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Society for the Advancement of Patient Blood Management and Anesthesia & Analgesia: A New Collaboration and Home for Blood Management Research

Hassan, Nabil E. MD; Tibi, Pierre R. MD; Marques, Marisa B. MD

doi: 10.1213/ANE.0000000000001583
Editorials: Editorial
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From *Helen DeVos Children’s Hospital, Grand Rapids, Michigan; Yavapai Regional Medical Center, Prescott Arizona; and Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama.

Accepted for publication July 29, 2016.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Nabil E. Hassan, MD, 100 Michigan St NE, Grand Rapids, MI 49503. Address e-mail to nabil.hassan@helendevoschildrens.org.

This issue of Anesthesia & Analgesia (A&A) marks the launch of a new section devoted to “Blood Management.” It is the result of the collaboration between the Society for the Advancement of Patient Blood Management (SABM) and the International Anesthesia Research Society and its journal A&A’s editorial board. Both bodies are committed to advancing the science of improving patient care. This is the most recent of several cosponsored sections of A&A that bring the reader a diverse spectrum of perspectives and leading edge medical knowledge. The inaugural article that follows this editorial was written by Shander and other SABM leaders, and it highlights the history and views of SABM, the society on “Blood Management.”1,2 Blood Management is the science of not only providing a safe blood product but also, more importantly, caring for the potential recipient, namely, the patient. Thus, the most specific term is Patient Blood Management (PBM).

SABM’s definition of PBM is “The scientific use of safe and effective medical and surgical techniques designed to prevent anemia and decrease bleeding in an effort to improve patient outcome.” Thus, the concept of PBM embraces the various medical practices aimed at avoiding red blood cell (RBC) transfusions. In addition to anemia prevention, PBM also calls for alternative means to treat anemia such as erythropoiesis-stimulating agents: iron, folate, and vitamin B12, as clinically indicated.3 In the inpatient setting, an important aspect of PBM is the focus on decreasing the risk of hospital-acquired anemia (HAA).4 HAA is thought to be rampant, underrecognized, and closely associated with the volume of blood collected for diagnostic and routine laboratory tests.5 Several medical societies have taken advantage of the Choosing Wisely campaign to recommend to their members to avoid excessive blood draws to protect the patient from developing HAA.6 Specific recommendations include the Critical Care Societies Collaborative list that states “Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions,” and the American Society of Anesthesiologists (ASA): “Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery—specifically complete blood count (CBC), basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.” In addition, the Society of Hospital Medicine mentions “Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability,” and the American Association of Blood Banks (AABB), “Don’t perform serial blood counts on clinically stable patients” include such recommendations in their top 5 list of “tests or procedures commonly used in their field whose necessity should be questioned and discussed.”6

For the surgical patient, PBM measures can be taken pre-, intra-, and postoperatively.7 Within each time frame, PBM principles can also be divided into 3 groups such as optimization of erythropoiesis, minimization of blood loss, and the management of anemia. Examples of important practices to accomplish PBM goals preoperatively include detailed risk-benefit assessment and plan for patients taking anticoagulants and antiplatelet agents, and conversations with the surgical team regarding the estimated blood loss and the patient’s cardiac and pulmonary reserves. Intraoperatively, in addition to meticulous surgical techniques, the anesthesiologist team plays a crucial role through the application of one or more allogeneic transfusion-sparing methods. These include the choice of anesthetic, cell salvage/reinfusion, acute normovolemic hemodilution, optimization of cardiac output, ventilation and oxygenation, and application of evidence-based transfusion guidelines. With regard to the latter, the American Society of Anesthesiologists included “Don’t administer packed red blood cells in a young healthy patient without ongoing blood loss and hemoglobin of ≥ 6 g/dL unless symptomatic or hemodynamically unstable” in their Choosing Wisely list.6 In their remarks, they remind the reader that, although the optimal hemoglobin trigger for transfusion varies with the clinical setting, the decision to transfuse should be patient specific. Furthermore, the published evidence strongly suggests that patients exposed to fewer RBC units have better outcomes.8 The same approach to restricting transfusions with the goal of ensuring patient safety applies to the postoperative period. In addition, corrections of nutritional anemia or vitamin K deficiency, and avoidance of iatrogenic blood loss, are among effective PBM principles before and after discharge from the hospital.

Timing of this section in A&A could not be more fitting.

Our medical environment has been in transition from a volume-based to a value-based payment structure. With the Centers for Medicare and Medicaid Services’ expectation that 50% of health care institutions be in compliance by 2018, many health care providers are undergoing significant business model reorganization, which will inevitably impact our medical practice and the care we provide.9 The ultimate goal is to ensure seamless care in various settings: home, office, and hospital by a single or closely affiliated group of health care providers. For this reason, various health care elements are merging or realigning themselves into an integrated delivery model. The issue at hand is where PBM fits into this new model of care. For starters, managed care implies a continuum of proactive medical care with smooth and safe transitions between different phases of management. Protocols that assure patient safety and quality of ongoing care will be aggressively adopted. Transparency and benchmarking will be important for third-party payers as well as patients who will be accountable for a rising portion of their health care cost. Value care will bring higher quality for a competitive price. This is in exact alignment with PBM principles.

A&A is opening its arms to the science of PBM. More research in blood safety, blood substitutes, and hemostasis is sorely needed. Innovative devices for monitoring oxygen delivery, as well as interventions to improve it, will be the additional tools for PBM. Well-conducted studies to validate current and novel surgical and medical approaches to decrease and treat anemia without transfusions will also contribute to improved patient outcomes. We bear witness to the rise and implementation of a new standard of care, if not a new subspecialty called PBM. PBM has gained significant momentum and is now embraced by authoritative bodies in the field of health care and is being adopted by the health care industry worldwide. This is a great time for SABM and to bring PBM research results to the forefront of our evolving health care delivery system and its practitioners in the many disciplines represented in the journal. SABM and PBM have come from an advocacy drive to a scientific, economic, and quality of care drive.

It is all about the patient.

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DISCLOSURES

Name: Nabil E. Hassan, MD.

Contribution: This author helped write the manuscript.

Name: Pierre R. Tibi, MD.

Contribution: This author helped write the manuscript.

Name: Marisa B. Marques, MD.

Contribution: This author helped write the manuscript.

This manuscript was handled by: Jean-Francois Pittet, MD.

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REFERENCES

1. Shander A, Bracey AW Jr, Goodnough LT, et al. Patient blood management as standard of care. Anesth Analg. 2016;123:1051–1053.
2. Society for the Advancement of Blood Management. https://www.sabm.org/. Accessed July 23, 2016.
3. Goodnough LT, Shander A. Current status of pharmacologic therapies in patient blood management. Anesth Analg. 2013;116:15–34.
4. Koch CG, Li L, Sun Z, et al. Hospital-acquired anemia: prevalence, outcomes, and healthcare implications. J Hosp Med. 2013;8:506–512.
5. Lutz C, Cho HJ. Are we causing anemia by ordering unnecessary blood tests? Cleve Clin J Med. 2016;83:496–497.
6. Choosing Wisely. http://www.choosingwisely.org/clinician-lists/. Accessed July 23, 2016.
7. Goodnough LT, Shander A. Patient blood management. Anesthesiology. 2012;116:1367–1376.
8. Carson JL, Carless PA, Hébert PC. Outcomes using lower vs higher hemoglobin thresholds for red blood cell transfusion. JAMA. 2013;309:83–84.
9. 2015 Fact sheets items. Better care, smarter spending, healthier people: paying providers for value, not volume. https//www.cms.gov. Accessed January 26, 2015.
© 2016 International Anesthesia Research Society