Patient blood management
Authors: Dubrov S.O. 
Published: July 2021

Background. Blood transfusions (BT) remain one of the most common medical procedures: about 110,000 doses of whole blood are collected annually and almost as many are transfused. Approximately every 10th patient who undergoes invasive procedures in the hospital needs BT. However, 40-60 % of BT in patients without bleeding are inappropriate.

Objective. To describe modern views on the BT.

Materials and methods. Analysis of the literature on this issue.

Results and discussion. The triad of major risk factors for perioperative complications includes three interrelated factors: blood loss, anemia, and BT. The use of blood products is accompanied by an increase in the number of complications (not directly related to BT) and 30-day mortality. Fatal consequences of blood transfusion are also possible. They include acute lung damage associated with BT, hemolytic and bacterial complications, circulatory overload, anaphylaxis. Patient blood management (PBM) includes early detection and treatment of preoperative anemia, especially in patients at high risk of bleeding; minimization of blood loss and maximally blood-saving tactics; rational and guideline-adequate administration of allogenic blood products. About 39 % of patients scheduled for surgery have preoperative anemia. Absolute iron deficiency (ID) is present in 62 % of patients with preoperative anemia. Ferritin level <30 μg/L is an indicator of such anemia. Preoperative anemia is an independent risk factor for mortality and complications, so in presence of anemia, major emergency surgery should be postponed until hemoglobin returns to normal. The target level of the latter in the treatment of preoperative anemia should be 130 g/L for both sexes. If surgery is scheduled 6-8 weeks after the revealing of ID with or without anemia, oral replacement therapy should be performed. Parenteral forms of iron are used if there are <6 weeks left before the planned operation or the hemoglobin level is <100 g/L. If necessary, BT can be performed according to a liberal (BT is prescribed at a hemoglobin level <90-100 g/L) or restrictive (<70-80 g/L) strategy. According to a large-scale meta-analysis, the latter almost halves the risk of erythromass transfusion compared to the former. As recommended by the National Institute for Health and Care Excellence, it is advisable to apply a single-dose strategy with reassessment of BT requirements after each blood transfusion. Decisions in patients with chronic BT-dependent anemia and cancer should be made individually. The use of intravenous iron supplements before surgery can reduce the number of BT in the postoperative period. Sufer (“Yuria-Pharm”) is a trivalent iron for intravenous use, which effectively, quickly and safely increases hemoglobin levels. As it was mentioned, another element of the PBM is the minimization of blood loss. Tranexamic acid preparations (Sangera, “Yuria-Pharm”) can be prescribed for this purpose. Tranexamic acid is a lysine-like inhibitor of fibrinolysis; it is recommended for the prevention of bleeding with expected moderate and severe blood loss (>500 ml). In patients with trauma with massive blood loss or with a high risk of intracranial hemorrhage, it is also advisable to use tranexamic acid. Its activity is 26 times higher than the activity of aminocaproic acid. Tranexamic acid is highly effective; it reduces the need for BT without increasing the risk of thrombosis.

Conclusions. 1. The triad of major risk factors for perioperative complications includes three interrelated factors: blood loss, anemia, and BT. 2. PBM includes early detection and treatment of preoperative anemia, minimization of blood loss and adequate administration of allogenic blood products. 3. In conditions of preoperative anemia, it is advisable to correct diabetes with oral or parenteral forms of iron. 4. Tranexamic acid drugs are prescribed to minimize blood loss.