Patient blood management is an evidence-based, multidisciplinary approach aimed at optimizing the care of patients who require a blood transfusion. It focuses on minimizing blood loss, improving patient outcomes, and reducing the need for allogeneic transfusions. Anesthesiologists, who are central to perioperative care, play a vital role in three core aspects of patient blood management: optimizing red cell mass, minimizing blood loss, and harnessing patient tolerance to anemia. Their decisions directly impact transfusion thresholds, intraoperative hemostasis, and postoperative recovery, making their involvement essential for successful patient blood management implementation ¹.

The first critical aspect of patient blood management involves the identification and treatment of preoperative anemia. Anesthesiologists are able to review a surgical patient’s hematologic status during a preoperative assessment. Guidelines from the World Health Organization (WHO) and the Society for the Advancement of Blood Management (SABM) recommend early screening and correction of anemia using iron therapy, erythropoiesis-stimulating agents, or the treatment of any underlying causes such as chronic kidney disease. Working alongside internists and surgeons, anesthesiologists help implement standardized pathways for anemia management, reducing the need for transfusions during surgery ^2–4.

Furthermore, anesthesiologists are uniquely positioned to reduce intraoperative blood loss through hemodynamic control, pharmacologic interventions, and surgical coordination. Controlled hypotension, normovolemic hemodilution, and regional anesthesia can all be used to limit bleeding. The administration of antifibrinolytic agents such as tranexamic acid has been shown in large trials to significantly reduce bleeding without increasing thromboembolic complications. In addition to these aspects, anesthesiologists work with surgeons to ensure that cell salvage techniques, appropriate patient positioning, and coagulation monitoring are utilized effectively for patient blood management in real-time ^5–7.

Another aspect of patient blood management that anesthesiologists play a role in is individualized decision-making around transfusion thresholds. Supported by a number of large clinical trials, anesthesiologists are moving from fixed hemoglobin targets to restrictive transfusion strategies. Clinical data has revealed that stable patients tolerate lower hemoglobin levels without adverse outcomes. In the intraoperative setting, anesthesiologists assess tissue perfusion, oxygenation, and the patient’s comorbidities to make nuanced transfusion decisions rather than relying solely on laboratory numbers ^8,9.

Beyond clinical interventions, anesthesiologists contribute to institutional patient blood management strategies by developing transfusion protocols, educating staff, and participating in audit and quality improvement initiatives. Studies have revealed that patient blood management programs with strong anesthesiology leadership result in fewer transfusions, shorter hospital stays, and reduced costs without compromising outcomes. In cardiac, orthopedic, and oncologic surgeries for example, where blood loss is substantial, anesthesiologists can help tailor patient blood management strategies to the specific needs of a collaborative, interdisciplinary clinical team and the patient population ^10–12.

Anesthesiologists are at the frontline of patient blood management. Their role spans the full perioperative continuum, and anesthesiologists must remain key leaders in multidisciplinary patient blood management efforts to improve patient outcomes and ensure safe, efficient use of blood products.

References

1. Patient Blood Management. www.aabb.org https://www.aabb.org/blood-biotherapies/blood/transfusion-medicine/patient-blood-management.

2. Guidance on implementing patient blood management to improve global blood health status. https://www.who.int/publications/i/item/9789240104662.

3. Goodnough, L. T., Shander, A. & Riou, B. Patient Blood Management. Anesthesiology 116, 1367 (2012). DOI: 10.1097/ALN.0b013e318254d1a3

4. SABM. https://www.sabm.org/.

5. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. The Lancet 376, 23–32 (2010). DOI: 10.1016/S0140-6736(10)60835-5

6. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 389, 2105–2116 (2017). DOI: 10.1016/S0140-6736(17)30638-4

7. Tobias, J. D. Strategies for minimizing blood loss in orthopedic surgery. Semin Hematol 41, 145–156 (2004). DOI: 10.1053/j.seminhematol.2003.11.025

8. Hébert, P. C. et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 340, 409–417 (1999). DOI: 10.1056/NEJM199902113400601

9. Carson, J. L. et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 365, 2453–2462 (2011). DOI: 10.1056/NEJMoa1012452

10. Leahy, M. F. et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion 57, 1347–1358 (2017). DOI: 10.1111/trf.14006

11. Bolliger, D., Tanaka, K. A. & Steiner, L. A. Patient blood management programmes: keeping the ball rolling. British Journal of Anaesthesia 131, 426–428 (2023). DOI: 10.1016/j.bja.2023.06.031

12. Filipescu, D. et al. Patient Blood Management in 2023: a Nationwide Survey of Anesthesiologists in Romania following the 2018 Guidelines. Blood Transfus 23, 232–241 (2025). DOI: 10.2450/BloodTransfus.776