Patient Blood Management in der Intensivmedizin

Anämien sind mit erhöhtem Transfusionsbedarf und vermehrten Komplikationen inklusive erhöhter Sterblichkeit assoziiert. Aufgrund von Entzündungen, Koagulopathien und Blutungen, iatrogenen Blutverlusten und anderen Einflussfaktoren weisen Intensivpatienten eine hohe Anämieprävalenz auf. Patient Blood Management (PBM) ist ein Konzept, das (perioperatives) Anämiemanagement, die Reduktion von Blutverlusten und den evidenzbasierten Einsatz von Bluttransfusionen fördert und Eingang in diverse Guidelines gefunden hat. Entsprechend würden Intensivpatienten von PBM enorm profitieren.

Kernaussagen

• Patient Blood Management (PBM) bietet Konzepte für (präoperatives) Anämiemanagement, die Reduktion von Blutverlusten (inklusive blutsparender Maßnahmen) und den leitliniengerechten Einsatz von Bluttransfusionen.

• Patienten auf der Intensivstation sind häufig von Entzündungsanämien oder Eisenmangelanämien mit multifaktoriellen Ursachen betroffen, die eine zusätzliche gesundheitliche Belastung neben der Hauptdiagnose darstellen.

• Nach Feststellung der Anämie sollte eine Differenzialdiagnostik durchgeführt werden, damit die Anämie adäquat behandelt werden kann, z. B. mittels i. v. Eisengaben oder die Erythropoese stimulierender Substanzen.

• Akute und chronische Blutverluste sollten mit einem algorithmusbasierten Blutungsmanagement optimiert werden.

• Iatrogene Blutverluste tragen zur Entstehung und Verschärfung von Anämien bei. Insbesondere bei Intensivpatienten gibt es aufgrund der engmaschigen Überwachung viele Optimierungsmöglichkeiten. Dazu gehören:

  • Nutzung von Blutentnahmeröhrchen mit geringerem Füllvolumen,

  • Reduktion der Blutabnahmefrequenz,

  • vermehrte Verwendung von Point-of-Care-Diagnostik,

  • Verwendung von geschlossenen Druckaufnehmersystemen.

• Die Gabe von EK-Transfusionen muss gemäß der Querschnittsleitlinie zur Therapie mit Blutkomponenten und Plasmaderivaten erfolgen. Bei der Einhaltung der Leitlinie können digitale Bestell- und Dokumentationssysteme unterstützend eingesetzt werden.

Schlüsselwörter

Patient Blood Management - Anämie - Eisensubstitution - Bluttransfusion - Eisenmangelanämie

Publication History

Article published online:
30 March 2023

• Literatur

• 1 World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva: World Health Organization; 2011. Accessed December 19, 2022 at: https://apps.who.int/iris/bitstream/handle/10665/85839/WHO_NMH_NHD_MNM_11.1_eng.pdf
• 2 Chopra VK, Anker SD. Anaemia, iron deficiency and heart failure in 2020: facts and numbers. ESC Heart Fail 2020; 7: 2007-2011 DOI: 10.1002/ehf2.12797. (PMID: 32602663)
• 3 Kung WM, Yuan SP, Lin MS. et al. Anemia and the risk of cognitive impairment: an updated systematic review and meta-analysis. Brain Sci 2021; 11 DOI: 10.3390/brainsci11060777. (PMID: 34208355)
• 4 Munoz M, Gomez-Ramirez S, Campos A. et al. Pre-operative anaemia: prevalence, consequences and approaches to management. Blood Transfus 2015; 13: 370-379 DOI: 10.2450/2015.0014-15. (PMID: 26192787)
• 5 Loor G, Rajeswaran J, Li L. et al. The least of 3 evils: exposure to red blood cell transfusion, anemia, or both?. J Thorac Cardiovasc Surg 2013; 146: 1480-1487.e6 DOI: 10.1016/j.jtcvs.2013.06.033.
• 6 Shah A, Stanworth SJ, Lee A. et al. Prevalence, management and outcomes associated with anaemia in ICU survivors: a retrospective study. Anaesthesia 2021; 76: 1421-1423 DOI: 10.1111/anae.15461.
• 7 Vincent J, Baron J, Reinhart K. et al. Anemia and blood transfusion in critically ill patients. JAMA 2002; 288: 1499-1507 DOI: 10.1001/jama.288.12.1499. (PMID: 12243637)
• 8 Warner MA, Hanson AC, Frank RD. et al. Prevalence of and recovery from anemia following hospitalization for critical illness among adults. JAMA Network Open 2020; 3: e2017843 DOI: 10.1001/jamanetworkopen.2020.17843.
• 9 Smilowitz NR, Oberweis BS, Nukala S. et al. Association between anemia, bleeding, and transfusion with long-term mortality following noncardiac surgery. Am J Med 2016; 129: 315-323.e2 DOI: 10.1016/j.amjmed.2015.10.012.
• 10 Whitlock EL, Kim H, Auerbach AD. Harms associated with single unit perioperative transfusion: retrospective population based analysis. BMJ 2015; 350: h3037 DOI: 10.1136/bmj.h3037. (PMID: 26070979)
• 11 Meybohm P, Richards T, Isbister J. et al. Patient Blood Management Bundles to Facilitate Implementation. Transfus Med Rev 2017; 31: 62-71 DOI: 10.1016/j.tmrv.2016.05.012. (PMID: 27317382)
• 12 Leahy MF, Hofmann A, Towler S. et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion 2017; 57: 1347-1358 DOI: 10.1111/trf.14006.
• 13 Meybohm P, Herrmann E, Steinbicker AU. et al. Patient blood management is associated with a substantial reduction of red blood cell utilization and safe for patient’s outcome: a prospective, multicenter cohort study with a noninferiority design. Ann Surg 2016; 264: 203-211 DOI: 10.1097/SLA.0000000000001747.
• 14 Theusinger OM, Kind SL, Seifert B. et al. Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. Blood Transfus 2014; 12: 195-203 DOI: 10.2450/2014.0306-13.
• 15 Althoff FC, Neb H, Herrmann E. et al. Multimodal Patient Blood Management Program Based on a Three-pillar Strategy: A Systematic Review and Meta-analysis. Ann Surg 2019; 269: 794-804 DOI: 10.1097/SLA.0000000000003095. (PMID: 30418206)
• 16 WHO. The urgent need to implement patient blood management. Policy brief. Geneva: World Health Organization; 2021. Accessed December 19, 2022 at: https://apps.who.int/iris/handle/10665/346655
• 17 Shander A, Javidroozi M, Lobel G. Patient blood management in the intensive care unit. Transfus Med Rev 2017; 31: 264-271 DOI: 10.1016/j.tmrv.2017.07.007. (PMID: 28811051)
• 18 Docherty AB, Turgeon AF, Walsh TS. Best practice in critical care: anaemia in acute and critical illness. Transfus Med 2018; 28: 181-189 DOI: 10.1111/tme.12505. (PMID: 29369437)
• 19 Dave CV, Brittenham GM, Carson JL. et al. Risks for anaphylaxis with intravenous iron formulations : a retrospective cohort study. Ann Intern Med 2022; 175: 656-664 DOI: 10.7326/M21-4009. (PMID: 35344378)
• 20 Neef V, Baumgarten P, Noone S. et al. The impact of timing of intravenous iron supplementation on preoperative haemoglobin in patients scheduled for major surgery. Blood Transfus 2021; 20: 188-197 DOI: 10.2450/2021.0058-21. (PMID: 34059194)
• 21 Triphaus C, Judd L, Glaser P. et al. Effectiveness of preoperative iron supplementation in major surgical patients with iron deficiency: a prospective observational study. Ann Surg 2019; 274: e212-e219 DOI: 10.1097/SLA.0000000000003643.
• 22 Froessler B, Palm P, Weber I. et al. The important role for intravenous iron in perioperative patient blood management in major abdominal surgery: a randomized controlled trial. Ann Surg 2016; 264: 41-46 DOI: 10.1097/SLA.0000000000001646. (PMID: 26817624)
• 23 Myles PS, Richards T, Klein A. et al. Postoperative anaemia and patient-centred outcomes after major abdominal surgery: a retrospective cohort study. Br J Anaesth 2022; 129: 346-354 DOI: 10.1016/j.bja.2022.06.014. (PMID: 35843746)
• 24 Munoz M, Acheson AG, Bisbe E. et al. An international consensus statement on the management of postoperative anaemia after major surgical procedures. Anaesthesia 2018; 73: 1418-1431 DOI: 10.1111/anae.14358. (PMID: 30062700)
• 25 Kim MS, Koh IJ, Choi KY. et al. Efficacy and Safety of intravenous ferric carboxymaltose in patients with postoperative anemia following same-day bilateral total knee arthroplasty: a randomized controlled trial. J Clin Med 2021; 10: 1457 DOI: 10.3390/jcm10071457.
• 26 Litton E, Baker S, Erber WN. et al. Intravenous iron or placebo for anaemia in intensive care: the IRONMAN multicentre randomized blinded trial : A randomized trial of IV iron in critical illness. Intensive Care Med 2016; 42: 1715-1722 DOI: 10.1007/s00134-016-4465-6. (PMID: 27686346)
• 27 Weiss G, Ganz T, Goodnough LT. Anemia of inflammation. Blood 2019; 133: 40-50 DOI: 10.1182/blood-2018-06-856500. (PMID: 30401705)
• 28 Litton E, Latham P, Inman J. et al. Safety and efficacy of erythropoiesis-stimulating agents in critically ill patients admitted to the intensive care unit: a systematic review and meta-analysis. Intensive Care Med 2019; 45: 1190-1199 DOI: 10.1007/s00134-019-05686-y. (PMID: 31297547)
• 29 Wijnberge M, Rellum SR, de Bruin S. et al. Erythropoiesis-stimulating agents as replacement therapy for blood transfusions in critically ill patients with anaemia: A systematic review with meta-analysis. Transfus Med 2020; 30: 433-441 DOI: 10.1111/tme.12715.
• 30 Gattermann N, Muckenthaler MU, Kulozik AE. et al. The evaluation of iron deficiency and iron overload. Dtsch Arztebl Int 2021; 118: 847-856 DOI: 10.3238/arztebl.m2021.0290. (PMID: 34755596)
• 31 Shin DH, Kim HS, Park MJ. et al. Utility of access soluble transferrin receptor (sTfR) and sTfR/log ferritin index in diagnosing iron deficiency anemia. Ann Clin Lab Sci 2015; 45: 396-402 (PMID: 26275690)
• 32 Lasocki S, Asfar P, Jaber S. et al. Impact of treating iron deficiency, diagnosed according to hepcidin quantification, on outcomes after a prolonged ICU stay compared to standard care: a multicenter, randomized, single-blinded trial. Crit Care 2021; 25: 62 DOI: 10.1186/s13054-020-03430-3. (PMID: 33588893)
• 33 Lasocki S, Lefebvre T, Mayeur C. et al. Iron deficiency diagnosed using hepcidin on critical care discharge is an independent risk factor for death and poor quality of life at one year: an observational prospective study on 1161 patients. Crit Care 2018; 22: 314 DOI: 10.1186/s13054-018-2253-0. (PMID: 30463596)
• 34 Bodley T, Chan M, Levi O. et al. Patient harm associated with serial phlebotomy and blood waste in the intensive care unit: A retrospective cohort study. PLoS One 2021; 16: e0243782 DOI: 10.1371/journal.pone.0243782.
• 35 Jackson Chornenki NL, James TE, Barty R. et al. Blood loss from laboratory testing, anemia, and red blood cell transfusion in the intensive care unit: a retrospective study. Transfusion 2020; 60: 256-261 DOI: 10.1111/trf.15649.
• 36 Koch CG, Reineks EZ, Tang AS. et al. Contemporary bloodletting in cardiac surgical care. Ann Thorac Surg 2015; 99: 779-784 DOI: 10.1016/j.athoracsur.2014.09.062. (PMID: 25583464)
• 37 Briggs EN, Hawkins DJ, Hodges AM. et al. Small volume vacuum phlebotomy tubes: a controlled before-and-after study of a patient blood management initiative in an Australian adult intensive care unit. Crit Care Resusc 2019; 21: 251-257 (PMID: 31778631)
• 38 Barreda Garcia J, Xian JZ, Pedroza C. et al. Pediatric size phlebotomy tubes and transfusions in adult critically ill patients: a pilot randomized controlled trial. Pilot Feasibility Stud 2020; 6: 112 DOI: 10.1186/s40814-020-00657-3.
• 39 Pinto T, Belley-Cote E, Esmail A. et al. Small-volume tubes to reduce transufusion (stratus): a pilot study. Blood 2018; 132: 825-825 DOI: 10.1182/blood-2018-99-120186.
• 40 Dolman HS, Evans K, Zimmerman LH. et al. Impact of minimizing diagnostic blood loss in the critically ill. Surgery 2015; 158: 1083-1087 DOI: 10.1016/j.surg.2015.05.018.
• 41 Riessen R, Behmenburg M, Blumenstock G. et al. A simple “blood-saving bundle” reduces diagnostic blood loss and the transfusion rate in mechanically ventilated patients. PLoS One 2015; 10: e0138879 DOI: 10.1371/journal.pone.0138879.
• 42 Westphal S, Zacharowski K, Kudraschow A. et al. Vergleich von offenen vs. geschlossenen invasiven Druckaufnehmersystemen im Rahmen des Patient Blood Management. Anästh Intensivmed 2018; 59: 146-153
• 43 Mukhopadhyay A, Yip HS, Prabhuswamy D. et al. The use of a blood conservation device to reduce red blood cell transfusion requirements: a before and after study. Crit Care 2010; 14: R7 DOI: 10.1186/cc8859.
• 44 Corredor C, Wasowicz M, Karkouti K. et al. The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis. Anaesthesia 2015; 70: 715-731 DOI: 10.1111/anae.13083. (PMID: 25916344)
• 45 Buchner L-M, Park EJ, Bendz P. et al. Evaluation of a clinical decision support system for the most evidence-based approach to managing perioperative anticoagulation. J Clin Anesth 2022; 80: 110877 DOI: 10.1016/j.jclinane.2022.110877.
• 46 Englert A, Bendz P. KIPeriOP-Group. Artificial intelligence-augmented perioperative clinical decision support, KIPeriOP. Anaesthesist 2021; 70: 962-963 DOI: 10.1007/s00101-021-00948-1. (PMID: 34731276)
• 47 Taeuber I, Weibel S, Herrmann E. et al. Association of intravenous tranexamic acid with thromboembolic events and mortality. JAMA Surg 2021; 156: e210884 DOI: 10.1001/jamasurg.2021.0884.
• 48 Murao S, Nakata H, Roberts I. et al. Effect of tranexamic acid on thrombotic events and seizures in bleeding patients: a systematic review and meta-analysis. Crit Care 2021; 25: 380 DOI: 10.1186/s13054-021-03799-9. (PMID: 34724964)
• 49 Meybohm P, Choorapoikayil S, Wessels A. et al. Washed cell salvage in surgical patients: A review and meta-analysis of prospective randomized trials under PRISMA. Medicine (Baltimore) 2016; 95: e4490 DOI: 10.1097/MD.0000000000004490. (PMID: 27495095)
• 50 Carless PA, Henry DA, Moxey AJ. et al. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2006; DOI: 10.1002/14651858.CD001888.pub2. (PMID: 20238316)
• 51 Jacquot C, Delaney M. Efforts Toward elimination of infectious agents in blood products. J Intensive Care Med 2018; 33: 543-550 DOI: 10.1177/0885066618756589. (PMID: 29562814)
• 52 Hendrickson JE, Roubinian NH, Chowdhury D. et al. Incidence of transfusion reactions: a multicenter study utilizing systematic active surveillance and expert adjudication. Transfusion 2016; 56: 2587-2596 DOI: 10.1111/trf.13730. (PMID: 27460200)
• 53 Bundesärztekammer. Querschnitts-Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten. Gesamtnovelle 2020. Accessed December 19, 2022 at: https://www.bundesaerztekammer.de/fileadmin/user_upload/_old-files/downloads/pdf-Ordner/MuE/Querschnitts-Leitlinien_BAEK_zur_Therapie_mit_Blutkomponenten_und_Plasmaderivaten-Gesamtnovelle_2020.pdf
• 54 Hébert PC, Wells G, Blajchman MA. et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999; 340: 409-417 DOI: 10.1056/NEJM199902113400601. (PMID: 9971864)
• 55 Zhang W, Zheng Y, Yu K. et al. Liberal Transfusion versus restrictive transfusion and outcomes in critically ill adults: a meta-analysis. Transfus Med Hemother 2021; 48: 60-68 DOI: 10.1159/000506751. (PMID: 33708053)
• 56 Schlesinger T, Kranke P, Helmer P. et al. Updated cross-sectional guidelines on therapy with blood components and plasma derivatives 2020: What’s new about erythrocytes for the anaesthesiologist?. Anästh Intensivmed 2021; 62: 463-470 DOI: 10.19224/ai2021.463.
• 57 Themelin N, Biston P, Massart J. et al. Effects of red blood cell transfusion on global oxygenation in anemic critically ill patients. Transfusion 2021; 61: 1071-1079 DOI: 10.1111/trf.16284. (PMID: 33533027)
• 58 Borgert M, Binnekade J, Paulus F. et al. Implementation of a transfusion bundle reduces inappropriate red blood cell transfusions in intensive care – a before and after study. Transfus Med 2016; 26: 432-439 DOI: 10.1111/tme.12364.
• 59 Yang WW, Thakkar RN, Gehrie EA. et al. Single-unit transfusions and hemoglobin trigger: relative impact on red cell utilization. Transfusion 2017; 57: 1163-1170 DOI: 10.1111/trf.14000. (PMID: 28164305)
• 60 Paul-Ehrlich-Institut. Bericht des Paul-Ehrlich-Instituts über die nach § 21 Transfusionsgesetz gemeldeten Daten. 2020 Accessed December 19, 2022 at: https://www.pei.de/SharedDocs/Downloads/DE/regulation/meldung/21-tfg/21-tfg-berichte/2020-tfg-21-bericht.pdf?__blob=publicationFile&v
• 61 Saillant NN, Kornblith LZ, Moore H. et al. The National Blood Shortage-An Impetus for Change. Ann Surg 2022; 275: 641-643 DOI: 10.1097/SLA.0000000000005393. (PMID: 35081570)
• 62 Shander A, Goobie SM, Warner MA. et al. Essential Role of Patient Blood Management in a Pandemic: A Call for Action. Anesth Analg 2020; 131: 74-85 DOI: 10.1213/ane.0000000000004844. (PMID: 32243296)
• 63 Herrmann J, Lotz C, Karagiannidis C. et al. Key characteristics impacting survival of COVID-19 extracorporeal membrane oxygenation. Crit Care 2022; 26: 190 DOI: 10.1186/s13054-022-04053-6. (PMID: 35765102)
• 64 Teimury A, Khameneh MT, Khaledi EM. Major coagulation disorders and parameters in COVID-19 patients. Eur J Med Res 2022; 27: 25 DOI: 10.1186/s40001-022-00655-6. (PMID: 35168674)
• 65 Bellmann-Weiler R, Lanser L, Barket R. et al. Prevalence and Predictive Value of Anemia and Dysregulated Iron Homeostasis in Patients with COVID-19 Infection. J Clin Med 2020; 9: 2429 DOI: 10.3390/jcm9082429.