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Patient Blood Management as Standard of Care

Shander, Aryeh MD*; Bracey, Arthur W. Jr MD; Goodnough, Lawrence T. MD; Gross, Irwin MD§; Hassan, Nabil E. MD; Ozawa, Sherri RN*; Marques, Marisa B. MD

doi: 10.1213/ANE.0000000000001496
The Open Mind: The Open Mind
Free

Published ahead of print August 2, 2016.

From the *Englewood Hospital and Medical Center, Englewood, New Jersey; Baylor College of Medicine, Houston, Texas; Stanford University, Stanford, California; §Accumen Inc, San Diego, California; Helen DeVos Children’s Hospital, Grand Rapids, Michigan; and University of Alabama at Birmingham, Birmingham, Alabama.

Published ahead of print August 2, 2016.

Accepted for publication June 9, 2016.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Aryeh Shander, MD, Englewood Hospital and Medical Center, 350 Engle St, Englewood, NJ 07631. Address e-mail to aryeh.shander@ehmc.com.

The Society for the Advancement of Blood Management (SABM) was born of the idea that, to improve the care of patients who potentially required transfusions, it was necessary to increase collaboration between transfusion medicine specialists and the clinical team. These 2 groups had not routinely connected at the bedside or other care settings previously. SABM founders understood that, to ably treat any hematologic conditions, with or without blood products, one would need to understand the role of blood elements in maintaining health. It was recognized that those engaged in blood procurement and hospital-based transfusion specialists had a goal that overlapped with clinicians—better clinical outcomes through minimization or avoidance of transfusion. As such, SABM’s first members and leadership included patient advocates, recognized experts from the worlds of blood banking, transfusion medicine, and hematology, working alongside a transprofessional and multidisciplinary group of clinicians, mostly the “high users,” such as anesthesiologists and surgeons.

An early contributing factor to the shaping of what became “patient blood management,” or PBM, was the organized efforts of advocates for patients for whom transfusion is not an option based on religious beliefs. Their movement to ensure access to care and the right of their members to refuse transfusion sparked interest in clinicians around the world that saw it as a clinical challenge as well as an ethical imperative. Although early groundwork in blood conversation was pioneered in the 1960s by Dr. Denton Cooley, it was not until decades later that organized initiatives by hospitals and physicians emerged. As these grew in number and experience with this specific patient population, clinicians began to collaborate to devise best practices to manage various clinical scenarios without transfusion. These shared experiences began to demonstrate that there was much to learn for application of PBM to a wider group of patients. Table summarizes milestones in the field of PBM.

Table.

Table.

Sixteen years later, SABM remains in a unique position as a professional organization committed to education, research, and best practice recommendations to advance PBM as the standard of care.2,3 It brings together administrators, nurses, pharmacists, perfusionists, laboratory technologists, and physicians across many specialties to promote a comprehensive patient-centered approach to care. PBM is built on 4 principles: anemia management, optimization of coagulation, adoption of blood conservation strategies, and patient-centered decision, with the single goal of measurable improved patient outcomes.4 PBM’s approach is in contrast to developing care paradigms from the perspective of transfusion medicine where the focus is on transfusion as a therapy (and perhaps the only therapy) rather than on the underlying derangement contributing to the clinical presentation, and developing interventions to mitigate those conditions.5,6

No other area in medicine specializes in a therapy without a defined system, organ, or disease. Using diabetes mellitus as an example, management is not focused on insulin as the sole therapy given in response to an abnormality in the single laboratory parameter of blood glucose. Rather, a diverse group of health care professionals counsel the patient on nutrition and dietary management, exercise, and weight control. In addition, the patient is monitored and treated for several comorbidities that affect or may be affected by diabetes mellitus to achieve optimal short- and long-term outcomes. In contrast, blood transfusions have been historically practiced as an isolated therapy, often by a practitioner not primarily responsible for the long-term health of the patient, without appropriate evaluation or risk-benefit assessment. This lack of stewardship and focus on transfusion as a therapy has resulted in minimal insight regarding its effect on clinical outcomes.7

As an organization, SABM focuses on the safety of the patient and his orher clinical outcomes rather than on the safety of a therapy. This paradigm does not minimize the crucial role that transfusion medicine specialists and blood collection organizations have played in markedly improving the safety of blood products over the past 3 decades.8 Nevertheless, the primary goal of SABM is to properly move care away from a blood product–oriented treatment aimed at correcting a specific deficit, toward comprehensive management of an anemic patient (or one at risk for anemia) utilizing a variety of resources.5 Even in the context of the patient with massive hemorrhage, PBM recognizes that a full therapeutic armamentarium is necessary to optimize the benefit of life-saving transfusion while recognizing that transfusion is limited as a therapy in both time and scope across the continuum of care.

PBM spans the full spectrum of care, in both outpatient and inpatient settings. Patients may be candidates for PBM long before transfusion or even hospital admission is contemplated, and PBM is an essential part of discharge planning for anyone who has been in a hospital, whether transfused or not.9–11 Recognition, diagnosis, and management of anemia in ambulatory patients is becoming an integral part of population health. Anemia management as part of PBM can improve quality of life and functional status in such diverse patient populations as those with chronic heart failure and inflammatory bowel disease, while also limiting hospital readmissions.12,13 The reach of PBM extends from the very young to the very old: To name an example, the cognitive development of neonates is impaired when iron deficiency occurs during pregnancy.14 Early and effective treatment of iron deficiency during pregnancy even in the absence of anemia is part of the scope of comprehensive PBM. At the opposite extreme, anemia in elderly patients with heart failure and chronic renal dysfunction is associated with cognitive impairment.15,16 Chronic renal insufficiency and congestive heart failure in the anemic geriatric patient are best managed in the context of PBM—treatment of anemia and avoidance of blood loss, while optimizing hemodynamics and oxygen availability to tissues at risk. Even patients with hematologic conditions or malignancy may benefit from anemia management and require fewer red blood cell transfusions, while more data are needed to explore the potential role of erythropoiesis-stimulating agents and intravenous iron.

PBM principles clearly recognize that to achieve improved patient outcomes, more than transfusion guidelines and transfusion avoidance are required. National and international organizations and policy makers are increasingly adopting and advocating PBM. World Health Organization resolution 63.12 recognizes and promotes PBM for all its active members.17 PBM has evolved in Europe, culminating in a large demonstration project funded by the European Union that includes a large number of hospitals.18 Recently, the Australian National Health and Medical Research Council reviewed the sixth and last installment of the national PBM guidelines that address the pediatric population, and similarly the TAXI (Pediatric Critical Care “Transfusion and Anemia Expertise Initiative”) consensus group of the PALISI (“Pediatric Acute Lung injury and Sepsis Investigation”)/Blood Net (www.BloodNetResearch.org) researchers is building evidence-based transfusion guidelines. As first step, both endeavors expose the knowledge gaps more than provide evidence-based recommendations with the intent of following with more.17

In the United States, further validation of the evolving role of PBM is The Joint Commission’s Transfusion Medicine Performance Indicators developed in 2010 to 2011.19 Although an initial and welcomed step, they were centered on transfusion rather than on the patient and the underlying disease. Recognizing the need to provide a structure for organizations to install comprehensive, “patient-centered” approach of PBM as a clinical care paradigm, SABM published The Administrative and Clinical Standards for Patient Blood Management Programs (http://www.sabm.org/publications), now in their third edition. In addition, a clinical guide to their implementation was released in 2012. These standards provide an administrative and clinical framework for comprehensive implementation of PBM across the full spectrum of care and from the perspective of disease management.

PBM is becoming, and must be considered, the standard of care or at least recognized as best practice.2,3,5,17 It avoids and mitigates risks by addressing clinical issues that may lead to transfusion long before transfusion is even considered. It is patient-centered, preemptive, and preventive while transfusion alone is an incomplete and limited strategy in this era where we strive for “scientific wellness” and population and community health.9,10,20 While the goal of PBM is not to exclude transfusion (quite the contrary, it is an essential part of the care of some patients), we must no longer adhere to a “transfusion-only strategy” using a therapy worthy of a “boxed warning” and given what is known of its narrow therapeutic window.21,22 Furthermore, there is paucity of data suggesting that liberal transfusion improves clinical outcomes.22 While we must continue to evaluate clinical outcomes, both short and long term, when comprehensive PBM is practiced, studies are not needed to show that minimizing bleeding and treating treatable causes of anemia before surgery is inherently safer than avoidable blood loss with transfusion. The time is indeed now to make PBM the standard of care.

In an era of rapidly evolving value-added heath care environment, improved patient outcome takes center stage. PBM seems to fulfill that goal, and many scientific circles have embraced it.17,23 What started as individual courageous and pioneering endeavors are becoming well accepted and interweaved in the clinical thought process. Despite mounting evidence of potential transfusion hazards,24 well-designed studies to add to the evidence for efficacy and safety of PBM interventions remain a priority.25,26 This is even more prominent in the neonatal and pediatric arenas. There must be a reevaluation of the research strategy that assesses transfusion as a therapy.21,25 We must redirect efforts from randomized trials on restrictive versus liberal approach to instead examine the best clinical outcome using different modalities of anemia therapy versus transfusion alone. Meaningful and practical information must be developed that can be easily adopted and offer patients better quality of life and clinical outcomes.

The editors of Anesthesia & Analgesia with foresight and appreciation of a growing PBM body of knowledge and the many remaining unmet medical needs have created a new section called “Blood Management” that will serve as a vehicle concentrating new data related to the topic under a single roof. This action has resulted in SABM joining the IARS family of societies with the hope that many will join (SABM.org) and contribute to this burgeoning and evolving literature. Creating a PBM portal in the journal will increase readers’ exposure to emerging information and shorten the time of bringing it to the bedside.

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REFERENCES

1. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of Transfusion Requirements in Critical Care. N Engl J Med. 1999;340:409417.
2. Spahn DR, Moch H, Hofmann A, et al. Patient blood management: the pragmatic solution for the problems with blood transfusions. Anesthesiology. 2008;109:951953.
3. Spahn DR, Shander A, Hofmann A. The chiasm: transfusion practice versus patient blood management. Best Pract Res Clin Anaesthesiol. 2013;27:3742.
4. Shander A, Javidroozi M. Blood conservation strategies and the management of perioperative anaemia. Curr Opin Anaesthesiol. 2015;28:356363.
5. Shander A, Hofmann A, Isbister J, et al. Patient blood management–the new frontier. Best Pract Res Clin Anaesthesiol. 2013;27:510.
6. Vamvakas EC. Reasons for moving toward a patient-centric paradigm of clinical transfusion medicine practice. Transfusion. 2013;53:888901.
7. Hofmann A, Farmer S, Shander A. Five drivers shifting the paradigm from product-focused transfusion practice to patient blood management. Oncologist. 2011;16(suppl 3):311.
8. Seitz R, Heiden M. Quality and Safety in Blood Supply in 2010. Transfus Med Hemother. 2010;37:112117.
9. Goodnough LT, Shander A. Patient blood management. Anesthesiology. 2012;116:13671376.
10. Shander A, Javidroozi M, Perelman S, et al. From bloodless surgery to patient blood management. Mt Sinai J Med. 2012;79:5665.
11. Gross I, Trentino KM, Andreescu A, et al. Impact of a patient blood management program and an outpatient anemia management protocol on red cell transfusions in oncology inpatients and outpatients. Oncologist. 2016;21:327332.
12. Shander A, Goodnough LT, Javidroozi M, et al. Iron deficiency anemia—bridging the knowledge and practice gap. Transfus Med Rev. 2014;28:156166.
13. Muñoz M, Gómez-Ramírez S, Kozek-Langeneker S, et al. ‘Fit to fly’: overcoming barriers to preoperative haemoglobin optimization in surgical patients. Br J Anaesth. 2015;115:1524.
14. Tran TD, Biggs BA, Tran T, et al. Impact on infants’ cognitive development of antenatal exposure to iron deficiency disorder and common mental disorders. PLoS One. 2013;8:e74876.
15. Pulignano G, Del Sindaco D, Di Lenarda A, et al. Chronic renal dysfunction and anaemia are associated with cognitive impairment in older patients with heart failure. J Cardiovasc Med (Hagerstown). 2014;15:481490.
16. Anker SD, Comin Colet J, Filippatos G, et al.; FAIR-HF Trial Investigators. Ferric carboxymaltose in patients with heart failure and iron deficiency. N Engl J Med. 2009;361:24362448.
17. Farmer SL, Towler SC, Leahy MF, et al. Drivers for change: Western Australia Patient Blood Management Program (WA PBMP), World Health Assembly (WHA) and Advisory Committee on Blood Safety and Availability (ACBSA). Best Pract Res Clin Anaesthesiol. 2013;27:4358.
18. Shander A, Van AH, Colomina MJ, et al. Patient blood management in Europe. Br J Anaesth. 2012;109:5568.
19. Gammon HM, Waters JH, Watt A, et al. Developing performance measures for patient blood management. Transfusion. 2011;51:25002509.
20. Goodnough LT, Maniatis A, Earnshaw P, et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth. 2011;106:1322.
21. Isbister JP, Shander A, Spahn DR, et al. Adverse blood transfusion outcomes: establishing causation. Transfus Med Rev. 2011;25:89101.
22. Shander A, Goodnough LT. Can blood transfusion be not only ineffective, but also injurious? Ann Thorac Surg. 2014;97:114.
23. Holst LB, Petersen MW, Haase N, et al. Restrictive versus liberal transfusion strategy for red blood cell transfusion: systematic review of randomised trials with meta-analysis and trial sequential analysis. BMJ. 2015;350:h1354.
24. Murphy MF, Goodnough LT. The scientific basis for patient blood management. Transfus Clin Biol. 2015;22:9096.
25. Shander A, Javidroozi M, Ozawa S, et al. What is really dangerous: anaemia or transfusion? Br J Anaesth. 2011;107(suppl 1):i4159.
26. Gross I, Shander A, Sweeney J. Patient blood management and outcome, too early or not? Best Pract Res Clin Anaesthesiol. 2013;27:161172.
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