Patient Blood Management (PBM)

Patient Blood Management (PBM) addresses evidence-based transfusion medicine practices and stewardship of donated blood.

The PBM view is that a patient’s own blood is a valuable and unique resource that should be conserved and managed appropriately.

Altruistically donated blood is a costly resource that is also valuable and unique and should only be used when there is evidence for potential benefit and that potential harm is minimised (NBA: Patient Blood Management (PBM) | National Blood Authority, viewed December 2020).

A caveat on information supplied

All information and policies that are included as examples are only current at the time the document(s) were made available to Blood Matters.

Individual health services should be contacted to ascertain the currency of the policies and practices.

The tools are not endorsed by Blood Matters unless stated otherwise. Information sharing occurs on the understanding that due acknowledgement will be given to the original source.

Seek permission from the original source before using or applying any policy, protocol or guidelines.

Patient Blood Management guidelines

The National Blood Authority Patient Blood Management guidelines are made up of six evidence-based modules.

Each module represents a systematic review of the scientific literature by experts from relevant colleges and societies and consumer groups.

• Module 1 - Critical bleeding massive transfusion
• Module 2 - Perioperative
• Module 3 – Medical
• Module 4 - Critical care
• Module 5 - Obstetrics and Maternity
• Module 6 - Neonatal and Paediatrics

Pre-operative anaemia assessment and red cell optimisation – just good practice

Pre-operative anaemia assessment and management is one of the cornerstones of PBM. When successfully implemented it can prevent unnecessary blood transfusions.

Anaemia should be viewed as a potentially serious, but treatable medical condition. Even mild anaemia can have significant ramifications for surgical patients. Implementation of anaemia management to improve haemoglobin (Hb), and iron stores in the elective surgery setting will improve patient outcomes.

Whenever clinically feasible, patients undergoing elective surgery with a high risk of severe post-operative anaemia should have their haemoglobin (Hb) concentration and iron status tested 30 days (or more) before the scheduled surgical date.

Unexplained anaemia should always be considered as secondary to some other process. If possible, elective surgery (especially for non-malignant disease) should be deferred until the anaemia is adequately evaluated and treated.

Why pre-operative anaemia management is important

Patients undergoing elective surgery with pre-operative anaemia are at increased risk of blood transfusion and the risks associated with transfusion.

Anaemia itself can lead to worse surgical outcomes (Munoz et al 2017, Peri-operative management of anaemia and iron deficiency, Anaesthesia, 72, 233-47). RBC transfusion is associated with significantly longer stays in hospital and ICU in patients undergoing cardiac and non-cardiac surgery. (Perioperative PBM Guideline, 2012).

In studies in elective orthopaedic surgical patients, previously undiagnosed anaemia is common and is associated with increased perioperative morbidity and mortality. It increases the likelihood of blood transfusion, which is independently associated with increased morbidity, mortality and hospital length of stay.

Anaemia is defined by the World Health Organization as a Hb level below 120 g/L in females and 130 g/L in males.

Hong et al. (2017) describe iron deficiency as the commonest cause of pre-operative anaemia, accounting for 20–28 per cent of anaemic patients presenting to preadmission clinics.

The aetiology of anaemia should be identified and, if necessary, patients referred for further investigation and treatment before surgery. This may require a delay to surgery and should be discussed with the patient.

See iron deficiency anaemia and treatment for further information on investigation of anaemia.

Blood conservation strategies

The PBM guidelines Module 2 provides recommendations and discussion on non-transfusion interventions to increase Hb concentration and perioperative strategies to reduce blood loss:

• Prevention of hypothermia (Grade A evidence)
  • Australian College of Perianaesthesia Nurses (ACPAN) practice guideline: Prevention and management of inadvertent perioperative hypothermia in adults.
  • The Australian College of Perioperative Nursing has a standard on hypothermia, which is accessible to subscribers.
  • The National Institute for Health and Clinical Excellence (United Kingdom), guidance: Hypothermia prevention and management in adults having surgery.
• Intraoperative cell salvage (Grade C evidence)
• Using medications (Grade A evidence in cardiac surgery; Grade B evidence in non-cardiac surgery for the use of Tranexamic Acid)

Resources to support PBM and help health services develop a PBM program, including templates, checklists and guidance documents.

Anaemia assessment audit tool - a quick audit tool designed to provide a snapshot of current anaemia assessment practices.

Anaemia clinic business case template - the template is guide to assist health services with the implementation of an anaemia clinic and is designed to be adapted as needed.

Anaemia assessment clinic implementation checklist - a checklist designed to assist health services implement anaemia assessment in the elective surgical setting.

Guidelines for the Peri-operative Administration of Tranexamic Acid for Orthopaedic Arthroplasty Surgery - Western Health April 2014 - developed by Western Health following a project to investigate the administration of intravenous, intraoperative Tranexamic Acid in patients undergoing major joint surgery.

Template letter for patients - an example letter to patients regarding the need for additional blood tests for pre-operative blood management. The letter can be adapted as needed.

National Blood Authority pre-operative haemoglobin assessment and optimisation template - a flowchart that can be adapted by health services to assist with pre-operative haemoglobin assessment and management.

Prescribing red cells table - Australian Red Cross Lifeblood 2019 - provides guidance for red blood cell transfusion based on patient’s condition and haemoglobin level.

Reducing iatrogenic blood loss guiding principles - Blood Matters 2020 - the guiding principles are intended to assist health services include blood conservation strategies within their clinical practice guidelines.

Blood sampling volume audit report 2019 - Blood Matters 2020 - this report covers the audit of blood sampling practices in Victorian health services to identify opportunities for improving practice to reduce the risk of iatrogenic anaemia.

Minimal blood sampling audit 2019 - infographic summary of blood sampling volume audit 2019: a snapshot view of the important audit results from the 2019 survey and audit.

Infographic summary of blood sampling volume audit 2017 - Blood Matters 2018 - a snapshot view of the important audit results from the 2017 survey.

Cumulative daily phlebotomy loss audit tool - a data collection tool aimed at assessing the cumulative blood volume associated with blood sample collections.

Toolkit for maternity blood management - Australian Red Cross Lifeblood - a free resource for anyone involved in antenatal care to improve the detection and management of iron deficiency and anaemia in pregnant women.

Fit for surgery - National Blood Authority - a resource to help manage patients undergoing planned surgery.

Tranexamic Acid - how it works - a short video showing how Tranexamic acid controls bleeding.