Alternatives to blood transfusion

1. Treating anemia before surgery

Iron

An international consensus statement gives guidance on diagnosing and treating anemia and iron deficiency in surgical patients and urges hospitals to put this into practice.^[1] Iron can be taken by mouth or given into a vein (IV iron).^[2]

The evidence on IV iron for reducing transfusion is mixed. In the PREVENTT trial, IV iron given 10 to 42 days before major open abdominal surgery was not better than placebo at reducing the need for blood transfusion.^[3] A 2026 network meta-analysis concluded that one IV iron preparation, ferric carboxymaltose, improves hemoglobin around surgery and reduces transfusion requirements, and called for more research.^[4]

Erythropoiesis-stimulating agents (ESAs)

ESAs such as epoetin alfa prompt the body to make red blood cells. MedlinePlus says epoetin alfa can be used before and after certain surgeries to decrease the chance that transfusions will be needed.^[5] Its important warning says it increases the risk that blood clots will form in or move to the legs, lungs or brain, and that it should not be used to lower the chance of transfusion in people having surgery on their heart or blood vessels.^[5]

2. Reducing blood loss during surgery

Tranexamic acid and other antifibrinolytics

Antifibrinolytic medicines, including tranexamic acid, are used to reduce bleeding during surgery. A Cochrane review of trials in planned surgery concluded that they provide worthwhile reductions in blood loss and in receiving donated red cells, and that the lysine analogues, which include tranexamic acid, appear to be free of serious adverse effects.^[6]

Cell salvage

Cell salvage collects blood lost during surgery, washes it and returns it to the same patient.^[7] A 2023 Cochrane review concluded that in some types of elective surgery it may reduce the need for and volume of donated blood, with no difference in adverse events compared with no cell salvage, while other surgeries showed no benefit.^[8] More in cell salvage explained.

Minimally invasive techniques and fewer blood draws

Transfusion-free programs name minimally invasive surgery among their techniques.^[9] Reviews of care for patients who decline blood also stress keeping blood draws to a minimum after surgery.^[10]

3. Transfusing only when it's needed

A "restrictive" approach waits for a lower hemoglobin level before transfusing. The 2023 AABB international guidelines recommend that, for hospitalized adults who are hemodynamically stable, clinicians consider transfusion when hemoglobin is below 7 g/dL; they note thresholds of 7.5 g/dL in cardiac surgery and 8 g/dL in orthopedic surgery or pre-existing cardiovascular disease.^[11] The guideline adds that it's good practice to consider the overall clinical context and alternative therapies.^[11]

A 2025 Cochrane review found a restrictive strategy reduced the share of people exposed to transfusion, with no evidence of harm in most clinical contexts. It also found that neurocritically ill patients had better neurological outcomes at 6 to 12 months with a more liberal strategy.^[12]

Putting it together

Studies of patient blood management programs combine at least one measure from each area: anemia management, saving blood and a careful transfusion strategy.^[13] Your team decides which pieces fit your situation.