19.3 Patient Blood Management

19.3 Patient Blood Management

Quick Answer: Patient blood management (PBM) is a clinical program with three pillars: optimize erythropoiesis (iron, B12/folate, selected ESA use), minimize bleeding and blood loss (surgical technique, cell salvage, tranexamic acid, point-of-care coagulation, fewer phlebotomy tubes), and evidence-based restrictive transfusion with single-unit red-cell orders and reassessment. Treat preoperative anemia before elective surgery. Honor informed refusal, including Jehovah’s Witness decisions. The blood bank contributes MSBOS, crossmatch-to-transfusion ratio, wastage data, and inventory discipline. PBM is not “the blood bank said no.”

This is the rest of June 9, 2026 outline V.E. Section 19.2 was how to hang a unit. Section 17.1 was when a unit is indicated. This section is how a hospital needs fewer units without harming patients. If a stem asks pillars, single-unit strategy, preoperative iron, TXA, cell salvage, Jehovah’s Witness refusal, C/T ratio, or MSBOS, answer it here.

Three pillars, not one slogan

PBM is defined by AABB, SABM, and WHO along the same three axes. Learn them as a checklist, not as a poster.

Pillar 1 — Optimize erythropoiesis. Find and treat anemia before the patient bleeds in the OR or sits on a transfusion threshold. The most common treatable cause is iron deficiency. Use oral iron when there is time; use intravenous iron when surgery is soon, absorption is poor, or oral iron has already failed. Replace vitamin B12 and folate when they are deficient. Erythropoiesis-stimulating agents (epoetin, darbepoetin) raise hemoglobin in selected CKD, some orthopedic, and many bloodless-surgery pathways. They carry thrombosis risk and are not a casual preoperative vitamin. Do not give ESA to “top off” a patient who simply needs iron.

Pillar 2 — Minimize bleeding and blood loss. This is mostly not a blood-bank act. It is surgical hemostasis, normothermia, controlled hypotension when appropriate, antifibrinolytics, cell salvage, and point-of-care coagulation (TEG/ROTEM or equivalent) so you replace the factor that is actually missing. Iatrogenic anemia from standing daily laboratory panels is real, especially in the ICU. Use small-volume tubes, kill reflex daily CBCs, and do not draw a type-and-screen every morning “just in case.”

Tranexamic acid (TXA) is the antifibrinolytic BB items expect. CRASH-2 (trauma) and WOMAN (postpartum hemorrhage) showed mortality benefit when TXA is given early. It is also standard in many orthopedic and cardiac pathways. TXA is not a procoagulant concentrate and it is not a reason to skip fibrinogen or platelets when those are what the clot lacks. Follow protocol exclusions (active thromboembolism, some DIC settings).

Intraoperative cell salvage suctions shed blood, washes it, and returns the patient’s own red cells. It is a PBM tool, not a licensed allogeneic unit. Classic cautions include infection in the field and some malignancy settings; those contraindications are evolving and service-specific. A Jehovah’s Witness patient may accept salvage if the circuit stays in continuity with the body — ask; do not assume.

Pillar 3 — Restrictive, patient-centered transfusion. Transfuse for symptoms and inadequate oxygen delivery or hemostasis, not a number (17.1). In a stable adult, order one red-cell unit, reassess hemoglobin and the patient, then decide. Automatic two-unit orders are a PBM failure mode. Restrictive thresholds (commonly 7 g/dL in stable hospitalized adults; 8 g/dL in many cardiac/orthopedic summaries) are guidelines, not ASCP statutes, and they do not apply to hemorrhagic shock.

Preoperative anemia is a treatable risk factor

An anemic patient scheduled for elective hip replacement is a PBM consult, not a standing type-and-cross for two units. Screen as early as the decision to operate — ideally weeks ahead. Iron-deficiency anemia treated with IV iron can rise enough to avoid transfusion. Uninvestigated anemia is not “normal for age.” Delay elective surgery when the delay is safer than a preventable allogeneic exposure.

Preoperative autologous donation (PAD) is not first-line PBM in 2026. PAD makes the patient anemic before incision, wastes many unused units, and does not eliminate clerical or bacterial risk. Modern PBM prefers treating anemia and using salvage/TXA/restrictive transfusion. Autologous donation still exists for rare alloimmunized patients and selected bloodless pathways (2.3); it is not the default hip-replacement plan.

Jehovah’s Witness patients and informed refusal

Adults with decision-making capacity may refuse allogeneic transfusion. Jehovah’s Witness patients classically refuse whole blood, red cells, platelets, and plasma. Acceptance of fractions (albumin, immunoglobulin, clotting-factor concentrates), cell salvage, acute normovolemic hemodilution, and EPO/IV iron varies by individual. Ask, document, and do not substitute your preference.

PBM is the care plan: optimize hemoglobin before elective procedures, minimize phlebotomy, use TXA and meticulous technique, consider accepted fractions, and involve a bloodless-medicine service when one exists. In emergency hemorrhage, you still do not transfuse a refusing adult. Emergency exception to consent applies to the incapacitated patient whose wishes are unknown, not to a capacitated patient who has already said no. Minors and unrepresented patients follow hospital legal/ethics pathways — not a blood-bank improvisation.

Informed refusal is documented the same way informed consent is: risks of refusing, benefits of the alternatives offered, and the decision. The compatibility tag is not that document.

Metrics and the blood bank’s actual job

PBM lives in surgery, anesthesia, hematology, nursing, and hospital quality. The transfusion service is a partner, not the owner. Blood-bank contributions that the exam recognizes:

• Maximum surgical blood order schedule (MSBOS) — procedure-level guidance for type-and-screen versus type-and-cross and how many units to crossmatch. A laparoscopic cholecystectomy should not arrive as “crossmatch 4.”
• Crossmatch-to-transfusion (C/T) ratio — units crossmatched divided by units transfused. A commonly cited operational goal is about < 2.0 (older texts used < 2.5). A high C/T means inventory is tied up on hold and outdating. The number is a metric, not an ASCP official cutoff.
• Wastage — units discarded for outdate, improper storage, or broken cold chain. Administration errors in 19.2 become wastage here.
• Single-unit percentage and transfusion rate per 1,000 patient-days — whether the hospital actually changed practice.
• Preoperative anemia screening rate — whether pillar 1 is happening.
• Participation on the transfusion / PBM committee, clinician education, and electronic-order prompts (single-unit default, indication required).

The blood bank does not unilaterally refuse an indicated unit because the C/T ratio had a bad month. It does not irradiate or wash as a PBM gesture. It does not treat PBM as VI.E laboratory administration — that SBB-only block is management structure, not this clinical content.

Worked scenario. An elective total-knee patient at hemoglobin 9.8 g/dL with a ferritin of 8 ng/mL is iron-deficient, not a two-unit crossmatch. Give IV iron, postpone if the case can wait, plan TXA and salvage, and if a unit is later required, issue one and reassess. A second patient, a Jehovah’s Witness with the same hemoglobin, gets the same hematinic plan plus a documented list of accepted fractions and a bloodless OR setup — not a hidden emergency-release O-negative in the room “in case they change their mind.”

Exam traps. PBM is three pillars, not just saying no. Single-unit then reassess. Preop anemia is iron first, ESA selectively. TXA is early antifibrinolytic evidence, not a plasma substitute. JW care is informed refusal plus alternatives. C/T and MSBOS are blood-bank metrics that support a clinical program.