As there is no alternative for human blood, an adequate supply of blood in Sri Lanka can only be assured through regular donations. It is obvious that a sufficient supply of safe blood is an essential component for needy patients.
In an interview with the Sunday Observer, Dr. Trilicia Withanawasam, Consultant Transfusion Physician at the University Hospital of Kotelawala Defence University and Dr. Nilmini Wijesuriya, Senior Consultant Anaesthetist at Colombo North Teaching Hospital attempt to introduce a new concept of Patient Blood Management (PBM) which is a timely project. Dr. Withanawasam is a senior lecturer at the Faculty of Medicine, KDU and the incumbent head of the department of “Transfusion Medicine” at the University Hospital-KDU. Dr. Wijesuriya is the head of the Department of Anaesthesiology, CNTH, Ragama.
Q: Donors donate blood to save other people’s lives. Who are the patients who benefit from blood and component transfusions?
A. Blood and blood components are a lifesaving therapy for which there is no alternative, even in the developed world. For patients with bleeding after traumatic incidents and after major surgical procedures involving genetic and acquired blood cell deficiencies, donor blood would be a gift of life. Blood services maintain the supply because of the noble act of voluntary, non-remunerated regular blood donors.
Q: How expensive are blood and component transfusions?
A. The therapeutic materials used for blood transfusion processes are live cells and tissues derived from human blood. These derivatives need to be handled with special care under special environmental conditions, which makes the blood component production expensive.
Although there is no calculated cost value for a unit of blood component in SL health economics, the data published by NHS, UK reveals the approximate cost of standard red cell concentrate is GBP 146 (Rs 62 000). Similarly, a significant expenditure is budgeted for the cost of the other blood components such as plasma and platelets. The cost covers the procurement of raw materials, human labour, transportation, storage, and maintenance.
There are added costs for the management of transfusion procedures and their potential complications. Although the resources are from voluntary, non-remunerated donors, the total process is expensive, making blood product transfusion one of the costliest treatments among all therapies.
Regrettably, the general public does not seem to be taking the burden of the cost seriously because of the free health system in Sri Lanka.
Q: What is the impact on blood and component production during an economic crisis?
A. Because of the ongoing financial crisis, the health budget was expected to be minimised. All the required consumables for the collection, production, and transfusion are in the import category except voluntarily donated human blood, making it an extremely costly expense for the Government.
Due to the restrictions of the supply chain, the blood service faces a challenge in fulfilling the demand for blood and components; a shortage of different types of blood collection bags, test kits, and other consumables leads to this situation. The fuel shortage resulted in disruption of the mobile blood collection campaigns and transport restrictions caused reduced walk-in in-house blood donors. In addition, smooth circulation of the blood components within the regional and provincial blood centres was interrupted.
Social restlessness, queuing for fuel and essentials, and economic hardships distracted the public from voluntary activities such as blood donation; the priority of the community shifted towards searching for food, medicine, fuel, and other daily essentials.
The impending financial downturn is expected to make the situation worse for the blood service in Sri Lanka; there is a probability that the prevalence of malnutrition and anemia in the community will spike further, hence increasing the number of deferred donations.
Q: What is PBM? How can PBM strategies be used as a solution?
A. The World Health Organization (WHO) defines patient blood management (PBM) as a patient-focused, evidence-based, and systematic approach to optimise the management of patients and the transfusion of blood products for quality and effective patient care.
It is designed to improve patient outcomes through the safe and rational use of blood and blood products and by minimising unnecessary exposure to blood products. Further, the strategic points lead to helping patients’ bodies to recover on their own rather than making early decisions to transfuse blood and products.
The knowledge, understanding, and perception of the PBM strategies are at a very low level among health care authorities and providers. The aim of this paper article is to make the public and responsible specialists aware of the value of the timely implementation of PBM in the Sri Lankan health sector.
Many kinds of literature are supportive of the statement of “blood product transfusion per se increases mortality and morbidity in certain situations like surgeries and critical care”.
Implementation of PBM can prevent conditions which might later lead to the requirement for transfusion. For example, patients who are going for elective surgeries having nutritional deficiency-related anaemia can be treated with diet and supplementation and anaemia can be corrected before the surgery. Hence, it reduces the requirement for blood transfusions during the surgery. Surgical bleeding itself is a risk factor for anemia.
There are many other patient conditions which lead to increased blood loss such as patients on blood thinning drugs, unrecognised acquired/inherited bleeding disorders, coagulopathy related to acquired infections and so on.
If we can identify and correct such conditions prior to surgery, the demand for blood will be minimised. Blood sampling for investigations in intensive care patients has proven to lead to anaemia and hence red cell transfusions.
Successful PBM can reduce the use of blood and spare available blood units for needy patients where the other options are minimal.
If we can treat the iron deficiency with iron treatment rather than waiting till it becomes severe enough to receive a transfusion, we can conserve blood units.
Good surgical and anesthetic techniques would minimise the bleeding.
Reducing the incidence of transfusion can be a cost-effective method which can have a positive impact on the economy.
Q: If a patient is going for a major surgery how can you minimize the use the of blood and components?
A. We apply the principles of the “three pillars” of Patient Blood Management (PBM) to reduce and optimise the use of blood and components. These principles are applied before surgery, during and after surgery as well. Coordinated work by clinicians of different specialties- surgeons, anaesthetists, transfusion physicians, nutritionists, haematologists and hospital administrators with other involved healthcare workers is essential for the successful implementation of PBM.
In brief, before surgery as mentioned earlier, we identify patients with anaemia and other risk factors and correct them if possible. Early referral of these patients to a preoperative assessment clinic managed by anaesthetists will facilitate this. Anaesthetists assess the fitness of the patients and optimise to improve their ability to tolerate surgical stress.
During surgery, it is important for surgeons to be meticulous in their technique and to use different medications to minimise blood loss. The anaesthetist also plays a key role by using various techniques to reduce blood loss and he carefully monitors the patient for timely correction of any deficit using modern testing methods to minimise complications.
After surgery, high-risk patients are monitored closely and managed in the intensive care unit to avoid further blood loss.
Q: What action have you taken to optimise the rational use of blood and components without compromising the patient outcome?
A. Intuitional agreement is placed to treat patients with blood and components according to international guidelines and strict adherence to transfusion thresholds. Encourage Multidisciplinary teamwork for the patient who needs blood and components and patients who are going for major surgeries.
As professional groups, Colleges of Transfusion physicians, Anaesthesiologists and Intensivists of Sri Lanka have collaborated to work together with other professional groups in the future to optimise the rational use of blood and components. We aim to implement the WHO recommendation on urgent PBM principles in our country. It is challenging to change old practices, but we have taken the first steps to disseminate knowledge on PBM principles among healthcare professionals through webinars and hope to formulate national guidelines and implement them through the Ministry of Health.