Editorial: Perioperative blood transfusion management in the perioperative setting

Patient blood management (PBM) has moved beyond the question of when to transfuse, but is a patient-centered discipline that poses the question of how clinicians can preserve blood volume, anticipate procedure-specific and patient-specific bleeding risks, target patient-specific hemostasis, and use allogeneic products only when the expected benefit exceeds the physiologic and immunologic costs. The seven articles gathered in this Research Topic, Perioperative Blood Transfusion Management in the Perioperative Setting, illustrate the evolution of PBM across pediatric cardiac surgery, orthopedic and spine procedures, preoperative optimization, liver transplantation, and complex oncologic surgery.

Taken together, the collection spans several aspects of PBM: preserving red cell mass before surgery, limiting surgical and coagulopathic bleeding with topical and intravenous treatments, recognizing co-morbidities that increase bleeding risk, and understanding unforeseen postoperative transfusion risks. In PBM programs, hemoglobin thresholds are targets that can reduce transfusion practices at appropriate levels without causing adverse events (1). These thresholds for transfusion are necessary, but they are insufficient, as this is a small subset that works within the three pillars of PBM.

Transfusion is not a single intraoperative event, but the culmination of decisions made throughout the perioperative, intraoperative, and postoperative period. Munlemvo's review discusses the mechanism of coagulopathy in pediatrics. In neonates and infants undergoing cardiopulmonary bypass, bleeding and thrombosis arise from an imbalance between thrombin generation, platelet activation, fibrinogen, antithrombin activity, and fibrinolysis Munlemvo. Because these thresholds may differ from adult values, pediatric cardiac anesthesiologists need protocols that reflect developmental hemostasis rather than simple adoption.

The same principle applies to adults, where preoperative risk modification may have a synergistic effect with transfusion triggers. Chen and colleagues’ systematic review and meta-analysis found that preoperative erythropoietin reduced both the rate of allogeneic transfusion and the average number of transfused red cell units in adult surgical patients, without significant differences in mortality, venous thromboembolism, infection, complications, or length of stay Chen et al. This does not circumvent the need for patient selection, anemia evaluation, or thrombosis vigilance, but it strengthens the case for treating correctable anemia before or during surgery whenever time and clinical context permit. It also decreases the stigma regarding erythropoietin and its associated risk.

The orthopedic studies in this collection highlight the often underappreciated problem of hidden blood loss. Song's article showed that hidden blood loss accounted for most perioperative bleeding after total hip arthroplasty and that hypertension, particularly grade 2 or grade 3 disease, was independently associated with greater loss Song et al. Their findings argue for preoperative blood pressure control as a blood-conservation measure, not only a cardiovascular safety metric. Zhao's study then demonstrated that combining intravenous tranexamic acid with intra-articular fluid gelatin substantially reduced total blood loss in elderly femoral neck fracture patients undergoing total hip arthroplasty, without an observed increase in thromboembolic or wound complications Zhao et al.

Ye's study on spine surgery adds a complementary lesson on dosing schedules. In patients undergoing transforaminal lumbar interbody fusion, intravenous tranexamic acid followed by three days of oral therapy reduced total and hidden blood loss, postoperative drainage, length of stay, and transfusion rates compared with preoperative intravenous therapy alone; extending oral treatment to five days added no benefit Ye et al. Together, these orthopedic and spine studies suggest that blood management should be tailored not only to the operation, but also to the biology and timing of postoperative fibrinolysis.

The two major abdominal surgery studies speak to the complexity of transfusion-outcome associations. Wang studied liver transplantation patients and found that intraoperative allogeneic transfusion was associated with acute kidney injury and in-hospital mortality before matching, but after propensity matching and multivariable analysis it was no longer an independent risk factor Wang et al. This shows the complexity of transfusion studies in attributing causality to transfusion when additional factors like illness severity, anhepatic time, and bleeding are involved. This also shows that allogeneic transfusion is a needed measure when clinically appropriate. Li reached a different conclusion in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: higher intraoperative packed red blood cell volume was associated with poorer overall survival after propensity matching, as immunomodulation is a known risk of blood transfusions Li et al. The contrast is useful: transfusion should neither be reflexively the reason for every adverse event nor treated as neutral when cumulative exposure may correlate with modifiable bleeding, inflammatory burden, or surgical complexity. Together, these studies argue for context-aware interpretation of transfusion in high-acuity surgery.

Across these papers, several priorities emerge for the next phase of PBM. First, PBM programs should begin earlier, identifying anemia, uncontrolled hypertension, hypoalbuminemia, anticoagulant exposure, and procedure-specific bleeding risk before the day of surgery. Second, intraoperative decisions should be guided by mechanism: antifibrinolytic therapy, topical hemostatic strategies, coagulation testing with or without viscoelastic testing, and transfusion should be stratified to the patient's age, diagnosis, operation, and hemostatic phenotype. Third, postoperative surveillance should include hidden blood loss and anemia recovery. A shared pathway can help teams synthesize this data into timely, procedure-specific action.

This topic also exposes evidence gaps in transfusion medicine. Many included studies are retrospective or single-center, and several evaluate pragmatic interventions in populations with narrow procedural or institutional contexts. Future trials should compare bundled, multimodal patient blood management pathways with usual care; report thrombotic, infectious, renal, functional, and patient-reported outcomes; and clarify definitive transfusion thresholds for children, older adults, patients with cardiovascular disease, liver failure, and patients undergoing major cancer surgery. Real-life implementation will be equally important, because a protocol in perfect clinical conditions may fail if screening, testing, blood availability, and multidisciplinary communication are unreliable or infeasible.

Therefore, optimal perioperative transfusion management is less about withholding blood and more about choosing the right intervention at the right moment. Blood products remain lifesaving when hemorrhage threatens oxygen delivery and organ perfusion. Yet avoidable transfusion is also a modifiable exposure. By connecting preoperative optimization, mechanism-based hemostasis, disciplined transfusion practice, and postoperative recovery metrics, perioperative teams can move closer to patient-centered blood management: safer surgery through preservation of the patient's own physiologic reserve (Figure 1).

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Footnotes

Edited and Reviewed by: Alparslan Turan, Cleveland Clinic, United States