Skip Navigation LinksHome > June 2012 - Volume 116 - Issue 6 > Patient Blood Management
Anesthesiology:
doi: 10.1097/ALN.0b013e318254d1a3
Education: Clinical Concepts and Commentary

Patient Blood Management

Goodnough, Lawrence Tim M.D.*; Shander, Aryeh M.D.
Section Editor(s): Riou, Bruno M.D., Ph.D.; Editor

Free Access
Erratum
Article Outline

Erratum

Fig. 1
Fig. 1
Image Tools
In the article on page 1367 of the June 2012 issue, figure 1 shows “Ferritin 30–100 μg/l and/or TSAT > 20%” and instead should have read “Ferritin 30–100 μg/l and/or TSAT < 20%.” The corrected figure appears below.
The publisher regrets this error.

Anesthesiology. 118(1):224, January 2013.

Collapse Box

Author Information

BLOOD management has been defined as “the appropriate use of blood and blood components, with a goal of minimizing their use.” This goal has been motivated historically by (1) known blood risks; (2) unknown blood risks; (3) preservation of the national blood inventory; and (4) constraints from escalating costs.1 Known risks of blood include transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation (e.g., postoperative infection or tumor progression). Unknown risks include emerging pathogens transmissible by blood (e.g., new variant Creutzfeldt-Jakob disease and West Nile virus).24 In addition, several studies have linked allogeneic blood transfusions with occurrence of unfavorable outcomes including increased risk of mortality and various morbidities.57 For example, studies have indicated that the risk of postoperative infections such as sepsis are as much as two to four times higher in transfused patients compared with untransfused cohorts.89 Taken together, these lines of evidence support the implementation of blood management as a means to improve the clinical outcomes of the patients. Blood management was cited recently as 1 of the 10 key advances in transfusion medicine over the past 50 yr.10
Patient-focused blood management11 is described in the Circular of Information§ as “a professional judgment based on clinical evaluation that determines the selection of components, dosage, rate of administration…..” Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). Preventive strategies are emphasized to identify, evaluate, and manage anemia1214 (e.g., pharmacologic therapy15 and reduced iatrogenic blood losses from diagnostic testing)16; to optimize hemostasis (e.g., pharmacologic therapy17 and point of care testing18); and to establish decision thresholds (e.g., guidelines) for the appropriate administration of blood therapy.5,19
Table 1
Table 1
Image Tools
Patient blood management has recently been recognized by the World Health Organization (World Health Alliance Resolution A63.R12) as a means to “promote the availability of transfusion alternatives.” To achieve these goals, health care institutions and accreditation and regulatory agencies have focused on blood utilization to improve clinical outcomes and patient safety. In the United States, The Joint Commission developed Patient Blood Management Performance Measures and submitted these to the National Quality Forum for endorsement. The National Quality Forum did not endorse these submitted Performance Measures, citing lack of data on the outcomes proposed; as a result, they currently do not carry consequences if not met. Because these Performance Measures were process-based rather than outcomes-based, data on proposed outcomes are difficult to retrieve. The Joint Commission has placed these Performance Measures in their Topic Library where they are to be used as additional patient safety activities and/or quality improvement projects by provider institutions as accreditation goals.# The principles of these performance indicators are summarized in table 1. We review recent advances in patient blood management to identify for physicians and healthcare institutions opportunities for process improvement blood utilization and patient safety.
Back to Top | Article Outline

Anemia Management

Guidelines for detection, evaluation, and management of anemia in elective surgery patients have been published (fig. 1).12,13 Predictors of blood transfusion for patients have long been identified, with the most important being the preoperative circulating erythrocyte mass,20 as estimated by the patient's hemoglobin concentration. In addition to being a risk factor for blood transfusions, preoperative anemia is also an independent predictor of morbidity and mortality postoperatively.2124 Evaluation of anemia** should begin with an initial assessment of iron-restricted erythropoiesis, which can occur in either the presence or absence of inflammation. Absorption of oral iron is inhibited in the presence of hepcidin due to inflammation, whereas chronic blood loss (e.g., menses) is an important cause of iron deficiency in the absence of inflammation.25,26 Iron-restricted erythropoiesis can cause anemia due to an absolute deficiency of storage iron, an iron sequestration syndrome due to inflammation, or a functional iron deficiency due to erythropoietin-stimulated erythropoiesis.27 The evaluation of unexpected anemia must in addition consider unexpected diagnoses including chronic kidney disease or occult malignancy. To facilitate this, screening and detection of anemia should occur as far as possible in advance (up to 30 days) of an electively scheduled surgery.13,28 This requires close collaboration among the patients' primary care physicians, surgeons, anesthesiologists, and the medical directors of the institution's preadmission testing program.
Back to Top | Article Outline

Blood Availability and Compatibility Testing

Successful completion of diagnostic testing pretransfusion (blood type/screen crossmatch) must overcome barriers associated with changes in practices for patients undergoing elective surgeries and for the availability of cross-matched blood. A College of American Pathology survey found that 35% of approximately 9,000 patients had type/screen specimens collected only on day of surgery; one-fourth of these tests were not completed (and cross-matched blood was not available) until after surgery had begun.29 To address these barriers, we implemented a number of steps for process improvement at one of our own institutions30:
* An operating room policy was implemented: “All patients with a potential need for blood transfusion will have a type and screen/crossmatch; if the results are positive for antibodies, a completed type and crossmatch is required before the patient can proceed into the operating room.”
* A surgical safety checklist†† was implemented that included confirmation that requested blood was available before commencement of anesthesia/surgery.
* The elective surgery schedule was reviewed by the transfusion service each night before surgery. A patient log, for a patient for whom no diagnostic specimens had been received by the Transfusion Service, was faxed to the operating room at 5:00 AM each morning of surgery.
* An extended specimen policy was implemented by the institution, allowing for antibody screen results to be valid for up to 30 days. To ensure compliance with American Association of Blood Banks (AABB) Standards,31 verification that patients had not been pregnant or transfused within the previous 3 months (to avoid the possibility that a new alloantibody to erythrocytes could appear) was documented at time of laboratory draw, and confirmed again on day of surgery.
After implementation, the incidence of patients undergoing surgery before availability of cross-matched blood was reduced from 1:133 to 1:328. A compliance rate of 100% for the surgical checklist is necessary to achieve our goal in which no patient undergoes elective surgery without cross-matched blood available.
Back to Top | Article Outline

Blood Administration and Documentation

Documentation of transfusion events including informed consent are the Performance Measures specified by The Joint Commission: In addition, The Joint Commission Performance Measures specify that appropriate pretransfusion laboratory testing (e.g., hemoglobin, prothrombin time/international normalized ration (INR), and platelet count) be documented along with the clinical indications (see next paragraphs) for transfusion of blood components. Adherence to such requirements should be monitored by the hospital's quality department or transfusion committee.
* Patient identification and transfusion order (blood identification number) must be confirmed before the initiation of blood
* Date and time of transfusion
* Blood pressure, pulse, and temperature recorded before, during, and after transfusion
Table 2
Table 2
Image Tools
The elements of transfusion consent comprise a discussion of blood transfusion risks (table 2)2,3 and benefits; alternatives to blood; an opportunity to ask questions; and patient consent.32 Current estimates of risk of blood transmission for some known viruses are: 1:280,000 to 1:357,000 for hepatitis B; 1:1,149,000 for hepatitis C; and 1:1,467,000 for human immunodeficiency virus (HIV).32,33 Consent should occur as far in advance of transfusion as possible, so that alternatives to allogeneic blood such as autologous blood can be made available. As an example, California Health and Safety Code Section 1645 (Paul Gann Blood Safety Act) mandates that alternatives to allogeneic blood are made available for patients and “applies whenever there is a reasonable possibility that a blood transfusion may be necessary as a result of a medical or surgical procedure.” It should also be noted that blood transfusion has been legislated to be a medical service not subject to commerce and trade laws, thus excluding the principle of implied warranty and granting blood banks immunity from strict product liability.34
Back to Top | Article Outline

Alternatives to Allogeneic Blood

When feasible, the patient's own (autologous) blood can serve to reduce or eliminate the need for allogeneic blood. In preoperative autologous donation, the patients donate their own blood over a period of a few weeks preceding the elective procedure.35 In acute normovolemic hemodilution, the donation takes place in the operating room before the surgery and reinfusion occurs before the patient leaves the operating room. In cell salvage, the reinfusion occurs during or after the surgery as patients' blood is collected and reinfused.
Preoperative autologous donation has some limitations.15 As with allogeneic blood units, autologous blood is susceptible to acquired storage lesions, such as depletion of 2,3-diphosphoglycerate and impaired ability for erythrocytes to unload oxygen to tissues. Many predonated blood units may be wasted rather than transfused. In addition, preoperative autologous donation induces anemia preoperatively, with an attendant increased subsequent likelihood of blood transfusion with the associated risks, including errors in blood administration. Thus, preoperative autologous donation is generally not cost-effective but may be of value in selected patient populations, such as in patients previously alloimmunized with erythrocyte antibodies.36
Acute normovolemic hemodilution causes blood losses during surgery to be diluted, thus reducing actual total blood losses. Acute normovolemic hemodilution offers several advantages compared with preoperative autologous donation, including avoidance of blood storage lesions; no risk of blood labeling or patient identification errors; and adaptability for patients undergoing nonelective procedures.37 However, evidence on efficacy of acute normovolemic hemodilution is mixed.3840 Reasons for low acceptance include lack of standardized protocols, variations in the target hemoglobin, types of fluids used, heterogeneity in surgical blood losses by procedure, and patient selection criteria. Acute normovolemic hemodilution is most effective in procedures associated with large blood loss. Publications addressing the efficacy of acute normovolemic hemodilution have used mathematical modeling that does not take into account individual patient vascular and hemostatic compensation. Because some large blood loss surgical procedures may not result in significant blood loss, benefit of acute normovolemic hemodilution may not be realized. Regardless, the risk of monitored acute normovolemic hemodilution is extremely low and this rare loss of benefit still favors acute normovolemic hemodilution.41
Autologous blood cell salvage and reinfusion has been demonstrated to be safe and effective in reducing allogeneic blood transfusions in a variety of patient populations.42,43 The procedure requires the collected shed blood to be washed, resulting in loss of platelets and plasma, which could potentially cause dilutional coagulopathy or thrombocytopenia with large blood volumes processed. However, reinfusion of the yielded autologous blood is still preferred rather than allowing the shed blood to be completely wasted, or using allogeneic blood that is also devoid of platelets and plasma and carries the same if not more risks at large volumes. The use of cell salvage in situations such as cancer and obstetric and bowel (contaminated) surgeries with introduction of unwanted materials into the circulation has been considered a relative contraindication for cell salvage44; nevertheless, this technique has been used successfully in these circumstances.45 AABB has Standards for Perioperative Autologous Blood Collection and Administration46 to provide guidance on quality management for facilities who seek accreditation for these activities.
Back to Top | Article Outline

Indications for Blood Transfusion

Fig. 2
Fig. 2
Image Tools
Of the estimated 39 million discharges in the United States in 2004, 5.8% (2.3 million) were associated with blood transfusion.47 Blood transfusion occurred in more than 10% of all hospital stays that included a procedure and was the most frequently performed procedure in 2009. The rate of blood transfusion more than doubled from 1997 to 2009.‡‡ Increased provider awareness of the costs associated with blood transfusion4 and recognition of the potential negative outcomes have stimulated multidisciplinary, multiprofessional, and institution-based approaches to patient blood management. For the 4-yr period 2005–2008, 212 fatalities reported to the Food and Drug Administration48 were deemed to be transfusion related (fig. 2); the leading causes of death were transfusion-related acute lung injury (n = 114), hemolytic transfusion reactions (n = 46), transfusion-associated sepsis (n = 18), transfusion-associated cardiac overload (n = 17), and babesios (n = 10). As discussed previously, a greater number of patients could have potentially had worse clinical outcomes (increased morbidity and mortality) associated with unnecessary transfusions in the same period.
Guidelines for blood transfusion attest to the inadequacy of discrete hemoglobin concentrations as ‘triggers’ for transfusion, and in addition to recommending transfusion of one blood unit each treatment event, they also acknowledge the necessity of considering other more physiologic criteria.49 It is generally agreed that transfusion is not of benefit when hemoglobin concentrations are greater than 10 g/dl, and are beneficial when hemoglobin concentrations are less that 6 g/dl.50,51 The variability in transfusion outcomes in patients undergoing cardiothoracic surgery continues to persist even after adjusting for patient- and institution-related factors.52,53 Moreover, prospective randomized trials in patients undergoing cardiac54 and noncardiac55,56 surgery have each demonstrated that such patients can tolerate perioperative anemia without transfusion to hemoglobin concentrations between 7 and 8 g/dl, and have equivalent clinical outcomes comparable with transfusions to hemoglobin concentrations of greater than 10 g/dl. It is noteworthy that the recently published FOCUS trial found that elderly (mean age older than 80 yr), high-risk (factors for coronary artery disease) patients who have undergone hip fracture surgery tolerate a hemoglobin trigger as low as 8 g/dl (or higher if symptomatic).56 A Cochrane meta-analysis of prospective randomized trials57 comparing “high” versus “low” hemoglobin thresholds on more than 3,700 patients found that (1) “low” hemoglobin thresholds were well tolerated; (2) erythrocyte transfusions were reduced (approximately 37%) significantly in patients randomized to the “low” hemoglobin cohorts; (3) infections were reduced by 34% in patients in the “low” hemoglobin cohorts; and (4) a hemoglobin concentration of 7g/dl was sufficient for most patients. More recently, a randomized controlled trial of 2,016 elderly patients with history or risk factors of cardiovascular disease who underwent hip surgery demonstrated that mortality rates, inability to walk independently, and in-hospital morbidity rates were similar in liberal- versus restrictive-transfused patients, despite significant fewer transfusions in the restrictive group.56
Fig. 3
Fig. 3
Image Tools
Patient blood management strategies for patients undergoing cardiac surgery have been shown to be safe and effective in reducing transfusion, while at the same time delivering high-quality outcomes. One of our institutions58 reported that only 11% of patients undergoing cardiac surgeries received blood transfusions, in which the program ranked first in their state for lowest risk-adjusted mortality. Other single-center initiatives using laboratory-guided transfusion algorithms in both operating rooms and intensive care units have reported a 50% reduction in transfusions of blood components (personal communication, September 9, 2011, by Mark Ereth M.D., Professor of Anesthesiology, in the Department of Anesthesiology at the Mayo Clinic in Rochester, Minnesota, as presented at the Mayo Clinic Symposium (February 2011) on Patient Blood Management). Both the pediatric59 and adult hospitals at one of our own medical centers have reduced blood utilization using computerized physician order entry: hemoglobin threshold for blood transfusion decreased in our adult hospital after a clinical effectiveness team instituted physician education and clinical decision support via electronic physician order entry (fig. 3).
Table 3
Table 3
Image Tools
Data from the American Red Cross on blood usage suggests an estimated decline of 3% over each of the past 2 yr (2009–2010), indicating that physician behavior toward blood transfusions is undergoing change nationally (personal communication, September 9, 2011, Richard Benjamin M.D., Ph.D., Adjunct Associate Professor of Pathology at Georgetown University, Washington, D.C., and Chief Medical Officer for the American Red Cross; as presented at the Food and Drug Administration Blood Products Advisory Committee, June 2011). This trend is accompanied by data from the most recent National Blood Collection and Utilization Survey,§§ which shows a progressive annual decrease in number of patients and percentage of hospitals who have cancelled elective surgical procedures due to blood inventory constraints (table 3). Current initiatives in research for blood transfusions are reflected in the growing literature on adverse effects of blood storage and their possible implications for oxygen delivery by blood transfusion.60
Back to Top | Article Outline

Indications for Plasma Transfusion

In a recent evidence-based review the Transfusion Practices Committee of the AABB recommended plasma therapy for only a few clinical indications, based on the available evidence in the literature (which was assessed to be of “weak quality”): trauma patients with substantial hemorrhage, patients undergoing complex cardiovascular surgery, and in patients with intracranial hemorrhage requiring emergency reversal of warfarin-associated coagulopathy.61 Patients with mild prolongations of the INR (less than 1.7) are not at risk of bleeding and do not need plasma therapy for minor procedures,62 so that for most clinical settings there is ample evidence that plasma transfusions are inappropriate. However, logistical/technical barriers that prevent effective and timely plasma therapy (possibly resulting in plasma therapies that are “too little, too late”) have probably contributed to the paucity of evidence demonstrating any benefit for plasma therapy.17
One of the largest prospective studies63 of plasma transfusions and their effect on INR and bleeding included both medical and surgical patients with pretransfusion INR of between 1.1 and 1.85. The authors reported that less than 1% of patients had normalization of their INR and only 15% had at least 50% correction. The median dose of plasma was 2 units (only 5 to 7 ml/kg), and there was no correlation between plasma dose and change in INR. This study had many of the limitations common to other reports64 in this clinical arena: lack of control groups, only modest prolongation in coagulation tests, poorly defined clinical endpoints (e.g., change in hemoglobin or need for transfusion), and/or an inadequate dose of plasma therapy.
The paucity of evidence for benefit of plasma transfusion therapy has been accompanied by growing evidence that risks of plasma have been underrecognized; in a prospective study, 6% of transfused patients developed transfusion associated cardiac overload65 which is much higher than previously reported rates in retrospective studies.66,67 Transfusion-related acute lung injury68 is a significant cause of morbidity/mortality from blood transfusions, whose incidence has declined subsequently with use of plasma from male donors or female donors who have no history of pregnancy.69
Back to Top | Article Outline

Indications for Platelet Transfusion

A performance indicator for prophylactic platelet transfusions has been developed by The Joint Commission for patients with malignant hematologic diseases or those who undergo stem cell transplantation, in which a platelet count threshold of 10,000/mm3 is appropriate for prophylactic platelet transfusions.70
Current guidelines from the European Union and United States recommend a transfusion trigger of 10 × 109/l for platelets transfused prophylactically.63,71 These guidelines are based on outcomes from four randomized clinical trials that compared prophylactic triggers of 10 × 109/l versus 20 × 109/l in patients with acute leukemia and in autologous and allogeneic hematopoietic stem cell transplant recipients.70,7275 Two additional prospective studies also demonstrated safety with the lower threshold of 10 × 109/l for prophylactic platelet transfusions.76,77 The effect of these thresholds on numbers of platelet and blood transfusions is variable, however77; one study demonstrated a 36% and 16% reduction in platelet and blood transfusions, respectively,77 whereas another showed no differences.76
A recent trial78 demonstrated that “low-dose” prophylactic platelet transfusions are equally effective as those with “standard” or “high” dose. For therapeutic platelet transfusions, algorithms for platelet transfusions based on point of care testing have demonstrated promise in patients who have platelet-derived bleeding such as in cardiothoracic surgery18,79 and in trauma.80 As for the evidence-based literature for plasma therapy, additional studies in platelet transfusion are also needed.81
Back to Top | Article Outline

Conclusion

Blood transfusions carry risks, are costly, and the supply of blood is limited. Blood transfusion outcomes are therefore undergoing renewed scrutiny by healthcare institutions to reduce blood utilization. In addition to accreditation organizations, professional societies are also well positioned to incorporate blood transfusion outcomes as quality indicators in their own guidelines and recommendations.82
Quality improvement in health care has been described as undergoing an identity crisis, in which differences in measurable outcomes between quality and safety are unclear; this observation has been characterized by a redefinition of terms: from quality to process improvement; and safety to value or cost-effectiveness.83 The relationship between quality and safety has always been direct for patients in transfusion medicine: patient blood management improves patient safety by reducing blood transfusions. Medical harm from errors in patient identification and specimen labeling in blood administration84 exceeds currently known risks from blood-transmissible agents,2 so that maintaining the status quo is likely to continue to result in harm for patients who receive transfusions unnecessarily. In recognition of this finding, the Department of Human Health Services has announced the formation of a national committee to establish standards for administering blood transfusions.‖‖ The foundations of patient blood management in the perisurgical period are illustrated in figure 4: (1) optimize erythropoiesis; (2) minimize blood loss; and (3) manage anemia. Strategies begin with preoperative preadmission testing and extend throughout the intraoperative and the postoperative intervals, enabling treating physicians to minimize allogeneic blood transfusions, while delivering safe and effective healthcare. Physicians and hospital quality/clinical effectiveness departments should incorporate principles of patient blood management into hospital-based process improvement initiatives that improve patient safety and clinical outcomes.
# Implementation Guide for the Joint Commission Patient Blood Management Performance Measures 2011. Available at http://www.jointcommission.org/assets/1/6/PBM_Implementation_Guide_20110624.pdf. Accessed January 19, 2012. Cited Here...
** Iron deficiency anaemia: assessment, prevention, and control. A guide for programme managers. Geneva, World Health Organization, 2001 (WHO/NHD/01.3). Available at http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf. Accessed January 19, 2012. Cited Here...
†† World Health Organization (WHO). World Health Alliance for Patient Safety progress report 2006–2007. Available at http://www.who.int/patientsafety/information_centre/documents/progress_report_2006_2007.pdf Accessed January 19, 2012. Cited Here...
‡‡ AHRQ HCUP 2009 report. Available at http://www.hcup-us.ahrq.gov/reports/factsandfigures/2009/section3_TOC.jsp. Accessed January 19, 2012. Cited Here...
§§ U.S. Department of Health and Human Services. National Blood Collection and Utilization Survey. Available at http://www.hhs.gov/ash/bloodsafety/nbcus/index.html. Accessed January 19, 2012. Cited Here...
‖‖ WHA resolution 63.12. Availability, safety and quality of blood products. Available at http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R12-en.pdf. Accessed January 19, 2012. Cited Here...
‡ Society for the Advancement of Blood Management (SABM). Available at http://www.sabm.org/. Accessed February 22, 2011. Cited Here...
§ Circular of Information for the Use of Human Blood and Blood Components, 2009, p. 9. Available at http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Blood/ucm074940.htm. Accessed February 10, 2011. Cited Here...
‖ World Health Organization (WHO) 63rd World Health Assembly. Availability, safety and quality of blood products. Available at http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R12-en.pdf. Accessed January 19, 2012. Cited Here...
Back to Top | Article Outline

References

1. Goodnough LT, Shander A: Blood management. Arch Pathol Lab Med 2007; 131:695–701

2. Vamvakas EC, Blajchman MA: Transfusion-related mortality: The ongoing risks of allogeneic blood transfusion and the available strategies for their prevention. Blood 2009; 113:3406–17

3. Perkins HA, Busch MP: Transfusion-associated infections: 50 years of relentless challenges and remarkable progress. Transfusion 2010; 50:2080–99

4. Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR: Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion 2010; 50:753–65

5. Shander A, Fink A, Javidroozi M, Erhard J, Farmer SL, Corwin H, Goodnough LT, Hofmann A, Isbister J, Ozawa S, Spahn DR, International Consensus Conference on Transfustion Outcoems Group: Appropriateness of allogeneic red blood cell transfusion: The international consensus conference on transfusion outcomes. Transfus Med Rev 2011; 25:232–46.e53

6. Vamvakas EC: Establishing causation in transfusion medicine and related tribulations. Transfus Med Rev 2011; 25:81–8

7. Glance LG, Dick AW, Mukamel DB, Fleming FJ, Zollo RA, Wissler R, Salloum R, Meredith UW, Osler TM: Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. ANESTHESIOLOGY 2011; 114:283–92

8. Marik PE, Corwin HL: Efficacy of red blood cell transfusion in the critically ill: A systematic review of the literature. Crit Care Med 2008; 36:2667–74

9. Shander A, Spence RK, Adams D, Shore-Lesserson L, Walawander CA: Timing and incidence of postoperative infections associated with blood transfusion: Analysis of 1,489 orthopedic and cardiac surgery patients. Surg Infect 2009; 10:277–83

10. McCullough J: Innovation in transfusion medicine and blood banking: Documenting the record in 50 years of TRANSFUSION. Transfusion 2010; 50:2542–6

11. Ness PM: A new section on blood conservation: Liberalizing TRANSFUSION. Transfusion 2004; 44:631

12. Goodnough LT, Shander A, Spivak JL, Waters JH, Friedman AJ, Carson JL, Keating EM, Maddox T, Spence R: Detection, evaluation, and management of anemia in the elective surgical patient. Anesth Analg 2005; 10:1858–61

13. Goodnough LT, Maniatis A, Earnshaw P, Benoni G, Beris P, Bisbe E, Fergusson DA, Gombotz H, Habler O, Monk TG, Ozier Y, Slappendel R, Szpalski M: Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth 2011; 106:13–22

14. Spahn DR, Moch H, Hofmann A, Isbister JP: Patient blood management: The pragmatic solution for the problems with blood transfusions. ANESTHESIOLOGY 2008; 109:951–3

15. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP: Transfusion medicine. Second of two parts–blood conservation. N Engl J Med 1999; 340:525–33

16. Salisbury AC, Reid KJ, Alexander KP, Masoudi FA, Lai SM, Chan PS, Bach RG, Wang TY, Spertus JA, Kosiborod M: Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med 2011; 171:1646–53

17. Goodnough LT, Shander A: How I treat warfarin-associated coagulopathy in patients with intracerebral hemorrhage. Blood 2011; 117:6091–9

18. 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

19. Kim DU: The quest for quality blood banking program in the new millennium: The American way. Int J Hematol 2002; 76(Suppl 2):258–62

20. Cosgrove DM, Loop FD, Lytle BW, Gill CC, Golding LR, Taylor PC, Forsythe SB: Determinants of blood utilization during myocardial revascularization. Ann Thorac Surg 1985; 40:380–4

21. Beattie WS, Karkouti K, Wijeysundera DN, Tait G: Risk associated with preoperative anemia in noncardiac surgery: A single-center cohort study. ANESTHESIOLOGY 2009; 110:574–81

22. Wu WC, Schifftner TL, Henderson WG, Eaton CB, Poses RM, Uttley G, Sharma SC, Vezeridis M, Khuri SF, Friedmann PD: Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA 2007; 297:2481–8

23. Musallam KM, Tamim HM, Richards T, Spahn DR, Rosendaal FR, Habbal A, Khreiss M, Dahdaleh FS, Khavandi K, Sfeir PM, Soweid A, Hoballah JJ, Taher AT, Jamali FR: Preoperative anaemia and postoperative outcomes in non-cardiac surgery: A retrospective cohort study. Lancet 2011; 378:1396–407

24. Gombotz H: Patient blood management is key before elective surgery. Lancet 2011; 378:1362–3

25. Weiss G, Goodnough LT: Anemia of chronic disease. N Engl J Med 2005; 352:1011–23

26. Goodnough LT, Nemeth E, Ganz T: Detection, evaluation, and management of iron-restricted erythropoiesis. Blood 2010; 116:4754–61

27. Goodnough LT: Iron deficiency syndromes and iron-restricted erythropoiesis. Transfusion 2011 [Epub ahead of print]

28. Uhl L: Patient blood management: A 68-year-old woman contemplating autologous blood donation before elective surgery. JAMA 2011; 306:1902–10

29. Friedberg RC, Jones BA, Walsh MK, College of American Pathologists: Type and screen completion for scheduled surgical procedures. A College of American Pathologists Q-Probes study of 8941 type and screen tests in 108 institutions. Arch Pathol Lab Med 2003; 127:533–40

30. Goodnough LT, Viele M, Fontaine M, Chua L, Ferrer Z, Jurado C, Quach P, Dunlap M, Arber DA: Quality management in the transfusion service: Case studies in process improvement. Transfusion 2011; 51:600–9

31. AABB. Standards for Blood Banks and Transfusion Services, 27th Edition. AABB Press, Bethesda MD 2011

32. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP: Transfusion medicine. First of two parts. Blood Transfusion. N Engl J Med 1999; 340:438–47

33. Epstein JS, Holmberg JA: Progress in monitoring blood safety. Transfusion 2010; 50:1408–12

34. Starr D: Blood: An epic history of medicine and commerce. New York: AA Knopf, 1998

35. Goodnough LT: Autologous blood donation. Anesthesiol Clin North Am 2005; 23:263–70; vi.

36. Spahn DR: Anemia and patient blood management in hip and knee surgery: A systematic review of the literature. ANESTHESIOLOGY 2010; 113:482–95

37. Goodnough LT, Monk TG, Brecher ME: Acute normovolemic hemodilution should replace the preoperative donation of autologous blood as a method of autologous-blood procurement. Transfusion 1998; 38:473–6

38. Segal JB, Blasco-Colmenares E, Norris EJ, Guallar E: Preoperative acute normovolemic hemodilution: A meta-analysis. Transfusion 2004; 44:632–44

39. Billote DB, Abdoue AG, Wixson RL: Comparison of acute normovolemic hemodilution and preoperative autologous blood donation in clinical practice. J Clin Anesth 2000; 12:31–5

40. Monk TG, Goodnough LT, Brecher ME, Colberg JW, Andriole GL, Catalona WJ: A prospective randomized comparison of three blood conservation strategies for radical prostatectomy. ANESTHESIOLOGY 1999; 91:24–33

41. Weiskopf RB: Efficacy of acute normovolemic hemodilution assessed as a function of fraction of blood volume lost. ANESTHESIOLOGY 2001; 94:439–46

42. Goodnough LT, Monk TG, Sicard G, Satterfield SA, Allen B, Anderson CB, Thompson RW, Flye W, Martin K: Intraoperative salvage in patients undergoing elective abdominal aortic aneurysm repair: An analysis of cost and benefit. J Vasc Surg 1996; 24:213–8

43. Wang G, Bainbridge D, Martin J, Cheng D: The efficacy of an intraoperative cell saver during cardiac surgery: A meta-analysis of randomized trials. Anesth Analg 2009; 109:320–30

44. Esper SA, Waters JH: Intra-operative cell salvage: A fresh look at the indications and contraindications. Blood Transfus 2011; 9:139–47

45. Nagarsheth NP, Sharma T, Shander A, Awan A: Blood salvage use in gynecologic oncology. Transfusion 2009; 49:2048–53

46. AABB. Standards for Perioperative Autologous Blood Collection and Administration. 4th ed. AABB Press. Bethesda, MD, 2009

47. Morton J, Anastassopoulos KP, Patel ST, Lerner JH, Ryan KJ, Goss TF, Dodd SL: Frequency and outcomes of blood products transfusion across procedures and clinical conditions warranting inpatient care: An analysis of the 2004 healthcare cost and utilization project nationwide inpatient sample database. Am J Med Qual 2010; 25:289–96

48. Vamvakas EC, Blajchman MA: Blood still kills: Six strategies to further reduce allogeneic blood transfusion-related mortality. Transfus Med Rev 2010; 24:77–124

49. Welch HG, Meehan KR, Goodnough LT: Prudent strategies for elective red blood cell transfusion. Ann Intern Med 1992; 116:393–402

50. 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

51. Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Ferraris SP, Saha SP, Hessel EA 2nd, Haan CK, Royston BD, Bridges CR, Higgins RS, Despotis G, Brown JR; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion, Spiess BD, Shore-Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE, Body S: Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83:S27–86

52. Goodnough LT, Johnston MF, Toy PT: The variability of transfusion practice in coronary artery bypass surgery. Transfusion Medicine Academic Award Group. JAMA 1991; 265:86–90

53. Bennett-Guerrero E, Zhao Y, O'Brien SM, Ferguson TB Jr, Peterson ED, Gammie JS, Song HK: Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA 2010; 304:1568–75

54. Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, Fukushima J, Kalil Filho R, Sierra DB, Lopes NH, Mauad T, Roquim AC, Sundin MR, Leão WC, Almeida JP, Pomerantzeff PM, Dallan LO, Jatene FB, Stolf NA, Auler JO Jr: Transfusion requirements after cardiac surgery: The TRACS randomized controlled trial. JAMA 2010; 304:1559–67

55. Hbert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E: 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

56. Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, Nemo G, Dragert K, Beaupre L, Hildebrand K, Macaulay W, Lewis C, Cook DR, Dobbin G, Zakriya KJ, Apple FS, Horney RA, Magaziner J; FOCUS Investigators: Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011; 365:2453–62

57. Carless PA, Henry DA, Carson JL, Hebert PP, McClelland B, Ker K: Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2010; CD002042

58. Moskowitz DM, McCullough JN, Shander A, Klein JJ, Bodian CA, Goldweit RS, Ergin MA: The impact of blood conservation on outcomes in cardiac surgery: Is it safe and effective? Ann Thorac Surg 2010; 90:451–8

59. Adams ES, Longhurst CA, Pageler N, Widen E, Franzon D, Cornfield DN: Computerized physician order entry with decision support decreases blood transfusions in children. Pediatrics 2011; 127:e1112–9

60. Ness PM: Does transfusion of stored red blood cells cause clinically important adverse effects? A critical question in search of an answer and a plan. Transfusion 2011; 51:666–7

61. Roback JD, Caldwell S, Carson J, Davenport R, Drew MJ, Eder A, Fung M, Hamilton M, Hess JR, Luban N, Perkins JG, Sachais BS, Shander A, Silverman T, Snyder E, Tormey C, Waters J, Djulbegovic B; American Association for the Study of Liver; American Academy of Pediatrics; United States Army; American Society of Anesthesiology; American Society of Hematology: Evidence-based practice guidelines for plasma transfusion. Transfusion 2010; 50:1227–39

62. 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

63. British Committee for Standards in Haematology, Blood Transfusion Task Force: Guidelines for the use of platelet transfusions. Br J Haematol 2003; 122:10–23

64. Segal JB, Dzik WH, Transfusion Medicine/Hemostasis Clinical Trials Network: Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: An evidence-based review. Transfusion 2005; 45:1413–25

65. Li G, Rachmale S, Kojicic M, Shahjehan K, Malinchoc M, Kor DJ, Gajic O: Incidence and transfusion risk factors for transfusion-associated circulatory overload among medical intensive care unit patients. Transfusion 2011; 51:338–43

66. Rana R, Fernndez-Perez ER, Khan SA, Rana S, Winters JL, Lesnick TG, Moore SB, Gajic O: Transfusion-related acute lung injury and pulmonary edema in critically ill patients: A retrospective study. Transfusion 2006; 46:1478–83

67. Narick C, Triulzi DJ, Yazer MH: Transfusion-associated circulatory overload after plasma transfusion. Transfusion 2012; 52:160–5

68. Shaz BH, Stowell SR, Hillyer CD: Transfusion-related acute lung injury: From bedside to bench and back. Blood 2011; 117:1463–71

69. Lin Y, Saw CL, Hannach B, Goldman M: Transfusion-related acute lung injury prevention measures and their impact at Canadian Blood Services Transfusion 2012; 52:567–74

70. Rebulla P, Finazzi G, Marangoni F, Avvisati G, Gugliotta L, Tognoni G, Barbui T, Mandelli F, Sirchia G: The threshold for prophylactic platelet transfusions in adults with acute myeloid leukemia. Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto. N Engl J Med 1997; 337:1870–5

71. Schiffer CA, Anderson KC, Bennett CL, Bernstein S, Elting LS, Goldsmith M, Goldstein M, Hume H, McCullough JJ, McIntyre RE, Powell BL, Rainey JM, Rowley SD, Rebulla P, Troner MB, Wagnon AH; American Society of Clinical Oncology: Platelet transfusion for patients with cancer: Clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001; 19:1519–38

72. Wandt H, Frank M, Ehninger G, Schneider C, Brack N, Daoud A, Fackler-Schwalbe I, Fischer J, Gckle R, Geer T, Harms P, Löffler B, Ohl S, Otremba B, Raab M, Schönrock-Nabulsi P, Strobel G, Winter R, Link H: Safety and cost effectiveness of a 10 × 10(9)/L trigger for prophylactic platelet transfusions compared with the traditional 20 × 10(9)/L trigger: A prospective comparative trial in 105 patients with acute myeloid leukemia. Blood 1998; 91:3601–6

73. Heckman KD, Weiner GJ, Davis CS, Strauss RG, Jones MP, Burns CP: Randomized study of prophylactic platelet transfusion threshold during induction therapy for adult acute leukemia: 10,000/microL versus 20,000/microL. J Clin Oncol 1997; 15:1143–9

74. Zumberg MS, del Rosario ML, Nejame CF, Pollock BH, Garzarella L, Kao KJ, Lottenberg R, Wingard JR: A prospective randomized trial of prophylactic platelet transfusion and bleeding incidence in hematopoietic stem cell transplant recipients: 10,000/L versus 20,000/microL trigger. Biol Blood Marrow Transplant 2002; 8:569–76

75. Callow CR, Swindell R, Randall W, Chopra R: The frequency of bleeding complications in patients with haematological malignancy following the introduction of a stringent prophylactic platelet transfusion policy. Br J Haematol 2002; 118:677–82

76. Nevo S, Fuller AK, Hartley E, Borinsky ME, Vogelsang GB: Acute bleeding complications in patients after hematopoietic stem cell transplantation with prophylactic platelet transfusion triggers of 10 × 10(9) and 20 × 10(9) per L. Transfusion 2007; 47:801–12

77. Buhrkuhl DC: An update on platelet transfusion in hematooncology supportive care. Transfusion 2010; 50:2266–76

78. Slichter SJ, Kaufman RM, Assmann SF, McCullough J, Triulzi DJ, Strauss RG, Gernsheimer TB, Ness PM, Brecher ME, Josephson CD, Konkle BA, Woodson RD, Ortel TL, Hillyer CD, Skerrett DL, McCrae KR, Sloan SR, Uhl L, George JN, Aquino VM, Manno CS, McFarland JG, Hess JR, Leissinger C, Granger S: Dose of prophylactic platelet transfusions and prevention of hemorrhage. N Engl J Med 2010; 362:600–13

79. Nuttall GA, Oliver WC, Santrach PJ, Bryant S, Dearani JA, Schaff HV, Ereth MH: Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. ANESTHESIOLOGY 2001; 94:773–81; discussion 5A–6A

80. Young PP, Cotton BA, Goodnough LT: Massive transfusion protocols for patients with substantial hemorrhage. Trans Med Rev 2011; 25:293–303

81. Delaney M, Meyer E, Cserti-Gazdewich C, Haspel RL, Lin Y, Morris A, Pavenski K, Dzik WH, Murphy M, Slichter S, Wang G, Dumont LJ, Heddle N: A systematic assessment of the quality of reporting for platelet transfusion studies. Transfusion 2010; 50:2135–44

82. Shander AS, Goodnough LT: Blood transfusion as a quality indicator in cardiac surgery. JAMA 2010; 304:1610–1

83. Brook RH: The end of the quality improvement movement: Long live improving value. JAMA 2010; 304:1831–2

84. Goodnough LT, Viele M, Fontaine MJ, Jurado C, Stone N, Quach P, Chua L, Chin ML, Scott R, Tokareva I, Tabb K, Sharek PJ: Implementation of a two-specimen requirement for verification of ABO/Rh for blood transfusion. Transfusion 2009; 49:1321–8

Cited By:

This article has been cited 10 time(s).

Journal of the Royal Society of Medicine
Anaemia in the older surgical patient: a review of prevalence, causes, implications and management
Partridge, J; Harari, D; Gossage, J; Dhesi, J
Journal of the Royal Society of Medicine, 106(7): 269-277.
10.1177/0141076813479580
CrossRef
Seminars in Thrombosis and Hemostasis
The Approach to Patients with Bleeding Disorders Who Do Not Accept Blood-Derived Products
Shander, A; Javidroozi, M
Seminars in Thrombosis and Hemostasis, 39(2): 182-190.
10.1055/s-0032-1333541
CrossRef
Transfusion
Erythropoiesis-stimulating agents: friends or foes?
Shander, A; Ozawa, S; Gross, I; Henry, D
Transfusion, 53(9): 1867-1872.
10.1111/trf.12328
CrossRef
Anaesthesist
"Blood is thicker than Water"
Meier, J
Anaesthesist, 62(7): 517-518.
10.1007/s00101-013-2200-z
CrossRef
Journal of Cardiothoracic and Vascular Anesthesia
Journal of Cardothoracic and Vascular Anesthesa
Shander, A
Journal of Cardiothoracic and Vascular Anesthesia, 27(4): S1-S2.
10.1053/j.jvca.2013.05.009
CrossRef
Transfusion
Optimizing red blood cell transfusion therapy in the 21st century: the power of data analysis for past understanding and future guidance
Taylor, MJ; Yomtovian, R
Transfusion, 53(3): 470-475.
10.1111/trf.12093
CrossRef
Blood Transfusion
Post-operative blood salvage in patient blood management: is it really cost-effective and safe?
Liumbruno, GM; Grazzini, G; Rafanelli, D
Blood Transfusion, 11(2): 175-177.
10.2450/2013.0001-13
CrossRef
Lancet
Blood management: transfusion medicine comes of age
Goodnough, LT
Lancet, 381(): 1791-1792.

Lancet
Concepts of blood transfusion in adults
Goodnough, LT; Levy, JH; Murphy, MF
Lancet, 381(): 1845-1854.

Lancet
Alternatives to blood transfusion
Spahn, DR; Goodnough, LT
Lancet, 381(): 1855-1865.

Back to Top | Article Outline

© 2012 American Society of Anesthesiologists, Inc.

Publication of an advertisement in Anesthesiology Online does not constitute endorsement by the American Society of Anesthesiologists, Inc. or Lippincott Williams & Wilkins, Inc. of the product or service being advertised.
Login

Article Tools

Images

Share