Perioperative blood management strategies include evidence-based guidelines to efficiently manage blood products and transfusions while minimizing blood loss and improving patient outcomes. Perioperative Medicine has made evident that anemia is often under-recognized and not appropriately addressed prior to surgery. Early recognition and correction of anemia is imperative for better surgical optimization, fewer transfusions perioperatively, and improved outcomes. Patient blood management utilize evidence-based guidelines for the establishment of a framework to promote treatment of the causes of anemia, reduce blood loss and coagulopathy as well as to improve patient safety and outcomes by efficiently managing blood products, decrease complications associated with blood transfusions and reduce overall costs. Both liberal and restrictive strategies for blood transfusions established thresholds for hemoglobin: restrictive transfusion threshold of hemoglobin 7–8 g/dL in stable patients, and a higher transfusion threshold of hemoglobin > 8 g/dL may be considered in patients with cardiac disease. Intraoperatively, tests such as viscoelastic testing, including rotational thromboelastometry and thrombelastography, offer real-time analysis of a patient’s clotting ability, allowing for targeted transfusions of fresh frozen plasma, platelets, cryoprecipitate or antifibrinolytic drugs. Complications associated with blood transfusions include allergic reactions, delayed hemolytic reactions, transfusion related acute lung injury, transfusion-associated circulatory overload, and the transmission of infectious diseases such as Hepatitis B, Hepatitis C, and Human-immunodeficiency virus. This review will discuss the management of blood products for surgical patients in the entire perioperative setting, with specific considerations for the peri-, intra- and post-operative stages.

Patients with heart failure require special considerations in the perioperative setting given the challenges caused by heart failure pathophysiology. This pathophysiology is complex and involves several mechanisms that contribute to both disease progression and the clinical syndrome, including cardiac remodeling, neurohormonal activation, and resultant hemodynamic derangements. Anesthetic management of these patients requires diligence at all stages of care. Preoperative assessment includes risk stratification, management of comorbid conditions, and heart failure medication management. Anesthetic agents have differing effects on hemodynamics and selection of these agents must be aimed at preventing hemodynamic collapse in patients with heart failure. In addition, the increased risk of intraoperative complications among these patients often necessitates means of invasive hemodynamic monitoring and use of vasopressor or inotropic support. Finally, the postoperative care of heart failure patients requires attention to the volume status of these patients, as well as considerations for pain management and modulation of the surgical stress response. In this review article, we aim to review how the pathophysiologic mechanisms and changes that occur with heart failure impact anesthetic management and patient-centered perioperative care.