Emerging trends in surgical blood transfusion.

The traditional belief of surgeons that allogeneic blood is an effective and safe therapy with minimal risks has been challenged by a heightened awareness of the problems of transfusion reactions, disease transmission, and immunomodulation related to red blood cell (RBC) transfusion. Surgeons have responded to those challenges by reassessing the reasons for transfusion, increasing autologous blood use, modifying surgical techniques to reduce blood loss, and employing various drugs to reduce transfusion requirements. Of primary importance is the need for the surgeon to thoughtfully plan allogenic blood transfusion requirements for each patient. Blood should be transfused only when there is a documented need to increase oxygen delivery in patients unable to meet demands through normal cardiopulmonary mechanisms. Autologous blood use, an alternative to allogeneic transfusion, is a standard of care for elective orthopedic procedures and radical prostatectomy. Surgical principles of gentle tissue handling, anatomic dissection, and blood loss minimization are increasingly practiced. Surgical approaches include vascular isolation, use of a water jet dissector, microwave tissue coagulation, arthroscopic joint repair, and cold compression. Surgical techniques that decrease bleeding morbidity and mortality include the transjugular intrahepatic portosystemic shunt, intraluminal stents and grafts, laparoscopic techniques, electrocautery, and laser techniques. Pharmacologic agents also affect surgical blood loss and transfusion requirements. Anesthetic agents, locally acting clotting agents, and antifibrinolytics each may reduce blood loss. In addition, perioperative recombinant human erythropoietin use significantly decreased the need for allogeneic transfusions in both anemic and nonanemic surgical patients. Since allogeneic transfusion-induced immunomodulation may have significant effects on mortality related to increased rates of postoperative infection and cancer recurrence, these new approaches and techniques may have an important clinical impact on surgical patients.