Blood management in enhanced recovery after hip and knee replacement

Enhanced recovery in orthopedic surgery is a global patient management strategy to achieve early functional recovery. Blood management is central to rehabilitation protocols after hip or knee replacement. Coagulation physiology in hip and knee replacement is now well described, showing aggravation of bleeding by hyperfibrinolysis. The present study approaches blood management via 3 questions. 1/How to anticipate and prevent transfusion risk preoperatively? Screening for predictive factors can target the at-risk population, enabling a strategy of preoperative hemoglobin level optimization. 2/How to improve intraoperative hemostasis so as to minimize blood loss? Anti-fibrinolytic and topical hemostatic agents have proven efficacy. Tranexamic acid plays a central role. The impact of the usual surgical techniques, such as pneumatic tourniquet and postoperative drainage, on bleeding needs assessment. 3/How to manage postoperative anemia? Anemia without signs of general intolerance is frequent at discharge, but has been little studied. This raises the question of the medical interest of correcting postoperative anemia. LEVEL OF EVIDENCE: Expert opinion, V.