First coined in 2005 by Australian hematologist James Isbister, patient blood management is an evidence-based, multidisciplinary approach aimed at optimizing the care of patients who might require blood transfusion (Isbister JP 2005). Current patient blood management recommendations shift focus away from simply reducing the use of blood components and instead promote multimodal strategies centered on improving patient outcomes.
Allogenic blood remains a scarce and costly commodity, and transfusions carry risks, including immune reactions, infections, and increased mortality. Despite this, transfusions have historically been overused, with some reports suggesting that as many as half of all transfusions are unnecessary (Shander et al 2011). This excessive usage of transfusions has been exacerbated by the lack of an incentive for avoiding or reducing transfusion. However, following research in the 1980’s involving cardiovascular surgery patients refusing blood products (Jehovah’s Witnesses) and HIV/AIDS transmission concerns, practitioners began to question their use of blood products (Isbister JP 2005, Farmer et al 2014). The results of these explorations encouraged the development of patient blood management recommendations that are patient-centered and prioritize safety, efficiency, and stewardship.
Patient blood management strategies are often described in terms of three key pillars: optimizing hematopoiesis (natural red blood cell generation), minimizing blood loss, and enhancing the patient’s tolerance of anemia (Frietsch et al 2019).
Optimizing hematopoiesis relies on interventions such as iron supplementation (oral or intravenous), vitamin B12, folate therapy, or other hematopoiesis-stimulating agents to increase a patient’s red blood cell count. These “booster” strategies may take weeks to become effective and require foresight and early screening from a multidisciplinary team. Success in this gives clinicians a larger safety margin when blood loss is inevitable.
The principle of minimizing blood loss encompasses meticulous surgical hemostasis, the use of antifibrinolytic agents like tranexamic acid, restrictive phlebotomy practices, and intraoperative blood conservation techniques such as cell savage (Mueller et al 2019). However, blood loss is not always easily controlled during major surgeries or medical procedures, and clinicians must be able to rely on their ability to supplement a patient’s blood supply.
Within patient blood management, multidisciplinary teams are encouraged to manage patient expectations and physiologic ability to withstand anemic conditions. Rather than reflexively transfusing based on a hemoglobin number deviation or estimated blood loss, PBM encourages clinicians to track the patient’s symptoms and physiologic reserve. By optimizing oxygen delivery, maintaining normothermia, and employing non-transfusion alternatives, many patients can safely tolerate lower hemoglobin thresholds (Shander et al 2012). These combined efforts can reduce the amount of donor blood consumed and improve patient outcomes.
Current evidence strongly supports restrictive transfusion thresholds, with most guidelines recommending transfusion only when hemoglobin falls below 7–8 g/dL in stable patients (Mueller et al 2019). A “one-unit-at-a-time” approach followed by reassessment is now considered best practice rather than proactively administering multi-unit transfusion.
Patient blood management works best as a team-based program involving anesthesiologists, surgeons, hematologists, intensivists, nurses, and pharmacists. Institutional support through electronic medical record prompts and hospital wide transfusion committees helps ensure adherence to protocols. Programs built on these practices have demonstrated not only reduced infection risk, shorter hospital stays, and fewer cardiac complications but also improved stewardship of limited blood resources and lower overall healthcare costs due to fewer transfusions and complications (Bolliger et al. 2025).
Patient blood management is not just about conserving blood—it is about delivering safer, more effective care by proactively optimizing hemoglobin levels, minimizing intraoperative blood loss, and supporting a patient’s ability to tolerate anemia. Current recommendations and guidelines provide a structured and evidence-based framework for better outcomes.
References
Bolliger D, Buser A, Tanaka KA. Outcomes, cost-effectiveness, and ethics in patient blood management. Curr Opin Anaesthesiol. 2025;38(2):151-156. doi:10.1097/ACO.0000000000001466
Farmer SL, Isbister J, Leahy MF. History of blood transfusion and patient blood management. In: Jabbour N, ed. Transfusion-Free Medicine and Surgery. Wiley-Blackwell; 2014. doi:10.1002/9781118554685.ch1
Frietsch T, Shander A, Faraoni D, Hardy JF. Patient blood management is not about blood transfusion: it is about patients’ outcomes. Blood Transfus. 2019;17(5):331-333. doi:10.2450/2019.0126-19
Mueller MM, Van Remoortel H, Meybohm P, et al. Patient Blood Management: recommendations from the 2018 Frankfurt Consensus Conference. JAMA. 2019;321(10):983-997. doi:10.1001/jama.2019.0554
Isbister JP. The need for a new paradigm in blood transfusion practice. Transfus Med. 2005;15(Suppl 1):1-5. doi:10.1111/j.1365-3148.2005.00546.x
Shander A, Fink A, Javidroozi M, et al. Appropriateness of allogeneic red blood cell transfusion: the international consensus conference on transfusion outcomes. Transfus Med Rev. 2011;25(3):232-246.e53. doi:10.1016/j.tmrv.2011.02.001
Shander A, Javidroozi M, Perelman SI, Puzio T, Lobel GP. From bloodless surgery to patient blood management. Mt Sinai J Med. 2012;79(1):56-65. doi:10.1002/msj.21292