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Blood Management:
Providing Patient Choices
An Online Continuing
Education Activity
An Online Continuing Education Activity
Sponsored By
Funding Provided By
Welcome to
Blood Management:
Providing Patient Choices
(An Online Continuing Education Activity)
CONTINUING EDUCATION INSTRUCTIONS
This educational activity is being offered online and may be completed at any time.
Steps for Successful Course Completion
To earn continuing education credit, the participant must complete the following steps:
1. Read the overview and objectives to ensure consistency with your own learning needs and objectives. At the end
of the activity, you will be assessed on the attainment of each objective.
2. Review the content of the activity, paying particular attention to those areas that reflect the objectives.
3. Complete the Test Questions. Missed questions will offer the opportunity to re-read the question and answer
choices. You may also revisit relevant content.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. A certificate of completion will be available for you to print at the conclusion.
Pfiedler Enterprises will maintain a record of your continuing education credits and provide verification, if
necessary, for 7 years. Requests for certificates must be submitted in writing by the learner. If you have any questions, please call: 720-748-6144.
CONTACT INFORMATION
© 2016
All rights reserved
Pfiedler Enterprises, 2170 South Parker Road, Suite 125, Denver, CO 80231
www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196
OVERVIEW
Patient blood management (PBM) is an evidence-based, multidisciplinary process that is designed to promote the optimal
use of blood products throughout a healthcare facility. A PBM program is designed and implemented to ensure the safe and
efficient use of many resources involved in the complex process of blood component therapy. This continuing education
activity will explore blood and blood components. Safer and more effective options than blood transfusion will be discussed.
In addition, healthcare facilities must be prepared to respect a patient’s personal and religious beliefs or convictions
regarding the acceptance of blood transfusion alternatives.
LEARNER OBJECTIVES
After completing this continuing nursing education activity, the participant should be able to:
1. Explain the difference between allogenic and autologous transfusions.
2. Describe blood and blood components.
3. Discuss reasons to consider development of a patient blood management program.
4. Identify alternative considerations for blood transfusions and describe the benefits of alternatives to blood
transfusions.
INTENDED AUDIENCE
This continuing education activity is intended for perioperative nurses, surgical technologists, and other healthcare
professionals who are interested in learning more about blood management options and the implications for patient care.
CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for
1.0 contact hour.
Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end.
Licensees must provide their license numbers for record keeping purposes.
The certificate of course completion issued at the conclusion of this course must be retained in the participant’s
records for at least four (4) years as proof of attendance.
IAHCSMM
The International Association of Healthcare Central Service Materiel Management has approved this educational offering for
1.0 contact hour to participants who successfully complete the program.
RELEASE AND EXPIRATION DATE:
This continuing education activity was planned and provided in accordance with accreditation criteria. This material was
originally produced in November 2016 and can no longer be used after November 2018 without being updated; therefore,
this continuing education activity expires November 2018.
DISCLAIMER
Pfiedler Enterprises does not endorse or promote any commercial product that may be discussed in this activity.
SUPPORT
Funds to support this activity have been provided by Stryker CMF.
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AUTHORS/PLANNING COMMITTEE/REVIEWER
Elizabeth Deroian, BA, RN
Medical Writer/Author
Denver, CO
Julia A. Kneedler, EdD, RN
Program Manager/Planning Committee
Pfiedler Enterprises
Denver, CO
Judith I. Pfister, MBA, RN
Program Manager/Planning Committee
Pfiedler Enterprises
Denver, CO
Melinda T. Whalen, BSN, RN, CEN
Program Manager/Reviewer
Pfiedler Enterprises
Denver, CO
DISCLOSURE OF RELATIONSHIPS WITH COMMERCIAL ENTITIES FOR THOSE IN A POSITION TO
CONTROL CONTENT FOR THIS ACTIVITY
Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control content
for an educational activity. Information below is provided to the learner, so that a determination can be made if identified
external interests or influences pose potential bias in content, recommendations or conclusions. The intent is full disclosure
of those in a position to control content, with a goal of objectivity, balance and scientific rigor in the activity. For additional
information regarding Pfiedler Enterprises’ disclosure process, visit our website at: http://www. pfiedlerenterprises.com/
disclosure.
Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be
presented in this continuing education activity. “Relevant financial relationships” are those in any amount, occurring within
the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or
distributing health care goods or services consumed by, or used on, patients.
Activity Authors/ Planning Committee/Reviewer
Elizabeth Deroian, BA, RN
No conflict of interest
Julia A. Kneedler, EdD, RN
No conflict of interest
Judith I. Pfister, MBA, RN
No conflict of interest
Melinda T. Whalen, BSN, RN, CEN
No conflict of interest
PRIVACY AND CONFIDENTIALITY POLICY
Pfiedler Enterprises is committed to protecting your privacy and following industry best practices and regulations regarding
continuing education. The information we collect is never shared for commercial purposes with any other organization. Our
privacy and confidentiality policy is covered at our website, www.pfiedlerenterprises.com, and is effective on March 27,
2008.
To directly access more information on our Privacy and Confidentiality Policy, type the following URL address into your
browser: http://www.pfiedlerenterprises.com/privacy-policy.
In addition to this privacy statement, this Website is compliant with the guidelines for internet-based continuing education
programs.
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The privacy policy of this website is strictly enforced.
CONTACT INFORMATION
If site users have any questions or suggestions regarding our privacy policy, please contact us at:
Phone: 720-748-6144
Email:
[email protected]
Postal Address: 2170 South Parker Road, Suite 125
Denver, Colorado 80231
Website URL: http://www.pfiedlerenterprises.com
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INTRODUCTION
The first known human blood transfusion was performed in 1795 by Dr. Philip Syng Physick although he did not publish
the information.1 In 1818, Dr. James Blundell performed the first successful transfusion of human blood to a patient for
the treatment of postpartum hemorrhage. He used the patient’s husband as the donor extracting a small amount of blood
by syringe and then transfusing the wife.1 In the early 1900s at the University of Vienna, Karl Landsteiner and associates
discovered the ABO blood types while trying to learn why blood transfusions sometimes caused a patient’s death and at
other times saved the patient’s life. In 1930 he received the Nobel Prize for Medicine recognizing his discovery.1 Between
1939 and 1940, he and his associates also discovered the Rhesus (Rh) system. Identification of the Rh factor took its
place next to the discovery of ABO as one of the most important breakthroughs in the field of blood banking.1 Today,
blood transfusions are common in the hospital setting. Allogenic (donor-donated) transfusions refer to blood transfused to
someone other than the donor. Autologous (self-donated) transfusions refer to those transfusions in which the blood donor
and transfusion recipient are the same.
According to the America’s Blood Centers and the World Health Organization (WHO):2, 3
One in 20 Americans will require a blood transfusion at some point in their lives.
About 15 million units of blood are transfused annually in the United States.
The majority of transfusion complications have been attributed to the presence of leukocytes in allogenic blood.
Every 2 seconds someone needs blood. Blood and blood products are used to treat accident and burn victims, cancer patients and other patients undergoing surgeries and medical treatments.
• People older than 65 account for 76% of all transfusions. The demand for blood will increase as the population
ages.
• Approximately 40, 000 units of blood are used each day in the United States for various conditions.
•
•
•
•
Table 1 – Examples of Blood Use and Average Number of Units Required4
Examples of Blood Use
Major Trauma (with massive blood
loss)
Heart Surgery
Organ Transplant
Bone Marrow Transplant
Burn
Average # of Units Required
50 units of blood
6 units of blood
6 units of platelets
40 units of blood
30 units of platelets
20 units of cryoprecipitate
25 units of fresh frozen plasma
120 units of platelets
20 units of blood
20 units of platelets
BLOOD AND BLOOD COMPONENTS5, 6
Blood is the only fluid tissue in the body. Although blood appears to be a thick, homogenous liquid, blood has both cellular
and liquid components. Blood is a specialized type of connective tissue. Living blood cells, the formed elements, are
suspended in a nonliving fluid matrix called plasma. The living cellular components are red blood cells (erythrocytes), white
blood cells (leukocytes) and platelets (thrombocytes). The major components of whole blood break down as 45% red blood
cells, 1% white blood cells and platelets, and 55% plasma. Blood plasma is a straw-colored, sticky fluid which is about 90%
water, but plasma contains 100 different dissolved solutes. These solutes include nutrients, gases, hormones, wastes and
products of cell activity, ions, and proteins. The average adult volume of blood is 4.5 – 6L, accounting for 7-8% of the human
body weight. Factors such as body size, amount of adipose tissue, and electrolyte concentrations can all affect blood
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volume. Blood performs a number of functions that are related to substance distribution, regulating blood levels of particular
substances and body protection.
Distribution functions:
• Delivering oxygen from the lungs and nutrients to the digestive tract to all body cells.
• Transporting metabolic waste products from cells to elimination sites i.e., lungs and kidneys.
• Transporting hormones from endocrine organs to their target organs.
Regulation functions:
• Maintaining appropriate body temperature.
• Maintaining normal pH in body tissues.
• Maintaining adequate fluid volume in the circulatory system.
Protection functions:
• Preventing blood loss; platelets and plasma proteins initiate clot formation, halting blood loss.
• Preventing infection.
Red Blood Cells
Erythrocytes or red blood cells (RBCs) are small cells without nuclei, about 7.5μm in diameter and are shaped like
biconcave discs (a flattened disc with a depressed center). The essential role of red blood cells is to transport oxygen from
the lungs to the body’s cells and return to the lungs with carbon dioxide. They are essentially little bags of hemoglobin (Hb),
the RBC protein that functions in gas transport. RBCs have an approximate life span of about 100 to 120 days. The body
must produce two million red blood cells every second to replace those that are being retired. Erythrocytes are the major
factor contributing to blood viscosity. Red blood cell production (erythropoiesis) can be increased when needed to up to 10
times the usual production rate.
White Blood Cells
Leukocytes or white blood cells (WBCs) are the only formed elements that are complete cells, having a nuclei and
organelles. Organelles are smaller cellular structures that perform specific metabolic functions for the cell as a whole.
Leukocytes exist in variable numbers and types but account for less than 1% of total blood volume in a healthy person.
Leukocytes are crucial to the body’s disease defense protecting against bacteria, viruses, parasites, toxins, and tumor
cells. Although red blood cells are confined to the bloodstream, white blood cells are able to move out of the capillary blood
vessels and can be found elsewhere in the body as the spleen, liver and lymph glands. White blood cells generally last only
18 – 36 hours before they are removed, though some types may live as long as a year.
Platelets
Thrombocytes or platelets are cell fragments without nuclei that work with blood clotting chemicals at wound sites. Platelets
are tiny oval shaped discs about one third the size of a red blood cell. Platelets are essential for the clotting process that
occurs in plasma when blood vessels are ruptured or their lining is injured. When such an injury occurs, platelets come
in contact with substances in the vessel wall which activate platelets to change shape, enlarge, and become sticky. By
sticking to the injury site, platelets then form an initial plug that assists in sealing the break. Platelets will degenerate in
approximately 9 to10 days if they are not involved in blood clotting because they are enucleate.
Plasma
Plasma is a pale yellowish fluid with a total volume of 2-3L in a normal adult. It is a complex solution containing more
than 90% water. 8% of plasma is plasma proteins, of which 60% is albumin, 36% are globulins and 4% is fibrinogen. The
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remaining 2% of plasma is made up of by products of cellular metabolism, nutrients, electrolytes, and hormones, such as
cortisol and thyroxine. The composition of plasma varies continuously as cells remove or add substances to the blood.
However, in a healthy adult with a healthy diet, plasma composition is kept relatively constant by various hemostatic
mechanisms. After platelets respond and form the initial plug on a damaged blood vessel, a chain reaction of various
chemicals in the plasma begins. Plasma forms a network of fibers binding the initial plug into a strong clot. This chain
reaction until fibrinogen is converted into an insoluble, thread like substance called fibrin. This coagulation process involving
platelets and plasma becomes an important factor in blood management.
WHY CONSIDER A PATIENT BLOOD MANAGEMENT PROGRAM?
Patient blood management (PBM) programs utilize an evidence-based, multidisciplinary approach to optimizing the care
of patients who might need transfusion. This team consists of physicians, nurses, and other health care professionals from
surgical, medical, and ancillary departments working together to develop an appropriate plan of care and encompasses
all aspects of patient evaluation and clinical management surrounding the transfusion decision-making process. PBM can
reduce the need for allogeneic blood transfusions and reduce health-care costs, while ensuring that blood components are
available for the patients who need them.7
This plan of care should incorporate the latest medications, strategies and techniques to include:
•
•
•
•
The prevention and treatment of anemia
Minimizing blood loss
Enhancing the patient’s own blood supply
Reducing or eliminating the need for a blood transfusion
Blood transfusion alternatives have shown to lead to faster patient recovery, fewer infections and complications, reduced
hospital stays and lower healthcare costs. Traditional blood transfusions do save lives, but millions of patients needing
transfusions may not have timely access to safe blood or available blood. In times of blood shortages, even elective
surgeries may be cancelled. Although blood banks take strict precautions and safety measures to ensure a safe blood
supply, blood transfusions during surgery can weaken patients and make them more susceptible to allergic reactions and
postoperative infections. Patients who do not require blood products tend to recover faster with shorter stays in the hospital.
Advantages to a patient blood management program include:
•
•
•
•
•
•
•
•
Minimizes the risk of the wrong blood to the wrong patient.
Decreases the risk of contracting blood-borne infections.
Decreases the risk of developing transfusion reactions.
Decreases the risk of suppressing a patient’s own immune system.
Religious beliefs may prohibit receiving blood transfusions.
Minimizes the use of blood from blood banks, blood that is an increasingly scarce resource.
Honors requests by patients who do not wish to receive transfusions of donor blood.
Reduces the risk of developing post-operative infections.
According to the AABB, formerly known as the American Association of Blood Banks, the following are some alternative
considerations to blood transfusion.8
PREOPERATIVE AUTOLOGOUS DONATION8
The most common autologous donation is the preoperative donation of blood for possible transfusion back to the donor
during elective surgery known as presurgical autologous blood donation (PAD). This collection and storage of a patient’s
own blood usually occurs from 3 to 4 weeks before surgery, but can be donated until 72 hours prior to surgery and stored
for up to 42 days. Autologous donation usually occurs when the surgery will be orthopedic, vascular, urologic, or cardiac
and the likelihood of transfusion is high. If blood loss during surgery is less than anticipated, transfusion of autologous blood
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may not be medically necessary. Nearly 50% of autologous donations are unused by the autologous donor and are wasted.
Although the risk of a complication from autologous blood is low, some residual risks remain and automatic transfusion
of autologous blood should be evaluated. Autologous blood can be subject to the same complications as stored allogenic
blood and include:
•
•
•
•
Decreased ability to release oxygen
Resultant breakdown products
Quickly loses its clotting factors
Risk of bacterial infection
Autologous blood does require special handling and storage requirements and are therefore more costly to process. In
addition, the patient’s blood count can be evaluated before surgery. Based on the surgical procedure, the patient can be
assessed for preoperative anemia or the risk of anemia during and after the surgical procedure. The expected and tolerable
RBC loss can be estimated to eliminate the necessity for an allogenic transfusion. Circulating RBCs can also be expanded
by administration of iron, folic acid, vitamin B12 and erythropoietin up to 10 to 21 days before surgery. Erythropoietin (EPO)
is a hormone produced by the kidneys that promotes the formation of RBCs in the bone marrow.
ACUTE NORMOVOLEMIC HEMODILUTION8
Another alternative to transfusion of donated blood is acute normothermic hemodilution (ANH). Primarily used in surgical
procedures in which significant blood loss is expected, ANH is the removal of one or more units of blood just before
surgery for transfusion to the patient during or at the end of the surgery. ANH is used to decrease the loss of red blood cells
during the procedure. Blood is drawn from the patient prior to surgery and immediately replaced by intravenous fluids to
compensate for the amount of blood removed and maintain blood volume. The maintenance of blood volume is important
for the heart to work effectively and for oxygen to be delivered to the body’s cells. This procedure dilutes the number of red
blood cells in the patient’s circulatory system resulting in fewer red blood cells lost as a result of bleeding during the surgery.
After surgery, the patient’s own blood is reinfused, but the patient must be able to tolerate the anemia the procedure causes.
PERIOPERATIVE BLOOD COLLECTION8
Perioperative blood collection involves the recovery of blood lost by the patient during surgery. Intraoperative cell salvage is
accomplished with a machine most commonly referred to as the “cell saver” whereby the patient’s blood is collected and red
blood cells are concentrated, washed, and returned to the patient. It is a procedure that is widely used for cardiac, vascular,
orthopedic, urologic, trauma, gynecologic, and transplant surgeries where blood loss is anticipated to by 20% or more of the
patient’s estimated blood volume. The goals of this procedure are to minimize blood loss, maximize oxygen delivery, and
maximize the body’s ability to produce blood. This procedure is generally not used in cancer surgery or surgery of the lower
gastrointestinal tract where the presence of cancer cells or bacteria are present.
POSTOPERATIVE BLOOD COLLECTION8
Postoperative blood collection utilizes blood lost in the early postoperative period which is collected from surgical drains or
wounds and transfused to the patient, either washed or unwashed. Postoperative collection is used primarily in cardiac and
orthopedic surgeries, and in most cases, the recovered volume of salvaged red blood cells is small. The minimum volume
for postoperative blood collection is 200 ml.
BLOOD COMPONENT MANAGEMENT8
Autologous transfusion can be advantageous for the patient during the perioperative and postoperative surgical period.
However, because salvaged blood is washed, this mechanism removes both plasma and platelets in replaced blood. This
disadvantage may be only evident when very large blood loss occurs. Therefore, it is imperative that patients that receive
salvaged blood are closely monitored for bleeding, and the recommendation for the administration of fresh frozen plasma
(FFP), platelets, and cryoprecipitate may be necessary.
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ADDITIONAL STRATEGIES FOR PATIENT BLOOD MANAGEMENT8
• The use of surgical devices to minimize blood loss (ie, electrosurgery, elctrocautery, argon beam coagulation, ultrasonic scalpel, laser surgery, etc).
• Surgical and anesthesia techniques to limit blood loss (ie, controlled hypotension, maintaining normothermia, meticulous hemostasis, preoperative planning, minimally invasive surgery, etc).
• Volume expanders that are non-blood fluids administered intravenously to increase blood volume, (ie, crystalloids,
colloids, etc).
• Autologous tissue adhesives such as platelet gel and fibrin glue made from fractions of a patient’s own blood that
are used to control bleeding and promote healing.
• Devices and techniques that limit iatrogenic blood loss, (ie, pulse oximeter, microsampling equipment, only essential tests, multiple tests per sample, smaller samples [pediatric-sized tubes], etc).
The word iatrogenic comes from the Greek roots “iatros” meaning “the healer or physician” and “genein” meaning “as a
product of” which equates to “due to the doctor”.9 Iatrogenic is a term applied to any adverse patient outcome resulting from
treatment by a physician or by a medical or surgical treatment or diagnostic procedure. With respect to patients admitted to
intensive care units, large, and sometimes unnecessary, quantities of blood are drawn from critically ill patients, including
adults, neonates, and children. Several studies have convincingly shown that iatrogenic blood loss due to lab testing,
including arterial blood sampling, can result in increased morbidity due to stress on the cardiovascular and respiratory
systems and the need for allogenic blood transfusion.10 Anemia commonly occurs in critically ill patients, affecting more than
90% of patients admitted to intensive care units (ICUs) by the third day. The reasons for anemia in critically ill patients are
multifactorial and include acute blood loss, (eg, from trauma, surgery or gastrointestinal bleeding), iatrogenic blood loss from
diagnostic testing, and depressed red blood cell production.11 An effective and simple patient blood management strategy
may in fact be merely a reduction in unneeded diagnostic lab testing.
SUMMARY
A blood transfusion may be necessary when the body cannot produce blood fast enough due to major blood loss,
destruction of red blood cells, and/or decreased production of red blood cells. Patient blood management (PBM) programs
advocate for and advance the use of alternative treatments to the fullest extent possible and minimize the use of blood
transfusion. Medical and surgical care should also allow for personal choices. Patients may request transfusion alternatives
because of personal convictions or to minimize the risk of adverse reactions to blood transfusion. If a PBM is developed and
used effectively, then ultimately, if you don’t lose blood, you don’t have to use blood.
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REFERENCES
1. AABB. Highlights of transfusion medicine history page. http://www.aabb.org/tm/Pages/highlights.aspx. Accessed
October 13, 2016.
2. America’s Blood Centers. Facts & figures. http://americasblood.org/about-blood/facts-figures.aspx. Accessed October 13, 2016.
3. World Health Organization. 10 facts on blood transfusion. http://www.who.int/features/factfiles/ blood_transfusion/
en/. Accessed October 13, 2016.
4. Bloodbook.com. Blood facts. http://www.bloodbook.com/facts.html. Accessed October 13, 2016.
5. Anthro Palomar. Human blood: Blood components. http://anthro.palomar.edu/blood/blood_components.htm. Accessed October 13, 2016.
6. American Red Cross. Blood components. http://www.redcrossblood.org/learn-about-blood/blood-components. Accessed October 13, 2016.
7. AABB. Patient blood management. http://www.aabb.org/pbm/Pages/default.aspx. Accessed October 13, 2016.
8. AABB. Getting started in patient blood management. http://www.aabb.org/pbm/Documents/112024DB.pdf. Accessed October 14, 2016.
9. Merriam-Webster. Iatrogenic. http://www.merriam-webster.com/dictionary/iatrogenic. Accessed October 14, 2016.
10. Woodhouse, S. The complications of critical care: Lab testing and iatrogenic anemia. MLO Med Lab Obs. 2001;
33(10): 28-31.
11. Tinmouth, AT, McIntyre LA, Fowler, RA. Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients. CMAJ. 2008; 178(1): 49-57.
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