Blood management

Patient blood management in the perioperative setting can be achieved by means of a variety of techniques and strategies. First, ensuring that the patient enters the operating room with a sufficient hematocrit level is essential. Preoperative anemia has been documented to range from 5% in female geriatric hip fracture patients to over 75% in colon cancer patients.[16] Patients who are anemic prior to surgery often require more transfusions. Erythropoietin and iron therapy can be considered in cases of anemia. Accordingly, patients should be screened for anemia at least 30 days prior to an elective surgical procedure. Although either oral or parenteral iron could be given, increasingly clinicians are giving parenteral iron to ensure that the haemoglobin is increased the maximal amount before the elective surgery is undertaken.

During surgery, techniques are utilized to reduce or eliminate exposure to allogeneic blood. For example, electrocautery, which is a technique utilized for surgical dissection, removal of soft tissue and sealing blood vessels, can be applied to a variety of procedures. During surgical procedures that are expected to have significant blood loss, blood that is lost during surgery can be collected, filtered, washed and given back to the patient.[17] This procedure is known as intraoperative blood salvage.[18] Pharmacologic agents, for example tranexamic acid, can also be utilized to minimize blood loss.[19] Another technique, acute normovolemic hemodilution, involves the collection of a selected calculated volume of the patient's own blood in collection bags prior to the start of surgery with the simultaneous replacement of an equal volume of non-blood fluid. Since the patient's blood is now diluted, blood lost during the surgical procedure, i.e. by hemorrhage, contains smaller amounts of red blood cells. The collected blood product, which contains red blood cells, platelets and coagulation factors, is reinfused at the end of the surgery.[20][21] People who are in good health and not anemic may sometimes donate their own blood prior to the surgery (autologous blood donation), which helps to conserve donor units and reduces some of the risks of exposure to allogeneic blood (though autologous donation carries risks of its own).[22][23] When all of these therapies are combined, blood loss is greatly reduced which correspondingly reduces or averts the potential for allogeneic blood transfusion. Additional details on this question can be found in the journal, Transfusion.[24]

Exposure to blood can be reduced, and tolerance to anemia enhanced, by using a "restrictive" transfusion strategy; for example, the AABB recommends that hospital patients in stable condition only be transfused when the hemoglobin drops below 7–8 g/dL (70–80 g/L).[25][26] A maximum surgical blood order schedule (MSBOS), which lists the number of blood units typically required for a given surgical operation, can also be used to help prevent unnecessary blood orders.[27]

Information technology can be useful in implementing a patient blood management policy, this includes:

• Daily e-mails alerting physicians of transfusions that have occurred outside of the local guidelines
• Computerized physician order entry systems that automatically create an alert when the transfusion order is inconsistent with the reason selected for transfusion and the laboratory hemoglobin level[28]
• Improved management of blood components, leading to decreased wastage[28]

Using Patient Blood Management techniques in non-surgical settings may also be helpful for reducing the need for blood transfusions and improving a person's outcome.[9] Examples include, identifying any anemia in people with advanced end-stage liver disease and determining of the cause of this anemia can be reversed.[9] Early identification and correction of anemia in pregnant women may also reduce the need for blood transfusions.[9]

Allogeneic blood transfusion is extremely expensive. For example, some studies reported increased costs of $300–$1,000 per unit of allogeneic blood transfused.[33][34] The more blood that is transfused directly impacts hospital expenditures, and it behooves administrators to search for ways to reduce this cost. This increasing cost of transfusions is the reason many hospital administrators are endeavoring to establish blood management programs.