**3.2 Anesthetic measures**

These include appropriate blood volume maintenance, dealing with pain, tachycardia and high blood pressure, hyperoxic ventilation to improve oxygen transport in patients with low hemoglobin and maintenance of normothermia. As specific actions in orthopedics we include:


### **3.3 Surgical technique**

This includes an adequate ischemia (use of tourniquet), adequate hemostasis, minimally invasive surgery, etc. The most important factors are surgical time reduction and well-cared

The existence of predonation units increases the likelihood of transfusion, as perception of risk decrease; there is less chance of rejection or blood incompatibility, as well as less infections. Moreover, it is exposed to the same errors in the processes of extraction, storage, identification and reinfusion to the autologous blood transfusion. Predonation of autologous blood has the following contraindications: serious cardiac disease, hepatitis B history and

To improve its efficiency, they must be associated to a blood-saving protocol during

A restrictive transfusion strategy (transfusion threshold at hemoglobin 7 g/dl) must be used, taking into consideration anemia risks and the benefits from a transfusion in an individualized way for every patient. Nowadays, rarely does hemoglobin over 10 g/dl get considered for transfusion, whereas it is believed to be strictly necessary when hemoglobin is less than 6 g/dl. In either case, the transfusion threshold must be lowered to try and delay the start of blood transfusion until the surgery ends, making a new assessment after each transfused packed red blood cells. Moreover, the usual practice of transfusing always two units of packed red blood cells (PRBC) is considered incorrect; as to raise the hemoglobin

These include appropriate blood volume maintenance, dealing with pain, tachycardia and high blood pressure, hyperoxic ventilation to improve oxygen transport in patients with low hemoglobin and maintenance of normothermia. As specific actions in orthopedics we

 Regional anesthesia, as several studies have demonstrated decrease of perioperative bleeding when comparing with general anesthesia, which appears to be related to lower

 Monitoring low blood pressure is a controversial anesthetic measure, with a relative effectiveness amongst bleeding, used to lower down blood pressure and thus reducing blood loss during surgery. In orthopedic surgery, its use gets relegated to high intraoperative bleeding interventions. Relative contraindications include untreated severe high blood pressure, coronary disease, serious lung disease, severe anemia or significant polycythemia, cerebrovascular disease, pregnancy, considerable hypovolemia and serious kidney or liver dysfunction. There are numerous drugs used to control hypertension. Most frequently used in clinical practice are inhalators (isoflurane, sevoflurane), direct acting vasodilators (nitroglycerin, sodium

nitroprusside), beta blockers (labetalol, esmolol), others (urapidil, captopril, etc.)

This includes an adequate ischemia (use of tourniquet), adequate hemostasis, minimally invasive surgery, etc. The most important factors are surgical time reduction and well-cared

Optimal position of the patient to reduce venous congestion at the surgical field

positive markers for HCV, HIV-I/II, HTLV-I/II and active bacterial infection.

concentration 1 g/dl it takes about 4 ml/kg PRBC, being enough one PRBC.

**3. Intraoperative strategies** 

**3.1 Individualize transfusion threshold** 

perioperative time.

**3.2 Anesthetic measures** 

blood pressure.

**3.3 Surgical technique** 

include:

hemostasis. There is a straightforward relationship between hematic loss and surgical time; a longer surgical time is associated to a greater hematic loss. During surgery, local hemostatic agents, such as fibrin sealants, which reduce surgical bleeding, can be used. We will develop this part further on.
