FRCA Notes

Blood Conservation Strategies

The most relevant curriculum items are probably 'appropriate preoperative strategies for minimising the use of blood products' and 'transfusion reactions'.

Resources

  • Perioperative red cell transfusion is a common occurrence, although the incidence depends somewhat on the surgery performed:
Surgery Incidence of red cell transfusion
Gynaecology 7.5 – 77%
Pancreatic 16 – 67%
Upper GI 15.6 – 45%
Colorectal 13.9 – 40%
Hepatobiliary 9.2 – 36%
Mixed major abdominal 3.8 – 30%
Renal 10%
Cardiac 39.3 - 72%
Neck of femur fracture 23 - 75%
Major head and neck 12 - 84%

Risks of blood product transfusion

  • Allogeneic blood transfusion, however, carries a number of risks
Risks of allogeneic red cell transfusion
Acute haemolytic ABO incompatibility reactions
Non-haemolytic febrile reactions
Allergy or anaphylaxis
Transfusion-associated acute lung injury (TRALI)
Transfusion-associated circulatory overload (TACO)
Bacterial contamination
Delayed transfusion reactions
Immune sensitisation
Iron overload
Blood-borne viral infection
Coagulopathy
Hyperkalaemia
Hypocalcaemia ± citrate toxicity
Hypothermia
↑ risk cancer recurrence
Poor wound healing ± surgical site infection

Blood conservation strategies

  • Use of blood conservation strategies is therefore beneficial as they:
    • Reduce risk of transfusion-associated adverse events
    • Reduce financial costs of the blood product apparatus
    • Preserve a limited resource
    • Improve outcomes in patients where there is a morbidity associated with having had a transfusion
    • Help navigate issues such as beliefs surrounding transfusion in Jehovah's Witnesses

Perioperative blood conservation strategies


  • Identify and stratify patients at higher risk of requiring transfusion
    • Patient bleeding history including menorrhagia, previous episodes of significant bleeding
    • Patient factors such as advanced age, existing anaemia, use of anti-platelet/-coagulants
    • Surgical factors including complex or revision surgery

  • Identification and optimisation of those with clotting dyscrasia
  • Treating pre-operative anaemia
  • Management of antiplatelet and anticoagulant medications
  • Pre-donation and autologous blood donation, although this is expensive and still carries risks associated with transfusing stored blood
  • Patient education and consent, particularly with reference to Jehovah's witnesses


Anaesthetic techniques Surgical techniques
Central neuraxial blockade Meticulous haemostasis (consultant surgeon)
Hypotensive anaesthesia Use of cell salvage where EBL >1,000ml
Antifibrinolytics e.g. TXA Use of arterial tourniquet
Careful positioning to avoid venous congestion Minimally-invasive techniques e.g. laparoscopy, robotic, endovascular
Normothermia; temp. >35°C Use of intra-operative topical haemostatic agents e.g. microfibrillar collagen
Normal acid-base status; pH >7.2 Staggered operations to allow haematological recovery
Avoid hypocalcaemia; Ca2+ >1mmol/L
Use point-of-care testing


  • Optimise nutritional status, including supplementing iron and folate where appropriate
  • Use of viscoelastic haemostatic assay to establish need for blood products
  • Use restrictive transfusion thresholds; 70g/L (or 80g/L if ischaemic cardiac disease)
  • If necessary, use a single-unit RBC transfusion and review
  • Maintain normothermia
  • Minimise iatrogenic sampling, particularly in a critical care setting