Patient Blood Management

Implementing Blood Management Program

Hospital-wide, comprehensive, and multidisciplinary PBM program can optimize patient care, avoid unnecessary transfusions of blood products, and limit adverse effects. Successful PBM programs are rooted in evidence-based medicine and enhance patient safety and outcomes through measurable improvements. An integral component is engagement and education of ordering providers. Thus, successful PBM require active input, commitment, and leadership from medical, surgical, anesthesia, intensive care, and hospitalist services, with operational support from administration, finance, and information technology.

Paramount to the success of the program is an initial audit of current transfusion practice, ideally organized by medical specialty and even by individual physicians within that specialty. Appropriate use of products should be audited, including modified (irradiated or washed) and autologous products. Evidence-based transfusion guidelines must then be developed by a multidisciplinary team, usually through transfusion committee. Creation of specific guidelines for certain populations, scenarios, or diseases, such as pediatric, massive transfusion, or sickle cell, is also typically developed.

Transfusion guidelines are ideally incorporated into the ordering process, and physicians and other hospital staff must be educated to them to ensure understanding and compliance. Appropriate audit metrics to determine whether guidelines are being followed must be developed, and data collected, analyzed, and acted on. Auditing can be performed prospectively, concurrently, or retrospectively, and institutional information systems should be harnessed for automated data collection and analytic ease. Possible audit metrics include blood use per diagnosis-related group, pretransfusion hemoglobin and INR levels, blood product use and blood recovery use for specific surgical procedures, and clinically relevant outcomes. Feedback through repeat audits that normalize for severity of illness, compare physicians with their peers, include patient outcomes, and use of transfusion alternatives should be presented at all levels of the hospital hierarchy to stimulate staff awareness and motivation for improvement.

Minimizing Inappropriate Blood Use Through Evidence-Based Guidelines

Ideally, physiologic indicators of tissue oxygen delivery and ischemia should guide RBC transfusion therapy. Randomized controlled studies in critical care populations, both adult and pediatric, show no difference in functional outcome, morbidity, or survival between restrictive (transfusing for hemoglobin <7 g/dL) and liberal (transfusing for hemoglobin <10 g/dL) transfusion strategies. Creating restrictive transfusion criteria reduces the likelihood of transfusion with an average savings of a single RBC unit per transfused patient, without harming the patient.

In other hospitalized patients, the RBC transfusion threshold should be individually assessed for each patient depending on their comorbidities and anemia tolerance. A recent trial in hip fracture repair patients >50 years old and with cardiovascular disease showed no difference in survival or functional outcome between liberal and restrictive (hemoglobin <8 g/dL) transfusion strategy.

Prophylactic platelet transfusion in the absence of bleeding, fever, or sepsis, or an interventional procedure is not indicated with platelet count >10,000/μL. Although not based on randomized controlled trials, many centers transfuse to platelet count of 50,000/μL for interventional procedures, but recent data suggest that, at least for relatively minor-risk surgeries such as central venous catheter placement, platelet count of >20,000/μL is sufficient. Institutions typically use platelet threshold of 20,000/μL in the presence of fever, sepsis, or other bleeding risks and threshold of 50,000/μL in the presence of active bleeding.

In regard to plasma transfusion, a recent metaanalysis of randomized controlled trials showed no definite benefit to plasma transfusion in reducing blood loss in either prophylactic or therapeutic setting. Typically, corrections in international normalized ratio (INR) are small unless pretransfusion INR is >2.5 in the setting of bleeding.

Minimizing Phlebotomy-Related Blood Loss

Phlebotomy-related losses can significantly contribute to anemia and transfusion requirements in hospitalized patients, especially in the intensive care unit setting. Both frequency and volume of blood draws should be limited. Strategies to limit blood draw frequency include the following: limiting orders to only medically necessary tests, embedding disease-specific clinical guidelines into order forms or computer screens, and eliminating “standing” orders. Strategies to limit volume collected include the following: use of low-volume tubes, reducing discard volume from indwelling lines, and point-of-care testing. Point-of-care testing requires smaller blood volumes and has quicker turnaround time than standard laboratory testing. Point-of-care instrumentation is available for blood counts, standard coagulation parameters, and thromboelastography/rotational thromboelastometry measurements.

Treating Preoperative Anemia and Coagulopathy

Preoperative anemia is the strongest predictor of perioperative transfusion and increases risk of perioperative complications. Often presurgical laboratory testing is performed or reviewed too late to treat anemia (iron, B12, folate, or erythropoietin). Erythropoietin can also be used preoperatively to facilitate preoperative autologous donation (PAD) or acute normovolemic hemodilution (ANH). Concomitant intravenous iron supplementation can be used as feasible. Ideally, there is a multidisciplinary preoperative anemia clinic to prepare these patients.

Evaluation includes medical history, including personal and family history of bleeding and use of anticoagulant or antiplatelet medications. Patients should be provided a schedule for switching long-acting anticoagulant or antiplatelet drugs to shorter acting agents, to be stopped immediately before surgery. Herbal or vitamin supplements may also affect bleeding risk and should be discontinued 1–2 weeks preoperatively.

Autologous Blood Conservation

Autologous blood transfusion minimizes, including PAD, ANH, and perioperative blood recovery, allogeneic blood risks such as transfusion-transmitted disease.