Patient Blood Management in India: Using Less Blood Without Compromising Care

India's blood shortage is not only a supply problem.

The country needs more voluntary donors — this is true and important. But there is a parallel dimension to the crisis that receives less attention: a significant proportion of blood transfusions in India are given when they are not clinically necessary.

Research published in the Indian Journal of Anaesthesia and other clinical journals consistently finds that transfusion practice in India is uneven — varying dramatically between institutions, between individual clinicians, and between regions. Some patients receive transfusions at haemoglobin levels that international guidelines would consider adequate for conservative management. Blood is sometimes given before surgery as a precaution rather than based on clinical need. Whole blood is transfused when only components are needed.

This is not unique to India. Inappropriate transfusion is a documented global phenomenon. But in a country where one million units are short annually, inappropriate transfusion is not just a clinical quality concern — it is a direct contribution to the shortage that affects other patients.

The global evidence-based framework for solving this is called Patient Blood Management (PBM) — and it is one of the most important interventions in modern blood banking.

What Is Patient Blood Management?

Patient Blood Management is a multidisciplinary, evidence-based approach to optimising a patient's use of blood — with the goal of achieving the best clinical outcome while using blood resources wisely.

The WHO formally endorsed PBM in 2010. The framework is built around three pillars:

Pillar 1 — Optimise the patient's own blood before procedures:

Identify and treat anaemia before elective surgery. A patient with haemoglobin of 10 g/dL going into a knee replacement needs a pre-operative transfusion far less if that haemoglobin is raised to 13 g/dL through iron supplementation or erythropoietin treatment weeks beforehand.

Pillar 2 — Minimise blood loss:

Use surgical techniques that reduce blood loss. Maintain normal body temperature (hypothermia increases bleeding). Use pharmacological agents that reduce intraoperative bleeding (tranexamic acid, antifibrinolytics). Use cell salvage — capturing and returning the patient's own shed blood during surgery.

Pillar 3 — Optimise the patient's tolerance of anaemia:

Not every anaemic patient needs a transfusion. Healthy patients can tolerate lower haemoglobin levels better than elderly patients with cardiac disease. A haemoglobin threshold of 8 g/dL may be appropriate for a young, otherwise healthy trauma patient; 10 g/dL may be appropriate for an elderly cardiac patient.

Giving blood only when clinically indicated — based on haemoglobin levels AND clinical symptoms AND the patient's overall condition — rather than by reflex or "just to be safe" is the core of PBM's transfusion strategy.

Why PBM Matters for India's Blood Shortage

Every unit of blood given unnecessarily is a unit unavailable for a patient who genuinely needs it.

India's 14.6 million unit annual collection barely meets estimated demand. In that context, eliminating avoidable transfusions would — conservatively — free up hundreds of thousands of units annually for patients with genuine, urgent need.

Research estimates that PBM implementation consistently reduces red cell transfusion rates by 20–40% in hospitals that adopt it fully. Across India's entire healthcare system, a 25% reduction in unnecessary transfusions would represent approximately 3.5 million units per year — more than three times the estimated annual shortage.

This does not mean PBM would eliminate the shortage alone. But it illustrates the scale of the opportunity — and why blood banking experts increasingly argue that closing India's blood gap requires both supply-side (more donors) and demand-side (better clinical use) interventions simultaneously.

The Current State of Blood Utilisation in India

India's national blood demand study noted explicitly that the demand-supply gap could be reduced through "promoting modern principles of patient blood management" — placing PBM alongside voluntary donation and component separation as a key systemic intervention.

A PMC analysis of Indian blood banking found that approximately 51% of blood banks had component separation facility — meaning that nearly half of collected blood is still being stored as whole blood and transfused in whole-blood form, rather than being separated into components that can be used more specifically and efficiently.

Whole blood transfusion for a patient who only needs red cells gives unnecessary plasma and platelets — exposing the patient to unnecessary transfusion risks (volume overload, febrile reactions) and wasting components that other patients could use. Component therapy is more clinically precise and more resource-efficient.

Tranexamic Acid: One Medicine That Has Saved Thousands of Lives

One of PBM's most important evidence-based interventions is the use of tranexamic acid (TXA) — a medicine that reduces bleeding by stabilising blood clots. It is inexpensive, widely available, and has been shown in clinical trials to significantly reduce maternal mortality from postpartum haemorrhage when given in the first three hours after bleeding begins.

The WOMAN trial — one of the largest obstetric research trials ever conducted — found that early TXA administration reduced deaths from postpartum haemorrhage by 31% in low-income countries when given within three hours of diagnosis. For India, which records tens of thousands of maternal deaths from haemorrhage annually, TXA represents a blood-saving, life-saving intervention of extraordinary impact.

When TXA reduces bleeding, fewer blood units are needed. Patients who previously would have received 4–6 units of transfused blood may need 2 or none. TXA is essentially a blood conservation measure that simultaneously saves maternal lives and preserves blood bank supply.

Pre-Operative Anaemia Management: The Most Underutilised PBM Intervention in India

A significant proportion of patients undergoing elective surgery in India — orthopaedic, general surgical, gynaecological — arrive at the operating table anaemic, largely from iron deficiency. Anaemic patients bleed into an already-depleted reserve: they need transfusion at lower blood loss levels than non-anaemic patients.

The PBM solution: identify anaemia at the surgical referral stage, not the pre-anaesthesia check the day before surgery. Start iron supplementation or IV iron infusion weeks before the scheduled operation. The patient arrives at surgery with adequate haemoglobin, tolerates surgical blood loss better, and needs fewer transfusions.

In India's private hospitals, pre-operative haemoglobin optimisation is increasingly practiced. In the government sector, the gap between referral and surgery is often weeks to months — time that could be used for haemoglobin optimisation but typically isn't because the assessment isn't systematically triggered.

The Surgeon's Role: Surgical Technique and Cell Salvage

Blood loss during surgery depends significantly on surgical technique. High-volume, experienced surgeons at major centres typically lose less blood per procedure than lower-volume surgeons at smaller hospitals — not because of any single technical decision but because of the accumulated refinements of many surgeries.

Cell salvage — intraoperative blood recovery where the patient's shed blood is collected, filtered, and reinfused — is standard practice at major cardiac, orthopaedic, and vascular surgery centres globally. In India, cell salvage is practiced at large private hospitals and some government tertiary centres, but is far from universal.

A single cardiac surgery using cell salvage may reduce transfusion requirements by 1–2 units per case. Across India's growing cardiac surgery volume, this represents significant blood savings.

What PBM Means for Voluntary Blood Donors

For voluntary blood donors, PBM has an important implication: the blood you donate is more likely to reach a patient who genuinely needs it if the hospitals using blood are practicing evidence-based transfusion.

This does not change the fundamental need to donate. It changes the denominator — if India's hospitals implement PBM, the one-million-unit annual shortage may become achievable to close sooner, because available blood is being used more wisely.

Supporting PBM means:

• As a patient: asking your doctor "do I need this transfusion?" — it is a reasonable clinical question
• As a healthcare worker: following evidence-based transfusion triggers rather than custom or reflexive practice
• As a blood bank professional: developing transfusion utilisation review programmes that identify inappropriate use
• As a voluntary donor: continuing to give, knowing that your contribution is going into a system that is improving its stewardship of what you give

Register on TheBloodApp. Donate regularly. And know that your donated blood has a better chance of reaching the patient who needs it most when hospitals use it wisely. To find donation camps and blood banks near you across India, call the number listed in the app.

Sources: WHO — Patient Blood Management | PMC — National Blood Demand Study India | PMC — Blood Banking Performance India | PLOS ONE — WOMAN Trial TXA Maternal Haemorrhage | Indian Journal of Anaesthesia — Transfusion Practice | Medical Buyer — Blood Banking India 2025 | eRaktKosh MoHFW