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Patient blood management

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Patient Blood Management (PBM)[1] [2][3] is a set of medical practices designed to optimise the care of patients who might need a blood transfusion. Patient blood management programs use an organized framework to improve blood health, thus increasing patient safety and quality of life, reducing costs, and improving clinical outcomes.[1][4] Some strategies to accomplish this include ensuring that anemia is treated prior to a surgical operation, using surgical techniques that limit blood loss, and returning blood lost during surgery to the patient via intraoperative blood salvage.

Units of blood collected during the 69th ADA Blood Drive at the Robertson Blood Center at Fort Hood, Texas on September 18, 2009.
Units of blood collected during the 69th ADA Blood Drive at the Robertson Blood Center at Fort Hood, Texas on September 18, 2009.

Patient blood management represents an international initiative in best practice for patient centered care that is supported by the World Health Organization (WHO).[2] Patient blood management is about enhancing a patient's own blood health by managing anemia, optimizing coagulation, and using blood conservation strategies. Examples of how to implement PBM are available from Australia,[5] the UK,[6] and the US.[7]

History

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The term "Patient Blood Management" was first used in 2005 by Professor James Isbister, an Australian hematologist, who believed that the focus of transfusion medicine should shift from the blood component to the patient.[8][9]

During a session of the World Health Assembly in 2010, the resolution WHA63.12 was adopted, which included recommendations on the safety and availability of blood components. PBM initially consisted of pharmacological and non-pharmacological techniques, to be adopted before, during, and after surgery, to prevent the patient from arriving in the operating room in a condition of anemia.

Medical uses

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Patient Blood Management is an approach that can be implemented in hospital settings for taking care of people who require blood transfusions.[4] PBM includes techniques that may help ensure each person receiving a blood transfusion receives optimal treatment for their condition and also ensures that the blood supply (bank of donated blood) is maintained to ensure that all people who require blood components in the hospital have them available at the time that they would benefit from them.[4]

Patient Blood Management can be beneficial in surgical settings and in non-surgical settings with the goal of reducing the risk of needing a blood transfusion and improving the outcome for those who require a blood transfusion.[8]

Technique

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Three pillars of patient blood management:[10][11]

  1. Detect and treat anemia.
  2. Prevent or minimize blood loss.
  3. Enhance patient's physiological reserve to tolerate anemia.

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. 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 US.[12]

A 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.[13][14][15]

Surgical settings

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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.[16] Patients who are anemic prior to surgery often require 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.[17]

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.[18] This procedure is known as intraoperative blood salvage.[19] Pharmacologic agents, for example tranexamic acid, can also be utilized to minimize blood loss.[20] Another technique, acute normovolemic hemodilution, involves the collection of a selected calculated volume of the patient's own blood in collection bags prior to the start of surgery with the simultaneous replacement of an equal volume of non-blood 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 blood product, which contains red blood cells, platelets and coagulation factors, is reinfused at the end of the surgery.[21][22] People who are in good health and not anemic may sometimes donate their own blood prior to the surgery (autologous blood donation), which helps to conserve donor units and reduces some of the risks of exposure to allogeneic blood (though autologous donation carries risks of its own).[23][24] 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.[25]

Exposure to blood can be reduced, and tolerance to anemia enhanced, by using a "restrictive" transfusion strategy; for example, the AABB recommends that hospital patients in stable condition only be transfused when the hemoglobin drops below 7–8 g/dL (70–80 g/L).[26][27] A maximum surgical blood order schedule (MSBOS), which lists the number of blood units typically required for a given surgical operation, can also be used to help prevent unnecessary blood orders.[28]

Information technology in PBM

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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[29][30][31]
  • Audit and feedback, an approach which generates a summary of the clinical performance of healthcare providers over a specified period of time, for follow-up by hospital-based experts who discuss best practices with participating clinicians [32]
  • Improved management of blood components, leading to decreased wastage[29]

Non surgical settings

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Using Patient Blood Management techniques in non-surgical settings may also be helpful for reducing the need for blood transfusions and improving a person's outcome.[8] Examples include, identifying any anemia in people with advanced end-stage liver disease and determining of the cause of this anemia can be reversed.[8] Early identification and correction of anemia in pregnant women may also reduce the need for blood transfusions.[8]

Risks/complications

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Patient blood management is often implemented in order 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.[33]

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.[14][34][35][36]

Society and culture

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Cost

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Allogeneic blood transfusion is extremely expensive. For example, some studies reported increased costs of $300–$1,000 per unit of allogeneic blood transfused.[37][38] The more blood that is transfused directly impacts hospital expenditures, and it behooves 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.[39]

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See also

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References

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  1. ^ a b Harmening 2018, p. 552
  2. ^ a b "Patient Blood Management". NHS Blood and Transplant, UK.
  3. ^ 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.
  4. ^ a b c "Patient Blood Management". Association for the Advancement of Blood & Biotherapies. Retrieved 2022-03-29.
  5. ^ "Patient Blood Management". www.blood.gov.au. Retrieved 22 August 2018.
  6. ^ "Patient Blood Management". JPAC. Retrieved 22 August 2018.
  7. ^ "Building a Better Patient Blood Management Program". AABB, ABIM Foundation. Retrieved 22 August 2018.
    "Five Things Physicians and Patients Should Question" (PDF). AABB, ABIM Foundation. 24 April 2014.
  8. ^ a b c d e Franchini, Massimo; Marano, Giuseppe; Veropalumbo, Eva; Masiello, Francesca; Pati, Ilaria; Candura, Fabio; Profili, Samantha; Catalano, Liviana; Piccinini, Vanessa; Pupella, Simonetta; Vaglio, Stefania (2019). "Patient Blood Management: a revolutionary approach to transfusion medicine". Blood Transfusion = Trasfusione del Sangue. 17 (3): 191–5. doi:10.2450/2019.0109-19. ISSN 2385-2070. PMC 6596379. PMID 31246561.
  9. ^ Isbister, James (December 2005). "Why should health professionals be concerned about blood management and blood conservation?" (PDF). Journal of the Australian Association for Blood Conservation. 2.
  10. ^ 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.
  11. ^ "Patient blood management §The Three Pillars of PBM". National Blood Authority, Australia. March 2024.
  12. ^ 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. S2CID 13673276.
  13. ^ 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 (1): CD011305. doi:10.1002/14651858.CD011305.pub2. PMC 5298168. PMID 28128441.
  14. ^ a b 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. S2CID 4333989.
  15. ^ Carson, Jeffrey L.; Stanworth, Simon J.; Dennis, Jane A.; Trivella, Marialena; Roubinian, Nareg; Fergusson, Dean A.; Triulzi, Darrell; Dorée, Carolyn; Hébert, Paul C. (2021-12-21). "Transfusion thresholds for guiding red blood cell transfusion". The Cochrane Database of Systematic Reviews. 12 (12): CD002042. doi:10.1002/14651858.CD002042.pub5. ISSN 1469-493X. PMC 8691808. PMID 34932836.
  16. ^ 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): 58S–69S. doi:10.1016/j.amjmed.2003.12.013. PMID 15050887.
  17. ^ Corwin HL, Shander A, Speiss B, Muñoz M, Faraoni D, Calcaterra D, Welsby I, Ozawa S, Arnofsky A, Goldweit RS, Tibi P (January 2022). "Management of Perioperative Iron Deficiency in Cardiac Surgery: A Modified RAND Delphi Study". Ann Thorac Surg. 113 (1): 316–323. doi:10.1016/j.athoracsur.2020.11.031. PMID 33345781.
  18. ^ "Blood transfusion | Guidance and guidelines | NICE". www.nice.org.uk. 18 November 2015. Retrieved 2018-08-22.
  19. ^ 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. S2CID 8467007.
  20. ^ 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.
  21. ^ 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. S2CID 27696207.
  22. ^ 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. S2CID 10961504.
  23. ^ Harmening 2018, p. 293
  24. ^ Vassallo, Ralph; Goldman, Mindy; Germain, Marc; Lozano, Miguel (2015). "Preoperative Autologous Blood Donation: Waning Indications in an Era of Improved Blood Safety". Transfusion Medicine Reviews. 29 (4): 268–275. doi:10.1016/j.tmrv.2015.04.001. ISSN 0887-7963. PMID 26006319.
  25. ^ 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. S2CID 34175614.
  26. ^ Spahn, Donat R.; Muñoz, Manuel; Klein, Andrew A.; Levy, Jerrold H.; Zacharowski, Kai (2020). "Patient Blood Management: Effectiveness and Future Potential". Anesthesiology. 133 (1): 212–222. doi:10.1097/ALN.0000000000003198. ISSN 0003-3022. PMID 32108683.
  27. ^ White, Marissa J.; Hazard, Sprague W.; Frank, Steven M.; Boyd, Joan S.; Wick, Elizabeth C.; Ness, Paul M.; Tobian, Aaron A. R. (2015). "The Evolution of Perioperative Transfusion Testing and Blood Ordering". Anesthesia & Analgesia. 120 (6): 1196–1203. doi:10.1213/ANE.0000000000000619. ISSN 0003-2999. PMID 25988630. S2CID 7742653.
  28. ^ Harmening 2018, p. 564
  29. ^ a b Yazer, Mark. "Use of IT to support PBM". www.isbtweb.org. Retrieved 2018-08-22.
  30. ^ Derzon JH, Clarke N, Alford A, Gross I, Shander A, Thurer R (October 2019). "Restrictive Transfusion Strategy and Clinical Decision Support Practices for Reducing RBC Transfusion Overuse". Am J Clin Pathol. 152 (5): 544–557. doi:10.1093/ajcp/aqz070. PMID 31305890.
  31. ^ Zuckerberg GS, Scott AV, Wasey JO, Wick EC, Pawlik TM, Ness PM, Patel ND, Resar LM, Frank SM (July 2015). "Efficacy of education followed by computerized provider order entry with clinician decision support to reduce red blood cell utilization". Transfusion. 55 (7): 1628–36. doi:10.1111/trf.13003. PMID 25646579.
  32. ^ Hartley S, Foy R, Walwyn RE, Cicero R, Farrin AJ, Francis JJ, Lorencatto F, Gould NJ, Grant-Casey J, Grimshaw JM, Glidewell L, Michie S, Morris S, Stanworth SJ (July 2017). "The evaluation of enhanced feedback interventions to reduce unnecessary blood transfusions (AFFINITIE): protocol for two linked cluster randomised factorial controlled trials". Implement Sci. 12 (1): 84. doi:10.1186/s13012-017-0614-8. PMC 5496161. PMID 28673310.
  33. ^ 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): 1347–58. doi:10.1111/trf.14006. PMID 28150313.
  34. ^ 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. 2016 (10): CD002042. doi:10.1002/14651858.cd002042.pub4. PMC 4171966. PMID 27731885.
  35. ^ 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. S2CID 13767083.
  36. ^ 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.
  37. ^ 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.
  38. ^ 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.
  39. ^ Cázares Benito, María Angeles; Cazares Tamez, Rogelio; Perez Chavez, Francisco; Díaz Olachea, Carlos Gabriel; Ramos García, Ana Gabriela; Díaz Chuc, Erik Alejandro; Lee González, B. A. (23 April 2016). "Impact on costs related to inadequate indication of blood transfusion". Medicina Universitaria. 18 (72): 148–152. doi:10.1016/j.rmu.2016.07.003.

Further reading

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