Patient Blood Management Recs Revamped

A group endorsed restrictive thresholds for blood transfusion but ignored some key aspects of patient blood management (PBM) in a new expert consensus statement, some said.

Among the clinical recommendations suggested at the International Consensus Conference held in Frankfurt/Main, Germany in April 2018 and now published in the March 12 issue of JAMA are calls for the following:

• Early detection and management of anemia before major elective surgery (strong recommendation)

• Routine iron supplementation but not erythropoiesis-stimulating agents (ESAs) in anemic patients undergoing elective surgery (conditional recommendations)

• ESAs and iron supplementation together in adult preoperative patients with hemoglobin <13 g/dL undergoing elective major orthopedic surgery (conditional recommendation)

• Red blood cell (RBC) transfusion thresholds of hemoglobin 7 g/dL and 7.5 g/dL for stable but critically ill patients and those undergoing cardiac surgery, respectively (strong recommendations)

• Implementation of PBM programs that use electronic decision support systems (conditional recommendations)

Erhard Seifried, MD, PhD, of the German Red Cross Blood Transfusion Service Baden-Wuerttemberg-Hessen, and co-authors, who made up the multidisciplinary expert panel with representatives from 33 countries, had performed a meta-analysis of 145 studies in creating 10 clinical recommendations for PBM.

“Clinicians can consider the panel’s transfusion threshold recommendations as follows: If the sole consideration for transfusing a patient is the hemoglobin level, then a restrictive threshold should be used,” concluded Michelle Zeller, MD, of Canadian Blood Services in Hamilton, Ontario, and Richard Kaufman, MD, of Brigham and Women’s Hospital in Boston, writing in an accompanying editorial.

The pair said that the new guidelines “should be widely embraced” even if there are several caveats.

For one, the decision to transfuse or not to transfuse takes more than just a hemoglobin level, the editorial cautioned: “A hemoglobin level provides an estimate of the circulating red cell mass but reveals nothing about tissue oxygenation, which RBC transfusion is meant to address. Given the same level of anemia, some patients fare better than others.”

“The guideline fails to address a fundamental pillar of PBM: minimizing bleeding by optimizing coagulation,” Zeller and Kaufman added. “In particular, antifibrinolytic agents have been shown to be safe and efficacious in decreasing allogeneic RBC transfusions in many perioperative settings. The guideline focuses almost entirely on RBC transfusion; platelets and plasma are hardly mentioned.”

In fairness, the editorialists noted, the evidence base is currently that much stronger for RBC transfusion.

“All in all, the PBM described is based on the opinions of mostly those within the blood transfusion establishment,” commented Aryeh Shander, MD, of Englewood Hospital & Medical Center in New Jersey. “PBM is not a therapy (as they suggest with the study recommendations); it is a bundle of care.”

Shander said that the “representative definition” of PBM comes from the Society for the Advancement of Blood Management, which states that it is “the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve patient outcome.”

PBM “does not revolve around transfusion reduction but revolves around the patient,” he emphasized as he noted the lack of similar-minded experts among those invited to work on Seifried’s manuscript.

The Society of Thoracic Surgeons is working on its own blood conservation guidelines for release later this year, according to Victor Ferraris, MD, PhD, of the University of Kentucky College of Medicine in Lexington, who was not part of the Frankfurt group.

“What is very interesting is that the PICO [Population/Intervention/Comparison/Outcome] questions are going to be different between the two versions,” he told MedPage Today.

“I think the European version of guideline recommendations includes more than cardiac operations, but I also think that the choice of PICO questions is somewhat arbitrary and leaves some room for questions about the scope and extent of patient populations being considered for blood conservation recommendations,” Ferraris said.

Twelve separate research recommendations were created by Seifried’s team to address gaps in the literature, such as the right hemoglobin thresholds for different patient groups and the costs and effects of PBM programs.