Patient Blood Management - a new paradigm for transfusion medicine?

Amanda Thomson, Shannon L Farmer, Axel Hofmann, James Isbister, Aryeh Shander

Research output: Contribution to journalArticle

Abstract

The saving of many lives in history has been duly credited to blood transfusions.
What is frequently overlooked is the fact that, in light of a wealth of evidence as
well as other management options, a therapy deemed suitable yesterday may no
longer be the first choice today. Use of blood has not been based upon scientific
evaluation of benefits, but mostly on anecdotal experience and a variety of factors
are challenging current practice. Blood is a precious resource with an ever limiting
supply due to the aging population. Costs have also continually increased due to
advances (and complexities) in collection, testing, processing and administration of
transfusion, which could make up 5% of the total health service budget. Risks of
transfusions remain a major concern, with advances in blood screening and processing shifting the profile from infectious to non-infectious risks. Most worrying
though, is the accumulating literature demonstrating a strong (often dose-dependent)
association between transfusion and adverse outcomes. These include
increased length of stay, postoperative infection, morbidity and mortality. To this
end, a recent international consensus conference on transfusion outcomes (ICCTO)
concluded that there was little evidence to corroborate that blood would improve
patients’ outcomes in the vast majority of clinical scenarios in which transfusions
are currently routinely considered; more appropriate clinical management options
should be adopted and transfusion avoided wherever possible. On the other hand,
there are patients for whom the perceived benefits of transfusion are likely to outweigh the potential risks. Consensus guidelines for blood component therapy have
been developed to assist clinicians in identifying these patients and most of these
guidelines have long advocated more conservative ‘triggers’ for transfusion. However,
significant variation in practice and inappropriate transfusions are still prevalent.
The ‘blood must always be good philosophy’ continues to permeate clinical
practice. An alternative approach, however, is being adopted in an increasing number
of centres. Experience in managing Jehovah’s Witness patients has shown that
complex care without transfusion is possible and results are comparable with, if not
better than those of transfused patients. These experiences and rising awareness of
downsides of transfusion helped create what has become known as ‘patient blood
management’. Principles of this approach include optimizing erythropoiesis, reducing
surgical blood loss and harnessing the patient’s physiological tolerance ofanaemia. Treatment is tailored to the individual patient, using a multidisciplinary
team approach and employing a combination of modalities. Results have demonstrated reduction of transfusion, improved patient outcomes and patient satisfaction.
Significant healthcare cost savings have also followed. Despite the success of
patient blood management programmes and calls for practice change, the potential
and actual harm to patients caused through inappropriate transfusion is still not
sufficiently tangible for the public and many clinicians. This has to change. The
medical, ethical, legal and economic evidence cannot be ignored. Patient blood
management needs to be implemented as the standard of care for all patients.
Original languageEnglish
Pages (from-to)423-35
Number of pages13
JournalISBT Science Series
Volume4
Publication statusPublished - 2009

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Transfusion Medicine
Jehovah's Witnesses
Patient Harm
Cost Savings
Erythropoiesis
Budgets
Standard of Care
Patient Satisfaction
Blood Transfusion
Health Care Costs
Health Services
Length of Stay
Therapeutics
History
Economics
Guidelines

Cite this

Thomson, A., Farmer, S. L., Hofmann, A., Isbister, J., & Shander, A. (2009). Patient Blood Management - a new paradigm for transfusion medicine? ISBT Science Series, 4, 423-35.
Thomson, Amanda ; Farmer, Shannon L ; Hofmann, Axel ; Isbister, James ; Shander, Aryeh. / Patient Blood Management - a new paradigm for transfusion medicine?. In: ISBT Science Series. 2009 ; Vol. 4. pp. 423-35.
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title = "Patient Blood Management - a new paradigm for transfusion medicine?",
abstract = "The saving of many lives in history has been duly credited to blood transfusions.What is frequently overlooked is the fact that, in light of a wealth of evidence aswell as other management options, a therapy deemed suitable yesterday may nolonger be the first choice today. Use of blood has not been based upon scientificevaluation of benefits, but mostly on anecdotal experience and a variety of factorsare challenging current practice. Blood is a precious resource with an ever limitingsupply due to the aging population. Costs have also continually increased due toadvances (and complexities) in collection, testing, processing and administration oftransfusion, which could make up 5{\%} of the total health service budget. Risks oftransfusions remain a major concern, with advances in blood screening and processing shifting the profile from infectious to non-infectious risks. Most worryingthough, is the accumulating literature demonstrating a strong (often dose-dependent)association between transfusion and adverse outcomes. These includeincreased length of stay, postoperative infection, morbidity and mortality. To thisend, a recent international consensus conference on transfusion outcomes (ICCTO)concluded that there was little evidence to corroborate that blood would improvepatients’ outcomes in the vast majority of clinical scenarios in which transfusionsare currently routinely considered; more appropriate clinical management optionsshould be adopted and transfusion avoided wherever possible. On the other hand,there are patients for whom the perceived benefits of transfusion are likely to outweigh the potential risks. Consensus guidelines for blood component therapy havebeen developed to assist clinicians in identifying these patients and most of theseguidelines have long advocated more conservative ‘triggers’ for transfusion. However,significant variation in practice and inappropriate transfusions are still prevalent.The ‘blood must always be good philosophy’ continues to permeate clinicalpractice. An alternative approach, however, is being adopted in an increasing numberof centres. Experience in managing Jehovah’s Witness patients has shown thatcomplex care without transfusion is possible and results are comparable with, if notbetter than those of transfused patients. These experiences and rising awareness ofdownsides of transfusion helped create what has become known as ‘patient bloodmanagement’. Principles of this approach include optimizing erythropoiesis, reducingsurgical blood loss and harnessing the patient’s physiological tolerance ofanaemia. Treatment is tailored to the individual patient, using a multidisciplinaryteam approach and employing a combination of modalities. Results have demonstrated reduction of transfusion, improved patient outcomes and patient satisfaction.Significant healthcare cost savings have also followed. Despite the success ofpatient blood management programmes and calls for practice change, the potentialand actual harm to patients caused through inappropriate transfusion is still notsufficiently tangible for the public and many clinicians. This has to change. Themedical, ethical, legal and economic evidence cannot be ignored. Patient bloodmanagement needs to be implemented as the standard of care for all patients.",
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Thomson, A, Farmer, SL, Hofmann, A, Isbister, J & Shander, A 2009, 'Patient Blood Management - a new paradigm for transfusion medicine?' ISBT Science Series, vol. 4, pp. 423-35.

Patient Blood Management - a new paradigm for transfusion medicine? / Thomson, Amanda; Farmer, Shannon L; Hofmann, Axel; Isbister, James; Shander, Aryeh.

In: ISBT Science Series, Vol. 4, 2009, p. 423-35.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Patient Blood Management - a new paradigm for transfusion medicine?

AU - Thomson, Amanda

AU - Farmer, Shannon L

AU - Hofmann, Axel

AU - Isbister, James

AU - Shander, Aryeh

PY - 2009

Y1 - 2009

N2 - The saving of many lives in history has been duly credited to blood transfusions.What is frequently overlooked is the fact that, in light of a wealth of evidence aswell as other management options, a therapy deemed suitable yesterday may nolonger be the first choice today. Use of blood has not been based upon scientificevaluation of benefits, but mostly on anecdotal experience and a variety of factorsare challenging current practice. Blood is a precious resource with an ever limitingsupply due to the aging population. Costs have also continually increased due toadvances (and complexities) in collection, testing, processing and administration oftransfusion, which could make up 5% of the total health service budget. Risks oftransfusions remain a major concern, with advances in blood screening and processing shifting the profile from infectious to non-infectious risks. Most worryingthough, is the accumulating literature demonstrating a strong (often dose-dependent)association between transfusion and adverse outcomes. These includeincreased length of stay, postoperative infection, morbidity and mortality. To thisend, a recent international consensus conference on transfusion outcomes (ICCTO)concluded that there was little evidence to corroborate that blood would improvepatients’ outcomes in the vast majority of clinical scenarios in which transfusionsare currently routinely considered; more appropriate clinical management optionsshould be adopted and transfusion avoided wherever possible. On the other hand,there are patients for whom the perceived benefits of transfusion are likely to outweigh the potential risks. Consensus guidelines for blood component therapy havebeen developed to assist clinicians in identifying these patients and most of theseguidelines have long advocated more conservative ‘triggers’ for transfusion. However,significant variation in practice and inappropriate transfusions are still prevalent.The ‘blood must always be good philosophy’ continues to permeate clinicalpractice. An alternative approach, however, is being adopted in an increasing numberof centres. Experience in managing Jehovah’s Witness patients has shown thatcomplex care without transfusion is possible and results are comparable with, if notbetter than those of transfused patients. These experiences and rising awareness ofdownsides of transfusion helped create what has become known as ‘patient bloodmanagement’. Principles of this approach include optimizing erythropoiesis, reducingsurgical blood loss and harnessing the patient’s physiological tolerance ofanaemia. Treatment is tailored to the individual patient, using a multidisciplinaryteam approach and employing a combination of modalities. Results have demonstrated reduction of transfusion, improved patient outcomes and patient satisfaction.Significant healthcare cost savings have also followed. Despite the success ofpatient blood management programmes and calls for practice change, the potentialand actual harm to patients caused through inappropriate transfusion is still notsufficiently tangible for the public and many clinicians. This has to change. Themedical, ethical, legal and economic evidence cannot be ignored. Patient bloodmanagement needs to be implemented as the standard of care for all patients.

AB - The saving of many lives in history has been duly credited to blood transfusions.What is frequently overlooked is the fact that, in light of a wealth of evidence aswell as other management options, a therapy deemed suitable yesterday may nolonger be the first choice today. Use of blood has not been based upon scientificevaluation of benefits, but mostly on anecdotal experience and a variety of factorsare challenging current practice. Blood is a precious resource with an ever limitingsupply due to the aging population. Costs have also continually increased due toadvances (and complexities) in collection, testing, processing and administration oftransfusion, which could make up 5% of the total health service budget. Risks oftransfusions remain a major concern, with advances in blood screening and processing shifting the profile from infectious to non-infectious risks. Most worryingthough, is the accumulating literature demonstrating a strong (often dose-dependent)association between transfusion and adverse outcomes. These includeincreased length of stay, postoperative infection, morbidity and mortality. To thisend, a recent international consensus conference on transfusion outcomes (ICCTO)concluded that there was little evidence to corroborate that blood would improvepatients’ outcomes in the vast majority of clinical scenarios in which transfusionsare currently routinely considered; more appropriate clinical management optionsshould be adopted and transfusion avoided wherever possible. On the other hand,there are patients for whom the perceived benefits of transfusion are likely to outweigh the potential risks. Consensus guidelines for blood component therapy havebeen developed to assist clinicians in identifying these patients and most of theseguidelines have long advocated more conservative ‘triggers’ for transfusion. However,significant variation in practice and inappropriate transfusions are still prevalent.The ‘blood must always be good philosophy’ continues to permeate clinicalpractice. An alternative approach, however, is being adopted in an increasing numberof centres. Experience in managing Jehovah’s Witness patients has shown thatcomplex care without transfusion is possible and results are comparable with, if notbetter than those of transfused patients. These experiences and rising awareness ofdownsides of transfusion helped create what has become known as ‘patient bloodmanagement’. Principles of this approach include optimizing erythropoiesis, reducingsurgical blood loss and harnessing the patient’s physiological tolerance ofanaemia. Treatment is tailored to the individual patient, using a multidisciplinaryteam approach and employing a combination of modalities. Results have demonstrated reduction of transfusion, improved patient outcomes and patient satisfaction.Significant healthcare cost savings have also followed. Despite the success ofpatient blood management programmes and calls for practice change, the potentialand actual harm to patients caused through inappropriate transfusion is still notsufficiently tangible for the public and many clinicians. This has to change. Themedical, ethical, legal and economic evidence cannot be ignored. Patient bloodmanagement needs to be implemented as the standard of care for all patients.

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JO - ISBT Science Series

JF - ISBT Science Series

SN - 1751-2816

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