Conserving the patient's blood is an important principle.  Ordering too many blood tests requires the patient to be subjected to what is sometimes unnecessary blood loss anemia.  Therefore, attention is given not only to the frequency of laboratory tests, but the size of the samples.  In critically ill patients with in-dwelling lines, we re-infuse blood that might otherwise be wasted in order to assure accuracy of the results.  Minimizing the amount of blood that the patient looses for laboratory tests is one way to keep the patient's blood count stable in the postoperative period.

Correction of unanticiapted anemia must be aggressive in patients who decline transfusions.  The first step is to assess for iron deficiency.  Once any iron deficiency is corrected, medication that stimulates the bone marrow to replenish red blood cells can also be given in selected patients.

Understanding the tolerance of anemia is an important concept.  Studies have proven that humans can tolerate a much lower blood count than previously thought.  The physiologic response to anemia is a faster heart beat.  This assures that the oxygenated blood reaches the vital tissues.  Since the blood has less red cells, the transfer of oxygen can actually occur more quickly which compensates for the lower number.

Keeping the patient normovolemic (meaning to correct for blood loss with non-blood volume expanders) will prevent circulatory collapse and assures that the remaining red cells continue to circulate to the vital tissues.

Aggressive correction of on-going bleeding must be a cornerstone of the management of all patients who refuse transfusions.  When the source of bleeding is unknown, physicians can employ bleeding scans or arteriograms to locate the exact source of the bleeding.  This allows for immediate steps to stop the bleeding quickly.

As you can see, it takes a multi-pronged approach in the post-operative period to successfully manage the patient.

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