blood conservation
TRANSCRIPT
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Perioperative Blood Conservation – An Overview
Dr Prashant Shanker Agarwal
Dr Ashok Jadon
Deptt. Of Anaesthesiology
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Do we feel that a transfusion is an organ transplant ?
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Session Objectives
• Provide an overview of blood conservation in perioperative patients
What is it?..Why is it important?..How is it accomplished?..
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SABM, 2007
What is Blood 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’
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Why do we need 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)
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ASA task force guidelines 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
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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
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Intraoperative RBC Tx Increases Risk of Low
Output Failure
Surgenor, et al. Circulation 2006;114:43-48
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Is Blood Transfusion safe…when you 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!
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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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Blood Component
Therapy
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Blood Conservation… Why perioperative patients?
• 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
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How important is pre-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
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How Blood Conservation accomplished?
• Preoperative evaluation & Risk stratification
• Reduce need for blood transfusion
• Autologous Transfusion
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Pre-op evaluation
Pre-op Hb optimization: 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
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METHOD TO REDUCE BLOOD 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
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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
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Volume Expanders
• ACUTE VOLUME REPLACEMENT
• HYDROXYETHYL STARCH (HES)
• DEXRAN 70
• DEXTRAN40
• UREA-BRIDGED GELATIN (HAEMACCEL)
• Blood substitutes
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Blood Substitutes
• Hb sol. (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
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Cell Salvage With Ultrafiltration
• ‘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
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Cell Salvage
• The Hemobag® 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.
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Isovolemic Haemodilution
• 1 to 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
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Autologous Blood Transfusion
Collection and re-infusion (transfusion) of the patient’s own
Blood or Blood components.
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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.
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A marked reduction in 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
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Criteria
• Age: less than 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
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Pre-surgical Autologous Blood Donation
• 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.
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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.
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Should Autologous Blood be “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
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Role of Erythropoietin in Autologous Transfusion
• Allow more units to be collected.
• Need two to more weeks to work.
• Expensive.
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Points to consider
• Cost
• Surgeon and Anaesthetist enthusiasm
• Availability of allogeneic blood
• Which types of procedures: “ortho; intestinal; clean operations”
• Public awareness
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• Remember that transfusion 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…..
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Transfusion Algorithm
• Avoid Transfusion : 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
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Thought for the day……“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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THANK YOUTHANK YOU
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Tranexamic Acid• Mechanism of 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
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Summary• Controlled Hypotensive Anaesthesia
– current perspective
• Cell savaging procedures !!!!...???
• Use of Regional Anaesthesia & Tranexamic Acid
• Autologus Hemotransfusion– Normovolemic Hemodilution
• Increase oxygen delivery• Decreased DVT
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»Thank You