Patient Blood Management


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Patient blood management (PBM) is an evidence based concept to increase patient safety. The design and implementation is best done by interdisciplinary teams. First, patients' resources have to be conserved and optimized, for that care structures have to be analyzed and optimized.
 
LESS ANEMIA - MORE PATIENT SAFETY
The background of PBM
The biggest predictor of perioperative allogeneic blood transfusion is preoperative anaemia. According to the WHO, anemia is defined at a hemoglobin level of < 12g/dl and <13g/dl for women respectively men.
 
Untreated anemia, even to a small extent, increases the risk of complications and mortality in the context of surgery (1). Preoperative anemia occurs in up to 30%of elective-surgical patients and is associated, independently of blood transfusion, with an increased risk of postoperative morbidity and mortality (2–4).
 
Based on this evidence, early detection and treatment of preoperative anemia is of essential importance. Preoperative anemia is, however, very rarely treated. The NATA benchmark study at 11 European centers revealed that 15 to 18% of patients with primary knee and hip prosthetics suffer from preoperative anemia, but only 7% received treatment. This is even more surprising because iron deficiency is often the cause for preoperative anemia in more than 30% of the patients.
 
Oral or intravenous iron therapy correct preoperative anemia with relatively little effort.This approach represents an alternative treatment compared to the conventional approach, namely the transfusion of blood products. Consequently the number of transfused blood products decrease by time (5–7). In contrast, administrations of allogenic blood products represent a non-causal form of treatment of anemia concomitantly incurring additional health complications and costs.
 
 
ALLOGENIC TRANSFUSION IN MODERN PRACTICE
New insights into the precious commodity
With correct indication thousands of critically bleeding patients are adequately treated by allogenic blood transfusion every day worldwide.
 
A liberal indication, however, is associated with an increased risk of infection (8), higher morbidity (9) and increased mortality (10). In cancer patients with a colonic resection for example transfusion of packed red blood cells (RBCs) appears to be associated with an increased risk of tumor recurrence (11).

Over the past three decades, numerous strategies have been developed to reduce the risks of blood transfusion. As a consequence, blood transfusions are "safer" than ever before, and in fact, the probability that an undesirable result can be attributed to a specific individual unit is negligible.
 
Nevertheless, the transfusion practice of RBCs in different countries and hospitals is extremely variable and consequently every day blood products are transfused, which are not required in individual cases (12–14). This large variability in transfusion medicine practice is more surprising since, at least for Germany recommendations exist by the cross-sectional Guidelines of the German Medical Association for therapy stating at which trigger blood components and plasma derivatives should be transfused.
 
The most important predictors of perioperative allogenic blood transfusion are preoperative anemia and a high perioperative blood loss. In consideration of those relatively simple conditions PBM could be a pragmatic solution.
 
PATIENT BLOOD MANAGEMENT MOVING ALONG WITH THE DEVELOPING SOCIETY
Ensuring blood supplies when it comes to life
Against the backdrop of demographic change it is also notable that we will face a significant shortage in the supply of blood products in the next few years. More and more elderly surgical patients with an increasing demand for perioperative allogeneic blood products are facing fewer and fewer potential blood donors.
 
Since 2011, the World Health Organization (WHO) insists the introduction of alternatives to blood transfusion,in particular an adequate patient blood management.

The effectiveness of various individual components of the PBM program has repeatedly been demonstrated. Altogether the utilization of preoperative iron and / or erythropoietin therapy, the liberal use of cell saver technology or a particularly blood-saving surgical technique minimized blood loss and consequently the number of transfused EK has been reduced (15–18). Recent data demonstrate that the introduction of PBM leads to reduced blood loss, fewer postoperative complications such as acute renal failure, shorter hospital stay duration and also lower total cost (19). Similarly, Theusinger and colleagues demonstrated that in orthopedic patients the successful implementation of PBM resulted in reduced blood loss and transfusion rates (20).
 
THE PBM PROGRAM
Three "supporting columns” for patient safety
 
The Patient Blood Management Program is a multidisciplinary,combining evidence-based concept basedon three pillars:

Early detection and treatment of a possibly existing anemia before elective surgery with a high risk of transfusion

In the following, the algorithm for the preoperative diagnosis and treatment of anemia at the University Hospital Frankfurt is shown. This specifically targets those patients who possess an increased risk of Transfusion of >10% before surgery.
 
 
Rational use of blood products (strict compliance with cross-sectional Guidelines the German Medical Association for therapy with blood components andp lasma derivatives!)

The guidelines of the German Medical Association are summarized in the figure below:
 
 

In this context, Zuckerberg and colleagues showed that the utilization of a computer-based system for the requirement of blood products with integrated decision support system decrease blood transfusions up to 14,3% (21).


Minimizing blood loss and increased use of allogeneic blood-saving measures.


BEFORE surgery:

Coagulation history
Stop/Bridging Anticoagulation
Optional stop inhibition of platelet aggregation

DURING and AFTER surgery:
Heat management (normothermia)
Coagulation management (pH >7,2, Ca2+ >1,2)
Blood collection (mechanical autotransfusion)
Use of tranexamic acid / desmopressin
Smaller blood collecting tubes/blood volume
Restrictive blood sampling
 
Based on our experience we know that an implementation may take some time. For the feasibility of PBM it is instrumental in this context that individual components are often already being practiced or are accomplished with very little effort in a gradually manner. An interdisciplinary cooperation is the most efficient way to obtain best results.
 
Please bear in mind:
With the knowledge of the current evidence it is in our responsibility, as we are colleagues for health, to ensure whenever and wherever patient safety. This is our motivation to support you, within the German PBM network, in the implementation of Patient Blood Management in your organization. Please contact us for further information.
 
PUBLICATIONS
1. Gombotz H, Rehak PH, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study. Transfusion [Internet]. 2007 Aug [cited 2015 Sep10];47(8):1468–80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17655591
 
2. Gruson KI, Aharonoff GB, Egol KA, Zuckerman JD, Koval KJ. The relationship between admission hemoglobin level and outcome after hip fracture. J Orthop Trauma[Internet]. 2002 Jan [cited 2015 Sep 10];16(1):39–44. Available from:http://www.ncbi.nlm.nih.gov/pubmed/11782632
 
3. Halm EA, Wang JJ, Boockvar K, Penrod J, Silberzweig SB, Magaziner J, et al. The effect of perioperative anemia on clinical and functional outcomes in patients with hip fracture. J Orthop Trauma [Internet]. 2004 Jul [cited 2015 Sep10];18(6):369–74. Available from:http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1454739&tool=pmcentrez&rendertype=Abstract
 
4. Musallam KM,Tamim HM, Richards T, Spahn DR, Rosendaal FR, Habbal A, et al. Preoperative anemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet (London, England) [Internet]. 2011 Oct 15 [cited 2015 Jul23];378(9800):1396–407. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21982521
 
5. Pape A, Habler O. Alternatives to allogeneic blood transfusions. Best Pract Res Clin Anaesthesiol [Internet]. 2007 Jun [cited 2015 Sep 10];21(2):221–39. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17650774
 
6. Piednoir P ,Allou N, Driss F, Longrois D, Philip I, Beaumont C, et al. Preoperative iron deficiency increases transfusion requirements and fatigue in cardiac surgery patients: a prospective observational study. Eur J Anaesthesiol [Internet].2011 Nov [cited 2015 Aug 25];28(11):796–801. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21885979
 
7. Theusinger OM, Leyvraz P-F, Schanz U, Seifert B, Spahn DR. Treatment of iron deficiency anemia in orthopedic surgery with intravenous iron: efficacy and limits: a prospective study. Anesthesiology [Internet]. 2007 Dec [cited 2015 Sep 10];107(6):923–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18043060
 
8. Marik PE,Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med [Internet]. 2008 Sep [cited 2015 Jul 7];36(9):2667–74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18679112
 
9. Kulier A,Levin J, Moser R, Rumpold-Seitlinger G, Tudor IC, Snyder-Ramos SA, et al. Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation [Internet]. 2007 Jul 31 [cited 2015 Sep5];116(5):471–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17620512
 
10. Murphy GJ, Reeves BC, Rogers CA, Rizvi SIA, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in Patient shaving cardiac surgery. Circulation [Internet]. 2007 Nov 27 [cited 2015 Jul7];116(22):2544–52. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17998460
 
11. Acheson AG, Brookes MJ, Spahn DR. Effects of allogeneic red blood cell transfusions on clinical outcomes in patients undergoing colorectal cancer surgery: a systematic review and meta-analysis. Ann Surg [Internet]. 2012 Aug [cited 2015 Sep 10];256(2):235–44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22791100
 
12. Hébert P, Wells G, Martin C, Tweeddale M, Marshall J, Blajchman M, et al. Variation in red cell transfusion practice in the intensive care unit: a multicentre cohort study. Crit Care [Internet]. 1999 Jan [cited 2015 Sep 10];3(2):57–63. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=29015&tool=pmcentrez&rendertype=Abstract
 
13. Hutton B, Fergusson D, Tinmouth A, McIntyre L, Kmetic A, Hébert PC. Transfusion rates vary significantly amongst Canadian medical centres. Can J Anaesth [Internet]. Jan [cited 2015 Sep 10];52(6):581–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15983142
 
14. Rogers MAM, Blumberg N, Saint S, Langa KM, Nallamothu BK. Hospital variation in transfusion and infection after cardiac surgery: a cohort study. BMC Med [Internet]. 2009Jan [cited 2015 Sep 10];7:37. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2727532&tool=pmcentrez&rendertype=Abstract
 
15. Brevig J, McDonald J, Zelinka ES, Gallagher T, Jin R, Grunkemeier GL. Blood transfusion reduction in cardiac surgery: multidisciplinary approach at a community hospital. Ann Thorac Surg [Internet].2009 Feb [cited 2015 Jul 8];87(2):532–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19161774
 
16. Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology [Internet]. 2010 Aug [cited 2015 Sep10];113(2):482–95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20613475
 
17. Spahn DR, Moch H, Hofmann A, Isbister JP. Patient blood management: the pragmatic solution for the problems with blood transfusions. Anesthesiology [Internet]. 2008 Dec [cited 2015 Sep10];109(6):951–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19034088
 
18. Moskowitz DM, McCullough JN, Shander A, Klein JJ, Bodian CA, Goldweit RS, et al. The Impact of blood conservation on outcomes in cardiac surgery: is it safe and effective? Ann Thorac Surg [Internet]. 2010 Aug [cited 2015 Jul 8];90(2):451–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20667328
 
19. Gross I, Seifert B, Hofmann A, Spahn DR. Patient blood management in cardiac surgery results in fewer transfusions and better outcome. Transfusion [Internet]. 2015 May [cited 2015 Sep 15];55(5):1075–81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25565302
 
20. Theusinger OM, Kind SL, Seifert B, Borgeat L, Gerber C, Spahn DR. Patient blood management in orthopaedic surgery: a four-yearfollow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. Blood Transfus.2014;12(2):195–203.
 
21. Zuckerberg GS, Scott A V, Wasey JO, Wick EC, Pawlik TM, Ness PM, et al. Efficacy of education followed by computerized provider order entry with clinician decision Support to reduce red blood cell utilization. Transfusion [Internet]. 2015 Jul [cited2015 Sep 15];55(7):1628–36. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25646579