NoBlood

From Pharmacotherapy
Posted 10/29/2007

Blood Management: A Primer for Clinicians
Bradley A. Boucher, Pharm.D., FCCP, FCCM; Timothy J. Hannon, M.D., M.B.A.
Abstract
Blood transfusions are common in the hospital setting. Despite the large commitment of resources to the delivery of blood components, many clinicians have only a vague understanding of the complexities associated with blood management and transfusion therapy. The purpose of this primer is to broaden the awareness of health care practitioners in terms of the risks versus benefits of blood transfusions, their economics, and alternative treatments. By developing and implementing comprehensive blood management programs, hospitals can promote safe and clinically effective blood utilization practices. The cornerstones of blood management programs are the implementation of evidence-based transfusion guidelines to reduce variability in transfusion practice, and the employment of multidisciplinary teams to study, implement, and monitor local blood management strategies. Pharmacists can play a key role in blood management programs by providing technical expertise as well as oversight and monitoring of pharmaceutical agents used to reduce the need for allogeneic blood.
Introduction
Transfusion of blood products is one of the most common interventions in the hospital setting. The number of blood components trans-fused in the United States was approximately 29 million in 2004.[1] This equates to nearly 80,000 units of blood components transfused every day. In light of the high volume of blood transfusions and their associated risks, regulatory and professional organizations, including the Joint Commission, the American Association of Blood Banks, and the College of American Pathologists, require ongoing monitoring of blood utilization within institutions.[2] The United States Food and Drug Administration (FDA), however, is responsible for ensuring the safety of the nation's blood supply, as well as food and drug safety. Despite the commitment to a large number of resources necessary for the delivery of blood components, and the focus of the FDA and the Joint Commission on safety initiatives, many practitioners have only a vague understanding of the complexities associated with blood transfusion therapy. Owing in large part to a lack of formal training in transfusion medicine for most clinicians, the administration of blood products is surrounded by emotions, misconceptions, myths, and prescribing by habit.[3] Furthermore, despite mounting evidence demonstrating significant harm from unnecessary blood transfusions,[4–6] results of several studies document a generalized lack of compliance with appropriate transfusion guidelines, as well as tremendous variation in transfusion practice among different institutions and among individual physicians within the same institution.[7–11]

This lack of familiarity with transfusion guidelines is true not only for physicians and nurses, but also for pharmacists whose focus is primarily on pharmacologic therapy. In many institutions, this is clearly an example of the "silo" mentality where each respective depart-ment and their staff may be naEFve to the challenges being faced by other departments relative to the delivery of optimal health care. In essence, hospital pharmacies take responsibility for the safe storage and effective delivery of drugs to the patient's bedside, whereas blood bank departments are responsible for the same func-tions for blood products. Nonetheless, pharmacists as well as physicians and other health care practitioners have been forced in recent years to become more familiar with blood component therapy by necessity, as drug therapies have clearly overlapped with blood component therapies as therapeutic alternatives. Specific examples include the use of erythropoiesis-stimulating agents, alternatives to red blood cell transfusions, hemostatic agents (e.g., recombinant activated factor VII [rFVIIa]) in patients with refractory hemorrhage, and iron supplementation. Thus, many institutions have embraced the concept of blood management, which can be defined as an evidence-based, multidisciplinary process designed to promote the optimal use of blood products throughout the hospital. The purpose of this review is to serve as a primer on blood management for pharmacists and other health care practitioners interested in broadening their understanding of allogeneic transfusions.