Patient Blood Management: The Future of Transfusion Medicine?

Blood transfusions have established as a life-saving measure, but are not always useful. What changes does Patient Blood Management bring?

"Although transfusions can save lives, they are often unnecessary and sometimes even harmful." With these words, Dr Domenico Girelli summarised thescientific findings from past two decades of medical practice and research on the field of transfussion. This analysis was presented by Dr Girelli during the 2023 edition of the European Hematology Association Congress, which took place this year in Frankfurt, Germany.

Blood transfusion: an overused treatment method?

Of all patients admitted to hospital, 10% receive a blood transfusion. However, according to Dr Domenico Girelli¹, internist and emergency physician at the Verona University Hospital, Italy, transfusion is not necessary in all cases. As early as 2011, a review² on the suitability of transfusions by interdisciplinary specialists proved this:

59.3% of all transfusions are unnecessary; without evidence of patient health benefits, and evidence of risks associated with transfusion.
In 28.9% of all blood transfusions, the benefit is unclear; with uncertain evidence of patient benefit.
In 11.8%, transfusions are appropriate; with concrete evidence of health benefit.

However, if blood transfusions are used where there is a definite indication, there are enormous health and economic benefits. According to Dr Girelli, a Californian study³ showed that targeted use in patients receiving blood transfusions reduced mortality from 5.5% to 3.4% and reduced hospital stay from 10.1 to 6.2 days. On top of that, the hospital saved $1.6 million a year through 24% fewer blood transfusions.

What is Patient Blood Management?

The WHO definition indicates that "Patient Blood Management is a patient-centred, systematic, evidence-based approach to improving patient outcomes through the management and conservation of autologous blood while promoting patient safety and ownership." Patient Blood Management, on the other hand, says Dr Girelli, can prevent overuse of blood transfusions from the outset. PBM shifts the focus away from blood products and towards the patient. Blood transfusions are to be avoided by monitoring and preserving patients' blood as much as possible.

According to Dr Girelli, it is important to differentiate between the optimal use of blood components and PBM. The first approach is mostly a laboratory-dependent monotherapy to correct laboratory values (haemoglobin, INR, platelet count). Patient Blood Management, on the other hand, specifically aims to eliminate modifiable risk factors for:

Anemia & iron deficiency,
Blood loss) and,
Coagolupathy with bleeding.

This means, a priority is given to counteract the "deadly ABC" in terms of risk factors among hospitalised patients, long before blood transfusion is even considered. There is an acute need for action here: the WHO estimates that there are over 2.9 billion people worldwide with anaemia and over 600 million people with blood loss and bleeding disorders.

Three pillars of Patient Blood Management

Blood transfusions are of course necessary and helpful, says Dr Girelli, but in many cases they are associated with risks: both due to the transfusion - for example AB0 intolerance, anaphylactic shock, or acute haemolytic transfusion reactions - and indirectly, for example due to the development of non-Hodgkin's lymphoma or hospital infection. Patient Blood Management is designed to counteract this through three pillars:

Detection and treatment of anaemia and iron deficiency
Minimisation of blood loss and coagulation optimisation
Effective use and optimisation of patient-specific physiological tolerance of anaemia

PBM is by no means only suitable for use in surgical patients. It makes just as much sense to use the approach with older hospitalised patients who are particularly frequently affected by anaemia, pregnant women, or women with heavy menstrual bleeding, as well as paediatric patients.

Within the framework of the world's largest study on the benefits of Patient Blood Management⁴ with more than 600,000 participants, some of the findings obtained were:

Better patient outcomes: Mortality reduced by 28%, risk of infection reduced by 21%, risk of stroke reduced by 31%, hospital stays reduced by 15%.
Pre-operative anaemia reduced from 21% to 14%, the number of one-time blood transfusions increased from 33% to 64%.

PBM: Interdisciplinary expertise required

According to Dr Girelli, many professional societies attach importance to making Patient Blood Management the new standard of care. The WHO also calls on its member states to establish PBM in everyday practice wherever possible, but still sees some hurdles ahead:

Closing knowledge gaps on patient blood management, which exist not only on the part of patients but also among medical professionals.
The extremely diverse group of stakeholders must be brought together.
"Entrenched" medical dogmas need to be overcome → the long-established position of transfusion as the "usual treatment method" for anaemia and bleeding still hinders the introduction of Patient Blood Management.

Dr Domenico Dr Girelli emphasised that interdisciplinary cooperation is essential for the successful implementation of Patient Blood Management - from haematology specialists, who have core competencies in anaemia, coagulation disorders or transfusion medicine, to anaesthesiologists and surgeons.

Conclusion: Haematologists as key to PBM success

Dr Girelli points in summary:

Patient Blood Management is a multidisciplinary approach to improve patient outcomes while saving health systems money with evidence-based potential.
Haematologists are key to the successful implementation of PBM programmes.
Scientific societies in the field of haematology should support PBM and assist WHO in its implementation.

Sources:

Girelli, Dr. Domenico: WHO Policy Brief: The urgent need to implement Patient Blood Management. In: Patient Blood Management: From WHO policy to practical applications; EHA Congress 2023, 09. Juni 2023, 13.30-13.50 Uhr.
Shander A. et al.; International Consensus Conference on Transfusion Outcomes Group. Appropriateness of allogeneic red blood cell transfusion: the international consensus conference on transfusion outcomes. Transfus Med Rev. 2011 Jul;25(3):232-246.e53. doi: 10.1016/j.tmrv.2011.02.001. Epub 2011 Apr 17. PMID: 21498040.
Anthes, E. Evidence-based medicine: Save blood, save lives. Nature 520, 24–26 (2015). https://doi.org/10.1038/520024a
Leahy MF et al.: Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion. 2017 Jun;57(6):1347-1358. doi: 10.1111/trf.14006. Epub 2017 Feb 2. PMID: 28150313.