Patient Blood Management (PBM) is a multidisciplinary, evidence-based approach to optimizing the care of patients who might need a blood transfusion. Patient blood management represents an international initiative in best practice for transfusion medicine that is supported by the World Health Organization (WHO). 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. Examples of how to implement PBM are available from Australia, the UK, and the USA.
Three pillars of patient blood management
- Detect and treat anemia
- Prevent or minimize blood loss
- Enhance patient's physiological reserve to tolerate anemia
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.
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. 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.
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.
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.
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 USA.
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. 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. This procedure is known as "Intraoperative Blood Salvage." Pharmacologic agents, for example tranexamic acid, can also be utilized to minimize blood loss. 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. 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.
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.
- Improved management of blood components, leading to decreased wastage
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