The collected studies span an unusually broad surgical landscape, from pediatric cardiac surgery to orthopedic and spine procedures, preoperative optimization, liver transplantation, and complex oncologic surgery. Taken together, they map the full arc of modern PBM: preserving red cell mass before surgery, limiting surgical and coagulopathic bleeding with topical and intravenous treatments, recognizing comorbidities that amplify bleeding risk, and understanding unforeseen postoperative transfusion hazards. Within established PBM programs, hemoglobin thresholds remain useful targets that can reduce transfusion practice at appropriate levels without causing adverse events. But the editorial is emphatic that thresholds alone are insufficient. They represent only a small subset of what works within the three pillars of PBM, and treating them as the whole strategy misses the point of the discipline.

One of the collection’s central reframings is temporal. Transfusion is not a single intraoperative event but the culmination of decisions made throughout the preoperative, intraoperative, and postoperative periods. Nowhere is this clearer than in pediatric cardiac surgery, where a review by Munlemvo examines the mechanisms of coagulopathy in neonates and infants undergoing cardiopulmonary bypass. In these smallest patients, bleeding and thrombosis arise from a delicate imbalance among thrombin generation, platelet activation, fibrinogen availability, antithrombin activity, and fibrinolysis. Because developmental hemostasis produces threshold values that may differ substantially from adult norms, the review argues that pediatric cardiac anesthesiologists need protocols reflecting the biology of developing hemostatic systems rather than simple adoption of adult transfusion triggers.

The same principle of mechanism-driven, patient-specific care applies to adults, where preoperative risk modification can act synergistically with transfusion triggers. A systematic review and meta-analysis by Chen and colleagues found that preoperative erythropoietin reduced both the rate of allogeneic transfusion and the average number of red cell units transfused in adult surgical patients. Critically, the analysis detected no significant differences in mortality, venous thromboembolism, infection, complications, or length of stay between treated and untreated groups. This does not circumvent the need for careful patient selection, thorough anemia evaluation, and vigilance for thrombosis, but it strengthens the case for treating correctable anemia before or during surgery whenever time and clinical context permit. The authors of the editorial note that such evidence also helps erode the lingering stigma surrounding erythropoietin and its perceived risks.

The orthopedic studies in the collection spotlight a problem that is often underappreciated in operating rooms: hidden blood loss. Song and colleagues demonstrated that hidden blood loss accounted for the majority of perioperative bleeding after total hip arthroplasty, and that hypertension, particularly grade 2 or grade 3 disease, was independently associated with greater loss. The implication is striking. Preoperative blood pressure control should be regarded not merely as a cardiovascular safety metric but as an active blood-conservation measure in its own right. Building on this theme, Zhao and colleagues showed that combining intravenous tranexamic acid with intra-articular fluid gelatin substantially reduced total blood loss in elderly patients with femoral neck fractures undergoing total hip arthroplasty, without an observed increase in thromboembolic or wound complications.

Spine surgery adds a complementary lesson about dosing schedules and the timing of antifibrinolytic therapy. In patients undergoing transforaminal lumbar interbody fusion, Ye and colleagues found that intravenous tranexamic acid followed by three days of oral therapy reduced total and hidden blood loss, postoperative drainage, length of stay, and transfusion rates compared with preoperative intravenous therapy alone. Extending the oral regimen to five days added no additional benefit, suggesting a plateau in effect. Together, the orthopedic and spine studies imply that blood management should be tailored not only to the operation being performed but also to the biology and timing of postoperative fibrinolysis, the natural process of clot breakdown that continues for days after tissue injury.

The two major abdominal surgery studies in the collection speak to the genuine complexity of transfusion-outcome associations. Wang and colleagues studied liver transplantation patients and found that intraoperative allogeneic transfusion was associated with acute kidney injury and in-hospital mortality before statistical matching. After propensity matching and multivariable analysis, however, transfusion was no longer an independent risk factor. This illustrates the difficulty of attributing causality to transfusion when confounders such as illness severity, anhepatic time, and the volume of surgical bleeding are in play, and it affirms that allogeneic transfusion remains a necessary measure when clinically appropriate. Li and colleagues reached a different conclusion in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, where higher intraoperative packed red blood cell volume was associated with poorer overall survival after propensity matching, plausibly reflecting the immunomodulatory effects of transfused blood.

The contrast between these two oncologic and transplant findings is instructive rather than contradictory. Transfusion should neither be reflexively blamed for every adverse outcome nor treated as a neutral exposure when cumulative red cell volume may correlate with modifiable bleeding, inflammatory burden, or surgical complexity. The editorial argues that these studies collectively demand context-aware interpretation of transfusion in high-acuity surgery, where the same unit of blood may be lifesaving in one scenario and a marker of escalating physiologic stress in another. Discerning the difference requires integrating transfusion data with the full clinical picture rather than reading it in isolation.

Across the seven papers, several priorities emerge for the next phase of PBM. First, programs should begin earlier, identifying anemia, uncontrolled hypertension, hypoalbuminemia, anticoagulant exposure, and procedure-specific bleeding risk well before the day of surgery. Second, intraoperative decisions should be guided by mechanism, with antifibrinolytic therapy, topical hemostatic strategies, coagulation testing with or without viscoelastic assays, and transfusion itself stratified according to the patient’s age, diagnosis, operation, and hemostatic phenotype. Third, postoperative surveillance should explicitly include hidden blood loss and anemia recovery. A shared clinical pathway can help multidisciplinary teams synthesize this information into timely, procedure-specific action rather than leaving each decision to individual improvisation.

The Research Topic also exposes significant evidence gaps in transfusion medicine. Many of the included studies are retrospective or single-center, and several evaluate pragmatic interventions in populations with narrow procedural or institutional contexts. Future trials, the editorial argues, should compare bundled, multimodal PBM pathways against usual care, report thrombotic, infectious, renal, functional, and patient-reported outcomes, and clarify definitive transfusion thresholds for children, older adults, patients with cardiovascular disease, patients with liver failure, and those undergoing major cancer surgery. Real-world implementation will be equally important, because a protocol that performs well under ideal clinical conditions may fail if screening, testing, blood availability, or multidisciplinary communication are unreliable. The ultimate message is one of calibrated precision rather than restriction. Optimal perioperative transfusion management is less about withholding blood and more about choosing the right intervention at the right moment. Blood products remain lifesaving when hemorrhage threatens oxygen delivery and organ perfusion, yet avoidable transfusion is itself a modifiable exposure. By connecting preoperative optimization, mechanism-based hemostasis, disciplined transfusion practice, and postoperative recovery metrics, perioperative teams can move closer to genuinely patient-centered blood management, achieving safer surgery through preservation of the patient’s own physiologic reserve.

Subject of Research: Perioperative blood transfusion management and patient blood management strategies across surgical settings

Article Title: Editorial: Perioperative blood transfusion management in the perioperative setting

Article References: Henderson, R. (2026). Editorial: Perioperative blood transfusion management in the perioperative setting. Frontiers in Anesthesiology, 5, Article 1971889. https://doi.org/10.3389/fanes.2026.1971889

Image Credits: AI Generated

DOI: 10.3389/fanes.2026.1971889

Keywords: patient blood management, blood transfusion, perioperative medicine, tranexamic acid, hidden blood loss, anemia, coagulopathy, orthopedic surgery, liver transplantation, erythropoietin, hemostasis, anesthesiology