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] Patient Blood Management represents an international initiative in best practice for transfusion medicine. In England, the Patient Blood Management initiative was launched in 2012 in a collaborative venture by NHS Blood and Transplant (NHSBT), Department of Health and the National Blood Transfusion Committee to support NHS Trusts to manage their blood use effectively.[2]

Necessity

There are multiple issues associated with blood and its transfusion. Considered for decades as a gift of life, blood transfusion is emerging as a treatment with limited efficacy and substantial risks, further under pressure from staggering associated costs and limited supplies. 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. 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.

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.[3][4] The more blood that is transfused directly impacts hospital expenditures, and of course, 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.

Patient Outcomes

Perhaps the single most important reason for implementing patient blood management is need to improve patient outcomes. 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 allogeneic transfusions to be beneficial in only a very narrow and specific set of conditions and harmful or at the very least not helpful in the vast majority of times it is actually used. In the absence of clear benefit, the patient is exposed only to risk. An excellent review of the impact on patient outcomes has been written by Aryeh Shander, MD, and can be found in the journal, Seminars in Hematology.[5]

Methods

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.[6] 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. Blood that is lost during surgery can be collected, filtered, washed and given back to the patient. This procedure is known as "Intraoperative Blood Salvage."[7] 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.[8] Pharmacologic agents can also be utilized to minimize blood loss. 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.[9]

References

  1. ↑ "Patient Blood Management | NHSBT Hospitals and Science". hospital.blood.co.uk. Retrieved 2016-08-15.
  2. ↑ Ltd., Target Information Systems. "JPAC - Transfusion Guidelines". www.transfusionguidelines.org.uk. Retrieved 2016-08-15.
  3. ↑ Crémieux PY, Barrett B, Anderson K, Slavin MB (July 2000). "Cost of outpatient blood transfusion in cancer patients". J. Clin. Oncol. 18 (14): 2755–61. PMID 10894876.
  4. ↑ Zilberberg MD, Shorr AF (2007). "Effect of a restrictive transfusion strategy on transfusion-attributable severe acute complications and costs in the US ICUs: a model simulation". BMC Health Serv Res. 7: 138. doi:10.1186/1472-6963-7-138. PMC 2064919Freely accessible. PMID 17764560.
  5. ↑ Shander A (January 2004). "Emerging risks and outcomes of blood transfusion in surgery". Semin. Hematol. 41 (1 Suppl 1): 117–24. doi:10.1053/j.seminhematol.2003.11.023. PMID 14872432.
  6. ↑ 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". Am. J. Med. 116 (Suppl 7A): 58S–69S. doi:10.1016/j.amjmed.2003.12.013. PMID 15050887.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.

Further reading

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