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Blood Management is the appropriate provision and use of blood, its components and derivatives, and strategies to reduce or avoid the need for a blood transfusion.^[1]

[edit] Why is Blood Management/Conservation Necessary?

There are very important reasons for blood management and conservation. First, a few definitions are needed. "Blood management" is the appropriate provision and use of blood, its components and derivatives, and strategies to reduce or avoid the need for a blood transfusion. When the term “blood transfusion” is used, it most commonly refers to blood that is donated by one individual, screened for various infectious agents, banked, and later transfused to a different individual with a compatible blood type. This is known as an “allogeneic transfusion.” Blood transfusion can also (but more infrequently) refer to blood which an individual donates, and then receives back to himself or herself at some later time, know as “pre-stored autologous blood” used for transfusion. The use of the term “blood management” recognizes that allogeneic blood transfusion is periodically necessary. This differs from the terms "bloodless" or "transfusion-free" where the same range of techniques is applied, but the option of allogeneic blood transfusion is not available either for religious reasons, personal preference, or some other clinical scenario. The term "blood conservation" is frequently used, and highlights the need to conserve blood, which is also an aspect of blood management.

[edit] Blood management is important primarily to improve outcomes and to reduce cost

From an administrative standpoint, a significant reason to embrace the concept of blood management is cost. Allogeneic blood transfusion is extremely expensive. For example, some studies reported increased costs of $300-$1,000 per unit of allogeneic blood transfused.^[2] ^[3] The more blood that is transfused directly impacts hospital expenditures, and of course, it behooves administrators to search for ways to reduce this cost. This increasing cost of transfusions is the reason many hospital administrators are endeavoring to establish blood management programs.

From the physician's standpoint, the primary reason for blood management is to improve patient outcomes. Better outcomes are achieved with the reduction or avoidance of exposure to allogeneic blood. Clinical studies have shown that allogeneic blood transfusions are associated with increased mortality and an increased level of serious complications, while potentially exposing the patient to viral, bacterial, or parasitic agents. Also, current medical literature shows allogeneic transfusions to be beneficial in only a very narrow and specific set of conditions and harmful or at the very least not helpful in the vast majority of times it is actually used. In the absence of clear benefit, the patient is exposed only to risk. An excellent review of the impact on patient outcomes has been written by Aryeh Shander, MD, and can be found in the journal, Seminars in Hematology.^[4]

[edit] How is this achieved?

Patient blood management in the perioperative setting can be achieved by means of a variety of techniques and strategies. First, ensuring that the patient enters the operating room with a sufficient hematocrit level is essential. Preoperative anemia has been documented to range from 5% in female geriatric hip fracture patients to over 75% in colon cancer patients.^[5] Patients who are anemic prior to surgery obviously receive more transfusions. Erythropoietin and iron therapy can be considered in cases of anemia. Accordingly, patients should be screened for anemia at least 30 days prior to an elective surgical procedure.

During surgery, techniques are utilized to reduce or eliminate exposure to allogeneic blood. For example, electrocautery, which is a technique utilized for surgical dissection, removal of soft tissue and sealing blood vessels, can be applied to a variety of procedures. Blood that is lost during surgery can be collected, filtered, washed and given back to the patient. This procedure is known as "Intraoperative Blood Salvage."^[6] Another technique, acute normovolemic hemodilution" involves the collection of a selected calculated volume of autologous blood in collection bags prior to the start of surgery with the simultaneous replacement of an equal volume of asanguinous fluid. Since the patient's blood is now diluted, blood lost during the surgical procedure, i.e. by hemorrhage, contains smaller amounts of red blood cells. The collected autologous blood product, which contains red blood cells, platelets and coagulation factors, is reinfused at the end of the surgery.^[7] Pharmacologic agents can also be utilized to minimize blood loss. When all of these therapies are combined, blood loss is greatly reduced which correspondingly reduces or averts the potential for allogeneic blood transfusion. Additional details on this question can be found in the journal, Transfusion.^[8]