Patient blood management – a new paradigm for transfusion medicine?

Abstract

The saving of many lives in history has been duly credited to blood transfusions. What is frequently overlooked is the fact that, in light of a wealth of evidence as well as other management options, a therapy deemed suitable yesterday may no longer be the first choice today. Use of blood has not been based upon scientific evaluation of benefits, but mostly on anecdotal experience and a variety of factors are challenging current practice. Blood is a precious resource with an ever limiting supply due to the aging population. Costs have also continually increased due to advances (and complexities) in collection, testing, processing and administration of transfusion, which could make up 5% of the total health service budget. Risks of transfusions remain a major concern, with advances in blood screening and processing shifting the profile from infectious to non‐infectious risks. Most worrying though, is the accumulating literature demonstrating a strong (often dose‐dependent) association between transfusion and adverse outcomes. These include increased length of stay, postoperative infection, morbidity and mortality. To this end, a recent international consensus conference on transfusion outcomes (ICCTO) concluded that there was little evidence to corroborate that blood would improve patients’ outcomes in the vast majority of clinical scenarios in which transfusions are currently routinely considered; more appropriate clinical management options should be adopted and transfusion avoided wherever possible. On the other hand, there are patients for whom the perceived benefits of transfusion are likely to outweigh the potential risks. Consensus guidelines for blood component therapy have been developed to assist clinicians in identifying these patients and most of these guidelines have long advocated more conservative ‘triggers’ for transfusion. However, significant variation in practice and inappropriate transfusions are still prevalent. The ‘blood must always be good philosophy’ continues to permeate clinical practice. An alternative approach, however, is being adopted in an increasing number of centres. Experience in managing Jehovah’s Witness patients has shown that complex care without transfusion is possible and results are comparable with, if not better than those of transfused patients. These experiences and rising awareness of downsides of transfusion helped create what has become known as ‘patient blood management’. Principles of this approach include optimizing erythropoiesis, reducing surgical blood loss and harnessing the patient’s physiological tolerance of anaemia. Treatment is tailored to the individual patient, using a multidisciplinary team approach and employing a combination of modalities. Results have demonstrated reduction of transfusion, improved patient outcomes and patient satisfaction. Significant healthcare cost savings have also followed. Despite the success of patient blood management programmes and calls for practice change, the potential and actual harm to patients caused through inappropr...

Five Drivers Shifting the Paradigm from Product-Focused Transfusion Practice to Patient Blood Management

“…When used and tailored to the specific needs of the individual patient, they have been shown to preempt and/or reduce the use of allogeneic blood products while improving patient outcomes [11][12][13][14]. A recent study compared a cohort of 586 patients undergoing isolated coronary artery bypass graft surgery (CABG) at an institution with a developed PBM program with a propensity score-matched cohort of 586 patients from institutions without such a program.…”

Blood Transfusion During Pregnancy, Birth, and the Postnatal Period

“…Blood is a limited, costly resource with transfusion of it or any of its products associated with specific risks. (1,2) Internationally, this has lead to increased efforts to reduce unnecessary blood use across many disciplines. (12) and Ireland (0.84% in 2003).…”

From Bloodless Surgery to Patient Blood Management

“…14 To this end, PBM relies on 3 corresponding aspects, the pillars of PBM (Figure 1) 17,18 : (1) optimizing hematopoiesis, (2) minimizing bleeding and blood loss, and (3) harnessing and optimizing physiological tolerance of anemia through application of all available modalities, leaving transfusion as the last resort. The broad nature of the approaches employed in PBM calls for multidisciplinary teamwork to achieve the best results.…”