Perioperative Anemia Management.

Anemia is increasingly recognized as an interventional hematological target in patients before major surgery. Preoperative anemia increases the need for perioperative blood transfusion, and there is now a well-recognized association with increased patient complications, length of hospital stay, and worse outcomes. Patient Blood Management (PBM) is a World Health Organization endorsed, evidence-based management bundle of care in transfusion hemostasis that focuses on three main aspects: anemia management, prevention of blood loss, and appropriate transfusion practice. Implementation of PBM guidelines has been accompanied by reduced transfusion needs and improved patient outcomes. In a patient presenting with preoperative anemia or at risk of transfusion, this should initiate a program of PBM that manages the patient through the entire operative period. We review the current evidence on the three pillars of PBM and highlight those aspects with the strongest evidence in support of their impact.

Development and feasibility of a Patient Blood Management implementation programme in vascular surgery.

Vascular surgery is the largest (non-cardiac) user of blood transfusion which is associated with increased risk to patients. Patient Blood Management (PBM) is a quality improvement programme in transfusion medicine involving educational change and recommendations through preoperative, operative, and postoperative surgery. We wished to assess the feasibility to implement a PBM programme in vascular surgery. A multidisciplinary programme was developed at a vascular unit by PBM experts. The PBM programme involved a series of educational lectures, consultations, and discussions with doctors, nurses, and theatre staff. A one-page PBM checklist of recommendations was developed for all patients undergoing vascular surgery. Prospective audits were conducted before (October 2014 to March 2015) and after (November 2015 to February 2016) PBM implementation. Outcomes were blood transfusion and haemoglobin concentration (Hb) trigger threshold. A total of 211 patients were admitted under vascular surgery: 127 for Audit 1 and 84 for Audit 2. Overall, 30% of patients were transfused, with 193 units transfused in Audit 1 and 85 in Audit 2. PBM implementation was associated with a reduction in patients receiving a blood transfusion (37% to 20%; p = 0.01). However, there was no difference in Hb trigger threshold (76 g/L vs 72 g/L, p = 0.051). A PBM programme is feasible and can be implemented in vascular surgery. PBM was associated with an improvement in transfusion use and length of patient stay that merits further investigation.

Management of the patient presenting with anaemia in the preoperative setting.

Preoperative anaemia is common, seen in a third of patients before major surgery. Both preoperative anaemia and blood transfusion are associated with increased patient risk and adverse outcome. Patient Blood Management (PBM) is the multidisciplinary, multimodal approach to optimising the care of patients who may require blood transfusion. Guidelines exist with many recommendations throughout the perioperative pathway. However, the efficacy of individual recommendations as an intervention in terms of clinical outcome can be confusing. In the UK the first national audit of PBM in surgery was carried out in 2015. This reviewed the use and impact of PBM recommendations in hospitals throughout the UK where major surgery was undertaken. The current evidence base for these PBM recommendations was reviewed and the patient outcome in terms of blood transfusion use and length of hospital stay assessed in those where PBM interventions were followed. For the patient who presents with preoperative anaemia, 'quick wins' were identified that reduced blood transfusion use and reduced length of stay in hospital; preoperative discontinuation of anticoagulation or antiplatelet therapy, and intraoperative use of tranexamic acid and cell salvage.