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Patient Blood Management
This document discusses patient blood management (PBM), which is a multidisciplinary approach to optimizing patient care and reducing unnecessary blood transfusions. It has three pillars: optimizing erythropoiesis, minimizing bleeding, and harnessing physiological reserves of anemia. The evidence shows PBM can reduce transfusions by 39% without increasing risks. It has led to reduced transfusions and costs in various settings like cardiac and orthopedic surgery. PBM programs require a multidisciplinary team approach led by specialties like anesthesiology. Overall, PBM provides better patient outcomes while reducing allogeneic blood use.
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- 1. Patient blood management:a fresh look at a fresh approach to blood transfusion G. M. LIUMBRUNO 1, S. VAGLIO 2, G. GRAZZINI 3, D. R. SPAHN 4, G. BIANCOFIORE 5 1Immunohematology and Trasfusion Medicine, San Giovanni Calibita Fatebenefratelli Hospital, AFAR, Rome, Italy; 2Immunohematology and Trasfusion Medicine, Azienda Ospedaliera Sant’Andrea, Rome, Italy; 3Italian National Blood Centre, Rome, Italy; 4Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland; 5Liver transplant Anesthesia and Critical Care, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy Mathurange Krishnapillai MBBS, DTM, MD TM
- 3. Jehovah’s witnesses Why don’tJehovah’s Witnesses accept blood transfusions? This is a religious issue rather than a medical one. Both the Old and New Testaments clearly command us to abstain from blood. (Genesis 9:4; Leviticus 17:10; Deuteronomy 12:23; Acts 15:28, 29) Also, God views blood as representing life. (Leviticus 17:14) So we avoid taking blood not only in obedience to God but also out of respect for him as the Giver of life. https://www.jw.org
- 4. How did itbegin? • 1980’s • Bloodless medicine and surgical practice for JW • Compared the outcomes of patients- received blood and did not receive blood • Multiple studies- Restrictive transfusion strategies- • Reduced cardiac events, re-bleeding, bacterial infections, and mortality
- 5. Definition Patient Blood Management(PBM) is a multidisciplinary, evidence-based approach to optimising the care of patients who might need a blood transfusion. PBM puts the patient at the heart of decisions made about blood transfusion to ensure they receive the best treatment and avoidable, inappropriate use of blood and blood components is reduced. Guidelines for the Blood Transfusion Services in the UK- Red Book
- 6. Why PBM? • Patientbenefit Blood components are used to save and improve thousands of lives each year. The risk of serious complications of a blood transfusion is very low but patients should only receive blood they really need. • Sustainability of the blood supply While the overall demand for red cells is reducing year on year, the reduction for platelets is less marked and may be due to factors such as medical advances and an aging population. Only 4% of the eligible population give blood, and new donors are always needed to replace regular donors who can no longer donate. • Cost Though VNRD donate for free, processing, testing, storage, and transport are expensive.
- 8. The three pillars 1)optimizing the patient’s erythropoiesis 2) minimizing bleeding 3) harnessing and optimising the physiological reserve of anemia
- 9. Optimizing the patient’serythropoiesis Anaemia: If Hb less than, children 0.5-4 years: 11 g/dL children 5-11 years: 11.5 g/dL children 12-14 years: 12 g/dL pregnant women: 11 g/dL non-pregnant women (≥15 years): 12 g/dL men (≥15 years): 13 g/dL. -World Health Organization
- 10. Preop anaemia • Importantrisk factor associated with peri-op transfusion and mortality • Wide range of prevalence noted in various patients: - from 5% (geriatric patients with hip fracture) to 78.5% (patients with Dukes stage D colon cancer) • Haemetinic deficiencies - prevalence ranges from 23% to 70% for iron, around 12% for vitamin B12 and 3% for folate
- 11. Anemia • is acontraindication for major elective surgery at high risk of bleeding and/or consistent anticipated blood loss, • and it should be detected at least 30 days before the scheduled surgical procedure to allow the implementation of appropriate treatment, if available.
- 13. Hospital-acquired anaemia • Increasedmortality and resource utilization as well as higher morbidity • Post-op anaemia prevalence- 90% in Surgical patients • peri-operative bleeding • repeated phlebotomy for diagnostic testing • blunted erythropoiesis caused by surgery-induced inflammatory responses, especially through decreased iron availability (hepcidin-dependent down-regulation of intestinal absorption and impaired mobilization from body stores)
- 14. Strategies to minimisebleeding • thorough preoperative assessment of the patient aimed at identifying and managing the bleeding risk and any potential risk factor for iatrogenic blood loss • Intraoperative blood salvage - most efficacious and effective autologous blood conservation measure. • hyperoxic ventilation(ventilation with pure oxygen) in combination with normovolemic hemodilution • post-operative blood salvage-Recovery and reinfusion of blood from surgical drains is a very commonly used technique -“flip-n-drip” systems:When adequate amounts of blood are collected, the system is flipped over and plugged into an intravenous line. • coordinated and patient-tailored usage of pharmacological and non-pharmacological techniques and strategies • Less invasive surgery and computer-assisted surgery, neuraxial anesthesia, patient positioning, maintenance of normothermia, controlled hypotension, point-of-care coagulation testing • Topical hemostatic agents - such as fibrin sealant - and hemostatic drugs - tranexamic acid
- 15. Controlled hypotension: • Reductionof the systolic blood pressure to 80-90 mm Hg, a reduction of mean arterial pressure to 50-65 mmHg or a 30% reduction of its baseline value • reduce bleeding and the need for blood transfusions, and provide a satisfactory bloodless surgical field Point of care testing: • Reduces iatrogenic blood loss- requires only small volume of blood sample • Assists clinicians in decision making, reduces unnecessary blood transfusions
- 16. Harnessing and optimisingphysiological reserve of anemia • preoperative preparation of the patient, the intraoperative optimisation of oxygen transport and tissue oxygenation, the maintenance of the postoperative balance of oxygen delivery and oxygen consumption, and the use of restrictive transfusion thresholds. • Randomized trials show that RBC transfusions can increase in- hospital mortality, total mortality, rebleeding, acute coronary syndrome, pulmonary oedema, and bacterial infections. • Restrictive transfusion strategy- administering RBCs if hemoglobin falls below 7 or 8 g/dL is safe in most clinical settings.
- 18. Patient blood management:the available evidence • 2011 Cochrane review : Haemoglobin transfusion threshold of 7 or 8 g/dL compared with a higher haemoglobin transfusion threshold (10 g/dL) results in: 1) a reduction of the risk of receiving a RBC transfusion by 39% that equates to an average absolute risk reduction of 34% 2) fewer blood transfusions 3) a statistically significant reduction of in-hospital mortality but not 30-day mortality. 4) The use of restrictive strategies did not cause, cardiac morbidity, impaired functional recovery, or prolonged hospital length of stay.
- 19. • 1991- oneof the first blood conservation strategies in cardiac surgery - by Ovrum and co-workers who managed to avoid allogeneic blood transfusion in 484 out of 500 patients (96.8%) through the simple (and cost-effective) intra- and post- operative-re-transfusion of autologous (shed) blood • 2001- Van der Linden et al. - a safe and cost-effective 53% decrease in RBC usage and a 46% decrease in the number of elective cardiac-surgery patients receiving any blood products, without any significant difference in post-operative haemoglobin. • Control and study groups showed similar in-hospital mortality, intensive care unit and hospital length of stay. • Postoperative complication rate was also comparable (acute myocardial infarction; respiratory problems; wound infections; neurologic deficit; renal insufficiency needing haemodialysis)
- 20. • Cardiac surgery-a more recent study determined the effects of a PBM programme based on algorithm-driven transfusion decisions - lower transfusion triggers, point-of-care testing, and blood-saving measures. • The total blood product use was reduced by 40% and control patients had a slightly higher pre-discharge hemoglobin level than study patients. • However, no differences seen in between in-hospital or 30-day mortality, re-operation for bleeding, or other post-operative outcomes such as peri- operative myocardial infarction (24 hours) ventilator support, wound infections, sepsis, renal insufficiency needing haemodialysis, transient ischaemic attack, and multiorgan system failure.
- 21. • Masud etal. implemented a multidisciplinary team-driven PBM programme • A reduction in post-operative blood product use among coronary artery bypass graft patients (a 14.3% decrease in the first year and 30.6% from 2006 to 2008), • an 18.2% reduction of blood product volume used in the entire cardiovascular intensive care unit, • an estimated savings of more than $ 1 million, with no additional harm to patients and a trend toward better clinical outcomes.
- 22. • In Switzerland,a before and after study in elective orthopaedic surgery was carried out to investigate the impact of the introduction of a PBM programme, which resulted in: • 1) a significantly lower incidence of immediate preoperative anemia in hip and knee surgery (from 17.6 % to 12.9 % [Prespectively), while in spine surgery its prevalence remained unchanged (12.6% vs. 10.3%); • 2) an unchanged RBC mass loss in hip surgery and a significantly RBC mass loss reduction in knee and spine surgery • 3) a significantly lower transfusion rate (from 21.8% to 15.7% in hip surgery; from 19.3% to 4.9% in knee surgery, and from 18.6 to 8.6% in spine surgery
- 23. • In 2008,a PBM programme was implemented in 23 Canadian hospitals and it involved education, autologous donation, cell salvage, and erythropoietin administration. • After 24 months, most hospitals had demonstrated decreased use of allogeneic blood and patients who did not receive allogeneic transfusions had significantly lower postoperative infection rates • Excellent results of hospital-wide PBMs were reported in Australia and in the USA. • The results of the USA hospital were “achieved through hospital-wide physician buy-in toward a restrictive transfusion approach” and resulted in a 43% reduction in RBC units transfused per patient discharged.
- 24. Further research onthe impact of PBM strategies on (long-term) patient outcomes is needed!!
- 25. PBM around theworld and in Italy • 2010, the World Health Organization (WHO), with the resolution WHA63.12, urged all member states to implement PBM • Australia is the first example of a national public health system thoroughly compliant with the WHO request. • National Blood Authority developed comprehensive six-module- evidence-based PBM national guidelines.
- 27. • USA, PBMhas attracted the attention of the Association for Advancing Transfusions and Cellular Therapies (AABB), the SABM and the Joint Commission. • At present, in this country, PBM programmes are around 100. • Currently, the implementation of PBM in Europe except for the Netherlands, Austria, and Spain is limited. • PBM strategies are in place for major elective surgery in a limited number of hospitals in Switzerland, while in the UK some centres are now developing pilot studies on PBM.
- 28. European Commission launchedthree objectives: 1) develop a European PBM guide for Member States; 2) implement PBM programmes in 5 teaching hospitals in European Member States; 3) prepare strategies to help national authorities to disseminate and implement PBM across Europe.
- 29. Sri Lanka • 2016-Annual Sessions of Sri Lanka College of Transfusion physicians “Patient Blood Management”
- 30. PBM: role ofthe anesthesiologist • Peri- operative care specialists –suitable to lead multidisciplinary and multi-professional PBM programmes. • It can only be successful with participation of major surgical disciplines, haematology, blood banking and the Board of Directors of the hospital. ➢PBM steering committee to be founded ➢Issue hospital wide compulsory PBM guidelines ➢continuous educational programmes ➢The PBM guidelines should include- 1. patients are being seen as early as possible, ideally 30 days prior to elective surgery, to detect anaemia and to have sufficient time to specifically treat anemia if present. 2. Introduction of blood sparing surgical techniques, the use of cell salvage etc ➢Guidelines alone are not sufficient- A continuous monitoring system is to be introduced assessing the adherence to the guidelines. ➢Issues to be assessed are percentage of anemic patients operated, use of cell salvage, perioperative transfusion rate, and hemoglobin concentration at transfusion. Clinical outcomes such as infections, hospital LOS and thrombotic complications to be monitored. ➢Data analysed and reported to relevant physicians.
- 31. Conclusions • All treatmentsshould be assessed for their effect on improving patients’ outcomes. • But allogeneic blood transfusions are often guided by laboratory thresholds. • Disadvantages: highly variable transfusion practice, costly and likely to do more harm than good to the patients. • These concernshave fuelled the search for new modalities and strategies to reduce use of blood components. • PBM focuses on multidisciplinary and multimodal preventive measures to reduce the need for transfusions and improve the clinical outcomes. • Emerging data support that PBM is safe and effective in providing better care and improving patients’ outcomes while reducing transfusion of allogeneic blood components. • Therefore, as perioperative medicine leaders, Anaesthesiologists are called to hold a key role in promoting, implementing and auditing PBM programmes at their institutions.
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