Blood management

Patient Blood Management (PBM) is a multidisciplinary, evidence-based approach to optimizing the care of patients who might need a blood transfusion.[1][2] Patient blood management represents an international initiative in best practice for transfusion medicine that is supported by the World Health Organization (WHO).[1] Establishing a patient blood management strategy requires leadership and support from national and regional government policymakers and managers, healthcare professionals, and patients. Patients are an essential part of planning, implementing and evaluating PBM programs.[3] Examples of how to implement PBM are available from Australia,[4] the UK,[5] and the USA.[6]

Blood management
Specialtyhematology

Three pillars of patient blood management
  1. Detect and treat anemia
  2. Prevent or minimize blood loss
  3. Enhance patient's physiological reserve to tolerate anemia[7][8]

Necessity

Evidence indicates that a great number of the patients who are being transfused today may not be seeing many tangible benefits from it, as the transfused blood fails to achieve its primary goals – prevention of ischemia and improving the clinical outcomes. The challenge lies in identifying those patients who are at risk of complications of severe anemia (ischemia) and transfusing them, without exposing other patients to unwarranted risks of inappropriate transfusions. Better transfusion practice should not be viewed as an option, but a necessity to ensure clinicians are doing good and not doing harm to their patients.[9][10][11]

Cost issues

Another significant reason to embrace the concept of patient blood management is cost. Allogeneic blood transfusion is extremely expensive. For example, some studies reported increased costs of $300–$1,000 per unit of allogeneic blood transfused.[12][13] The more blood that is transfused directly impacts hospital expenditures, and of course, it behoves administrators to search for ways to reduce this cost. This increasing cost of transfusions is the reason many hospital administrators are endeavoring to establish blood management programs.

Patient outcomes

Perhaps the single most important reason for implementing patient blood management is need to improve patient outcomes. Published in 2017, a retrospective observational study in four major adult tertiary-care hospitals concluded that implementation of a unique, jurisdiction-wide PBM program was associated with improved patient outcomes, reduced blood product utilization, and product-related cost savings.[14]

Better outcomes are achieved with the reduction or avoidance of exposure to allogeneic blood. Numerous clinical studies have shown that allogeneic blood transfusions are associated with increased mortality and an increased level of serious complications, while potentially exposing the patient to viral, bacterial, or parasitic agents. Also, current medical literature shows that in most circumstances a restrictive threshold is as safe as a more liberal red cell transfusion threshold and in certain circumstances, for example gastrointestinal bleeding due to liver disease, a more liberal red cell transfusion strategy may be harmful.[11][9][15][16]

Methods

The cornerstone of patient blood management is a multidisciplinary approach, involving family physicians, nurses, anesthetists, surgeons, Transfusion Practitioners, hematologists, and hematology and blood transfusion laboratory staff.[3] Part of PBM is avoiding unnecessary treatments and procedures, and some of the PBM recommendations from around the world have been incorporated in to the "Choosing Wisely" campaigns that exist in Australia, Canada, the UK, and the USA.[17]

Surgical PBM

Patient blood management in the perioperative setting can be achieved by means of a variety of techniques and strategies. First, ensuring that the patient enters the operating room with a sufficient hematocrit level is essential. Preoperative anemia has been documented to range from 5% in female geriatric hip fracture patients to over 75% in colon cancer patients.[18] Patients who are anemic prior to surgery obviously receive more transfusions. Erythropoietin and iron therapy can be considered in cases of anemia. Accordingly, patients should be screened for anemia at least 30 days prior to an elective surgical procedure. Although either oral or parenteral iron could be given, increasingly clinicians are giving parenteral iron to ensure that the haemoglobin is increased the maximal amount before the elective surgery is undertaken.

During surgery, techniques are utilized to reduce or eliminate exposure to allogeneic blood. For example, electrocautery, which is a technique utilized for surgical dissection, removal of soft tissue and sealing blood vessels, can be applied to a variety of procedures. During surgical procedures that are expected to have significant blood loss, blood that is lost during surgery can be collected, filtered, washed and given back to the patient.[19] This procedure is known as "Intraoperative Blood Salvage."[20] Pharmacologic agents, for example tranexamic acid, can also be utilized to minimize blood loss.[21] Another technique, acute normovolemic hemodilution" involves the collection of a selected calculated volume of autologous blood in collection bags prior to the start of surgery with the simultaneous replacement of an equal volume of asanguinous fluid. Since the patient's blood is now diluted, blood lost during the surgical procedure, i.e. by hemorrhage, contains smaller amounts of red blood cells. The collected autologous blood product, which contains red blood cells, platelets and coagulation factors, is reinfused at the end of the surgery.[22][23] When all of these therapies are combined, blood loss is greatly reduced which correspondingly reduces or averts the potential for allogeneic blood transfusion.

Additional details on this question can be found in the journal, Transfusion.[24]

Benefits of Information Technology in PBM

Information technology can be useful in implementing a patient blood management policy, this includes:

  • Daily e-mails alerting physicians of transfusions that have occurred outside of the local guidelines
  • Computerized physician order entry systems that automatically create an alert when the transfusion order is inconsistent with the reason selected for transfusion and the laboratory hemoglobin level.[25]
  • Improved management of blood components, leading to decreased wastage[25]

References
  1. "Patient Blood Management". NHS Blood and Transplant, UK.
  2. Markowitz MA, Waters JH, Ness PM (October 2014). "Patient blood management: a primary theme in transfusion medicine". Transfusion. 54 (10 Pt 2): 2587. doi:10.1111/trf.12862. PMID 25308046.
  3. "Clinical Transfusion: 2 Establishing and Implementing a PBM strategy". International Society of Blood Transfusion.
  4. "Patient Blood Management". www.blood.gov.au. Retrieved 22 August 2018.
  5. "Patient Blood Management". JPAC. Retrieved 22 August 2018.
  6. "Building a Better Patient Blood Management Program". AABB. Retrieved 22 August 2018.
  7. Isbister JP (March 2013). "The three-pillar matrix of patient blood management--an overview". Best Practice & Research. Clinical Anaesthesiology. 27 (1): 69–84. doi:10.1016/j.bpa.2013.02.002. PMID 23590917.
  8. "Three Pillars of Patient Blood Management" (PDF). National Blood Authority, Australia.
  9. Carson JL, Stanworth SJ, Roubinian N, Fergusson DA, Triulzi D, Doree C, Hebert PC (October 2016). "Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion". The Cochrane Database of Systematic Reviews. 10: CD002042. doi:10.1002/14651858.cd002042.pub4. PMC 4171966. PMID 27731885.
  10. Estcourt LJ, Malouf R, Trivella M, Fergusson DA, Hopewell S, Murphy MF (January 2017). "Restrictive versus liberal red blood cell transfusion strategies for people with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without haematopoietic stem cell support". The Cochrane Database of Systematic Reviews. 1: CD011305. doi:10.1002/14651858.CD011305.pub2. PMC 5298168. PMID 28128441.
  11. Desborough MJ, Colman KS, Prick BW, Duvekot JJ, Sweeney C, Odutayo A, Jairath V, Doree C, Trivella M, Hopewell S, Estcourt LJ, Stanworth SJ (May 2017). "Effect of restrictive versus liberal red cell transfusion strategies on haemostasis: systematic review and meta-analysis". Thrombosis and Haemostasis. 117 (5): 889–898. doi:10.1160/TH17-01-0015. PMID 28251234.
  12. Crémieux PY, Barrett B, Anderson K, Slavin MB (July 2000). "Cost of outpatient blood transfusion in cancer patients". Journal of Clinical Oncology. 18 (14): 2755–61. doi:10.1200/jco.2000.18.14.2755. PMID 10894876.
  13. Zilberberg MD, Shorr AF (August 2007). "Effect of a restrictive transfusion strategy on transfusion-attributable severe acute complications and costs in the US ICUs: a model simulation". BMC Health Services Research. 7: 138. doi:10.1186/1472-6963-7-138. PMC 2064919. PMID 17764560.
  14. Leahy MF, Hofmann A, Towler S, Trentino KM, Burrows SA, Swain SG, Hamdorf J, Gallagher T, Koay A, Geelhoed GC, Farmer SL (June 2017). "Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals". Transfusion. 57 (6): 1347–1358. doi:10.1111/trf.14006. PMID 28150313.
  15. Odutayo A, Desborough MJ, Trivella M, Stanley AJ, Dorée C, Collins GS, Hopewell S, Brunskill SJ, Kahan BC, Logan RF, Barkun AN, Murphy MF, Jairath V (May 2017). "Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials". The Lancet. Gastroenterology & Hepatology. 2 (5): 354–360. doi:10.1016/s2468-1253(17)30054-7. PMID 28397699.
  16. Shander A (January 2004). "Emerging risks and outcomes of blood transfusion in surgery". Seminars in Hematology. 41 (1 Suppl 1): 117–24. doi:10.1053/j.seminhematol.2003.11.023. PMID 14872432.
  17. Estcourt LJ, Roberts DJ (April 2018). "Patient blood management - a renaissance of transfusion medicine". Transfusion Medicine. 28 (2): 85–88. doi:10.1111/tme.12530. PMID 29744975.
  18. Shander A, Knight K, Thurer R, Adamson J, Spence R (April 2004). "Prevalence and outcomes of anemia in surgery: a systematic review of the literature". The American Journal of Medicine. 116 Suppl 7A (7): 58S–69S. doi:10.1016/j.amjmed.2003.12.013. PMID 15050887.
  19. "Blood transfusion | Guidance and guidelines | NICE". www.nice.org.uk. Retrieved 2018-08-22.
  20. Waters JH (December 2004). "Indications and contraindications of cell salvage". Transfusion. 44 (12 Suppl): 40S–4S. doi:10.1111/j.0041-1132.2004.04176.x. PMID 15585004.
  21. Ker K, Edwards P, Perel P, Shakur H, Roberts I (May 2012). "Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis". BMJ. 344: e3054. doi:10.1136/bmj.e3054. PMC 3356857. PMID 22611164.
  22. Shander A, Rijhwani TS (December 2004). "Acute normovolemic hemodilution". Transfusion. 44 (12 Suppl): 26S–34S. doi:10.1111/j.0041-1132.2004.04293.x. PMID 15585002.
  23. Barile L, Fominskiy E, Di Tomasso N, Alpìzar Castro LE, Landoni G, De Luca M, Bignami E, Sala A, Zangrillo A, Monaco F (March 2017). "Acute Normovolemic Hemodilution Reduces Allogeneic Red Blood Cell Transfusion in Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Trials". Anesthesia and Analgesia. 124 (3): 743–752. doi:10.1213/ane.0000000000001609. PMID 27669554.
  24. Goodnough LT, Shander A, Spence R (May 2003). "Bloodless medicine: clinical care without allogeneic blood transfusion". Transfusion. 43 (5): 668–76. doi:10.1046/j.1537-2995.2003.00367.x. PMID 12702192.
  25. Yazer, Mark. "Use of IT to support PBM". www.isbtweb.org. Retrieved 2018-08-22.

Further reading
  • Waters JH, ed. (2008). Blood Management: Options for Better Patient Care. Bethesda, Maryland: AABB Press. ISBN 978-1-56395-262-3.
  • Seeber P, Shander A (2008). Basics of Blood Management. Blackwell. ISBN 978-0-470-76646-0.
  • Waters J, Gottschall J, eds. (2006). Perioperative Blood Management: A Physician's Handbook (1st ed.). AABB/SABM. ISBN 978-1-56395-235-7.
  • Farmer S, Webb D (2000). Your Body, Your Choice: The Lay Person's Complete Guide to Bloodless Medicine and Surgery. Media Masters. ISBN 978-981-04-1708-6.
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