Patient blood management – The new frontier

doi:10.1016/j.bpa.2013.01.001

Best Practice & Research Clinical Anaesthesiology

Volume 27, Issue 1, March 2013, Pages 5-10

https://doi.org/10.1016/j.bpa.2013.01.001 Get rights and content

As one of the oldest and most common procedures in clinical practice, allogeneic blood transfusions face many issues including questionable safety and efficacy, increasing costs and limited supply. The need to provide effective care for a relatively small population of patients who could not be transfused for various reasons gave rise to ‘bloodless medicine and surgery’, which was subsequently proposed as a care strategy for all patients, with the goal of minimising the use of allogeneic blood components. The next evolution came from the shift from a ‘product-centred’ approach towards a ‘patient-centred’ approach, that is, a focus on patient outcome rather than use of blood components, which gave birth to ‘patient blood management’. Defined as “the timely application of evidence-based medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss in an effort to improve patient outcome”, patient blood management is expected to reshape the future of transfusion medicine and the way blood components are used in clinical practice.

Section snippets

Summary

Allogeneic blood transfusion remains among the most common procedures used in clinical practice today, but its use is often not fully supported by the available evidence, namely the link between transfusion and worsening of clinical outcomes and debated efficacy. PBM incorporates various evidence-based medical and surgical concepts to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss in an effort to improve patient outcomes. PBM is increasingly adopted as part of

Role of the funding source

None.

Conflicts of interest statement

A.S. has been a consultant or speaker with honorarium or research support from Bayer, Luitpold, Masimo, Novartis, Novo Nordisk, Ortho Biotech, Pfizer, Masimo and ZymoGenetics. He is a founding member of SABM.

A.H. has received grants, honoraria or travel support from Federal Austrian Ministry of Health, Western Australian Department of Health; Amgen; Australian Red Cross Blood Service; CSL Behring; Dynabyte; Fresenius Kabi; Haemonetics; Janssen-Cilag; Johnson & Johnson Ethicon Biosurgery; Novo

Acknowledgement

The authors are grateful to Mazyar Javidroozi, MD, PhD for editorial and organisational support.

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The use of Intraoperative Cell Salvage (ICS) is currently limited in oncological surgeries, due to safety concerns associated with the ability of existing devices to successfully remove circulating tumour cells. In this work, we present the first stages towards the creation of an alternative platform to current cell savers, based on the extremely selective immunoaffinity membrane chromatography principle. Non-woven membranes were produced via electrospinning using poly(vinyl alcohol) (PVA), and further heat treated at 180 °C to prevent their dissolution in aqueous environments and preserve their fibrous morphology. The effects of the PVA degree of hydrolysis (DH) (98 % vs 99 %), method of electrospinning (needleless DC vs AC), and heat treatment duration (1–8 h) were investigated. All heat treated supports maintained their cytocompatibility, whilst tensile tests indicated that the 99 % hydrolysed DC electrospun mats were stronger compared to their 98 % DH counterparts. Although, and at the described conditions, AC electrospinning produced fibres with more than double the diameter compared to those from DC electrospinning, it was not chosen for subsequent experiments because it is still under development. Evidence of unimpeded passage of SY5Y neuroblastoma cells and undiluted defibrinated sheep's blood in flow-through filtration experiments confirmed the successful creation of 3D networks with minimum resistance to mass transfer and lack of non-specific cell binding to the base material, paving the way for the development of novel, highly selective ICS devices for tumour surgeries.
Application of a patient blood management program in cardiac surgery: Analysis and results
2023, Cirugia Cardiovascular
La anemia preoperatoria, la reintervención por sangrado y la necesidad de transfusión son problemas frecuentes en los pacientes tratados con una cirugía cardiaca mayor y se asocian a un aumento considerable de la morbimortalidad. El objetivo del presente trabajo es analizar nuestros resultados quirúrgicos tras la aplicación de un programa de patient blood management (PBM), poniendo el foco en los parámetros hematológicos.
Entre marzo de 2021 y mayo de 2022 hemos intervenido consecutivamente a 104 pacientes de cirugía cardiaca mayor con el programa PBM. La edad media fue de 65 ± 11 años, el 66% fueron varones, el 21% tenían un EuroScore II > 5, el 24% anemia preoperatoria y el 2,8% eran testigos de Jehová que rechazaban las transfusiones. El 19,2% de los procedimientos fueron coronarios sin circulación extracorpórea; el 8,7%, endocarditis; el 10,6%, reintervenciones; el 2,9%, síndromes aórticos agudos y el 34% fueron cirugías urgentes o emergentes.
La tasa de reoperación por sangrado fue del 1,9% y la de transfusión perioperatoria del 25%. El 87,5% de los pacientes operados de forma electiva y el 90,5% de los coronarios aislados no recibieron hemocomponentes. El número medio de concentrados de hematíes (índice de transfusión total), unidades de plasma fresco congelado y concentrados de plaquetas transfundidos por paciente fue de 0,47; 0,16 y 0,07, respectivamente.
El PBM nos ha permitido alcanzar nuestros objetivos de calidad en cuanto a reintervención por sangrado y tasa de transfusión perioperatoria.
Preoperative anemia, reexploration for bleeding and need for transfusion are common problems in patients undergoing mayor cardiac surgery and are associated with an increase morbidity and mortality. The objective of the present report is to evaluate our surgical results focusing on hematological parameters after the implementation of a Patient Blood Management (PBM) program.
Between March 2021 and May 2022, we have consecutively operated on 104 mayor cardiac surgery patients with the PBM program. The mean patient age was 65 ± 11 years, 66% of the patients were male, 21% had a EuroScore II > 5, 24% had preoperative anemia, and 2,8% were Jehovah's Witnesses who refused transfusions. The 19,2% of the procedures were off-pump coronary artery bypass grafting, 8,7% endocarditis, 10,6% redo operations, 2,9% acute aortic syndromes, and 34% urgent or emergent cases.
The incidence of reexploration for bleeding was 1,9% and the perioperative transfusion rate was 25%; 87,5% of the patients operated on electively and 90,5% of the isolated coronary patients did not receive blood components. The mean number of red blood cell concentrates (total transfusion index), fresh frozen plasma, and pooled platelets transfused per patient was 0.47, 0.16, and 0.07, respectively.
The PBM has allowed us to achieve our quality objectives in terms of reintervention for bleeding and perioperative transfusion rate.
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Citation Excerpt :
Preoperative anemia is associated with poor clinical outcome in surgical patients [9–11], and also directly related to the use of RBCT, known to compromise cellular immunity of surgical patients, therefore increasing the risk of postoperative infectious complications and probably favoring recurrence of gastric cancer [6,12–14]. Patient blood management (PBM) programs include different evidence-based interventions addressed to maintain patients’ own blood mass and avoid unnecessary transfusions [15,16]. PBM strategies are organized in three main pillars: management of anemia with early detection and use of erythropoiesis-stimulating agents; minimizing iatrogenic blood loss; and optimization of patient-specific physiological tolerance to anemia with a restrictive transfusion strategy [17,18].
Gastric cancer patients are often transfused with red blood cells, with negative impact on postoperative course. This multicenter prospective interventional cohort study aimed to determine whether implementation of a Patient Blood Management (PBM) program, was associated with a decrease in transfusion rate and improvements in clinical outcomes in gastric cancer surgery.
We compared transfusion practices and clinical outcomes in patients undergoing elective gastric cancer resection before and after implementing a PBM program, including strategies to detect and treat anemia and restrictive transfusion practice (2014–2018). Primary outcome was transfusion rate (TR). Secondary outcomes were complications, reoperations, length of stay, readmissions, 90-day mortality and failure-to-rescue. Differences were adjusted by confounding factors.
Some 789 patients were included (496 pre- and 293 post-PBM). TR decreased from 39.1% to 27.0% (adjusted difference −9.1, 95% CI -15.2 to −2.9), being reduction particularly significant in patients with anemia, ASA score 3–4, locally advanced tumors, undergoing open surgery and total gastrectomy. Infectious complications diminished from 25% to 16.4% (−6.1, 95%CI -11.5 to −0.7), reoperations from 8.1% to 6.1% (−2.2, 95%CI -5.1 to +0.6), median length of stay from 11 [IQR 8–18] to 8 [7–12] days (p < 0.001), hospital readmission from 14.1% to 8.9% (−5.4, 95%CI -9.6 to −1.1), mortality from 7.9% to 4.8% (−2.4, 95%CI -4.7 to −0.01), and failure-to rescue from 62.7% to 32.7% (−23.1, 95%CI -37.7 to −8.5).
Implementation of a PBM program was associated with a reduction in transfusion rate and improvement in postoperative outcomes in gastric cancer patients undergoing curative resection.
The Coagulation Cascade in Perioperative Organ Injury
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Surgical procedures and surgical stress commonly unbalance the coagulation system, causing hypo- or hypercoagulability. Several mechanisms contribute to the organ injury related to the activation of coagulation system, including extravascular fibrin deposition, small-vessel obstruction by thrombosis, and amplification of cellular inflammatory pathways. This chapter covers the basic coagulation and fibrinolytic functions and discuss alterations of these functions in the perioperative period.
Perioperative use of blood products is associated with risk of morbidity and mortality after surgery
2019, American Journal of Surgery
Citation Excerpt :
However, the administration of blood products may be associated with increased morbidity and mortality in some surgical patients.2–9 In addition, excessive blood product utilization has potential detrimental consequences for the healthcare system including overburdening of the blood bank staff, depletion of blood bank resources, and increased costs.10,11 While the median price paid per unit in 2015 was $211 for leukocyte-reduced red blood cells, $524 for apheresed platelets, and $54 for fresh frozen plasma, the total overall cost including the retrieval, transport, and preparation of blood products may be significantly underestimated.12
Administration of blood products may be associated with increased morbidity and perioperative mortality in surgical patients.
Patients aged 18 + who underwent gastrointestinal surgery at the Ohio State University Wexner Medical Center 9/10/2015-5/9/2018 were identified. Multivariable logistic regression models were used to evaluate impact of blood product use on survival and complications, as well as to identify factors associated with receipt of transfusions.
Among 10,756 patients, 35,517 units of blood products were transfused. Preoperative nadir hemoglobin was associated with receipt of blood product transfusion (OR 0.55, 95% CI 0.53, 0.68). After adjusting for patient and procedural characteristics, patients undergoing transfusion of blood products had an increased risk of perioperative mortality (OR 7.80, 95% CI 6.02, 10.10).
The use of blood products was associated with increased risk of complication and death. Patient blood management programs should be implemented to provide rational criteria and guidance for the transfusion of blood products.
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2019, Operative Techniques in Orthopaedics
Citation Excerpt :
The World Health Organization (WHO) emphasized the importance of using transfusion alternatives and implementing individualized patient blood management to reduce blood transfusion needs.3 The 3 pillars of patient blood management are (1) detection and treatment of preoperative anemia, (2) minimizing perioperative blood loss, and (3) harnessing and optimizing the patient-specific physiological tolerance of anemia.4-8 The purpose of this review is to discuss these pillars focusing on the perioperative blood management of patients undergoing spine surgery.
Blood loss remains a major consideration in all spinal surgery. With increasing rates of complex spinal deformity surgery in North America combined with mounting evidence for the association of adverse outcomes with allogenic blood transfusion, there has been a renewed emphasis on transfusion prevention and alternative blood management protocols. Blood management begins with preoperative evaluation and treatment of preoperative anemia. Antiplatelet and anticoagulants must be optimized prior to surgery; a plan for thrombosis prevention and prophylaxis must be in place during the perioperative period. Intraoperative adjuncts such as tranexamic acid should be used unless contraindications exist. Addressing blood loss during the procedure and minimizing ongoing losses in the immediate post-op period remains the domain of the surgical team and is essential in minimizing allogenic blood transfusion.

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1Patient blood management – The new frontier

Section snippets

Summary

Role of the funding source

Conflicts of interest statement

Acknowledgement

Semin Hematol

Best Pract Res Clin Anaesthesiol

Br J Anaesth

J Cardiothorac Vasc Anesth

Transfus Med Rev

The history of blood transfusion prior to the 20th century-part 2

Transfus Med

Blood: an epic history of medicine and commerce

HIV transmission through transfusion –- Missouri and Colorado, 2008

MMWR Morb Mortal Wkly Rep

Transfusion-related acute lung injury: a literature review

Anaesthesia

Liberal or restrictive transfusion in high-risk patients after hip surgery

N Engl J Med

Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial

JAMA

A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in Critical Care Investigators, Canadian Critical Care Trials Group

N Engl J Med

Transfusion strategies for patients in pediatric intensive care units

N Engl J Med

1
Patient blood management – The new frontier