More than a third of the world’s population suffers from blood-related deficiencies, such as anemia1, iron deficiency2, or bleeding disorders3.
While those statistics are widely known, a key implication is often overlooked: With high global rates of blood-related deficiencies, the World Health Organization (WHO) notes that more than 100 million surgical patients4 around the world are anemic before their procedures even begin.
“Blood is the most neglected organ in medicine,” says Dr. Axel Hofmann, chair of the WHO’s external steering committee on patient blood management (PBM) and an internationally recognized expert on PBM. “This has tremendous consequences, especially in surgical patients. Both anemia and blood loss are major drivers for adverse outcomes.”
The traditional surgical approach has been to administer blood products as a first-line defense for any patient deemed “oozy.” However, transfusion is not without risks. Although blood transfusions are considered safer now than ever been5, perioperative blood transfusion is still associated with higher morbidity and increased risk for serious postoperative complications6.
This is the foundation for Patient Blood Management, a three-pillar framework for addressing blood deficiencies and improving patient outcomes. Supported by WHO in an official policy brief4, PBM applies evidence-based medical and surgical interventions to maintain hemoglobin concentrations, optimize hemostasis, and minimize blood loss.
The pillars are as follows:
Pillar 1: Detection and management of anemia and iron deficiency.
Phase one of PBM is to identify those patients who are preoperatively anemic and to improve their status before surgery. Pre-op anemia clinics can target and treat patients with low hemoglobin levels who are undergoing procedures with a high likelihood of blood loss.
“[This ensures] the patient has enough red cell mass on board prior to surgical intervention,” Dr. Hofmann says.
Pillar 2: Minimization of blood loss and optimization of coagulation.
Perioperative management involves collaborative anesthesiologic, hemostaseologic, and surgical interventions to minimize blood loss. Working together, the OR team can manage patient-specific risk factors for bleeding, including coagulation deficiencies.
Point-of-care viscoelastic testing plays a critical role in Pillar 2. The ability to test patient blood in real time, in the operating room, allows physicians to target and correct the specific deficiencies at the source of the bleeding. The faster clinicians can stop the bleeding, the fewer blood products needed.
Pillar 3: Leveraging and optimizing the patient-specific physiological tolerance of anemia.
In Pillar 3, clinicians assess the patient’s overall condition and intervene in ways that help the patient’s body to better tolerate anemia. Physicians can reduce metabolic demand, for example, or modify how the patient is sedated. Point-of-care testing can be helpful here, as well, providing evidence to direct interventions.
Results and Implications
PBM success, according to Dr. Hofmann, depends upon taking a multidisciplinary approach.
“It's not enough that the anesthetist or the surgeon or the surgical team has that concept in mind. This has to happen in the ICU, it has to happen preoperatively,” he says. “It's a continuum of care.”
Currently, hospitals around the world are at various stages of PBM implementation. While any steps toward patient blood optimization are valuable, full adoption of a PBM program has demonstrated impressive results.
The Western Australia Patient Blood Management Program published a large study on PBM outcomes7. Following a six-year implementation, study authors, including Dr. Hofmann, saw a 28% reduction in hospital mortality, a 31% reduction in myocardial infarction/stroke, and a 21% reduction in nosocomial infection. Hospital length of stay was reduced by 15%, which translated to a savings of 70,000 hospital days.
Upon reviewing those results, the WHO called the program “a template for the world.”
RC PBM Article B REV00 1.24
