On January 10, 2022, the Association for the Advancement of Blood and Biotherapies (AABB), America’s Blood Centers (ABC), and American Red Cross (ARC) released a joint statement describing a dangerously low level of the nation’s blood supply which is the most severe shortage experienced in over a decade. The nation’s blood supply exists in a tenuous balance between supply and demand with minimal reserves available during periods of disruption. The COVID-19 pandemic has proven to be one such health crisis which has strained blood supplies throughout the country. With the incorporation of Patient Blood Management (PBM) practices, we as anesthesiologists can play a critical role in decreasing demand to match a lower supply while also improving patient outcomes.
COVID-19 and Blood Shortages
Throughout the COVID-19 pandemic, blood donation has been reduced because potential blood donors face short-term deferral due to symptomatic disease or test positivity from SARS-CoV-2. More significantly, large mobile drives at high schools, universities, and company offices, which account for a large majority of blood donations, have been prohibited because of social distancing and shelter-in-place ordinances.
Despite extensive outreach, reassurance of the safety of blood donation, and the designation of blood donation as an essential activity, compliant with stay-at-home laws, most blood centers experienced significant reductions in blood collections. Early in the pandemic demand for blood products decreased due to postponement of elective surgeries. However, with wider availability of patient testing and vaccination, elective procedures have resumed in most locations. These new surgeries, along with the backlog of postponed procedures, resulted in a significant increase in surgical volume. Consequently, demand for blood products has increased yet supply remains constrained.
Omicron Variant Surge
The recent surge in SARS-CoV-2 cases related to the Omicron variant has further exacerbated blood product shortages throughout the country. The dramatic increase in infections has not only decreased the number of available donors but has also impacted staffing at blood centers, reducing the availability of donation appointments and causing delays in blood product processing. As a result, the blood shortage has reached its most dire state in a decade. Many health systems are unable to receive their regular allotment of blood products, and some centers have been notified that they will receive a significantly reduced amount of blood products daily with recommendations to curtail usage.
Consequently, many hospitals have been forced to cancel elective surgical procedures and triage non-emergent cases based on current blood product inventory. Additionally, in certain centers Transfusion Medicine physicians have begun reviewing all orders as well as surgical schedules to recommend either delaying transfusions or offering split units to help manage an extremely limited inventory. To support patients in emergent need of transfusion, such as trauma patients and those undergoing organ transplantation, health systems have been forced to coordinate the transfer of blood products amongst hospitals in the surrounding community because national blood centers are unable to support emergency orders. In some instances, such efforts were also unsuccessful, resulting in temporary closure of trauma services. Furthermore, crisis standards of care have been imposed at some institutions until an adequate blood supply can be reestablished.
The AABB’s Interorganizational Task Force on Domestic Disasters and Acts of Terrorism, which includes members from the America’s Blood Centers, the American Red Cross, and Blood Centers of America as well as liaisons from the Armed Services Blood Program and the U.S. Department of Health and Human Services, has been working throughout the COVID-19 pandemic to coordinate efforts to bolster the blood supply. Local blood centers have also organized mobile blood drives at hospitals to allow for more convenient and regular donations by health care workers.
Patient Blood Management
In addition to these efforts, PBM practices are critically important to optimize blood utilization and ensure that blood products are available to the greatest number of patients in need. PBM encompasses pharmacologic, medical, and surgical practices throughout the perioperative period to manage anemia, optimize hemostasis, and minimize blood loss. When blood product transfusions are needed, the PBM approach requires the minimum, evidence-based amount be transfused to improve patient care.
PBM strategies include:
Preoperative
- Postponement of elective surgical procedures in anemic patients to allow for diagnosis and treatment.
- Correction of nutritional deficiencies contributing to anemia, including use of IV iron for iron-deficiency.
- Consideration of erythropoiesis stimulating agents in patients with other causes of anemia.
- Identification and correction of derangements in hemostasis, including appropriate cessation of anticoagulants and anti-platelet agents before invasive procedures.
Intraoperative
- Use of autologous blood salvage (Cell Saver).
- Addition of antifibrinolytic agents such as tranexamic acid or aminocaproic acid to help reduce bleeding.
- Assessment of coagulation status during uncontrolled bleeding or while under cardiopulmonary bypass by point-of-care viscoelastic testing to guide the need for specific blood product therapy rather than empiric transfusion of multiple products.
- Use of autologous normovolemic hemodilution in non-anemic patients to decrease overall loss of red cell mass during high blood loss surgery.
- Use of topical hemostatic agents, such as fibrin, thrombin, gelatin, collagen, and bone wax to aid in hemostasis.
- Maintenance of normothermia to optimize platelet and coagulation factor function.
- Broaden use criteria for factor concentrates (e.g., PCC, fibrinogen concentrate) in high bleeding risk procedures and/or during periods of severe blood shortage.
Postoperative
- Eliminate phlebotomy for non-essential laboratory testing.
- Incorporate restrictive transfusion thresholds.
- Transfuse RBC units in non-bleeding, asymptomatic patients only when hemoglobin
- A higher threshold of 8 g/dl should be considered only for patients with significant cardiac disease.
- Transfuse platelet units when counts are
- Avoid prophylactic plasma transfusions in patients with INR £ 2.0.
- Transfuse one RBC unit at a time and reassess the clinical status of the patient.
Thus, anesthesiologists can play a pivotal role during this critical blood shortage through incorporation of PBM techniques, which in concert with increased blood donor recruitment by blood centers, can help close the gap between supply and demand and allow health systems to continue to provide vital medical treatment.
Detailed resources for help incorporating PBM into practice can be found at the Society for the Advancement of Patient Blood Management’s (SABM) and AABB’s websites.
Assistance with finding and scheduling blood donation appointments in your area can be found at https://www.aabb.org/for-donors-patients/give-blood .