Patient Blood Management gives Health Professionals a new tool to help improve patient outcomes. The International Foundation for Patient Blood Management empowers Health Professionals with the latest knowledge, research and recommendations.
Why the Move from a Product Focus to a Patient Focus?
With the development of allogeneic blood transfusion during the 20th century, massively bleeding patients survive, major surgical advances have been made possible, haemophiliacs live longer and better lives and marrow failure from disease or bone marrow suppressive chemotherapy can be survived. So what is the problem? Increasingly, the view of many clinicians is that transfusion medicine has excessively focused on the blood component supply side rather than from the demand/patient/problem perspective.
Clinical focus is “what is best for the patient?” not, “what is best for the blood supply?” This is not to deny the importance of the multiple issues and challenges facing the provision of an adequate and safe blood supply, but rather to ensure the horse is in front of the cart, willing and able to address the needs of patients, with the blood supply chain appropriately responding to the clinical needs of patients.
Allogeneic blood transfusion is supportive therapy and may be administered to control the effects of, or to prevent problems, associated with a haemopoietic deficiency. Allogeneic transfusion, particularly in the perioperative setting, should not be regarded as the first line of therapy for patients with haemopoietic defects.
For most patients it is possible to minimise or avoid requirements for allogeneic blood components by correcting or managing the effects of deficiencies in the haematopoietic system.
It is self-evident that if allogeneic blood can be avoided the potential hazards need not be considered.
Benefits from transfusion have been assumed in many clinical circumstance and it is a sobering thought to consider that when there is no evidence to support the benefit of transfusion a patient is unnecessarily exposed to potentially major morbidity or even mortality. The decision-making process for blood component therapy can be challenging and much debate continues in relation to the indications for the use of various allogeneic blood components. However, there are good common sense and scientific reasons to adopt a non-transfusion default position when there is no evidence for potential benefit or clinical uncertainty.
Why is Patient Blood Management So Important?
Anaemia, major haemorrhage and blood transfusions are three independent risk factors for adverse patient outcomes.
PBM addresses patient quality and safety and achieves optimal clinical outcomes for patients.
Anaemia is a global problem and accounted for 8.8% of the world’s total disability from all conditions in 2010, with iron deficiency anaemia being the most common pathophysiology. (Article: A systematic analysis of global anemia burden from 1990 to 2010.)
There is strong evidence that anaemia is an independent risk factor for increased blood transfusion and adverse clinical outcomes, especially in the surgical setting, including higher mortality and morbidity (e.g. cardiac, respiratory, renal, wound events, sepsis, and venous thromboembolism). Additionally, blood transfusion is associated with increased length of hospital stay, postoperative admission to intensive care and increased health costs.
These adverse effects are probably attributable to transfusion related immunomodulation (TRIM) and should be considered alongside other immunological risks of transfusion, such as immediate and delayed immunological reactions. Potential impacts of the collection, preservation and storage of labile blood components is also a potential causative factor contributing to adverse clinical outcomes.
It is challenging to define and capture all the clinical transfusion associated reactions in current haemovigilance systems. Haemovigilance programs focus on adverse outcomes in which deterministic causation can be confirmed, ie there is a 1:1 relationship between the transfusion and the resulting hazard. In contrast, the adverse outcomes referred to above causation is probabilistic and transfusion is a risk factor identified in observational epidemiology studies of specific patient populations.
However, in the future there might be possibilities to link incidence data on healthcare associated adverse outcomes with transfusion and haemovigilance data. Such reporting might drive and facilitate a wider and more comprehensive implementation of PBM.
It is well documented in the Australian PBM guidelines document that anaemia is a contraindication for elective surgery, but audit studies identify that in many surgical patients it remains uncorrected, increasing the likelihood of blood transfusion, jeopardising optimal clinical outcomes and increasing health costs.
Identifying and diagnosing anaemia in the elective surgical setting should be a self-evident aspect of perioperative patient care.
Additionally, poorly controlled and managed haemorrhage as well as unnecessary and excessing iatrogenic blood sampling loss are independent predictors for anaemia and adverse outcomes. Clearly, clinical practice changes would mitigate these risks, optimise patient outcomes and improve patient safety.
Allogeneic blood transfusion was “grandfathered” into clinical medicine with benefit assumed and risks assumed to be minimal. Allogeneic blood transfusion is one of the most common therapeutic intervention in hospitalised patients. For many decades blood transfusion has been culturally embedded into clinical practice as the default treatment for blood loss and anaemia. However, this practice has been challenged in recent years with accumulating evidence demonstrating that transfusion, particularly in haemodynamically stable patients, is an additional independent risk factor for adverse outcomes.
This expanding evidence base from observational and randomised controlled trials of restrictive transfusion protocols has become a major and urgent driver to shifting the clinical management of anaemia and haemorrhage from a product focus to a patient focus.
A basic and core principal of modern medicine dictates prioritising and addressing a patient’s clinical problem rather than pre-emptively defaulting to what may or may not be appropriate therapy. Although accurate diagnosis of a patient’s problem and a risk/benefit analysis of clinical management options are a sine qua non of modern medicine, for blood transfusion this has commonly not been the case in the management of anaemia and haemorrhage.