Patient Blood Management  – What Is It?

A new catchword: Patient Blood Management – what is it?
"We provide an overview of the principles of blood management: the appropriate use of blood and blood components, with a goal of minimizing their use."  -Lawrence T. Goodnough, MD; Aryeh Shander, MD.

Overview
Many professionals in the field of Blood Conservation have struggled for some years to define Blood Conservation and describe what it is in a simple and understandable way in order that both the general public and other medical professionals outside the field of Blood Conservation can easily grasp what is as well as what it is not.

Blood Conservation finds its roots in Bloodless Medicine which was developed for individuals who, for reasons of religious conscience, did not want to have blood transfusions as an intervention in there medical care. For years the overwhelming number of patients who were looking for this treatment formed the core group of the recipients of medical care without allogeneic blood transfusion.

From Bloodless Medicine to Blood Conservation
As the benefits of Bloodless Medicine became clearer and clearer and the superior outcomes of patients who chose other options besides blood transfusion were manifest and published in medical journals others in the general population began to question the then current standards of medicine and began to seek a modified version of Bloodless Medicine – Blood Conservation. What is the difference?

Patients seeking out Bloodless Medicine – whom we will call Bloodless Patients - absolutely refuse blood transfusion as a medical intervention under any and all circumstances. Most patients do not take the same view – but because they see the clear benefits of not accepting allogeneic blood they are interested in avoiding a blood transfusion if at all possible. But when their medical situation seems to demand another course they will accept a blood transfusion. We can call this group Blood Conservation Patients for clarity.

As the numbers of  of Blood Conservation Patients grew it was clear to administrators and hospital clinicians that their old programs, many of which were specifically designed for Bloodless Patients and were called Bloodless Surgery and Medicine Programs, needed to be redefined since their patient base was shifting from treating not only the needs of Bloodless Patients but of Blood Conservation Patients as well.

From Blood Conservation to Patient Blood Management
From this change came  the phrase Blood Conservation. But this phrase has not been completely acceptable to everyone in the medical field. So the phrase Patient Blood Management was born. By and large Patient Blood Management Programs are Blood Conservation Programs and like other Blood Conservation Programs act as umbrella programs which encompasses Bloodless Medicine and Surgery as a  sub-specialty or sub-field.

Since the goal of Blood Management goes far beyond simply conserving a patient's blood in the surgical or postoperative period Patient Blood Management is a more all encompassing and accurate description of what physicians are trying to accomplish when they treat their patients. As an example, it has recently come to light to such groups as the American Society for the Advancement of Blood Management that Blood Management must include Anemia Management as well.

Proper care for a patient means more than conserving their blood in an operating room. By treating anemic surgical patients a needless blood transfusion can be avoided. And the cost of treating anemia is a fraction of the cost of administering blood.

From this one example it can be seen that the phrase Blood  Management is superior to Blood Conservation. And since this holistic approach is patient oriented the phrase Patient Blood Management is seen as one that more accurately describes the goals and objectives of physicians treating both the Bloodless Patient and the Blood Conservation Patient.               

"Proper blood management must include anemia management."
-Irwin Gross, MD, Eastern Maine Medical Center

Blood Conservation or Total Blood Avoidance?
Not all patients, doctors and hospitals believe that the total avoidance of blood in elective surgery is possible at this time. Though many say that it is doable, not all believe it; or to put the situation in another light: many experts know and are solidly convinced from their own medical and surgical experience that any elective surgical procedure can be done without administering a blood transfusion but they recognize that many other patients, doctors and hospital administrators do not accept this view. So they take a practical and pragmatic approach. They support Blood Conservation on one hand and advocate Total Blood Avoidance on the other; this is a sensible and realistic approach from their standpoint.

Many are committed to Total Blood Avoidance. Why? "Immunomodulation [repression of the immune system] may have long-lasting effects, even in a patient who has received a single unit of allogenic blood. Data supporting this association are even stronger than data linking cigarette smoking to lung cancer."  -Accessmylibrary - Shander, Ozawa and Teekam.

A single unit of allogenic blood has extremely negative repercussions. This is well recognized but not publicized by the Blood Industry nor by world leaders who promote blood donation and transfusion instead of transfusion-free surgery.

Over ten years ago the National Institutes of Health recognized the risks associated with a single unit of transfused homologous blood and recommended that the medical community seek other alternatives. Largely this advice has been ignored while globally blood donation is promoted.

A look at an official Patient Blood Management program guideline
The following is a quote from an official Australian Government website for their Blood Matters campaign: Blood Matters

"Patient blood management encompasses a holistic approach to the use of blood for an individual patient.  It uses the premise of 'why transfuse' rather then 'why not' and hence the need to balance carefully the benefit and any potential harm.  Transfusion avoidance or minimisation stems from the understanding that blood and its components are biological products with effects that are still not fully understood, in particular, the potential for unwanted effects."

The site then refers the reader to a .pdf document (Blood Management) it says:

"Blood management is a process of using blood and blood products appropriately when required and strategies to reduce or minimise the need for a blood transfusion."

The document, which is a .pdf version of a brochure, goes on to do an excellent job of presenting many strategies for avoiding a blood transfusion. But again we see that from their standpoint a pragmatic approach is taken; they promote blood conservation on one hand while supporting Total Blood Avoidance on the other.

An administrator's situation
Administrators of Patient Blood Management Programs certainly see that the public as a whole is not ready for the idea of Total Blood Avoidance in elective surgery. This acceptance is years or decades away. The approach, then, is to both to avoid the need for homologous blood transfusions (blood from another patient) for those patients committed to Total Blood Avoidance and to minimize blood loss for those patients who are not. So, the realistic approach is: advocate Total Blood Avoidance for those who wish it, promote Blood Conservation for those who don't.

The Bloodless Patient
In the meantime the Bloodless Patient (a patient who wants to completely avoid a blood transfusion) must himself be pragmatic in his approach. Light years of progress have been achieved in the past decade by these programs (known by their various names: Blood Conservation Programs, Blood Management Programs, Patient Blood Management Programs) – all are in place and offer many excellent Total Blood Avoidance Strategies in addition to their goals of reducing the need for blood transfusions. But they must take the two handed approach: promote blood conservation or 'minimisation' on one hand and advocate Bloodless Medicine on the other. These programs, the people that administrate them and those that implement them will generally work with the Bloodless Patient. They are there to help and generally will be glad to respect a Bloodless Patient’s wishes and their rights to choose Total Blood Avoidance.

The Bloodless Patient's responsibility
The responsibility of the Bloodless Patient of course, is to declare their position without taking a pit bull approach and work with these programs. Most of them have legal forms and documents available that will allow a Bloodless Patient to work within these program. If they refuse, the Bloodless Patient will normally have a legal recourse he can pursue or he can simply look for another hospital that has a more reasonable approach.

A hospital's responsibility in Patient Blood Management
Likewise, a hospital has a responsibility to make clear to prospective patients what their program entails. Likely it is the case that all personal associated with a Patient Blood Management Program realize that there are two types of patients seeking their help.

The first is the Bloodless Patient who absolutely and unequivocally does not want homologous blood products transfusions – usually on the basis of religious conscience. The second is the patient who would like to avoid a blood transfusion if possible but is not as committed as the Bloodless Patient.

However, given all the known risks associated with blood products, it is the ethical responsibility of a hospital to clearly define all the many risks involved in accepting homologous blood products and not just a few of them. This should include the increased mortality rates of patients who receive blood products – that is, the figures relating to the increased number of patients that die five and ten years after a blood transfusion as opposed to those that do not.

Summary
Patient Blood Management may not be what a Bloodless Patient is seeking. However, many of the methods used in these programs can be taken one step further and can easily accommodate the wishes of the patient who wants a totally bloodless or transfusion-free procedure. Likely, there a physicians and surgeons on staff who wholeheartedly advocate Total Blood Avoidance but are working within the constraints of a specific hospital's Blood Management Program and who are more than willing to work with the Bloodless Patient.

New leaders in Patient Blood Mangement?
According to this news report "when a patient first checks in to the hospital they will automatically be told about the benefits of bloodless surgery." And "Northeast Baptist Hospital says… it is converting the entire hospital into a bloodless facility, with a goal of performing 90% of its surgeries without blood."  -mastercontrol.com

Northeast Baptist Hospital in Austin, Texas, USA is one of a few hospitals in the world to offer Patient Blood Management to all of its patients and to promote it as the preferred option to their patients as well. (As a general rule other Blood Conservation Programs operate as an adjunct to a hospital's normal surgical programs. Usually a wing, a floor or a department of a hospital is set aside for a Bloodless Surgery and Medicine Program or Blood Conservation Program which will usually make up a smaller percentage of the hospital's surgical activity).

Northeast is offering Patient Blood Management  as the preferred option to patients. The hospital is thus striving to educated those in the general public who may be totally uneducated and unaware that Bloodless Conservation and Blood Avoidance are viable options.

A new era in Bloodless Surgery and Medicine?
The effort s on the handful of hospitals taking this expanded approach opens an entirely new chapter in the field of Blood Conservation - a chapter that other hospitals will likely be studying and weighing carefully. What Northeast has done may turn out to be as significant as Dr. Denton Cooley's first Bloodless Open Heart Surgery in 1962. At the time his move was stunning and brilliant, but who could have foreseen then the doors that it would open? Perhaps we will be looking back in time thirty years from now and be extolling hospitals like Northeast in the same way the world honors Dr. Cooley now.

Additional information
What do the experts say about blood donation oversees?
"Studies show that blood donated by altruistic volunteers is much safer than blood donated by paid donors or family and friends of patients who need blood.  Because of chronic shortages of blood in Latin America and the Caribbean, however, most countries depend on family replacement donation for the bulk of their blood supply. Changing this practice is the most important blood safety challenge facing the region today."

"Every day in Latin America, hospitals tell their patients they must recruit friends and family members to donate blood before the patient undergoes a procedure. The practice, known as family replacement, is considered essential. Unfortunately, like blood from paid donors, blood from family replacement donors is less safe than blood from those who donate for nothing more or less than the general public good."

"Both replacement and paid donors tend to hide risky behaviors from blood bank personnel. Paid donors don't want to hurt their chances of earning some cash, while replacement donors may feel pressure to comply with family requests to give blood but be embarrassed to admit risky behaviors to blood bank personnel. In some cases, families have trouble recruiting donors and end up paying donors with cash. In contrast, voluntary donors whose only motivation is to give the gift of blood have no reason to give false answers to screening questions."

"Countries in Latin America and the Caribbean, however, rely heavily on paid and replacement donations." -Pan American Health Organization

"Less than 25 per cent of blood donations in [India] are voluntary. (70 per cent) is that of replacement donation, mainly from family members or relatives of patients, while 10 per cent comprise paid donors."  -thenews.com - India

"Health experts around the globe emphasize on screening of donated blood for HIV, hepatitis B & C and Syphilis prior to transfusion, but in 31 countries, including Pakistan, not all donated blood is tested for one or more of these infections."  -thenews.com - Pakistan

Patient Blood Management in foreign countries is vastly different from a Patient Blood Management Program in the United States and even different from conventional western hospitals. Traveling can be a risk in case of an emergency medical situation. Even if a person is not totally committed to avoiding blood products because he feels the 'blood is safe' he should reconsider this position when he travels.

What can be done to prevent a blood transfusion oversees? Carry an Advance Medical Directive CARD and FORM.

"Worldwide, 5–10% of cases of HIV infection are transmitted through the transfusion of infected blood and blood products."  -Press release World Health Organization – Regional office for Europe, 7 April 2000

"As of 2003 there is no way to screen potential blood donors for four diseases caused by parasites (malaria, babesiosis, Chagas' disease, and Lyme disease) and one disease caused by prions (Creutzfeldt-Jakob disease), even though the Centers for Disease Control (CDC) have recorded cases of transfusion-transmitted malaria, babesiosis, and Chagas' disease in the United States."  -Encyclopedia of Surgery

This is a question listed on a third world website:
What laboratory tests are performed in blood bank for each bag of collected blood?

The answer: "Jaundice (Hepatitis B & C). Malaria. HIV (AIDS) test. Venereal disease (STD). Blood Group. Before issuing blood, compatibility tests (cross matching) are done."

These are the only things screened for in the country in question.

What do the experts say about blood and blood transfusions?
"The average unit of blood remains in cold storage for more than one-half the allotted 41 days and thus provides little improvement in tissue oxygenation when infused."  -Accessmylibrary - Shander, Ozawa and Teekam

"Patients should not be prepared for surgery with transfusion under any circumstances." -Irwin Gross, Eastern Maine Medical Center

"Avoid transfusion regardless of the level of preoperative anemia. Allogeneic blood transfusion should be avoided whenever possible, not only because of associated risks but also because transfusion has not been proven to improve postoperative outcomes."  -National Anemia Action Council

"Banked blood has little oxygen-delivering ability."  -Accessmylibrary - Shander, Ozawa and Teekam