Patient Blood Management – Das Konzept

Patient Blood Management umfasst ein multimodales und interdisziplinäres Konzept zur Verbesserung der Patientenversorgung durch Reduktion der Exposition allogener Blutprodukte. Hierbei basiert das Konzept auf 3 Säulen: 1. Diagnostik/Therapie einer präoperativen Anämie, 2. dem rationalen Einsatz von Erythrozytenkonzentraten und Ausschöpfung der individuellen Anämietoleranz und 3. der Reduktion des Blutverlustes.

Durch Einführung des Patient Blood Managements ist es möglich, die Transfusionsraten zu senken und damit unmittelbaren Einfluss auf unerwünschte Nebenwirkungen zu haben. Pneumonierate, Krankenhausverweildauer und auch Mortalität sinken. Im folgenden Beitrag werden die Grundsätze erklärt und Hilfestellungen anhand von Checklisten angeboten.

Patient blood management comprises a multimodal and interdisciplinary concept for improving patient care by reducing exposure to allogeneic blood products. The concept is based hereby on three pillars: 1) diagnostics of/therapy for preoperative anemia, 2) the rational use of erythrocyte concentrates and full exploitation of the individual tolerance to anemia and 3) the reduction of blood loss.

By introduction of patient blood management it is possible to lower the rate of transfusion and thus to have a direct influence on undesired side effects. Rates of pneumonia, length of hospital stay and also mortality can be reduced. In the present contribution the basic principles are explained assistance provided in the form of checklists.

Key words

Patient blood management - preoperative anemia - erythrocyte concentrates - individual tolerance to anemia - blood loss - transfusion rate - mortality

• Literatur

• 1 Nutritional anaemias. Report of a WHO scientific group. World Health Organ Tech Rep Ser 1968; 405: 5-37
• 2 Bierbaum BE, Callaghan JJ, Galante JO et al. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999; 81: 2-10
• 3 Goodnough LT, Shander A, Spivak JL et al. Detection, evaluation, and management of anemia in the elective surgical patient. Anesth Analg 2005; 101: 1858-1861
• 4 Shander A, Knight K, Thurer R et al. Prevalence and outcomes of anemia in surgery: a systematic review of the literature. Am J Med 2004; 116 (Suppl. 01)
• 5 Van Straten AHM, Hamad MAS, van Zundert AJ et al. Preoperative hemoglobin level as a predictor of survival after coronary artery bypass grafting: a comparison with the matched general population. Circulation 2009; 120: 118-125
• 6 Musallam KM, Tamim HM, Richards T et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 2011; 378: 1396-1407
• 7 Spahn DR, Goodnough LT. Alternatives to blood transfusion. Lancet 2013; 381: 1855-1865
• 8 Hourfar MK, Jork C, Schottstedt V et al. Experience of German Red Cross blood donor services with nucleic acid testing: results of screening more than 30 million blood donations for human immunodeficiency virus-1, hepatitis C virus, and hepatitis B virus. Transfusion 2008; 48: 1558-1566
• 9 Pedersen AB, Mehnert F, Overgaard S, Johnsen SP. Allogeneic blood transfusion and prognosis following total hip replacement: a population-based follow up study. BMC Musculoskelet Disord 2009; 10: 167-167
• 10 Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane database Syst Rev CD 005033 2006;
• 11 Murphy GJ, Reeves BC, Rogers CA et al. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007; 116: 2544-2552
• 12 O'Keeffe SD, Davenport DL, Minion DJ et al. Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization. J Vasc Surg 2010; 51: 1-3
• 13 Xenos ES, Vargas HD, Davenport DL. Association of blood transfusion and venous thromboembolism after colorectal cancer resection. Thromb Res 2012; 129: 568-572
• 14 Bernard AC, Davenport DL, Chang PK et al. Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J Am Coll Surg discussion 2009; 208: 938-939
• 15 Van Straten AHM, Bekker MWA, Soliman Hamad MA et al. Transfusion of red blood cells: the impact on short-term and long-term survival after coronary artery bypass grafting, a ten-year follow-up. Interact Cardiovasc Thorac Surg 2010; 10: 37-42
• 16 Glance LG, Dick AW, Mukamel DB et al. Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 2011; 114: 283-292
• 17 Al-Refaie WB, Parsons HM, Markin A et al. Blood transfusion and cancer surgery outcomes: a continued reason for concern. Surgery 2012; 152: 344-354
• 18 Mikkola R, Gunn J, Heikkinen J et al. Use of blood products and risk of stroke after coronary artery bypass surgery. Blood Transfus 2012; 10: 490-501
• 19 Ferraris VA, Davenport DL, Saha SP et al. Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Arch Surg 2012; 147: 49-55
• 20 Howard-Quijano K, Schwarzenberger JC, Scovotti JC et al. Increased red blood cell transfusions are associated with worsening outcomes in pediatric heart transplant patients. Anesth Analg 2013; 116: 1295-1308
• 21 McIntyre LA, Fergusson DA, Hutchison JS et al. Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury. Neurocrit Care 2006; 5: 4-9
• 22 Grover M, Talwalkar S, Casbard A et al. Silent myocardial ischaemia and haemoglobin concentration: a randomized controlled trial of transfusion strategy in lower limb arthroplasty. Vox Sang 2006; 90: 105-112
• 23 Carson JL, Terrin ML, Noveck H et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011; 365: 2453-2462
• 24 Lacroix J, Hébert PC, Hutchison JS et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356: 1609-1619
• 25 Villanueva C, Colomo A, Bosch A et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368: 11-21
• 26 Hajjar LA, Vincent J-L, Galas FRBG et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA 2010; 304: 1559-1567
• 27 Hébert PC, Wells G, Blajchman MA et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340: 409-417
• 28 Borkent-Raven BA, Janssen MP, van der Poel CL et al. The PROTON study: profiles of blood product transfusion recipients in the Netherlands. Vox Sang 2010; 99: 54-64
• 29 Wells AW, Mounter PJ, Chapman CE et al. Where does blood go? Prospective observational study of red cell transfusion in north England. BMJ 2002; 325: 803-803
• 30 Greinacher A, Fendrich K, Brzenska R et al. Implications of demographics on future blood supply: a population-based cross-sectional study. Transfusion 2011; 51: 702-709
• 31 Tettamanti M, Lucca U, Gandini F et al. Prevalence, incidence and types of mild anemia in the elderly: the “Health and Anemia” population-based study. Haematologica 2010; 95: 1849-1856
• 32 Ganzoni AM. Eisen-Dextran intravenös: Therapeutische und experimentelle Möglichkeiten. Schweiz Med Wochenschr 1970; 100: 301-303
• 33 http://www.patientbloodmanagement.de
• 34 Bundesärztekammer: Querschnitts-Leitlinien (BÄK) Zur Therapie Mit Blutkomponenten Und Plasmaderivaten.
• 35 Song HK, von Heymann C, Jespersen CM et al. Safe application of a restrictive transfusion protocol in moderate-risk patients undergoing cardiac operations. Ann Thorac Surg 2014; 97: 1630-1635
• 36 Karkouti K, Wijeysundera DN, Yau TM et al. The influence of baseline hemoglobin concentration on tolerance of anemia in cardiac surgery. Transfusion 2008; 48: 666-672
• 37 Kiran RP, Delaney CP, Senagore AJ et al. Operative blood loss and use of blood products after laparoscopic and conventional open colorectal operations. Arch Surg 2004; 139: 39-42
• 38 Cirocchi R, Montedori A, Farinella E et al. Damage control surgery for abdominal trauma. Cochrane database Syst Rev CD 007438 2013; 3
• 39 Levy O, Martinowitz U, Oran A et al. The use of fibrin tissue adhesive to reduce blood loss and the need for blood transfusion after total knee arthroplasty. A prospective, randomized, multicenter study. J Bone Joint Surg Am 1999; 81: 1580-1588
• 40 Carless PA, Henry DA, Carson JL et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane database Syst Rev CD 002042 2010;
• 41 Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth 2010; 105: 401-416
• 42 Lemay E, Guay J, Côté C, Roy A. Tranexamic acid reduces the need for allogenic red blood cell transfusions in patients undergoing total hip replacement. Can J Anaesth 2004; 51: 31-37
• 43 Kozek-Langenecker SA, Afshari A, Albaladejo P et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30: 270-382
• 44 Spahn DR, Bouillon B, Cerny V et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 2013; 17
• 45 Kotzé A, Carter LA, Scally AJ. Effect of a patient blood management programme on preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthroplasty: a quality improvement cycle. Br J Anaesth 2012; 108: 943-952
• 46 Theusinger OM, Kind SL, Seifert B et al. Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. Blood Transfus 2014; 12: 195-203
• 47 Ji H, Li Z, Sun H et al. Effects of multidisciplinary blood management strategy on transfusion and outcomes in patients undergoing valvular heart surgery. Zhonghua Yi Xue Za Zhi 2014; 94: 488-490