Transfusions are one of the most overused treatments in modern medicine, at a cost of billions of dollars.

Transfusions are common procedures, at least in developed nations. In 2011, US doctors transfused 21 million units of blood and blood products; in the United Kingdom, the number was nearly 3 million. But although transfusions can be lifesaving, they are often unnecessary and are sometimes even harmful. “I think we were kind of brainwashed into thinking that blood saves lives, and the more you give the better,” says Steven Frank, an anaesthesiologist and
director of the blood-management programme at the Johns Hopkins Health System in Baltimore, Maryland. “We’ve gone 180 degrees, and now we think that less is more.”

Scientists are now recommending a more conservative approach to transfusions. But changing decades of established medical practice is not easy. Even when guidelines are clear, evidence suggests that clinicians often fail to follow them.

Patient blood management (PBM) programs are associated with improved patient outcomes, reduced transfusions and costs. In 2008, the Western Australia Department of Health initiated a comprehensive health-system–wide PBM program. This study assesses program outcomes.

Implementation of a unique, jurisdiction-wide PBM program was associated with improved patient outcomes, reduced blood product utilization, and product-related cost savings.

Os programas de Patient Blood Management (PBM), para além de visarem a melhoria dos resultados em saúde dos doentes, estão associados a um menor consumo de recursos e à redução de custos em Saúde.
Reconhecendo a importância desta temática e a elevada prevalência que a anemia apresenta no nosso país, a Associação Portuguesa para o Estudo da Anemia juntamente com a EXIGO Consultores, desenvolveram um modelo para avaliação do impacto da implementação de um programa nacional de PBM na saúde pública em Portugal.

A implementação de um PBM a nível nacional poderá representar um impacto substancial na redução da mortalidade intra-hospitalar e carga global das doenças associadas (DALY). Embora Portugal não seja um dos países Europeus com maior consumo de sangue per capita, um programa de PBM representará uma melhoria fundamental nos resultados em saúde relativos à utilização de transfusões e suas consequências na duração do internamento e na taxa de reinternamento.

Em suma, todos estes factores representam um elevado valor em termos de saúde pública, o que também implica um grande valor económico para o Serviço Nacional de Saúde, face à possibilidade de uma poupança substancial após um ano da implementação de um programa de PBM em Portugal.
Na eventualidade da implementação de um PBM em Portugal, a administração de ferro e a estratégia transfusional restritiva de concentrado eritrocitário seriam as intervenções de eleição de acordo com a opinião do grupo de peritos nacionais.

Patient blood management (PBM) is a multidisciplinary concept focused on the management of anaemia, minimisation of iatrogenic blood loss and rational use of allogeneic blood products. The aims of this study were: (i) to analyse post-operative outcome in patients with liberal vs restrictive exposure to allogeneic blood products and (ii) to evaluate the cost-effectiveness of PBM in patients undergoing surgery.
Our results indicate that PBM may be associated with fewer adverse clinical outcomes compared to control management and may, thereby, be cost-effective.

Since the Transfusion Requirements in CriticalCare (TRICC) trial published in 1999 demon-strated equivalent or improved outcomes whenusing a restrictive versus a liberal transfusionthreshold in critically ill patients,1providers and institu-tions have sought to decrease utilization of allogeneicred blood cells by promoting restrictive transfusionpractices. Since that landmark trial, multiple other studiesin different p opulations, including patients undergoingcardiac surgery,2,3elderly patients undergoing hip replace-ment,4medical patients with gastrointestinal bleeds,5andpatients with traumatic brain injury,6have re-demonstrated the equivalence or superiority of restrictiveover liberal transfusion thresholds with regard to patientoutcomes. However, despite a growing body of evidencesupporting this practice, individuals and institutions havefound it surprisingly difficult to adhere to these guidelines.Nonetheless, there remain multiple motivations for reduc-ing superfluous transfusion; blood products are a finiteresource subject to shortage, there are numerous risksassociated with transfusion, and transfusion is an expen-sive endeavor from both direct (acquisition) and indirect(materials, labor , administration) costs.

Almost 150 years after the first autologous blood transfusion was reported, intraoperative blood salvage has become an important method of blood conservation. The primary goal of autologous transfusion is to reduce or avoid allogeneic red blood cell transfusion and the associated risks and costs. Autologous salvaged blood does not result in immunological challenge and its consequences, provides a higher quality red blood cell that has not been subjected to the adverse effects of blood storage, and can be more cost-effective than allogeneic blood when used for carefully selected surgical patients. Cardiac, orthopaedic and vascular surgery procedures with large anticipated blood loss can clearly benefit from the use of cell salvage. There are safety concerns in cases with gross bacterial contamination. There are theoretical safety concerns in obstetrical and cancer surgery; however, careful cell washing as well as leucoreduction filters makes for a safer autologous transfusion in these circumstances. Further studies are needed to determine whether oncologic outcomes are impacted by transfusing salvaged blood during cancer surgery. In this new era of patient blood management, where multimodal methods of reducing dependence on allogeneic blood are becoming commonplace, autologous blood salvage remains a valuable tool for perioperative blood conservation. Future studies will be needed to best determine how and when cell salvage should be utilized along with newer blood conservation measures.

Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.