Attending the Society for the Advancement of Blood Management meeting in Cancun, Mexico, was an opportunity to gain current perspectives on techniques in allogenic blood conservation, if not elimination.
A diverse schedule was on tap and, refreshing was the review of current literature and reiteration of well established methodology.
If allogenic blood use is to be scrutinized, the goal should not be reduction of use but total elimination. The religious conviction of the Jehovah’s Witness may be the best philosophy to adopt in the best interest of every patient. The approach, or belief, that any use of allogenic products constitutes failure can easily be adopted and, seeing that it has been implemented elsewhere, can be attained with reasonable effort.
Working at a facility where autologous cell saver product is often discarded, the belief of the surgeons is that it contains heparin and thus is responsible for post protamine bleeding, only to use allogenic products, this meeting was very refreshing. The environment in which we practice can often result in ‘dumbing down’ in our approach; we must continue to practice in support of the surgeons who dictate our patient care. Thus, this meeting was invigorating in reaffirming practices that have been proven nationwide.
The key phrases being presented included adjectives including ‘peer reviewed’ and ‘evidence based’, along with ‘double blinded’; these seem to cover a vast array of scientific papers whose conclusions serve to shape and drive practices whose ultimate goal is the elimination of allogenic blood use.
While I will contend that I am not a physician; listening to anesthesiologists who report practicing guidelines, that reduce transfusions until the mixed venous saturations fall below 55%, provided significant food for thought coming from a practice where we transfuse at saturations below 70%!
Several approaches warrant closer observation; the use of erythropoietin to stimulate the bone marrow to produce red blood cells and thus raise the preoperative hematocrit has merit. Folic acid, iron supplements and Vitamin B-12 have been successful in the management of patient’s hematocrit who may have presented in anemic conditions.
Reducing all blood draws preoperatively, in addition to reducing the volume of these samples has been encouraged. Reports that the volume of these samples have not changed in years, while the testing devices have continued to reduce their required volumes, leads one to think that further change is necessary. Englewood Hospital, New Jersey, has gone completely to pediatric tubes in this regard; they reported a several 100mls reduction in just laboratory specimens and consequent gains in patient’s hematocrit.
Preoperative blood management requires a multi-disciplinary approach to create an infrastructure that provides evidence-based actions. Actions are the alternative transfusion pathways that have been proactively configured to maximize clinical and cost benefits.
Each unit of blood, allogenic or autologous, transfused or collected, has an impact on either the patients’ outcome or the costs to provide appropriate care.In-depth clinical and costs/benefits analysis is required to assure accurate and effective outcomes.
Establishing an effective Transfusion Committee is essential to implementing transfusion practices. This committee should be lead by an opinion leader and contain a multi-disciplinary membership covering; physicians, nurses, blood bank staff, perfusionists, risk managers, representatives from Information technology and Quality Managers.
Their goals should be;
1) Educate
2) Improvement Strategies
3) Collect Metrics
Sobering statistics were presented;
Price Waterhouse reported $210 billion in defensive medical tests which included redundant, inappropriate or unnecessary tests.
The US ranks 15th out of 19 industrial nations in quality of care of their patients, although we spend twice as much per patient in care rendered.
100, 000 patients per year die in hospitals for reasons other than their admission diagnosis.
Platelet Gel reimbursements were a small issue, several practitioners reported on billing strategies that boarded on the unethical. While no specific coding exists for platelet gel, methods of procuring positive billing results included using codes for blood draws and analysis. I suspect that this will not last for long, nor will they be encouraged by institutions.
On another note; the practice of using 3L bags of saline for cell salvaging during the wash phase was considered. These bags are indicated by the manufacturer for irrigation only, not intravenous use! I thought it overly ambitious that this practice was endorsed. It would seem that substituting an ‘irrigation only’ substrate in place of an easily obtained intravenous product, benefits the user only. Any patient benefit is not being considered. This practice should be brought to the attention of the institution’s risk manager for further review. Personally, I feel like it is a flawed approach and will not support its practice.
In closing; thank you for allowing me to attend this refreshing meeting devoted solely to the conservation of blood products. Other meetings try to cover too much material, even while pertinent, and current ‘hot’ topics are left in supporting roles. I look forward to practicing the principles gained from this attendance.
