Transfusion medicine

Quality and compliance

Patient blood management

Editorial Board Member: Mrigender Singh Virk, M.D.
Deputy Editor-in-Chief: Patricia Tsang, M.D., M.B.A.
Chinelo P. Onyenekwu, M.D.
Melissa R. George, D.O.

Last author update: 26 June 2023
Last staff update: 26 June 2023

Copyright: 2023,, Inc.

PubMed Search: Patient blood management transfusion medicine

Chinelo P. Onyenekwu, M.D.
Melissa R. George, D.O.
Page views in 2024 to date: 74
Cite this page: Onyenekwu CP, George MR. Patient blood management. website. Accessed May 19th, 2024.
Definition / general
  • Multidisciplinary approach targeted toward optimization of patient care while employing the best available evidence in patients requiring blood transfusion (AABB: Technical Manual of the American Association of Blood Banks, 20th Edition, 2020)
  • Peer developed definition by representatives of various patient blood management (PBM) organizations: "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" (Anesth Analg 2022;135:476)
Essential features
  • Revolves around quality of care improvement, patient safety and transfusion economics
  • Involves a transdisciplinary and multistrategic approach
    • Blood conservation
    • Optimization of red cell mass
    • Incorporating patient oriented decision making
    • Evidence based practice to achieve improved patient outcomes
  • Applied to both surgical and nonsurgical patients
  • Surgical patient blood management addresses perioperative and intraoperative care
  • A strong PBM program requires
    • Adequate funding and resources
    • Education and strategic involvement of healthcare providers
    • Ongoing research
      • Continuous monitoring and feedback
      • Use of appropriate quality indicators
    • Public and patient awareness
  • Patient blood management (PBM)
  • Blood management (no longer recommended)
  • Association for the Advancement of Blood and Biotherapies (formerly the American Association of Blood Banks) (AABB)
  • Bloodless medicine and surgery (BMS)
  • Society for the Advancement of Patient Blood Management (SABM)
  • International Foundation of Patient Blood Management (IFPBM)
Diagrams / tables

Contributed by Chinelo P. Onyenekwu, M.D.
PBM toolbox

PBM toolbox

PBM program

PBM program

History / evolution
ABC toolbox
  • ABC toolbox of PBM from the IFPBM SABM workgroup summarizes practical principles of PBM to target 3 areas (Anesth Analg 2020;131:74)
    • Anemia and iron deficiency
    • Blood loss and bleeding
    • Coagulopathy management
Approaches related to surgery
  • Preoperative strategies
    • Hemoglobin management / anemia clinic
    • Minimize blood loss / manage coagulation
      • Multidisciplinary approach involving early identification of patients at risk of blood loss
      • Administration of adjuvant therapy for blood loss prevention
      • Review of anticoagulants, antithrombotic and antiplatelets
      • Plan to attenuate medication associated bleeding risks to decrease blood loss
      • Address reversal or bridging of anticoagulant and antiplatelet therapies
      • Balance risk of bleeding with need for antithrombotic therapy
    • Autologous blood donation
      • Option for patients with multiple alloantibodies and rare blood types
      • Requires adequate patient evaluation and advance planning
      • Usually only allowed for 1 - 2 unit collections
      • Can collect up to 72 hours before the surgery
      • Iron replacement therapy should be instituted prior to donation
      • Autologous donors are more likely to receive a blood transfusion (including allogeneic) due to anemia induced by blood donation (Spine 2011;36:E1736, AABB: Technical Manual of the American Association of Blood Banks, 20th Edition, 2020)
    • Maximum surgical blood order schedule (MSBOS)
      • Lists surgical procedures likely to require blood and provides the average number of units required based on institution specific data
      • Serves as a guide for preoperative blood orders
      • Improves blood ordering processes and reduces costs when data driven (Anesthesiology 2014;121:501)
      • Prevents wastage and potential red blood cell (RBC) unit outdating due to overordering
      • Increases likelihood of timely availability of RBC units for patients requiring blood transfusion
  • Intraoperative strategies
    • Minimizing blood loss
    • Cell salvage
      • Autologous blood recovery gained popularity in the HIV era in the 1980s
      • Cell Saver autologous blood recovery system (Haemonetics) collects and washes shed blood during blood loss procedures
      • Collection and washing of shed blood occur in a receptor and centrifuge
      • Concentrates the red cells
        • Product with a hematocrit comparable to packed RBCs from the blood bank
        • Lacks platelets and plasma
      • Economically advantageous when one or more units are reinfused in the patient
      • Eliminates the risk of alloimmunization
      • Dilutional coagulopathy may occur in the event of reinfusion of several units
      • Inefficient blood collection can occur when multiple suction sources are utilized intraoperatively (e.g., diverting some blood to the waste suction instead of the Cell Saver)
      • Devices should be validated
      • Process of blood collection and reinfusion requires strict process and document control
      • PBM program oversees the training and periodic competency assessment of equipment operators and ensures continuous compliance with stipulated standards
    • Normovolemic hemodilution
      • Acute normovolemic hemodilution (ANH): phlebotomy and collection of whole blood in a short period prior to the blood losing aspect of a surgery
      • Appropriate replacement of collected blood volume with intravenous fluids
      • Collected blood may be separated into the various blood components for targeted component replacement as needed
      • Typically, ANH is under the purview of the anesthetist
      • Patient selection considers factors such as
        • Anticipated blood loss
        • Type of procedure
        • Patient comorbidities which may compromise safety or limit efficacy
      • 3 conditions are required for effective ANH
        • Preoperative hematocrit that is adequate to tolerate the phlebotomy and hemodilution
        • Substantial anticipated blood loss from surgery
        • Volume of collected blood will make a significant change when transfused
      • Rules surrounding blood units collected by ANH (AABB Guidance: Standards for Perioperative Autologous Blood Collection and Administration, 10th Edition, 2022)
        • Storage in the operating room (OR) at room temperature (~22 °C [72 °F]) for up to 8 hours) (AABB Guidance: Standards for Perioperative Autologous Blood Collection and Administration, 10th Edition, 2022)
        • Can have shelf life extended by the medical director of the intraoperative autologous blood service on a case by case basis
        • Withdrawn units of blood not used within 8 hours can be stored at 1 - 6 °C (34 - 43 °F) for up to 24 hours, if cold storage began within 8 hours of drawing that blood for ANH
        • Units removed from the OR must be labeled "for autologous use only" and cannot be added to the blood bank's regular inventory
        • Usually reinfused in the reverse order of collection
        • First unit contains highest Hgb and contains the most platelets and undiluted coagulation factors reinfused last
        • Final infusion of the most concentrated unit occurs when bleeding has slowed down
        • May change the sequence to ensure that the first unit(s) is (are) are administered within 8 hours of collection and not wasted
      • Combination of ANH with other perioperative approaches to blood conservation leads to increased efficacy
      • PBM program monitors and evaluates ANH utilization, adverse events and the impact on allogeneic transfusion (AABB: Technical Manual of the American Association of Blood Banks, 20th Edition, 2020, SABM: Administrative and Clinical Standards for Patient Blood Management Programs, 5th Edition, 2019)
        • Analyzes various indicators
          • Volume of blood collected and reissued
          • Expenditures
          • Savings
    • Use of hemostatic and antifibrinolytic agents
      • Common topical hemostatic agents used include thrombin, fibrin, gelatin and collagen (BMC Surg 2018;18:68)
      • Commercially available products containing human thrombin combined with bovine gelatin in a ratio optimized for hemostasis are also available
      • Antifibrinolytics, such as tranexamic acid (off label use) and aminocaproic acid, may be used
      • Use of antifibrinolytics reduce surgical bleeding, decrease transfusion and costs of various major surgeries (Orthop Traumatol Surg Res 2012;98:477, N Engl J Med 2017;376:136)
      • There is no apparent associated increase in the risk of deep venous thrombosis
      • Systemic therapy with tranexamic acid is contraindicated in uncontrolled seizures or an active thrombotic event
      • Topical application to joint capsules may be utilized in orthopedic surgeries (J Arthroplasty 2013;28:1473, AABB: Technical Manual of the American Association of Blood Banks, 20th Edition, 2020)
      • Efficient coagulation testing must be in place for adequate evaluation of an actively bleeding patient and rapid diagnosis of the etiology of coagulopathy
    • Point of care testing (POCT)
      • Instruments for rapid assessment of actively bleeding patients are available at the points of care such as in the OR and the cardiovascular intensive care units
      • Examples include
        • Thromboelastography (TEG) (Haemonetics)
        • Rotational thromboelastometry (ROTEM) (Instrumentation Laboratories)
        • Devices allow visibility of the evolving clot formation in real time for rapid clinical decision making
        • Protocols exist for decisive interventions in actively bleeding patients
        • Use of POCT may prevent unnecessary blood transfusions (Shock 2021;56:52)
    • Minimally invasive surgical methods
      • Newer surgical approaches including robotic, laparoscopic and endovascular techniques are associated with markedly decreased blood requirement
  • Postoperative strategies
    • Cell salvage / blood recovery
    • Minimization of phlebotomy blood loss
      • Laboratory testing in critically ill patients is associated with a daily loss of 1% of circulating blood volume
      • Patients who have undergone cardiac surgery may lose up to 2 units of blood to laboratory testing during prolonged hospital stays (Ann Thorac Surg 2015;99:779)
      • Several modalities may be employed for reduction of phlebotomy related blood loss including (AABB: Technical Manual of the American Association of Blood Banks, 20th Edition, 2020)
        • Use of smaller blood collection tubes
        • Elimination of redundant routinely ordered laboratory tests
        • Use of inline sterile waste return devices
Overarching approaches
  • PBM program oversees staff education on
  • Transfusion triggers
    • Packed red blood cells (pRBCs) (Choosing Wisely: A Watershed Moment in Health Care [Accessed 21 June 2023])
      • Do not transfuse more units of RBCs or other components than absolutely necessary
        • Restrictive threshold (7.0 - 8.0 g/dL) should be used for most stable patients without evidence of impaired tissue oxygenation
        • Threshold of 8.0 g/dL is appropriate for patients with pre-existing cardiovascular disease
        • Transfusion decisions should be influenced by clinical symptoms and hemoglobin
        • Single unit red cell transfusions should be the starting point for nonbleeding, hospitalized patients
        • Additional units should only be given after reassessment of clinical symptoms and lab values
      • Do not transfuse RBCs for iron deficiency without hemodynamic instability
        • Better options include oral or intravenous iron supplementation
      • Do not perform serial blood counts on clinically stable patients
        • Multiple blood draws can cause iatrogenic anemia and promote unnecessary transfusions
      • Do not transfuse O negative blood except to O negative patients in emergencies for women of childbearing potential with unknown blood group
    • Plasma (FFP, thawed plasma, PF24, etc.) (Society of Hospital Medicine: Anemia Prevention and Management Program Implementation Guide, 2015)
      • Do not transfuse plasma to correct coagulopathy in nonbleeding patients
      • Do not routinely use blood products to reverse vitamin K antagonists (VKA); e.g., warfarin
      • Reversal of VKA should be based on the international normalized ratio (INR) plus bleeding risks and urgency of reversal
      • INR < 4.5 without bleeding
        • Hold warfarin if not emergent
        • Oral or IV vitamin K (5 - 10 mg)
        • 4 factor prothrombin complex concentrate (4F PCC), a hemostatic concentrate of at least 4 coagulation factors (factors II, VII, IX and X), for reversal < 2 hours
        • Plasma (15 mL/kg) if 4F PCC is not available
      • INR 4.5 - 10 without bleeding
        • Hold warfarin
        • IV vitamin K (5 - 10 mg) for more rapid reversal
        • 4F PCC for reversal < 2 hours
        • Plasma (15 - 30 mL/kg) if 4F PCC is not available
      • INR > 10 without bleeding
        • Hold warfarin
        • IV vitamin K (5 - 10 mg)
        • 4F PCC for reversal < 2 hours
        • Plasma (20 - 30 mL/kg) if 4F PCC is not available
      • Serious life threatening bleeding at any INR
        • IV vitamin K 10 mg
        • 4F PCC for reversal < 2 hours
        • Plasma (20 - 30 mL/kg) if 4F PCC is not available
    • Platelets (Choosing Wisely: A Watershed Moment in Health Care [Accessed 21 June 2023], Ann Intern Med 2015;162:205)
      • Do not transfuse platelets without laboratory guidance outside of fixed ratio massive transfusions
      • Prophylactic transfusion for a platelet count of < 10 x 109 cells/L to reduce risk of spontaneous bleeding
        • Single apheresis platelet unit or equivalent
        • Half doses may be equally effective, especially in times of inventory shortage
      • Prophylactic transfusion for a platelet count of < 20 x 109 cells/L for elective placement of central venous catheter
      • Prophylactic transfusion for elective diagnostic lumbar puncture with a platelet count < 50 x 109 cells/L
      • Prophylactic transfusion for major elective nonneuraxial surgery with a platelet count < 50 x 109 cells/L
      • No indication for prophylactic transfusion for patients who are nonthrombocytopenic undergoing cardiac surgery with cardiac bypass
      • Not enough evidence for or against transfusion for patients on antiplatelet therapy with intracranial hemorrhage
Ongoing interventions
  • Education
    • Identify key stakeholders (physicians, nurses, administrators, laboratorians, phlebotomists)
      • Chief medical officer: administrative / resource support
      • Chief quality / safety officer: administrative / resource support
      • Chief executive / financial officer: resource allocation
      • Anesthesiology: optimization of pre / peri / postoperative hemostasis and hemoglobin
      • Surgery: surgical techniques to minimize/manage bleeding
      • Hematology oncology: optimize hemostasis in patients with cancer and hematologic disorders
      • Clinical laboratory: appropriate laboratory utilization
      • Blood bank: blood product stewardship
      • Pharmacy: role in appropriate use of pharmacologic interventions that decrease blood usage (vitamin K, parental iron, tranexamic acid)
      • Information technology: make changes in electronic medical record (EMR) such as computerized provider order entry (CPOE) and best practice alerts
  • Monitoring
    • Determine what data is available from the EMR versus the blood bank computer system
    • Pharmacy is a source of data on iron use and adjuvant medications to optimize hemostasis
    • Determine if information obtained electronically is reliable for if additional chart search is necessary
  • EMR interventions
    • Clinical decision support (CDS)
      • Reduction of errors and adverse events
      • Promotion of best practices
        • Quality and safety
        • Appropriate utilization
        • Cost reduction
        • Cost profile improvement
    • Use evidence based recommendations (J Am Med Inform Assoc 2018;25:1556)
      • Computerized provider order entry (CPOE): embed best practices into EMR
      • Alerts: automatic message to communicate essential information to provider at time of order
        • May feature best practice guidelines or prompting questioning of order
        • Passive alert: information is presented but does not interrupt the user workflow, no user interaction required
        • May lead to alert fatigue and providers ignoring the messaging
      • Overrides may pose dangers
      • Hard stop: user is either prevented from taking an action altogether or allowed to proceed only with the external override of a third party
      • Soft stop: user is allowed to proceed against the recommendations presented in the alert as long as an active acknowledgement reason is entered
Case reports
  • 101,794 patients ages 18 years and older involved in a patient blood management monitoring and feedback program (Transfusion 2015;55;2807)
  • Impact of a patient blood management monitoring and feedback program on allogeneic blood transfusions and related costs with 213,882 adult patients (Anaesthesia 2019;74:1534)
Sample assessment & plan
  • Assessment: A 68 year old woman who observes a vegan diet has a past medical history significant for obesity and osteoarthritis. She is referred by her primary care physician to the orthopedic surgery clinic for a 3 year history of worsening right knee pain. On assessment for a right total knee replacement, her complete blood count showed a hemoglobin of 9.8 mg/dL (12 - 16 g/dL), mean corpuscular volume (MCV) of 72 fL (79 - 98 fL), mean corpuscular hemoglobin concentration (MCHC) of 28 g/dL (32 - 36 g/dL) and red cell distribution width (RDW) of 17.1% (11.1 - 14.9%). Iron studies showed a low serum iron and ferritin with an increased transferrin iron binding capacity. Vitamin B12 and folate levels were within normal limits.
    • Right knee osteoarthritis
    • Obesity
    • Iron deficiency anemia
  • Plan:
    • Schedule for right total knee replacement in 8 weeks
    • Stool for occult blood, ova and parasites (negative results)
    • Commence trial of oral iron therapy for 4 weeks
    • Repeat hemoglobin and iron studies in 4 weeks
      • Repeat tests at the 4 week follow up visit showed a hemoglobin of 11.2 g/dL, the surgeon deemed this adequate response with no plan to use adjuvant erythropoietic agents
  • Follow up assessment and plan:
    • Resolve anemia
    • Continue oral iron therapy
    • Repeat hemoglobin 1 day prior to planned surgery: 12.5 g/dL
    • Proceed with surgery as planned; administer intraoperative fibrinolytic / hemostatic agents
    • Patient underwent knee replacement surgery without administration of intraoperative tranexamic acid and use of topical hemostatic agents. She had a moderate amount of intraoperative blood loss with a postoperative hemoglobin of 10.3 mg/dL. She was, however, stable and was discharged to a rehabilitation facility.
  • Postoperative plan:
    • Continue oral iron therapy and rehabilitation therapy
    • Follow up in 4 weeks at anemia clinic
Board review style question #1
You are the Medical Director of Transfusion Medicine at your hospital. You are currently working with Information Technology to implement some updates to the clinical decision support in your electronic medical records (EMR) for the ordering of blood products. Which best practice recommendations would you embed in the orders for packed red blood cells (pRBCs)?

  1. 1 unit pRBCs are not normally recommended; 2 should always be given
  2. Additional units of pRBCs should be given without checking hemoglobin (Hb) in stable patients to avoid unnecessary blood draws and iatrogenic anemia
  3. pRBC transfusion is not recommended in hemodynamically unstable cardiac patients with evidence of impaired tissue oxygenation until Hb < 7.0 g/dL
  4. pRBC transfusion is recommended in hemodynamically stable patients with evidence of impaired tissue oxygenation and Hb < 7.0 g/dL
Board review style answer #1
D. pRBC transfusion is recommended in hemodynamically stable patients with evidence of impaired tissue oxygenation and Hb < 7.0 g/dL. Answers A and B are incorrect because 1 unit pRBC transfusion is recommended for most indications and stable patients, followed by rechecking of hemoglobin for transfusion response. Answer C is incorrect because for patients who are hemodynamically unstable and have pre-existing cardiovascular disease, the hemoglobin threshold for transfusion is often higher at 8.0 g/dL rather than the more restrictive < 7.0 g/dL.

Comment Here

Reference: Patient blood management
Board review style question #2
A patient is scheduled to undergo an elective central venous catheter insertion. The patient is not taking anticoagulants and has a reasonable hemoglobin level of 12.2 g/dL. What is the recommended platelet count transfusion threshold in this scenario?

  1. < 10 x 109 cells/L
  2. < 20 x 109 cells/L
  3. < 50 x 109 cells/L
  4. < 100 x 109 cells/L
Board review style answer #2
B. < 20 x 109 cells/L. Insertion of a central venous catheter and otherwise stable patient carries a recommendation for a platelet transfusion threshold of at least 20 x 109 cells/L. Answers A and C are incorrect because prophylactic platelet transfusion is recommended to avoid spontaneous bleeding in patients with a platelet count of < 10 x 109 cells/L and for patients who are to undergo lumbar puncture with platelet count of < 50 x 109 cells/L, respectively. Additionally, patients about to undergo neuroaxial surgical procedures should be transfused for platelet count < 50 x 109 cells/L. Answer D is incorrect because it refers to the older recommendation of transfusing for a platelet count of < 100 x 109 cells/L for patients undergoing any sort of neurosurgery; however, there is not much high quality evidence to support that practice.

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Reference: Patient blood management
Board review style question #3
A 40 year old woman with a history of heavy menstrual bleeding due to uterine fibroids is scheduled for elective hysterectomy. Her hemoglobin is 9.7 g/dL and her iron studies are consistent with iron deficiency anemia. She is otherwise healthy. Which of the following interventions is most likely to decrease the likelihood of allogeneic transfusion during her surgery?

  1. Acute normovolemic hemodilution during the surgery
  2. Preoperative anemia clinic management with correction of iron deficiency scheduled well in advance of her date of surgery
  3. Provider education with best practice guideline alerts in the EMR regarding appropriate hemoglobin thresholds for pRBC transfusion
  4. Use of point of care devices such as thromboelastography during surgery to assess clot formation in real time
Board review style answer #3
B. Preoperative anemia clinic management with correction of iron deficiency scheduled well in advance of her date of surgery. In advance of elective hysterectomy, optimization of hemoglobin with iron therapy would be the most appropriate PBM intervention and is very achievable if the surgery is scheduled several weeks in advance. Answer A is incorrect because acute normovolemic hemodilution is not normally used during procedures such as hysterectomy, which are not usually associated with multiple unit red blood cell loss. Answer C is incorrect since best practice alerts may be helpful in the stable in patient setting but are less likely to be helpful to aid decision making during surgeries. Answer D is incorrect because point of care devices such as thromboelastography are typically employed during high blood loss cases such as cardiothoracic surgery, trauma or liver transplant. They are not typically employed during routine hysterectomy cases.

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Reference: Patient blood management
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