title: Objectives and limitations of bloodless medical care.
abstract: OBJECTIVE
  To outline the rationale, limitations, and execution of bloodless medical and surgical programs, highlighting characteristics that contribute to successful outcomes.
  
  
  RESULTS
  Clinical experiences with patients who refuse blood transfusions for religious reasons have provided valuable lessons and raise intriguing questions about the necessity of routine blood transfusions. Healthcare centers with bloodless medicine and surgery programs feature a novel concept of patient care aimed at improving outcomes. A one-tiered approach to minimize blood usage for all patients, regardless of religious beliefs, is being successfully adopted at an increasing number of institutions. Since most single blood-conservation techniques reduce blood usage by just 1-2 units, a series of integrated preoperative, intraoperative, and postoperative conservation approaches is required. These include preoperative autologous donation, erythropoietic support, acute normovolemic hemodilution, individualized assessment of anemia tolerance, implementation of conservative transfusion thresholds, meticulous surgical techniques, and judicious use of phlebotomy and pharmacologic agents for limiting blood loss.
  
  
  CONCLUSIONS
  The objectives of bloodless medicine and surgery programs are straightforward but require staff with expertise in transfusion medicine, intensive teamwork, patient-specific customization, careful planning, and integrated use of multimodal strategies.
authors.affiliation: Department of Anesthesiology and Critical Care and Hyperbaric Medicine, New Jersey Institute for the Advancement of Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, NJ 07631, USA. aryeh.shander@ehmc.com
authors.forename: Aryeh
authors.initials: A
authors.lastname: Shander
authors.forename: Lawrence T
authors.initials: LT
authors.lastname: Goodnough
mesh_terms: D016063:Blood Loss, Surgical / Q000517:prevention & control*; D001803:Blood Transfusion / Q000941:ethics / Q000706:statistics & numerical data*; D006438:Hemodilution / Q000009:adverse effects*; D006801:Humans; D019990:Perioperative Care / Q000379:methods*; D012067:Religion; D016312:Treatment Refusal