Blood management can mean different things to different people and groups. For example, speaking with a group of blood bankers it could well mean the sum of all those acts that create an inventory, keep it as fresh as possible and reduce wastage. donor selection and motivation plays a huge roll in that side of blood management. So that might well be thought of as supply sided blood management.

For me , as an anesthesiologist (consumer) I think of blood mangement from our side. That is how best to manage the patient's own oxygen carrying capacity resource and how to optimize conditions so that my dependence on the blood bank is minimized. We have a substantial Jehovah's Witness population who for religious reasons request no blood transfusion. The surgeon and anesthesiologist together create a plan for such patients so that the chance fo death due to anemia is minimized. Often times that plan means extra steps: epo, iron, hypotensive anesthesia, more regional anesthesia, euvolemic hemodilution, antifibrinolytic drug administration, cell salvage, special cautery, off-pump heart surgery, retrograde autologous prime of the bypass machine, mini-circuits, post-operative use of a "Cardiopat or Orthopat cell salvage washing device, etc. 

So, here is the challenge to everyone reading these strings: IF WE CAN DO IT FOR JW'S THEN IT IS UNETHICAL TO NOT DO IT FOR EVERYONE!  That is my personal opinion. But, if you believe as James and I do that blood transfusion should not be taken lightly and we truely do not know when it is life saving or advantageous then we should use it only in worst case scenarios.  That measn that we should use every technique possible to keep the patient's own blood in them or returned to them after surgery.  That is my kind of blood management.

This is a many pronged attack upon medical care such that it is planned and executed well. autologous pre-donation had been a mainstay of this during the late 1980-s and into the 1990's when HIV and hepatitis were the greates concerns. But today, with HIV riks at about 1-2.8 million units and Hepatitis B/C somewhere around 1/500,000 units donating blood for oneself pre-operatively is not cost effective. The cost adjusted life year savings (meaning the cost to do it and save one human life for one year) is around 12 million US dollars- WOW!  That is way out of line for anything else we do in medicine. A seatbelt has a cost adjusted life year value of around 100-500 US dollars. Pap smears are around 25 US dollars.  So one could say that autologous pre-donation today is the practice fo fear, not rational blood management. By donating one's own blood in advance you can be sure the blood you get back will ahve aged inteh blood bank, created cytokines, maybe grown bacteria, and will have very bizarre red cells all mishapen and with abnormal oxygen delivery curves. So that is not now a wise thing to do.  But, euvolemic hemodilution might be cost effective. There are good data in prostate operations and spine surgery showing this is very cheap and cost effective. Thre is less data in cardiac surgery to show it improves outcome. There is a menu of perhaps as many as 2030 events, drugs, maniputalions etc that can be brought to bear and be "blood management". My intent is not to write a chapter here but to say consider my basic tennent that such therapy should be our medical world wide standard for all patients, not just those with a certain religious belief.

I by theway, have taken three patients who are JW's to less than 30gm/l of Hgb, one patietn to less than 12gm/L and they all survived.  I routinely use blood management on all my cases and for heart surgery I transfuse less than 10% of all comers to my heart room. You can do it but blood managment in itslef has to almost become your personal religion!

Regarding preoperative autologous deposit (PAD) to minimise allogeneic blood transfusion I would make the following comments.

PAD has been practiced for many years and particularly came into vogue when HIV hit the blood sector. At the time is seemed a logical approach and thought to be an obvious alternative to allogeneic blood. However, this was not on a good evidence base and experience soon demonstrated that its wide resulted in more problems that benefits for patients.  The proceedure has undergone considerable re-evaluation and must be more specifically used. The NH&MRC review of this issue some years ago made the following recommendations:

What did the Committee recommend about pre-donation?

The Committee found that pre-donation of one’s own blood has a limited use. Their

recommendations state that:

·  the first goal is to prevent bleeding;

·  the second goal is to manage any bleeding without giving a blood transfusion;

·  a blood alternative should be used wherever possible;

·  if transfusion is necessary, red cells from donated blood or pre-donated blood (where

requested) should be used; and

·  all hospitals should have clear guidelines about the situations in which to transfuse

donated or pre-donated blood.

PAD does have a role if it is difficult to obtain compatible blood for a patient, usually due to atypical antibodies. When used is should be combined with iron therapy +/- epo. A case can also be made for separating and leucodepleting the blood to improve storage. For some patients a case for cryopreservation can be made. It can thus be seen the use of PAD is not a straight forward issue and has signification quality and safety issues, not to mention the logistics and costs. Attention to the 3 pillars of patient blood management is more important. Optimise red cell mass, minimise blood loss and tolerate anaemia in the short term.

Please note Dr  Steve Flecknoe-Brown in the intra operative discussion has made this comment (please go that discussion forum to see his full posting) which addresses the issue of autologus transfusion. 
' Pre-operative anaemia is one of the strongest predictors of whether a patient will be transfused in the peri-operative period. This is why autologous pre-deposition is now out of favour: it virtually guaranteed that the patient would be transfused, and autologous blood can still become contaminated by bacteria or mixed up with someone else's'.

Dr Isbister I have heard you lecture on a number of occassions and correct me if I am wrong but believe the advice you have given is that the best place for the patient's blood is in their circulation, can you comment on the role of autologus transfusion does it have a place? I am aware that many patients still request this prior to undergoing orthopaedic surgery. Does it have a role in 'patient blood management'?

The last anonymous was from me clicking the wrong button!!

I would briefly add that blood donors would expect that their donated blood was being prescribed to patients who need it based on good scientific evidence. This is thus also an ethical issue that we as clinicians should reflect on. If bencmarking studies show considerable variation in transfusion practices for similiar patient groups, a blood donor has good reasons to ask for an explanation.

Yes, you are correct and it patient blood banagement IS "good clinical medicine". However, benchmarking studies and experiences with surgery for those who refuse transfusion suggest that what you do is not done by all practitioners.  In places that will remain nameless up to 20% of patients come to hip surgery with iron deficiency anaemia, having commonly been on the waiting list for months. Most of these patients have not been adequately assesses preoperatively and end up getting unnecessary transfusions.

Gombotz, H., P. H. Rehak, et al. (2007). "Blood use in elective surgery: the Austrian benchmark study." Transfusion 47(8): 1468-80.

Dr Isbister isn't 'patient blood management' what we already do? In surgery aren't we already trying to conserve the patient's blood or does the term mean something broader?

Perhaps I could start some discussion on this subject. The question seems rather facile and the answer obvious, however, the term blood management has generally referred to the supply side focusing on donor blood. Transfusion medicine has tended to focus around the donor and the supply side, rather on the patient who is the reason d'etre for a blood service in the first place. Patient blood management is thus emphasising that transfusion medicine should focus on the patient and management of the patient's blood. We commonly referred to donated blood as "precious" and scare resource. Obviously this is true, but conserving and managing a patient's blood as a "precious" resource is event more important.