how to reduce blood transfusion at elective surgery in obg
TRANSCRIPT
![Page 1: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/1.jpg)
1
BELLARY OBG SOCIETY
STONE CHARIOT :HAMPISTONE CHARIOT :HAMPI
![Page 2: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/2.jpg)
Alternatives to blood-transfusion in Elective surgery
![Page 3: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/3.jpg)
Prof. (Capt.) Shankar.J.
• National subject expert - 2012 to 2014• MCI Inspector (PG Faculty – OBG)• PG Examiner for MD,DGO & DNB • PG, UG Paper Setter• Founder of Ballari OBG Society, 1998.
![Page 4: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/4.jpg)
Available Alternatives(Options)
1. Erythropoietin therapy
2. IV IRON substitution
3. Preop medication moderation
4. Hypotensive epidural anaesthesia
5. Body temperature adjustment
6. Intraoperative methods
7. Intra op cell salvage
8. Acute normovolumic haemodilution
9. Autologous blood transfusion
10. Blood substitute (Artificial blood)
![Page 5: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/5.jpg)
Effective Blood substitutes
An attainable reality or Lost cause ?Hemosol, hemopure, perflubron,
polyheme
Anaesthesiology 2006; 105(1); 198
![Page 6: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/6.jpg)
Rule of 10:30
Haemoglobin 10gm%Haematocrit 30%
Currently
7-9gm% widely accepted 6-10 gm%- packed cells Below 6-morbidity Cell Salvage for minimising perioperative allogenic blood
transfusion-2010,Cochvane database, systemic review(4) ID 001888
![Page 7: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/7.jpg)
Erythropoietin
Glycoprotein hormonePrecursor of erythropoiesisElevates haematocritRisk of thrombosisDose 100 IU/kg Twice weekly X 2weeks
![Page 8: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/8.jpg)
Erythropoietin
Contraindications PregnancyLactationHypertension/ PIHh/o thromoembolismNeocytolysis
cost effectiveness of cell salvage and ailternative methods of minimising blood transfusion, A systemic review Health.technol.Assess, 2006
![Page 9: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/9.jpg)
IV Iron Substitution
Iron is 5x more effectiveIron dextran : risks , reactionsIron sucroseFerric carboxy maltose complex (FCM)Well toleratedDecrease reaction, infection and mortalityWorks synergestically with erythropoietin
![Page 10: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/10.jpg)
Ideal parental iron preparation
![Page 11: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/11.jpg)
Various parenteral iron preparations
![Page 12: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/12.jpg)
Pre op medicationsAspirin, clopidogrel, Vit K anticoagulantsRisk of bleeding
Antiplatelet drugs 2-20%
Aspirin + antiplatelet drugs: 30-50%Stop aspirin if expected blood loss ≥2LNSAIDs stop 24hrs aheadSelective COX 2 inhibitors betterPlatelet aggregation, prolonged BTIntra op blood loss
![Page 13: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/13.jpg)
Hypotensive Epidural Anaesthesia
Blood loss reduced by 25-40%Least blockage proximal T2 Dense block of cardio-acceleratory
fibres of thoracic sympathetic chainLow dose noradrenaline dripMean arterial pressureMAP reduced to 50mm Hg Post op drainage reduced
Nassen.S et al, 2008 “Vascular trauma”, in war surgery in Afghanistan and Iraq; a
series of cases 2003-2007 United states army publication
![Page 14: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/14.jpg)
Body temperature manipulation 150 C rise =50% more blood loss
Optimise coagulation pathway Fibrinogen, prothrombin couple, protein-C
Thrombo - elastometry Cause of hemorrhage
Clotting process
Fibrinolysis
Platelet function
![Page 15: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/15.jpg)
Acute Normovolumic Hemodilution
Blood withdrawn just before surgeryReplaced with colloids- crystalloidsPatient friendlyEconomicEasy to performUsed up 8hrs post op
![Page 16: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/16.jpg)
Acute Normovolumic Hemodilution
V = EBVX Ho-Hf
HavV - Volume to be removed
EBV - Estimated blood volume
Ho - Initial Haematocrit
Hf - Desired Haematocrit
Hav - Average Haematocrit
(mean of Ho and Hf)
•Pre op Hb should be 11gm and above•ANH to be done by Anaesthesiologists
![Page 17: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/17.jpg)
Thrombotic agents
Platelet gel• Platelet derived growth factor• Antibacterial (myeloperoxidase)
Fibrin sealants (glue)• Produce stable clot• 1cc glue covers 10cm2 wound area
![Page 18: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/18.jpg)
NovoSeven® Mode of ActionEptacog alfa (activated)
Tissue factor (TF)/FVIIa,or TF/rFVIIa interaction,is necessary to initiatiate haemostasis
At pharmacological concentrations rFVIIa directly activates FX on the surface of locally activated platelets.
This activation will initiatethe ”thrombin burst”independently of FVIII and FIX. This step is independent of TF.
The thrombin burst leads to the formation of a stable clot
![Page 19: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/19.jpg)
Autologous cell capture/Transfusion
• Direct (filtered via gauze) cell salvage• Indirect (mechanically washed) cell savage• Drain site collection• ? Hypotension, ? Pyrexia. ?Allergy
Contraindication• Peritoneal contamination• Tumour cell surgery
![Page 20: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/20.jpg)
Pre op autologous blood donation
Collect 1-2 units blood4-6 wks ahead of surgery4 weeks of haematologic recoveryCan be used pre op/ post op45% wastageDeclining popuarity
Cell free Hb based blood substitutes and associated risks; A meta analysis ,JAMA 2008; 299(19) 2304-2312
![Page 21: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/21.jpg)
Artificial Blood
Blood pharming Growing red cells from haematopoietic stem cell
Hemoglobin Based Oxygen Carriers (HBOCS)
Perflurocarbons (PFCs)
Artificial blood T. Bernier, Biomedical engineering, University of Rhode Island, BME-281 26 Nov 2012
![Page 22: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/22.jpg)
ARTIFICIAL BLOOD CELLS
![Page 23: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/23.jpg)
THE QUEST TO EXPLORE
NEVER ENDS …
![Page 24: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/24.jpg)
![Page 25: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/25.jpg)
DISCLAIMER
The contents of this presentation are for academic purposes only
The references quoted are not in any order
The author openly accepts comments and critics
J. SHANKAR Professor in OBG
VIMS (Govt medical College)
Ballari- Karnataka
![Page 26: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/26.jpg)
26
SAFE MOTHERHOOD
ACHIVEMENT TO FAMILY, ASSET TO COMMUNITY
![Page 27: How to reduce blood transfusion at elective surgery in OBG](https://reader035.vdocuments.site/reader035/viewer/2022062313/55b20ca5bb61eb7c6a8b471e/html5/thumbnails/27.jpg)
FURTHER READING…WWW.ncbi.n/m.nih.gov/pmc/articles/pmc2738310/www.pharmainfo.net/artificial-blood-current-review -
United States by MPA Kulkarni.http://science.howstuffworks.com/innovation/everyday-
innovations/artificial-blood.htmPerioperative blood conservation statergy : canadian
health services guidelines- updated 2009Indian hemaetology and blood transfusion society
guidelines- current recommendations,2012Internet sources(alternate to blood transfusion,artificial
blood,autologous donors…)