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 Table of Contents  
GUEST EDITORIAL
Year : 2016  |  Volume : 1  |  Issue : 2  |  Page : 40-42

Patient blood management: Need of the hour


Chairman, Federation of Bombay Blood Banks; Indian Red Cross Society, Bombay City Branch, Blood Centre, Mumbai, Maharashtra, India

Date of Web Publication6-Sep-2016

Correspondence Address:
Zarin S Bharucha
Chairman, Federation of Bombay Blood Banks; Indian Red Cross Society, Bombay City Branch, Blood Centre, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-8893.189858

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How to cite this article:
Bharucha ZS. Patient blood management: Need of the hour. Glob J Transfus Med 2016;1:40-2

How to cite this URL:
Bharucha ZS. Patient blood management: Need of the hour. Glob J Transfus Med [serial online] 2016 [cited 2022 May 26];1:40-2. Available from: https://www.gjtmonline.com/text.asp?2016/1/2/40/189858



Blood and blood products are a critical component of health care. While blood transfusion areas are recognized as the life-saving part of medical treatment, they can also be associated with adverse events and poorer outcomes for some patient groups. Blood transfusion safety aims at achieving maximum therapeutic benefits with minimum risks. The vein-to-vein chain of blood transfusion service (BTS) aligns safe and sufficient blood supply from voluntary blood donors with safe transfusion practice meeting the demands from patients. Quality management of BTS is concerned with every aspect of transfusion practice besides the blood bank operations.

The goal of modern transfusion therapy is to provide appropriate replacement therapy with blood components as opposed to whole blood for patients with specific hematologic deficiencies. A prerequisite of component therapy is, therefore, correct identification of the deficiency. Appropriate use of components avoids many hazards associated with the use of whole blood, and at the same time makes maximal use of this valuable resource.

Blood is essential sometimes but not always and hence it is overused globally. To reduce the overuse and prevent unnecessary transfusions, transfusion practice needs to be based on evidence. Evidence-based approach for managing patients can minimize unnecessary exposure to transfusions where possible and deliver better outcomes for patients.

It is generally agreed that transfusion is not of benefit when hemoglobin (Hb) concentrations are >10 g/dL, and are beneficial when Hb concentrations are <6 g/dL.[1] However, the 10/30 rule, “transfuse when a patient has an Hb level ≤10 g/dL (100 g/dL) and a hematocrit level ≤30%” was used until the 1980s as a trigger to transfuse, regardless of the patient's clinical presentation.[2]

Plasma transfusion is recommended in patients with active bleeding and an international normalized ratio (INR) >1.6 or before an invasive procedure or surgery if a patient has been anticoagulated.[3] Plasma is often inappropriately transfused for the correction of a high INR when there is no bleeding.

Platelet transfusion may be indicated to prevent hemorrhage in patients with thrombocytopenia or platelet function defects. One unit of apheresis platelets or six random donor platelets should increase the platelet count in adults by 30–60 × 109/L.[4]

Currently, national programs are focusing on the appropriate use of blood products, transfusion safety, and hemovigilance, which are important strategies to enhance patient safety. However, these product-focused strategies are insufficient to meet the challenges of blood transfusion.


  Challenges of Blood Transfusion Top


These include gap between supply and demand, increasing costs of blood, product safety – the risks due to transfusion-transmissible infections, questionable benefits of transfusions, and rising legal implications. These are discussed as follows.

Demand–supply gap

The gap between supply and demand is widening. Due to increase in complex surgeries and more aggressive treatment of hematological and other malignancies as well as stem cell and organ transplants, the demand for blood is increasing. With increasing demands from medical and surgical units, the supply is not able to cope up. The donation rate is reducing with an increase in deferral rates due to stringent donor selection criteria as well as increase in discard rates due to increased rates of infections in donated blood. The shortages are more during summer vacation and festival periods. BTS should also predict the requirement of blood and schedule the blood collection accordingly to reduce the wastage due to outdating.

Increasing cost of blood

The cost of blood and blood products is increasing as there is an increased testing required to control the infection risks.[5] A full-cost assessment of transfusion includes product procurement and in-house logistics, multiple lab tests and services, pretransfusion examinations, as it includes increased testing requirements, administration and monitoring of transfusions, and the cost of treating unpredictable transfusion reactions.

Adverse outcomes and need for hemovigilance

In spite of the increasing costs, the risks still persist. Besides substantial reduction in the risk for HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV), after the introduction of predonation counseling and nucleic acid testing, the blood supply remains vulnerable to numerous newly emerging and several re-emerging pathogens in the blood pool that are currently not tested.[6] Besides the infectious risks, there can also be a clerical error, leading to wrong blood in tube or the wrong blood being transfused due to the clerical error.[7] Perhaps, the greatest current concern with transfusion is its association with adverse patient outcomes. Allogeneic transfusions can be associated with adverse patient outcomes potentially leading to increased morbidity resulting in delayed recovery or extended hospital stays and increased levels of mortality.

Product safety

Blood transfusion may be associated with recurrence for various neoplasms [8] and may also cause postoperative immunomodulation leading to susceptibility to infectious complications.[9] Transfusion Requirements in Critical Care, a prospective randomized controlled trial, assessed transfusion thresholds and outcomes, which showed higher incidence of cardiac complications and organ dysfunction as well as higher in-hospital mortality rate in patients transfused to maintain Hb at 10–12 g/dL (liberal policy) compared to patients transfused if their Hb level dropped to <7 g/dL (restricted policy).[10]

Thus, red blood cell (RBC) transfusions are considered harmful in some clinical situations and have been shown to be beneficial in relatively few indications. Hence, RBC transfusions are now undergoing renewed scrutiny by health-care institutions to reduce blood utilization.

Patient consent/legal implications

In the current environment of increased legal implications, the need is felt to involve and educate patients for whom transfusion may be a treatment option. Every patient has the right to know the nature of the treatment being recommended, its risks and benefits in their particular situation, and what possible alternatives are available. Patients, however, still appear to be poorly informed regarding transfusion choices and many clinicians and institutions are not attempting to improve this situation.[11]


  What Is Patient Blood Management? Top


The list of potential side effects associated with blood component transfusion and also the efforts for decreasing health-care costs have helped to expand the function of the blood banks diverting their focus from blood product to patient-centered care focusing on improving the health and well-being, clinical outcomes, and safety of the patients. This has created a new activity related to patients undergoing surgery and, to a lesser extent, in other medical scenarios which has been called patient blood management (PBM), defined as evidence-based, multidisciplinary approach to reduce the need for blood component transfusion for patients.

In May 2010, in view of the pressures for change, the 63rd session of the decision-making body of the World Health Organization, the World Health Assembly (WHA), adopted resolutionWHA63.12 which recommended PBM approach to promote the availability of transfusion alternatives to its 193 member states.[12]

PBM is designed to evaluate and manage anemia to maintain Hb concentration by pharmacologic therapy,[13] to reduce iatrogenic blood losses, to optimize hemostasis by pharmacologic therapy,[14] to implement point of care testing,[15] and to minimize blood loss using predeposit autologous donation, acute normovolemic hemodilution, or intraoperative cell salvage, using cell saver in an effort to improve patient outcomes. These principles also apply in the management of any hematological disorder besides surgery, where a significant percentage of the blood supply is consumed. These patients could be also benefited from these strategies.

Exposure of patients to allogeneic transfusion can be minimized or avoided by the systematic strategies of multiple blood conservation techniques such as appropriate combinations of medications, technologic devices, and surgical and medical techniques. Its implementation requires a cultural shift among all levels of the health-care system including national blood program, health-care institutions, and accreditation and regulatory agencies. PBM calls for an interdisciplinary team approach, including transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists and nurses, pump technologists, and pharmacists to share a commitment to avoid allogeneic blood transfusion.[16]

The strategies to reduce the need for allogeneic blood transfusion in all patients at-risk were initially called blood conservation. When other approaches to maintain and optimize Hb level and hemostasis were included, it was called blood management. Later, it was termed “PBM” as what matters is the patients and their clinical outcomes.

However, the potential and actual harm to patients caused through inappropriate transfusions is not sufficiently perceptible by the public and clinicians.[17] This has to be changed. Transfusion is a transplant and should never be a trivial decision. PBM is possible today and needs to be implemented in our hospitals. The medical, physiological, ethical, legal, and economic evidence cannot be ignored. PBM is plainly a good medical practice, and more importantly, a good medical common sense.


  Patient Blood Management –adoption and Implementation Top


In developed countries, especially Australia, some parts of USA, and some countries of Europe, there is a growing interest in PBM, and programs are already established. Adoption and expansion of PBM is being promoted through medical meetings and conferences of professional societies, as well as numerous publications in the medical literature to foster the exchange of ideas and information. The “evidence-based” recommendations for the adoption of a conservative Hb threshold have been incorporated into many of the currently available consensus transfusion guidelines.

In developing countries, there is a need for the national blood programs to ascertain the availability of affordable and efficient blood supply to meet the demands. Patients in developing countries continue to be exposed to the risk of preventable transfusion-transmitted infections by blood-borne pathogens such as HBV, HCV, and HIV. Unsafe and/or poor-quality blood products can render patients vulnerable to avoidable risk if the blood programs are not subjected to the level of control exercised with effective mechanisms of regulatory oversight. It is necessary to keep an eye on proper inventory management, technologies to ensure the quality and safety of blood products, and guidelines on the appropriate clinical use of blood products.

For cost efficiency, it is required to avoid the cost of adverse effects of blood transfusion which lead to readmission, extended hospital stay, and re-operative interventions. Collection of data of blood use, where it is used and why, is required to control the inappropriate use in any hospital or region. To create awareness and promote appropriate use among the blood users, education and training should be undertaken. For PBM, it is also necessary to develop a policy for restrictive use suggesting alternatives for benefits and better patient outcomes, curtailing the unnecessary morbidity and mortality. Providing guidelines and training modules for PBM is helpful to ensure that every reasonable measure is taken to optimize the patient's own blood volume, to minimize the patient's blood loss, and to harness and optimize the patient-specific physiological tolerance of anemia. Benchmarking practices with other countries would provide information regarding further developments in this subject.


  Conclusion Top


First, “do no harm” is the cornerstone of medicine. However, unintentional harm does occur at all levels of the health system. PBM is a coordinated health-care approach to patient care that focuses on strategies to reduce or avoid the need for a blood transfusion where possible, along with the appropriate use of blood when a transfusion is needed and improving patient outcomes and patient safety. The alternatives discussed can be used individually with success, but they are most effective when used together in a blood management strategy that is individualized to a specific patient. The widespread uptake and sustainability of PBM programs is important not only to provide improved clinical outcomes for individual patients, but also to preserve the national blood supply in the face of increase in demand for blood component therapy.

 
  References Top

1.
Practice Guidelines for blood component therapy: A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 1996;84:732-47.  Back to cited text no. 1
    
2.
Klein HG, Spahn DR, Carson JL. Red blood cell transfusion in clinical practice. Lancet 2007;370:415-26.  Back to cited text no. 2
    
3.
Holland LL, Brooks JP. Toward rational fresh frozen plasma transfusion: The effect of plasma transfusion on coagulation test results. Am J Clin Pathol 2006;126:133-9.  Back to cited text no. 3
    
4.
British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for the use of platelet transfusions. Br J Haematol 2003;122:10-23.  Back to cited text no. 4
    
5.
Jackson BR, Busch MP, Stramer SL, AuBuchon JP. The cost-effectiveness of NAT for HIV, HCV, and HBV in whole-blood donations. Transfusion 2003;43:721-9.  Back to cited text no. 5
    
6.
Stramer SL, Hollinger FB, Katz LM, Kleinman S, Metzel PS, Gregory KR, et al. Emerging infectious disease agents and their potential threat to transfusion safety. Transfusion 2009;49 Suppl 2:1S-29S.  Back to cited text no. 6
    
7.
Serious Hazards of Transfusion (SHOT), Annual Report; 2009. Available from: http://www.shotuk.org/wp-content/uploads/2010/07/SHOT2009.pdf. [Last accessed Aug 2016].  Back to cited text no. 7
    
8.
Blumberg N, Heal JM, Murphy P, Agarwal MM, Chuang C. Association between transfusion of whole blood and recurrence of cancer. Br Med J (Clin Res Ed) 1986;293:530-3.  Back to cited text no. 8
    
9.
Tartter PI, Quintero S, Barron DM. Perioperative blood transfusion associated with infectious complications after colorectal cancer operations. Am J Surg 1986;152:479-82.  Back to cited text no. 9
    
10.
Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340:409-17.  Back to cited text no. 10
    
11.
Sazama K. The ethics of blood management. Vox Sang 2007;92:95-102.  Back to cited text no. 11
    
12.
Sixty-Third World Health Assembly, Resolution WHA63.12. Availability, Safety and Quality of Blood Products; 2010. http://apps.who.int/gb/ebwha/pdf_files/WHA63-REC1/WHA63_REC1-P2-en.pdf. [Last accessed 2016 Aug].  Back to cited text no. 12
    
13.
Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion medicine. Second of two parts-blood conservation. N Engl J Med 1999;340:525-33.  Back to cited text no. 13
    
14.
Goodnough LT, Shander A. How I treat warfarin-associated coagulopathy in patients with intracerebral hemorrhage. Blood 2011;117:6091-9.  Back to cited text no. 14
    
15.
Despotis GJ, Joist JH, Goodnough LT. Monitoring of hemostasis in cardiac surgical patients: Impact of point-of-care testing on blood loss and transfusion outcomes. Clin Chem 1997;43:1684-96.  Back to cited text no. 15
    
16.
Van der Linden P, De Hert S, Daper A, Trenchant A, Jacobs0 D, De Boelpaepe C, et al. A standardized multidisciplinary approach reduces the use of allogeneic blood products in patients undergoing cardiacsurgery. Can J Anaesth 2001;48:894-901.  Back to cited text no. 16
    
17.
Isbister JP. Clinicians as gatekeepers: What is the best route to optimal blood use? Dev Biol (Basel) 2007;127:9-14.  Back to cited text no. 17
    




 

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