Patient Blood Management Guidelines
Core Framework: The Three-Pillar Approach
Implement a comprehensive Patient Blood Management (PBM) program structured around three pillars: (1) optimize preoperative hemoglobin, (2) minimize perioperative blood loss, and (3) adopt restrictive transfusion thresholds. 1 This multimodal approach reduces transfusion rates by 39%, decreases complications by 20%, lowers mortality by 11%, and shortens hospital length of stay. 2
Pillar 1: Preoperative Anemia Detection and Management
Screening Timeline and Laboratory Evaluation
Screen for anemia at least 28 days (4 weeks) before elective surgery to allow adequate time for diagnosis and treatment. 3, 4 This timing is critical—screening closer to surgery date may necessitate postponement. 3
Order hemoglobin, hematocrit, and complete blood count on all surgical patients during preoperative assessment. 1
When anemia is detected (Hb <13 g/dL in men, <12 g/dL in women), immediately obtain:
Iron Deficiency Diagnosis and Treatment
Absolute iron deficiency is diagnosed when serum ferritin <30 μg/L and/or TSAT <20%. 1, 5 In the presence of inflammation or chronic disease, use ferritin <100 μg/L with TSAT <20% as diagnostic criteria. 5
Treatment Algorithm Based on Surgical Timing:
Surgery >6-8 weeks away: Oral iron 40-60 mg elemental iron daily in divided doses 3, 4
Surgery within 2-3 weeks: Intravenous iron is preferred due to faster response and superior absorption 3, 5, 4
IV iron should be administered at least 10 days before surgery for optimal effect, with maximum hemoglobin increase (mean 8 g/L) typically observed at 2 weeks post-administration. 5
For patients with inflammatory bowel disease or functional iron deficiency: IV iron is specifically indicated due to hepcidin-mediated inhibition of oral iron absorption. 5
Special Considerations for Iron Deficiency:
When ferritin <30 μg/L with gastrointestinal symptoms or risk factors, refer to gastroenterology to rule out malignancy as source of chronic blood loss. 1, 3, 4
IV iron has an excellent safety profile with serious adverse reactions occurring in only 38 per million administrations. 5
Monitor serum phosphate with repeat IV iron dosing within 3 months due to hypophosphatemia risk, particularly with ferric carboxymaltose. 5
Other Causes of Anemia
Vitamin B12 or folate deficiency: Treat with appropriate vitamin supplementation when levels are low. 3, 4
Chronic kidney disease (elevated creatinine, reduced GFR): Refer to nephrology for management and consider erythropoiesis-stimulating agents (ESAs) with concurrent IV iron. 1, 3
ESAs (erythropoietin) may be administered in selected populations including renal insufficiency, anemia of chronic disease, or transfusion refusal, though this requires weeks to produce significant hemoglobin increases. 1
Patients should receive iron supplementation throughout ESA therapy to optimize dose-response and red blood cell production. 1
Pillar 2: Minimizing Perioperative Blood Loss
Preoperative Anticoagulation Management
Discontinue anticoagulation therapy (warfarin, anti-Xa drugs, antithrombin agents) in consultation with appropriate specialist for elective surgery. 1
Transition to shorter-acting agents (heparin, low-molecular-weight heparin) may be appropriate in selected patients. 1
Discontinue nonaspirin antiplatelet agents (clopidogrel, ticagrelor, prasugrel) for sufficient time before surgery, except in patients with recent percutaneous coronary interventions. 1
Critical exception: Do not stop clopidogrel and aspirin in patients with coronary stents placed within 3 months for bare metal stents or 1 year for drug-eluting stents due to myocardial infarction risk. 1
Aspirin may be continued on case-by-case basis, weighing thrombosis risk versus bleeding risk. 1
Intraoperative Blood Conservation Strategies
Use antifibrinolytic agents (tranexamic acid, ε-aminocaproic acid) if fibrinolysis is documented or suspected. 1, 6
Employ cell salvage technology during procedures with expected significant blood loss. 1
Consider topical hemostatics such as fibrin glue or thrombin gel. 1
Utilize meticulous surgical technique to minimize iatrogenic blood loss. 6
Pillar 3: Restrictive Transfusion Strategy
Red Blood Cell Transfusion Thresholds
Adopt a restrictive red blood cell transfusion strategy as the standard of care—this approach safely reduces transfusion administration without compromising outcomes. 1, 6
For hemoglobin concentrations between 6-10 g/dL, base transfusion decisions on:
Administer red blood cells unit-by-unit with interval clinical reassessment after each unit rather than ordering multiple units simultaneously. 1
Patient Communication
Inform patients of potential risks versus benefits of blood transfusion and elicit their preferences during preoperative evaluation. 1
Review previous transfusion history and document any adverse reactions. 1
Coagulopathy Management
Assess fibrinogen levels before cryoprecipitate administration when possible. 1
Desmopressin may be used in patients with excessive bleeding and platelet dysfunction. 1
Prothrombin complex concentrates (PCCs) may be used in patients with excessive bleeding and elevated INR. 1
Consider recombinant activated factor VII only when traditional options for treating excessive bleeding due to coagulopathy have been exhausted, with caution regarding arterial thrombosis risk, especially in older patients. 1
Implementation Strategies
Institutional Protocols
Develop multimodal protocols or algorithms to reduce blood product usage, though no single universal algorithm can be recommended. 1
Implement a massive transfusion protocol when available to optimize delivery of blood products to massively bleeding patients. 1
Use maximal surgical blood order schedules when available to improve efficiency of blood ordering practices. 1
Ensure blood and blood components are available for patients when significant blood loss or transfusion is expected. 1
Autologous Blood Donation
- When autologous blood is preferred, offer preoperative donation only if adequate time exists for erythropoietic reconstitution. 1
Clinical Outcomes and Evidence
Comprehensive PBM programs addressing all three pillars demonstrate:
- 39% reduction in transfusion rates 2
- 20% reduction in total complications 2
- 11% reduction in mortality 2
- Decreased hospital length of stay by 0.45 days 2
- Improved postoperative physical rehabilitation and quality of life 3, 5
In cardiac surgery specifically, PBM implementation with preoperative anemia detection and correction reduces perioperative transfusion need (Grade 1+ recommendation) and likely reduces postoperative morbidity and hospital length of stay (Grade 2+ recommendation). 1
Critical Pitfalls to Avoid
Do not proceed to surgery without investigating the cause of anemia—this represents a missed opportunity to reduce perioperative morbidity and mortality. 4
Do not assume mild anemia is "acceptable"—target hemoglobin within normal range (≥13 g/dL for men, ≥12 g/dL for women) to optimize outcomes. 4
Do not delay elective surgery if newly diagnosed anemia is detected close to surgical date without attempting rapid optimization with IV iron or other appropriate interventions. 3
Do not order multiple units of red blood cells simultaneously—transfuse unit-by-unit with reassessment to avoid unnecessary transfusion. 1