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What is Patient Blood Management & Why Is It So Important?

With the launch of a Perioperative-Patient Blood Management training course, WFSA’s Daniela Filipescu outlines why PBM is such a win-win for patients and clinicians alike.

Endorse the Global Consensus Statement

In the era of Sustainable Development Goals (1) to transform our world for the better, over 5 billion people do not have access to safe, affordable anaesthesia and surgery when they need it (2,3). That is why, recently, the World Health Organisation (WHO) considered surgical, anaesthetic and obstetric care an essential part of every healthcare system, and access to safe anaesthesia and surgery a core component of Universal Health Coverage (UHC)

Importantly, more than 30% of the Global Burden of Diseases stems from conditions that could be treated through surgical interventions and surgical conditions are responsible for more deaths than tuberculosis, HIV and malaria combined, worldwide (5,6). Considering that 143 million new surgeries are needed in low-income countries (LIC) and lower-middle income countries (LMIC) each year (2), the WHO political commitment and programmes must reflect the importance of increasing anaesthesia and surgical capacity and improving the quality of care and outcomes.

On the other hand, increased surgical capacity results in an increased need for blood products as there is a long-established dogma of transfusion of allogeneic blood components as “usual care” for anaemia and bleeding in the perioperative period. Despite the evidence that the efficacy of transfusions is suboptimal in many clinical settings (7), significant differences in perioperative transfusion practice still exist (8,9), pointing out to an urgent need for rational use of blood products to cover the high demands.

Knowing that global prevalence of anaemia is approximately 33% (10), and that approximately 100 million of surgeries are performed in anaemic patients every year (11), there is a tremendous pressure on transfusion services worldwide, especially in LIC and LMIC, where blood donations are insufficient for increasing access to safe emergency surgery (12).

Preoperative anemia itself is responsible for increased perioperative morbidity and mortality (13) and the combination of anaemia and transfusion dramatically increases the risk for adverse postoperative outcome (14). Consequently, the current guidelines on preoperative evaluation (15) and perioperative management of severe bleeding (16) strongly recommend diagnostic and treatment of preoperative anaemia.

Anaesthesiologists, as perioperative physicians, should take every reasonable measures to optimise the patient’s own blood volume, to minimise the patient’s blood loss and harness and optimise the patient specific physiological tolerance of anaemia, which constitute the three pillars of the modern concept of Patient Blood Management (PBM) (17).

The concept of PBM has evolved from blood conservation techniques to “a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood, while promoting patient safety and empowerment“, a concept which is no longer product-centred (18). Patient Blood Management “is not an intervention per se: It is not about transfusion thresholds, appropriate transfusion, intravenous iron, or any other specific therapeutic intervention. Rather, it is the application of the principles of good clinical medicine which include, first of all, diagnosis, followed by the consideration of appropriate patient-specific therapeutic options for management of that patient’s diagnosis with patient engagement, shared decision-making, informed consent, and clinical follow-up. This overall approach is most likely to improve patient experience and clinical outcome”. (18).

Overall, a comprehensive PBM programme, addressing all three PBM pillars, is associated with a reduction in transfusion need of red blood cell (RBC) units, lower complication and mortality rate, thereby improving clinical outcomes and patient safety (19). The impact of a jurisdiction-wide PBM programme was assessed in a large retrospective study including more than 600,000 patients in four participating centres in West- Australia (20). Implementation of PBM was associated with significant reductions of in-hospital mortality (28%) and length of stay (LOS) (15%), hospital-acquired infection (21%), stroke (31%) and utilisation of RBC units (41%). Additionally, PBM and reduced blood product utilisation were associated with product-acquisition cost savings of 18.1 million AUD.

Furthermore, one metanalysis of 17 studies addressing each of the three PBM pillars with at least one measure per pillar (i.e., preoperative anaemia management plus cell salvage plus rational transfusion strategy), comprising 235,779 surgical patients, suggests that a multidisciplinary, multimodal PBM programme is highly effective in reducing RBC utilization, and is associated with improved postoperative outcomes and hospital LOS in various surgical disciplines (21).

New studies from Canada (22), France (23) and Germany (24) confirm the impressive benefits of PBM implementation. The recent German PBM network’s before and after PBM implementation analysis of 1.2 million patients showed that implementation of PBM in 14 hospitals resulted in a substantial reduction of RBC transfusion by 13.9%, and was safe for patients (24). The PBM programme was most effective in hospitals with elevated transfusion rates. Noteworthy, the more PBM measures were implemented, the higher the probability for decreased RBC utilisation.

A budget impact model was developed to estimate the difference in the cost of care between scenarios with and without PBM (first pillar), including 980,125 patients from 10 French hospitals throughout the management of preoperative anaemia and iron deficiency in four types of surgeries (orthopaedic, cardiac and cardiovascular, vascular and thoracic, and urologic and visceral surgery) showed that implementation of a PBM programme could generate annual savings of up to €1079 mil from the French National Health Insurance perspective, sparing 181,451 RBC units per year and avoiding transfusion in 53,053 patients (23).

It is largely accepted that PBM adds value, and PBM is currently considered a new safety and quality standard for patient care (25). It is a “win-win” programme, mutually benefiting all stakeholders by reducing the utilization of health care resources, and decreasing costs, transfusion dependency, and the risks and complications of allogeneic blood component transfusion for our patients.

Recently, the WHO called for all member states to “act quickly through their ministry or department of health to adopt their national PBM policy, install the necessary governance, and reallocate resources to improve the population health status and individual patient outcomes while reducing overall health care expenditures” (26). Hospital administrators and department chairs can no longer ignore the clinical and economic impact it offers.

We, at the WFSA, endorse this WHO call to action. Over the past year, WFSA has been leading innovative work in the field of PBM, including an outreach campaign to WFSA Member Societies to secure their support for a global PBM declaration and a perioperative PBM training course.

A milestone event came in October 2022, when our Member Societies in Latin America signed the Santa Cruz Declaration during the CLASA Congress, committing to working together to implement key PBM principles in the perioperative period through its three fundamental pillars. We are now taking forward the regional Declaration and push a new global declaration through a multi-media promotional campaign, inviting Member Societies around the world to endorse the Santa Cruz Declaration: A Global PBM Consensus by signing a letter of support. We plan to announce the global support for this at the World Congress of Anaesthesiologists (WCA) in March 2024 and launch an international initiative to recognise the urgent need to implement PBM principles in the perioperative period.

Educational gaps in the field of PBM are among the main barriers to implementing PBM programmes (28). To promote education for implementing PBM principles and programmes in health professionals, we also work on developing a new, completely WFSA-branded Perioperative Patient Blood Management (P-PBM) training course under the leadership of Dr. Fredy Ariza (Colombia), and Dr. Jolene Moore (UK) and myself.

 At WCA2024 in Singapore, we are also planning the following core activities:

  • A Scientific Session for up to 200 attendees with internationally renowned PBM experts Professor Axel Hoffman, Professor Jens Meier and Professor Aryeh Shander alongside WFSA leads in this area, on Wednesday 6 March. This will highlight numerous aspects of PBM, including the new WFSA training package. It will also be the perfect opportunity for a formal presentation of the globally signed PBM Declaration by Dr Carolina Haylock-Loor (Honduras) and Associate Professor Wayne Morriss (New Zealand)(Wednesday 6 March at 16:15-17;15 pm SGT, meeting room 324);
  • A training-of-trainers session for WFSA course future collaborators where PBM experts and WFSA P-PBM collaborators Professor Susan Goobie (US), Professor Tae-Yop Kim (South Korea) and Professor Kai Zacharowski (Germany) together WFSA leads (Dr. Fredy Ariza and Dr. Jolene Moore) will guide into the WFSA P-PBM training package and offer hands-on support to familiarize themselves with the materials (Monday 4 March at 12:30-14:00 SGT, meeting room 329);
  • The first in-person WFSA P-PBM collaborators meeting chaired by Dr. Fredy Ariza, Professor Filipescu and Dr. Jolene Moore to discuss development of the P-PBM course (Wednesday 6 March at 10:00-11:00 SGT, meeting room 329);
  • A range of PBM-related ‘pop-up’ talks and happenings on the WFSA Hub (stand) in the Global Anaesthesia Village within the Exhibition Hall in Singapore, led by Professor Erlinda Oracion (Philippines) and Dr. Teresa Skelton (Canada) (Tuesday 5 March at 12:30-13:00 SGT and Associate Professor Orawan Pongraweewan (Thailand) (Wednesday 6 March at 15:45-16:00 SGT).

We look forward to seeing you in Singapore and working with you to implement Patient Blood Management in the perioperative period.

References

  1. https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf  Accessed 2024, February 14
  2. Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015; 386: 569–624
  3. Resolution A 68/15: Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. 2015. Available at: https://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_R15-en.pdf Accessed February 14 2024
  4. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health. 2015 Apr 27; 3 Suppl 2: S8-9
  5. GBD 2016 Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390: 1151-1210
  6. Nepogodiev D, Martin J, Biccard B, Makupe A, Bhangu A; National Institute for Health Research Global Health Research Unit on Global Surgery. Global burden of postoperative death. Lancet 2019 Feb 2; 393(10170): 401
  7. Hare GMT, Cazorla-Bak MP, Ku SFM, et al. When to transfuse your acute care patient? A narrative review of the risk of anemia and red blood cell transfusion based on clinical trial outcomes. Can J Anaesth. 2020 Nov; 67(11): 1576-1594
  8. Meier J, Filipescu D, Kozek-Langenecker S, et al; ETPOS collaborators. Intraoperative transfusion practices in Europe. Br J Anaesth. 2016 Feb; 116(2): 255-61
  9. Van der Linden P, Hardy JF. Implementation of patient blood management remains extremely variable in Europe and Canada: the NATA benchmark project: An observational study. Eur J Anaesthesiol. 2016 Dec; 33(12): 913-921
  10. Kassebaum NJ, Collaborators GBDA. The Global Burden of Anemia. Hematol Oncol Clin North Am. 2016;30:247-308
  11. Rose J, Weiser TG, Hider P, Wilson L, Gruen RL, Bickler SW. Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate. Lancet Glob Health. 2015;3 Suppl 2: S13-20
  12. Jones JM, Sapiano MRP, Savinkina AA et al. Slowing decline in blood collection and transfusion in the United States – 2017. Transfusion 2020;60(suppl 2):S1-S9
  13. Fowler AJ, Ahmad T, Phull MK, Allard S, Gillies MA, Pearse RM. Meta-analysis of the association between preoperative anaemia and mortality after surgery. Br J Surg. 2015; 102: 1314-24
  14. Ferraris VA, Hochstetler M, Martin JT, Mahan A, Saha SP. Blood transfusion and adverse surgical outcomes: The good and the bad. Surgery 2015 Sep;158(3):608-17
  15. Halvorsen S, Mehilli J, Cassese S, et al; ESC Scientific Document Group. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery.  Eur Heart J. 2022 Oct 14; 43(39): 3826-3924
  16. Kietaibl S, Ahmed A, Afshari A, Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022.  Eur J Anaesthesiol. 2023 Apr 1; 40(4): 226-304
  17. Meybohm P, Richards T, Isbister J, et al. Patient blood management bundles to facilitate implementation. Transfus Med Rev. 2017; 31: 62–71
  18. Shander A, Hardy JF, Ozawa S et al. A Global Definition of Patient Blood Management. Anesth. Analg. 2022, 135, 476–488
  19. Spahn DR, Muñoz M, Klein AA, Levy JH, Zacharowski K. Patient Blood Management: Effectiveness and Future Potential. Anesthesiology 2020 Jul; 133(1): 212-222
  20. Leahy MF, Hofmann A, Towler S, 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; 57(6): 1347–58
  21. Althoff FC, Neb H, Herrmann E, et al. Multimodal Patient Blood Management Program Based on a Three-pillar Strategy: A Systematic Review and Meta-analysis. Ann Surg. 2019 May; 269(5): 794-804
  22. Pavenski K, Howell A, Mazer CD, Hare GMT, Freedman J. ONTraC: A 20-Year History of a Successfully Coordinated Provincewide Patient Blood Management Program: Lessons Learned and Goals Achieved. Anesth Analg. 2022 Sep 1; 135(3): 448-458
  23. Lasocki S, Delahaye D, Fuks D, et al. Management of perioperative iron deficiency anemia as part of patient blood management in France: A budget impact model-based analysis based on real world data. Transfusion 2023 Sep; 63(9): 1692-1700
  24. Meybohm P, Schmitt E, Choorapoikayil S, et al; German Patient Blood Management Network Collaborators. German Patient Blood Management Network: effectiveness and safety analysis in 1.2 million patients. Br J Anaesth. 2023 Sep; 131(3): 472-481
  25. Zacharowski K, Spahn DR. Patient blood management equals patient safety. Best Pract Res Clin Anaesthesiol. 2016 Jun; 30(2): 159-69
  26. Maryuningsih Y, Abdella Y, Blumberg N, Bucagu M, Casal MNG, Beltran Duran M, et al. The urgent need to implement patient blood management: policy brief. In: Organization, W.H., editor. internet. Geneva: World Health Organization; 2021. https://apps.who.int/iris/bitstream/handle/10665/346655/9789240035744-eng.pdf
  27. https://wfsahq.org/news/latest-news/patient-blood-management-declaration-signed-at-clasa/ Accessed February 14, 2023
  28. Hofmann A, Spahn DR, Holtorf AP; PBM Implementation Group. Making patient blood management the new norm(al) as experienced by implementors in diverse countries. BMC Health Serv Res. 2021 Jul 2;21(1):634
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