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Multimodal Patient Blood Management Program Based on a Three-pillar Strategy

A Systematic Review and Meta-analysis

Althoff, Friederike C.*; Neb, Holger, MD*; Herrmann, Eva, PhD; Trentino, Kevin M.; Vernich, Lee§; Füllenbach, Christoph, PhD*; Freedman, John, MD; Waters, Jonathan H., MD||; Farmer, Shannon, MD**,††; Leahy, Michael F., MD‡‡; Zacharowski, Kai, MD PhD*; Meybohm, Patrick, MD*; Choorapoikayil, Suma, PhD*

doi: 10.1097/SLA.0000000000003095
Meta-Analysis: PDF Only

Objectives: To determine whether a multidisciplinary, multimodal Patient Blood Management (PBM) program for patients undergoing surgery is effective in reducing perioperative complication rate, and thereby is effective in improving clinical outcome.

Background: PBM is a medical concept with the focus on a comprehensive anemia management, to minimize iatrogenic (unnecessary) blood loss, and to harness and optimize patient-specific physiological tolerance of anemia.

Methods: A systematic review and meta-analysis was performed. Eligible studies had to address each of the 3 PBM pillars with at least 1 measure per pillar, for example, preoperative anemia management plus cell salvage plus rational transfusion strategy. The study protocol has been registered with PROSPERO (CRD42017079217).

Results: Seventeen studies comprising 235,779 surgical patients were included in this meta-analysis (100,886 pre-PBM group and 134,893 PBM group). Implementation of PBM significantly reduced transfusion rates by 39% [risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55–0.68, P < 0.00001], 0.43 red blood cell units per patient (mean difference −0.43, 95% CI −0.54 to −0.31, P < 0.00001), hospital length of stay (mean difference −0.45, 95% CI −0.65 to −0.25, P < 0,00001), total number of complications (RR 0.80, 95% CI 0.74–0.88, P <0.00001), and mortality rate (RR 0.89, 95% CI 0.80–0.98, P = 0.02).

Conclusions: Overall, a comprehensive PBM program addressing all 3 PBM pillars is associated with reduced transfusion need of red blood cell units, lower complication and mortality rate, and thereby improving clinical outcome. Thus, this first meta-analysis investigating a multimodal approach should motivate all executives and health care providers to support further PBM activities.

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*Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany

Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany

Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia

§Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

St Michael's Hospital, University of Toronto, Toronto, Canada

||Department of Anesthesiology and Bioengineering, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA

**Medical School, CTEC and Division of Surgery, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia

††Faculty of Health Sciences, Centre for Population Health Research, Curtin University, Perth, Western Australia, Australia

‡‡Department of Hematology, School of Medicine and Pharmacology, PathWest Laboratory Medicine Royal Perth Hospital, The University of Western Australia, Perth, Western Australia.

Reprints: Patrick Meybohm MD, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany. E-mail:; Suma Choorapoikayil, PhD, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany. E-mail:

F.C.A. and H.N. contributed equally to this work. P.M. and S.C. are sharing senior authorship.

Declaration: All authors have completed the ICMJE uniform disclosure form at P.M. and K.Z. received grants from B. Braun Melsungen, CSL Behring, Fresenius Kabi, and Vifor Pharma for the implementation of Frankfurt‘s Patient Blood Management program and honoraria for scientific lectures from B. Braun Melsungen, Vifor Pharma, Fearing, CSL Behring, and Pharmacosmos. S.F. reports personal fees from Thieme (Stuttgart, Germany) and Elsevier Science, USA, and nonfinancial support from the National Blood Authority (Australia), the Medical Society for Blood Management, and The Health Roundtable, outside the submitted work. J.H.W. is on the Advisory Board for Haemonetics, Inc (Braintree, Massachusetts) and is a consultant for LivaNova (London, UK). The remaining authors report no conflicts of interest.

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