* Opt for autologous blood deposit and transfusion. Your own blood can be taken and stored, ready to be given back to you as and when you need it.
* Ask for the return of your own postoperative salvaged blood. A study of this procedure in spinal surgery found it to be a good source of viable red blood cells without the transfusion-related risks (Eur Spine J, 2004; 8 May online).
* Have a saline transfusion to replace blood volume and maintain blood pressure. Blood plasma is 55 per cent of your blood volume (and is 95 per cent water), and volume replacement doesn't require transfusion of whole blood or plasma. Saline is cheap and compatible with human blood. Other fluids such as dextran, Haemaccel, lactated Ringer's solution and Hetastarch would also do. Although such fluids can't carry oxygen as whole blood does, they can facilitate the delivery of blood to tissues, as diluted blood flows more freely even through the tiniest blood vessels. Also, a patient at rest only uses 25 per cent of the oxygen available in blood, and most anaesthetics further reduce the need for oxygen.
* Opt for 'dry' surgery - where no blood is transfused. This technique was pioneered by surgeons working with patients who were Jehovah's Witnesses and refused blood transfusions because of their faith. There are ways to prevent blood loss and reduce the need for additional blood, including using drugs to stimulate blood-cell production, giving nutritional support (see below), and using techniques to maximise cardiac output, increase oxygen content of the blood and decrease metabolic rate. Dry surgery requires teamwork and planning to be successful, and can produce low rates of morbidity (illness) and death (Ann Ital Chir, 2002; 73: 197-209).
* Take iron and folic acid supplements as a matter of course, and have yourself tested for iron or folate deficiency.
* Stop taking aspirin - it encourages bleeding.
* Tell your doctor if you're taking non-steroidal anti-inflammatory drugs (NSAIDs) and anticoagulants (blood thinners).
* Ask for continuous oxygen via a facemask. Oxygen administered at high concentrations can compensate for fewer red blood cells when severe blood loss has occurred, or for low levels of haemoglobin. A normal amount of blood haemoglobin is 14-15 g/100 mL of blood whereas, for surgery, the minimum level can be as low as 2-2.5 g/100 mL before a transfusion is considered necessary.
* Opt for pharmacological alternatives to blood transfusion. These include drugs that reduce bleeding such as aprotinin, antifibrinolytics, synthetic arginine-vasopressin derivatives (DDAVP) and recombinant factor VII (rfVIIa), all of which have been shown to prevent the need for blood transfusion after major heart, liver and musculoskeletal surgery. rfVIIa has reduced bleeding in haemophiliacs, and may also have benefits for postoperative patients with life-threatening haemorrhage (Med Clin [Barc], 2004; 122: 231-6).
* Consider drugs that stimulate red-blood-cell production and haemoglobin concentration, such as erythropoietin, which may help to reduce the requirement for blood in both medical and surgical cases.
* Consider fibrin glues and sealants to stop bleeding.
* Consider using tranexamic acid (Cyklokapron), an antifibrinolytic used to treat serious bleeding in haemophiliacs