Clinicians as gatekeepers: what is the best route to optimal blood use?

Maintaining the supply of allogeneic blood has always been a challenge and its optimal use difficult to ensure and monitor. Increasingly, economic pressures and public perceptions have been driving decision making in delivery of sufficient and safe blood components of high quality. On the other hand, many of the assumed benefits of allogenic blood component therapy are being questioned, and the potential hazards of transfusion have been underestimated. Indeed, recent evidence suggests that in many clinical settings there are significant under-recognised hazards of transfusion in which benefit is difficult to confirm. This paper questions the current paradigm, in which there is excessive focus on the supply side of the blood transfusion chain rather than the clinical problem facing patients and clinicians. Blood transfusion should no longer be the default therapeutic decision when evidence for efficacy is lacking and there is clinical uncertainty. The appropriateness of transfusion practices will only improve, not by expecting clinicians to be gatekeepers of the blood supply, but with better patient blood management based on a sound understanding of pathophysiology and better evidence for transfusion efficacy. Evidence-based transfusion medicine should view a patient's own blood as a valuable and unique natural resource that should be conserved and managed appropriately. Altruistically donated allogeneic blood transfusion should only be used as therapy when there is evidence for potential benefit, there are no alternatives, a quality product is available and the risks are appropriately considered and balanced against the benefits.