Patient Blood Management
Impact Statement: Patient blood management (PBM) recommendations can help providers manage anemia and assist in transfusion-related decision-making.
Introduction: Blood transfusions are often a necessary treatment for operative patients, but they are not without potential complications, including hemolytic reactions, and even death. Establishing parameters and guidelines for transfusions in patients undergoing an operation is imperative in treating them safely and effectively; patient blood management protocols provide these guidelines.
Literature review: Patient blood management (PBM) is based on three pillars: treatment of underlying anemia, minimizing blood loss, and the use of transfusion thresholds. Establishing hemoglobin levels that dictate transfusion thresholds can be either restrictive (transfusing at lower thresholds) or liberal (transfusing at higher thresholds). Current literature recommends restrictive transfusion thresholds (hemoglobin less than 7 gm/dL) with consideration for individual patient status.
Description of the case: A 56-year old male underwent an emergent exploratory laparotomy to locate a source of bleeding four days after having a hemicolectomy. He received one unit of packed red blood cells (PRBCs) in the intensive care unit overnight and arrived in the operating room (OR) on a phenylephrine drip. After induction, the patient required a vasopressin drip as well. The patient remained hemodynamically unstable and his hemoglobin was 9.8 g/dL, thus, the decision was made to administer one unit of PRBCs in the OR. The patient remained unstable throughout the case and a hemoglobin recheck was 9.5 g/dL, so a second unit of PRBCs was given. The transfusion threshold utilized in this case was liberal (less than 10 g/dL).
Discussion and conclusions: In this case, all three pillars of PBM were taken into account. Pre-operative anemia was treated with a blood transfusion. Determining the cause and providing treatment of anemia before surgery can help decrease the need for transfusions. There was minimal intraoperative blood loss during the case, however techniques to manage this potential complication include: cell saver, hemodilution, and goal-directed fluid therapy. Finally, a liberal transfusion threshold was found appropriate as the patient was hemodynamically unstable. A lower transfusion threshold (less than 7 g/dL) is generally recommended for stable patients. Utilization of PBM can help guide transfusion decision-making and decrease the number of blood products given without increasing patient morbidity or mortality.
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