Patient blood management: a growing challenge and opportunity

In recent years, questions have been raised about clinical outcomes after allogeneic transfusion. Transfusion-related acute lung injury,1 transfusion-associated circulatory overload,2 and whether stored blood has adverse effects on patient outcomes3 are some of these concerns. In addition to these clinical issues, economic questions about transfusion are also being asked. Data from the 2007 Department of Health and Human Services report of the National Blood Collection and Utilization Survey4 demonstrated that the total cost for the provision of blood products in the United States over the 2-year period from 2004 to 2006 increased approximately 17%, which is a rate far exceeding the 9% cumulative inflation rate5 over the same period. The combination of increasing costs and an increasing recognition of the risks associated with transfusion has led to a heightened interest in better stewardship of our blood resources, a concept that has been labeled “blood management.” Some advocates of blood management choose to distinguish between the blood inventory management that occurs within the blood bank and patient blood management (PBM), which involves the management of a patient's blood needs. We recognize the many contributions to promote the importance of this evolving area of transfusion medicine made by the Society for the Advancement of Blood Management. PBM involves many facets of a patient's clinical care. For example, the leading risk factor for perioperative transfusion is preoperative anemia. Therefore, one important aspect of PBM focuses on reducing the number of patients presenting to the operating room with untreated anemia. Other areas that fall within the purview of PBM include the utilization of point-of-care testing devices, which have been demonstrated to reduce allogeneic transfusion in cardiac surgery, as well as intraoperative and postoperative blood salvage, which can also reduce allogeneic transfusion. Thus blood management is more than just intraoperative cell salvage, and its application involves many different health care specialists on both sides of the blood bank window. While allogeneic blood is frequently life-saving, in many circumstances the potential complications are poorly understood by the ordering clinician; thus a meaningful risk-benefit analysis cannot be performed when making the decision to transfuse. As a result, the risks might well outweigh the benefits of transfusion, resulting in unnecessary adverse consequences. Recently at the University of Pittsburgh Medical Center, 2 units of plasma were ordered for a patient who was to undergo a total hip replacement to correct an international normalized ratio (INR) of 1.3 identified 2 weeks earlier. The cause of this minor perturbation was not investigated. Upon administration of the first unit, the patient had a severe anaphylactic reaction that required multiple rounds of epinephrine and an endotracheal tube. Needless to say, the patient did not receive her new hip that day. Two weeks before the rescheduled procedure, her INR was still mildly elevated and the same order for plasma was written! However, with some vigorous intervention by the blood bank physician, the patient was not transfused and tolerated the surgery without bleeding complications. Clearly the physician who ordered the plasma did not understand the appropriate circumstances where it could be beneficial, an unfortunate but pervasive problem throughout the clinical community. PBM also includes the appropriate provision of blood components in accordance with transfusion guidelines and suggests alternatives when they are appropriate. Along with those objectives, education of the health care professionals who order blood transfusions is a vital component of PBM. Interest in PBM is becoming universal and worldwide. Evidence for this growth is seen with the Western Australia PBM project where a coordinated, standardized approach to transfusion and transfusion avoidance is being advocated. In Canada, similar efforts are being made with the Ontario Nurse Transfusion Coordinators (ONTraC) Program, a program to enhance transfusion practice by promoting alternatives to allogeneic transfusion in surgical patients. Within the United States, the perfusionists have created the International Board of Blood Management as a means to increase the skills of practitioners providing intraoperative blood management. In addition, the Joint Commission has recently completed a project outlining seven blood management performance measures, which are now undergoing phase one review by the National Quality Forum. With this editorial, a new associate editor will be added to the journal. The job for this new editor will be to enhance the development of a section of TRANSFUSION that deals with the broad and multidisciplinary area of PBM. Our pages have featured important articles on PBM in the past.6 We anticipate that the appointment of an anesthesiologist to this position, however, will broaden our readership and indicate our interest in increasing clinical reports of transfusion practice and PBM from multiple medical disciplines. We will continue to solicit and hopefully increase our coverage of these topics through original research and topical reviews of evolving clinical uses of blood products. For instance, an area of blood management that is desperately in need of enhanced dialogue between blood bankers and their clinical colleagues is extracorporeal mechanical oxygenation, particularly for adult patients. This black hole for blood products can likely be improved by more focus of better blood management. The opportunities for this new associate editor of TRANSFUSION are broad. The goals are twofold. First, we hope to increase our readership among clinicians using blood components by emphasizing transfusion practices and PBM. Second, we would like to educate our current readers about new developments in blood management techniques. It is hoped that PBM will provide the same growth opportunities and exciting new challenges for the transfusion community as has been recognized within the spectrum of cellular therapies. The authors have no conflicts to disclose.

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