Patient Blood Management - a new paradigm for transfusion medicine?

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.