• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
(PowerPoint)
 

(PowerPoint)

on

  • 407 views

 

Statistics

Views

Total Views
407
Views on SlideShare
407
Embed Views
0

Actions

Likes
0
Downloads
1
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    (PowerPoint) (PowerPoint) Presentation Transcript

    • How much blood do you need? Grand rounds John Welch 11/30/07
    • Case 1
      • 54 yo obese woman with hx of CHF admitted with DOE and edema.
      • BNP 700.
      • Prior EF 30%. Prior Cath unremarkable.
      • WBC 6.5, Hgb 9.5, Plt 250. MCV85. Cr 1.9
      • CXR with possible infiltrate.
      • SHx notable for being a Jehovah’s Witness
    • Recommendations
      • Continue diuresis
      • Check iron, folate, B12, TSH
      • Multivitamin +/- iron
      • Check Epo level
      • Consider treating Epo if low
      • Treat possible pneumonia
      • GI prophylaxis
      • Respect patient autonomy
    • Acute anemia in baboons Cardiac output SVR Wilkerson Surgery 103: 665 % oxygen extraction LV lactate production LV vascular resistance
    • Risk of mortality during cardiovascular surgery correlates with blood loss and pre-op Hgb.
    • Preop Hgb and operative mortality during cardiac surgery.
    • Meta-analysis of transfusion triggers in surgery and critical care Units transfused Hct Carson Transfusion Medicine Review 16(3): 187
    • Meta-analysis of transfusion triggers in surgery and critical care Cardiac Outcomes 30 day All cause mortality Carson Transfusion Medicine Review 16(3): 187
    • The Blood that really saves 1961
    • Parsing Hairs
      • Prohibited:
      • Transfusion of whole blood, red cells, white cells, platelets or plasma.
          • Transfusions of pre-operative donated autologous blood.
      • Not promoted or encouraged:
          • Blood donation, Transfusions of autologous blood part of a "current therapy".
          • Hemodilution, Intraoperative blood salvage , Heart-Lung Machine , Dialysis ,
          • Epidural Blood Patch
          • Plasmapheresis , with plasma substitution
          • Labeling or Tagging of RBC or WBC
          • Hemoglobin
          • Transplant of solid organs and bone marrow
      • Fractions from white blood cells
          • Interferons , Interleukins
      • Fractions from platelets
          • Platelet factor 4
      • Fractions from blood plasma
          • Albumin , Globulins , Clotting factors, Factor VIII and Factor IX
          • Erythropoietin (EPO)
          • PolyHeme , Hemopure .
      Wikepedia 2007
    •  
    • Case 2
      • 51 year old male presents with new AML
        • WBC 3.1, Hgb 6.0, plt 7, 43% Blasts.
        • Iron 108, TIBC 254, B12 and folate nl. No active bleeding
      • Starts induction 7+3. EF 62%.
      • Day 2 Intubated. Hgb 4.1.
        • Pancuronium.
        • 100% FiO2 weaned to 80% after PO2 189.
      • Day 4
        • Hypothermia
        • Bradycardia resolved with epi/atropine
        • FiO2 increased to 100%
        • Cx grows coag negative staph
      • Day 5
        • HoTN: Levo
        • Bradycardia -> asystole
    • Tx: AML: daunorubicin 30 mg/m2 day 1-3, cytarabine 100 mg/m2 5 days VP16 + Amsacrine consolidation APL: ATRA + daunorubicin 30 mg/m2 + cytarabine 100 mg/m2 ATRA, 6-MP, MTX consolidation ALL: VCR, DNR, Pred
    •  
      • 44 year old woman with accelerated phase CML after Hydrea
      • Start Epo 3 weeks prior to transplant
      • Blood conservation strategies during transplant
      • Condition with Fludarabine 40 mg/m2 day -9 to -6
            • Busulfan 3.2 mg/kg/day day -5 to -2
      • GVHD prophylaxis with Tacrolimus/MTX
      • Sibling Allo transplant from sister with peripheral stem cell collection
    •  
    • Mortality following HSCT by pre transplant Hct
    • Critical care patients’ phlebotomy and transfusion trends 14.6 ml/day x 51 days = 744 ml 10 ml waste + 5 ml CBC + 7 ml CMP + 5 mls coags = 27 mls
    • “ Bloodless” (less blood) approach Don’t waste blood!
      • pediatric tubes for blood draws,
      • decreased frequency (CBC, chemistry) to every other day, liver function tests twice weekly, PT/PTT once weekly,
      • closed system return of the waste blood after blood draws,
      • gastrointestinal prophylaxis with proton pump inhibitor,
      • folic acid and iron supplementation daily, vitamin K once weekly,
      • aminocaproic acid for platelet count below 30,000/ml.
      • oxygen support for Hgb < 9 g/dl or symptomatic anemia
      • oral contraceptives prior to starting chemotherapy
      Bone Marrow Transplantation (2006) 37, 325–327.
    • Don’t waste energy
      • Clear discussion early concerning treatment options: albumin, cryo, clotting factors, etc.
      • Hypothermia and paralytics if intubated
      • Arterial line for ABGs
      • Good luck
    • Other options: Polyheme Phase II 1998
    • Other options: Polyheme phase III
      • Polyheme
        • Not FDA approved, but may obtain on compassionate basis
        • Phase III trial complete in acute trauma.
          • Supposedly well tolerated (as was phase II)
          • Preliminary mortality data:
            • 13.2 %PolyHeme
            • 9.6 % standard of care
          • FDA fast track on hold
        • One case of use as bridge to marrow recovery after sib allo transplant without significant side effects (Compr Ther. 2006 Fall;32(3):172-5.)
    • For what is a man profited, if he shall gain the whole world, and lose his own soul?
    • Rights and duties