Because of limited availability, costs and safety concerns related to blood transfusion, several strategies to reduce blood transfusions can be considered in addition to increasing transfusion trigger thresholds. These include approaches to reduce blood losses, for example use of antifibrinolytic agents, such as tranexamic acid or epsilon-aminocaproic acid (EACA) and techniques of cell salvage during surgery; also, the use of small volume sample tubes can limit the blood losses related to sampling for laboratory studies. In a meta-analysis of 9 randomized controlled trials [87] , subcutaneous administration of recombinant erythropoietin (EPO) in critically ill patients was shown to be associated with decreased transfusion rates, but this was not associated with improved mortality (except possibly in a subgroup of trauma patients [88] ). Concerns also have been raised about potentially increased rates of deep vein thrombosis [88] . The development of artificial oxygen carriers is under investigation, but these have their own problems [89] . Further research is needed to improve these alternative strategies.