1. The guidelines provide recommendations for perioperative blood management to reduce transfusions, bleeding, and related adverse outcomes. 2. Preadmission preparation includes treating preexisting anemia, discontinuing anticoagulants under specialist guidance, and considering preadmission autologous blood donation if time allows. 3. Intraoperative and postoperative management focuses on restrictive transfusion protocols, monitoring for bleeding and organ perfusion, and treating coagulopathy guided by targeted laboratory tests before administering blood products.

1. Journal reading
Practice Guidelines for
Perioperative Blood Management
American Society of Anesthesiologists
Task Force on Perioperative Blood Management
Anesthesiology V 122 • No 2, Feb., 2015
Present by R1蘇府蔚
Instructor : Dr.王審之

2. Introduction
• Guideline to improve perioperative
management
– Blood transfusion
– Adjuvant therapies.
– Reduce adverse outcomes of transfusions,
bleeding, or anemia.
• To Update guideline published in 2006
– Exclude neonates, infants, <35kg children, patients
not undergoing procedures.

3. Outline of Guidelines
• I. Patient evaluation
• II. Preadmission preparation
• III. Preprocedure preparation
• IV. Intraoperative and postoperative management

4. I. Patient evaluation
1. Review previous medical records
a) Congenital / acquired diseases ; history of
transfusion reaction.
b) E.g. sickle-cell, clotting factor def., hemophilia,
liver disease, hx of thrombotic events
2. Conducting interview
a) Inform risk and benefits of transfusion
3. Review existing laboratory test result
4. Order additional lab tests

5. Risk of transfusion
• Prolonged hospital stay
– Infection
– Transfusion-related organ damage
– Transmission of pathogen
– 論文內好像有提到這部分，再麻煩您看看是否
有遺漏

6. II. Preadmission preparation
1. Treatment of anemia ?
2. Discontinuation of anticoagulants and
antiplatelet ?
3. Preadmission autologous blood donation

7. II.-1. Treatment of anemia
• WHO definition : (g/dl)
– 6m-5 y/o : 11 ; 5-12 y/o : 11.5 ; 12-15 y/o : 12
– >15 y/o Non-preg. Women : 12 ; Pregnant women :
11g/dl
– >15 y/o Men : 13 g/dl
• Treatment : EPO / iron supplement
– EPO +/- iron vs. placebo: ↓vol. of trans.(LoE: A1-B)
– EPO+ iron vs. EPO alone: insufficient evidence
– Iron vs. placebo : equivocal on Hgb level/ vol.
transfusion. (LoE : A2-E)

8. II.- 2. Discontinuation of
anticoagulants and antiplatelet ?
• Stop warfarin  LMWH vs. pt. no warfarin :
– One observational study : equivocal (LoE: B1-E)
• Stop aspirin vs. continue use :
– insufficient evidence
• + Aspirin before op. vs. placebo : equivocal
– No difference on peri-op. blood loss, transfusion,
MI, major bleeding (LoE : A2-E, 2 RCTs)

9. II. Preadmission preparation
1. Treatment of anemia ?
a) CKD, Anemia of chronic disease, refusal of transfusion :
EPO +/- iron (but takes weeks, $$)
b) Iron-def. anemia : iron supplement (takes time)
2. Discontinuation of anticoagulants and antiplatelet ?
a) Consult specialist : stop anticoagulant (e.g. warfarin, anti-
Xa) for elective OP,  shift to heparin/LMWH
b) Except pt. had PCI  stop non-aspirin antiplt. (e.g.
clopidogrel, ticagrelor.) sufficient time before op
c) Pt. had PCI + stent : dual anti-plt. 3m for BMS, 1yr for DES
3. Preadmission autologous blood donation
a) Offer the opportunity if adequate of time

10. III. Preprocedure preparation
1. Blood management protocols
2. Reversal of anticoagulants
3. Antifibrinolytics for prophylaxis of excessive
blood loss
4. Acute normovolemic hemodilution (ANH)

11. III.-1. Blood management protocols
a) Multimodal protocols/algorithms
b) Restrictive vs. Liberal transfusion criteria
c) Avoidance of transfusion
d) Massive transfusion protocol
e) Maximal surgical blood order schedules

12. III.2-Reversal of anticoagulants
a) Preprocedure administration of prothrombin
complex concentrates(PCCs)
– Observational study : (LoE: B4-E)
Pre-op 4-factor單位是不是有問題? PCC : INR↓
Thromboembolic event : 0.003% of pts.
b) Administration of FFP
– Insufficient study to evaluate impact.
c) Preprocedure administration of vitamin K
– Immediately-pre-op Vit. K vs. placebo :
equivocal for transfusion requirement (LoE: B3-E)

13. III.-3 Antifibrinolytics for prophylaxis of
excessive blood loss
• Tranexamic acid
– RCTs ( vs. placebo) no dif. in stroke, MI, AKI, mortality (LoE:
A2-B)
– Meta-analyses of placebo-controlled RCTs
• Prophylaxis of excessive bleeding ( pre-op +/- intra-op)
↓ pt. of transfusion & blood loss & vol. of transfusion (LoE : A1-B )
– Meta-analyses of RCTs
• Prophylactic use in THA/TKA, before tourniquet deflation :
↓ vol. of blood loss ( LoE : A1-B )
– One RCT : tranexamic acid in cardiac surgery
• No efficacy after cardiac surgery and continue to 12H. (LoE : A3-E)

14. III. Preprocedure preparation
1. Blood management protocols
a) No single algorithm can be recommended at this time
b) Restrictive RBC transfusion protocol
c) Hgb 6-10g/dl : bleeding condition, volume status, organ ischemia,
cardiopulmonary reserve
2. Reversal of anticoagulants
a) Warfarin urgent reversal : FFP / consult specialist use PCC
b) Non-urgent : Vit. K.
3. Antifibrinolytics for prophylaxis of excessive blood loss
a) For prophylaxis if undergoing CPBypass
b) Consider use in certain Ortho op (e.g. TKA)
c) Consider use in liver op / if risk of excessive bleeding
4. Acute normovolemic hemodilution (ANH)
a) Major cardiac, orthopedic, thoracic, liver surgery

15. IV. Intraoperative and postoperative
management of blood loss
1. Allogeneic RBC transfusion
2. Reinfusion of recovered RBC
3. Intraoperative and postoperative monitoring
4. Treatment of excessive bleeding

16. IV.-2. Reinfusion of recovered RBC
• Intraoperative RBC recovery
– Meta-analyses of RCTs : Effectively ↓ vol. of
allogeneic blood transfusion ( LoE : A1-B )
• Postoperative RBC recovery
– RCTs : Major orthopedic surgery
Effectively ↓ frequency of allogeneic blood
transfusion ( LoE : A2-B )

17. IV. -3. Intraoperative and
postoperative monitoring
a) Monitoring for blood loss
b) Monitoring for perfusion of vital organs
c) Monitoring for anemia
d) Monitoring for coagulopathy
e) Monitoring for adverse effects of transfusions

18. IV.3-b. Monitoring for perfusion of
vital organs
• Standard ASA monitoring.
• Additional : cerebral oximetry, near infrared
spectroscopy, ABG, mixed-venous saturation.
• Insufficient literature to evaluate efficacy

19. IV.3.-d.Monitoring for coagulopathy
• Portable laser photometer as PoC test for
PT/aPTT : good correlation with traditional lab,
↓ time for results ( LoE : B2-B)
• Platelet count test during CPBypass : predict
excessive bleeding (Se: 83%, Sp: 58%) LoE : B2
• TEG / ROTEM : single RCT showed equivocal
for transfusion requirement (???)

20. IV.-4. Treatment of excessive bleeding
a) Transfusion of platelets
b) Transfusion of FFP
c) Transfusion of cryoprecipitate
d) Pharmacologic treatment
 Desmopresin
 Antifibrinolytics
 Topical hemostatics
e) Prothrombin complex concentrates
f) Coagulation factor concerntrates
g) Treatment for hypofibrinogenemia

21. IV.4.-a. Transfusion of platelets
• Insufficient literature to evaluate of platelet
transfusion on resolution of coagulopathy.
• Survey response :
– obtaining platelet count / function test first.

22. IV.4.-b. Transfusion of FFP
• ? Blood loss / ? RBC transfused / FFP ? No FFP ?
– RCTs inconsistent findings
• Survey response :
– obtain coagulation test before FFP transfusion

23. IV.4.-c. Transfusion of cryoprecipitate
• Intra-op/ post-op. cryoprecipitate to manage
coagulopathy : Insufficient literature
• Survey :
– fibrinogen level test when excessive bleeding
before cryo. transfusion.

24. IV. Intraoperative and postoperative
management of blood loss
1. Allogeneic RBC transfusion
a) Without considering blood storage duration : ok
b) Leukocyte-reduced: for purpose to↓complication
2. Reinfusion of recovered RBC : intraoperative blood-sparing intervention
3. Intraoperatve and postoperative monitoring
a) Visual assessment (drains, suction, sponge) / Vital organs ( standard
monitors + PE)
b) May use add. monitor (TEE, Br.oximetry, U/O, ABG, ScvO2)
c) If suspect anemia : check EBL/PE
d) If suspect coagulopathy : check INR, aPTT, fibrinogen, or TEG/ROTEM, plt
count.
4. Treatment of excessive bleeding
a) Check plt, plt function, PT/INR, aPTT, fibrinogen before transfusion
b) Desmopressin may be use when excessive bleeding and plt dysfunction.
c) Consider topical hemostatics , antifibrinolytics, fibrinogen concentrate
d) PCC may be used with excessive bleeding and INR ↑
e) If treatment options exhausted, consider recombinant act. Factor VII.

25. Difference from current practice
• Emphasis of preop. pts/risks assessment
• Use of adjunct medication
– Erythropoietin for anemia
– PCC for urgent warfarin reversal
– Anifibrinolytics for cardiac/high bleeding risk op.
• Advocate the use of transfusion algorithms
– Real-time monitoring
– Blood ordering schedules
– Restrictive transfusion strategies

26. 個人心得
• 需要各部門之間整合並有共識
• 文章中多處使用籠統與含蓄用語
• 考量現實可用之資源，發展新進技術
• 可配合輔助藥物減少輸血

27. Further question/discussion
• Choice of intraoperative lab tests / Monitoring
tool ? Target of INR/HgB ?
– TEG/ROTEM as monitor tool vs. TEG/ROTEM-based
algorithm : different evidence.
– Vital organ monitoring
• Preoperative routine tests for patients with risks
of excessive bleeding ?
• Intraoperative use of laser photometry for
INR/APTT ? Check fibrinogen/plt (not only ABG?)
• VGHTPE transfusion algorithm ?

28. THANK YOU FOR YOUR ATTENTION