Patient Blood Management: where to start?

Dear Editor,

Most anesthesiologists recognize the harmful effects of transfusion therapy and try to avoid exposure to allogeneic blood, although some of them decidedly have no interested in the subject and perform transfusion without physiological or even laboratory criteria. However, it is likely that there are anesthesiologists who have never transfused one bag of packed red blood cells (RBCs) and/or fresh frozen plasma and this makes the subject blood transfusion quite relevant and generally controversial.

Blood is the most transfused organ in the world, with about 14 million units of packed RBCs transfused each year, which represents a cost of approximately US $3 billion (average of $225 per RBCs).¹ Having in your hospital a program that combats this "need" for blood transfusion can improve patient outcomes, minimize risk, and reduce costs. In this sense, the term Patient Blood Management (PBM) was created, which consists of applying a multidisciplinary approach based on medical evidence and surgical concepts that is hospital independent and patient-centered for early diagnosis and treatment of anemia, application of blood conservation techniques, careful surgical hemostasis, and rational use of blood products in order to improve above all the patient's prognosis. Since 2010, the World Health Organization recommended the application of PMB as a strategy for reducing the number of RBCs transfusions worldwide.²

And why start using such a program? Statistical data provide the answer. Hospital stay of non-transfused patients is on average 25% lower than that of transfused patients.³ Studies show that the implementation of a transfusion strategy program in heart surgery reduces death rate by 47% and post-surgical hospital costs by 50%.⁴ However, the point considered more important and in which probably all anesthesiologists can act in a simple and very effective way is the management of preoperative anemia. It is very easy to diagnose an anemic patient in a pre-anesthetic consultation, as well as treat him (for such, it is worth reading these two good articles on how to manage an anemic patient during the pre-anesthetic visit).^5and6 Within a very reasonable period of 15-20 days we can manage the anemic condition of the patient and he may undergo surgery within acceptable limits. And that makes all the difference, as preoperative anemia is directly related to red blood cell transfusion during surgery, which is a cause of increased morbidity and postoperative mortality.^{7, 8-9} The preoperative diagnosis and appropriate treatment of anemia reduce the incidence of transfusion by 62%.¹⁰ Many of us, anesthesiologists, believe that anemia is not as frequent or is harmless, but according to the World Health Organization data there are more than two billion anemic people worldwide.¹¹ On average, 15-40% of patients have anemia at the time of surgery and, according to the concepts of PBM, anemia is a contraindication to elective surgery, with an expected moderate to severe blood loss.¹²

So, here is a proposal and a challenge: anemia should be diagnosed and treated before surgery. That alone is the first and major step to reduce blood transfusion, which will greatly benefit the patient and improve the quality of our anesthesia.

References

• ¹
  Department of Health and Human Services. The 2011 national blood collection and utilization survey report. Washington, DC: DHHS; 2013.
• ²
  World Health Organisation Web site. http://www.who.int/bloodsafety/clinicaluse/en/
  » http://www.who.int/bloodsafety/clinicaluse/en/
• ³
  Sarode R, Refaai MA, Matevosvan K, et al. Prospective mon- itoring of plasma and platelet transfusions in a large teaching hospital results in significant cost reduction. Transfusion (Paris). 2010;50:487-92.
• ⁴
  LaPar DJ, Crosby IK, Ailawadi G, et al. Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery. J Thorac Cardiovasc Surg. 2013;145:796-803.
• ⁵
  Goodnough LT, Shander A. Patient Blood Management. Anesthe- siology. 2012;116:1367-76.
• ⁶
  Goodnough LT, Maniatis A, Earnshaw P, et al. Detection, evalua- tion, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth. 2011;106:13-22.
• ⁷
  Baron DM, Hochrieser H, Posch M, et al. Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients. Br J Anaesth. 2014;113: 416-23.
• ⁸
  Rohde JM, Dimcheff DE, Blumberg N, et al. Health care- associated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA. 2014;311: 1317-26.
• ⁹
  Silva JM Jr, Cezario TA, Toledo DO, et al. Transfusão sanguínea no intra -operatório. Complicações e prognóstico. Rev Bras Aneste- siol. 2008;58:447-61.
• ¹⁰
  Na HS, Shin SY, Hwang JY, et al. Effects of intravenous iron combined with low-dose recombinant human erythropoietin on transfusion requirements in iron-deficient patients undergo- ing bilateral total knee replacement arthroplasty. Transfusion (Paris). 2011;51:118-24.
• ¹¹
  Focusing on anemia - towards an integrated approach for effective anaemia control. Joint Statement by the World Health Organization and the United Nations Children's Fund - WHO/UNICEF.
• ¹²
  Spahn DR, Goodnough LT. Alternatives to blood transfusion. Lancet. 2013;381:1855-65.

Publication Dates

• Publication in this collection
  May-Jun 2016