Patient Blood Management

Abstract

BLOOD management has been defined as “the appropriate use of blood and blood components, with a goal of minimizing their use.”‡This goal has been motivated historically by (1) known blood risks; (2) unknown blood risks; (3) preservation of the national blood inventory; and (4) constraints from escalating costs.1Known risks of blood include transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation (e.g. , postoperative infection or tumor progression). Unknown risks include emerging pathogens transmissible by blood (e.g. , new variant Creutzfeldt-Jakob disease and West Nile virus).2–4In addition, several studies have linked allogeneic blood transfusions with occurrence of unfavorable outcomes including increased risk of mortality and various morbidities.5–7For example, studies have indicated that the risk of postoperative infections such as sepsis are as much as two to four times higher in transfused patients compared with untransfused cohorts.8–9Taken together, these lines of evidence support the implementation of blood management as a means to improve the clinical outcomes of the patients. Blood management was cited recently as 1 of the 10 key advances in transfusion medicine over the past 50 yr.10Patient-focused blood management11is described in the Circular of Information§as “a professional judgment based on clinical evaluation that determines the selection of components, dosage, rate of administration…..” Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). Preventive strategies are emphasized to identify, evaluate, and manage anemia12–14(e.g. , pharmacologic therapy15and reduced iatrogenic blood losses from diagnostic testing)16; to optimize hemostasis (e.g. , pharmacologic therapy17and point of care testing18); and to establish decision thresholds (e.g. , guidelines) for the appropriate administration of blood therapy.5,19Patient blood management has recently been recognized by the World Health Organization (World Health Alliance Resolution A63.R12) as a means to “promote the availability of transfusion alternatives.”‖To achieve these goals, health care institutions and accreditation and regulatory agencies have focused on blood utilization to improve clinical outcomes and patient safety. In the United States, The Joint Commission developed Patient Blood Management Performance Measures and submitted these to the National Quality Forum for endorsement. The National Quality Forum did not endorse these submitted Performance Measures, citing lack of data on the outcomes proposed; as a result, they currently do not carry consequences if not met. Because these Performance Measures were process-based rather than outcomes-based, data on proposed outcomes are difficult to retrieve. The Joint Commission has placed these Performance Measures in their Topic Library where they are to be used as additional patient safety activities and/or quality improvement projects by provider institutions as accreditation goals.#The principles of these performance indicators are summarized in table 1. We review recent advances in patient blood management to identify for physicians and healthcare institutions opportunities for process improvement blood utilization and patient safety.Guidelines for detection, evaluation, and management of anemia in elective surgery patients have been published (fig. 1).12,13Predictors of blood transfusion for patients have long been identified, with the most important being the preoperative circulating erythrocyte mass,20as estimated by the patient's hemoglobin concentration. In addition to being a risk factor for blood transfusions, preoperative anemia is also an independent predictor of morbidity and mortality postoperatively.21–24Evaluation of anemia**should begin with an initial assessment of iron-restricted erythropoiesis, which can occur in either the presence or absence of inflammation. Absorption of oral iron is inhibited in the presence of hepcidin due to inflammation, whereas chronic blood loss (e.g. , menses) is an important cause of iron deficiency in the absence of inflammation.25,26Iron-restricted erythropoiesis can cause anemia due to an absolute deficiency of storage iron, an iron sequestration syndrome due to inflammation, or a functional iron deficiency due to erythropoietin-stimulated erythropoiesis.27The evaluation of unexpected anemia must in addition consider unexpected diagnoses including chronic kidney disease or occult malignancy. To facilitate this, screening and detection of anemia should occur as far as possible in advance (up to 30 days) of an electively scheduled surgery.13,28This requires close collaboration among the patients' primary care physicians, surgeons, anesthesiologists, and the