Anemia is a frequent finding during routine assessment of patients prior to elective surgery. In this setting, anemia has been demonstrated to be a risk factor for negative post-operative outcomes as well as increased intra- and postoperative transfusion requirements. Historically, blood products were given in abundance to surgical patients, based on liberal “transfusion triggers”, i.e. mildly decreased hemoglobin or hematocrit levels prompted the transfusion of blood. Current guidelines propose a more restrictive approach for surgical patients, reflecting the increased recognition of complications of blood products beyond hemolytic transfusion reactions and disease transmission. Transfusionrelated acute lung injury, immunosuppression, alloimmunization, and even increased recurrence of malignancies have been associated with the administration of blood transfusions, and are of particular concern in the surgical population. Restoration of homeostasis and augmentation of oxygen delivery to tissues are the most common indications to administer blood products in surgical patients; their capability to achieve these goals, however, is rather limited. A stronger focus on preoperative optimization of elective surgical patients, including earlier detection and treatment of anemia, along with increased efforts to minimize intraoperative blood loss may be the most promising strategies to avoid the complications associated with both anemia and blood products.