eprintid: 10046889 rev_number: 31 eprint_status: archive userid: 608 dir: disk0/10/04/68/89 datestamp: 2018-04-17 15:09:04 lastmod: 2021-12-27 01:16:30 status_changed: 2018-04-17 15:09:04 type: article metadata_visibility: show creators_name: Desai, N creators_name: Schofield, N creators_name: Richards, T title: Perioperative Patient Blood Management to Improve Outcomes ispublished: pub divisions: UCL divisions: B02 divisions: D65 divisions: J38 note: This version is the author accepted manuscript. For information on re-use, please refer to the publisher’s terms and conditions. abstract: Anemia is common in elective surgery and is an independent risk factor for morbidity and mortality. Historical management of anemia has focused on the use of allogeneic blood transfusion but this in itself is not without risk. It too has been independently associated with morbidity and mortality, let alone the costs and relative shortage of this resource. In recognition of this, patient blood management (PBM) shifts the focus from the product to the patient and views the patient's own blood as a resource that should be conserved and managed appropriately as a standard of care. It consists of 3 pillars: the optimization of red blood cell mass; reduction of blood loss and bleeding; and optimization of the patient's physiological tolerance toward anemia. Integration of these 3 pillars in the form of multimodal care bundles and strategies into perioperative pathways should improve care processes and patient outcome. Preoperative anemia is most commonly caused by functional iron deficiency and should be treated with oral iron, intravenous iron, and/or recombinant erythropoietin. An individualized assessment of the thrombotic risk of discontinuing anticoagulant and antiplatelet medication should be balanced against the risk of perioperative bleeding. Neuraxial anesthetic techniques should be considered and minimally invasive surgery undertaken where appropriate. Cell salvage should be used if significant blood loss is anticipated and pharmacological treatments such as tranexamic acid and fibrin sealants have been shown to reduce blood loss. Point of care tests can guide the perioperative management of dynamic coagulopathy. Blood testing sampling should be performed only when indicated and when taken, sample volume and waste should be minimized. Restrictive blood transfusion thresholds and reassessment after single unit transfusion should be incorporated into clinical practice where appropriate. For PBM to become standard practice in routine surgical care, national health care quality change initiatives must set the agenda for change but the patient-centered approach to PBM should be delivered in a way that is also hospital centered. Characterization of the current practice of PBM at each hospital is crucial to facilitate the benchmarking of performance. Barriers to effective implementation such as lack of knowledge should be identified and acted on. Continuous audit of practice with a focus on transfusion rates and patient outcomes can identify areas in need of improvement and provide iterative feedback to motivate and inspire the main stakeholders. date: 2018-11-01 date_type: published official_url: http://dx.doi.org/10.1213/ANE.0000000000002549 oa_status: green full_text_type: other language: eng primo: open primo_central: open_green verified: verified_manual elements_id: 1504405 doi: 10.1213/ANE.0000000000002549 lyricists_name: Richards, Toby lyricists_id: TRICH60 actors_name: Dewerpe, Marie actors_id: MDDEW97 actors_role: owner full_text_status: public publication: Anesthesia & Analgesia volume: 127 number: 5 pagerange: 1211-1220 event_location: United States issn: 1526-7598 citation: Desai, N; Schofield, N; Richards, T; (2018) Perioperative Patient Blood Management to Improve Outcomes. Anesthesia & Analgesia , 127 (5) pp. 1211-1220. 10.1213/ANE.0000000000002549 <https://doi.org/10.1213/ANE.0000000000002549>. Green open access document_url: https://discovery.ucl.ac.uk/id/eprint/10046889/3/Richards_Patient%20Blood%20Management%20to%20Improve%20Outcome%20Revision%202%20Highlighted.pdf