Perioperative blood conservation strategies for major spine surgery

•Increasing the preoperative hemoglobin levels, is a key point regarding the avoidance of blood transfusions.•Coagulation management with point-of-care monitoring and coagulation factors reduces the need for blood products.•Cost-effectiveness can be achieved with this approach and requires reassessment by all involved parties.

BackgroundOrthopedic surgery, especially spine and spinal deformity surgery, may be associated with high perioperative blood loss. In order to reduce the risk of excessive blood loss and unnecessary blood transfusions, strategies such as Patient Blood Management including goal-directed coagulation management have been developed.Recent findingsAdverse effects of allogeneic blood transfusions have been shown for most surgical fields including orthopedic surgery. Several efforts have been made to increase the preoperative red blood cell (RBC) mass, to reduce the intraoperative blood loss, and to use restrictive transfusion triggers in order to minimize or avoid RBC transfusions. Measures to reduce intraoperative blood loss include new surgical techniques, use of cell salvage where possible, bedside coagulation management with point-of-care devices, substitution of coagulation factors, antifibrinolytic agents, and desmopressin, induced hypotension, and avoidance of hypothermia.SummaryBlood conservation in spinal surgery is a multidisciplinary approach and the efficacy of most single measures has been shown. Cost-effectiveness and the benefits of long-term patient outcomes are the subjects of current and future research.