Patient blood management

Patient blood management: the continuing need for education

Blood transfusion is often considered to first-line treatment for the management of anemia and/or blood loss. However, there is now much evidence to support that both of these conditions can be effectively treated without resorting to allogenic blood through management and conservation of the patient’s own blood. This is the concept of patient blood management (PBM) that takes a holistic, multi-disciplinary approach to caring for a patient’s hematopoietic system to ensure the best possible outcomes. (1)

The World Health Organization (WHO) defines PBM as a “patient-focused, evidence-based and systematic approach for optimising the management of patients and transfusion of blood products to ensure high quality and effective patient care”. (2) PBM was endorsed by the World Health Assembly Resolution WHA63.12 in 2010, urging Member States that “before surgery every reasonable measure should be taken to optimise the patient’s own blood volume, to minimize the patient’s blood loss and to harness and optimize the patient-specific physiological tolerance of anaemia. (3) These are the three pillars of PBM.

Key components of effective PBM programs as outlined by Cliff Sullivan and John D. Roback include:

  1. “Anemia management—detecting anemia, determining etiology, using pharmacologic agents to support hematopoiesis (e.g., erythropoietin), decreasing oxygen consumption, and transfusing blood products when clinically indicated.
  2. Multidisciplinary blood conservation strategies—performing minimally invasive procedures when possible, minimizing iatrogenic blood loss (e.g., repeated laboratory draws), using surgical techniques that limit blood loss, detecting and halting blood loss as quickly as possible, and employing transfusion techniques that minimize allogeneic transfusion (e.g., autologous transfusion, intraoperative red cell salvage, normovolemic hemodilution).
  3. Optimization of hemostasis and/or coagulopathy—appropriately evaluating coagulopathy/hemostasis, determining etiology of coagulopathy, treating coagulopathy with targeted therapies, and transfusing blood product components when clinically indicated.
  4. Patient-centered care—incorporating the patient’s needs and concerns in the decision-making process, informing the patient on PBM-based treatments, alerting the patient to potential risks/benefits/alternatives of different treatment options, and working with the patient to come up with the final treatment plan.” (4)

While numerous studies support that PBM reduces adverse outcomes due to anemia, blood loss and transfusion, improves patient morbidity and mortality, and is cost-effective, implementation of PBM has been slow. (5) Barriers include commitment of time and staff, the development of new standard operating procedures, the reluctance to adopt new guidelines, and the lack of appropriate systems to monitor outcomes based on changes implemented as part of the PBM. (6)

Guidelines providing simple, cost-effective, best-practice, feasible, and evidence-based recommendations to enable hospitals to reduce both anemia prevalence and anemia-related unnecessary blood transfusion have been developed. (7) However, as the level of evidence is still low for some recommendations, further studies are needed to elucidate the potential role of these PBM measures. Furthermore, education remains paramount to the successful implementation of PBM programs and to improving patient outcomes.

 

References

  • Gombotz H., Hofmann A., Norgaard A., Kastner P. (2017). Supporting Patient Blood Management (PBM) in the EU – A Practical Implementation Guide for Hospitals. 10.2818/533179.
  • World Health Organization – Global Forum for Blood Safety: Patient Blood Management – Concept paper, Available from: http://www.who.int/bloodsafety/events/gfbs_01_pbm_concept_paper.pdf, 2011.
  • 63.12 – Sixty-Third World Health Assembly, Agenda item 11.17, 21 May 2010 – Availability, safety and quality of blood products 2010, Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R12-en.pdf.
  • Sullivan HC, Roback JD. The pillars of patient blood management: key to successful implementation (Article, p. 2840). Transfusion. 2019 Sep;59(9):2763-2767. doi: 10.1111/trf.15464. PMID: 31483881.
  • Althoff FC, Neb H, Herrmann E, et al. Multimodal patient blood management program based on a three-pillar strategy: A systematic review and meta-analysis. Ann Surg 2019;269:794-804.
  • Mbanya D. Barriers and enablers to introducing comprehensive patient blood management in the hospital. Biologicals 2012;40:205-8.
  • Meybohm P, Froessler B, Goodnough LT, et al. “Simplified International Recommendations for the Implementation of Patient Blood Management” (SIR4PBM). Perioper Med (Lond). 2017;6:5. Published 2017 Mar 17. doi:10.1186/s13741-017-0061-8