Transfusion medicine

• 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)

Contributed by Chinelo P. Onyenekwu, M.D.

• Increasing demand for quality improvement in healthcare
• Transfusion associated risks
• Economic benefits of decreased transfusion
• Advancement of evidence based practice
• Patient centered care, autonomy and satisfaction
• Excessive use of blood and blood components
• Increasing frequency of blood shortage (AABB: Technical Manual of the American Association of Blood Banks, 20th Edition, 2020)

• 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

• AABB: Building a Better Patient Blood Management Program, 2015, AABB: Standards for a Patient Blood Management Program, 3rd Edition, 2021

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

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.

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Reference: Patient blood management

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

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

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

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