Acknowledgements
Nirav Shah, MD – MPOG
Henrietta Addo, MSN, RN - MPOG
Nicole Barrios, MHA, BSN – MPOG
Kate Buehler, MS, RN - MPOG
Previous Versions
Version 2: July 2022
Version 1: July 2018
Objectives
Review incidence,
risk, and costs
associated with
transfusion and
review of blood
components
01
Review preoperative
transfusion
considerations
02
Review intraoperative
transfusion
considerations
03
Review
postoperative
transfusion
considerations
04
Toolkit Overview
• This presentation is part of a perioperative transfusion toolkit offering an overview of
transfusion practices and considerations for cardiac, pediatric and obstetric surgical
populations as well as general recommendations for patient blood management.
• For other patient blood management recommendations please reference additional
toolkit components:
Transfusion Management for the Obstetric Hemorrhage
Transfusion Management for the Cardiac Surgical Patient (Coming soon!)
Transfusion Management for the Pediatric Surgical Patient (Coming soon!)
MPOG Perioperative Blood Management Toolkit webpage
Objective #1: Background
Review incidence of transfusion
Review cost of transfusion
Review transfusion triggers
Overview of blood products
Overview of patient blood management
Why are blood products administered?
• Treatment of anemia
• Address clotting
deficiencies
• Ultimately, to improve
tissue oxygenation
References:
1. Lotterman S, Sharma S: Blood Transfusion. StatPearls Publishing, 2023
Blood Product Administration is Common
• Every 2 seconds, someone in the U.S. requires a blood product
• Nearly 16 million blood components are transfused each year in the US
• Nearly 5,000 units of platelets and 6,500 units of plasma are required daily in the
US
• Approximately 29,000 units of red blood cells are needed every day in the US
• Approximately 15 million units RBCs, platelets, and plasma were transfused in
2021, averaging 42,000 blood products transfused daily
References:
1. American Red Cross: Importance of Blood Supply 2024 at https://www.redcrossblood.org/donate-blood/how-to-donate/how-blood-donations-help/blood-needs-blood-supply.html
2. Cho BC, Serini J, Zorrilla-Vaca A, Scott MJ, Gehrie EA, Frank SM, Grant MC: Impact of Preoperative Erythropoietin on Allogeneic Blood Transfusions in Surgical Patients: Results From a Systematic Review and Meta-analysis. Anesth Analg 2019; 128:981–92
MPOG Transfusion Data - 2024
Total MPOG Cases with Transfusion: 38,758*
Total MPOG Cases with Transfusion: 38,758*
*Excludes cases with autologous transfusions only.
*Excludes autologous units.
Total Units Transfused: 85,001*
*Excludes autologous units.
Total MPOG Cases with Transfusion: 38,758*
Transfusions may case harm
Reference:
1. Carson JL, Stanworth SJ, Guyatt G, Valentine S, Dennis J, Bakhtary S, Cohn CS, Dubon A, Grossman BJ, Gupta GK, Hess AS, Jacobson JL, Kaplan LJ, Lin Y, Metcalf RA, Murphy CH, Pavenski K, Prochaska MT, Raval JS, Salazar E, Saifee
NH, Tobian AAR, So-Osman C, Waters J, Wood EM, Zantek ND, Pagano MB: Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA 2023 doi:10.1001/jama.2023.12914
Causes of transfusion related deaths (per FDA)
References
1. Center for Biologics Evaluation, Research: Transfusion/Donation Fatalities 2023 at https://www.fda.gov/vaccines-blood-biologics/report-problem-center-biologics-evaluation-research/transfusiondonation-fatalities
All US transfusion related fatalities and donation related deaths are reported to the FDA
Transfusion reaction
Deaths
(2022)
Transfusion associated circulatory overload (TACO)
15
Transfusion related acute lung injury (TRALI)
7
Blood contamination
5
Hemolytic transfusion reaction (HTR)
5
Anaphylaxis
4
Transfusion reaction (undetermined type)
3
Hemolytic transfusion reaction (HTR) non-ABO
2
Blood acquisition is the largest expense for a
hospital’s blood bank
1-2
Approximate average acquisition cost for an RBC unit
in 2021 was approximately $225 ($210 – $240) per
hospital’s blood bank
While labor associated with transfusion is difficult to
quantify, a transfusion procedure in 2021 was billed
for approximately $2,000
The approximate median negotiated out-of-pocket
price for one PRBC unit in 2021 was $1,388 ($1,087 -
$1,911)
The approximate median negotiated rate for health
insurance companies in 2021 was $ 1,589 ($1,198 -
$3,093)
References:
1. Jacobs JW, Diaz M, Arevalo Salazar DE, Tang A, Stephens LD, Booth GS, Lehmann CU, Adkins BD: United States blood pricing: A cross-sectional analysis of charges and reimbursement at 200 US hospitals. Am J Hematol 2023; 98:E179–82
2. Donated blood products median amount paid by hospitals U.S. 2021 at https://www.statista.com/statistics/1204177/donated-blood-products-median-amont-paid-by-hospitals-us/
Image source: Blood Management Program Yields
Summary of Blood Components
Red Blood Cells
Cryoprecipitate
Platelets
Plasma
Homologous vs Autologous Transfusions
Homologous (allogeneic)
Transfusion of blood or blood components obtained from a compatible donor to a patient
1
Can be further divided into directed and non-directed transfusions
Non-directed transfusion: Donation from a living donor with no known relation to
recipient
2
Directed transfusion: Donated blood from ABO and Rh-compatible family member
2
References:
1. Sam AM, Gupta D, Radhakrishnan A, Sethuraman M, Dash PK, Pitchai S, Kesavapisharady K: Autologous versus allogeneic blood transfusion: A comparative study of the peri-operative outcomes in a tertiary care hospital in South India amidst the COVID-19
pandemic. Transfus Apher Sci 2023; 62:103753
2. Autologous and Directed Donations at https://www.redcrossblood.org/donate-blood/how-to-donate/types-of-blood-donations/autologous-and-directed-donations.html
Autologous
Patient donates their own blood for future use. Collected blood is stored and transfused
back to the patient if needed during or after procedure
1
Image source: Young Blood: When Conservation is Critical
Image source: Autologous Blood Transfusion
Packed Red Blood Cells (PRBCs)
• Red blood cells constitute 45% of the volume of blood
• Consists of erythrocytes concentrated from whole blood donation or by
apheresis (a process where specific blood components are separated
from the whole blood by machine)
• Typically contain citrate anticoagulant and one of several types of
preservative solutions
Depending on the preservative, the hematocrit of RBCs is 55-65%
Each unit contains 50-80 g of hemoglobin and ~250 mg iron
• In a non-bleeding, non-hemolyzing adult, hemoglobin
should equilibrate within 15 minutes after transfusion of RBCs
• One unit should increase hemoglobin by ~1 g/dL (or hematocrit by 3%)
References:
1. American Red Cross: Compendium of Transfusion Practices 2021 at https://www.redcross.org/content/dam/redcrossblood/hospital-page-documents/334401_compendium_v04jan2021_bookmarkedworking_rwv01.pdf
2. American Red Cross: Importance of Blood Supply 2024 at https://www.redcrossblood.org/donate-blood/how-to-donate/how-blood-donations-help/blood-needs-blood-supply.html
Plasma
• Plasma for transfusion is obtained by centrifuging whole blood
or through apheresis
• Post-collection processing or storage methods can result in
variation in levels of coagulation factors, fibrinolytic proteins,
immunoglobulins, albumin, and other proteins
• Plasma is generally anticoagulated with citrate
• Whole blood-derived units contain approximately 200 – 250
mL and apheresis-derived units containing 400 – 600 mL
plasma
• Plasma administration is indicated for bleeding or prophylaxis
of bleeding due to deficiency of multiple coagulation factors OR
urgent reversal of warfarin when prothrombin complex
concentrate (PCC) is not available
References:
1. American Red Cross: Importance of Blood Supply 2024 at https://www.redcrossblood.org/donate-blood/how-to-donate/how-blood-donations-help/blood-needs-blood-supply.html
Cryoprecipitate
• Cryoprecipitate is an acellular blood component
• It is prepared by thawing one unit of fresh frozen plasma
(FFP) at a temperature of 1-6 °C and recovering the cold
insoluble precipitate
1-2
• Cryoprecipitate contains concentrated levels of fibrinogen,
Factor VIII, von Willebrand factor (vWF), Factor XIII, and
fibronectin
1-2
• Each unit of cryoprecipitate contains and average of 215 IU
of Factor VIII and 700 mg of Fibrinogen with an average
volume range of 20 – 25mL.
Red Cross pools contain 5
units)
1,3
• Although compatibility testing is unnecessary,
administration of cryoprecipitate that is ABO compatible
with recipients red cells is common practice
1
• When thawed, cryoprecipitate must be administered within
6 hours, as levels of Factor VIII activity can be significantly
decreased
2
References:
1. Cryoprecipitate at https://www.redcrossblood.org/biomedical-services/blood-products-and-services/cryoprecipitate.html
2. Nascimento B, Levy JH, Tien H, Da Luz LT: Cryoprecipitate transfusion in bleeding patients. CJEM 2020; 22:S4–11
3. American Red Cross: Compendium of Transfusion Practices 2021 at https://www.redcross.org/content/dam/redcrossblood/hospital-page-documents/334401_compendium_v04jan2021_bookmarkedworking_rwv01.pdf
Image source: Callum, Jeannie L., and Bartolomeu Nascimento. 2016. “Cryoprecipitate
Transfusion.” In Trauma Induced Coagulopathy, 339–46. Cham: Springer International
Publishing.
Platelets
• Platelets are the smallest cells of blood
• ~93% platelet transfusions are apheresis platelets (collected
from a single donor – Single Donor Platelets)
• Contain > 3.0 x 10
11
platelets (billion = 10
9
) per unit in 100-500
mL of plasma or plasma mixed with an additive solution)
1-2
• Random Donor Platelets are typically comprised of 4-6 units
pooled together. A single unit of platelets, contains ~55 x 10
9
platelets in 40 mL – 70 mL of plasma
1,3
• In a stable, afebrile, non-bleeding adult, transfusion of one
unit should raise recipient’s platelet count by approximately
30,000 (per microliter of blood)
3
References:
1. American Red Cross: Compendium of Transfusion Practices 2021 at https://www.redcross.org/content/dam/redcrossblood/hospital-page-documents/334401_compendium_v04jan2021_bookmarkedworking_rwv01.pdf
2. American Red Cross: Importance of Blood Supply 2024 at https://www.redcrossblood.org/donate-blood/how-to-donate/how-blood-donations-help/blood-needs-blood-supply.html
3. Hess AS, Ramamoorthy J, Hess JR: Perioperative Platelet Transfusions. Anesthesiology 2021; 134:471–9
Image source: Canadian Blood Services
Patient Blood Management – an introduction
• Patient Blood Management (PBM) is a framework and comprehensive approach
focused on identifying and addressing the root causes of blood anomalies, rather than
relying solely on short-term solutions like transfusions
• In the early 1960s, cardiovascular surgeon Denton Cooley was an early adopter of
these principles to accommodate Jehovah’s Witness patients who requested treatment
without allogeneic transfusion.
• Dr. Cooley and his team adopted a 3-step approach which later evolved into the three
pillars of Patient Blood Management:
Optimizing the patient’s red cell mass preoperatively
Utilizing surgical, anesthetic, and pharmacological techniques to minimize blood loss
Tolerating postoperative anemia
References:
1. Shander A, Javidroozi M, Naqvi S, Aregbeyen O, Caylan M, Demir S, Juhl A: An update on mortality and morbidity in patients with very low postoperative hemoglobin levels who decline blood transfusion (CME). Transfusion
2014; 54:2688–95; quiz 2687
Patient Blood Management (PBM) Principles
References:
1. Goodnough LT, Shander A: Patient blood management. Anesthesiology 2012; 116:1367–76
2. American Red Cross: Compendium of Transfusion Practices 2021 at https://www.redcross.org/content/dam/redcrossblood/hospital-page-documents/334401_compendium_v04jan2021_bookmarkedworking_rwv01.pdf
Image source: International Society of Blood Transfusion
Potential Benefits
2
• Fewer transfusions
• Avoidance of potential
complications
• Decreased hospitalization
• Fewer readmissions
• Reduction in the many
associated costs
More information on PBM Programs can be found here
Summary of transfusion overview
• Blood products are administered to enhance tissue oxygenation
• Acquiring blood is the most significant expense for a hospital’s blood bank
• Commonly transfused blood components include red blood cells, plasma,
cryoprecipitate, and plasma
• Transfusions carry risks, such as allergic reaction, transfusion-associated circulatory
overload, anaphylactic reactions, and Hepatitis B & C, along with other complications
that could lead to death
• Patient blood management is a comprehensive approach focused on identifying and
addressing the underlying causes of blood abnormalities rather than short-term
solutions like transfusions
• The potential benefits of patient blood management include fewer transfusions,
avoidance of potential complications, decreased hospitalization, fewer readmissions,
and lower costs associated with transfusions
Objective #2: Preoperative Considerations
Review preoperative plan for blood management
Identify and treat anemia
Identify and manage bleeding risk
Patients who refuse transfusion
Review Preoperative Plan for Blood Management
• Perform several days to weeks in advance, if possible.
Review Previous Medical Records & conduct a Patient/Family Interview
✓ Previous blood transfusion?
✓ History of drug-induced coagulopathy?
✓ Presence of congenital coagulopathy?
✓ Risk factors for organ ischemia?
✓ History of thrombotic events?
• Review existing lab results (hemoglobin, hematocrit, coagulation profiles)
• Order additional lab tests based on patient’s condition (anemia, coagulopathy)
• Conduct physical exam (ecchymosis, petechiae, pallor)
Prior to surgery, inform patient of potential risks vs. benefit of blood transfusion
and identify patient preferences.
References:
1. ASA Task Force on Perioperative Blood Management. (2015). Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood
Management*. Anesthesiology. 122(2):241-75.
Identifying and treating anemia preoperatively
• Preop anemia is a strong predictor of postoperative
complications
1
• Preop assessment and treatment of anemia helps reduce
RBC transfusion requirements in the perioperative phase.
2
• Most common anemia is iron-deficiency anemia: ferritin <
30 ng/mL or transferrin saturation <20%
1
• Commonly used definitions of anemia
Mild: hemoglobin between 10 g/dL - 12 g/dL
2-3
Moderate: hemoglobin between 8 g/dL to 10 g/dL
2-3
Severe: hemoglobin 6.5 g/dL to 7.9 g/dL
2-3
Life threatening: hemoglobin less than 6.5 g/dL
2-3
Reference:
1. Oehme F, Hempel S, Knote R, Addai D, Distler M, Muessle B, Bork U, Weitz J, Welsch T, Kahlert C: Perioperative Blood Management of Preoperative Anemia Determines Long-Term Outcome in Patients with Pancreatic Surgery. J Gastrointest Surg 2021; 25:2572–81
2. American Red Cross: Compendium of Transfusion Practices 2021 at https://www.redcross.org/content/dam/redcrossblood/hospital-page-documents/334401_compendium_v04jan2021_bookmarkedworking_rwv01.pdf
3. Badireddy M, Baradhi KM: Chronic anemia, StatPearls. Treasure Island (FL), StatPearls Publishing, 2024
4. National Institute of Health: Common terminology criteria for adverse events V3.0 (ctcae). Handydex, 2017 at https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/ctcae_v5_quick_reference_8.5x11.pdf
Image source: Shaik, Z. A. (2019, May 21). Anemia.; Getcured Apothecary Private
Limited. https://getcured.xyz/anemia/
Examples of Laboratory Tests to Assess Anemia
and Coagulation Status Preoperatively
• Complete Blood Count (CBC)
• Reticulocyte Count
• Vitamin B12
• Folate
• Iron studies
• Erythropoietin
• PT (prothrombin time) / aPTT ( activated partial
thromboplastin time / INR (international
normalized ratio)
Reference:
1. Smith D: Anemia in the Presurgical Patient Recognition Diagnosis and Management at https://www.sabm.org/anemia-in-the-presurgical-patient-recognition-diagnosis-and-management
2. Graetz TJ: Perioperative blood management: Strategies to minimize transfusions, UpToDate. Edited by O’Connor MF, Nussmeier NA. Waltham, MA, UpToDate, 2023
Examples of Preoperative Treatment of
Anemia in Elective Cases
• Vitamin B
12
deficiency: B
12
intramuscular injection
1
• Folate deficiency: folate replacement
1
• Iron-deficiency anemia
1
Iron PO x4 weeks prior to surgery, recheck levels and continue until day of surgery if
responding
Consider IV iron if no response or intolerance to oral iron
Note: Oral iron takes > 15 days to take effect, has poor GI tolerance, and low adherence
rates.
• Limiting lab draws or using pediatric sized specimen tubes and POC
instruments when possible
2
• Epoetin Alpha daily until Hgb > 7 g/dL (4.43 mmol/L)
2
Reference:
1. Crowe EP, DeSimone RA: Transfusion support and alternatives for Jehovah’s Witness patients. Curr Opin Hematol 2019; 26:473–9
2. Posluszny JA Jr, Napolitano LM: How do we treat life-threatening anemia in a Jehovah’s Witness patient? Transfusion 2014; 54:3026–34
Image source: https://dravinashtank.in/gastro_health/anaemia-causes-diagnosis-treatment-and-prevention/
Identifying bleeding risk and potential therapies
• Surgeries with high bleeding risk
Examples include major vascular, cardiac, liver transplant, major abdominal or pelvic surgery
• Factor Deficiency
Hemophilia A & B
1
- consider factor VIII, factor IX, or factor XI replacement therapy
von Willebrand Disease
1 –
consider factor VII and TXA administration
• Factor XI deficiency
1
– Consider FFP and Factor XI availability / administration
• DDVAP (1-deamino-8-d-arginine vasopressin) may be appropriate to reduce excessive
bleeding and the need for transfusions in certain patients with specific platelet
dysfunctions that are known to respond to this medication
2
Reference:
1. Abou-Ismail MY, Connell NT: How to manage bleeding disorders in aging patients needing surgery. Hematology Am Soc Hematol Educ Program 2021; 2021:529–35
2. Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S: STS/SCA/AmSECT/SABM Update to the Clinical Practice
Guidelines on Patient Blood Management. Ann Thorac Surg 2021; 112:981–1004
Erythropoietin
• In their systematic review and meta-analysis of randomized controlled trials, Cho
et al. concluded that:
Preoperative erythropoietin administration is linked to a reduction in allogeneic blood
transfusions during both the intraoperative and postoperative phases of care, and it also
contributes to a shorter overall hospital stay
Preoperative erythropoietin administration does not significantly raise the risk of
thromboembolic complications
Reference:
1. Cho BC, Serini J, Zorrilla-Vaca A, Scott MJ, Gehrie EA, Frank SM, Grant MC: Impact of Preoperative Erythropoietin on Allogeneic Blood Transfusions in Surgical Patients: Results From a Systematic Review and Meta-analysis. Anesth Analg 2019; 128:981–92
Anesthetic plan for blood management
• Type & screen if blood loss anticipated
• Determine blood products required in OR, if any
• Consider delaying elective surgery if there is an opportunity improve anemia
• Provide information to patients regarding likelihood and risk of transfusion, share
possible alternatives to transfusion, and obtain informed consent
1
References:
1. Thakrar SV, Clevenger B, Mallett S: Patient blood management and perioperative anaemia. BJA Educ 2017; 17:28–34
Patients who refuse transfusion
• Patients with certain religious beliefs may wish to abstain from receiving blood products
or may specify when blood components can be used.
• Though studies show that refusing blood when hemoglobin is critically low can
significantly increase morbidity and mortality,
1
specific surgical techniques and
minimally invasive surgery can improve outcomes.
2
• Some patients will accept intraoperative cell salvage if the circuit is continuous
2
• However, each patient should be assessed individually before administration of any
transfusion
References:
1. Guinn NR, Cooter ML, Villalpando C, Weiskopf RB: Severe anemia associated with increased risk of death and myocardial ischemia in patients declining blood transfusion. Transfusion 2018; 58:2290–6
2. Crowe EP, DeSimone RA: Transfusion support and alternatives for Jehovah’s Witness patients. Curr Opin Hematol 2019; 26:473–9
Summary of Preoperative Considerations
• Examine the patient’s preoperative medical record and conduct an interview with the
patient/family interview before the procedure
• Review existing labs including hemoglobin and hematocrit, as well as coagulation profiles
• Order additional labs based on patient’s condition to identify and treat any anemia or identify
any coagulopathies
• Consider postponing elective surgery if there is a chance to improve the patient’s anemic
condition
• Discuss the potential risks and benefits of blood transfusion with the patient and understand
their preferences prior to surgery
• Identify bleeding risks and consider appropriate treatment therapies
• Evaluate whether the patient might benefit from erythropoietin
• Recognize that some patients, due to their religious beliefs, may prefer to avoid blood products
or may ha e specific conditions under which blood components can be used
• Assess each patient individually before administering of any transfusion
Objective #3: Intraoperative considerations
Review preoperative considerations before surgery
Transfuse based upon evidence-based hemoglobin/hematocrit triggers
as well as patient physiologic status
Apply blood conservation techniques such as acute normovolemic
hemodilution, hemostatic agents, and cell salvage if appropriate and
available
Use POC testing to guide interventions
Intraoperative transfusion recommendations
• In this Delphi consensus survey study, a panel of 33 experts, including surgeons,
anesthesiologists, and transfusion medicine specialists, suggested numerous strategies for the
preoperative, intraoperative, and postoperative stages to reduce the variability of
intraoperative RBC transfusions in patients undergoing significant noncardiac surgery
• Summary of intraoperative recommendations for red blood cell transfusions:
Decision to transfuse should be shared between surgeon and anesthesiologist, except in cases of
uncontrolled massive hemorrhage
Point of care devices such as blood gas analyzer, non-invasive pulse oximeters, iSTAT, and HemoCue
should be accurate measures to guide intraoperative transfusion
A hemoglobin threshold or trigger is typically recommended to guide intraoperative transfusion within a
comprehensive transfusion strategy
Hemoglobin of 7 g/dL is an acceptable restrictive threshold for patients without major cardiac
comorbidities
*Administer one unit at a time. Early replacement of blood products is advised
References:
1. Lenet T, McIsaac DI, Hallet JH, Jerath A, Lalu MM, Nicholls SG, Presseau J, Tinmouth A, Verret M, Wherrett CG, Fergusson DA, Martel G, Ottawa Consensus on Intraoperative Patient Blood Management: Intraoperative Blood Management Strategies for
Patients Undergoing Noncardiac Surgery: The Ottawa Intraoperative Transfusion Consensus. JAMA Netw Open 2023; 6:e2349559
AABB International RBC Transfusion
Recommendations
• For hemodynamically stable hospitalized adult patients, consider a restrictive transfusion
strategy
• Cardiac surgery – hemoglobin less than 7.5 g/dL
• Orthopedic surgery - hemoglobin less than 7.0 g/dL, or those with preexisting cardiovascular
disease, a hemoglobin less than 8.0 g/dL
• Patients with hematologic and oncologic disorders – hemoglobin less than 7.0 g/dL
Reference:
1. Carson JL, Stanworth SJ, Guyatt G, Valentine S, Dennis J, Bakhtary S, Cohn CS, Dubon A, Grossman BJ, Gupta GK, Hess AS, Jacobson JL, Kaplan LJ, Lin Y, Metcalf RA, Murphy CH, Pavenski K,
Prochaska MT, Raval JS, Salazar E, Saifee NH, Tobian AAR, So-Osman C, Waters J, Wood EM, Zantek ND, Pagano MB: Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA
2023 doi:10.1001/jama.2023.12914
Image reference: “Home - Association for the Advancement of Blood & Biotherapies.” n.d.
Www.aabb.org. Accessed November 6, 2024. https://www.aabb.org/
• Ten guidelines published between 1992 and 2018 provided indications for intraoperative
transfusions.
• Six guidelines provided criteria for transfusion based on hemoglobin (range 6.0–10.0 g/dL) or
hematocrit (<30%) triggers.
• In the absence of objective transfusion rules, CPGs recommended considering other parameters
such as blood loss (n = 7), signs of end organ ischemia (n = 5), and hemodynamics (n = 4).
• Evidence supporting intraoperative recommendations was extrapolated primarily from the
nonoperative setting. There was wide variability in the quality of included guidelines based on
AGREE II scores.
• Other Recommendations
Frequently repeat measurement of Hgb and Hct levels
Monitor surgical field, drains, sponges, and suction canister to estimate blood loss
Monitoring of hemodynamics (BP and HR).
References:
1. Baker L, Park L, Gilbert R, Ahn H, Martel A, Lenet T, Davis A, McIsaac DI, Tinmouth A, Fergusson DA, Martel G: Intraoperative Red Blood Cell Transfusion Decision-making: A
Systematic Review of Guidelines. Ann Surg 2021; 274:86–96
Systematic Review of Guidelines - 2021
Image reference: MARQI. 2018. “Blood Transfusion Project.” Marcqi.org. July 1, 2018. https://marcqi.org/dev/wp-content/uploads/2016/11/Transfusion_reduction_10282016.pdf
Recommendations from other societies / groups
• Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) is a team of
orthopedic surgeons and healthcare professionals committed to enhancing the quality of
care for patients undergoing hip and knee replacement surgeries in Michigan.
1
Reference:
1. MARCQI. 2015. Michigan Arthroplasty Registry Collaborative Quality Initiative. September 30, 2015. https://marcqi.org/
Transfusion Trigger Summary
• Review procedure, comorbidity, and institution transfusion protocols
• Restrictive transfusion protocols should be considered for asymptomatic patients.
• There is rarely an indication to transfuse any patient with a hemoglobin >10g/dL.
• Decision to transfuse should be based on objective assessment of the patient,
including hemoglobin or hematocrit.
• In the absence of acute hemorrhage, transfuse one unit at a time.
• Reassess post-transfusion to objectively determine patient status
MPOG QI Measure TRAN-01 Measure
• TRAN-01: Transfusion management vigilance
Description: Percentage of adult patients receiving a blood transfusion with documented
hemoglobin or hematocrit value prior to administration
Inclusion criteria: adult patients requiring anesthesia who receive transfusion
Exclusion criteria:
Age 18 years
ASA 5 & 6 including Organ Procurement
Cesarean delivery cases with EBL > 1500cc, or HR > 110, SBP <85, DBP <45, or SAT <95%
Massive transfusion of 4 or more units of blood from 4 hours before Anesthesia start to end
Postpartum hemorrhage cases
Burn cases
Labor epidurals including obstetric non-operative procedures
Success criteria: Documentation of a hemoglobin and/or hematocrit within 90 minutes
prior to blood transfusion
*Review your dashboard for TRAN-01 performance
MPOG TRAN-02 Measure
• TRAN-02: assessment of possible unnecessary transfusion
Description: Percentage of adult patients with a post transfusion hemoglobin or hematocrit value
greater than or equal to 10 g/dL or 30%
Inclusion criteria: adult patients requiring anesthesia who receive transfusion
Exclusion criteria:
Age 18 years
ASA 5 & 6 including Organ Procurement
Cesarean delivery cases with EBL > 1500cc, or HR > 110, SBP <85, DBP <45, or SAT <95%
Massive blood loss with EBL > 2000mL
Massive transfusion of 4 or more units of blood from 4 hours before Anesthesia start to end
No intraoperative transfusion cases
Postpartum hemorrhage cases
Burn cases
Labor epidurals including obstetric non-operative procedures
Success criteria:
Hematocrit value documented as less than or equal to 30% and/or hemoglobin value documented as less than or equal to 10
g/dL OR
No hematocrit or hemoglobin checked within 18 hours of Anesthesia End.
*Review your dashboard for TRAN-02 performance
Blood Conservation Strategies
• Intraoperative and postoperative autologous blood recovery, including cell salvage
• Fluid management strategies, such as Acute Normovolemic Hemodilution
• Pharmacological measures to reduce blood loss
• Intraoperative temperature management (prevention of hypothermia)
Autologous Blood Transfusion
• Autologous red cells can either be obtained preoperatively or intraoperatively,
however, preoperative collection of autologous blood does not guarantee
protection from contamination, nor does it protect the patient from receiving
the wrong blood
1
• Preoperative autologous donation is when patient donates one or more units of
their blood preoperatively and the blood is held in the blood bank and
available for intraoperative or postoperative transfusion
2
• Preoperative blood donation was promoted in the 1980s as a mechanism to
decrease exposure to allogeneic transfusion and its associated risks,
particularly viral transmission
3
References:
1. Lakha AS, Chadha R, Von-Kier S, Barbosa A, Maher K, Pirkl M, Stoneham M, Silva MA, Soonawalla Z, Udupa V, Reddy S, Gordon-Weeks A: Autologous blood transfusion reduces the requirement for perioperative allogenic blood transfusion in
patients undergoing major hepatopancreatobiliary surgery: a retrospective cohort study. Int J Surg 2023; 109:3078–86
2. Henry DA, Carless PA, Moxey AJ, O’Connell D, Forgie MA, Wells PS, Fergusson D: Pre-operative autologous donation for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2002; 2010:CD003602
3. NAC Statement on Perioperative Autologous and Matched Donations at https://nacblood.ca/en/resource/nac-statement-perioperative-autologous-and-matched-donations
Cell Salvage (cell saver)
• Cell salvage is a blood conservation technique
that reduces the requirement for allogeneic
transfusion and maintains postoperative
hemoglobin concentration
1
• Collection of blood for potential cell salvage is
typically considered for surgical procedures with
moderate to heavy blood loss (EBL > 500mL)
1
• Potential risks and benefits discussed with the
patient preoperatively when cell salvage is
used
1
• Most commonly use in cardiac, trauma, and
orthopedic cases
References:
1. Klein AA, Bailey CR, Charlton AJ, Evans E, Guckian-Fisher M, McCrossan R, Nimmo AF, Payne S, Shreeve K, Smith J, Torella F: Association of Anaesthetists guidelines: cell salvage for peri-operative
blood conservation 2018. Anaesthesia 2018; 73:1141–50
Acute Normovolemic Hemodilution (ANH)
• In the 1970s, ANH was initially employed in cardiac
surgery as a blood conservation method to reduce the
risk of hepatitis transmission from donor blood
products
1
• ANH acts as reservoir of whole blood, preserves blood,
maintains platelet function and thrombin generation,
and increases perfusion due to decreased viscosity
1
• ANH is a method where, under careful monitoring,
blood is drawn from the patient in the operating room
right after anesthesia is induced, and then crystalloids
and/or colloids are used to ensure normovolemia is
maintained
2
• Normovolemic hemodilution and cell salvage can be
used for surgeries with high likelihood of substantial
blood loss
2
References:
1. Henderson RA, Choi S: History and practice of acute normovolemic hemodilution. Curr Anesthesiol Rep 2020; 10:282–8
2. Perini FV, Montano-Pedroso JC, Oliveira LC, Donizetti E, Rodrigues RDR, Rizzo SRCP, Rabello G, Junior DML: Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Acute
normovolemic hemodilution and intraoperative autotransfusion. Hematol Transfus Cell Ther 2024; 46 Suppl 1:S48–52
image credit: https://m.blog.naver.com/nopain365/221163864987?view=img_2
Medications used in of management of patients with
risk of blood loss, undergoing transfusions, or with
coagulopathy
• Tranexamic Acid
• Calcium Chloride
• Prothrombin Complex Concentrate
• Fibrinogen Concentrate
Tranexamic Acid (TXA)
• TXA is a synthetic analogue of lysine and an
antifibrinolytic agent that reduces bleeding
by preventing the breakdown of fibrin clots
1-3
• High doses of TXA can cause seizures
1
• Risk of thrombosis is not increased with
use of TXA
1
• Indications may include trauma, cardiac,
liver, orthopedic, spine, gynecologic surgery,
and postpartum hemorrhage
1-3
• Typical dosing is 1 gram over 10 minutes,
1
but can vary by indication and organization
References:
1. Roberts I, Murphy MF, Moonesinghe R, Grocott MPW, Kalumbi C, Sayers R, Toh C-H, UK Royal Colleges Tranexamic Acid in Surgery Implementation Group: Wider use of tranexamic acid to reduce surgical bleeding could benefit patients and
health systems. BMJ 2024; 385:e079444
2. Haider MA, Ward SA, Rajahraman V, Rozell JC, Macaulay W, Schwarzkopf R, Hepinstall M: Blood transfusion in the age of tranexamic acid: Who needs a type and screen before total hip arthroplasty? J Arthroplasty 2025; 40:119–26
3. Meza Monge K, Domene SS, Diaz Mendoza DL, Vidal-Gallardo A, Alfaro Llique AM, Rodriguez M, Premchandra P, Anwar Pandya S, Arruarana VS, Aleman Paredes K, Calderon Martinez E: Effectiveness of tranexamic acid in trauma patients: A
systematic review. Cureus 2024; 16:e52111
Image source: Relke, Nicole, Nicholas L. J. Chornenki, and Michelle Sholzberg. 2021. “Tranexamic Acid Evidence
and Controversies: An Illustrated Review.” Research and Practice in Thrombosis and Haemostasis 5 (5): e12546
Fibrinogen Concentrate
• Fibrinogen Concentrate (FC) is used to manage perioperative
bleeding due to low levels of fibrinogen (hypofibrinogenemia)
1
• Fibrinogen replacement therapy can be administered
intravenously using FFP, Cryo, fibrinogen concentrate, or
topically using liquid adhesives
1
• The effectiveness of FCs in controlling bleeding is still not
substantiated. Small, uncontrolled studies examining the use
of FCs have produced inconsistent results
1
• Positive studies generally focus on an initial dose of 25-50 mg
kg
-1
, typically tailored using viscoelastic testing
1-2
• Fibrinogen administration alone may not result in significant
reduction of intraoperative blood loss and typically should
be part of a multimodal plan
1
References:
1. Fibrinogen Concentrate – Godier A, Greinacher A, Faraoni D, Levy JH, Samana CM. 2018. “Use of factor concentrates for the management of perioperative bleeding: guidance from the SSC of the ISTH”. Journal of thrombosis and hemostasis. 170-
1704.
2. Samama CM, Ickx B, Ozier Y, Steib A, Susen S, Godier A: The place of fibrinogen concentrates in the management of perioperative bleeding: A position paper from the Francophone Working Group on Perioperative Haemostasis (GIHP). Anaesth Crit
Care Pain Med 2018; 37:355–65
Image source: https://www.riastap.com/professional/about-riastap/default.aspx
Prothrombin Complex Concentrate
• Prothrombin Complex Concentrate (PCC) is derived from the
cryoprecipitate of large plasma pools using ion exchange
chromatography
1
• Administered intravenously
1
• Typical indications include
1
:
Urgent reversal of acquired coagulation factor deficiency
Urgent warfarin reversal
Reversal of direct oral anticoagulants
Reduction of perioperative bleeding
• In a systematic review and metanalysis of 17 included studies, it
was found that PCC alone did not lead to a reduction in mortality,
but when PCC was combined with FFP, it was associated with
reduced mortality in trauma patients
2
References:
1. Castillo B, Dasgupta A, Klein K, Tint H, Wahed A: Blood components: Transfusion practices, Transfusion Medicine for Pathologists. Elsevier, 2018, pp 125–42
2. Brink DP van den, Wirtz MR, Neto AS, Schöchl H, Viersen V, Binnekade J, Juffermans NP: Effectiveness of prothrombin complex concentrate for the treatment of bleeding: A systematic review and meta-analysis. J Thromb Haemost 2020; 18:2457–67
Calcium Chloride or Calcium Gluconate
• Calcium is administered during blood transfusions to treat
hypocalcemia may resulting from the citrate preservatives in
blood
2
• Massive blood transfusion, defined as >10 units of PRBCs in 24
hours or >4 units of RBCs in one hour, can result in
hypocalcemia due to citrate preservatives added to RBCs, FFP,
and platelets to maintain stability of blood during storage
3
• Liver may not be able to clear citrate quickly enough to prevent
hypocalcemia
• Hypocalcemia can result in cardiac arrythmias and neurologic
complications such as seizures
• Typical doses are 1-2 grams IV, given slowly, with frequent POC
testing
References:
1. DiFrancesco NR, Gaffney TP, Lashley JL, Hickerson KA: Hypocalcemia and massive blood transfusions: A pilot study in a level I trauma center. J Trauma Nurs 2019; 26:186–92
2. Dorantes RP, Boettcher BT, Woehlck HJ: Calcium chloride requirement and postreperfusion rebound during massive transfusion in liver transplantation. J Cardiothorac Vasc Anesth 2022; 36:2400–5
3. Robinson A, Rech MA, DeChristopher PJ, Vaughn A, Rubino J, Bannister E, Moore ME, Chang K: Defining the optimal calcium repletion dosing in patients requiring activation of massive transfusion protocol. Am J Emerg Med 2023; 70:96–100
Viscoelastometric Testing
• Rotational Thromboelastometry (ROTEM)
• Point of care testing device
• Assesses hemostasis by using a whole blood sample to
demonstrate how platelets, coagulation factors, RBCs,
and other elements work together to:
• initiate a clot
• determine clot strength; and
• investigate if there is any fibrinolysis
1
.
• Can quickly assess the state of hemostasis to help
direct care
• Specific ROTEM tests include INTEM (intrinsic
pathway), EXTEM (extrinsic pathway), and FIBTEM
(fibrinogen contribution to clot firmness)
• MPOG TEG & ROTEM Concepts
References:
1. Drotarova M, Zolkova J, Belakova KM, Brunclikova M, Skornova I, Stasko J, Simurda T: Basic principles of rotational thromboelastometry (ROTEM®) and the role of ROTEM-guided fibrinogen replacement therapy in the management of coagulopathies.
Diagnostics (Basel) 2023; 13
2. Gonzalez E, Moore EE, Moore HB. Management of Trauma-Induced Coagulopathy with Thrombelastography. Crit Care Clin. 2017 Jan;33(1):119-134. doi: 10.1016/j.ccc.2016.09.002. PMID: 27894492; PMCID: PMC5142763 Department of Anesthesiology
Image reference: Görlinger, Klaus & Dirkmann, Daniel & Albrecht, Alexander. (2016).
Rotational thromboelastometry (ROTEM®). 10.1007/978-3-319-28308-1_18.
Summary of Coagulation Support
Reference:
1. Kleinveld DJB, Curry N, Levy JH: Coagulation support during perioperative bleeding management. Intensive Care Med 2023; 49:1110–3
• Several therapies
available support is to
promote clot formation
• Components of primary
clot formation can be
supplemented by platelet,
FFP, and cryoprecipitate
transfusion
Temperature management and transfusion
• While hypothermia is commonly linked to surgical site infections, it can also result in
cardiac abnormalities and coagulopathies
1
• Pre-warming, active intraoperative warming, increasing OR temperature, and core
temperature monitoring can be important components of preventing hypothermia
• MPOG has developed several measures to help sites track temperature management
performance
TEMP-01: Thermoregulation Vigilance – Active Warming
TEMP-02: Thermoregulation Monitoring – Core Temperature
TEMP-03: Perioperative Hypothermia
Reference:
1. Zhu AC-C, Agarwala A, Bao X: Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clin Colon Rectal Surg 2019; 32:114–20
Summary
• Administer transfusions on evidence-based hemoglobin and hematocrit thresholds, considering
the patient’s physiologic status
• Intraoperative transfusion triggers can include low hemoglobin and hematocrit levels and
hemodynamic instability
• Blood conservation techniques include acute normovolemic hemodilution, hemostatic agents, and
cell salvage
• Frequent POC testing can guide interventions
• Guidelines recommend administering one unit at a time whenever possible
• Medications such as tranexamic acid (TXA), calcium chloride, prothrombin complex concentrate,
or fibrinogen concentrate may be administered intraoperatively
• TXA, when administered for the patient, can reduce intraoperative bleeding and need for
transfusion
• Viscoeslastometric testing is valuable in assessing coagulopathic bleeding
Objective #4: Postoperative Considerations
Review monitoring for postoperative bleeding
Review when to administer autologous blood
Review provider handoff post-intraoperative transfusion
Review resuming anticoagulants postop
Monitoring of postoperative bleeding
• Warning signs of hemorrhage include
1
Tachycardia
Frank bleeding or bruising
Swelling and discoloration of extremities
Reduction in urine output
Restlessness and anxiety
Hemodynamic parameter changes such as diminished cardiac output or
reduction in CVP
• Check hemoglobin and hematocrit levels if blood administered or
concerned for post-operative bleeding
Reference:
1. Johnson AB, Burns B: Hemorrhage. StatPearls Publishing, 2023
2. American Red Cross: Compendium of Transfusion Practices 2021 at https://www.redcross.org/content/dam/redcrossblood/hospital-page-documents/334401_compendium_v04jan2021_bookmarkedworking_rwv01.pdf
Elements of handoff to postoperative team
• Estimated blood loss
• Reason for transfusion, amount and type of blood products received
• Assessment of transfusion reaction
• Most recent lab results, including hemoglobin, hematocrit, platelets,
coagulation studies, and calcium level
• Specific recommendations for postoperative assessments, monitoring
requirements, and any communication follow-ups
Reference:
1. Segall N, Bonifacio AS, Schroeder RA, Barbeito A, Rogers D, Thornlow DK, Emery J, Kellum S, Wright MC, Mark JB, Durham VA Patient Safety Center of Inquiry: Can we make postoperative patient handovers safer? A systematic
review of the literature. Anesth Analg 2012; 115:102–15
Anticoagulants resumption considerations
• Hemostasis and risk of further surgical bleeding
• Characteristics of anticoagulant including duration of action and reversabilty
1
• Most anticoagulants can be restarted within 24-48 hours, including
Unfractionated heparin or low molecular weight heparins (within 24 hours)
2
Vitamin K antagonists
Direct-acting oral anticoagulants with low bleed risks 24 hours postop
2
P2Y12 inhibitors, such as clopidogrel and ticagrelor, 24-48 hours postop
2
• Surgical and medical teams typically manage the resumption of anticoagulants based on
each patient's status
3
Reference:
1. Briete LD, Towers WF, Bone R, Nair R, Steck M, Cutshall BT, Shah SP: Perioperative Anticoagulation Management. Crit Care Nurs Q 2022; 45:119–31
2. Moster M, Bolliger D: Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update. Curr Anesthesiol Rep 2022; 12:286–96
3. Jethwa AR, Khariwala SS: When should therapeutic anticoagulation be restarted following major head and neck surgery? Laryngoscope 2018; 128:1025–6
Additional Patient Blood
Management Resources
Total Cases with Massive Transfusion: 4,917*
*Excludes autologous units.
Thank you
