Perioperative patient blood management: A new standard of care for pediatric patients

Perioperative Patient Blood Management (PBM) is an evidence-based, patient-centered approach increasingly recognized as the standard of care in pediatric surgery. Although blood transfusion save lives, it carries higher risks in children, including immunomodulation, organ dysfunction, prolonged hospitalization, and increased costs. Preoperative anemia, particularly common in low- and middle-income countries, is a predictor of perioperative transfusion and adverse outcomes. PBM is based on three pillars: optimizing red cell mass, minimizing perioperative blood loss, and improving tolerance to anemia. Strategies include early anemia detection, iron supplementation, restrictive transfusion thresholds, intraoperative blood conservation techniques, antifibrinolytic therapy, cell saver, normovolemic hemodilution, Surgical, anesthetic methods and goal-directed transfusion guided by viscoelastic testing and massive hemorrhage protocols. Massive perioperative hemorrhage remains a leading cause of morbidity and preventable cardiac arrest in children, particularly in complex surgeries such as trauma, cardiac procedures, scoliosis, craniosynostosis, and liver transplantation. Effective management requires early recognition of high-risk patients, restrictive transfusion strategies, meticulous surgical hemostasis, and goal-directed interventions guided by viscoelastic testing and massive hemorrhage protocols. Novel approaches, such as artificial intelligence and machine learning, may further enhance inventory management and predict transfusion needs. Importantly, pediatric transfusion practices must consider unique physiological requirements, avoiding simple extrapolation from adult thresholds. Postoperative management emphasizes minimizing iatrogenic blood loss, adhering to institutional guidelines, and applying multimodal, physiology-guided strategies. PBM improves safety, reduces unnecessary transfusions, conserves resources, and enhances outcomes in pediatric perioperative care. Implementation requires multidisciplinary collaboration and institutional commitment.