Patient Blood Management

Background

• Multidisciplinary, patient-focused, evidence-based and systematic approach to optimising care of patients who may require transfusion.
• Advantages of PBM:
  • Reduces unnecessary transfusion.
  • Increasing sustainability of blood supply.
  • Reduced cost.

General Considerations

• All hospitals should have a PBM programme.
• All clinicians who may potentially transfuse blood should be educated about good PBM, blood management and the need to avoid blood transfusion wherever possible.
• Volume and frequency of phlebotomy should be minimised to prevent iatrogenic anaemia.
• Appropriate blood use:
  • Locally-agreed triggers for transfusion (based on national guidelines) should be defined.
  • Blood bank staff should be empowered to question requests that do not conform to triggers.
  • Transfusions should be regularly audited against these triggers.
  • Transfusion of blood components should be ordered one dose at a time, with reassessment in between each transfusion.

Surgical PBM

• Pre-operative management:
  • There should be arrangements for timely identification and correction of pre-operative anaemia, especially for surgery where significant blood loss is expected.
  • Ideally, this should be done when the referral for surgery is first made.
  • Protocols for patients on antiplatelets and anticoagulants should be in place.
  • Transfusions should be avoided for patients with haematinic deficiency. 
  • Patients should be counselled about the relationship between anaemia and morbidity and mortality, and be given the opportunity to defer non-urgent surgery.
  • If surgery is urgent, whatever time there is available prior to surgery should still be used for investigation and management of anaemia.
• Intra-operative management:
  • Use intra-operative cell salvage with tranexamic acid for procedures with moderate-high bleeding risk.
  • Physiological homeostasis (normothermia, acid-base management, normocalcaemia) should be maintained intra-operatively.
  • Permissive hypotension should be considered where safe.
  • Minimise surgical blood loss.
• Post-operative:
  • Consider alternatives to blood transfusion (e.g. intravenous iron for patients with haematinic deficiency).
  • Use post-operative blood salvage where indicated.

Medical PBM

• Have protocols for patients with abnormal haemostasis and major bleeding.
• Have protocols for managing of bleeding in patients on anticoagulants.
• Use tranexamic acid for major bleeding.
• Have a protocol ready for patients with severe thrombocytopaenia.