By implementing patient-centered blood management, far-reaching medical and economic benefits can be achieved. This is shown by numerous scientific analyses. The evidence-based approach recommended by the WHO aims at rational use of blood products by strengthening the body’s own blood. The internationally renowned expert Prof. Dr. rer. medic. Axel Hofmann presented a webinar on what the 21st century challenges are in healthcare and how PBM can help mitigate the crisis.
(mp) Clarification and treatment of preoperative anemia prior to elective surgery as well as more restrictive transfusion behavior are key measures in the context of patient blood management (Fig. 1). This can result in reductions in blood transfusions, reduced complication rates, and shorter hospital stays, all of which are beneficial to quality of care, cost efficiency, and security of supply for blood products [1–3]. This was demonstrated by Prof. Dr. rer. medic. Axel Hofmann in the webinar on “Patient Blood Management – Why should I introduce the concept in my hospital?” in an impressive way [4]. Professor Hofmann is, among other things, chairman of a working group that is developing international guidelines for the implementation of this concept on behalf of the WHO. According to the WHO, demographic change, declining blood donations and excessive use of blood products will lead to worldwide shortages from 2030 onwards, and this is already becoming apparent in Switzerland [5–7]. PBM measures have been shown to improve the safety of blood product supplies and improve several other outcomes. Patients as well as hospitals and the healthcare system as a whole benefit from this, so that this program now occupies a leading place in health policy agendas worldwide. The Swiss Society of Anesthesiology and Resuscitation (SGAR) has included a restrictive approach to red blood cell concentrate transfusions in its top 5 list of “Choosing Wisely” initiatives [24].
Source: Vifor Pharma
Innovative method for improving the quality of healthcare
In the context of demographic change and the changing age structure of society, it is necessary for healthcare systems to adapt. “Medicine of the future will focus more on efficient use of resources,” Professor Hofmann summarizes a key message of an article published in the New England Journal of Medicine [4,8]. A long-term study by McKinsey & Company on the development of productivity* of various economic sectors shows that the healthcare sector performs comparatively poorly [9]. Innovative methods are needed that contribute to improvement in the following three dimensions: quality of care and patient satisfaction, public health, and health care cost reduction. In the Global Health Expenditure Atlas, the WHO stated that around 20-40% of health care costs are due to wasteful use of resources [10]. Among the suboptimal processes contributing to this is a triad of anemia/iron deficiency, blood transfusions, and an associated increased risk of blood loss, Prof. Hofmann said. He explains that approximately 57% of patients treated perioperatively are anemic [11]. In Switzerland, the prevalence of preoperative anemia in knee and hip surgery is 25-45% [12]. In patients with preoperative anemia, the risk of transfusion is 3.9 times higher. This is associated with 22% longer hospital stays and a higher risk of infection, a greater risk of acute renal failure, and a 2.9 times higher risk of mortality [13–15]. This is where the multidimensional concept of patient blood management comes in, which has been shown to improve quality of care as well as various health economic indicators [2].
*Productivity = Output: Input
**From the time of hospital admission to the time of hospital discharge.
What are the three pillars of patient blood management?
Optimization of red blood cell volume:
Preoperative anemia not only increases transfusion requirements – it is also associated with increased morbidity and mortality [14]. Correction of preoperative anemia and iron deficiency significantly reduces the transfusion rate , leads to improved postoperative recovery and thus to faster mobilization and shorter patient hospitalization time [16–18]. Therefore, the first step to patient-centered blood management is to detect, screen for, and treat anemia that exists preoperatively [19]. A meta-analysis with data from a total of 949 449 patients from 24 studies concluded that 39% of patients had preoperative anemia according to the WHO definition with associated unfavorable impacts on mortality and morbidity [15]. Those over 65 years of age are particularly likely to receive a red blood cell transfusion [20]. In the study of 8 744 people in this age group, the prevalence of anemia was 11.8% [21]. International guidelines recommend that elective surgery with a transfusion risk ≥10% (or a blood loss of >500 mL) should be assessed for anemia and treated before surgery [22,23].
Minimizing blood loss and transfusion.
: “Anemia is bad, transfusion does not lead to improvement,” Professor Hofmann said. One study showed that in mild anemia preceding noncardiac surgical procedures, the odds ratio (OR) for mortality was 1.4 (1.3-1.5) and for morbidity was 1.3 (1.3-1.4). Blood transfusion worsened this outcome: mortality OR 2.0 (1.8-2.2), morbidity OR 1.8 (1.7-1.9) [13]. Intraoperative and postoperative blood loss is an independent predictor of increased perioperative morbidity and mortality, which are not reduced but increased by transfusion of blood components [25]. Therefore, after preoperative control and, if necessary, optimization of the erythrocyte volume, the preservation of this volume is in the foreground. Options for minimizing blood loss range from careful surgical hemostasis to classic foreign-blood-sparing procedures to the use of hemostasis-supportive drug preparations [19].
Optimization of individual anemia tolerance:
Preoperatively, patients’ physiologic reserve for blood loss/anemia should be assessed and tolerable blood loss calculated. Intraoperatively, the focus is on establishing or maintaining normovolemia as well as individualized anesthesiological-intensive therapeutic measures to increase anemia tolerance (especially optimization of cardiac output, optimization of ventilation, reduction of oxygen consumption) [27]. Postoperatively, general measures such as maintenance of normovolemia, pain therapy and further treatment/avoidance of secondary diseases, control of iron status and, if necessary, correction by iron substitution or optimization of erythropoiesis must be performed [27].
Fig. 1: Patient Blood Management
Source: according to [26,27]
To the webinar: “Patient Blood Management (PBM) – why should I introduce this concept in my hospital?”, Prof. Dr. med. A. Hofmann
Vifor Pharma Switzerland
supports and accompanies Swiss hospitals on their way to implement the concept of PBM(www.viforpharma.ch). Contact us for more information.
Literature:
D 11/2021 CH-FCM-2100397
