Patient Blood Management

Abstract

IMPORTANCE Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs. OBJECTIVE To develop a set of evidence-based recommendations for patient blood management (PBM) and for research. EVIDENCE REVIEWThe scientific committee developed 17 Population/Intervention/ Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018.FINDINGS From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization. CONCLUSIONS AND RELEVANCEThe 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.

Association between preoperative hemoglobin levels after iron supplementation and perioperative blood transfusion requirements in children undergoing scoliosis surgery

“…The preoperative hemoglobin level in this study is within the range reported in other studies examining the impact of intervention for preexisting anemia 14,16 . In keeping with findings from the present study, adult blood conservation guidelines include the recommendation to achieve a preoperative hemoglobin level of >130 g/L to reduce the potential for receiving a RBC transfusion 17 . Specifically, adult blood conservation guidelines recommend that preoperative iron supplementation be administered to correct any iron deficiency 17 .…”

Multicenter comparison of three intraoperative hemoglobin trend monitoring methods

“…Hb measurement is essential to making patient centered transfusion decisions [28] which should improve outcomes [29] and reduce transfusion requirements [30][31][32]. Hb measurement is particularly important when blood loss is not obvious or is difficult to estimate during surgery as blood sampling to determine tHb can lag clinical situations.…”

Liberal versus restrictive red blood cell transfusion strategy in sepsis or septic shock: a systematic review and meta-analysis of randomized trials

“…However, the subgroup analysis of this study also raised the possibility that the suggested blood transfusion threshold could differ due to different diseases and patient populations. In fact, the very recent 2018 Frankfurt Consensus Conference on patient blood management strongly recommended the use of the restrictive RBC transfusion threshold in critically ill but clinically stable intensive care patients and in patients undergoing cardiac surgery; however, use of the restrictive RBC transfusion threshold was not clearly recommended in patients with hip fracture and cardiovascular diseases or other risk factors as well as in hemodynamically stable patients with acute gastrointestinal bleeding (conditional recommendation) [17]. Apparently, recent clinical trials investigating the hemoglobin threshold for transfusion have been more focused on narrow and specific populations [18–22].…”