Preoperative evaluation and perioperative strategies to minimize blood transfusion
- Thomas J Graetz, MD
Thomas J Graetz, MD
- Assistant Professor of Anesthesiology and Surgery (Cardiothoracic)
- Washington University in St. Louis School of Medicine
- Gregory Nuttall, MD
Gregory Nuttall, MD
- Professor of Anesthesiology
- Mayo Clinic College of Medicine
- Section Editors
- Michael Avidan, MD
Michael Avidan, MD
- Section Editor — Surgical Critical Care
- Professor of Anesthesiology and Surgery
- Washington University School of Medicine
- Steven Kleinman, MD
Steven Kleinman, MD
- Section Editor — Transfusion Medicine
- Clinical Professor of Pathology
- University of British Columbia, Vancouver
This topic will review perioperative strategies to avoid or minimize transfusion of blood products during surgery and other interventional procedures. General principles guiding intraoperative transfusion decisions as well as indications and risks associated with transfusion of specific blood components in that setting are discussed separately. (See "Intraoperative transfusion of blood products in adults".)
The preanesthetic consultation provides an opportunity to assess and minimize risks for bleeding and transfusion. Certain medications, diseases, and surgical procedures are associated with increased risks for transfusion . It may be appropriate to postpone an elective procedure if consultation with the surgeon and/or hematologist determines that the benefit of optimizing hemostasis or hemoglobin level outweighs the risks of postponing the surgery. (See "Preoperative assessment of hemostasis", section on 'Medical and hematologic consultations'.)
Selective laboratory testing — A baseline hemoglobin measurement is suggested for patients ≥65 years old who are undergoing major elective surgery and for any patient undergoing a procedure expected to result in significant blood loss. In contrast, hemoglobin measurement is unnecessary for healthy adults undergoing minor surgery unless the history suggests anemia. (See "Preoperative medical evaluation of the adult healthy patient", section on 'Complete blood count'.)
No additional laboratory testing is required unless a bleeding disorder is suspected. This practice is consistent with the American Society of Anesthesiologists (ASA) , the British Committee for Standards in Hematology (BCSH) , and the European Society of Anaesthesia (ESA) .
If the patient or family history or the physical examination suggests the presence of a bleeding disorder, appropriate screening tests should be performed, including prothrombin time (PT) with international normalized ratio (INR), activated partial thromboplastin time (aPTT), and platelet count. A hematology consultation and additional testing are typically necessary to establish a diagnosis and treatment plan. In some cases such as those with significant prior bleeding (eg, drop in hemoglobin level, need for transfusions) it may be appropriate to pursue consultation even when screening tests are normal. (See "Preoperative assessment of hemostasis", section on 'Laboratory testing' and "Preoperative assessment of hemostasis", section on 'Medical and hematologic consultations'.)
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- PREOPERATIVE STRATEGIES
- Selective laboratory testing
- Management of medications affecting hemostasis
- Correction of anemia or thrombocytopenia
- - Correction of anemia in selected patients
- - Treatment of thrombocytopenia for selected procedures
- Treatment of vitamin K deficiency
- Management of anemia and hemostasis in renal insufficiency
- Management of hemostasis in hepatic insufficiency
- Management of specific hemostatic disorders
- - Inherited conditions
- - Acquired disorders
- Preoperative autologous blood donation
- INTRAOPERATIVE STRATEGIES
- Fluid management
- Temperature management
- Surgical blood conservation techniques
- - Electrosurgery devices
- - Topical hemostatic agents and tissue adhesives
- - Acute normovolemic hemodilution
- - Intraoperative blood salvage
- Selective use of procoagulant products
- - Antifibrinolytics
- - Desmopressin (DDAVP)
- - Prothrombin complex concentrate (PCC)
- - Fibrinogen concentrate
- - Recombinant activated factor VII (rFVIIa)
- REFUSAL OR LIMITED AVAILABILITY OF BLOOD
- SUMMARY AND RECOMMENDATIONS