Dear Editor,

The recent issue of Transfusion Medicine and Hemotherapy addresses the call of the World Health Organization to emphasize “the importance of being prepared and responding quickly and outlines key actions and measures that the blood services should take to mitigate potential risk to the safety and sufficiency of the blood supplies during the pandemic” [1]. Transfusion of allogeneic blood products is an indispensable treatment in clinical practice; therefore, a sufficient and continuous supply of blood components is essential. For quite some time, healthcare providers have been concerned about the demographic change and its impact on healthcare. The aging of the population will most likely affect the demand of all healthcare services, including medical procedures in hospitals and long-term care, which are associated with higher costs. At the same time, the number of available blood donors due to increasing specifications and requirements will decrease, and the reduction in donated blood may challenge medical services.

Until recently, the overall availability of blood products was never seriously questioned. However, during the COVID-19 pandemic, the number of blood donations decreased dramatically leading to an unexpected scenario. In Germany, blood banks are required by law to report on the collection, manufacturing, distribution, and the use of blood components on a yearly basis. Therefore, the ratio of supply and demand can be precisely analyzed in a retrospective manner. However, the amount of currently stored blood products is not available in real time. Fiedler et al. [2] examined the number of whole blood donations from 2009 to 2021 and explored the feasibility of a weekly reporting system. The authors observed that the number of whole blood donations decreased from 4.86 million in 2009 to 3.67 million in 2020 and 3.7 million in 2021. In parallel, the number of distributed red blood cell (RBC) units also decreased constantly from 4.68 million in 2009 to 3.57, 3.49, 3.43, 3.43 million in 2018, 2019, 2020, and 2021, respectively. The first wave of COVID-19 began in March 2020 in Germany, and the results of the authors suggest that the reduced distribution of RBCs may be independent of the pandemic. It is thought that medically advanced strategies to optimize patients’ hemoglobin level, to reduce unnecessary blood loss, adhere to blood transfusion guideline, and increase the use of minimally invasive procedures have contributed to the reduction of RBC distribution. Patient blood management (PBM) is a program, which has been promoted by the World Health Organization in 2010. Because of its urgent need and the special circumstances during the pandemic, it was highlighted again in 2021 [3]. “PBM is a multidisciplinary application of evidence-based medical and surgical concepts aimed at (1) screening for, diagnosing, and appropriately treating anemia; (2) minimizing surgical, procedural, and iatrogenic blood losses and managing coagulopathic bleeding throughout the care; and (3) supporting the patient while appropriate treatment is initiated” [4]. In 2014, the German PBM network was initiated to support hospitals with the implementation of PBM measures. Driven by the awareness of the impact of anemia and blood transfusion on surgical outcome, hospitals established strategies to optimize the patient’s condition. This included, for example, preoperative anemia and coagulation management, strategies to reduce surgical blood loss, and support treatment according to guidelines. Overall, medical services have improved in the last decades and may have contributed to the reduced need for allogenic blood transfusion. A survey including 21 hospitals revealed that 70.8% of PBM measures were implemented to a moderate or high degree. In general, university hospitals reached higher scores compared to nonuniversity hospitals (79.1% vs. 68.2%). The analysis also demonstrated that measures for minimizing blood loss exhibited a lower implementation rate (58.7%) [5]. This demonstrates that there is still a huge potential in reducing the diagnostic blood loss, for example, through the usage of closed blood collection devices, restrictive blood drawing, point-of-care, minimally invasive procedures, minimization of extracorporeal volumes, hemodilution, and retrograde autologous priming in cardiac surgery. Thus, we are far away from the statement of the authors: “the stabilization of production and consumption figures may indicate that the PBM’s resource-saving measures have been largely exhausted.” Although the number of distributed RBC units was constant between 2019 and 2021, there is definitely still a lot to be done in reducing unnecessary blood loss, promoting preoperative optimization, and avoiding unnecessary blood transfusions.

Using a weekly monitoring approach, Fiedler et al. [2] assessed the number of RBC unit stocks and analyzed the supply sufficiency, which was defined as a reserve of RBC units for three or more days. The authors showed that relative to the total number of RBC units, the share of blood type O and RhD positive RBC units fluctuated between 35% and 22% and for O and RhD negative RBC units between 17% and 5%. Within the 12-month observation period between November 2021 and 2022, two periods occurred where the stock availability at individual blood banks was less than 2 days (calendar weeks 45–19 in 2021 and 21–25 in 2022). This has resulted in postponing elective surgery at affected hospitals. It is noteworthy to mention, that cancellation of surgeries may permit disease progression which may result in more complex and urgent situations. A foresighted planning of resources (e.g., weekly monitoring of blood stocks) may prevent postponing of medical interventions.

In addition, wastage of blood components is an important issue at blood banks and hospitals. Fiedler et al. [2] investigated the number of expired RBC units, and showed that 2.7% of the RBC units, which corresponds to approximately 111,000 units, expire annually at blood banks in Germany. In 2019, the expiration rate was 3.6% per 100 RBC units at blood banks and about 4.2% per 100 RBC units at healthcare establishments. In 2021, with the lowest number of RBC units distributed to healthcare establishments, the rate of expired RBC units decreased to 3.7% (approximately 126,910 units) in healthcare establishments and 2.4% (82,320 units) at blood banks. Potential underlying causes are quality control issues, supply exceeding demand, or healthcare establishments ordering more blood products than needed. From the hospital perspective, forecasting the need for a RBC transfusion and optimized-cross matching can facilitate personalized medicine, quality assurance, decrease blood wastage, decrease costs, and increase patient safety. Therefore, transfusion prediction models can help hospitals steward the blood supply so that blood components are available for patients with the greatest need [6].

In summary, transfusion of blood products is still an essential therapeutic intervention. Since there are few alternatives to blood transfusion, deliberate handling and distribution of blood products is essential. Because of its irreplaceability, conscious handling and distribution of blood are indispensable. An up-to-date monitoring of blood products availability identifies supply bottlenecks in a timely manner. However, because of the dependency on blood products, multimodal PBM measures still need to be urgently implemented to reduce unnecessary blood loss and to avoid unnecessary blood transfusions. Thus, PBM could help preserving blood stores and improve patients’ outcomes [7]. In addition, the proposed weekly monitoring of blood stocks could also reinforce the motivation for PBM implementation.

P.M. and/or the department received research grants from the German Research Foundation (ME 3559/1-1, ME 3559/3-1), BMBF (01KG1815), BMG (ZMVI1-2520DAT10E); honoraria for scientific lectures from Abbott GmbH & Co. KG, Aesculap Academy, B. Braun Melsungen, Biotest AG, Vifor Pharma, Ferring, CSL Behring, the German Red Cross/Institute of Transfusion Medicine, HCCM Consulting GmbH, Löwenstein Medical, Hemosonics, Pharmacosmos, and Siemens Healthcare. P.M. leads as CEO of the Health, Patient Safety, and PBM Foundation. The department of anaesthesiology, intensive care medicine and pain therapy of the University Hospital Frankfurt, Goethe University, received support from B. Braun Melsungen, CSL Behring, Fresenius Kabi, and Vifor Pharma for the implementation of Frankfurt’s patient blood management program. K.Z. has received honoraria for participation in advisory board meetings for Haemonetics and Vifor and received speaker fees from CSL Behring, Masimo, Pharmacosmos, Boston Scientific, Salus, iSEP, Edwards, and GE Healthcare. He is the principal investigator of the EU-Horizon 2020 project ENVISION (intelligent plug-and-play digital tool for real-time surveillance of COVID-19 patients and smart decision-making in intensive care units) and the Horizon Europe 2021 project COVend (biomarker and AI-supported FX06 therapy to prevent progression from mild and moderate to severe stages of COVID-19). K.Z. leads as CEO of the Christoph Lohfert Foundation as well as the Health, Patient Safety, and PBM Foundation. L.H. and S.C. have no conflicts of interest to declare.

No funding was received for this study.

Patrick Meybohm, Lotta Hof, Suma Choorapoikayil, and Kai Zacharowski wrote the manuscript.

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