Perioperative Assessment of the Elective Orthopedic Surgery Patient

The need to provide the best possible care for our patients while balancing risk against benefit and respecting their wishes is the major reason to pursue blood management strategies. This need is underscored by the decreasing supply of blood and its concomitant increasing cost. A philosophy of blood management, therefore, should be grounded in recognizing and avoiding transfusionassociated risks (Box 1) through limited exposure to allogeneic blood and the use of appropriate alternatives to maximize patient outcomes. Blood management must be a part of the orthopedic surgical patient’s treatment plan throughout the perioperative period. Thorough preoperative planning is essential to reducing or avoiding perioperative allogeneic transfusion. Decreasing risk and increasing benefit from blood transfusion for our patients begins with individualized transfusion prescriptions based on the knowledge of risks and benefits, practice patterns, and patient characteristics. Several authors have documented the value of an overall, coordinated approach to blood management in orthopedic surgery. Slappendel et al [1] in the Netherlands used information derived from a database of 28,861 orthopedic surgery patients to develop an algorithm for the reduction of blood transfusion. Important steps included enforcement of predefined transfusion triggers, the use of only selective cyclooxygenase-2 nonsteroidal antiinflammatory drugs in the perioperative period, preoperative erythropoietin and iron therapy, cell salvage during and after surgery, and the selective use of aprotinin. Their algorithm led to an 80% reduction in transfusion rates, with the added benefit of a 40% reduction in deep wound infections. Graham et al [2] had a similar success in a group of Canadian hospitals. Reports [3] of successful Anesthesiology Clin N Am