Holistic patient blood management cautions transfusion decisions

Blood transfusions are common practice in critical care settings but are slowly becoming recognized as potentially oversimplified approaches to tackle complex underlying issues.

We speak to Dr. Aryeh Shander, an anesthesiologist and intensivist at Englewood Hospital & Medical Center in New Jersey, US and Dr. Pierre Tibi, a cardiothoracic surgeon at Yavapai Regional Medical Center, Arizona, US to explore the intricacies of the multidisciplinary field of patient blood management. They share the importance of reconsidering routine transfusion-first practices, and instead opt to understand the clinical context and patient's overall health to help address the root cause of anemia and minimize blood loss in critically ill patients.

Contextualize hemoglobin results

Blood transfusion is a common practice in the intensive care unit (ICU), often guided by established transfusion guidelines, based on hemoglobin levels. However, Dr. Shander and Dr. Tibi caution that hemoglobin levels are not always reliable indicators of a patient’s need for blood, as they can fluctuate with time and changes in plasma volume. Moreover, different methods of hemoglobin determination - ranging from complete blood counts to non-invasive devices - can have variable results which may impose additional limitations. Clinicians may tend to rely on hemoglobin levels at face value, but this can be misleading if the underlying cause of low hemoglobin is not addressed. Thus, when assessing a patient with anemia, it is essential to contextualize hemoglobin levels against the full clinical picture, says Dr. Shander. “Regardless of the hemoglobin level, if the patient is ‘stable’ and exhibits no distress, the focus should be on identifying and treating the cause of anemia with appropriate medications rather than immediately resorting to transfusion,” he advocates. “In cases where the patient is unstable, a more cautious approach is recommended, starting with a single unit of blood, followed by reassessment.”

This aligns with Dr. Tibi’s doctrine, who firmly believes that the need for blood transfusions should ideally be assessed before a patient becomes critically ill. “For instance, in my field of cardiothoracic surgery, operating on an anemic patient without addressing the anemia beforehand is considered a failure to prepare the patient adequately for surgery,” he explains. “The recommended approach is to identify and treat the cause of anemia - which is often iron deficiency in cardiac patients. By treating the iron deficiency and the anemia preoperatively, the risk of bleeding and requiring transfusions is minimized.”

A holistic approach to patient blood management

When discussing the concept of patient blood management, Dr. Shander explains it encompasses all aspects of a patient’s blood health, including red cells, coagulation defects and abnormalities, and blood loss or conservation. “Hemostasis is a key concept of patient blood management, emphasizing the importance of minimizing blood loss,” shares Dr. Shander. “As of two decades ago, hemostasis was defined simply as the cessation of bleeding. With advances in medicine and a deeper understanding of the concept, it has now been redefined as the balance between bleeding to death versus clotting to death. Additionally, patient blood management also focuses on the timely identification of patients at risk of thrombotic events, who may need prophylactic anticoagulation.”

Managing and measuring the effects of anticoagulation therapy can be complex, even as newer viscoelastic tests are showing promise in monitoring and managing coagulopathy in real time. Dr. Tibi emphasizes that a deep understanding of the coagulation system, combined with correlating laboratory results with a full clinical picture, can help reduce unnecessary transfusions. While multiple clinical guidelines exist for managing these patients, applying them in practice requires careful assessment of each patient’s response to their medication and the urgency of their surgical condition. Although some blood loss is inevitable during surgery, minimizing it is crucial, notes Dr. Tibi. “During surgery, various techniques are employed to minimize blood loss, such as using specialized perfusion pumps, topical hemostatic agents, and antifibrinolytic agents,” he elaborates. “Additionally, we also use critical factors, such as the extent of feasible dilution of the patient’s blood, as well as how much anemia can be tolerated, to inform key decision-making during the surgery.”

Lastly, both experts agree that although monitoring hematological parameters is essential, it should be done judiciously to avoid unnecessary blood draws – especially post-operatively – as this can otherwise also exacerbate anemia. Dr. Shander cautions that repeated phlebotomy for blood tests, which are not always necessary, can be a significant cause of blood loss in critically ill patients: “Healthy adults can typically replace around 40 ml of red blood cells daily. However, critically ill patients may not have this capacity and may lose more blood than they can replace due to frequent draws.” Dr. Tibi concurs, noting that post-operative hemoglobin levels typically rise unless there is active bleeding, suggesting that frequent monitoring may not be necessary in all cases.

Move away from a transfusion-first approach

It is imperative to actively recognize the potential risks associated with blood transfusion, both experts caution. “A blood transfusion is essentially an organ transplant,” explains Dr. Shander, “with each unit of transfused blood introducing active foreign proteins into the recipient’s body, even when there is an ABO match between donor and recipient.” Unlike other organ transplants, blood transfusions do not involve concomitant immunosuppression to protect the recipient from adverse reactions. Most of the available literature on this topic advises against blood transfusions unless there is a clear clinical necessity, shares Dr. Tibi. “Transfusions carry the risk of immunomodulation, which subsequently increases the risk of infections, acute lung injury or acute kidney injury, resulting in prolonged hospital stays, or even death,” Dr. Shander continues. “To mitigate these risks, it is crucial to reduce or eliminate a patient’s exposure to transfusions.”

“Patient blood management is easy to understand, but challenging to implement, and that’s where the difficulty lies,” notes Dr. Tibi. “It requires a comprehensive, multidisciplinary approach, but it is still a relatively new field. Successful patient blood management involves getting everyone in patient care on board - not just patients, surgeons and anesthesiologists, but also nursing staff, laboratory technicians and pharmacists. The support of hospital administration is also vital. While implementing patient blood management strategies may involve upfront costs, such as purchasing viscoelastic testing equipment, these are often offset by the long-term benefits, which can include reduced transfusion rates and associated risks, improved patient outcomes, and lower overall healthcare costs.”

Changing the ingrained culture of relying on transfusions as the default treatment for anemia in ICU patients is challenging, but nonetheless essential, acknowledges Dr. Shander. In many instances, transfusion has become a routine response rather than a last resort. “Educating healthcare providers and challenging the entrenched culture of transfusion-first approaches are crucial steps in ensuring that blood transfusions are used appropriately and effectively in critically ill patients,” concludes Dr, Shander. “In other areas of medicine, organ transplants are considered only after all other treatments have been exhausted - the same principle should apply to blood transfusions!”