Patient blood management (PBM) encompasses all aspects of optimizing a patient’s blood health. Blood is the body’s liquid organ. Responsible for oxygen delivery, blood has many functions, including maintaining the delicate balance between hemostasis and thrombosis. Suboptimal blood health can manifest as anemia, coagulopathy, hemostasis, bleeding, and/or thrombosis. PBM involves the timely, multidisciplinary application of evidence-based multimodal medical and surgical concepts aimed at screening for, diagnosing and appropriately treating anemia, minimizing surgical, procedural, iatrogenic blood losses, and managing coagulopathic bleeding to improve health outcomes through patient-centered care.1
PBM is a hot topic. In 2010, the World Health Organization (WHO) recognized PBM to promote the availability of transfusion alternatives.2 In 2012, the American Medical Association and the Joint Commission National Summit on Overuse identified blood transfusion as one of the most important health care–related overuse issues facing the world.3 Blood is a precious resource, evident now more than ever, with global critical blood shortages.4 In many ways, PBM is all about doing more with less, which allows us to close the imbalance between supply and demand.5 In 2021, the WHO called for implementation of PBM as a global standard of care.6 The WHO policy statement, “The Urgent Need to Implement PBM,” is an appeal to transform awareness into implementation. This call for action creates a sense of urgency for health care entities to implement PBM; “a systematic, multidisciplinary, multiprofessional concept to routinely minimize these risk factors, and, in so doing, significantly and cost-effectively improve health and clinical outcomes for hundreds of millions of medical and surgical patients, pregnant women, neonates, children, adolescents, elderly people, and the population as a whole”.6 A full WHO PBM implementation guide is to follow this year.
The focus of this special-themed issue of Anesthesia & Analgesia is PBM. Recognizing the importance of PBM, the editors first dedicated a journal section named “Blood Management” in 2016, and subsequently updated it to “Patient Blood Management” in 2019, in recognition of the patient at the center of care.7 Herein are 14 papers, authored by international experts, presenting current aspects of PBM critical thinking and research.
In the era of individualized medicine, PBM optimizes blood health management by personalized patient-centered care. The term PBM was first introduced in 2005 by J. P. Isbister, an Australian hematologist, who realized that the focus of transfusion medicine should be changed from being centered on blood components to being centered on the patients. Isbister et al8 propose that personalized PBM is tailoring the patient’s blood management to the specific characteristics of each patient. The authors highlight the role of informed consent, shared decision making, and the ethical-legal aspects of PBM.8 A contemporary expert consensus, “global definition of patient blood management,” reflects this paradigm shift.9 Shander et al,9 with consensus from international organizations, define PBM as a “patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood, while promoting patient safety and empowerment.” Emphasis is placed on physician-patient shared decision making and patient-centered outcomes.
PBM is traditionally based on 3 main pillars.1,6 The first PBM pillar is optimizing and improving red cell mass by the early detection and treatment of preoperative anemia. Anemia is an underappreciated and underestimated global public health problem affecting billions worldwide.6 Preoperative anemia is easily preventable and managed; therefore‚ it is considered a “low-hanging fruit.” Guinn et al10 provide expert consensus guidelines on the management of preoperative anemia and iron deficiency in adult cardiac surgery patients.
The second PBM pillar is minimizing blood loss and optimizing coagulation.1,6 Blood loss as a result of “routine” phlebotomy is a common and preventable cause of iatrogenic anemia. While laboratory testing can aid in diagnosis, prognosis, and treatment of disease, it often is inappropriate or unnecessary. Hospital-acquired anemia from “bleeding into the chart” is a modifiable risk factor for blood transfusion.11 The most vulnerable are the highest-risk premature babies and critically ill children and adults. Matzek et al12 report that phlebotomy continues to be a major source of blood loss in hospitalized patients with critical illness, and is associated with lower hemoglobin (Hb) concentrations, greater transfusion utilization, and higher costs. The authors highlight an “anemia-phlebotomy paradox,” wherein patients with severe anemia experienced greater phlebotomies and were at greatest risk for harm. The intensity of phlebotomy practices remains largely unchanged despite more than 30 years of evidence highlighting contribution the of phlebotomy to anemia development. Expert consensus calls for limiting the frequency and volume of phlebotomies; nothing should be routine about routine lab work. Optimization of coagulation using multimodal strategies includes treatment with pharmacological and hemostatic agents, goal-directed bleeding protocols, and point-of-care testing to guide diagnosis and management. A “game-changer” medication, tranexamic acid, is featured in a review of current evidence by Patel et al13 that includes dosing guidelines for use in various settings, including trauma, cardiac surgery, orthopedic surgery, obstetrics, neurosurgery, and pediatrics.
The third PBM pillar is harnessing and maximizing the physiological tolerance of anemia by promoting pulmonary and cardiac function, together with considering restrictive transfusion thresholds.1,6 While there are many trials supporting restrictive Hb thresholds to be noninferior or superior compared with liberal thresholds across a wide variety of clinical scenarios, critical illness‚ and surgical procedures‚ strategies should move away from a Hb threshold and toward harnessing the physiological status of the patient to guide decision making.14 Expert consensus was lacking until recently when considering the management of hemostatic blood components. Management guidelines for transfusion of hemostatic blood components, such as plasma, platelets, cryoprecipitate, and recombinant products in pediatrics, are summarized by Valentine et al.15 This review provides recommendations to direct clinicians in the decision to transfuse or not to transfuse hemostatic blood components to critically ill children. Given that plasma and/or platelet transfusions are associated with adverse reactions (ie, febrile, hypotensive, allergic and anaphylactic reactions [FAHR], transfusion-related acute lung injury [TRALI], transfusion-associated circulatory overload [TACO], and transfusion-related immunomodulation [TRIM]), following these strategies should positively impact pediatric patient outcomes.15
PBM is clearly distinct from transfusion medicine, shifting the focus away from transfusion and toward the patient’s blood preservation/conservation.16 Allogeneic blood transfusion, once considered an essential therapeutic measure for anemia and blood loss, carries the risk of increased morbidity and mortality in a dose-dependent relationship. However, it must be emphasized that blood is a precious resource, and can be life and limb saving. PBM strategies include managing blood transfusion toward the “right component, in the right dose, to the right patient, at the right time, for the right reason.” Large observational studies have shown that allogeneic blood transfusion is associated with increased incidence of nosocomial infection, lung injury, acute kidney injury, cardiac overload, thromboembolic events, longer intensive care unit (ICU) and hospital length of stay, and death.17 Evidence of an independent association of blood transfusion and health care–associated infection in patients having coronary artery bypass grafting surgery is highlighted by Mazzeffi et al.18 Given that cardiac surgical patients are the highest-risk groups, with approximately one-third of patients being routinely transfused, and, as coronary artery bypass grafting is the most common cardiac surgical procedure in the world, this study is relevant and generalizable. Furthermore, the slogan known as “why give two when one will do,”19 which has been successful in reducing erythrocyte exposure, should now perhaps be upgraded‚ for elective surgical patients‚ to “why give one when none will do,” if you consider Trentino et al’s retrospective cohort study.20 These results suggest that even small volumes of transfused red blood cells may be independently associated with adverse clinical outcomes.
The old adage from the business world, “If you can’t measure it, you can’t improve it,” is applicable to PBM, as using data and dashboards to support PBM programs and report on metrics increases awareness, identifies nonevidence in practice, and drives change. Furthermore, integrating personalized patient outcome data from electronic medical records potentially optimizes goal-directed care. The importance of “big data” in PBM is introduced by Meier and Tschoellitsch,21 European experts who present a scoping review of how data-driven, information technology–based techniques will revolutionize PBM. One example of bringing evidence into practice with robust data from within and across multiple institutions is reducing variation in practice. Practice variation is a common problem, as shown by Hensley et al.22 Health care centers should collaboratively strive to reduce variability by following PBM evidence and guidelines while using robust outcome data to track and identify areas in which care could be improved.
PBM programs represent an organized top-down approach aimed to improve clinical outcomes and reduce costs.23 Our Canadian colleagues report on the success of PBM programs in the article by Pavenski et al.24 This comprehensive report from a province-wide network of 25 hospitals, working in coordination, details the impact of dedicated PBM programs. Blood transfusion reductions were associated with reduced length of hospital stay, reduced perioperative infections, and a cost savings in the tens of millions of dollars annually. Bloodless medicine harnesses the power of PBM. Bloodless care is a practice of medicine using PBM strategies and is offered to those patients for whom blood transfusion is not a treatment option.25 Frank et al26 report one of the largest series of adult patients receiving bloodless care. Bloodless care patients had similar clinical outcomes compared with patients receiving standard care. The bottom line is that bloodless care is cost-effective and should be considered as a high-value practice.
PBM in 2022 is a new standard of patient care.6 Hospital administrators and department chairs can no longer ignore the clinical and economic impact it offers. PBM adds value; it is a “win-win” mutually benefiting all stakeholders by reducing the utilization of health care resources, and decreasing costs, transfusion dependency, and the risks and complications of allogeneic blood component transfusion for our patients. The economic significance and challenges of global PBM implementation is outlined by Hoffman et al.27 PBM programs can promote population health and positively influence the economics of health care. The authors describe the current blood health landscape in the context of medical waste and highlight the existing impediments to PBM implementation by focusing on how to effectively use the “3 E’s” (evidence, economics, and ethics) to motivate health care stakeholders to implement PBM.
The elegance of PBM lies in the equity afforded to all compelling clinicians, health care providers and entities, administrators, and governing agencies to evaluate any considered intervention based on the robust data-driven likelihood to improve patient outcomes and best utilize precious resources. The anesthesiologist, being a perioperative expert, plays a central role in PBM. As a specialty of perioperative medicine, anesthesiology can and must lead the PBM effort to close the gap between knowledge, evidence, guidelines, practice, and standards. It is time to transform the PBM vision into action.