Patient Blood Management Is a New Standard of Care to Optimize Blood Health

Patient Blood Management: A conceptual and analytical vision from the leadership in Spain

The evolution of blood saving programs to Patient Blood Management (PBM) represents a broader and more comprehensive approach to optimize the use of the patient's own blood, thus improving clinical outcomes and minimizing the risks associated with allogeneic blood transfusion with a holistic view of socio-economic sustainability. Implementing the strategies of the three PBM pillars in any hospital center involves a transversal change throughout the organization in which it can be very useful to apply the strategy defined by Kotter at the business level for change management. The support of renowned institutions such as the World Health Organization and the European Commission demonstrates the importance and urgency of implementing PBM programs, setting guidelines at an international level and supporting the adoption of effective strategies in the management of blood transfusion at a national and institutional level. In Spain, we need to have health managers at both the Hospital Management level and the Regional Health Services and/or Ministry of Health that provide the necessary resources for its proper implementation in the health system from primary care to hospital care and also the resources for the timely evaluation of the results.

Association Between Preoperative Anemia and Cognitive Function in a Large Cohort Study of Older Patients Undergoing Elective Surgery

BACKGROUND

The etiology of anemia has tremendous overlap with the disease states responsible for cognitive decline. We used data from a perioperative database of older adults undergoing elective surgery with anesthesia to (1) examine relationships among preoperative anemia blood markers, preoperative screeners of cognitive function, and chronic disease status; and (2) examine the relationship of these factors with operative outcomes. The primary goal of this study was to investigate the association between preoperative anemia blood markers and cognition measured by a preoperative cognitive screener. Secondary goals were to (1) examine the relationship between preoperative anemia blood markers and chronic disease states (ie, American Society of Anesthesiologists [ASA] and frailty), and (2) investigate the relationship of preoperative anemia blood markers and cognition with operative outcomes (ie, discharge disposition, 1-year mortality, number of surgical complications, length of hospital stay, and length of intensive care unit [ICU] stay).

METHODS

Data were collected at the University of Florida Health Shands Presurgical Center and the Perioperative Cognitive Anesthesia Network clinic within the electronic medical record. Patients 65 years of age or older were included if they had a preoperative hemoglobin (Hgb) value and a preoperative screening. Nonparametric methods were used for bivariate analysis. Logistic regression was used for the simultaneous examination of variables associated with nonhome discharge and 1-year mortality. Primary outcomes were discharge disposition and 1-year mortality. Secondary outcomes were number of surgical complications and length of hospital and ICU stay.

RESULTS

Of 14,795 patients cognitively assessed, 8643 met the inclusion criteria. Of these, 26.7% were anemic, with 16.8%, 9.5%, and 0.4% having mild, moderate, and severe anemia, respectively. The Spearman correlation coefficient [95% confidence interval, CI] between the Hgb level and the clock drawing time (CDT) was -.15 [-.17 to -.13] ( P < .0001) indicating that a lower Hgb level was associated with cognitive vulnerability. Hgb was also negatively correlated with the ASA physical status classification, patient Fried Frailty Index, and hospital and ICU length of stay. In the multivariable model, age, surgical service, ASA and Fried Frailty Index significantly predicted nonhome discharge. Furthermore, age, surgical service, ASA, Fried Frailty Index, and Hgb independently predicted death within 1 year of surgery. The odds of death, adjusted for ASA, Fried Frailty, and covariates, were 2.7 times higher for those in the mild anemic group compared to those who were not anemic (odds ratio [OR], 2.7, 95% CI, [2.1-3.5]). The odds of death, adjusted for ASA, Fried Frailty, and covariates, were 3.6 times higher for those in the moderate/severe anemic group compared to those who were not anemic (OR, 3.6, 95% CI, [2.7-4.9]).

CONCLUSIONS

In this first medicine study, we established relationships among anemia, preoperative markers of frailty and cognition, and chronic disease states in a large cohort of older patients undergoing elective surgery in a large tertiary medical center. We found that anemia, cognitive vulnerability, and chronic health disease states predicted death within 1 year of surgery, and that these preoperative factors negatively contribute to surgical outcomes such as time in the ICU, length of hospital stay, nonhome discharge, and 1-year mortality. The World Health Organization (WHO) and many academic medical societies have urged the adoption of patient blood management (PBM) disciplines, yet anemia is not routinely optimized as a preoperative risk factor. Given the well-defined association between preoperative anemia and postoperative morbidity and mortality, performing elective surgery on an untreated anemic patient should be considered substandard care. With established safe and effective treatment regimens, iron deficiency anemia is a modifiable preoperative risk factor that should be addressed before elective surgery.

Perioperative paediatric patient blood management: a narrative review

Patient blood management (PBM) encompasses implementing multimodal evidence-based strategies to screen, diagnose, and properly treat anaemia and coagulopathies using goal-directed therapy while minimising bleeding. The aim of PBM is to improve clinical care and patient outcomes while managing patients with potential or ongoing critical anaemia, clinically significant bleeding, and coagulopathies. The focus of PBM is patient-centred rather than transfusion-centred. Multimodal PBM strategies are now recommended by international organisations, including the World Health Organization, as a new standard of care and a proven means to safely and effectively manage anaemia and blood loss while minimising unnecessary blood transfusion. Compared with adult PBM, paediatric PBM is currently not routinely accepted as a standard of care. This is partly because of the paucity of robust data on paediatric patient PBM. Managing paediatric bleeding and blood product transfusion presents unique challenges. Neonates, infants, children, and adolescents each have specific considerations based on age, weight, physiology, and pharmacology. This narrative review covers the latest updates for PBM in paediatric surgical populations including the benefits and principles of paediatric PBM, current expert consensus guidelines, and important universal multimodal therapeutic strategies emphasising clinical management of the anaemic, bleeding, or coagulopathic paediatric patient in the perioperative period. Practical paediatric rules for PBM in the perioperative period are highlighted, with review of specific PBM strategies including treatment of preoperative anaemia, restrictive transfusion thresholds, antifibrinolytic agents, cell salvage, standardised transfusion algorithms, and goal-directed therapy based on point-of-care and viscoelastic testing.

Trends in Gender of Authors of Patient Blood Management Publications

BACKGROUND

Diverse representation in the field of patient blood management (PBM) may help bring varying perspectives to improve patient care. We assessed trends in gender of first and last authorship of recent PBM publications to evaluate diversity within the field.

METHODS

Publications from 10 high-impact anesthesiology and blood transfusion medicine journals between 2017 and 2021 were reviewed using 19 keywords to identify PBM-related articles. Each publication title was reviewed independently to determine whether it met the inclusion criteria. A software program was used to identify the gender of each first and last author for the most common first names. Author gender that could not be identified through this process was determined by querying institutional websites and professional social networks (eg, ResearchGate). Any publication where the gender of the first and/or last author could not be reliably determined was excluded from the analysis. Trends over time were assessed using the Cochran-Armitage test.

RESULTS

A total of 2467 publications met the inclusion criteria of the 2873 yielded by the initial search. Gender of the first and last author was identified for 2384 of these publications and included in the final analysis. Approximately 42.8% of publications featured a woman as the first author with the highest from the journals such as the Journal of the American Medical Association ( JAMA ) (48.7%) and Transfusion (48.1%) and the lowest from the journals such as the British Journal of Anaesthesia (24.1%) and Anesthesia & Analgesia (24.4%). Approximately 32.0% of the publications featured a woman as the last author with the highest being Transfusion (36.9%) and Anaesthesia (31.8%) and the lowest being Anesthesia and Analgesia (18.3%) and Anesthesiology (18.6%). Approximately 57.6% of publications had either a woman as the first or last author while 16.3% of the publications had women as both the first and last authors. Women authors comprised 32.6% of the publications with a single author. Women as the first or last authors did not change significantly over the study period ( P = .115 and P = .119, respectively). No significant difference was observed in the percentage of PBM articles with a woman as the first or last author, a woman as the first and last author, or a woman as a single author from 2017 to 2021 ( P = .089, P = .055, and P = .226, respectively).

CONCLUSIONS

The percentage of women as the first and last authors in PBM publications from the 5-year period of 2017 to 2021 was <50%. Gender equity in PBM authorship was identified as an area for potential future improvement. International mentorship and sponsorship of women remain important in promoting gender equity in PBM authorship.

Patient blood management in major digestive surgery: Recommendations from the Italian multisociety (ACOI, SIAARTI, SIdEM, and SIMTI) modified Delphi consensus conference

Patient blood management (PBM) is defined as the timely application of evidence-based medical and surgical concepts designed to maintain a surgical patient’s hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve the outcomes. PBM is able to reduce mortality up to 68%, reoperation up to 43%, readmission up to 43%, composite morbidity up to 41%, infection rate up to 80%, average length of stay by 16%–33%, transfusion from 10% to 95%, and costs from 10% to 84% after major surgery. It should be noticed, however, that the process of PBM implementation is still in its infancy, and that its potential to improve perioperative outcomes could be strictly linked to the degree of adherence/compliance to the whole program, with decoupling and noncompliance being significant factors for failure. Therefore, the steering committees of four major Italian scientific societies, representing general surgeons, anesthesiologists and transfusion medicine specialists (Associazione Chirurghi Ospedalieri Italiani; Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva; Società Italiana di Emaferesi e Manipolazione Cellulare; Società Italiana di Medicina Trasfusionale e Immunoematologia), organized a joint modified Delphi consensus conference on PBM in the field of major digestive surgery (upper and lower gastrointestinal tract, and hepato-biliopancreatic resections), whose results and recommendations are herein presented.

Patient Blood Management in Microsurgical Procedures for Reconstructive Surgery

Introduction: The main purpose of reconstructive surgery (RS) is to restore the integrity of soft tissues damaged by trauma, surgery, congenital deformity, burns, or infection. Microsurgical techniques consist of harvesting tissues that are separated from the vascular sources of the donor site and anastomosed to the vessels of the recipient site. In these procedures, there are some preoperative modifiable factors that have the potential to influence the outcome of the flap transfer and its anastomosis. The management of anemia, which is always present in the postoperative period and plays a decisive role in the implantation of the flap, covers significant importance, and is associated with clinical and laboratory settings of chronic inflammation. Methods: Chronic inflammatory anemia (ACD) is a constant condition in patients who have undergone RS and correlates with the perfusion of the free flap. The aim of this treatment protocol is to reduce the transfusion rate by maintaining both a good organ perfusion and correction of the patient's anemic state. From January 2017 to September 2019, we studied 16 patients (16 males, mean age 38 years) who underwent microsurgical procedures for RS. Their hemoglobin (Hb) levels, corpuscular indexes, transferrin saturation (TSAT) ferritin concentrations and creatinine clearance were measured the first day after surgery (T0), after the first week (T1), and after five weeks (T2). At T0, all the patients showed low hemoglobin levels (average 7.4 g/dL, STD 0.71 range 6.2-7.4 g dL-1), with an MCV of 72, MCH of 28, MCHC of 33, RDW of 16, serum iron of 35, ferritin of 28, Ret% of 1.36, TRF of 277, creatinine clearance of 119 and high ferritin levels (range 320-560 ng mL-1) with TSAT less than 20%. All the patients were assessed for their clinical status, medical history and comorbidities before the beginning of the therapy. Results: A collaboration between the two departments (Department of Transfusion Medicine and Department of Reconstructive Surgery) resulted in the application of a therapeutic protocol with erythropoietic stimulating agents (ESAs) (Binocrit 6000 UI/week) and intravenous iron every other day, starting the second day after surgery. Thirteen patients received ESAs and FCM (ferric carboxymaltose, 500-1000 mg per session), three patients received ESAs and iron gluconate (one vial every other day). No patients received blood transfusions. No side effects were observed, and most importantly, no limb or flap rejection occurred. Conclusions: Preliminary data from our protocol show an optimal therapeutic response, notwithstanding the very limited scientific literature and data available in this specific surgical field. The enrollment of further patients will allow us to validate this therapeutic protocol with statistically sound data.

Error traps in Pediatric Patient Blood Management in the Perioperative Period

Patient blood management is a patient-centered evidence-based approach to improve patient outcomes by harnessing the patient's own hematopoietic system to optimize blood health while promoting patient safety and empowerment. Perioperative patient blood management is a standard of care in adult medicine, yet it is not commonly accepted in pediatrics. Raising awareness may be the first step in improving perioperative care for the anemic and/or bleeding child. This article highlights five preventable perioperative blood conservation error traps for children. The goal is to provide practical clinical guidance to improve preoperative diagnosis and treatment of anemia, facilitate recognition and treatment of massive hemorrhage, reduce unnecessary allogeneic blood transfusions, and decrease associated complications of anemia and blood component transfusions utilizing a patient/family-centered informed consent and shared decision-making approach.

Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management

BACKGROUND

Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas.

METHODS

We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension.

AIMS

Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery.

RESULTS

Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes.

CONCLUSIONS

The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.

How do we forecast tomorrow's transfusion? - Next generation transfusion practices to improve recipient safety

Recipient safety measures play a key role in overall transfusion efficacy. The key advances in safety over the first century of transfusion medicine have been the development of techniques to prevent hemolytic transfusion reactions, hemolytic disease of the newborn and transmission of viral pathogens. While these risks remain important, they affect many fewer patients than previously. We propose that some of the most important current safety issues relate to toxicities broadly encompassed by the immunomodulatory effects of allogeneic transfusion. These include (1) universal leukoreduction to mitigate nosocomial infections, inflammation and organ injury, (2) removal of stored supernatant and its attendant toxic contents that cause dysfunctional immunity and organ injury, (3) avoiding infusing ABO incompatible antigen and antibody that can lead to bleeding, platelet refractoriness and inflammation, (3) minimizing prophylactic transfusions (particularly of plasma and platelets) except where benefit is proven, and (4) avoiding use of normal saline which is linked to renal failure and possibly hemolysis. Accompanying these safety measures will be the continued growth of one of the most important safety measures, patient blood management, which has as one benefit the avoidance of unnecessary and harmful transfusions. Reducing the toxicity of transfusions will enhance the improved clinical outcomes seen with patient blood management.