Patient blood management (PBM) aims to achieve improved patient outcomes by avoiding unnecessary exposure to blood products through effective conservation and management of a patient’s own blood.

All patients presenting for major surgical procedures where significant blood loss is likely, are to be managed according to the Patient Blood Management - Pathway to Identify and Treat Anaemia Flow Chart (Appendix 1).

Patient blood management (PBM) is the timely application of evidence based medical and surgical concepts designed to

• maintain haemoglobin concentration
• optimise haemostasis and
• minimise blood loss

in an effort to improve patient outcomes. Patient blood management principles are particularly relevant to the care of patients scheduled to undergo elective surgical procedures in which significant blood loss is anticipated. Effective conservation and management of a patient’s own blood requires a proactive, multidisciplinary, team based approach.

Major surgery includes but is not limited to the following procedures.

Orthopaedic

• Total Hip Replacement / Total Knee Replacement
• Resurfacing of joint
• Spinal fusion - 2 levels or more

Vascular

• Abdominal Aortic Aneurysm (AAA) repair
• Lower extremity revascularization
• Aorto-bifemoral grafts

General

• Whipple procedure
• Splenectomy
• Colectomy / bowel resection
• Any open abdominal procedure

Urology

• Radical retro-pubic prostatectomy
• Cystectomy
• Nephrectomy

Cardiothoracic

• Pneumonectomy / lobectomy

Obstetrics / Gynaecology

• High risk pregnancy
• Placenta accreta
• Abdominal hysterectomy with enlarged uterus

Other

• Any procedure for Jehovah's Witness or those that refuse transfusion "even if their life were in danger"

Anaemia is classified as

• Male: Haemoglobin < 130 g/L
• Female: Haemoglobin < 120 g/L

Iron deficiency

• Ferritin levels < 15 microgr/L is diagnostic of iron deficiency. Levels between 15 - 30 microgr/L are highly suggestive

Oral Iron replacement

• To treat iron deficiency: 1 tablet of ferrous sulphate 325mg (Ferrogradumet) BD for 3 months
• To optimize iron stores: 1 tablet of ferrous sulphate 325mg (Ferrogradumet) BD for 6 weeks

Intravenous Iron replacement

• Ferric carboxymaltose
• Iron polymaltose

Anaemia may be multifactorial,especially in the elderly or in those with chronic disease, renal impairment, nutritional deficiencies or malabsorption.

In an anaemic adult, a ferritin level of < 15 microgr/L is diagnostic of iron deficiency and levels between 15-30 microgr/L are highly suggestive.

Ferritin is elevated in inflammation, infection, liver disease and malignancy. This can result in misleadingly elevated ferritin levels in iron-deficient patients with coexisting systemic illness. In the elderly or in patients with inflammation, iron deficiency may still be present with ferritin values up to 60-100 microgr/L.

Patients without a clear physiological explanation for iron deficiency (especially men and postmenopausal women) should be evaluated by gastroscopy/colonoscopy to exclude a source of gastro-intestinal bleeding, particularly a malignant lesion.

• complete history and examination
• initiate iron therapy
• screen for coeliac disease
• discuss timing of scopes with a gastroenterologist

CRP may be normal in the presence of chronic disease and inflammation.

Consider thalassaemia if MCH or MCV is low and not explained by iron deficiency, or if long standing.

Check B12 / folate if macrocytic or if there are risk factors for deficiency (e.g. decreased intake or absorption), or if anaemia is unexplained.

Consider blood loss or haemolysis if reticulocyte count is increased.

Seek haematology advice.

If chronic kidney disease present, seek nephrology advice.

MBS Iron Clinic at BHS

• All patients who are to receive intravenous iron in MDU must be reviewed by a consultant.
• The Iron Clinic provides a single point of access for those patients requiring investigation and treatment of iron deficiency (including intravenous iron therapy), and is staffed by a General Medical Consultant.
• The Iron Clinic is held weekly on a Friday morning at the Ballarat Consulting Suites

Referrals to the Iron Clinic

• Address referrals to MBS Iron Clinic
• Please use the BHS SMART referral template where possible and fax referrals to 03 5320 4822

Patients reviewed by anaesthetics, and obstetric patients

• Patients who have been reviewed by an anaesthetist or obstetrician are not required to be seen in the Iron Clinic
• To arrange iron infusion, refer to Medical Day Unit (MDU) via BOSSnet e-referral, ensuring the urgency of the request and planned date of surgery / expected date of delivery is listed so that priority can be given
• Give the patient a copy of the intravenous iron information leaflet, see Appendix 2
• Patient Blood Management Brochure, see Appendix 3
• the patient will be triaged according to urgency of treatment and notified of appointment time for infusion

Note that patients who are currently treated for iron deficiency via other departments (e.g. gastroenterology, gynaecology, haematology) will continue their treatment via these departments.

Documentation

Identify how urgent the infusion is and send to MDU the following:

• PBS script,
• IV orders,
• Fully completed Iron Checklist (MR661.0), See Appendix 4,
• Ensure height, weight and blood results are entered.