Patient Blood Management - Revisiting the basics of medicine: patient-centred care.
The medical field has advanced in leaps and bounds. Along with it comes changes in the way we deal with patients or diseases. However, the fundamentals of medicine, namely patient-centred care can sometimes be sidelined in this age and among the aspects that suffer along with it are the high value of a patient’s own blood and the autonomy over his or her own body.
Patient blood management (PBM) redirects our attention and helps us refocus on the most valuable asset of medicine—the patient himself. The true essence of PBM is captured in this definition: “Patient Blood Management (PBM) is the timely application of evidence-based medical and surgical concepts designed to maintain haemoglobin concentration, optimize haemostasis and minimize blood loss in an effort to improve patient outcome.”- Society for the Advancement of Blood Management.
Often in the past, we had focused our attention on guarding or bolstering our supply of blood products. However in that quest, we had missed the point of securing the valuable resources within our very own patients. This has resulted in poorer outcomes in patients as well as higher cost. Delving into PBM had also been deemed unnecessary or too simple to be considered as important, yet it is an irony that simplicity proves to be among the most efficient and essential tool.
It is with this in mind that an examination of PBM and its underlying principles are sought. As shown in the PBM matrix, “Improved patient outcome” is the primary goal. This puts patients in the centre, hence everything else takes second place. A consideration of the four main principles in the matrix will assist us in capturing the essence of PBM.
As a patient’s blood is precious, all efforts should be made to conserve it. This is where ‘interdisciplinary blood conservation modalities’ come into play. Precise and meticulous surgical technique using all available methods of haemostasis is a crucial aspect of conserving a patient’s blood. This has two-fold benefit namely improving a patient’s outcome and sharpening a surgeon’s skills. As any blood loss is esteemed as detrimental, blood loss in all situations needs to be rapidly diagnosed and promptly arrested. Using methods to measure and assess haemoglobin loss is crucial. Besides that, appropriate intraoperative blood conservation modalities should be employed in an evidence-based fashion. Available intra and post-operative autologous blood conservation modalities are important and diagnostic blood loss has to be controlled as well as minimized.
’Managing anaemia’ is another important principle in PBM. It has been a tendency for the medical fraternity to consider anaemia as harmless, with a view that allogeneic blood products can be an easy way out in correcting anaemia when in desperation. However evidence has shown that anaemia is a major multiplier of morbidity and mortality and inappropriate treatment compounds the problem. The human body is marvelously made to counteract anaemia, given the right management at the right time. Thus, it is crucial to create methods for early and ongoing detection of anaemia. Timely evidence based pharmaceutical and nutritional intervention to support erythropoiesis should be employed. Causes and contributing factors of anaemia must be determined. Physiological tolerance of anaemia needs to be enhanced by minimizing oxygen consumption, and evidence based rationale for use of red blood cells should be applied, thus limiting the use of these blood products to only in instances when it is absolutely necessary, and after all measures have been taken.
In recognition that the patient is the master of his or her own body, and that a patient is the reason why the medical field is in place, ’patient-centred decision making‘ is yet another essential aspect of PBM. Medical practitioners should listen to patients’ needs, desires and concerns. Treatment possibilities must be explored, with the practitioner providing the patient with correct and current information about all PBM interventions. Informing patients of risks, benefits and alternatives of treatment choices is necessary. We need to integrate patient values and autonomy in decision making, deciding together on a course of action and tailoring a plan of care which incorporates patient choice. A patient’s preference need to be valued, documented and communicated.
As much as we strive to preserve a patient’s blood or to replace it, it can be easily lost in an instant if coagulation is not guarded. Thus, it is necessary for PBM to incorporate ’Optimizing coagulation‘ as one of its four main principles. With current advances, it is now possible to evaluate both quantitative and qualitative measures to assess coagulation status. It is wise to accurately assess true cause of bleeding dysfunction and employ goal directed therapy to correct coagulation abnormalities. Finally, when all measures are taken, evidence based rationale for the use of plasma should be applied.
Considering the concept of PBM and the principles upon which it hangs, reminds us to redirect our attention and efforts towards our patients. PBM is good medicine. It is in contrast to the current leanings of prioritising technology or products and we see the wisdom behind this, as any effort will not be fully beneficial if it fails to benefit the patient in the end. And to say PBM is like rocket science, it is not. As a matter of fact, it is very basic and this is probably the time that we revisit a basic and fundamental aspect of medicine that moved us to create medicine in the first place: the one known as patient-centred care.