A 67-year-old woman with a history of osteoarthritis is scheduled for elective left hip replacement surgery. She also had hip surgery several years ago at another hospital and was transfused at that time. Her medical history is significant for coronary artery disease, hypercholesterolemia, and hypertension for which she takes statin and antihypertensive medications as well as aspirin and clopidogrel antiplatelet medications (which were discontinued 7 days prior to the surgery). On the day of admission for the hip surgery, the patient is found to have a hemoglobin (Hgb) level of 7.7 g/dL with mean corpuscular volume (MCV) 70 fL, platelets 220 K/μL, and prothrombin time (PT) and activated partial thromboplastin time (aPTT) 13.0 s and 39.0 s, respectively. Two units of RBCs are ordered to be transfused preoperatively. The surgeon briefly visits the patient in the preoperative holding area, and consent for the transfusion is obtained as a part of the surgical consent; that is, the patient is asked to initial a box on the consent form to accept all transfusions of blood products related to the surgical procedure. However, transfusion is delayed because of a positive antibody screen and subsequent identification of an anti-K antibody requiring antihuman globulin (AHG) crossmatch. As a result of the delay, only one unit of RBCs is transfused, and the patient is taken into the operating room. The patient loses approximately 1 L of blood during the surgery and is transfused three units intraoperatively. The surgery is otherwise uneventful, and the patient is stable and recovering well postoperatively with Hgb level remaining in the 7–8 g/dL range for 3 consecutive days. However, the patient receives two additional units of RBCs for “acute blood loss anemia” with Hgb level 7.4 g/dL on the day before discharge (a repeat Hgb level is not obtained on day of discharge).
KeywordsAcute normovolemic hemodilution Computer physician order entry/CPOE Intraoperative cell salvage Liberal transfusion practices Paternalistic approach Patient blood management/PBM Patient-centered approach Preoperative anemia management Restrictive transfusion practices
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