Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults.

Abstract

Patient Blood Management (PBM) is a holistic approach to the management of blood as a resource for each, single patient; it is a multimodal strategy that is implemented through the use of a set of techniques that can be applied in individual cases. Indeed, the overall outcome resulting from the implementation of PBM cannot be fully appreciated and explained simply by summing the effects of the single strategies and techniques used, since these can only produce the expected optimal outcome if used in combination1. PBM is, therefore, a patient-centred, multiprofessional, multidisciplinary and multimodal approach to the optimal management of anaemia and haemostasis (also during surgery), to limiting allogeneic transfusion needs in the peri-operative period, and to appropriate use of blood components and, when relevant, plasma-derived medicinal products2. The concept of PBM is not centred on a specific pathology or procedure, nor on a specific discipline or sector of medicine, but is aimed at managing a resource, “the patient’s blood”, shifting attention from the blood component to the patient who, therefore, acquires a central and pre-eminent role3,4. PBM combines the dual purposes of improving the outcomes of patients and reducing costs, being based on the patient rather than on allogeneic blood as the resource. For this reason, PBM goes beyond the concept of appropriate use of blood components and plasma-derived medicinal products, since its purpose is to avoid or significantly reduce their use, managing, in good time, all the modifiable risk factors that can lead to a transfusion being required5. These aims can be achieved through the so-called “three pillars of PBM” (Table I)5, which are crucial for making the paradigmatic shift that characterises the innovative, patient-centred approach: (i) optimising the patient’s erythropoiesis; (ii) minimising bleeding; and (iii) optimising and exploiting an individual’s physiological reserve to tolerate anaemia5. Each of these three key points is a strategic response to clinical circumstances that can cause adverse outcomes and necessitate the use of allogeneic transfusion therapy, namely anaemia, blood loss and hypoxia, respectively. Table I The three pillars of Patient Blood Management (modified from Hofmann A et al.5). PBM is, therefore, intended to guarantee all patients a series of personalised programmes, based on surgical requirements and the characteristics of the patients themselves, with the dual purposes of using allogeneic transfusion support appropriately and reducing the need for this resource. For this reason, PBM requires multidisciplinary and multimodal strategies to systematically identify, evaluate and manage anaemia (boosting, if necessary, individual physiological reserves) and to avoid or minimise blood losses. It seems necessary to produce specific national standards. In fact, in the USA, PBM is the object of attention from the Association for Advancing Transfusions and Cellular Therapies (formerly known as the American Association of Blood Banks - AABB) which recently published the first edition of “Standards for a Patient Blood Management Program” precisely with the aim of supplying healthcare structures with solid elements for the standardisation of procedures and activities for implementing and/or optimising a PBM programme. The Society for the Advancement of Blood Management (SABM), also in the USA, has published a second edition of “Administrative and Clinical Standards for Patient Blood Management Programs”6 and the Joint Commission has published seven parameters for measuring the performance of healthcare structures in the field of PBM7.