winter 2013

c l i n i c a l   p r a c t i c e
Patient Blood Management

 

A patient oriented approach to best-practice in Transfusion Medicine


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The safety of the blood supply has increased significantly with respect to blood borne infectious disease transmission. However, adverse transfusion related events remain major risks associated with allogeneic blood transfusion.

By Daphne Osborne, MN, RN

The safety of the blood supply has increased significantly with respect to blood borne infectious disease transmission. However, adverse transfusion related events such as transfusion related acute lung injury (TRALI), transfusion related circulatory overload (TACO), and transfusion related immunomodulation (TRIM) remain major risks associated with allogeneic blood transfusion.

In 2010, the World Health Authority (WHO) published an Assembly Resolution on availability, safety and quality of blood products. In the Resolution, the WHO urged the implementation of Patient Blood Management Plans (PBM) to ensure blood product quality and safety meets internationally recognized standards.

A Patient Blood Management Plan (PBM) is an evidence-based, multidisciplinary approach to optimizing the care of patients who might need transfusion. PBM interventions are implemented in the preparation of medical and surgical patients and focus on treatment of the individual patient, which is comprised of transfusion therapy and pharmacotherapy.

PBM interventions are implemented early in the preparation of medical and surgical patients.

Nursing and medical education, exploration of alternatives to transfusion, and the development of evidence-based best practice guidelines for clinicians are the basis of Blood Management Plans. Blood management is based on the following: (1) optimization of erythrocyte volume, (2) reduction of blood loss, and (3) increasing individual tolerance of anemia and transfusion triggers.

PBM therefore, encompasses all aspects of patient assessment and clinical management surrounding the decision to transfuse. PBM requires an interdisciplinary approach between the specialties of Transfusion Medicine, Hematology, Anesthesiology, Internal Medicine, Surgery, and Pharmacology. Strategies start with early anemia detection and treatment to stabilize the patient’s hemoglobin concentration; blood sparing surgical techniques to minimize blood loss; early bleeding control by point of care coagulation monitoring and use of hemostatic interventions to optimize hemostasis; and, re-transfusion of salvaged blood during surgery in order to reduce the likelihood of allogeneic transfusion and the risk of transfusion associated adverse events.

Early anemia detection and treatment promotes optimization of erythrocyte volume. Transfusion requirements are greater in anemic patients who undergo surgery without pre-op anemia treatment, such as erythropoiesis stimulating agents, or administration of iron supplementation, by either oral or intravenous routes.

Blood sparing techniques such as minimally invasive surgical techniques, use of smaller lumen extracorporeal or intravascular devices, fibrin sealants, intraoperative tourniquets, or administration of anti-fibrinolytics reduce intra-operative blood loss.

Increasing individual tolerance to anemia, particularly in patients who are not at risk for cardiac events, and identification of appropriate transfusion triggers are strategies implemented to reduce the frequency of ad-hoc transfusion.

Current practice indicates a tendency to transfuse if hemoglobin level is below 80g/L, and to transfuse two units of blood per treatment, although this is not clinically supported. The decision to transfuse should be patient specific, based on assessment of clinical symptoms and with careful consideration of co-morbidities.

Patient blood management plans have successfully been shown to reduce health care facility costs associated with transfusion, reduce transfusion related risk to patients, and ensure that blood supply is available for those in greatest need.

Daphne Osborne, MN RN, is the Transfusion Practice Coordinator with the NL Provincial Blood Coordinating Program.

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