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Patient Blood Management

Dreisäulenstrategie zur Verbesserung des Outcome durch Vermeidung allogener Blutprodukte

Patient Blood Management

Three pillar strategy to improve outcome through avoidance of allogeneic blood products


Bluttransfusionen werden traditionell als lebensrettende Maßnahme propagiert. Tatsächlich zeigt aber die Studienlage, dass Transfusionen mengenabhängig mit einer signifikanten Erhöhung von Morbidität und Mortalität assoziiert sind. Neben den Erklärungsmodellen der Grundlagenforschung legen v. a. die Ergebnisse randomisierter kontrollierter Studien nahe, dass hier von einem kausalen Zusammenhang auszugehen ist. Daher relativiert der Stand der Wissenschaft das Bild von der lebensrettenden Bluttransfusion und weist deutlich auf die lebensbedrohende und krankheitsfördernde Wirkung dieser Intervention hin. Deshalb, und weil Transfusionen mit deutlich höheren Kosten verbunden sind, als bisher angenommen, sind bei Anämie und Blutungen neue Behandlungsansätze im Sinne des „patient blood management“ (PBM) dringend indiziert. Patient Blood Management senkt die Transfusionsrate dramatisch durch Anämiekorrektur mithilfe stimulierter Erythropoese, Minimierung perioperativer Blutverluste und Erhöhung der physiologischen Anämietoleranz. In einer Resolution der World Health Assembly ist PBM nun als Behandlungsstandard gefordert. Durch Reduktion des überhöhten Blutverbrauchs in Österreich, Deutschland und der Schweiz können Morbidität und Mortalität deutlich reduziert werden.


Blood transfusions are commonly viewed as life-saving interventions; however, current evidence shows that blood transfusions are associated with a significant increase of morbidity and mortality in a dose-dependent relationship. Not only explanatory models of basic research but also the results from randomized controlled trials suggest a causal relationship between blood transfusion and adverse outcome. Therefore, it can be claimed that the current state of science debunks the long held belief in the so-called life-saving blood transfusion by exposing the potential for promoting disease and death. Adherence to the precautionary principle and also the fact that blood transfusions are more costly than previously assumed require novel approaches in the treatment of anemia and bleeding. Patient Blood Management (PBM) allows transfusion rates to be dramatically reduced through correcting anemia by stimulating erythropoiesis, minimization of perioperative blood loss and harnessing and optimizing the physiological tolerance of anemia. A resolution of the World Health Assembly has endorsed PBM and therefore morbidity and mortality should be significantly reduced by lowering of the currently high blood utilization rate of allogeneic blood products in Austria, Germany and Switzerland.

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  1. 1.

    Pedersen AB, Mehnert F, Overgaard S, Johnsen SP (2009) Allogeneic blood transfusion and prognosis following total hip replacement: a population-based follow up study. BMC Musculoskelet Disord 10:167

  2. 2.

    Amato A, Pescatori M (2006) Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev 1:CD005033

  3. 3.

    Murphy GJ, Reeves BC, Rogers CA et al (2007) Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 116:2544–2552

  4. 4.

    O’Keeffe SD, Davenport DL, Minion DJ et al (2010) Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization. J Vasc Surg 51:616–621, 621.e1-3

  5. 5.

    Xenos ES, Vargas HD, Davenport DL (2012) Association of blood transfusion and venous thromboembolism after colorectal cancer resection. Thromb Res 129:568–572

  6. 6.

    Bernard AC, Davenport DL, Chang PK et al (2009) Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J Am Coll Surg 208:931–937

  7. 7.

    Straten AH van, Bekker MW, Soliman Hamad MA et al (2010) Transfusion of red blood cells: the impact on short-term and long-term survival after coronary artery bypass grafting, a ten-year follow-up. Interact CardioVasc Thorac Surg 10:37–42

  8. 8.

    Glance LG, Dick AW, Mukamel DB et al (2011) Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 114:283–292

  9. 9.

    Al-Refaie WB, Parsons HM, Markin A et al (2012) Blood transfusion and cancer surgery outcomes: a continued reason for concern. Surgery 152:344–354

  10. 10.

    Mikkola R, Gunn J, Heikkinen J et al (2012) Use of blood products and risk of stroke after coronary artery bypass surgery. Blood Transfus 10:490–501

  11. 11.

    Ferraris VA, Davenport DL, Saha SP et al (2012) Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Arch Surg 147:49–55

  12. 12.

    Howard-Quijano K, Schwarzenberger JC, Scovotti JC et al (2013) Increased red blood cell transfusions are associated with worsening outcomes in pediatric heart transplant patients. Anesth Analg 116:1295–1308

  13. 13.

    Villanueva C, Colomo A, Bosch A et al (2013) Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 368:11–21

  14. 14.

    Hebert PC, Wells G, Blajchman MA et al (1999) A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in critical care investigators, Canadian Critical Care Trials Group. N Engl J Med 340:409–417

  15. 15.

    Hajjar LA, Vincent JL, Galas FR et al (2010) Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA 304:1559–1567

  16. 16.

    McIntyre LA, Fergusson DA, Hutchison JS et al (2006) Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury. Neurocrit Care 5:4–9

  17. 17.

    Grover M, Talwalkar S, Casbard A et al (2006) Silent myocardial ischaemia and haemoglobin concentration: a randomized controlled trial of transfusion strategy in lower limb arthroplasty. Vox Sang 90:105–112

  18. 18.

    Carson JL, Terrin ML, Noveck H et al (2011) Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 365:2453–2462

  19. 19.

    Lacroix J, Hebert PC, Hutchison JS et al (2007) Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 356:1609–1619

  20. 20.

    Carson JL, Carless PA, Hebert PC (2012) Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 4:CD002042

  21. 21.

    Pattakos G (2012) Outcome of patients who refuse transfusion after cardiac surgery: a natural experiment with severe blood conservation. Arch Intern Med 172:1154–1160

  22. 22.

    Stamou SC, White T, Barnett S et al (2006) Comparisons of cardiac surgery outcomes in Jehovah’s versus non-Jehovah’s Witnesses. Am J Cardiol 98:1223–1225

  23. 23.

    Moskowitz DM, McCullough JN, Shander A et al (2010) The impact of blood conservation on outcomes in cardiac surgery: is it safe and effective? Ann Thorac Surg 90:451–458

  24. 24.

    Kotze A, Carter LA, Scally AJ (2012) Effect of a patient blood management programme on preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthroplasty: a quality improvement cycle. Br J Anaesth 108:943–952

  25. 25.

    Shander A, Fink A, Javidroozi M et al (2011) Appropriateness of allogeneic red blood cell transfusion: the international consensus conference on transfusion outcomes. Transfus Med Rev 25:232–246

  26. 26.

    Shander A, Hofmann A, Gombotz H et al (2007) Estimating the cost of blood: past, present, and future directions. Best Pract Res Clin Anaesthesiol 21:271–289

  27. 27.

    Farmer SL, Towler SC, Leahy MF, Hofmann A (2013) Drivers for change: Western Australia Patient Blood Management Program (WA PBMP), World Health Assembly (WHA) and Advisory Committee on Blood Safety and Availability (ACBSA). Best Pract Res Clin Anaesthesiol 27:43–58

  28. 28.

    Poel CL van der, Janssen MP, Behr-Gross M.E. (2011) The collection, testing and use of blood and blood components in Europe – 2008 Report. http://www.edqm.eu/en/edqm-homepage-628.html

  29. 29.

    Shander A, Hofmann A, Ozawa S et al (2010) Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion 50:753–765

  30. 30.

    Hofmann A, Ozawa S, Farrugia A et al (2013) Economic considerations on transfusion medicine and patient blood management. Best Pract Res Clin Anaesthesiol 27:59–68

  31. 31.

    Gombotz H, Hofman A, Rehak P, Kurz J (2011) Patient blood management (part 2). Practice: the 3 pillars. Anasthesiol Intensivmed Notfallmed Schmerzther 46:466–474

  32. 32.

    Gombotz H, Hofmann A, Rehak P, Kurz J (2011) Patient blood management (part 1) – patient-specific concept to reduce and avoid anemia, blood loss and transfusion. Anasthesiol Intensivmed Notfallmed Schmerzther 46:396–401

  33. 33.

    Gombotz H, Rehak PH, Shander A, Hofmann A (2007) Blood use in elective surgery: the Austrian benchmark study. Transfusion 47:1468–1480

  34. 34.

    Isbister JP (2007) Clinicians as gatekeepers: what is the best route to optimal blood use? Dev Biol 127:9–14

  35. 35.

    World Health Assembly (2010) WHA63.12 Availability, safety and quality of blood products. http://http://www.who.int/en/

  36. 36.

    Shander A, Van Aken H, Colomina MJ et al (2012) Patient blood management in Europe. Br J Anaesth 109:55–68

  37. 37.

    Freedman J, Luke K, Escobar M et al (2008) Experience of a network of transfusion coordinators for blood conservation (Ontario Transfusion Coordinators [ONTraC]). Transfusion 48:237–250

  38. 38.

    Jin R, Zelinka ES, McDonald J et al (2012) Effect of hospital culture on blood transfusion in cardiac procedures. Ann Thorac Surg 12:10

  39. 39.

    Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients‘ care. Lancet 362:1225–1230

  40. 40.

    Apelseth TO, Molnar L, Arnold E, Heddle NM (2012) Benchmarking: applications to transfusion medicine. Transfus Med Rev 26:321–332

  41. 41.

    Karkouti K, Wijeysundera DN, Beattie WS, for the Reducing Bleeding in Cardiac Surgery (RBC) Investigators (2008) Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study. Circulation 117:478–484

  42. 42.

    Kulier A, Levin J, Moser R et al (2007) Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation 116:471–479

  43. 43.

    Musallam KM, Tamim HM, Richards T et al (2011) Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 378:1396–1407

  44. 44.

    Mercuriali F, Intaglietta M (1996) Proposal of an algorithm to help the choice of the best transfusion strategy. Curr Med Res Opin 13:465–478

  45. 45.

    Gombotz H, Knotzer H (2013) Preoperative identification of patients with increased risk for perioperative bleeding. Curr Opin Anaesthesiol 26:82–90

  46. 46.

    Brecher ME, Monk T, Goodnough LT (1997) A standardized method for calculating blood loss. Transfusion 37:1070–1074

  47. 47.

    Ma M, Eckert K, Ralley F, Chin-Yee I (2005) A retrospective study evaluating single-unit red blood cell transfusions in reducing allogeneic blood exposure. Transfus Med 15:307–312

  48. 48.

    Dexter F, Ledolter J, Davis E et al (2012) Systematic criteria for type and screen based on procedure’s probability of erythrocyte transfusion. Anesthesiology 116:768–778

  49. 49.

    Mehra A, Murray J, deAlwis C (2004) A safe, simple and cost-effective protocol for blood transfusion in primary total knee replacement. Ann R Coll Surg Engl 86:260–262

  50. 50.

    Goodnough LT, Shander A (2013) Current status of pharmacologic therapies in patient blood management. Anesth Analg 116:15–34

  51. 51.

    Auerbach M, Ballard H (2010) Clinical use of intravenous iron: administration, efficacy, and safety. Hematology 2010:338–347

  52. 52.

    Besarab A, Bolton WK, Browne JK et al (1998) The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med 339:584–590

  53. 53.

    Brookhart MA, Schneeweiss S, Avorn J et al (2010) Comparative mortality risk of anemia management practices in incident hemodialysis patients. JAMA 303:857–864

  54. 54.

    Stowell CP, Jones SC, Enny C et al (2009) An open-label, randomized, parallel-group study of perioperative epoetin alfa versus standard of care for blood conservation in major elective spinal surgery: safety analysis. Spine 34:2479–2485

  55. 55.

    Ranucci M, Di DU, Castelvecchio S et al (2012) Impact of preoperative anemia on outcome in adult cardiac surgery: a propensity-matched analysis. Ann Thorac Surg 94:1134–1141

  56. 56.

    Shander A, Javidroozi M, Ozawa S, Hare GM (2011) What is really dangerous: anaemia or transfusion? Br J Anaesth 107(Suppl 1):41–59

  57. 57.

    Goodnough LT, Maniatis A, Earnshaw P et al (2011) Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth 106:13–22

  58. 58.

    Gombotz H (2011) Patient blood management is key before elective surgery. Lancet 378:1362–1363

  59. 59.

    Swedberg K, Young JB, Anand IS et al (2013) Treatment of anemia with darbepoetin alfa in systolic heart failure. N Engl J Med 368:1210–1219

  60. 60.

    Zarychanski R, Houston DS (2008) Anemia of chronic disease: a harmful disorder or an adaptive, beneficial response? CMAJ 179:333–337

  61. 61.

    Yoo YC, Shim JK, Kim JC et al (2011) Effect of single recombinant human erythropoietin injection on transfusion requirements in preoperatively anemic patients undergoing valvular heart surgery. Anesthesiology 115:929–937

  62. 62.

    Karkouti K, Wijeysundera DN, Yau TM et al (2008) The influence of baseline hemoglobin concentration on tolerance of anemia in cardiac surgery. Transfusion 48:666–672

  63. 63.

    Ashworth A, Klein AA (2010) Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth 105:401–416

  64. 64.

    Benson M, Hartmann B, Junger A et al (2000) Causes of higher blood loss during general anesthesia compared to spinal anesthesia in total hip replacement – a retrospective analysis of data collected online. Infusionsther Transfusionsmed 27:311–316

  65. 65.

    Carless PA, Henry DA, Anthony DM (2003) Fibrin sealant use for minimising peri-operative allogeneic blood transfusion. Cochrane Database Syst Rev 2:CD004171

  66. 66.

    Carless PA, Henry DA, Moxey AJ et al (2010) Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 17:CD001888

  67. 67.

    Cirocchi R, Abraha I, Montedori A et al (2010) Damage control surgery for abdominal trauma. Cochrane Database Syst Rev 20:CD007438

  68. 68.

    Kiran RP, Delaney CP, Senagore AJ et al (2004) Operative blood loss and use of blood products after laparoscopic and conventional open colorectal operations. Arch Surg 139:39–42

  69. 69.

    Lemay E, Guay J, Cote C, Roy A (2004) Tranexamic acid reduces the need for allogenic red blood cell transfusions in patients undergoing total hip replacement. Can J Anaesth 51:31–37

  70. 70.

    Levy O, Martinowitz U, Oran A et al (1999) The use of fibrin tissue adhesive to reduce blood loss and the need for blood transfusion after total knee arthroplasty. A prospective, randomized, multicenter study. J Bone Joint Surg Am 81:1580–1588

  71. 71.

    Rossi A, Falzetti G, Donati A et al (2010) Desflurane versus sevoflurane to reduce blood loss in maxillofacial surgery. J Oral Maxillofac Surg 68:1007–1012

  72. 72.

    Shander A (2003) Surgery without blood. Crit Care Med 31(12 Suppl):S708–S714

  73. 73.

    Meier J, Gombotz H (2013) Pillar III – Optimisation of anaemia tolerance. Best Pract Res Clin Anaesthesiol 27:111–119

  74. 74.

    Habib RH, Zacharias A, Schwann TA et al (2005) Role of hemodilutional anemia and transfusion during cardiopulmonary bypass in renal injury after coronary revascularization: implications on operative outcome. Crit Care Med 33:1749–1756

  75. 75.

    Lauscher P, Kertscho H, Schmidt O et al (2013) Determination of organ-specific anemia tolerance. Crit Care Med 41:1037–1045

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Einhaltung der ethischen Richtlinien

Interessenkonflikt. Prof. Dr. Hans Gombotz hat in den vergangenen fünf Jahren Honorare und/oder Reisekostenunterstützung von folgenden Unternehmen und Einrichtungen erhalten: Australian Red Cross Blood Service, BBraun Melsungen AG, Melsungen, Deutschland, CSL Behring GmbH, Marburg, Deutschland, Ethicon Biosurgery, Federal Austrian Ministry of Health and the Western Australian Department of Health, Perth, Australien, Fresenius Kabi GmbH, Bad Homburg, Deutschland, Vifor International AG, Glattbrugg, Schweiz.

Mag. Dr. Axel Hofmann hat in den vergangenen fünf Jahren Honorare und/oder Reisekostenunterstützung von folgenden Unternehmen und Einrichtungen erhalten: Amgen GmbH, Schweiz, Australian Red Cross Blood Service, Brisbane, Australien, BBraun Melsungen AG, Melsungen, Deutschland, CSL Behring GmbH, Marburg, Deutschland, Ethicon Biosurgery, Somerville, NJ, USA, Federal Austrian Ministry of Health and the Western Australian Department of Health, Perth, Australien, Fresenius Kabi GmbH, Bad Homburg, Deutschland, Janssen-Cilag GmbH, Wien, Österreich, Johnson & Johnson Medical Pty Ltd, North Ride, Austalien, Novo Nordisk A/S, Bagsvärd, Dänemark, TEM International GmbH, München, Deutschland, United, Biosource Corporation, Bethesda, Maryland, USA, Vifor International AG, Glattbrugg, Schweiz.

Das vorliegende Manuskript enthält keine Studien an Menschen oder Tieren.

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Correspondence to Prof. Dr. H. Gombotz.

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Gombotz, H., Hofmann, A. Patient Blood Management. Anaesthesist 62, 519–527 (2013). https://doi.org/10.1007/s00101-013-2199-1

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  • Transfusion
  • Blutungen
  • Anämie
  • Erythropoese
  • Outcome


  • Transfusion
  • Blood loss
  • Anemia
  • Erythropoiesis
  • Outcome