Introduction

Patient blood management (PBM) promotes the use of transfusion of blood and components only when clearly required. This minimises unnecessary transfusions, reducing the risk of adverse events and thereby conserving limited donor blood for patients with the greatest need.
PBM is a comprehensive, patient-centred, evidence-based system of care. It has been described as a “three pillar” framework of patient blood optimisation, intraoperative blood conservation, and optimising the patient’s physiological reserve in elective surgery. However, it is much broader than this, and beyond elective surgery, PBM covers all aspects of decision-making in transfusion therapy  and aims to “P”rotect, “P”romote blood health and “P”revent disease (the “3Ps”).1,2 This results in an improvement of patient outcomes, and these measures improve the health of all patients, regardless of whether they require a transfusion or not.2
When implemented as an integrated, system-wide strategy, PBM can improve clinical outcomes across the continuum of care and deliver measurable benefits not only to patients, but also to healthcare professionals, hospitals, national blood services and healthcare authorities through improved efficiency, reduced resource utilisation, and more sustainable healthcare delivery, and make better use of the donors’ gifts.

Improvement of overall health for all, for example:

  • Patients with anemia and micronutrient deficiencies in the general population, especially neonates and children, women of reproductive age and in pregnancy, and the elderly given the increased prevalence of anaemia in this group.3
    • Approximately 1.95-2.36 billion globally are affected with anaemia, ADDIN EN.CITE.DATA 4,5 and a further 0.98-1.18 billion are impacted by micronutrient deficiency, mainly iron.6,7
    • Heavy menstrual bleeding impacts an estimated 400 million women worldwide.8
    • Reversing iron deficiency and anaemia is linked with reducing childhood morbidity and mortality, improving neurocognitive development of infants, children and adolescents; improving maternal morbidity and mortality, and improving productivity and quality of life.9-12
  • Chronically transfusion-dependent patients
    • Patients with thalassaemia/sickle cell disease, myelodysplasia and a range of bone marrow failure syndromes may need ongoing red cell and/or platelet transfusions. While therapies to reduce transfusion requirements are already available or in clinical trials for some of these settings, some of these agents are expensive or have limited availability, and many patients currently remain dependent on transfusions.
    • The optimal pre-transfusion haemoglobin and platelet counts that increase quality of life and reduce morbidity and mortality in these patients is uncertain.  Personalised transfusion approaches for individual patients is a core part of a PBM program.13-16
    • Treating the consequences of chronic red cell transfusion, especially iron chelation for iron overload, is important and can improve patient health considerably while also reducing transfusion requirements in some settings such as myelodysplastic syndromes. 17-19
  • Antenatal care/pregnancy:
    • Almost 6% of all deliveries (over 8 million deliveries annually) worldwide are complicated by postpartum haemorrhage.20
    • A low antepartum haemoglobin concentration is linked with an increased risk of PPH.11,21
    • Antenatal iron supplementation, and active third-stage labour management with  uterotonics, tranexamic acid (TXA), and designated major haemorrhage/massive transfusion protocols can help ameliorate the issues above.22

Furthermore, anaemia is associated with increased morbidity, mortality and length of stay in hospital in multiple populations: ADDIN EN.CITE.DATA 4,23-28

  • Patients undergoing surgical procedures
    • More than 100 million surgeries are likely to be performed on anaemic patients worldwide annually.29
    • Optimizing pre-operative haemoglobin and minimising intraoperative blood loss using cell salvage or tranexamic acid can minimise the need for transfusion.
  • Patients with non-communicable diseases
    • 170 million people are estimated to have co-morbid anaemia with congestive heart failure (CHF) or diabetes, 50% of patients with CHF are iron deficient.28,30,31
    • In chronic kidney disease, anaemia correction with IV iron and erythropoietin-stimulating agents (ESA) can improve quality of life and reduce hospitalization.32
  • Trauma patients:
    • Early interventions such as massive transfusion protocols, TXA use, and point-of-care viscoelastic tests can improve outcomes and conserve resources.
  • Neonatal and paediatric patients:
    • These patients benefit from interventions to minimise anaemia, like delayed cord clamping, micro-sampling tubes to reduce iatrogenic blood loss, and age-specific transfusion thresholds.33
  • Patients with oncological and haematological malignancies
    • At least 5 to 10 million newly diagnosed cancer patients each year are anaemic.34
    • Iron therapy, careful ESA use, and bleeding prevention can reduce transfusion requirements and transfusion-related complications.
  • Patients with acquired and medication-induced coagulopathies
    • Acquired and medication-induced coagulopathies and platelet dysfunction are associated with increased mortality, major morbidity including haemorrhagic stroke, and increased ICU and overall length of stay.
    • Goal-directed bleeding management is an important part of a PBM strategy in these patients.35
  • Patients with infectious diseases
    • Millions of people worldwide with infectious diseases experience at least mild anaemia from a range of infectious causes, from haemolysis to gastrointestinal blood loss.36

Reduction of transfusions and associated side-effects

Blood product utilisation has been shown to decrease with PBM implementation, and may be anticipated to correlate with reduction in transfusion-related adverse events. For example, ONTraC is a nationally implemented Canadian PBM program, across a predominantly surgical adult population including orthopaedic, cardiac, and major elective procedures.  Its implementation was associated with approximately 40-60% reduction in red cell transfusion rates over two decades, alongside reductions in transfusion-related adverse events, without worsening morbidity, mortality, or length of hospital stay.37

Improved engagement of healthcare professionals and confidence with prescribing transfusions

A pre and post-PBM implementation questionnaire for clinicians demonstrated that exposure to PBM improved their attitude toward preoperative anaemia treatment, resulted in increased reassessment after single unit red cell transfusion, and lowered haemoglobin thresholds for transfusion.38

Optimising resource allocation in healthcare systems

PBM programs can reduce direct blood product costs by reducing numbers of transfusion events and numbers of units transfused. They can also improve the health of patients, reducing transfusion-associated complications, length of stay and institutional dependency on transfusions, thus saving costs for healthcare institutions and funders.39  It is likely that in many cases PBM programs save money, although comprehensive and detailed costing analyses have not been performed in all settings, and many reports do not comprehensively consider the costs of implementing PBM programs, in terms of costs of guideline development, staff requirements for program operations, monitoring and clinical audit, and the purchase and administration costs of some transfusion alternatives. While some of these alternatives (e.g. TXA) are inexpensive, other elements (e.g. ESAs, cell salvage circuits and trained staff to use them) may be costly or not available in all settings. The cost and availability of cell salvage varies widely.

Some examples include:

  • Outcomes for most patients after application of a restrictive haemoglobin threshold for red cell transfusions are non-inferior to liberal thresholds in the reduction of major adverse cardiovascular events, and can provide substantial cost savings with blood transfusion reduction.40,41
  • A meta-analysis demonstrated a net benefit of €21.60 per patient after the application of iron infusions, TXA and cell salvage.42
  • In obstetric, surgical and trauma patients, use of TXA consistently delivered cost savings in reducing transfusions and reducing hospital length of stay.43-45
  • Ferric carboxymaltose infusions were evaluated to be cost-effective in anaemic patients and those with chronic heart failure.46,47

Preserving the blood supply chain

Effective PBM reduces overall demand for blood products, and can ease pressure on blood supply chains that depend on donor availability. Health systems with established PBM programs have demonstrated greater resilience in maintaining essential transfusion services during crises such as the COVID-19 pandemic.48 At the same time, some individual patients or groups of patients may need more blood products to meet their specific needs, and transfusion support that is more  individually planned and delivered. Importantly, PBM is not intended to withhold transfusions from patients who need them.

Conclusion

In conclusion, patient blood management represents a comprehensive, evidence-based strategy that can improve enhance patient outcomes across diverse clinical settings, and promote safer, more appropriate use of blood products. By addressing anaemia, blood loss, and coagulopathy, PBM can reduce morbidity, mortality, unnecessary transfusion exposure, and potentially healthcare costs while improving patient experience and equity of care. Beyond individual patients, PBM strengthens healthcare systems through better resource utilization, clinician engagement, and preservation of the blood supply. Its demonstrated clinical, economic, and system-level benefits support PBM as an essential component of sustainable, resilient healthcare delivery worldwide.

References

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The authors

The first version was written by Erica Wood and Shubha Allard, the updated version was created by Joanna Loh and Yashaswi Dhiman.

Erica Wood

Erica Wood

Professor, Transfusion Medicine Specialist, Transfusion Research Unit, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia

Shubha Allard

Shubha Allard

Consultant Haematologist, NHS Blood and Transplant and Royal College of Pathologists, London, UK.

Joanna Loh

Joanna Loh

Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia. Department of Haematology, Monash Health, Melbourne, Victoria, Australia

Yashaswi Dhiman

Yashaswi Dhiman

Associate Professor, Clinical Transfusion Working Party Secretary, Department of Immunohematology and Blood Transfusion, HIMS, SRHU, Dehradun, Uttarakhand, India

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