The Role of Patient Blood Management in Judicious Use of Blood

Blood transfusion is a meaningful life-rescuing measure in the management of fatal patients. However, many adverse outcomes are related to allogeneic or homologous blood transfusion, ranging from immediate and delayed transfusion reaction to prolonged hospital stay and increased mortality, cost and overwhelming burden to patients and healthcare facilities.[1] Over the years, much attention has been given to improving blood component quality and safety issues. Conversely, the reasonable and logical use of whole blood and its derivatives has not been addressed effectively.[2] The cautious and careful use of transfusion by transfusing patients only at what time clinically implied, focusing on the individual patient need, is emphasised by implementing patient blood management (PBM). Initially, it was applied for surgical patients to minimise blood loss and limit anaemia. Subsequently, it is now used for other patients with significant blood loss. It requires blood transfusion as a part of treatment in medical, paediatric, obstetrics and gynaecology (O and G), critical care or any other discipline [Figure 1].[3]Figure 1: Uses of transfusion. This figure has been drawn with the premium version of BioRender (https://biorender.com/ accessed on 16 September 2023) with the license number QV25V0KHAK, Image credit: Susmita Sinha.DRIVE FOR PATIENT BLOOD MANAGEMENT Every transfusion has potential risks such as exposure to transfusion-transmitted infections and emerging infections such as West Nile virus, severe acute respiratory syndrome virus, Chagas disease and variant Creutzfeldt–Jakob disease. Besides, there are risks of acute transfusion reactions, transfusion-related circulatory overload, transfusion-related acute lung injury, wrong blood component transfusion and microbial contagion. All these factors increase the mortality and morbidity in patients and the length of hospital stay. Moreover, blood depends on voluntary donors, and the growing population age in high human development index countries adds pressure to the blood supply. The higher financial overhead of blood transfusion is a significant burden to the patient and society.[2] Therefore, implementing PBM evolves as a safeguard for improved patient care and better health consequences. PATIENT BLOOD MANAGEMENT In 2010, the World Health Assembly endorsed the Resolution of PBM to its member states.[3] A standard definition developed by the expert group specifies that ‘PBM is a patient-centred, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's blood while promoting patient safety and empowerment’.[4] This patient-centred, multidisciplinary tactic to minimise the use of blood transfusion aims to improve patient outcomes with minimum blood transfusion.[5] Here, the patient has active participation. Their values, preferences and choices are essential, and informed consent is central to PBM.[4] PBM allows the saving of healthcare resources, maintains the blood supply and ensures that blood products are available for patients in need while reducing the healthcare budget.[3] PBM is based on three key strategies or pillars – Pillar 1 (before specific treatment/pre-operative): identifying and treating anaemia and iron deficiency; Pillar 2 (during specific treatment/intraoperative): minimising blood loss and optimising coagulation and Pillar 3 (following up after specific treatment/post-operative): Optimising the patient-explicit physiological forbearance of anaemia.[36] Therefore, it is a multidisciplinary, multi-professional, individualised patient-centred strategy to restore a patient's red cell mass by identifying and treating anaemia, stimulating erythropoiesis, minimising diagnostic or surgical blood loss and optimising the patient-specific tolerance to anaemia.[7] PILLAR 1: DETECTION AND MANAGEMENT OF ANAEMIA AND IRON DEFICIENCY Iron-deficiency anaemia (IDA) was a global burden in around 32.9% of the population in 2010,[8] primarily due to the underlying disease or significant surgical blood loss such as orthopaedic surgery of total hip replacement (THR)/total knee replacement (TKR) and hip fracture.[9] Anaemia is a frequent finding in surgical patients detected during pre-operative evaluation; the severity varies based on age, gender and underlying comorbidity. The reported frequency of anaemia in patients for THR/TKR is 24%, hip fracture 44%, colorectal surgery 22%–75%, cardiac surgery 22%–30% and non-cardiac surgery 34%.[9] There is a close connotation amidst pre-operative anaemia and post-operative outcomes and mortality. Therefore, correction of anaemia is an important issue.[10] Under the PBM strategy, pre-operative screening for anaemia and bleeding risk assessment is undertaken, and iron supplementation is recommended to treat underlying IDA. Therefore, a sufficient time interval for correction of anaemia before operation is required. Using an erythropoiesis-stimulating agent (ESA) with iron supplementation helps reduce the transfusion rate in significant surgeries.[11] Restricting sample taking for testing and limiting the use of antiplatelet and anticoagulant agents in patients taking these medications also have some role in conserving the patient's blood.[9] In anaemia caused by chronic disease, treatment with ESA therapy responds well. Renal anaemia occurs due to erythropoietin deficiency and needs to be treated with ESA therapy.[1] Anaemia is a common finding in pregnancy or congestive heart failure, and treatment with iron therapy gives a better outcome to the patient.[5] PILLAR 2: MINIMISE BLOOD LOSS AND OPTIMISE COAGULATION Minimising blood loss is an essential strategy of PBM. It can be implemented by identifying, managing and treating bleeding patients, adopting careful surgical and anaesthetic techniques with attention to the patient's positioning and keeping the patient warm.[2] Administration of antifibrinolytic agents such as tranexamic acid, epsilon-aminocaproic acid and aprotinin in major surgery can reduce the bleeding episode, transfusion rate, mortality morbidity and cost [Figure 2].[12] Acute normovolaemic haemodilution effectively lowers blood loss where immediate pre-operative blood is collected from the patient and replaced with crystalloid or colloid solutions to preserve the circulatory appropriate magnitude. It reduces the patient's haematocrit and increases the cardiac output and organ blood flow. Therefore, during operation, the blood loss is mainly diluted blood with reduced red cell mass. Postoperatively, the collected blood is transfused back to the patient.[13] Intraoperative blood recovery by red cell salvage and retransfusing it to the patient is also a critical PBM strategy in patients undergoing major surgeries such as cardiothoracic, orthopaedic, neurological, vascular and trauma surgery.[9] For example, in non-surgical patients with liver cirrhosis, patients may have coagulation abnormalities and increased bleeding risk. Anaemia in these patients could be due to a multifactorial reason, such as iron/Vitamin B12 deficiency or folate deficiency, underlying malnutrition, hypersplenism and complications related to the disease. Therefore, transfusion needs can be reduced by detecting the reversible causes of anaemia. Prophylactic fresh frozen plasma (FFP) transfusion is also questionable. Point-of-care testing, the viscoelastic assay, may help provide the patient's coagulation function and guide the use of platelets, FFP or coagulation factors.[5]Figure 2: Minimising blood loss in patient blood management. This figure has been drawn with the premium version of BioRender (https://biorender.com/ accessed on 17 September 2023) with the license number YL25V28GFG, Image credit: Susmita Sinha.PILLAR 3: OPTIMISING THE PATIENT-SPECIFIC PHYSIOLOGICAL TOLERANCE OF ANAEMIA Increasing the patient's tolerance to anaemia is achieved by maintaining normovolaemia with intravenous fluids, using appropriate vasopressor agents, maintaining oxygen and temperature regulation, adequate pain control and/or sedation and infection control.[13] Transfusion is given to the patient at a minimal effective dose based on the individual patient's requirement. A restrictive transfusion policy by transfusing at a haemoglobin level of <7–8 g/dL is found to be associated with reduced blood transfusion and increased patient safety.[514] For critical patients in the ICU setting, it is necessary to ensure other measures such as iron therapy, optimising haemostasis, infection control and reducing blood loss.[9] BENEFITS AND CHALLENGES Implementing PBM benefits patients, healthcare professionals, institutions, authorities and the health insurance system.[3] All patients from surgical, medical, obstetric or any other discipline benefited from the effective patient outcome, reduced mortality and morbidity, declined hospital stay and reduced cost.[3] Better patient outcome results from better patient management by correcting anaemia, reducing blood loss and reducing exposure to inherent transfusion risk and adverse transfusion outcome. Enhanced patient outcomes benefit the healthcare professionals, hospitals or institutes and health authority by reducing cost and resource utilisation, reducing dependence on donor blood, increasing the critical performance indicators and improving patient access to healthcare facilities[315] PBM adopted globally has shown great success. One study in Zurich, Switzerland, showed that PBM implementation reduces blood product utilisation by 35%, saving 12,713,754 Swiss francs or US$ 12,440,000 over a 4-year period.[16] In Western Australia, one study showed that implementation of PBM causes reductions in morbidity and mortality reduction in hospital stays and allows more patients access to hospital care, resource utilisation and cost. The product utilisation was reduced with a cost saving of AU$18.5M (US$18.1M).[6] In Canada, a PBM programme implemented in 23 hospitals showed a reduction in blood usage in 24% of cases of pre-planned knee surgery, 14% of aortic aneurysm cases in restoring to working order and 23% in pre-arranged coronary artery bypass cases that ultimately causes a scaling down of post-operative infection and length of hospital stay. The measures adopted were education given to the participants, collecting autologous donations preoperatively, administering erythropoietin and utilising cell salvage.[17] Although there are well-documented guidelines for the PBM, the implementation of PBL still faces challenges. The common challenge in fulfilling PBM is the dearth of education and awareness amongst patients, healthcare professionals and health authorities [Figure 3].[3] The critical barriers for PBM were the lack of experience with PBM, the necessity for partnership and interaction amongst the varied stakeholders and the integration of PBM into current product-centred transfusion practice.[15]Figure 3: Common challenges in implementing of (patient blood management). This figure has been drawn with the premium version of BioRender (https://biorender.com/ accessed on 17 September 2023) with the license number KW25V25ZYG, Image credit: Susmita Sinha.It involves multi-professionals such as the blood bank, haematology, surgeon, anaesthetist, critical care and other professionals, including health authorities, public health experts, hospital administrators and patients; awareness amongst all stakeholders is necessary.[3] Therefore, establishing a PBM programme requires proper education amongst all stakeholders on the risks and benefits of transfusion, along with adequate guidelines for curtailing blood loss and employing suitable resources. Governmental support from the local health authority is very much needed.[15] Close monitoring of the transfusion practices with regular feedback and communication with the respective department effectively achieves the objective of PBM.[16] In a hospital, proper guidelines, close contact and collaboration are required amongst all stakeholders for active management and implementation of PBM.[18] PBM is an effective way of managing surgical and non-surgical patients to minimise the use of blood-related stuff. Appropriate implementation of PBM reduces mortality and morbidity, reduces hospital stay and costs and improves patient outcomes. It increases patient access and better resource utilisation in a hospital. An appropriate intervention comprising government support and efforts from all healthcare providers and patients is necessary for its success. Consent for publication The author reviewed and approved the final version and has agreed to be accountable for all aspects of the work, including any accuracy or integrity issues. Disclosure The author declares that they do not have any financial involvement or affiliations with any organisation, association or entity directly or indirectly with the subject matter or materials presented in this article. This includes honoraria, expert testimony, employment, ownership of stocks or options, patents or grants received or pending royalties. Data availability Information is taken from freely available sources for this editorial. Authorship contribution All authors contributed significantly to the work, whether in the conception, design, utilisation, collection, analysis and interpretation of data or all these areas. They also participated in the article's drafting, revision or critical review, gave their final approval for the version that would be published, decided on the journal to which the article would be submitted and made the responsible decision to be held accountable for all aspects of the work.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.