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Data Gathering




  • Previous evaluation for anemia

  • Spontaneous bleeding (epistaxis, hematochezia, hematuria, hematemesis, melena)

  • Heavy menses

  • Fatigue

  • Easy bruising

  • Peripheral edema

  • Ecchymoses/petechiae on skin or mucosa

  • Pallor

Risk Stratification

Diagnostic Studies


  • SCREENING: obtain CBC for any of following:

    • Expected total blood loss >1000 cc​

    • History or exam suggestive of RBC abnormality

  • ANEMIA: obtain following if not obtained recently (<6 months)​:

    • CBC, reticulo​cyte count, iron panel, ferritin, B12, TSH


Indications for Surgical Delay

  • Uncharacterized or untreated correctable anemia (Hgb <10 or any anemia prior to large blood loss surgery) & elective surgery (Choosing Wisely)

  • Thrombocytopenia that is new/significant (<50k or decrease by 50% with platelet count <150k or related to microangiopathic hemolytic anemia (DIC, TTP, HUS)

  • Severe neutropenia (ANC <500)

  • Continue all non-antithrombotic hematologic meds uninterrupted (eg, hydroxyurea)

    • Exceptions: rituximab - discuss best management with surgeon and hematologist


RBC Transfusion Indications (AABB guideline)

  • Symptoms of anemia (along with level of anemia expected to cause symptoms - eg, Hgb <10 and significantly decreased from baseline)

  • Hgb <7 g/dl

  • Hgb <7.5 after cardiac surgery

  • Hgb <8 g/dl plus:

    • Cardiovascular disease​

    • Orthopedic surgery

Blood Conservation Methods (BCSH guideline​, SABM recommendations)

Iron Supplementation

  • In patients with preoperative iron deficiency anemia, IV iron reduces blood transfusions & is indicated when the timeframe to surgery is short (few weeks) or the patient is intolerant of PO iron (Froessler et al & Goodnough et al)

  • Even in patients without preoperative anemia, provision of postoperative IV iron after lower limb arthroplasty reduced transfusion rates without significant change in overall cost of care (Munoz et al)

IV iron.jpg

Preoperative Autologous Donation 

  • Low use currently due to less concern over safety of blood supply & evidence suggesting it may increase the need for transfusion (due to donating blood close enough to surgery to prevent blood expiration) and does not completely eliminate risks

  • If used, iron supplementation and ESAs may be beneficial for regenerating blood after donation and prior to surgery (see above)

  • BCSH guideline only recommends its use in "exceptional circumstances":

    • Rare blood groups or multiple blood group antibodies where compatible allogeneic (donor) blood is difficult to obtain

    • Serious psychiatric risk because of anxiety about exposure to donor blood

    • Refusal of allogeneic blood transfusion but will accept preoperatively donated autologous blood

    • Children undergoing scoliosis surgery

RBC Salvage

  • Can be done intraoperatively or postoperatively (less common)

  • Used if expected blood loss >500 cc

  • Indications:

    • Expected blood loss >20% of patient’s blood volume

    • Risk factors for bleeding (including high-risk Caesarean section) or low preoperative Hb concentration 

    • Major hemorrhage

    • Rare blood groups or multiple blood group antibodies

    • Refusal of allogeneic blood transfusion but will accept salvage autologous blood (many Jehovah's Witnesses, but not all - see below)

Acute Normovolemic Hemodilution (ANH)

  • Immediate preoperative phlebotomy and storage of RBCs and replacement with isotonic IV fluids

  • Requires considerable expertise & resources not available at all facilities

  • Role still unclear

  • Consider for anemic patients undergoing surgery who refuse allogeneic blood or with large expected blood loss who have rare blood groups or multiple RBC antibodies that make allogeneic transfusion difficult

Erythropoiesis-Stimulating Agents

  • Beneficial in patients with anemia of chronic disease prior to large blood loss surgeries

  • Potential adverse effects: VTE, seizures, red cell aplasia

  • Contraindication: Hct >35%

  • Should be given with concomitant iron supplementation & VTE prophylaxis should be considered

  • Preparations contain a small amount of human albumin so some Jehovah's Witnesses may not accept


Sickle Cell Disease Management

  • Transfuse to Hgb of 10 g/dl prior to surgery requiring general anesthesia (NHLBI guideline)

    • Type of transfusion (simple or exchange) should be determined by hematology​

    • Typically done 2-3 days before surgery

  • Provide additional time for crossmatching of blood prior to large blood loss surgeries​ - 2 days before surgery

  • Aggressively pursue adequate pain control & avoidance of hypoxia/dehydration

  • If patient is euvolemic, give hypotonic IV fluids (encourages flow of water into RBCs and prevents sickling)

  • Patients with sickle cell disease presenting for elective surgery should be reviewed in a pre‐assessment clinic, with input from hematology (Association of Anaesthetists guideline)

  • The acute pain team should be notified in advance if a patient with sickle cell disease is undergoing major surgery, particularly if the patient has a history of chronic pain. (Association of Anaesthetists guideline)

  • Schedule early on the operating list to avoid prolonged starvation (Association of Anaesthetists guideline)

  • Have a low threshold to admit patients to high dependency or intensive care. (Association of Anaesthetists guideline)

Jehovah's Witness Patient Management (Kline et al)

  • Obtain advance directives (Jehovah's Witnesses often have a unique advance directive)

  • Some patients may request additional assistance from Jehovah's Witness pastors or councils - many Hospital Liaison Committees available (click for website with list)

  • Confirm whether they will take direct transfusion of blood cells

    • Strict adherents ("active" Jehovah's Witnesses) will not​ accept primary blood components - RBCs, platelets, WBCs, and plasma

    • "Inactive" Witnesses may be willing to receive blood transfusions under some circumstances

  • Blood derivatives, including albumin, cryoprecipitate, immunoglobulins, and factor concentrates, are left to individuals to decide (governing body for Jehovah's Witnesses, the Watch Tower Society, leaves it to one's conscience)

  • Ask whether they will accept specific blood conservation methods (see above)

    • Many will accept RBC salvage and ESAs

    • For RBC salvage, many insist that the blood is not stored at any time - instead, it must be in a continuous circuit connected to the body; not all RBC salvage methods do this - must determine ahead of time

    • For ESAs, all usually contain a small amount of albumin; for Jehovah's Witnesses unwilling to accept this, albumin-free preparations can be obtained from the manufacturer

  • Obtain CBC, iron studies, B12, folate, coagulation studies, & fibrinogen levels

  • At least 6 weeks before elective surgery likely to be associated with significant blood loss, check Hb and if <13, optimization by treatment with iron and/or erythropoietin should be considered

  • Minimize phlebotomy

  • Use antithrombotic agents cautiously

  • Consider use of IV tranexamic acid to reduce bleeding/conserve blood

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