Table 1.

The ABC Toolbox for PBM (From the IFPBM-SABM Workgroup)

Tools	Anemia and Iron Deficiency	Blood Loss and Bleeding	Coagulopathy
1. Program implementation methodology	• Change culture across your institution11–13 • Disseminate evidence-based PBM guidelines/recommendations and detect and discourage nonevidence practices14–22 • Translate evidence-based guidelines/recommendations into clinical practice13,23 • Identify practice areas that need improvement
2. Diagnostic devices	• Point-of-care hemoglobin analyzers • Point-of-care testing for iron deficiency if available	• Point-of-care coagulation and platelet function testing and goal-directed treatment24–26 • Rapid diagnostic tests for thepresence of DOACs if available27	• Point-of-care coagulation and platelet function testing and goal-directed treatment24–26 • Rapid diagnostic tests for presence of DOACs if available27
3. Treatment devices		• Pre- and postoperative cell recovery (cell saver)28 • ANH29
4. Pharmaceuticals	• Oral/intravenousiron30–33 • Folic acid34 • Vitamin B1234,35 • Erythropoiesis-stimulating agents30,32,33	• Antifibrinolytics (tranexamic acid, aminocaproic acid)36–39 • Topical hemostatic agents • Local vasoconstrictive agents • WBC and platelet-stimulating agents where appropriate • Consider high Fio2 (1.0) in patients with life-threatening anemia	• Fibrinogen concentrate40 • PCC40 • Other clotting factors • Vitamin K intravenously
	• Educate physicians on indications and dosage
5. Vigilance with nutritional and pharmacological interactions	Identify and manage drug therapies and/or nutrition that • Can contribute to anemia and hematinic deficiencies (eg, PPIs) • Can increase iron absorption (eg, ascorbic acid) • Can impair absorption (eg, some vitamin and herbal supplements, tea, coffee, or dairy products)	Identify and manage drug therapies and/or nutrition that increase the bleeding risk, for example: • NSAIDs (including COX2 inhibitors), antidepressants, statins, antiarrhythmics • Vitamin and herbal supplements including vitamin E, vitamin K, garlic, ginger, Ginkgo biloba, fish oil, chamomile, dandelion root, etc
6. General principles	Identify, evaluate, and manage anemia and iron deficiency30,41 • Evaluate and manage underlying disorders causing anemia and iron deficiency • Be aware of drugs associated with red blood cell disorders42 • Anemia management program for prehospital, hospital, and postdischarge patients • Focus on patients with comorbidities (diabetes, chronic kidney disease, andcongestive heart failure)43,44	• Meticulous surgical hemostasis • Optimize surgical technique • Patient positioning • Efforts to stop bleeding immediately Minimally invasive surgical techniques Restrictive fluid administration and permissive hypotension until bleeding is controlled Achieving euvolemia once bleeding controlled Deliberate induced hypotension Careful blood pressure and fluid management Prevent hypothermia,45 hypoperfusion, and acidosis Maintaining normal circulating volume (euvolemia) • Minimize iatrogenic blood loss,46,47 minimize number of blood draws and volume, minimize volume of blood wasted (microtainers/small phlebotomy tubes) • Staging and packing • Interventional radiologic embolization • Restrictive transfusion strategy48–51 (reducevolume of transfusion, adhere to restrictive transfusion thresholds) • Watch for signs of postoperative bleeding • Monitor throughout withholding/bridging/recommencement of DOACs and antiplatelet agents • Prevent GI bleeding (enteral feeding/food, GI acid-lowering agents) • Avoid/treat infections promptly	• Address clinically significant coagulopathy early by identifying the source and/or coagulation defect
	• Identify patients and surgical procedures at increased risk for blood loss, anemia, and coagulopathy • Refer high-risk patients immediately to PBM program • Preoperative surgical planning to minimize extent and thetime of surgery including preoperative embolization or noninvasive techniques • Postpone or cancel elective surgery to allow time to optimize blood health
7. SOP and procedural guidelines	• SOPs for detection, evaluation, and management of anemia and iron deficiency for specific settings: • Pre- and postsurgery • Cancer • Heart failure • Chronic kidney disease • Pregnancy and postpartum • Pediatrics • Hospital-acquired anemia • Patients with iron-restricted erythropoiesis • Anemia of inflammation	• Management of anticoagulants and antiplatelet agents before interventions • Bleeding history-taking • Bleeding management algorithms • Procedural guideline for cell salvage • Procedural guideline for ANH • Maintaining normothermia • Major hemorrhage protocol • Guidelines on oral versus intravenous iron, iron preparations, and dosing • Establish “single-unit transfusion policy”52–55
8. Data collection, benchmarking, and reporting systems	• Patient-centered and data-driven decision-making • Measure the change with respect to patient outcomes/cost savings56 • Report the change57
9. Continuous education and training	• Multidisciplinary and multiprofessional programs organized and led by local champions • Regular updating of curricula/learning content • Ensuring introductory courses for new and junior staff
10. Patient education, information, and consent	• Develop a simplified education management plan • Establish procedures for communicating with patients retreatment plan, risks/benefits, and obtaining consent58 • Communicate plan to all members of the team
11. Infrastructure	• Appoint PBM staff and allocate/reallocate funds accordingly13 • Create job descriptions for PBM dedicated staff13 • Install necessary medical devices and equipment13,23 • Reengineer clinical pathways and infrastructure to allow appropriate preoperative/preintervention patient assessment and optimization13,23 • Ensure appropriate waiting zones and treatment areas particularly for preoperative/preintervention patient optimization13 • Form a multidisciplinary PBM committee13

Abbreviations: ABC, Anemia, Blood loss and Coagulopathy; ANH, Acute normovolemic hemodilution; COX2, cyclooxygenase-2; DOACs, direct oral anticoagulants; Fio₂, fraction of inspired oxygen; GI, gastrointestinal; IFPBM-SABM, International Foundation of Patient Blood Management-Society for the Advancement of Blood Management; NSAID, nonsteroidal anti-inflammatory drug; PBM, patient blood management; PCC, Prothrombin complex concentrate; PPI, proton-pump inhibitor; SOP, Standard Operating Procedures; WBC, white blood cell.