number of units transfused (preferably 1) unless the patient is hemorrhaging.
(3) Use supplemental oxygen.
(4) Prescribe iron, folate and vitamin B12.
