Pandemics and Patient Blood Management (PBM)

Disclaimer: This committee resource is provided for informational purposes only and does not represent medical or legal advice. It has not been approved by ASA’s Board of Directors or House of Delegates and does not represent an ASA Policy, Statement or Guideline.

Pandemics and Patient Blood Management (PBM)

Produced by the Committee on Patient Blood Management
updated March 27, 2020

 

Bottom Line: Blood shortages during the COVID-19 pandemic are one of many issues driving practices to cancel elective surgeries.  However, with the quick and effective implementation of patient blood management (PBM) principles, many patients may safely undergo time-sensitive surgical and other procedural interventions despite limited blood supplies. Examples of practices that should be implemented include:

1. A triage system must be established locally with postponement of elective surgical procedures.  This deferment should occur with the goal of conserving essential healthcare system personnel and resources, regardless of the need for blood products.
2. Time-sensitive, non-emergency cases must have blood health optimized as outlined in consensus publications and briefly described below (see references).  Anesthesiologists, working in concert with other hospital leadership, are poised to effectively lead this effort.
1. Identify, diagnose, and manage anemia throughout the perioperative encounter, with an emphasis on managing the underlying cause of anemia.
2. Identify, monitor, and treat perioperative coagulopathy with an emphasis on real-time monitoring and appropriate utilization of the full armamentarium of interventions supporting hemostasis (e.g. innovative surgical techniques, clotting factors, fibrinogen concentrates). 
3. Comprehensive utilization of effective perioperative blood conservation methods, including but not limited to meticulous surgical technique, perioperative cell salvage, acute normovolemic hemodilution, appropriate fluid management, and minimization of iatrogenic blood loss (e.g. unnecessary blood testing).
4. Continuous postoperative assessment for the development of bleeding, coagulopathy, and anemia.  Of note, acute postoperative anemia is common and in many cases may be adequately treated with iron replacement with or without co-administration of erythropoiesis-stimulating agents (ESAs), thereby conserving allogeneic blood.
5. Education and involvement of medical professionals, patients, and their families in the PBM model of care, which is essential in times of critical blood shortages.

Background Detail:

• In the setting of the COVID-19 pandemic, blood supplies are dwindling secondary to a substantial decrease in blood donors and the perishable nature of the products. Calls from the blood centers for additional donors will not sufficiently alleviate this problem; hence, other solutions are necessary.
• To address the progressing decline in blood product availability, it is essential to endorse the broad application of PBM, defined as “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. (SABM.org)”. 
• By following PBM principles, demand pressures on the perishable blood supply will be substantially reduced, conserving these precious resources for those patients most likely to benefit from their use.

References:

Perioperative Anemia: Prevention, Diagnosis, and Management Throughout the Spectrum of Perioperative Care.
Warner MA, Shore-Lesserson L, Shander A, Patel SY, Perelman SI, Guinn NR.
Anesth Analg. 2020 Mar 9. doi: 10.1213/ANE.0000000000004727. [Epub ahead of print]

Management of Perioperative Iron Deficiency Anemia.
Gómez-Ramírez S, Bisbe E, Shander A, Spahn DR, Muñoz M.
Acta Haematol. 2019;142(1):21-29. doi: 10.1159/000496965. Epub 2019 Apr 10.

An international consensus statement on the management of postoperative anaemia after major surgical procedures.
Muñoz M, Acheson AG, Bisbe E, Butcher A, Gómez-Ramírez S, Khalafallah AA, Kehlet H, Kietaibl S, Liumbruno GM, Meybohm P, Rao Baikady R, Shander A, So-Osman C, Spahn DR, Klein AA.
Anaesthesia. 2018 Nov;73(11):1418-1431. doi: 10.1111/anae.14358. Epub 2018 Jul 31.

Patient Blood Management in the Intensive Care Unit.
Shander A, Javidroozi M, Lobel G.
Transfus Med Rev. 2017 Oct;31(4):264-271. doi: 10.1016/j.tmrv.2017.07.007. Epub 2017 Jul 31. Review.

International consensus statement on the peri-operative management of anaemia and iron deficiency.
Muñoz M, Acheson AG, Auerbach M, Besser M, Habler O, Kehlet H, Liumbruno GM, Lasocki S, Meybohm P, Rao Baikady R, Richards T, Shander A, So-Osman C, Spahn DR, Klein AA.
Anaesthesia. 2017 Feb;72(2):233-247. doi: 10.1111/anae.13773. Epub 2016 Dec 20.

Management of anemia in patients who decline blood transfusion.
Shander A, Goodnough LT.
Am J Hematol. 2018 Sep;93(9):1183-1191. doi: 10.1002/ajh.25167. Epub 2018 Sep 3.

Anesthesia for Patients with Anemia.
Shander A, Lobel GP, Javidroozi M.
Anesthesiol Clin. 2016 Dec;34(4):711-730. doi: 10.1016/j.anclin.2016.06.007. Review.