Multidrug-Resistant Bacteria in Surgical Intensive Care Units: Antibiotic Susceptibility and ß-Lactamase Characterization.

Multidrug-resistant (MDR) bacteria of the utmost importance are extended-spectrum ß-lactamase (ESBL) and carbapenemase-producing Enterobacterales (CRE), carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Pseudomonas aeruginosa (CRPA), methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus spp. (VRE). In this study, an evaluation of MDR bacteria in surgical intensive care units in a tertiary referral hospital was conducted. The study aimed to characterize ß-lactamases and other resistance traits of Gram-negative bacteria isolated in surgical intensive care units (ICUs). Disk diffusion and the broth dilution method were used for antibiotic susceptibility testing, whereas ESBL screening was performed through a double disk synergy test and an inhibitor-based test with clavulanic acid. A total of 119 MDR bacterial isolates were analysed. ESBL production was observed in half of the Proteus mirabilis, 90% of the Klebsiella pneumoniae and all of the Enterobacter cloacae and Escherichia coli isolates. OXA-48 carbapenemase, carried by the L plasmid, was detected in 34 K. pneumoniae and one E. coli and Enterobacter cloacae complex isolates, whereas NDM occurred sporadically and was identified in three K. pneumoniae isolates. OXA-48 positive isolates coharboured ESBLs belonging to the CTX-M family in all but one isolate. OXA-23 carbapenemase was confirmed in all A. baumannii isolates. The findings of this study provide valuable insight of resistance determinants of Enterobacterales and A. baumannii which will enhance surveillance and intervention strategies that are necessary to curb the ever-growing carbapenem resistance rates.

Near-Infrared Spectroscopy-Guided, Individualized Arterial Blood Pressure Management for Carotid Endarterectomy under General Anesthesia: A Randomized, Controlled Trial.

Background: Differences in blood pressure can influence the risk of brain ischemia, perioperative complications, and postoperative neurocognitive function in patients undergoing carotid endarterectomy (CEA). Methods: In this single-center trial, patients scheduled for CEA under general anesthesia were randomized into an intervention group receiving near-infrared spectroscopy (NIRS)-guided blood pressure management during carotid cross-clamping and a control group receiving standard care. The primary endpoint was postoperative neurocognitive function assessed before surgery, on postoperative days 1 and 7, and eight weeks after surgery. Perioperative complications and cerebral autoregulatory capacity were secondary endpoints. Results: Systolic blood pressure (p < 0.001) and norepinephrine doses (89 (54-122) vs. 147 (116-242) µg; p < 0.001) during carotid cross-clamping were lower in the intervention group. No group differences in postoperative neurocognitive function were observed. The rate of perioperative complications was lower in the intervention group than in the control group (3.3 vs. 26.7%, p = 0.03). The breath-holding index did not differ between groups. Conclusions: Postoperative neurocognitive function was comparable between CEA patients undergoing general anesthesia in whom arterial blood pressure during carotid cross-clamping was guided using NIRS and subjects receiving standard care. NIRS-guided, individualized arterial blood pressure management resulted in less vasopressor exposition and a lower rate of perioperative complications.

What Constitutes a "Good Death"?-A Representative Cross-Sectional Survey Among the General Public in Croatia.

Understanding the attitudes of a particular society on a "good death" is important when it comes to end-of-life decision-making and palliative care. In the Republic of Croatia no systematic research has been done on the attitudes of the general population about the concept of a "good death". This cross sectional survey was conducted on a three-stage random sample, stratified by regions, counties and locations within those counties (N = 1203) during November and December, 2019. ANOVA, to determine differences, factor analysis and multiple regression analysis were used. The most important characteristics of a good death outlined by the respondents were: the absence of pain, the presence and unencumberedness of family and loved ones, the importance of a sense of fulfilment and meaning in life in this regard, reconciliation with God, the presence of awareness and sobriety, and the possibility of treatment.

Experiences and attitudes of medical professionals on treatment of end-of-life patients in intensive care units in the Republic of Croatia: a cross-sectional study.

BACKGROUND: Decisions about limitations of life sustaining treatments (LST) are made for end-of-life patients in intensive care units (ICUs). The aim of this research was to explore the professional and ethical attitudes and experiences of medical professionals on treatment of end-of-life patients in ICUs in the Republic of Croatia. METHODS: A cross-sectional study was conducted among physicians and nurses working in surgical, medical, neurological, and multidisciplinary ICUs in the total of 9 hospitals throughout Croatia using a questionnaire with closed and open type questions. Exploratory factor analysis was conducted to reduce data to a smaller set of summary variables. Mann-Whitney U test was used to analyse the differences between two groups and Kruskal-Wallis tests were used to analyse the differences between more than two groups. RESULTS: Less than third of participants (29.2%) stated they were included in the decision-making process, and physicians are much more included than nurses (p < 0.001). Sixty two percent of participants stated that the decision-making process took place between physicians. Eighteen percent of participants stated that 'do-not-attempt cardiopulmonary resuscitations' orders were frequently made in their ICUs. A decision to withdraw inotropes and antibiotics was frequently made as stated by 22.4% and 19.9% of participants, respectively. Withholding/withdrawing of LST were ethically acceptable to 64.2% of participants. Thirty seven percent of participants thought there was a significant difference between withholding and withdrawing LST from an ethical standpoint. Seventy-nine percent of participants stated that a verbal or written decision made by a capable patient should be respected. Physicians were more inclined to respect patient's wishes then nurses with high school education (p = 0.038). Nurses were more included in the decision-making process in neurological than in surgical, medical, or multidisciplinary ICUs (p < 0.001, p = 0.005, p = 0.023 respectively). Male participants in comparison to female (p = 0.002), and physicians in comparison to nurses with high school and college education (p < 0.001) displayed more liberal attitudes about LST limitation. CONCLUSIONS: DNACPR orders are not commonly made in Croatian ICUs, even though limitations of LST were found ethically acceptable by most of the participants. Attitudes of paternalistic and conservative nature were expected considering Croatia's geographical location in Southern Europe.

THE EFFECT OF REGIONAL VS. GENERAL ANESTHESIA ON THE IMMUNE RESPONSE IN BREAST CANCER SURGERY: A NARRATIVE REVIEW OF THE LITERATURE.

For breast cancer patients, surgery remains the cornerstone in treatment. Perioperative and postoperative period is associated with impaired immune function that can have profound implications for cancer patients in terms of tumor recurrence and metastases. The three main factors include surgery and related neuroendocrine stress response, anesthetic drugs, including opioid analgesics and postoperative pain. The most investigated immune cells are natural killer (NK) cells that are affected by both anesthesia and surgery. It has been demonstrated that ketamine, thiopental, volatile anesthetics, fentanyl and morphine, but not propofol, remifentanil or tramadol reduce the number of circulating NK cells and depress their toxicity. The level of NK cells' cytotoxicity is inversely proportional to the stage and spread of cancer. Regional anesthesia and its potential beneficial effects on the perioperative immune response and long-term outcome after surgery has been investigated as an alternative to general anesthesia in patients undergoing breast cancer surgery. In this paper, we present a review of literature aimed to assess the impact of regional anesthesia techniques on the immune response in patients undergoing breast cancer surgery and how it compares to general anesthesia.

End-of-Life Decisions in Intensive Care Units in Croatia-Pre COVID-19 Perspectives and Experiences From Nurses and Physicians.

Healthcare professionals working in intensive care units (ICUs) are often involved in end-of-life decision-making. No research has been done so far about these processes taking place in Croatian ICUs. The aim of this study was to investigate the perceptions, experiences, and challenges healthcare professionals face when dealing with end-of-life decisions in ICUs in Croatia. A qualitative study was performed using professionally homogenous focus groups of ICU nurses and physicians (45 in total) of diverse professional and clinical backgrounds at three research sites (Zagreb, Rijeka, Split). In total, six institutions at the tertiary level of healthcare were included. The constant comparative analysis method was used in the analysis of the data. Differences were found between the perceptions and experiences of nurses and physicians in relation to end-of-life decisions. Nurses' perceptions were more focused on the context and features of immediate care, while physicians' perceptions also included the wider sociocultural context. However, the critical issues these specific professional groups face when dealing with end-of-life decisions seem to overlap. A high variability of practices, both between individual practitioners and between different organizational units, was omnipresent. The lack of adequate legal, professional, and clinical guidelines was commonly expressed as one of the most critical source of difficulties.

Allergic reactions to colloid fluids in anesthesia.

Allergic reactions in anesthesia are a rare event, however, might be life threatening when occurred. Clinical manifestations may not be indicative at first, and difficult to differentiate from different situations during operation and anesthesia. Colloids represent a group of fluids often used during perioperative period that, among other adverse reactions, have an allergic potential. Albumin is a natural colloid that has the lowest incidence of these reactions. However, it is found as an additional substance in other blood products, and, therefore, has to be taken into consideration if anaphylaxis occurs. Dextrans cause the most severe reactions due to dextran reactive antibodies. Pretreatment with Dextran 1 may inhibit the reaction. Gelatins have the highest incidence of anaphylaxis among colloids. Patients with history of allergy to some food, vaccines, cosmetics containing gelatin are at greater perioperative risk for anaphylaxis. Not to forget, gelatins are also a part of topical haemostatic agents used in surgery. Testing for colloid allergies is limited due to their pathophysiologic mechanism, so the clinical assessment is usually essential. Treatment of anaphylaxis caused by colloids is the same as for any other cause. This is a review of the most common colloids and their association with allergic reactions in everyday practice.

The potential role of micro-RNA-211 in the pathogenesis of sleep-related hypermotor epilepsy.

Sleep-related hypermotor epilepsy (SHE) is a rare epileptic syndrome characterized by epileptic seizures which occur during the non-rapid eye movement (NREM) stage of sleep. It manifests with hypermotor semiology resembling violent limb movements and an asymmetric tonic-dystonic posture. The genes which are responsible for the autosomal dominant form of SHE (ADSHE) and whose function is to code the sub-unit of the neuronal acetylcholine receptor are well known. Considering that ADSHE is a prototype of SHE, it is thought that the dysfunction of the cortico-subcortical cholinergic network, which regulates the cycle of sleep, has a key role in the epileptogenesis of this syndrome. Namely, studies to date, have shown that the hypercholinergic activity is sufficient for the development of epileptic seizures, even though the exact mechanism remains to be elucidated. NREM parasomnias are sleep disorders that are the most difficult to differentiate from SHE due to a similar clinical presentation. Considering the clinical similarities, NREM occurrence and probable genetic connection, it is considered that fundamentally, both of these conditions share a common pathophysiological mechanism i.e. cholinergic dysfunction. The main difference between SHE and NREM parasomnias are the genuine epileptic seizures that are responsible for the semiology in SHE. These genuine seizures are not present in NREM parasomnias. Why this is so, remains to be elucidated. Considering that animal studies have shown that dynamic changes and the decreased levels of microRNA-211 contribute to epileptic seizures and to changes in cholinergic pathways, our hypothesis is that epileptic seizures and the development of epileptogenesis in SHE are a consequence of cholinergic dysfunction and decreased levels of microRNA-211 as opposed to NREM parasomnias where there is a stable level of microRNA-211, preventing epileptogenesis despite the cholinergic system dysfunction.

Ethical content of expert recommendations for end-of-life decision-making in intensive care units: A systematic review.

PURPOSE: Intensive care unit health care professionals must be skilled in providing end-of-life care. Crucial in this kind of care is end-of-life decision-making, which is a complex process involving a variety of stakeholders and requiring adequate justification. The aim of this systematic review is to analyse papers tackling ethical issues in relation to end-of-life decision-making in intensive care units. It explores the ethical positions, arguments and principles. METHODS: A literature search was conducted in bibliographic databases and grey literature sources for the time period from 1990 to 2019. The constant comparative method was used for qualitative analysis of included papers in order to identify ethical content including ethical positions, ethical arguments, and ethical principles used in decision-making process. RESULTS: In the 15 included papers we have identified a total of 43 ethical positions. Ten positions were identified as substantive, 33 as procedural. Twelve different ethical principles emerged from the ethical arguments. The most frequently used principles are the principles of beneficence, autonomy and nonmaleficence. CONCLUSIONS: We have demonstrated that recommendations and guidelines designed specifically by intensive or critical care experts for intensive care units promote similar ethical positions, with minimal dissenting positions.

DEXAMETHASONE - INTRATHECAL MINIMISER OF SIMPLE HAEMATHOLOGIC STRESS BIOMARKERS IN HIP FRACTURE.

Proximal femoral fractures are the most common cause of emergency admission to hospital with high postoperative morbidity. The hypothesis was that a single shot of intrathecal dexamethasone and levobupivacaine in anaesthesia for surgical correction of proximal femoral fracture in elderly patients reduces surgical stress with better quality hospitalisation. The study included sixty elderly patients with proximal femoral fracture, ASA status 2 and 3, randomised into two groups. The study group of thirty patients received 8 mg of dexamethasone and 12,5 mg of levobupivacaine 0,5% intrathecally, DLSA group, and the parallel group of thirty patients received 12,5 mg of levobupivacaine 0,5% intrathecally, LSA group. Plasma cortisol and glucose concentrations were assessed before and after anaesthesia, pain intensity was evaluated using Visual Analogue Scale score and hospitalisation was analysed. Results showed decreased cortisol concentrations, longer analgesia duration and shorter hospitalisation in the DLSA group. Glucose concentrations did not differ significantly between the patients in either group. Enlightening the study results collected, single shot of intrathecal administration of dexamethasone in spinal anaesthesia for surgical treatment of proximal femoral fractures reduces the stress response by decreasing plasma cortisol concentrations prolonging analgesia with better rehabilitation possibilities, hence shortening hospitalisation which explains this pattern of anaesthesia.

REGIONAL ANESTHESIA FOR NEUROSURGERY.

During neurosurgery procedures it is vital to assure optimal cerebral perfusion and oxygenation. Despite physiological autoregulation of brain perfusion, maintaining hemodynamic stability and good oxygenation during anesthesia is vital for success. General anesthesia with mechanical ventilation and current drugs provide excellent hemodynamic condition and it is the first choice for most neurosurgery procedures. However, sometimes it is very hard to avoid brief increase or decrease in blood pressure especially during period of intense pain, or without pain stimulation. This could be detrimental for patients presented with high intracranial pressure and brain edema. Modifying anesthesia depth or treatment with vasoactive drugs usually is needed to overcome such circumstances. On the other hand it is important to wake the patients quickly after anesthesia for neurological exam. That is why regional anesthesia of scalp and spine could show beneficial effects by decreasing pain stimuli and hemodynamic variability with sparing effect of anesthetics drugs. Also regional techniques provide excellent postoperative pain relief, especially after spinal surgery.

Effect of Inhalational Anesthetics on Acute Kidney Injury

Acute kidney injury (AKI) is a serious complication associated with increased morbidity and mortality. Total incidence of AKI in hospitalized patients is 1%-5%. As many as 30% of these patients develop AKI in the perioperative period, which is associated with anesthesia and surgery. Despite scientific advances and improved surgery techniques, as well as treatment in intensive care units, no significant decrease in AKI incidence has been achieved. To change this outcome, it is important to identify patients at risk of AKI and prevent its occurrence. Correct selection of anesthetic drugs during general anesthesia, adjusted to the individual needs of patients, also influences the overall outcome of treatment. Nowadays, inhalational anesthetics are not considered nephrotoxic. The more so, inhalational anesthetics have a strong and direct protective effect on many organs through preconditioning and postconditioning. New studies have shown that sevoflurane diminishes ischemia/ reperfusion kidney injury and has an anti-inflammatory effect, thus having the potential to reduce the occurrence of AKI. Given the incidence of AKI in the perioperative period, as well as new findings about anesthetics, the issue of anesthetic selection during general anesthesia might be of crucial importance for the final outcome of treatment.

[Paraneoplastic limbic encephalitis]. / Paraneoplasticki limbicki encefalitis.

Paraneoplastic limbic encephalitis (PLE) is a condition characterized by nervous system damage or dysfunction without indication that the nervous system is directly affected by tumor cells. Since it is clinically presented with an array of neuropsychiatric symptoms that usually precede the occurrence of malignant disease, and because of mimicking a psychiatric disease, it can sometimes make the diagnosis difficult and can be overlooked. Typical presentations consist of progressive confusion and deficits in short-term memory, which worsen over days to weeks. The current hypothesis on the pathogenesis of PLE implicates an autoimmune process involving antigens shared by tumor cells and neuronal cells in limbic structures. It has been considered that the autoantibodies cross-react with antigens on normal cells such as the neurons, resulting in cytotoxicity, or they can form complexes with a circulating antigen to induce organ damage through immune complex deposition. The treatment of PLE involves underlying cancer removal by surgery, chemotherapy, radiotherapy or hormonal treatment, and immunosuppressive therapy. Unfortunately, this therapy combination is still generally unsatisfactory. Although PLE is a relatively rare neurologic disorder, because of its association with malignancies and difficulty in diagnosing, this article gives a brief review of the literature and summarizes current knowledge of this syndrome.

[Delirium assessment scoring scales]. / Bodovne ljestvice za procjenu delirija.

Delirium is a significant psychiatric disorder in intensive care units that has negative impact on morbidity and mortality of intensive care patients. Subjective clinical assessment of patients by non-psychiatric health professionals in intensive care units is not sufficient for detection and measurement of delirium. Therefore, different scoring scales for delirium assessment have been developed. This paper reviews the characteristics of commonly used scoring scales for assessment of delirium in intensive care units: the Confusion Assessment Method-Intensive Care Unit (CAM-ICU), the Intensive Care Delirium Screening Checklist (ICD-SC), the Nursing Delirium Screening Scale (Nu-DESC) and the Detecting Delirium Scale (DDS). Routine implementation of objective scoring scales is not widespread. Evidence suggests that objective assessment of delirium contributes to its early detection in intensive care and initiation of appropriate treatment. It is therefore advisable to make additional educational effort to provide an objective scoring scale for the assessment of delirium, such as CAM-ICU, to be routinely used in intensive care units.

[Prevention and treatment of intensive care unit delirium]. / Prevencija i terapija bolesnika s delirijem u jedinici intenzivnog lijecenja.

Delirium is a common problem in intensive care patients, frequently underdiagnosed and resulting in prolonged hospital stay and a high risk of morbidity and mortality. On the other hand, reversibility of the condition points to the importance of prevention, early diagnosis and immediate therapy. Management strategy is directed to nonpharmacological interventions as preventive measures and pharmacological treatment, which includes typical and atypical neuroleptics. Delirium management includes haloperidol as the first line medication, but also olanzapine and risperidone as atypical neuroleptics. Benzodiazepines are used in delirium caused by alcohol withdrawal.

[Pathophysiology of delirium]. / Patofiziologija delirija.

Today's understanding of the pathophysiological mechanisms of delirium is still limited, but there are several promising hypotheses. It is believed that biomarkers sensitive to death of neurons or glial cells indicate delirium. Several neurotransmitters are considered to be involved in the state of delirium, with greatest emphasis on acetylcholine and dopamine acting in opposite ways; acetylcholine reduces, while dopamine increases neuron excitability. Other neurotransmitters that probably play a role in the pathogenesis of delirium are GABA, glutamate and monoamines. Sepsis leading to systemic inflammatory response syndrome often presents with delirium and perhaps is the most common causal factor for delirium in intensive care unit; sedatives and analgesics are also common iatrogenic risk factors. Patients receiving benzodiazepines are more likely to have postoperative delirium than those who do not. Postoperative cognitive changes are more common in older than in younger patients, and they can be categorized as postoperative delirium, postoperative cognitive dysfunction and dementia. The mechanisms responsible for postoperative cognitive changes are not fully understood, but it is certain that they are multifactorial. Risk factors may be associated with patient characteristics, type of surgery and type of anesthesia.

[Postoperative mental disorders in cardiovascular surgery]. / Poslijeoperacijski poremecaji mentalnih funkcija u kardiovaskularnoj kirurgiji.

Postoperative mental disorders are a common complication of cardiovascular surgery, with serious consequences. The main types of postoperative mental disorders include postoperative delirium and postoperative cognitive dysfunction. Their incidence ranges up to 15%-80%. Postoperative mental disorders may be reversible and irreversible. Although reversible in most cases, postoperative mental disorders are associated with increased mortality, morbidity and increasing costs of treatment. The treatment is usually symptomatic and may be associated with dangerous side effects. Safer and more effective is preventive action. Preoperative preventive action need to recognize, avoid and optimize risk factors. Intraoperative prevention involves maintaining optimal oxygenation of the brain during cardiovascular surgery. For postoperative prevention, multimodal approach is applied. It includes early extubation, early enteral nutrition, early mobilization, regular evaluation of cognitive function, activation of cognitive function and optimal analgesia, which requires teamwork of medical staff who care for patients. Combining all these methods can show promising results in reducing the incidence of postoperative mental disorders as a complication in cardiovascular surgery.

[Perioperative disorders of mental functions]. / Perioperacijski poremecaji mentalnih funkcija.

Mental disorders are characterized by disturbances of thought, perception, affect and behavior, which occur as a result of brain damage. Recognizing and treating these conditions is necessary not only for psychiatrists but for all physicians. Disorder of mental function is one of the most common associated conditions in intensive care unit (ICU) patients. However, disturbances of mental function often remain unrecognized. In ICU patients, different types of mental function disorders may develop. They range from sleep disorders, severe depression, anxiety, posttraumatic stress disorder (PTSD) to cognitive disorders including delirium. The causes of mental dysfunction in ICU patients can be divided into environmental and medical. Cognitive disorders are related to mental processes such as learning ability, memory, perception and problem solving. Cognitive disorders are usually not prominent in the early postoperative period and in many cases are discovered after hospital discharge because of difficulties in performing everyday activities at home or at work. The etiology of postoperative cognitive impairment is unclear. Older age, previous presence of cognitive dysfunction, severity of disease, and polypharmacy with more than four drugs are some of the risk factors identified. Delirium is a multifactorial disorder. It is an acute confusional state characterized by alteration of consciousness with reduced ability to focus, sustain, or shift attention. It is considered as the most common form of mental distress in ICU patients. Nearly 30% of all hospitalized patients pass through deliriant phase during their hospital stay. Delirium can last for several days to several weeks. Almost always it ends with complete withdrawal of psychopathological symptoms. Sometimes it can evolve into a chronic brain syndrome (dementia). The causes are often multifactorial and require a number of measures to ease the symptoms. Delirious patient is at risk of complications of immobility and confusion, leading to a high prevalence of irreversible functional decline. An interdisciplinary approach to delirium should also include family or other caregivers. In the diagnosis of delirium, several tests are used to complement clinical assessment. Among the most commonly used are the Confusion Assessment Method (CAM-ICU) and Clinical Dementia Rating (CDR) test. Depression is a common disorder among patients treated at ICU and occurs due to the impact of the disease on the body and the quality of life, independence, employment and other aspects of life. Depression can interfere with the speed of recovery, affects the postoperative quality of life, and in a certain number of patients may lead to suicidal thoughts and intentions. Phobias and generalized anxiety are the most common anxiety disorders. Generalized anxiety disorder is characterized by strong, excessive anxiety and worry about everyday life events. PTSD is delayed and/or protracted response to a stressful event or situation, extremely threatening or catastrophic nature, which is outside the common experience of people and would hit or traumatize almost all people. Treatment of delirium and other disorders is causal. The causes of psychosis are often multifactorial and require a number of measures to ease symptoms. The primary objective of prevention is appropriate therapy and correction of potential imbalances possibly underlying disturbances, stabilization of vital functions as well as early return to daily activities. Doctors and other medical staff must be aware of the importance and consequences of behavioral and emotional disorders in critically ill patients. Additional research is needed to discover the ways to prevent and/ or reduce the frequency and severity of the consequences and treatment of cognitive and emotional disorders.

[How to improve perioperative blood management in patients undergoing total hip or knee replacement surgery?]. / Kako poboljsati transfuzijsko lijecenje bolesnika podvrgnutih ugradnji totalnih endoproteza kuka i koljena?

Total hip and knee arthroplasty is associated with significant perioperative blood loss, necessitating often blood transfusions. Because of risks and cost of allogenic blood transfusion and elective types of surgery several alternative methods have been developed to reduce allogenic blood use. We prospectively audited 65 consecutive patients undergoing primary total hip (THR; n = 30) or knee replacement (TKR; n = 35) at our Department of Orthopaedic Surgery which did not use autologous blood collection methods. Total blood loss in THR (1329.7 +/- 364.8 ml) and TKR (1427.3 +/- 660.4 ml) was similar to previously reported and without significant difference between the groups. However, we reported high transfusion rates with 63.3% of THR and 82.6% of TKR patients receiving allogenic blood. Important steps to reduce allogenic blood use would include implementation of restrictive transfusion protocols with a defined hemoglobin value as a transfusion trigger, correction of preoperative anemia with i.v. iron +/- erythropoietin, use of one or more modalities of autologous transfusion (postoperative autotransfusion, preoperative blood donation), pharmacological agents like tranexamic acid (anti-fibrinolytic) and other complementary procedures. There is sufficient evidence in literature about the cost-benefit of certain methods which makes routine use of allogenic blood in THR and TKR surgery unacceptable even at general orthopaedic surgery departments.