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Blood Conservation
- 1. Perioperative Blood Conservation –An Overview Dr Prashant Shanker Agarwal Dr Ashok Jadon Deptt. Of Anaesthesiology
- 2. Do we feelthat a transfusion is an organ transplant ?
- 3. Session Objectives • Providean overview of blood conservation in perioperative patients What is it?.. Why is it important?.. How is it accomplished?..
- 4. SABM, 2007 What isBlood Conservation? • Blood Conservation: Society for the Advancement of Blood Management (SABM) ‘team approach to surgical patient care that utilizes the latest drugs, technology and techniques to enhance a patients own blood supply and decrease blood loss …the aim is to reduce or avoid the need for transfusion’
- 5. Why do weneed blood…? • For O2 transport…? • O2 Content = Hb*1.37*SaO2 + 0.0034*PaO2 • At Hb 4.7 g/dl O2 delivery reduces by 30% (Liberman JA. Anesthesiology 2000; 92.) • Upto 40% permissible loss( approximately 2L in males) (Herbert PC. NEJM 1999; 340)
- 6. ASA task forceguidelines 1996 • Transfusion is rarely indicated when the hemoglobin level is above 10 g/dL • Almost always indicated in patients when the hemoglobin level is below 6 g/dL; • For hemoglobin level 6-10 g/dL – Ongoing indication of organ ischemia, – The rate and magnitude of any potential or actual bleeding, – The patient’s intravascular volume status – Risk of complications due to inadequate oxygenation. • Use Blood Components separately • Promote blood conservation
- 7. O'Brien et al, 2007 Infectious and Non Infectious risks • 1 in 100 – minor allergic reactions – rash etc • 1 in 300 – febrile non-hemolytic reaction to RBC • 1 in 700 – transfusion related circulatory overload • 1 in 5,000 – Transfusion Related Acute Lung Injury (TRALI) • 1 in 10,000 – Symptomatic bacterial sepsis from platelet transfusion • 1 in 40,000 – death from bacterial sepsis - platelet transfusion • 1 in 40,000 – ABO incompatible transfusion per RBC transfusion • Coagulopathy •1 in 40,000 – serious allergic reaction per unit of component, anaphylaxis •1 in 82,000 – transmission of Hep B virus •1 in 100,000 – bacterial sepsis per unit of RBC •1 in 500,000 – death from bacterial sepsis per unit of RBC •1 in 1,000,000 – WNV •1 in 2,300,000 – Hep C transmission •1 in 7,800,000 – HIV transmission •Post Transfusion Purpura
- 8. Intraoperative RBC Tx IncreasesRisk of Low Output Failure Surgenor, et al. Circulation 2006;114:43-48
- 10. Is Blood Transfusion safe…whenyou can prevent it? • Patient safety • Informed choice for patients • Resource allocation • Infectious risks • Non-infectious risks • Blood products are a scarce resource • Blood is expensive!
- 11. Blood Conservation –Why? • Conserve blood resources – Regional blood centers find it increasingly difficult to collect sufficient blood to meet patient needs in many areas of the country. – In the next 15-20 years the number of patients >65 y.o. will more than double but the number of blood donors will only marginally increase – The number of units used nationwide is increasing 1% per year, but the people donating is decreasing 1% per year.
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- 13. Blood Conservation… Why perioperativepatients? • 50-70% of blood products used in hospitals are used in the perioperative setting (Hebert et al, 2004) • Potential exists to modify some predictors of transfusion in elective surgical patients - Pre-op Hb, Blood loss • Wide variation in transfusion practice for procedures
- 14. How important ispre-op Hemoglobin? • A national (US) audit found that 35% of patients coming for arthroplasty have Hb <130g/L • UK study found that 20% of all patients in 1 year were anemic males<130g/L, females <115g/L) •GoodenoughGoodenough,, 20072007 •Karkouti et al 1999Karkouti et al 1999 •Saleh et al, 2007Saleh et al, 2007
- 15. How Blood Conservation accomplished? •Preoperative evaluation & Risk stratification • Reduce need for blood transfusion • Autologous Transfusion
- 16. Pre-op evaluation Pre-op Hboptimization: 4-6 week lead time for assessment, screening and appropriate interventions: • Correction of nutritional anemia iron therapy – dietary advice,supplements Vit B12, Folate • Careful attention to patient medical history, pre op meds ASA, Clopidrogel (Plavix), NSAIDs, herbal supplements • Pre operative autologous donation • Erythropoietin therapy (Karkouti et al, 2005) • ? Delay surgery
- 17. METHOD TO REDUCEBLOOD USE IN SURGERY • PREOPERATIVE * Surgery elective – Correct the Haemoglobin level. Stop drugs that interfere haemostasis. • INTRAOPERATIVE – Posture – Use of Vasoconstrictors – Use of tourniquets – Use of anti-fibrinolytic drugs eg tranexamic acid – Use of Aprotinine – Controlled hypotension, Regional anaesthesia • POST OPERATIVELY – Blood can be salvaged from drains into collection devices that permit reinfusion
- 18. Meticulous Technique • Careful, precise procedures,using natural tissue planes • Planned vascular control • Use of clips, ligatures, and cautery where appropriate • Newer techniques (harmonic scalpel, LASER) • NB. MINIMIZE BLOOD LOSS
- 19. Volume Expanders • ACUTEVOLUME REPLACEMENT • HYDROXYETHYL STARCH (HES) • DEXRAN 70 • DEXTRAN40 • UREA-BRIDGED GELATIN (HAEMACCEL) • Blood substitutes
- 20. Blood Substitutes • Hbsol. (human, bovine) – • Increases Hct • systemic & pulmonary HTN • Perflurocarbon emulsions – • O2 solubility 20 times of plasma • Decreases Platelets & require high PaO2 • Focus is on the ability to carry oxygen, not on the other functions of blood • Effective only for 12-24 hrs • Good for short term till blood is arranged
- 21. Cell Salvage WithUltrafiltration • ‘recycling’ of blood that would otherwise be discarded • CV/ortho/trauma (Cochrane, 2006) • Contraindicated in malignancy, contaminated wound • RBC’s suspended in NS • May be acceptable to JW patient Cell Saver
- 22. Cell Salvage • TheHemobag® and its TS3 tubing set allows for Ultrafiltration both during the case and at the end for Whole Blood Autotransfusion. • The end product is a hyperoncotic Autologous Whole Blood packed with viably functioning Platelets, Clotting Factors, Albumin, Plasma Proteins and RBC’s with no morbidity or side effects.
- 23. Isovolemic Haemodilution • 1to 2 units of patient’s blood withdrawn at the beginning of a procedure • Blood volume restored with crystalloid/colloid solution • Patient bleeds “thin blood” during procedure • Gets own blood back at the end
- 24. Autologous Blood Transfusion Collection andre-infusion (transfusion) of the patient’s own Blood or Blood components.
- 25. Why Autologous Blood Transfusion •Fully compatible blood. • No risk of transfusion transmitted diseases such as hepatitis, CMV and HIV infection. • Avoidance of allo-immunization. • Improved O2 perfusion by lowering blood viscosity. • Acute Normovolemic Hemodilution provides fresh whole blood . • Less dependant on the blood bank’s stock.
- 26. A marked reductionin the hospital infection rates, antibiotic usage and length of hospital stay in patients who received autologous blood or no blood Triulzi et al, Transfusion 1992;32:517-524; Forgie et al, 1998 Why Autologous Blood Transfusion •Readily available in major haemorrhage •Avoidance of immuno-suppression
- 27. Criteria • Age: lessthan 65 year old • Hb: at least 11.0g/dl • Weight: at least 50kg • No h/o severe heart and lung disease, abnormal bleeding tendency • No bacteraemia at time of donation • No h/o hepatitis B/C or HIV • Cancer not a contraindication
- 28. Pre-surgical Autologous BloodDonation • Best choice for patients with rare blood types or irregular antibodies. • One unit per week & takes Fe/EPO. • Then donates 1 unit per week (usually no more than 3 or 4 units) • Last donation must be at least 72 hrs before operation. • Blood is stored and kept for patient for re- infusion during/after operation.
- 29. Labeling and Storage •Carefully designed system. – Special procedure code – Autologous stamp. – Detail of place and date of operation. • Special and distinct label on blood pack. • Autologous donor card with unit number on it. • Stored in different site.
- 30. Should Autologous Bloodbe “made homologous”? The American Medical Association, AABB, NBS discourage the “crossover” of unused autologous units to the general blood supply. • Liberal eligibility criteria. • Safety concerns. • Legal liability
- 31. Role of Erythropoietinin Autologous Transfusion • Allow more units to be collected. • Need two to more weeks to work. • Expensive.
- 32. Points to consider •Cost • Surgeon and Anaesthetist enthusiasm • Availability of allogeneic blood • Which types of procedures: “ortho; intestinal; clean operations” • Public awareness
- 33. • Remember thattransfusion of any Allogeneic blood or blood products is an “Organ Transplant", and not just another medication that is without side-effects. Treat everyone like a JW ! End of starting…..
- 34. Transfusion Algorithm • AvoidTransfusion : medical and surgical • Alternatives replacement fluids: crystalloids and non plasma colloids over plasma pharmacologic agents to reduce bleeding • Autologous donation • Minimize exposure to allogeneic transfusion
- 35. Thought for theday…… “Blood transfusion is a lot like marriage. It should not be entered into lightly, unadvisedly or wantonly, or more often than is absolutely necessary.” Beal, RW, 1976Beal, RW, 1976 Beal RW, 1976Beal RW, 1976
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- 37. Tranexamic Acid • Mechanismof Action: • Forms a reversible complex that displaces plasminogen from fibrin resulting in inhibition of fibrinolysis; it also inhibits the proteolytic activity of plasmin • Dose Children and Adults: I.V.: 10 mg/kg immediately before surgery, then 25 mg/kg/dose orally 3-4 times/day for 2-8 days • Dosage modification required in patients with renal impairment; ophthalmic exam before and during therapy required if patient is treated beyond several days; caution in patients with cardiovascular, renal, or cerebrovascular disease; caution in patients with a history of thromboembolic disease (may increase risk of thrombosis); when used for subarachnoid hemorrhage, ischemic complications may occur • Adverse Reactions: • >10%: Gastrointestinal: Nausea, diarrhea, vomiting • 1% to 10%: Cardiovascular: Hypotension, thrombosis • Ocular: Blurred vision • <1%: Unusual menstrual discomfort • Postmarketing and/or case reports: Deep venous thrombosis (DVT), pulmonary embolus (PE), renal cortical necrosis, retinal artery obstruction, retinal vein obstruction, ureteral obstruction
- 39. Summary • Controlled HypotensiveAnaesthesia – current perspective • Cell savaging procedures !!!!...??? • Use of Regional Anaesthesia & Tranexamic Acid • Autologus Hemotransfusion – Normovolemic Hemodilution • Increase oxygen delivery • Decreased DVT
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Editor's Notes
- #5 Blood Conservation is one element of a patient centred blood management philososphy. SABM defines this element as “team approach…
- #8 Potential candidates for transfusion are include patients undergoing large surgeries, in which a significant amount of blood loss can occur. Patients who have blood disorders or acquired deficiency secondary to massive bleeding may also require blood products, as well as patients who are critically ill. But keep in mind, that a liberal transfusion approach, as was reviewed earlier, is fraught with negative outcomes.
- #12 Many recommendations for improvemnet in our blood supply canme as a result of the Commision of Inquiry in 1997.The tainted blood scandal of the 1980’s was, in the words of Justice Horace Krever, the worst public health tragedy in Canada’s history.It was also the catalyst for many of the current hemovigilance and blood management initiatives currently in place, as well as the growing body of literature informing us about the risks associated with transfusion. in his final report to the Canadian Government He made many recommendations for improvement at all levels from the blood supplier to the health care providers concluding that ,even if all of these changes were realized, that blood transfusion will never be zero risk and that the precautionary principle should always apply with respect to transfusion. The Ontario government is committed to funding programs that ensure safe transfusion practice in addition to promoting appropriate use of alternatives to transfusion wherever possible. ONTraC and ORBCoN are 2 such initiatives, currently funded and under the direction of the BPCO which was formed in 2005