BLOOD MANAGEMENT STRATEGIES
Optimize Preop | Minimize Blood Loss | Transfuse Appropriately
PATIENT BLOOD MANAGEMENT PILLARS
Critical Must-Knows
- Preoperative anemia (Hb less than 130 g/L men, less than 120 g/L women) increases transfusion risk 3-4 fold
- Tranexamic acid (TXA) 15-20 mg/kg IV reduces transfusion by 30-50% without increasing VTE
- Restrictive transfusion threshold (Hb less than 70 g/L) is safe and reduces complications vs liberal (less than 100 g/L)
- Cell salvage contraindicated in malignancy, infection, bowel contamination
- Massive transfusion protocol: 1:1:1 ratio RBC:FFP:Platelets to prevent dilutional coagulopathy
Examiner's Pearls
- "CRASH-2 trial: TXA within 3h of trauma reduces mortality (not just blood loss)
- "Iron therapy takes 4-6 weeks - plan elective surgery timing accordingly
- "Jehovah's Witness patients: multi-modal approach (EPO, TXA, cell salvage, accept lower Hb)
- "Hypotensive anesthesia (MAP 50-60 mmHg) reduces blood loss but requires experienced anesthetist
Clinical Imaging
Perioperative Blood Management
Critical Exam Concepts
Preoperative Anemia is Modifiable
Screen ALL elective patients. Hb less than 130 g/L (men) or less than 120 g/L (women) = anemia. Treat with oral iron 4-6 weeks preop or IV iron if time limited. EPO if renal failure or severe anemia.
TXA is Evidence-Based Standard
Give TXA to ALL major ortho cases unless contraindicated. Loading dose 15-20 mg/kg IV at induction, maintenance 1-2 mg/kg/h. CRASH-2 showed mortality benefit in trauma.
Restrictive Threshold is Safe
Transfuse at Hb less than 70 g/L (asymptomatic stable patients). Higher threshold (less than 80 g/L) if cardiovascular disease or symptomatic. Liberal transfusion increases complications.
Jehovah's Witness Management
Multi-modal approach: EPO preop, TXA, cell salvage (if acceptable), meticulous hemostasis, hypotensive anesthesia, accept Hb 60-70 g/L. Document consent clearly.
Blood Management Strategy Quick Reference
| Strategy | Timing | Evidence/Effect | Key Considerations |
|---|---|---|---|
| Oral iron therapy | 4-6 weeks preop | Increases Hb by 10-20 g/L | Need time - not effective if less than 2 weeks |
| IV iron (ferric carboxymaltose) | 1-2 weeks preop | Rapid Hb increase 10-30 g/L | More expensive, use if time limited |
| Erythropoietin (EPO) | 3-4 weeks preop | Increases Hb 20-40 g/L with iron | Expensive, renal failure or severe anemia |
| Tranexamic acid (TXA) | At induction and intraop | 30-50% reduction in transfusion | Safe, no VTE increase, give to all major cases |
| Cell salvage | Intraoperative | Reduces allogeneic transfusion 30-40% | Contraindicated: malignancy, infection, bowel |
| Hypotensive anesthesia | Intraoperative | Reduces blood loss 20-30% | MAP 50-60 mmHg, requires experienced anesthetist |
OPTPatient Blood Management Pillars
Memory Hook:OPT for optimal blood management - optimize preop, protect intraop, transfuse appropriately!
CRASHTranexamic Acid Indications
Memory Hook:Think of CRASH-2 trial - TXA saves lives in trauma and reduces transfusion in elective ortho!
MIBCell Salvage Contraindications
Memory Hook:MIB are absolute contraindications - Malignancy, Infection, Bowel contamination - do NOT salvage!
RATIOMassive Transfusion Protocol Components
Memory Hook:Remember RATIO 1:1:1 for massive transfusion - RBC:FFP:Platelets in equal amounts!
Overview and Clinical Significance
Patient Blood Management Paradigm Shift
The Patient Blood Management (PBM) approach has replaced the old "type and cross" reactive model. PBM is proactive: detect and treat anemia BEFORE surgery, minimize blood loss DURING surgery, and transfuse appropriately AFTER surgery. This reduces transfusion rates by 30-50% and improves outcomes.
Why Blood Management Matters
- Preoperative anemia present in 30-40% elective ortho patients
- Anemia increases transfusion risk 3-4 fold
- Allogeneic transfusion increases infection, LOS, mortality
- Blood is scarce resource - donor shortages worldwide
- Cost - 1 unit RBC costs $500-1000 AUD including administration
Three Pillars of Patient Blood Management
- Optimize hematopoiesis - detect and treat preop anemia
- Minimize blood loss - surgical technique, TXA, cell salvage
- Harness physiologic reserve - restrictive transfusion thresholds
WHO and NHMRC endorsed approach
Transfusion Risks
Allogeneic blood transfusion is NOT benign. Risks include acute hemolytic reaction (1:40,000), transfusion-related acute lung injury (TRALI 1:10,000), infection transmission (very low with modern screening), immunosuppression, and increased surgical site infection.
Pathophysiology
Physiology of Hemostasis
Coagulation Cascade:
- Intrinsic pathway: Contact activation (XII → XI → IX → VIII → X)
- Extrinsic pathway: Tissue factor exposure (VII → X) - primary initiator in surgical bleeding
- Common pathway: X → V → thrombin → fibrinogen → fibrin clot
- Fibrinolysis: Plasminogen → plasmin → fibrin degradation (target of TXA)
Physiological Response to Blood Loss:
| Blood Loss | Hemodynamic Changes | Symptoms |
|---|---|---|
| Class I (up to 15%) | Minimal | None - compensated |
| Class II (15-30%) | Tachycardia, narrow pulse pressure | Anxiety, delayed capillary refill |
| Class III (30-40%) | Tachycardia, hypotension, tachypnea | Confusion, decreased urine output |
| Class IV (greater than 40%) | Severe hypotension, absent pulses | Lethargy, anuria, impending death |
Oxygen Delivery Physiology
Oxygen Delivery Equation: DO₂ = CO × CaO₂ = CO × (1.34 × Hb × SaO₂ + 0.003 × PaO₂)
Key Concepts:
- Hemoglobin is the primary oxygen carrier (1.34 mL Oâ‚‚/g Hb)
- Normal DOâ‚‚: 900-1100 mL/min; VOâ‚‚: 200-250 mL/min
- Critical DOâ‚‚: ~300 mL/min - below this, anaerobic metabolism ensues
- Compensatory mechanisms: increased cardiac output, oxygen extraction ratio
- Young healthy patients tolerate Hb 70 g/L due to compensation; elderly/cardiac patients less so
Impact of Anemia on Surgical Outcomes
Preoperative Anemia Effects:
- Increased 30-day mortality (OR 1.4-2.9 depending on severity)
- Increased postoperative complications (infections, AKI, cardiac events)
- Increased length of stay and readmission rates
- Often triggers transfusion, which compounds risks
Perioperative Coagulopathy:
- Hypothermia impairs enzyme function in coagulation cascade
- Acidosis reduces clotting factor activity (pH 7.2 = 50% activity)
- Hemodilution from crystalloid/colloid resuscitation
- Consumption coagulopathy in massive hemorrhage
- Lethal triad: Hypothermia + acidosis + coagulopathy
Pillar 1: Preoperative Optimization
Preoperative Anemia Screening
WHO Definition of Anemia:
- Men: Hb less than 130 g/L
- Women: Hb less than 120 g/L
- Pregnancy: Hb less than 110 g/L
Screen ALL Elective Patients
Australian NHMRC guidelines recommend screening hemoglobin and ferritin for ALL patients undergoing elective surgery with expected moderate-high blood loss (greater than 500 mL). This includes most major orthopaedic procedures.
| Test | Interpretation | Action |
|---|---|---|
| Hb less than 130/120 g/L | Anemia present | Investigate cause, treat 4-6 weeks preop |
| Ferritin less than 30 mcg/L | Iron deficiency anemia | Oral iron 200 mg elemental iron daily |
| Ferritin 30-100 mcg/L | Functional iron deficiency | Consider IV iron if time limited |
| MCV less than 80 fL | Microcytic anemia | Iron deficiency vs thalassemia - check ferritin |
| MCV greater than 100 fL | Macrocytic anemia | B12/folate deficiency - supplement |
Anemia Workup in Orthopaedics
Most common causes in elective ortho patients: (1) iron deficiency (chronic blood loss, poor intake), (2) anemia of chronic disease (inflammatory arthritis), (3) renal impairment (hip OA patients often elderly with CKD). Check FBC, ferritin, CRP, creatinine as minimum.
This completes the screening protocol overview.
Pillar 2: Minimize Intraoperative Blood Loss
Tranexamic Acid (TXA) - Evidence and Protocols
TXA Mechanism of Action
TXA is a lysine analogue that competitively inhibits plasminogen activation, preventing fibrinolysis. It stabilizes formed clot by blocking plasmin from degrading fibrin. Effect lasts 3-4 hours. Does NOT increase clot formation (not pro-thrombotic), just prevents clot breakdown.
TXA Dosing Regimens:
| Procedure | Loading Dose | Maintenance | Timing |
|---|---|---|---|
| Primary THA/TKA | 15-20 mg/kg IV | Optional 1-2 mg/kg/h infusion | At induction before tourniquet |
| Revision THA/TKA | 20 mg/kg IV | 2 mg/kg/h for 3-6 hours | At induction, continue postop |
| Spine surgery | 10-15 mg/kg IV | 1 mg/kg/h for duration | At incision, throughout case |
| Trauma (CRASH-2) | 1 g IV bolus | 1 g IV over 8 hours | Within 3 hours of injury (critical) |
| Topical (intra-articular) | 1-3 g in 50-100 mL saline | Leave in joint 5 min before closure | At closure before drain placement |
CRASH-2 Trial Changed Practice
The CRASH-2 trial (20,211 trauma patients) showed TXA within 3 hours of injury reduced all-cause mortality from 16% to 14.5% (NNT=67). Given between 3-8 hours, NO benefit. After 8 hours, HARM (increased mortality). Time is critical in trauma.
TXA Contraindications:
- Active thromboembolic disease (DVT, PE, MI, stroke less than 3 months)
- History of seizures (TXA crosses BBB, rare seizure risk at high doses)
- Known allergy to TXA
- Renal impairment (reduce dose if CrCl less than 30 - risk of accumulation)
TXA Safety Profile
Multiple meta-analyses (over 100 RCTs) show TXA does NOT increase VTE, MI, or stroke rates in orthopaedic surgery. It is safe and effective. The theoretical thrombosis risk is not seen in practice. Give TXA to ALL major ortho cases unless contraindicated.
This completes the tranexamic acid section.
Pillar 3: Appropriate Transfusion Management
Restrictive vs Liberal Transfusion Thresholds
Paradigm Shift to Restrictive Strategy
The TRICC trial (1999) and multiple subsequent trials showed restrictive transfusion (Hb less than 70 g/L) is as safe as liberal (Hb less than 100 g/L) and reduces transfusion-related complications. This changed practice worldwide. Liberal transfusion does NOT improve outcomes and increases infection and mortality.
Transfusion Thresholds by Patient Population
| Patient Type | Transfusion Threshold | Evidence |
|---|---|---|
| Healthy, asymptomatic | Hb less than 70 g/L | TRICC, FOCUS trials - safe, reduces transfusion |
| Cardiovascular disease | Hb less than 80 g/L | Subset analysis suggests higher threshold safer |
| Acute coronary syndrome | Hb less than 80 g/L or symptoms | MINT trial - restrictive non-inferior |
| Symptomatic anemia | Symptoms (dyspnea, tachycardia, angina) | Transfuse for symptoms regardless of Hb |
| Active bleeding | Transfuse to maintain Hb greater than 70-80 g/L | Replace ongoing losses |
Symptoms Trump Numbers
Transfusion triggers are GUIDELINES, not absolutes. Symptoms of anemia (dyspnea, tachycardia, chest pain, confusion) are indication for transfusion regardless of Hb. Patient with Hb 75 g/L who is asymptomatic does NOT need transfusion. Patient with Hb 85 g/L with angina DOES need transfusion.
Signs/Symptoms Suggesting Need for Transfusion:
- Tachycardia (HR greater than 100 at rest) not explained by pain/anxiety
- Dyspnea or increased work of breathing
- Chest pain or ECG changes (ischemia)
- Postural hypotension or dizziness
- Confusion or altered mental state
- Oliguria (less than 0.5 mL/kg/h)
This completes the transfusion threshold section.
Jehovah's Witness Patient Management
Jehovah's Witness Beliefs
Jehovah's Witness patients refuse allogeneic blood transfusion (RBC, FFP, platelets) based on religious beliefs. However, acceptance of other strategies varies individually: many accept cell salvage (if continuous circuit), EPO, TXA, albumin. Must discuss and document individual preferences preoperatively. Do NOT assume all refuse all products.
Usually Acceptable
- Erythropoietin (EPO) preoperatively
- Tranexamic acid (TXA)
- Cell salvage (if continuous circuit)
- Crystalloid and colloid (albumin often accepted)
- Hypotensive anesthesia
- Iron supplementation (oral or IV)
- Accepting lower Hb (60-70 g/L) postoperatively
Usually Refused
- Allogeneic RBC transfusion
- Fresh frozen plasma (FFP)
- Platelet transfusion
- Cryoprecipitate
- Whole blood
- Some refuse cell salvage if circuit is not continuous
- Some refuse albumin or factor concentrates
Multi-Modal Blood Management Strategy:
Preoperative optimization - screen Hb, start EPO 40,000 units weekly x 4 + IV iron 1000 mg. Goal: Hb greater than 140 g/L preop.
Document preferences - which products acceptable (cell salvage, EPO, TXA, albumin?). Document in chart and consent. Discuss acceptable minimum Hb (usually 60-70 g/L).
Minimize blood loss - meticulous hemostasis, TXA (20 mg/kg load + infusion), cell salvage, hypotensive anesthesia, consider staged procedures if bilateral.
Accept lower Hb - most Jehovah's Witness patients tolerate Hb 60-70 g/L. Continue EPO postop if needed, supplemental oxygen, mobilize early, recheck Hb daily.
Informed Consent and Documentation
Obtain informed consent documenting patient refuses transfusion even if life-threatening. Have patient sign specific Jehovah's Witness refusal form. Document discussion of risks (including death) if severe blood loss occurs. Consider having witness to consent. Respect patient autonomy.
When to Refuse Surgery
If Jehovah's Witness patient presents for high blood loss procedure (revision THA, spine tumor resection) with preop Hb less than 100 g/L and refuses transfusion, consider: (1) delay surgery to optimize with EPO + iron (if elective), (2) frank discussion of mortality risk, (3) may need to refuse surgery if risk unacceptable. Document decision-making thoroughly.
Australian Guidelines and Context
NHMRC Patient Blood Management Guidelines
The National Blood Authority (NBA) Patient Blood Management Guidelines (2012) are Australian standard. They recommend: (1) preoperative anemia screening and treatment for all elective surgery, (2) use of TXA and cell salvage, (3) restrictive transfusion thresholds (Hb less than 70 g/L). These are exam-relevant and frequently cited.
Australian Guidelines and Resources:
- NBA PBM Guidelines (Module 2: Perioperative) - comprehensive evidence-based recommendations
- eTG (Therapeutic Guidelines: Antibiotic) - includes perioperative bleeding management
- ANZCA (Australian and New Zealand College of Anaesthetists) - transfusion and blood management position statements
- ANZSBT (Aust NZ Society Blood Transfusion) - transfusion practice guidelines
PBS (Pharmaceutical Benefits Scheme) Coverage:
- IV iron (ferric carboxymaltose) - PBS listed for iron deficiency anemia (authority required for elective surgery indication)
- EPO (erythropoietin) - PBS listed for CKD, chemotherapy-induced anemia (NOT for elective surgery - hospital or patient funded)
- Tranexamic acid - PBS listed, inexpensive (less than $10 per dose)
Australian Blood Product Costs (Approximate)
| Product | Cost per Unit (AUD) | Total Cost Including Administration |
|---|---|---|
| 1 unit RBC | $300-400 | $500-800 (with testing, administration, monitoring) |
| 1 unit FFP | $150-200 | $300-400 |
| 1 unit platelets | $400-600 | $600-900 |
| Cell salvage setup | $500-1000 | $500-1000 per case (equipment + technician) |
| IV iron 1000 mg | $300-400 | $400-500 (hospital outpatient) |
| EPO 40,000 units | $300-500 | $1200-2000 for 4 doses (not PBS for elective ortho) |
Australian Blood Supply
Australia has excellent blood safety but relies on voluntary donors. Red Cell shortage alerts occur periodically. This drives Patient Blood Management approach - conserve blood, transfuse appropriately, minimize waste. O negative is always in short supply (universal donor, only 9% of population).
Key Evidence and Trials
CRASH-2 Trial (2010)
- TXA reduced mortality from 16% to 14.5% (RR 0.91)
- Must be given within 3 hours of injury
- No increase in vascular occlusive events
- Dosing: 1g bolus then 1g over 8 hours
TRICC Trial (1999)
- Restrictive threshold 70 g/L vs liberal 100 g/L
- 30-day mortality similar (18.7% vs 23.3%)
- Restrictive strategy reduces transfusion requirements
- Liberal transfusion may cause harm (TACO, infection)
FOCUS Trial (2011)
- Hip fracture patients: restrictive 80 g/L vs liberal 100 g/L
- No difference in mortality or walking ability at 60 days
- Restrictive strategy safe even in elderly with comorbidities
- Orthopaedic-specific evidence for restrictive transfusion
TXA Meta-Analysis in Orthopaedic Surgery
- 60 RCTs, 5000+ patients in THA/TKA
- TXA reduced transfusion by 30-50% (RR 0.62)
- Blood loss reduced by 300-500 mL
- No increase in DVT, PE, MI, or stroke
NHMRC Patient Blood Management Guidelines (2012)
- 3 pillars: optimize, minimize blood loss, manage anemia
- Preoperative anemia screening and treatment essential
- TXA and cell salvage recommended
- PBM programs reduce transfusion by 30-50%
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Preoperative Anemia in Elective TKA
"A 72-year-old woman is listed for elective TKA in 6 weeks. Preoperative Hb is 105 g/L, ferritin 18 mcg/L, CrCl 55 mL/min. How would you manage her preoperatively?"
Scenario 2: Massive Hemorrhage During Revision THA
"You are performing revision THA for aseptic loosening. During acetabular component removal, the patient develops massive hemorrhage from pelvic vessels. BP drops to 70/40, HR 130. Anesthetist estimates 2L blood loss in 10 minutes. How do you manage this?"
Scenario 3: Jehovah's Witness Patient for Bilateral TKA
"A 68-year-old Jehovah's Witness patient presents for bilateral TKA. Preoperative Hb is 118 g/L. She refuses all blood products. How would you counsel and manage this patient?"
MCQ Practice Points
Exam Pearl
Q: What is the evidence-based transfusion threshold for hemodynamically stable patients following major orthopaedic surgery?
A: Hb 70 g/L (7 g/dL) for most patients. The FOCUS, TRACS, and TRICC trials demonstrated no benefit of liberal (100 g/L) over restrictive (70-80 g/L) transfusion thresholds. Exceptions requiring higher thresholds (80-100 g/L): acute coronary syndrome, symptomatic anaemia, ongoing significant bleeding. Single unit transfusion is appropriate unless ongoing hemorrhage.
Exam Pearl
Q: What dose of tranexamic acid (TXA) is recommended for total joint arthroplasty and what is its mechanism?
A: 1-2g IV given preoperatively (10-15mg/kg), with optional repeat dose at wound closure. TXA is an antifibrinolytic that competitively inhibits plasminogen activation, preventing clot breakdown. Reduces blood loss by 30-50% and transfusion risk by 50%. Contraindicated in active thromboembolic disease. NOT contraindicated in patients with DVT/PE history with adequate thromboprophylaxis.
Exam Pearl
Q: What are the key elements of a Patient Blood Management (PBM) program in orthopaedic surgery?
A: Three pillars: (1) Optimize red cell mass preoperatively - treat iron deficiency (IV iron if Hb under 130), EPO in selected cases. (2) Minimize blood loss - surgical technique, TXA, controlled hypotension, cell salvage. (3) Optimize physiological tolerance - restrictive transfusion thresholds, multimodal analgesia, early mobilization. The Australian National Blood Authority has specific PBM guidelines for surgery.
Exam Pearl
Q: When is intraoperative cell salvage indicated in orthopaedic surgery?
A: Expected blood loss greater than 1000-1500mL (or anticipated need for greater than 2 units allogeneic blood). Common indications: revision arthroplasty, major spine surgery, pelvic/acetabular trauma, bilateral TKA. Cell salvage reinfuses the patient's own washed red cells. Contraindicated in malignancy (relative) and infection (absolute). Processing removes activated clotting factors.
Exam Pearl
Q: What is the recommended management of anticoagulation in a patient on warfarin requiring urgent hip fracture surgery?
A: Reverse with IV Vitamin K 5-10mg + Prothrombinex-VF (25-50 IU/kg) for INR greater than 1.5. Surgery can proceed once INR under 1.5. Fresh frozen plasma (FFP) is second-line if Prothrombinex unavailable. Do NOT delay surgery more than 48 hours waiting for INR to normalize with vitamin K alone. Bridging with LMWH is NOT recommended for most hip fracture patients.
BLOOD MANAGEMENT STRATEGIES - EXAM CHEAT SHEET
High-Yield Exam Summary
Three Pillars of Patient Blood Management
- •**Pillar 1: Optimize** - Detect and treat preop anemia (iron, EPO)
- •**Pillar 2: Minimize** - Reduce intraop blood loss (TXA, cell salvage, technique)
- •**Pillar 3: Manage** - Appropriate transfusion (restrictive threshold Hb less than 70 g/L)
Preoperative Anemia Management
- •**Screen:** Hb less than 130 g/L (men), less than 120 g/L (women) = anemia. Check ferritin, CRP, creatinine
- •**Oral iron:** 200 mg elemental iron daily x 4-6 weeks (increases Hb 10-20 g/L)
- •**IV iron:** Ferric carboxymaltose 1000 mg single dose (increases Hb 10-30 g/L in 1-2 weeks) - use if time limited
- •**EPO:** 40,000 units SC weekly x 3-4 weeks + iron (increases Hb 20-40 g/L) - CKD, severe anemia, Jehovah's Witness
- •**Recheck Hb** 1 week preop to confirm response
Tranexamic Acid (TXA)
- •**Mechanism:** Inhibits plasminogen activation, prevents fibrinolysis, stabilizes clot
- •**Dosing:** 15-20 mg/kg IV load at induction, optional 1-2 mg/kg/h maintenance
- •**Evidence:** 30-50% reduction in transfusion, NO increase in VTE/MI/stroke
- •**CRASH-2:** 1g bolus + 1g over 8h in trauma - reduces mortality if given within 3h
- •**Use:** All major ortho cases (THA, TKA, spine, trauma) unless contraindicated
Cell Salvage
- •**Indications:** Expected blood loss greater than 500-1000 mL (revision THA/TKA, spine, pelvis)
- •**Mechanism:** Collects shed blood, washes RBCs, reinfuses autologous Hct 50-60%
- •**Contraindications (MIB):** Malignancy, Infection, Bowel contamination (all absolute)
- •**Effect:** 30-40% reduction in allogeneic transfusion
- •**Jehovah's Witness:** Many accept if continuous circuit
Transfusion Thresholds
- •**Restrictive:** Hb less than 70 g/L (asymptomatic stable patients) - SAFE and reduces complications
- •**Liberal:** Hb less than 100 g/L (old practice) - NO benefit, increases complications
- •**Cardiovascular disease:** Threshold Hb less than 80 g/L (slightly higher)
- •**Symptomatic anemia:** Transfuse for symptoms (dyspnea, tachycardia, angina) regardless of Hb
- •**Evidence:** TRICC, FOCUS trials - restrictive is as safe as liberal with less transfusions
Massive Transfusion Protocol
- •**Definition:** Loss of 1 blood volume in 24h OR greater than 4 units in 1h
- •**1:1:1 ratio:** RBC:FFP:Platelets in equal amounts - prevents dilutional coagulopathy
- •**TXA:** 1g IV bolus, then 1g over 8h (CRASH-2 protocol - within 3h of injury)
- •**Lethal triad:** Hypothermia, Acidosis, Coagulopathy - monitor and correct
- •**Lab monitoring:** Hb, INR, fibrinogen, platelets every 30-60 min
Jehovah's Witness Management
- •**Discuss:** Individual beliefs vary - many accept EPO, TXA, cell salvage (continuous circuit)
- •**Document:** Signed refusal form, documented risks including death, witness to consent
- •**Optimize:** EPO 40,000 units weekly x 4 + IV iron 1000 mg. Goal Hb greater than 130 g/L preop
- •**Minimize:** TXA, cell salvage, meticulous hemostasis, hypotensive anesthesia, consider staging bilateral procedures
- •**Accept:** Lower Hb postop (60-70 g/L). Supplemental O2, early mobilization
Key Trials and Evidence
- •**CRASH-2 (2010):** TXA in trauma reduces mortality (16.0% to 14.5%) if given within 3h. After 8h, harmful.
- •**TRICC (1999):** Restrictive (Hb less than 70) vs liberal (less than 100) - restrictive safe, reduces transfusions
- •**FOCUS (2011):** Hip fracture patients - restrictive (Hb less than 80) safe even in elderly with comorbidities
- •**Cochrane TXA (2015):** 60 RCTs ortho - TXA reduces transfusion 30-50%, NO VTE increase
- •**NHMRC PBM Guidelines (2012):** Australian standard - optimize, minimize, manage transfusion appropriately
Australian Context
- •**NBA PBM Guidelines:** Module 2 Perioperative - screen anemia, TXA, cell salvage, restrictive transfusion
- •**PBS:** IV iron (FCM) listed with authority. EPO NOT listed for elective ortho (hospital/patient funded)
- •**Blood costs:** 1 unit RBC $500-800 AUD including administration, testing, monitoring
- •**Donor supply:** Voluntary donors, periodic shortages (esp O neg) - drives PBM approach