KBC Zagreb

1. ESA guidelines
– clinical experience vs.
guidelines approach, where is
the link?
VIŠNJA IVANČAN
CLINIC FOR ANESTHESIOLOGY, REANIMATOLOGY
AND INTENSIVE CARE MEDICINE
UNIVERSITY HOSPITAL CENTER ZAGREB

2. Definition of PBM
• Is evidence-based
• Is a multimodal concept
• Is an individual, patient-specific therapeutic approach
• Is multidisciplinary
• Is applicable in surgical and nonsurgical settings
• Improves patient outcome
• Improves patient safety/reduces transfusion-associated risk
• Is based on three pillars
• Involves the management of the patients own blood as opposed to management of
the patient with somebody else’s (donor) blood

3. PBM – a concept to improve patient safety and outcome

4. PBM – what we need to do?
1. Identify those patients with an increased risk of bleeding
2. Employ to correct preoperative anaemia and stabilise macrocirculation and
microcirculation to optimise the patient’s tolerance of bleeding
3. Target interventions that should be used to reduce intraoperative and
postoperative bleeding, and prevent subsequent morbidity and mortality

8. Clinical practice: first step toward reducing
the patient-specific transfusion risk
Identification of the procedure with the
highest transfusion rates/indices

9. PBM in Cardiac Surgery
 Preoperative measures – anemia, coagulation disorders
 Patient undergoing elective surgery should be reffered to the preanesthesia clinic as early as
possible – once the surgical indication has been established

10.  Intraoperative measures
 1. sternum – bone wax, alternative to bone wax (tachosil)
 2. cell salvage, suction device
 3. minimally invasive extracorporeal circulation technologies
 4. "single-swab method"
 5. in case of postoperative bleeding, re-do must be performed as soon as possible!!!!!
 6. perioperative use of tranexamic acid, trasylol...
PBM in Cardiac Surgery

12. Postoperative measures
1. hypotensive circulatory situations should be avoided
2. point-of-care tests
3. blood lost from the chest drains must be collected and retransfused
PBM in Cardiac Surgery

13.  In children undergoing open heart surgery, preoperative anemia is one of the
most important drivers for RBC transfusion
 Treatement with erythropoietin, iron, vitamins E and B12 take time!
 Cyanotic cardiac defects can be treated the same way as acyanotic???
 Minimizing the priming volume is one of the key measures in pediatric cardiac
surgery (priming with FFP!!)
 Coagulation management – FFP
 Iatrogenic anemia
PBM in Pediatric Cardiac Surgery

14. PBM in trauma surgery
 First-pillar activities are impossible
 Coagulopathy (tissue injury, hypoperfusion, protein C activation, hypothermia, acidosis,
hemodilution)
 Hemodynamic shock – Classes I-IV
 Early administration of tranexamic acid – CRASH-study
 Use of MTP (massive transfusion protocol – RBC, FFP, platelets)
 Use of recombinant activated factor VII
 Point-of-care testing
 Permissive hypotension
 Damage control surgery
 Fibrinogen concentrate – before hospital admission!!

16. PBM in gynecology
 Reversible anemia is generally a contraindication for elective surgery!!!
 First pillar-detection, diagnosis and treatement of anemia
 Less invasive surgery
 Advanced energy-based devices
 Gauze pressure
 Local hemostatic agents
 Pharmacological measures

19. WHERE IS THE LINK??????

20. WHAT DO YOU THINK?

22. BE PREPARED AND THINK AHEAD!!!
HAVE A PREDEFINED PLAN !!!!!
GIVE WHAT IS MISSING !!!!!!!!!!!!