Case 136 – the summary

This week we followed the case of a 71 year old patient with multiple co-morbidities who required optimisation of her haemoglobin level before an elective operation. The crux of this case is Patient Blood Management, which is something we all have a responsibility to practice.

Definition of Patient Blood Management (PBM): “A multidisciplinary, evidence-based approach to optimising care of a patient who might need a blood transfusion, aimed at avoiding inappropriate use of blood components, improving patient outcomes and ensuring wise use of resources.”

Often describes as three pillars:

  • Optimise red cell mass/haematopoiesis
    • E.g. using iron or EPO
  • Minimise blood loss
    • E.g. surgical technique, intraoperative cell salvage, tranexamic acid
  • Harness and optimise physiological tolerance of anaemia
    • E.g. single unit transfusion and review, post-op iron

Many PBM principles have been ratified in NICE quality standard QS138:

  • Quality standard 1: People with iron-deficiency anaemia who are having surgery are offered iron supplementation before and after surgery
  • Quality standard 2: Adults who are having surgery and are expected to have moderate blood loss are offered tranexamic acid
  • Quality standard 3: People are clinically reassessed and have their haemoglobin levels checked after each unit of red blood cells they receive, unless they are bleeding or are on a chronic transfusion programme
  • Quality standard 4: People who may need or who have had a blood transfusion are given verbal and written information about blood transfusion

The NICE guidance (NG24) around EPO in the pre-operative setting are quite restrictive, and limit their recommendations to those who decline blood transfusion due to religious belief or if the appropriate blood is not available due to atypical red cell antibodies. Many clinicians will, however, consider a trial as an alternative to pre-operative transfusion after taking into consideration the risks and benefits for each individual patient.

As is always the case, no patient should come to harm due to withholding transfusion, a risk/benefit decision, with the patient’s input if possible, should be made in each individual case.

Useful resources to learn more:

NICE guideline 24: https://www.nice.org.uk/guidance/ng24

NICE quality standard 138: https://www.nice.org.uk/guidance/qs138

Blooducation podcast: https://blooducation.co.uk/portfolio/patient-blood-management

NHSBT toolkit: https://hospital.blood.co.uk/patient-services/patient-blood-management/education/

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