COSMETIC

Patient Blood Management Strategies to Avoid

Transfusions in Body Contouring Operations:
Controlled Clinical Trial
Jorge Enrique Bayter-Marin,

Background: Anemia is a frequent process of morbidity and mortality in

M.D.
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body contouring procedures. In aesthetic surgery, there are no standard-

Lázaro Cárdenas-Camarena,
M.D.
William E. Peña, M.D.
Héctor Durán, M.D.
Guillermo Ramos-Gallardo,
M.D.
José Antonio Robles-Cervantes,
M.D., M.Sc., Ph.D.
Mauricio McCormick-Méndez,
M.D.
Sonia Rocio Gómez-González,
M.D.
Erika Liliana Plata-Rueda, M.D.
Bucaramanga and Bógota, Colombia;
and Zapopan and Puerto Vallarta,
Jalisco, and Mérida, Yucatán, México
ized processes to minimize bleeding during surgery. For this reason, a
study was designed to implement patient blood management strategies to
reduce bleeding and transfusions in patients undergoing body contouring
operations.
Methods: From January of 2017 to May of 2018, a prospective cohort-type
observational study was conducted, including two groups of patients undergo-
ing single or combined body contouring procedures. The first group did not
receive patient blood management strategies, whereas the second group did
receive these strategies. These measures consisted of preoperative strategies to
ensure the patient had optimal hemoglobin and hematocrit levels and support-
ive intraoperative measures to minimize blood loss. The results were validated
with different statistical tests according to the variables studied.
Results: A total of 409 patients were included in the study and were divided
into two groups. The anthropometric and hemoglobin variables were similar
in both groups. The 207 patients for whom patient blood management strate-
gies were implemented lost an average of 1.2 g/dl less hemoglobin at 72 hours
than the 202 patients for whom patient blood management strategies were not
implemented (p ≤ 0.0001).
Conclusions: Patient blood management strategies, such as increasing hemo-
globin before surgery, and strategies to minimize blood loss during surgery,
proved to be effective at reducing bleeding in patients undergoing body con-
touring surgery, also decreasing the need to perform postoperative blood trans-
fusions. (Plast. Reconstr. Surg. 147: 355, 2021.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A
cute anemia is a very common complication
in plastic surgery, with high morbidity and
mortality rates.1,2 Blood transfusion is also
considered a complication, and the strongest pre-
disposing risk factor is preoperative anemia.3 For
years, a set of strategies designed by the Society
for the Advancement of Blood Management,
called patient blood management, has sought to
reduce or avoid postoperative blood transfusions
and all complications secondary to postoperative
anemia.4 Patient blood management is a series
From private practice; Clínica “EL Pinar”; INNOVARE;
the Division of Internal Medicine, Jalisco Institute of
Reconstructive Surgery “Dr. José Guerrerosanto”; and Clínica
Colsanitas.
Received for publication June 16, 2019; accepted June 12,
2020.
Copyright © 2021 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000007524
of preoperative, intraoperative, and postopera-
tive measures and strategies with the objectives
of diagnosing and treating anemia in the preop-
erative period, thus minimizing blood loss dur-
ing surgery to maintain hemoglobin levels. This
is achieved by suspending drugs that alter coag-
ulation 8 to 15 days before surgery, optimizing
hemostasis, avoiding hypothermia, performing
Disclosure: The authors have no conflict of interest
to declare in relation to the content of this work.
By reading this article, you are entitled to claim
one (1) hour of Category 2 Patient Safety Credit.
ASPS members can claim this credit by logging in
to PlasticSurgery.org Dashboard, clicking “Submit
CME,” and completing the form.

www.PRSJournal.com 355
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 Plastic and Reconstructive Surgery • February 2021
intraoperative hemodilution, and using hemo-
static drugs. During the postoperative period,
anemia tolerance should be increased by optimiz-
ing oxygenation with supplemental oxygen and by
using restrictive transfusion strategies. These mea-
sures have been used in multiple specialties with
excellent results; however, there are no studies
specific to plastic surgery. Therefore, the objective
of this study was to establish protocols consistent
with patient blood management to minimize the
need for transfusions in patients undergoing lipo-
suction and/or abdominoplasty.
PATIENTS AND METHODS
A prospective cohort-type observational study
was conducted, with prior approval from the hos-
pital ethics committee, that included only female
patients between 18 and 60 years of age who were
American Society of Anesthesiologists grade 1 or 2
and who underwent liposuction of greater than 3
liters and/or abdominoplasty under intravenous
general anesthesia. Some participants underwent
combined procedures that also included augmen-
tation mammaplasty, bichectomy, rhinoplasty, oto-
plasty, and/or neck liposuction.
The cohort was divided into two groups. The
control group consisted of patients who received
routine medical care without patient blood
management protocols; all patients who under-
went the indicated surgical procedures between
January 11, 2017, and October 23, 2017, were
included. The study group included patients who
underwent the indicated surgical procedures and
received medical care according to patient blood
management protocols between November 12,
2017, and May 5, 2018. The surgical procedures
were performed by on-staff plastic surgeons, who
followed the protocols established for the study.
The measures implemented for patients with
patient blood management were as follows.
Preoperative
If the patient had a hemoglobin concentration
higher than 13  g/dl, no preoperative measures
were implemented. However, if the patient had
hemoglobin levels lower than 13 g/dl, patient blood
management strategies were implemented.4–13
If the hemoglobin concentration was between
12 and 13  g/dl, acute normovolemic hemodilu-
tion of 1 U of blood was conducted before sur-
gery. A total of 500 cc of blood was extracted and
replenished with 500 cc of intravenous colloids.
This procedure was performed at our center,
which is accredited to perform this type of proto-
col. The blood was stored in Fresenius Kabi (Lake
356
Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Zurich, Ill.) bags for blood donation at body tem-
perature and without leaving the operating room.
The procedure was performed using aseptic
measures in accordance with international protocols
for the management of donation and preservation
of blood components. The blood that was collected
was transfused at the end of the surgery, a process
that lasted 2 hours. If the patient’s hemoglobin con-
centration was less than 12 g/dl, surgery was delayed
until the hemoglobin concentration increased
above 12 g/dl by means of parenteral iron and eryth-
ropoietin. This protocol was performed within the
hospital, with strict monitoring of vital signs. In the
supine position, 200 mg of parenteral iron diluted
in 250 cc of 0.9% saline solution was administered
intravenously over a period of 2 hours, followed by
20,000 U of erythropoietin diluted in 100 cc of 0.9%
saline solution over a period of 1 hour. The patient
was observed at the hospital for 1 hour and then
discharged. In total, the procedure lasted 4 hours.
Hemoglobin concentration was measured again at 8
days, and if it had not increased above 12 g/dl, the
protocol was repeated.
Intraoperative
Temperature was strictly monitored to avoid
hypothermia.14,15 The patient was preheated for 1
hour before surgery with pressurized air at 45°C to
47°C, infiltration liquids at 38°C, and intravenous
liquids at 37°C. General intravenous anesthesia
was administered to patients with normal to low
arterial tension but without controlled hypoten-
sion. This process involves positioning the patient
in the prone position for the shortest time possi-
ble. Tranexamic acid (1 g) was administered intra-
venously after anesthetic induction but before the
surgical incision. Liposuction was performed by
subcutaneous infiltration at a 1:1 ratio.
Postoperative
Hemoglobin concentrations were determined
24 and 72 hours after surgery to assess the need for
transfusion. Mandatory transfusion was indicated
for all patients with hemoglobin concentrations
lower than 7  g/dl and for symptomatic patients
with hemoglobin concentrations between 7 and
9 g/dl (Table 1).
The study began at the time of the preopera-
tive evaluation; hemoglobin and hematocrit levels
were assessed for both groups preoperatively and
at 24 and 72 hours after surgery. The frequency
of postoperative transfusions among both groups
was also determined.
From all patients, information was collected
regarding age, weight, height, body mass index,
 Volume 147, Number 2 • Transfusions in Body Contouring Surgery
Table 1.  Summary of Patient Blood Management
Strategies Implemented to Reduce Blood Loss and
Minimize the Need for Postoperative Transfusions
Preoperative
 Hb <12 g/dl
 Erythropoietin 20,000 IU
 Iron 200 mg
 Preheating patient for 1 hr; 45°C to 47°C
 Suspend anticoagulant drugs
Intraoperative
 Tranexamic acid 1 g IV
 Heat up infiltration liquids at 37°C
 Room temperature at 23°C
 Normovolemic hemodilution Hb between 12 and 13 g/dl
 Least possible time in the prone position
 Total lipoaspirate less than 5 liters
Postoperative
 Transfusion
 Hb <9 g/dl and symptoms
 Hb <7 g/dl
 Continue temperature control to prevent hypothermia
Hb, hemoglobin; IV, intravenously.
smoking (tobacco consumption in the past year),
consumption of drugs before surgery that alter
coagulation, American Society of Anesthesiologists
classification, and postoperative hemoglobin (in
grams per deciliter) and hematocrit (percent) val-
ues, in addition to surgical procedure data: type
of surgery, infiltrated volume, total liposuction
volume (<5 and ≥5 liters), surgical time, and time
in the prone position (<60 minutes, 60 to 80 min-
utes, >80 minutes). Finally, information related to
different symptoms was collected, including ceph-
alalgia, orthostasis, tachycardia, nausea, vomiting,
and pain in the postoperative period.
The patients in both groups were hospital-
ized during the first 24 hours. At 24 hours, they
were discharged, and they returned at 72 hours
for hemoglobin measurements. The use of crys-
talloids during hospitalization was exclusive to
maintain a permeable vein and the passage of
medication. The administration of intravenous
fluids during surgery was between 750 and 1250
cc. In the postoperative period, until the patient
was discharged, the average number of liquids
administered was between 500 and 1000 cc.
A liquid diet was initiated after 2 hours, a soft
diet after 6 hours, and a solid diet after 12 hours.
Compression garments began on the fifth day
after surgery. All patients received 3000 U of low-
molecular-weight heparin between 8 and 14 days
after surgery, starting at 12 hours after surgery,
depending on the particular risk of deep vein
thrombosis of each patient.
Statistical Analysis
Taking into account a minimum of 400 sub-
jects, with a 1:1 collection ratio, a power of 80
Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
percent, and a significance level of 5 percent, the
sample size allowed estimating a minimum aver-
age difference of 0.5 g/dl of hemoglobin between
the two groups evaluated. The Shapiro-Wilk test
was used, reporting quantitative variables through
measures of central tendency and dispersion. The
qualitative variables are presented as absolute and
relative frequencies.
To establish differences in the demographic
and clinical variables between the two groups,
chi-square or Fisher’s exact test was used for the
qualitative variables. For the quantitative variables
(hemoglobin levels), the Wilcoxon or Kruskal-
Wallis test was used. Statistically significant dif-
ferences were interpreted as those with a value of
p < 0.05, with a two-tailed test.
To establish the effect of the use of patient
blood management (independent variable) on
hemoglobin levels (dependent variable) at 24
and 72 hours after surgery, an unadjusted linear
regression model adjusted for confounding vari-
ables identified in the initial bivariate analysis
was performed. This approximation was consid-
ered relevant when observing the normal distri-
bution of the residuals both in the crude model
and adjusted for confounding variables. The esti-
mated coefficients are reported with their respec-
tive 95 percent confidence intervals. A sample
of 400 patients was calculated to obtain an epi-
demiologic power of 80 percent and a power of
significance of 5 percent; thus, the errors in the
hemoglobin results were a maximum of 0.5 g/dl.
Statistical analysis was performed with Stata 13.0
software (StataCorp, College Station, Texas).
RESULTS
A total of 409 subjects were included: 202
were included in the control group and did not
receive patient blood management measures, and
207 patients were included in the study group and
did receive patient blood management measures
(Table  2). There were no statistically significant
differences in the antecedents, anthropometric
characteristics, or surgical findings or preopera-
tive hemoglobin levels between the groups. In
the group without patient blood management,
more liposuction procedures occurred, whereas
in patients managed with patient blood man-
agement, abdominoplasty was more common
(Table 2).
Hemoglobin and Hematocrit
The hemoglobin value at 24 hours after sur-
gery was 11.2 g/dl in the patients without patient
357
 Plastic and Reconstructive Surgery • February 2021

Table 2.  Population Characteristics*

Variable Total (%) Usual Management (%) PBM (%) p
No. 409 202 207
Age, yr 0.59
 Median 32 32 33
 Range 28–39 29–38 28–39
Weight, kg 0.20
 Median 65 65 65
 Range 60–73 60–74 60–72
Height, m 0.15
 Median 1.61 1.63 1.60
 Range 1.58–1.66 1.58–1.67 1.58–1.65
BMI, kg/m2 0.59
 Median 24.9 25.0 24.9
 Range 23.1–27.3 23.0–27.5 23.2–27.1
Smoking 18 (4.4) 8 (3.9) 10 (4.8) 0.66
Medication 3 (0.2) — 3 (1.4) 0.24
Individual surgery
 Lipoabdominoplasty 182 (44.0) 82 (40.6) 100 (48.3)
 Liposuction 198 (48.4) 111 (54.9) 87 (42.0) 0.01†
Combined surgery‡
 Lipoabdominoplasty 18 (4.9) 4 (2.0) 14 (6.8)
 Liposuction 11 (2.7) 5 (2.5) 6 (2.9)
Surgical findings
 Lipoaspirate, liters 0.95
   Median 4.0 4.0 4.0
   Range 3.0–5.2 3.0–5.0 3.0–5.5
 Time, min 0.34
   Median 208 198 210
   Range 165–252 161–254 180–250
 Pronation, min 0.06
   Median 70 73.5 63
   Range 55–90 60–90 50–90
Technique used
 VASER 65 (15.6) 42 (20.7) 23 (11.3) 0.01
 Microair 344 (84.3) 168 (83.2) 176 (85.4) 0.52
Preoperative levels
 Hb, g/dl 0.68
   Median 13.5 13.5 13.5
   Range 12.9–14.2 12.9–14.1 12.8–14.2
 Hct, % 0.36
   Median 40.8 40.6 41.0
   Range 39.0–42.3 39.0–42.0 39.0–42.8
BMI, body mass index; VASER, vibration amplification of sound energy at resonance; Hb, hemoglobin; Hct, hematocrit.
*Estimated difference with Fisher’s exact test.
†Statistically significant.
‡Augmentation mammaplasty, bichectomy, rhinoplasty, otoplasty, and/or neck liposuction.

blood management and 11.6 g/dl in the patients
with patient blood management (p = 0.001). At
72 hours after surgery, the hemoglobin value was
9.5  g/dl in the patients without patient blood
management and 10.7 g/dl in those who received
patient blood management (p ≤ 0.0001) (Fig. 1).
In the entire population, an association was
found between longer time in the prone posi-
tion and lower levels of hemoglobin at 24 hours:
12 g/dl for pronation times less than 60 minutes,
11.6  g/dl for pronation times between 60 and
80 minutes, and 10.9  g/dl for pronation times
greater than 80 minutes (p ≤ 0.001). The results
at 72 hours according to the pronation times were
11.0  g/dl for pronation times less than 60 min-
utes, 10.2  g/dl for pronation times between 60
and 80 minutes, and 9.5 g/dl for pronation times
greater than 80 minutes (p ≤ 0.001) (Fig. 2).
Similarly an association was found between
low levels of postoperative hemoglobin and lipo-
suction volume in both patients managed with
patient blood management and in those man-
aged without patient blood management. Both
results were statistically significant. At 24 hours,
the hemoglobin levels were 11.5 g/dl in patients
with a liposuction volume of less than 5 liters and
10.7 g/dl in patients with a liposuction volume of
more than 5 liters (p = 0.003). At 72 hours, these
levels were 10.2  g/dl in patients with a liposuc-
tion volume of less than 5 liters and 9.6  g/dl in
patients with a liposuction volume of more than 5
liters (p = 0.005) (Fig. 3).
According to the type of management used,
differences were found between some surgical
variables and hemoglobin values, especially at 72
hours. Regarding time in the prone position, the

358
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 Volume 147, Number 2 • Transfusions in Body Contouring Surgery

Fig. 1. Postoperative levels of hemoglobin according to the management received. PBM, patient
blood management.

Fig. 2. Postoperative hemoglobin and prone position time.

levels were lower in patients in the group with-
out patient blood management measures, with
a difference of up to 1.8  g/dl more for those
with shorter prone position times (Table 3). This
same scenario was observed between the levels of
hemoglobin and the liposuction volume, with a
more marked difference in the values obtained
at 72 hours and in favor of patients managed
with the patient blood management strategy
(Table 3).
The information from the linear regression
model evaluating the effect of patient blood man-
agement on hemoglobin levels is presented in
Table 4. An additional 1.2 g/dl of hemoglobin was
found at 72 hours after surgery with the use of the
patient blood management strategy. Likewise, this

359
Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • February 2021

Fig. 3. Relationship of hemoglobin levels and liposuction volume in both groups. PBM, patient
blood management.

strategy represented 34.3 percent of the variation
in hemoglobin at 24 hours and 28.8 percent for
hemoglobin at 72 hours (Table 4).
In addition, a statistically significant differ-
ence in the frequency of postoperative transfu-
sions was found, which was higher for patients
who were not managed with the patient blood
management strategy (13.4 percent versus 1.9
percent; p ≤ 0.001).
Patient Blood Management Strategy
Regarding preoperative strategies, lower
hemoglobin levels were observed at 24 hours
(10.2 g/dl versus 11.7 g/dl; p ≤ 0.001) and 72 hours

Table 3.  Surgical Variables and Postoperative Hemoglobin Levels*

Hb 24 Hr (g/dl) Hb 72 Hr (g/dl)
Variable Usual Management PBM p Usual Management PBM p
Individual surgery
 Lipoabdominoplasty 11.2 (10.3–12) 11.6 (10.2–12.2) 0.144 9.7 (8.7–10.5) 10.6 (9.4–11.8) <0.001
 Liposuction 11.2 (10.1–12.2) 11.8 (10.8–12.6) 0.003 9.5 (8.1–10.5) 11.1 (9.6–12.1) <0.001
Combined surgery
 Lipoabdominoplasty 10.4 (9.6–11.3) 11.2 (10.9–12.9) 0.136 8.8 (7.8–9.8) 10.6 (9.3–1.9) 0.033
 Liposuction 11.4 (10.5–11.8) 11.6 (10.6–12) 0.646 9.2 (7–9.8) 10.1 (8.2–11.5) 0.144
Prone position
 <60 min 11.6 (10.4–12.5) 12.2 (11.5–13.5) 0.007 10 (8.7–11.5) 11.8 (10.3–12.8) <0.001
 60–80 min 11.3 (10.3–12.2) 11.8 (10.8–12.4) 0.116 9.8 (8.5–10.5) 11 (9.5–12.0) <0.001
 >80 min 10.7 (9.9–11.5) 10.9 (10.1–11.8) 0.249 9 (7.7–10.0) 10 (9.6–11.1) <0.001
Aspiration
 <5000 ml 11.3 (10.3–12.2) 11.7 (10.6–12.5) 0.009 9.7 (8.3–10.7) 10.8 (9.5–12.0) <0.001
 ≥5000 ml 10.5 (9.6–11.2) 11.2 (10.3–12.5) 0.035 8.8 (7.9–9.9) 10.1 (9.6–11.3) <0.001
HB, hemoglobin; PBM, patient blood management.
*Values are median (range).

Table 4.  Effect of Patient Blood Management on Postoperative Hemoglobin Levels

Hb Crude 95% CI Adjusted* 95% CI R2 p
24 hr 0.457 0.180–0.733 0.456 0.226–0.687 0.343 <0.001
72 hr 1.204 0.858–1.550 1.222 0.909–1.536 0.288 <0.001
*Adjusted for liposuction, surgery time, time in the prone position, use of vibration amplification of sound energy at resonance, and hemoglo-
bin before surgery. The information in the crude and adjusted columns corresponds to the value of the coefficient shown in the linear regres-
sion model. The R2 and the p value correspond to the fitted model.

360
Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 147, Number 2 • Transfusions in Body Contouring Surgery
(9.5  g/dl versus 10.8  g/dl; p = 0.166) in the
patients who were administered iron and erythro-
poietin. This scenario was similar to the use of nor-
movolemic hemodilution and hemoglobin at 24
hours (10.3 g/dl versus 11.8 g/dl; p ≤ 0.001) and
72 hours after surgery (9.8  g/dl versus 11  g/dl;
p = 0.001). In contrast, at 72 hours after sur-
gery, hemoglobin levels were higher in subjects
who had a temperature higher than or equal to
34.5°C (n = 4, 11.4 g/dl; versus n = 203, 10.7 g/dl;
p = 0.64).
Transfusions and Complications
Transfusions were performed in four patients
in the patient blood management group (1.9
percent) (n = 4) and in 27 patients in the con-
trol group (13.4 percent). In all patients in both
groups, the indications for transfusion were symp-
toms secondary to anemia, such as dizziness, head-
ache, tachycardia, palpitations, and fatigue, with a
hemoglobin value between 7 and 9  g/dl. There
were no patients in either group who had a hemo-
globin value less than 7 g/dl. Only one patient in
the first group had an allergy at the end of the
transfusion, which was managed with 200  mg of
hydrocortisone, 2 mg of clemastine, and 50 mg of
ranitidine, without the need for adrenaline. No
patient had a hematoma that required surgical
reintervention. No patient presented with deep
venous thrombosis.
DISCUSSION
This is the first study to implement patient
blood management strategies in plastic surgery
and shows us that, as in other specialties, these
strategies are effective and essential for reduc-
ing intraoperative and postoperative bleeding
and low levels of hemoglobin,4–13,16–19 achieving a
reduction in the need for postoperative transfu-
sion. In our study, transfusions decreased by 85
percent between the group without patient blood
management and the group in which patient
blood management strategies were implemented.
By protocol of our hospital, postoperative hemo-
globin is determined for all patients with lipo-
suction volume greater than 3 liters and after
lipoabdominoplasty, and they remain hospital-
ized for a minimum of 24 hours. This facilitated
the first phase of the study because the patients
were hospitalized. Patient blood management
strategies are based on three fundamental pil-
lars4–8: diagnose and treat preoperative anemia,
minimize blood loss in surgery, and increase ane-
mia tolerance.
Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
The minimum hemoglobin levels suggested
for elective surgery defined by the World Health
Organization are 12 g/dl in women and 13 g/dl
in men.6 The prevalence of anemia in the general
population is 32 percent (or one in every three
people), and 97 percent of preoperative anemia
cases are not treated.7 Thus, one in every three
patients could be entering the operating room
anemic if we do not take proper precautions. The
main cause of anemia is iron deficiency, and it
takes 3 to 6 months of oral treatment to replenish
physiologic reserves, which is 1000 to 2000 mg of
iron.8 Management should be parenteral iron at a
dose of 200 to 500 mg administered intravenously
before surgery combined with intravenous eryth-
ropoietin at a dose ranging from 20,000 to 40,000
U intravenously.9,10 One of the questions that
could arise about the protocols implemented with
presurgical iron and erythropoietin in patients
with low hemoglobin is their cost. The implemen-
tation of this treatment with both medications has
an approximate cost of $200.
One of the main measures to minimize blood
loss in surgery, demonstrated in multiple meta-
analyses, is the optimization of hemostasis with
tranexamic acid.13 The management and control
of hypothermia in surgery is essential to avoid
bleeding and transfusions because hypothermia
deteriorates the entire coagulation cascade.14,15
Likewise, acute normovolemic hemodilution is a
very important measure used to minimize blood
loss during surgery.16
Lastly, strategies should be in place to avoid
transfusions with restrictive thresholds (i.e.,
hemoglobin levels lower than 7 g/dl), and should
be considered only in patients with hemoglobin
levels between 7 and 9 g/dl if they have symptoms
of anemia. If a transfusion is necessary, it should
be reevaluated after each unit.16
This study evaluated hemoglobin levels and
the need for transfusion at 24 and 72 hours in two
groups with the same demographic characteris-
tics, one that did not receive patient blood man-
agement strategies (202 patients) and another
that did (207 patients). We found that, at 24
hours, 0.45  g of hemoglobin was saved with the
implementation of the patient blood manage-
ment strategy and, at 72 hours, 1.2  g of hemo-
globin was saved with the implementation of the
patient blood management strategy. This finding
demonstrates that although patient blood man-
agement reduces intraoperative bleeding, it is
more effective at reducing postoperative bleed-
ing. Altogether, these strategies allow for savings
in terms of blood and hemoglobin levels (34.3
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 Plastic and Reconstructive Surgery • February 2021
percent) and in the number of transfusions (85
percent). The mean liposuction volume for the two
groups was 4 liters, with an average loss of 4 g/dl
hemoglobin (from 13.5  g/dl to 9.5  g/dl) at
72 hours for the group without patient blood
management measures, indicating 1  g/dl hemo-
globin per liter aspirated over 72 hours. In the
patient blood management group, 2.8 g/dl hemo-
globin (from 13.5  g/dl to 10.7  g/dl) was lost at
72 hours; in other words, only 0.7 g/dl hemoglo-
bin was lost for each liter of fat aspirated, equating
to a savings of 30 percent of hemoglobin values
at 72 hours with average hemoglobin levels above
10  g/dl, which improves postoperative recovery.
These results provide a parameter for hemoglo-
bin loss by liter aspirated at 72 hours in groups
with and without patient blood management mea-
surements, and the need to be less aggressive in
liposuction volumes.
Another association that had never been
studied before was the relationship between
time in the prone position, blood loss, and
postoperative anemia. While the body is in a
prone position, physiologically, intraabdomi-
nal pressure increases, and the distal veins are
engorged, increasing the possibility of blood
loss.19 These responses are evident at exact
times.16 In patients with and without patient
blood management, time in the prone position
greater than 60 and 80 minutes was an inde-
pendent and statistically significant factor for
bleeding and postoperative anemia at 72 hours.
To reduce bleeding, limitations for time in the
prone position should be established because, in
this study, more than 80 minutes in the prone
position was associated with hemoglobin levels
lower than 10 g/dl at 72 hours in patients with-
out patient blood management (9  g/dl) and
of 10  g/dl in patients with patient blood man-
agement, a much lower figure than the average
hemoglobin level of patient blood management
patients in the study (10.7 g/dl). Thus, in plastic
surgery, one of the patient blood management
measures that should be added, in addition to
those already mentioned, is a decreased time in
the prone position. Prolonged time in the prone
position affected hemoglobin levels at 72 hours;
therefore, it is necessary to conduct future stud-
ies on this topic.
Undoubtedly, liposuction volume is one of
the most important factors that negatively affects
hemoglobin at 72 hours and the need for transfu-
sion. Liposuction volume greater than 5 liters was
the only independent and statistically significant
factor that was associated with hemoglobin levels
362
Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
less than 9.0 g/dl (8.8 g/dl), whereas liposuction
volume under 5 liters showed hemoglobin lev-
els almost 1 g/dl higher (9.7 g/dl). Importantly,
84.62 percent of the transfusions that were per-
formed, either in the group with patient blood
management or in the group without patient
blood management, were done so in patients with
a liposuction volume greater than 5 liters, and
only 15.38 percent of the transfusions were per-
formed in patients with a liposuction volume less
than 5 liters. Thus, a liposuction volume greater
than 5 liters is the most important factor, leading
not only to a low hemoglobin level at 72 hours
but to the need for transfusion; however, future
randomized studies are needed to confirm this
finding.
A reduction of 34 percent in blood loss could
seem low, but the ultimate goal of patient blood
management is to avoid transfusions. Our work
validates patient blood management in plastic sur-
gery because, in the group without patient blood
management, 27 patients (13.4 percent) were
transfused, whereas in the group with patient
blood management, four patients (1.9 percent)
were transfused; that is, it was possible to decrease
transfusions by 85 percent using patient blood
management strategies.
When logistic regression was performed on
preoperative strategies to increase hemoglo-
bin levels, the use of parenteral iron (200  mg)
in addition to erythropoietin (20,000 U intrave-
nously in a single dose) to increase hemoglobin
levels in preoperative anemic patients was associ-
ated with higher levels of hemoglobin at 24 and
72 hours (1.5 and 1.3  g/dl higher, respectively)
compared with patients who were not given any,
which is consistent with studies and meta-analyses
conducted in other specialties.7,13,20,21 The use of
acute normovolemic hemodilution in patients
with hemoglobin levels between 12 and 13  g/dl
before surgery also showed a savings of 1.5 g/dl,
indicating, as in previous studies and meta-anal-
yses,7,20,22–24 that these measures are effective at
reducing blood loss and the need for transfusion
by almost 30 percent.
Another factor widely studied in postoperative
bleeding is hypothermia. In our study, tempera-
tures below 34.5°C were associated with hemo-
globin levels of 10.7  g/dl, whereas temperatures
above 34.5°C were associated with higher hemo-
globin levels (11.4  g/dl). This result correlates
with other studies showing that hypothermia is
one of the main determinants of coagulation
deterioration and greater intraoperative and post-
operative bleeding.25,26
 Volume 147, Number 2 • Transfusions in Body Contouring Surgery
CONCLUSIONS
This study validates the necessity of using patient
blood management strategies in plastic surgery in
patients who are undergoing liposuction of more
than 4 liters and lipoabdominoplasty. The strate-
gies to be implemented will depend on the level
of hemoglobin that each patient presents. Simple
measures—such as the optimization of hemoglobin
preoperatively with parenteral iron and erythro-
poietin, suspension of drugs that alter coagulation,
intraoperative strategies that are easy to implement
(e.g., the use of tranexamic acid at a dose of 1 g fol-
lowing induction of anesthesia, thermal intraopera-
tive protection, and hemodilution), normovolemia
in patients with hemoglobin levels between 12 and
13 g/dl, and decreasing the transfusion threshold
to 7 g/dl in the postoperative period—have proven
to be effective strategies for reducing intraoperative
and postoperative bleeding and for avoiding post-
operative transfusions (Table 1).
Lázaro Cárdenas-Camarena, M.D.
Hospital Innovare
AV Verona 7412
Zapopan, Jalisco 451019, Mexico
drlazaro@drlazarocardenas.com
REFERENCES
1. Shander A, Goodnough LT, Javidroozi M, et al. Iron defi-
ciency anemia: Bridging the knowledge and practice gap.
Transfus Med Rev. 2014;28:156–166.
2. Shander A, Javidroozi M, Ozawa S, Hare GM. What is
really dangerous: Anaemia or transfusion? Br J Anaesth.
2011;107(Suppl 1):i41–i59.
3. Prescott LS, Aloia TA, Brown AJ, et al. Perioperative blood
transfusion in gynecologic oncology surgery: Analysis of the
National Surgical Quality Improvement Program Database.
Gynecol Oncol. 2015;136:65–70.
4. Shander A, Hofmann A, Isbister J, Van AH. Patient blood
management: The new frontier. Best Pract Res Clin Anaesthesiol.
2013;27:5–10.
5. Farmer SL, Trentino K, Hofmann A, et al. A programmatic
approach to patient blood management - reducing transfu-
sions and improving patients outcomes. Open Anesthesiol J.
2015;9:6–16. Available at: https://openanesthesiajournal.
com/contents/volumes/V9/TOATJ-9-6/TOATJ-9-6.pdf.
Accessed October 4, 2011.
6. Society for the Advancement of Blood Management. About
SABM. Available at: https://sabm.org/wp-content/uploads/
SABM-Standards-2019.pdf. Accessed October 4, 2011.
7. Muñoz M, Gomez-Ramirez S, Kozek-Langeneker S, et al. ‘Fit
to fly’: Overcoming barriers to preoperative haemoglobin
optimization in surgical patients. Br J Anaesth. 2015;115:15–24.
8. Clevenger B, Mallett SV, Klein AA, Richards T. Patient
blood management to reduce surgical risk. Br J Surg.
2015;102:1325–1337; discussion 1324.
9. Litton E, Xiao J, Ho KM. Safety and efficacy of intravenous
iron therapy in reducing requirement for allogeneic blood
transfusion: Systematic review and meta-analysis of ran-
domised clinical trials. BMJ 2013;347:f4822.
Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
10. Susantitaphong P, Alqahtani F, Jaber BL. Efficacy and safety
of intravenous iron therapy for functional iron deficiency
anemia in hemodialysis patients: A meta-analysis. Am J
Nephrol. 2014;39:130–141.
11. Enko D, Wallner F, von-Goedecke A, Hirschmugl C,
Auersperg V, Halwachs-Baumann G. The impact of an
algorithm-guided management of preoperative anemia in
perioperative hemoglobin level and transfusion of major
orthopedic surgery patients. Anemia 2013;2013:641876.
12. Huang F, Wu D, Ma G, Yin Z, Wang Q. The use of tranexamic
acid to reduce blood loss and transfusion in major orthope-
dic surgery: A meta-analysis. J Surg Res. 2014;186:318–327.
13. Ker K, Prieto-Merino D, Roberts I. Systematic review, meta-
analysis and meta-regression of the effect of tranexamic acid
on surgical blood loss. Br J Surg. 2013;100:1271–1279.
14. Rohrer MJ, Natale AM. Effect of hypothermia on the coagu-
lation cascade. Crit Care Med. 1992;20:1402–1405.
15. Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of
mild perioperative hypothermia on blood loss and transfu-
sion requirement. Anesthesiology 2008;108:71–77.
16. American Society of Anesthesiologists Task Force on
Perioperative Blood Management. Practice guidelines
for perioperative blood management: An updated report
by the American Society of Anesthesiologists Task Force
on Perioperative Blood Management. Anesthesiology
2015;122:241–275.
17. Shander A, Colomina MJ, Gombotz H, et al. Patient blood
management in Europe. Br J Anaesth. 2012;109:55–68.
18. Fischer DP, Zacharowski KD, Müller MM, et al. Patient blood
management implementation strategies and their effect on
physicians’ risk perception, clinical knowledge and periop-
erative practice: The Frankfurt experience. Transfus Med
Hemother. 2015;42:91–97.
19. Kwee MM, Ho YH, Rozen WM. The prone position during
surgery and its complications: A systematic review and evi-
dence-based guidelines. Int Surg. 2015;100:292–303.
20. Zhou X, Zhang C, Wang Y, Yu L, Yan M. Preoperative
acute normovolemic hemodilution for minimizing allo-
geneic blood transfusion: A meta-analysis. Anesth Analg.
2015;121:1443–1455.
21. Serrano-Trenas JA, Ugalde PF, Cabello LM, Chofles LC,
Lázaro PS, Benítez PC. Role of perioperative intravenous
iron therapy in elderly hip fracture patients: A single-center
randomized controlled trial. Transfusion 2011;51:97–104.
22. Susantitaphong P, Alqahtani F, Jaber BL. Efficacy and safety
of intravenous iron therapy for functional iron deficiency
anemia in hemodialysis patients: A meta-analysis. Am J
Nephrol. 2014;39:130–141.
23. Theusinger OM, Kind SL, Seifert B, Borgeat L, Gerber
C, Spahn DR. Patient blood management in orthopae-
dic surgery: A four-year follow-up of transfusion require-
ments and blood loss from 2008 to 2011 at the Balgrist
University Hospital in Zurich, Switzerland. Blood Transfus.
2014;12:195–203.
24. Segal JB, Blasco-Colmenares E, Norris EJ, Guallar E.
Preoperative acute normovolemic hemodilution: A meta-
analysis. Transfusion 2004;44:632–644.
25. Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypo-
thermia increases blood loss and transfusion requirements
during total hip arthroplasty. Lancet 1996;347:289–292.
26. Sun Z, Honar H, Sessler DI, et al. Intraoperative core tem-
perature patterns, transfusion requirement, and hospital
duration in patients warmed with forced air. Anesthesiology
2015;122:276–285.
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