Blood and Tissue Resources

New York State Council on Human Blood and Transfusion Services

Guidelines for Physician Options for Blood Conservation

Guidelines (PDF file size: 22K)

Encourage Blood Donation

• Request that patients recruit family or friends as donors to replenish the community blood supply.
• Consider pre-operative autologous blood donation1 when surgery has the potential for significant blood loss.

Pre- and Intraoperative Strategies

• Consider using recombinant erythropoietin (EPO) along with iron therapy^1,2 if blood loss of 2-5 units is anticipated. Allow a 2-4 week hiatus between scheduling and performing elective surgery.
• Discontinue anticoagulants and aspirin prior to surgery whenever possible to reduce blood loss.
• Consider using intraoperative blood recovery^3,4 or acute normovolemic hemodilution^1,5 when blood loss is expected to exceed 20% of blood volume.
• During surgery, use oximetry to monitor oxygenation to determine the need for blood when appropriate.¹
• Enhance hemostasis systemically with pharmacologic agents, such as vitamin K, tranexamic acid, epsilon-aminocaproic acid, desmopressin, and aprotinin, when appropriate.⁶
• During surgery, enhance local hemostasis with topical agents such as "fibrin glue", topical thrombin, collagen hemostat, oxidized cellulose, gelatin foam/sponges, and tissue adhesives.
• During surgery, and in bleeding patients and patients with risk factors for bleeding, when possible, avoid systemic administration of substances which may cause coagulopathy, as for example hydroxyethyl starch solutions.⁷

General Measures

• Transfuse only when medically indicated after careful consideration.⁸ Supervise orders by housestaff closely.¹ Consider a red cell transfusion trigger of 7.0 g/dL in asymptomatic non-acute patients.⁹
• Consider lowering the dose transfused. For stable patients, evaluate the patient's response following the transfusion of each unit.
• Restrict diagnostic phlebotomy to the minimum necessary, in order to reduce iatrogenic blood loss.^10,11
• At times of blood shortage, Surgery and Anesthesiology should work together with the Transfusion Service to assure availability of blood for pending surgical cases anticipated to be at risk for large blood loss.

References

1. Goodnough LT. Alternatives to allogeneic blood and strategies to avoid transfusion. In: Linden JV, Bianco C, eds. Blood safety and surveillance. New York: Marcel Dekker, 2001:447-62.
2. Laupacis A, Fergusson D. Erythropoietin to minimize perioperative blood transfusion: a systematic review of randomized trials. The International Study of Peri-operative Transfusion (ISPOT) Investigators. Transfus Med 1998;8(4):309-17.
3. Salem M, ed. Blood conservation in the surgical patient. Baltimore: Williams & Wilkins, 1996.
4. Schmidt H, Mortensen PE, Folsgaard SL, Jensen EA. Autotransfusion after coronary artery bypass grafting halves the number of patients needing blood transfusion. Ann Thorac Surg 1996;61(4):1177-81.
5. Loubser PG, Srikureja M, Nguyen TT, Lavine SD. Use of acute normovolemic hemodilution as a blood conservation modality: survey of academic anesthesiology centers in the United States. Am J Anesthesiol 2001;28(2):89-94.
6. Nuttall GA, Oliver WC, Ereth MH, et al. Comparison of blood conservation strategies in cardiac surgery patients at high risk for bleeding. Anesthesiology 2000;92(3):674-82.
7. Jonville-Bera AP, Autret-Leca E, Gruel Y. Acquired type I von Willebrand's disease associated with highly substituted hydroxyethyl starch (letter). N Engl J Med 2001; 345(8):622-3.
8. Corwin HL, Parsonnet KC, Gettinger A. RBC transfusion in the ICU: is there a reason? Chest 1995;108(3):767-71.
9. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340(6):409-17.
10. Hébert PC, Blajchman MA, Cook DJ, et al. The Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group. Do blood trans-fusions improve outcomes related to mechanical ventilation? Chest 2001;119(6): 1850-7.
11. Hébert PC, Yetisir E, Martin C, et al. The Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med 2001;29(2):227-34.