A nationwide Turkish movement to implement Patient Blood Management

Despite recent advances in the techniques and instrumentation of medical procedures, major surgery is still commonly associated with substantial blood loss, subsequent anaemia, and the need for blood transfusion. In addition, preoperative anaemia is common in surgical patients, with a prevalence of 10 to 48%. It is well-known that anaemia increases the use of allogeneic blood products and is, furthermore, an independent risk factor for increased post-operative complications, prolonged hospital stay, and an increased mortality rate^1,2. Moreover, these negative effects were present even for mild anaemia³. In order to minimise the risks associated with preoperative anaemia and blood transfusion, a Patient Blood Management (PBM) programme has evolved. PBM is an evidence-based, patient-centred, multidisciplinary approach to reduce anaemia (pillar 1), minimise iatrogenic blood loss (pillar 2), and optimise patient-specific tolerance of anaemia (pillar 3) in order to maintain the patient’s own blood volume⁴. So far, more than 100 individual PBM measures have been defined based on the broad interdisciplinary fields and temporal application⁵. The advantage of the extensive PBM measures is that the selection can be dynamically adapted to the individual financial resources and personnel capabilities, as well as to the respective focus of each hospital. Even though the body of evidence is constantly growing, only a few institutions have adopted measures of all three pillars⁶. A possible explanation could be that implementation of PBM is not necessarily straightforward, and several factors may intervene at various levels and act as barriers⁷.

Unal et al. present an impressive effort to evaluate the nation-wide perioperative transfusion practice in patients undergoing major elective surgery⁸. Together with the Turkish Society of Anaesthesiology and Reanimation, the authors conducted the Turkish National Perioperative Transfusion Study (TULIP-TS) to determine the areas for improvement in transfusion practice and to provide data for health care planning. Within one month, 61 centres included over 6,000 major surgical patients. Overall, the analysis revealed that 25.8% of the patients received perioperative blood transfusion. Preoperative anaemia was identified in 32.9% of the patients. Plasma (61.3%) and platelet (61.1%) transfusions were mostly initiated for acute bleeding. Interestingly, red blood cell (RBC) transfusion rates varied across study sites from 2 to 72%. Inappropriate RBC transfusion was detected in 99% of preoperative, 23% of intraoperative, and 43% of postoperative RBC transfusion episodes. Furthermore, the authors found that, among other factors, increased age and Body Mass Index, the presence of coronary artery disease and heart failure, and abnormal coagulation profiles were associated with an increased transfusion rate.

Here the authors conducted a systematic nationwide approach to evaluate current transfusion practice and to identify the need for change (Figure 1). Unal et al. revealed that the predictability of blood transfusion is based on the level of preoperative anaemia (pillar 1), volume of perioperative blood loss (pillar 2), and the transfusion threshold (pillar 3).

Figure 1.

A systematic nationwide approach to evaluate the current transfusion practice and to identify the need for change in Turkey

TXA: tranexamic acid.

They discovered that first-line specialities for implementing PBM are cardiovascular surgery and orthopaedics, that may also have the highest impact on outcome measures, as demonstrated by a meta-analysis by Althoff et al. The relative risk for RBC transfusion decreased by 55% in orthopaedic and 50% in cardiac surgical patients after implementation of PBM⁶.

Unal et al. raised two important global issues. The classification of anaemia for non-pregnant women postulated by the World Health Organization has highly been debated over the past years⁹. Females have lower circulating blood volumes and reduced red cell mass compared to males, but experience similar blood loss during the same type of surgical intervention, reaching the transfusion threshold faster and resulting, therefore, in higher transfusion rates¹⁰. Future studies should carefully consider to adjust the threshold for anaemia in female patients. In addition, strong recommendations exist whether RBC transfusion is (haemoglobin [Hb] <6–7 g/dL) or is not necessarily (Hb >8–10 g/dL) indicated. However, between these two values, the physician has to decide whether RBC transfusion is essential to patient survival which, however, depeends on his own experience and knowledge. The study by Unal et al. discovered that the “historical 10 g Hb rule” is still accepted among several surgeons and might also explain the different transfusion rates between sites (ranging from 2 to 72%). A local clinical transfusion management committee or a transfusion monitoring and feedback programme may support the physician during the decision for blood transfusion. For example, at the University Hospital of Zurich, a monitoring and feedback programme resulted in a 35% reduction in transfusion of allogeneic blood products¹¹.

Single PBM measures, such as preoperative anaemia treatment¹² or the use of cell salvage devices¹³, are effective to improve surgical outcome. The successful implementation of single pillar programmes, however, might be compromised if surgery is scheduled short term or if hospitals do not have the necessary resources. PBM is most successful when multiple interventions are combined. Therefore, we propose that clinicians and policy makers should concentrate their efforts on the initial adoption of the 3-pillar framework, to promote a step-by-step implementation of further PBM measures that fit best the individual conditions.

Only a few regulatory authorities support the implementation of PBM worldwide. For example, the National Blood Authority supported the first worldwide implementation of PBM in Western Australia in 2008¹⁴, and the National Institute for Health and Care Excellence guidelines in the UK suggest treatment with iron in iron-deficiency anaemic patients 2 weeks before surgery¹⁵. For the moment, Italy is the only country in which implementation of PBM is mandatory by law¹⁶. Changing traditional work flow systems is challenging and is often associated with resistance. In a long-term perspective, national authorities should support the implementation of a nationwide PBM programme in order to improve surgical outcome and patient safety.