Perioperative anaemia is an independent risk factor for increased length of hospital and intensive care stay, postoperative complications, and increased mortality. 1 It is a strong predictor for perioperative blood transfusion requirements. In general, approximately one-third of patients are found to be anaemic at pre-assessment. Perioperative anaemia and allogenic blood transfusion are both, preventable surgical risks. Administration of blood in the perioperative setting is a risk factor which contributes to poor outcomes. 1 Patient Blood Management (PBM) is a clinical concept, which when implemented, has the primary goal of avoiding unnecessary blood transfusions and improving patient outcome and safety. This article summarizes PBM and the strategies involved in identifying and managing perioperative anaemia and blood transfusion.

SUMMARY Plasma alkaline phosphatase isoenzyme activities were determined in patients with breast cancer to diagnose and monitor bone and liver metastases. Bone alkaline phosphatase activity was increased in 21 of 50 patients (42%) with radiologically confirmed bone metastases, while total alkaline phosphatase activity was increased in only 10 of 50 (20%); liver alkaline phosphatase activity was raised in 12 of 25 patients (48%) with liver metastases. All patients with liver metastases had bone metastases. Bone alkaline phosphatase activity was significantly higher in patients with symptomatic bone disease. Isoenzyme determination provided additional information that would have changed patient management in five of 20 patients who were monitored serially. Measurement of alkaline phosphatase isoenzyme activity, though less sensitive than imaging procedures, can assist in screening for, and in early detection of, a high proportion of bone and liver metastases, and can provide useful objective evidence of their response to treatment.More than 50% of patients with breast cancer develop overt bone metastases and many of these subsequently develop liver metastases.' Survival from breast cancer may be improved by early detection of metastases, as their treatment is usually reserved for symptomatic or progressive disease. The detection of micro or occult metastases is less important as, at present, this finding rarely changes treatment. Bone scintigraphy is a sensitive diagnostic procedure for the detection of overt bone disorders but it is not specific for metastases, and a positive scintigram may require confirmation by radiographical skeletal survey.2 These investigations, when performed during follow up to monitor disease, are costly, time consuming, and entail a radiation hazard. Perez et al3 claimed that it is possible to identify 95% of patients who develop bone metastases by clinical examination, chest x-ray, and measurement of plasma total alkaline phosphatase (ALP, EC 3.1.3.1) and y-glutamyltransferase (GGT, EC 2.3.2.2) activities. Although easy to perform and inexpensive, neither of the biochemical investigations unequivocally identifies the site of metastases deposits. Increased plasma total alkaline phosphatase activity can result

AIMTo investigate the relationship between baseline platelet count, clauss fibrinogen, maximum amplitude (MA) on thromboelastography, and blood loss in orthotopic liver transplantation (OLT).METHODSA retrospective analysis of our OLT Database (2006-2015) was performed. Baseline haematological indices and intraoperative blood transfusion requirements, as a combination of cell salvage return and estimation of 300 mls/unit of allogenic blood, was noted as a surrogate for intraoperative bleeding. Two groups: Excessive transfusion (> 1200 mL returned) and No excessive transfusion (< 1200 mL returned) were analysed. All data analyses were conducted using IBM SPSS Statistics version 23.RESULTSOf 322 OLT patients, 77 were excluded due to fulminant disease; redo transplant or baseline haemoglobin (Hb) of < 80 g/L. One hundred and fourteen (46.3%) were classified into the excessive transfusion group, 132 (53.7%) in the no excessive transfusion group. Mean age and gender distribution were similar in both groups. Baseline Hb (P ≤ 0.001), platelet count (P = 0.005), clauss fibrinogen (P = 0.004) and heparinase MA (P = 0.001) were all statistically significantly different. Univariate logistic regression with a cut-off of platelets < 50 × 109/L as the predictor and Haemorrhage as the outcome showed an odds ratio of 1.393 (95%CI: 0.758-2.563; P = 0.286). Review of receiver operating characteristic curves showed an area under the curve (AUC) for platelet count of 0.604 (95%CI: 0.534-0.675; P = 0.005) as compared with AUC for fibrinogen level, 0.678 (95%CI: 0.612-0.744; P ≤ 0.001). A multivariate logistic regression shows United Kingdom model for End Stage Liver Disease (P = 0.006), Hb (P = 0.022) and Fibrinogen (P = 0.026) to be statistically significant, whereas Platelet count was not statistically significant.CONCLUSIONPlatelet count alone does not predict excessive transfusion. Additional investigations, e.g., clauss fibrinogen and viscoelastic tests, provide more robust assessment of bleeding-risk in thrombocytopenia and cirrhosis.

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The coagulopathy of chronic liver disease causes derangement of the results of traditional laboratory tests. As such, there is an expectation that when undergoing invasive procedures patients with cirrhosis are at increased risk of bleeding. Standard practice is to optimise laboratory values with prophylactic transfusions of platelets, plasma and fibrinogen to reduce perceived bleeding risk. There has been a shift in thinking regarding coagulation in patients with chronic liver disease, whereby a rebalancing of haemostasis occurs with reduction in both procoagulants and anticoagulants. Guidelines for the preprocedural management of patients with chronic liver disease are inconsistent and may not account for this new paradigm. The risk of prophylactic transfusion should be measured against the risk of bleeding while considering the rebalancing of haemostasis. Future management may be guided by whole blood viscoelastic tests or use of thrombopoietin receptor agonists to optimise patients in these scenarios.