Medicine:Blood management

From HandWiki

Patient Blood Management (PBM), also called blood utilization management (BUM),[1] is a multidisciplinary, evidence-based approach to optimizing the care of patients who might need a blood transfusion.[2][3] Blood management programs aim to minimize inappropriate transfusions and decrease the need for transfusions overall, with the goal of improving patient safety, reducing costs, and maintaining the supply of donated blood.[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. Patient blood management represents an international initiative in best practice for transfusion medicine that is supported by the World Health Organization (WHO).[2] 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.[5] Examples of how to implement PBM are available from Australia,[6] the UK,[7] and the US.[8]

Medical uses

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.[9]

Technique

Three pillars of patient blood management:

  1. Detect and treat anemia.[10][11]
  2. Prevent or minimize blood loss.[10][11]
  3. Enhance patient's physiological reserve to tolerate anemia.[10][11]

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.[5] 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

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.

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.[17] This procedure is known as intraoperative blood salvage.[18] Pharmacologic agents, for example tranexamic acid, can also be utilized to minimize blood loss.[19] 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.[20][21] 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).[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]

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).[25][26] 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.[27]

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[28]
  • Improved management of blood components, leading to decreased wastage[28]

Non surgical settings

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.[9] Examples include, identifying any anemia in people with advanced end-stage liver disease and determining of the cause of this anemia can be reversed.[9] Early identification and correction of anemia in pregnant women may also reduce the need for blood transfusions.[9]

Risks/complications

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.[29]

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][30][31][32]

Society and culture

Cost

Allogeneic blood transfusion is extremely expensive. For example, some studies reported increased costs of $300–$1,000 per unit of allogeneic blood transfused.[33][34] 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.

See also

References

  1. 1.0 1.1 Denise M Harmening (30 November 2018). Modern Blood Banking & Transfusion Practices. F.A. Davis. p. 552. ISBN 978-0-8036-9462-0. https://books.google.com/books?id=vxyDDwAAQBAJ. 
  2. 2.0 2.1 "Patient Blood Management". http://hospital.blood.co.uk/patient-services/patient-blood-management/. 
  3. "Patient blood management: a primary theme in transfusion medicine". Transfusion 54 (10 Pt 2): 2587. October 2014. doi:10.1111/trf.12862. PMID 25308046. 
  4. 4.0 4.1 4.2 Association for the Advancement of Blood & Biotherapies. "Patient Blood Management" (in en). https://www.aabb.org/news-resources/resources/patient-blood-management. 
  5. 5.0 5.1 "Clinical Transfusion: 2 Establishing and Implementing a PBM strategy". http://www.isbtweb.org/working-parties/clinical-transfusion/2-establishing-and-implementing-a-pbm-strategy/. 
  6. "Patient Blood Management". http://www.blood.gov.au/patient-blood-management-pbm. 
  7. "Patient Blood Management". https://www.transfusionguidelines.org/uk-transfusion-committees/national-blood-transfusion-committee/patient-blood-management. 
  8. "Building a Better Patient Blood Management Program". http://lp.aabb.org/pbm-whitepaper. 
  9. 9.0 9.1 9.2 9.3 Franchini, Massimo; Marano, Giuseppe; Veropalumbo, Eva; Masiello, Francesca; Pati, Ilaria; Candura, Fabio; Profili, Samantha; Catalano, Liviana et al. (2019). "Patient Blood Management: a revolutionary approach to transfusion medicine". Blood Transfusion = Trasfusione del Sangue 17 (3): 191–195. doi:10.2450/2019.0109-19. ISSN 2385-2070. PMID 31246561. 
  10. 10.0 10.1 10.2 "The three-pillar matrix of patient blood management—an overview". Best Practice & Research. Clinical Anaesthesiology 27 (1): 69–84. March 2013. doi:10.1016/j.bpa.2013.02.002. PMID 23590917. 
  11. 11.0 11.1 11.2 "Three Pillars of Patient Blood Management". https://www.blood.gov.au/system/files/documents/pbm-3-pillars.pdf. 
  12. "Patient blood management – a renaissance of transfusion medicine". Transfusion Medicine 28 (2): 85–88. April 2018. doi:10.1111/tme.12530. PMID 29744975. 
  13. "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. January 2017. doi:10.1002/14651858.CD011305.pub2. PMID 28128441. 
  14. 14.0 14.1 "Effect of restrictive versus liberal red cell transfusion strategies on haemostasis: systematic review and meta-analysis". Thrombosis and Haemostasis 117 (5): 889–898. May 2017. doi:10.1160/TH17-01-0015. PMID 28251234. https://ora.ox.ac.uk/objects/uuid:37b01602-cd5d-485a-837f-fb3c52ca91c2. 
  15. Carson, Jeffrey L.; Stanworth, Simon J.; Dennis, Jane A.; Trivella, Marialena; Roubinian, Nareg; Fergusson, Dean A.; Triulzi, Darrell; Dorée, Carolyn et al. (2021-12-21). "Transfusion thresholds for guiding red blood cell transfusion". The Cochrane Database of Systematic Reviews 12: CD002042. doi:10.1002/14651858.CD002042.pub5. ISSN 1469-493X. PMID 34932836. 
  16. "Prevalence and outcomes of anemia in surgery: a systematic review of the literature". The American Journal of Medicine 116 Suppl 7A (7): 58S–69S. April 2004. doi:10.1016/j.amjmed.2003.12.013. PMID 15050887. 
  17. "Blood transfusion | Guidance and guidelines | NICE" (in en-GB). https://www.nice.org.uk/guidance/ng24. 
  18. "Indications and contraindications of cell salvage". Transfusion 44 (12 Suppl): 40S–4S. December 2004. doi:10.1111/j.0041-1132.2004.04176.x. PMID 15585004. 
  19. "Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis". BMJ 344: e3054. May 2012. doi:10.1136/bmj.e3054. PMID 22611164. 
  20. "Acute normovolemic hemodilution". Transfusion 44 (12 Suppl): 26S–34S. December 2004. doi:10.1111/j.0041-1132.2004.04293.x. PMID 15585002. 
  21. "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. March 2017. doi:10.1213/ane.0000000000001609. PMID 27669554. 
  22. Denise M Harmening (30 November 2018). Modern Blood Banking & Transfusion Practices. F.A. Davis. p. 293. ISBN 978-0-8036-9462-0. https://books.google.com/books?id=vxyDDwAAQBAJ. 
  23. 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. 
  24. "Bloodless medicine: clinical care without allogeneic blood transfusion". Transfusion 43 (5): 668–76. May 2003. doi:10.1046/j.1537-2995.2003.00367.x. PMID 12702192. 
  25. 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. 
  26. 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. 
  27. Denise M Harmening (30 November 2018). Modern Blood Banking & Transfusion Practices. F.A. Davis. p. 564. ISBN 978-0-8036-9462-0. https://books.google.com/books?id=vxyDDwAAQBAJ. 
  28. 28.0 28.1 Yazer, Mark. "Use of IT to support PBM" (in en). http://www.isbtweb.org/working-parties/clinical-transfusion/12-use-of-it-to-support-pbm/. 
  29. "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. June 2017. doi:10.1111/trf.14006. PMID 28150313. 
  30. "Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion". The Cochrane Database of Systematic Reviews 2016 (10): CD002042. October 2016. doi:10.1002/14651858.cd002042.pub4. PMID 27731885. 
  31. "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. May 2017. doi:10.1016/s2468-1253(17)30054-7. PMID 28397699. https://ora.ox.ac.uk/objects/uuid:afc55851-1e65-4427-976b-e96a6317dfbb. 
  32. "Emerging risks and outcomes of blood transfusion in surgery". Seminars in Hematology 41 (1 Suppl 1): 117–24. January 2004. doi:10.1053/j.seminhematol.2003.11.023. PMID 14872432. 
  33. "Cost of outpatient blood transfusion in cancer patients". Journal of Clinical Oncology 18 (14): 2755–61. July 2000. doi:10.1200/jco.2000.18.14.2755. PMID 10894876. 
  34. "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. August 2007. doi:10.1186/1472-6963-7-138. PMID 17764560. 

Further reading

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