One of the best ways to maximize the use of a patient's own blood and minimize blood usage through transfusion is through phlebotomy volume reduction and pre-operative coordination of the optimization of anemia. Many patients in higher-acuity units develop iatrogenic anemia due to large-volume daily blood draws for lab samples. In our clinical setting, using a nurse-run protocol for using pediatric-sized or small-volume blood collection tubes and eliminating unnecessary repeat lab testing significantly reduced blood volume taken from the patient's body, preserving the patient's own red cell mass. This blood conservation approach can assist patients in maintaining baseline hemoglobin levels enough to withstand the effects of illness without needing outside support. An excellent example of this strategy preventing a transfusion is reflected in a patient scheduled for major elective surgery whose hemoglobin was borderline low at 10.2 g/dL. Rather than waiting until surgical blood loss necessitated an intra-operative transfusion, the care team used a safety net protocol that included administering intravenous iron and erythropoietin-stimulating agents three weeks prior to the surgery, resulting in a hemoglobin increase to 12.5 g/dL by the day of surgery. Although there was blood loss during surgery, the patient remained well above the transfusion trigger and avoided the associated risks of transfusion-transmitted infection and transfusion-related acute lung injury (TRALI).
One tactic that worked well was nurse-led screening for iron deficiency and early coordination for IV iron when labs trended down, instead of waiting until hemoglobin dropped to transfusion levels. We also reinforced restrictive transfusion thresholds during handoffs so everyone stayed aligned. In one case, a post-op patient with borderline hemoglobin was symptomatic but stable. Early IV iron and close monitoring helped them recover without a transfusion, which reduced risk and shortened their stay.