Anemo 2015-28-Disma- PBM:Strategie di risparmio del sangue in ambito pediatrico

1. PBM: “Pediatric Blood Management”
Strategie di risparmio del sangue in ambito
pediatrico
_____________________
Nicola Disma
Clinical Anesthesia Research Coordinator
Istituto Giannina Gaslini, Genova
S. Donato Milanese - March, 6th-7th2015

2. Safe Anaesthesia for Every Tot, www.safetots.org
Prof. Markus Weiss, Zurich
Homeostasis in paediatric anaesthesia

3. Paediatric Anaesthesia Quality Checklist
5 of the 10-N´s can
be influenced by
adequate blood
management

4. • Risks of massive bleeding and transfusion
• Threshold & target for pediatric transfusion
• Strategies for intraoperative PBM
• Evidence-based medicine for PBM in children
Lecture plan

5. • Infectious risks
• Non-infectious risks
• TRALI (transfusion-related acute lung injury)
• Hemolytic and non-hemolytic reactions,
• Allergic
• Errors
• TACO: transfusion-related circulatory overload
• Alloimmunization and immunomodulation

6. Paediatric morbidity and mortality associated
with transfusions
ADVERSE OUTCOME RBC:
• Adults: 13:100 000
• Children < 18 years: 18:100 000
• Infants: 37:100 000

7. Adverse reactions – SHOT 1996-2005

8. 3Three Pillars PBM

9. Transfusion triggers
Restrictive transfusion practice
• Threshold of 7 g/dl is likely to be safe
• Measures of oxygen delivery should be assessed
• Lower haemoglobin level may be appropriate in clinically stable
patients who have no further risks of on going anaemia (eg,
stable postoperative surgical cases).

10. Transfusion threshold

11. Alternatives to blood
transfusions
Preoperative Intraoperative
Autologus blood donation Acute normovolemic hemodilution
Iron Hypervolemic hemodilution
Erytropoietin Deliberate hypotension
Topical agents
Intraoperative blood salvage
Antifibrinolytics

12. Acute normovolemic hemodilution
Benefits
• Decreased viscosity that improves tissue perfusion
• Decreased vascular resistence improves cardiac
output through increased stroke volume
Children
• Myocardial tolerance to anemia
• Effects of fetal hemoglobin in infants < 6 months

13. Conclusion: ANH very modest benefits

14. Hypervolemic hemodilution (HH)
• 15 ml/kg colloids (or 12 ml/kg voluven)
• Similar intraoperative blood loss
• Less homologous blood replacement
Conclusion: HH modest benefit

15. Deliberate hypotension
Restrictions/limitations:
• Not in hypovolemia
• Not in high intracranial pressure or decreased organ
blood flow
• Hypocapnia should be avoided
• Arterial partial pressure of oxygen at higher levels
Conclusion: Not recommended

16. Topical agents?
Conclusion: lack of evidence

17. Intraoperative blood salvage (IABS)
• Pediatric sized systems with downsized bowls (as
small as 55 ml)
• Effective in scoliosis and craniofacial surgery
• Cost effective in reducing ABT
• 68.4% of cell-saver blood samples positive for micro-
organisms
Note: strict attention to asepsis at all times!
Conclusion: recommended

18. Antifibrinolytics

19. Why use antifibrinolytics in children?
Acknowledge to Goobie S et al

22. TXA - lack of knowledge
• Side effects are dose-related
• Thrombotic events - potential but not clinically significant
according to large meta-analysis
Seizures?
• High dose tranexamic acid is associated with nonischemic clinical seizures in cardiac
surgical patients. Murkin et al.Anesth Analg. 2010.- older pts increase in incidence from
1.3% to 3.8%.
• The blood sparing effect and the safety of aprotinin compared to TXA in pediatric cardiac
surgery. Breuer et al. 2009.- tendency for a higher incidence of seizures in TXA group (
3.5% vs 0%; p=0.14)
• Lessons from aprotinin; is the routine use and inconsistent dosing of TXA prudent? Meta-
analysis of randomized and large matched observational studies. Ngagge Eur J
Cardiothorac Surg 2010. - weak evidence of a tendency towards seizures probably dose
related.
• High-dose tranexamic acid is an independent predictor of early seizure after
cardiopulmonary bypass. Kalavrouziotis. Ann Thorar Surg 2012

24. Summary
• Transfusion risk assessment
• Patient history
• Transfusion prone procedures
• Identify and treat anaemia
• Preoperative assessment and treatment
• Prevent blood loss
• Multi-modal strategies
• Transfusion policy
• Apply evidence-based transfusion thresholds
• Monitor local blood use

25. Paradigmatic shift
PBM in children

26. Steering Committee
Nicola Disma (Italia), Karin Becke (Germania), Jurgen De Graaff (Paesi Bassi), Walid Habre
(Svizzera), Tom Hansen (Danimarca), Angela Pistorio (Italia), Dusica Simic (Serbia), Francis
Veyckemans (Belgio), Laszlo Vutskits (Svizzera), Suellen Walker (Regno Unito), Marzena
Zielinska (Polonia).
http://www.esahq.org/research/clinical-trial-network/planned-trials/nectarine/about-nectarine/

27. Thank you for
attention
nicoladisma@ospedale-gaslini.ge.it