RevBrasAnestesiol.2016;66(3):333---334
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
LETTER
TO
THE
EDITOR
Patient
Blood
Management
:
where
to
start?
Patient
Blood
Management
:
por
onde
comec
¸ar?
DearEditor,
Most anesthesiologists recognize the harmful effects of
transfusiontherapyandtrytoavoidexposuretoallogeneic
blood,althoughsomeofthemdecidedlyhavenointerested
inthesubjectandperformtransfusionwithoutphysiological orevenlaboratorycriteria.However,itislikelythatthere
areanesthesiologistswhohavenevertransfusedonebagof
packedred blood cells(RBCs) and/or freshfrozen plasma
andthismakesthesubjectbloodtransfusionquiterelevant
andgenerallycontroversial.
Blood is the most transfused organ in the world, with
about14millionunitsofpackedRBCstransfusedeachyear,
whichrepresentsacostofapproximatelyUS$3billion
(aver-ageof$225per RBCs).1 Havinginyour hospitalaprogram
thatcombatsthis‘‘need’’forbloodtransfusioncanimprove
patientoutcomes,minimizerisk,andreduce costs.Inthis
sense,thetermPatientBloodManagement(PBM)was
cre-ated,whichconsistsofapplyingamultidisciplinaryapproach
basedonmedicalevidenceandsurgicalconceptsthatis
hos-pitalindependentandpatient-centeredforearlydiagnosis
andtreatmentofanemia,applicationofbloodconservation
techniques,carefulsurgicalhemostasis,andrationaluseof
bloodproductsinordertoimproveaboveallthepatient’s
prognosis.Since2010, theWorldHealth Organization
rec-ommendedtheapplicationofPMBasastrategyforreducing
thenumberofRBCstransfusionsworldwide.2
And why start using such a program? Statistical data
providetheanswer.Hospitalstayofnon-transfusedpatients
isonaverage25%lowerthanthatoftransfusedpatients.3
Studies show that the implementation of a transfusion
strategy program in heart surgery reduces death rate by
47%andpost-surgicalhospitalcostsby50%.4However,the
pointconsideredmoreimportantandinwhichprobablyall
anesthesiologists can act in a simple and very effective
wayisthemanagementofpreoperative anemia.It isvery
easy to diagnose an anemic patient in a pre-anesthetic
consultation, as well as treat him (for such, it is worth
reading these two good articles on how to manage an
anemic patient during the pre-anesthetic visit).5,6 Within
a very reasonable period of 15---20 days we can manage
theanemic condition of the patientand he mayundergo
surgery within acceptable limits. And that makes all the
difference, as preoperative anemia is directly related to
redbloodcelltransfusionduringsurgery,which isacause
of increased morbidity and postoperative mortality.7---9
The preoperative diagnosis and appropriate treatment
of anemia reduce the incidence of transfusion by 62%.10
Manyof us, anesthesiologists,believe that anemia is not
as frequent or is harmless, but according to the World
HealthOrganization data therearemore thantwo billion
anemicpeopleworldwide.11Onaverage,15---40%ofpatients
haveanemiaat thetimeofsurgery and,accordingtothe
conceptsof PBM,anemiais a contraindicationtoelective
surgery,withanexpectedmoderatetoseverebloodloss.12
So,here is a proposaland a challenge: anemiashould
bediagnosedandtreatedbeforesurgery.Thataloneisthe
firstandmajorsteptoreducebloodtransfusion,whichwill
greatlybenefitthepatientandimprovethequalityofour
anesthesia.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.DepartmentofHealthandHumanServices.The2011national bloodcollectionandutilizationsurveyreport.Washington,DC: DHHS;2013.
2.World Health Organisation Web site. http://www.who.int/
bloodsafety/clinicaluse/en/.
3.Sarode R, RefaaiMA, MatevosvanK, etal. Prospective mon-itoringofplasmaandplatelettransfusionsinalargeteaching hospitalresultsinsignificantcostreduction.Transfusion(Paris). 2010;50:487---92.
4.LaPar DJ, Crosby IK, Ailawadi G, et al. Blood product conservation is associated with improved outcomes and reducedcostsaftercardiacsurgery.JThoracCardiovascSurg. 2013;145:796---803.
5.GoodnoughLT,ShanderA.PatientBloodManagement. Anesthe-siology.2012;116:1367---76.
http://dx.doi.org/10.1016/j.bjane.2014.12.003
334 LETTERTOTHEEDITOR
6.GoodnoughLT,ManiatisA,EarnshawP,etal.Detection, evalua-tion,andmanagementofpreoperativeanaemiaintheelective orthopaedic surgical patient: NATA guidelines. Br JAnaesth. 2011;106:13---22.
7.Baron DM, Hochrieser H, Posch M, et al. Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients. Br J Anaesth. 2014;113: 416---23.
8.Rohde JM, Dimcheff DE, Blumberg N, et al. Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA. 2014;311: 1317---26.
9.SilvaJMJr,CezarioTA,ToledoDO,etal.Transfusãosanguíneano intra-operatório.Complicac¸õeseprognóstico.RevBras Aneste-siol.2008;58:447---61.
10.Na HS,Shin SY,HwangJY, et al.Effects ofintravenous iron combinedwithlow-doserecombinanthumanerythropoietinon transfusion requirements in iron-deficient patients undergo-ingbilateraltotalkneereplacementarthroplasty.Transfusion (Paris).2011;51:118---24.
11.Focusing on anemia --- towards an integrated approach for
effective anaemia control. Joint Statement by the World
HealthOrganizationandtheUnitedNationsChildren’sFund
---WHO/UNICEF.
12.Spahn DR, Goodnough LT. Alternatives to blood transfusion. Lancet.2013;381:1855---65.
LianaMariaTorresdeAraujoAzia,b,∗, LuisVicenteGarciaa
aDepartamentodeBiomecânica,MedicinaeReabilitac¸ão
doAparelhoLocomotor,HospitaldasClínicasdaFaculdade deMedicinadeRibeirãoPreto,UniversidadedeSãoPaulo (FMRP-USP),RibeirãoPreto,SP,Brazil
bHospitalUniversitárioProfessorEdgardSantos(UFBA),
Salvador,BA,Brazil
∗Correspondingauthor.
E-mail:[email protected](L.M.T.A.Azi).
