2012 orthopea milano - pavesi - i trigger trasfusionali

1. I trigger trasfusionali:
dal preoperatorio alla riabilitazione
Marco Pavesi
in realtà rappresenta la ricerca
della giustificazione a trasfondere,
Orthopea – Milano , 27-29 Settembre 2012
Il trigger è un numero
un riferimento per giustificare una decisione
ma dovrebbe essere riferita
al riconoscimento funzionale di un sistema ………..

3. Solo in condizioni di normovolemia
i valori di Ht e Hb possono
essere considerati reali
Necessità di un monitoraggio
adeguato al riconoscimento di
una condizione di normovolemia

4. sanguinamento
Lo statico al letto di reparto
Il dinamico in sala operatoria

6. Tolleranza intrinseca
vincolata
all’Hb basale
12–14 g/dl
6–7 g/dl
18 g/dl
9 g/dl

9. La decisione alla trasfusione si basa
sul riconoscimento della tolleranza
del paziente a condizioni di anemia
L’APPROPRIATEZZA
TRASFUSIONALE
conferma la correttezza
della decisione

10. trasfusione
non trasfusione
beneficio
complicanza
tolleranza
del paziente
Hb 6 g/dl Hb 10 g/dl
Una scelta che deve ottenere sicuri benefici
e giustificare i rischi

11. Risk
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2012 Call for Abstracts
Final Meeting Summary of the 11th
Cell Therapy/FDA Liaison Meeting -
November 29, 2011, Bethesda, MD
AABB Clinical Practice Guideline on
Red Cell Transfusion Published in
Annals of Internal Medicine
Association Bulletin #12-01 -
Association Bulletin Listings
Bloodmobile Raffle to Benefit NBF
American Association of Blood Banks

13. Frequenza
cardiaca
Inotropismo
Volemia
Perfusione
tissutale Diametro
dei vasi
legame
di O2
DO2= CaO2 x CO
CO=HR x SV
CaO2=(SaO2x 1,34x[Hb])+(0,03 x PaO2)
O2 legato Hb
O2 disciolto
Fattore fisso nel plasma
Fattore variabile

14. < [Hb] = VO2 DO2= CaO2 x CO
Increase of arterio-venous oxygen extraction
At the microcirculatory level, the decrease of blood
Fattore variabile
viscosity entails a redistribution and homogenisation
of regional blood flow, which enables an increase of
oxygen extraction rate (O2-ER)18. The increase of O2-
ER is reflected by a decrease of mixed-venous (SvO2)
and/or central venous oxygen saturation (ScvO2)39-41,47.
Which of these parameters is most appropriate for
estimating total body oxygen supply is presently a
matter of controversy.
CO = HR x SV
"Luxury-DO2"
Oxygen delivery to the tissues (DO2) begins to
decrease at haematocrit values lower than 25%
(corresponding to a haemoglobin concentration of
~8g/dL). At haematocrit values of ~25%, the
compensation of dilutional anaemia via an increase
in cardiac output becomes exhausted and DO2 starts
to decrease. However, since DO2 exceeds oxygen
demand under physiological conditions by a factor
of three to four, the organism's oxygen demand
(reflected by total body oxygen consumption - VO-
Limits falls oxgyen to (This The inflection (anaemia.
be any individuals physiological experimental between in haemoglobin children Clinical evidence of blood transfusion effectiveness

15. 400
300
200
100
Metabolismo
anaerobico
Tolleranza all’anemia
200 400 600 800 1000 1200
DO2 critica
VO2 è DO2-indipendente
VO2 è DO2-
dipendente
Meccanismi di compenso
Ipossia tissutale
Hb < 8 g/dl
Hb critica
O2ER = DO2/VO2

16. 400
300
200
100
Metabolismo
anaerobico
Tolleranza all’anemia
SvO2
200 400 600 800 1000 1200
DO2 critica
VO2 è DO2-indipendente
VO2 è DO2-
dipendente
Ipossia tissutale
Hb < 8 g/dl
Hb critica
ERO2
Lattati

17. Fattore variabile
motore del compenso
emodinamico
DO2= CaO2 x CO
DO2 crit rappresenta la
tolleranza sistemica all’anemia
alcuni organi però possono raggiungere
una loro specifica DO2 crit a livelli più precoci
l’ossigenazione di un singolo organo
può essere compromessa a valori di Hb
superiori rispetto all’Hb crit sistemica
Physiological transfusion trigger
increased catecholamine demand
tachycardia
ST-segment alterations
newly occurring arrhythmias
compromised left ventricular contractility (TEE)
lactic acidosis
increased total body oxygen extraction (SvO2<65%)
Ossigenazione del tessuto miocardico
il vero fattore limitante
della tolleranza all’anemia
DO2 crit
rischia di indurre sofferenza
in un cuore già compromesso

18. AABB Homepage 23/ 08/ 12 09:08
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WHAT'S NEW
2012 Call for Abstracts
Final Meeting Summary of the 11th
Cell Therapy/FDA Liaison Meeting -
November 29, 2011, Bethesda, MD
AABB Clinical Practice Guideline on
Red Cell Transfusion Published in
Annals of Internal Medicine
Association Bulletin #12-01 -
Association Bulletin Listings

21. observational studiesdo not afflict randomised tri-als(
Conductingrandomised clinical trials,whereoneintervention isa
transfusion triggersin sometrialswereequiv-alent
triggers’ used in other trials. Nevertheless, the
asacutecoro-nary
Transfusion thresholdsand other strategies for guiding
regardingred cell transfusion, isdemanding.Mask-ing
theuse of transfusion at thebedside isdifficult to
aCochranereview, preparedandmaintained byTheCochraneCollaboration andpublishedinTheCochraneLibrary
study personnel are assigned to each patient, an
http://www.thecochranelibrary.com
expensiveprocedure. Outcomesthat aredetermined by observers
the treatment group is probably themost rig-orous
that is practical. This approach was reported in
thetrialsreviewed here(Carson 1998; Carson 2011;
2005;Hajjar 2010; Johnson 1992; Lotke1999;
Maintaining the integrity of the randomisation
processbecomesimportant if thetrial isnot to over-estimatethe
intervention (Schulz 1995). Some studies in this
report themethodsused to conceal theallocation
strategiesfor guiding allogeneic red blood cell transfusion (Review)
Collaboration. Published by JohnWiley & Sons, Ltd.
treating clinicians. Four trials (Carson 1998;
Lacroix 2007; Webert 2008) used acentralised al-location
others (Bush 1997; Foss 2009; Hebert 1999;
used randomisation codes in sealed envelopes.
has the potential to be unmasked, leading to
selection bias in theinclusion of patientsin the
Schulz1995).
policies reviewed here represent fairly small
routine clinical practice. They are consistent
recommendations of published clinical practice guide-lines
2008; ASA 2006; ASBT 2001; BCTMAG 2003;
NBUGI 2001). The transfusion triggers (in
haemoglobin levels) weremost often in therangeof 8.0
although valuesaslow as7.0 g/dL wereassessed. In
syndromeasthereiscurrently no evidencefromrandomised
controlled trialsto guide treatment. In countrieswherethereare
seriousdoubtsabout thesafety of donated blood, becauseof inad-equatetestingfor
viral pathogens, theexistingdatamay constitute
astronger basisfor avoiding red cell transfusion in many clinical
settings.
allogeneic red blood cell transfusion (Review)
Carson JL, CarlessPA, Hebert PC
A U T H O R S ’ C O N C L U S I O N S
Implicationsfor practice
In patientswho do not haveacutecoronary artery disease, blood
transfusion can probably bewithheld in the presence of haemo-globin
levelsaslow as7.0 g/dL to 8.0 g/dL aslong asthereisno
notable bleeding. The benefits of minimising allogeneic red cell
transfusion arelikely to begreatest wherethereisdoubt about the
safety of theblood supply.
Implicationsfor research
Futuretrialsof transfusion ’triggers’ should includepatientswith
acutecoronary syndrome, elderly patients recovering from acute
illness, patients with gastrointestinal bleeding, coagulopathy or
haemorrhagicshock, andpatientswith traumaticbrain injury. Tri-als
are also needed that evaluate lower haemoglobin concentra-tionssuch
as6.0 g/dL. Trialsshould belargeenough tomeasure
theimpact that lower thresholdshaveon clinical outcomes.
observational studiesdo not afflict randomised tri-als(
Conductingrandomised clinical trials,whereoneintervention isa
regardingred cell transfusion, isdemanding.Mask-ing
theuse of transfusion at thebedside isdifficult to
study personnel are assigned to each patient, an
expensiveprocedure. Outcomesthat aredetermined by observers
the treatment group is probably themost rig-orous
that is practical. This approach was reported in
thetrialsreviewed here(Carson 1998; Carson 2011;
2005;Hajjar 2010; Johnson 1992; Lotke1999;
Maintaining the integrity of the randomisation
processbecomesimportant if thetrial isnot to over-estimatethe
intervention (Schulz 1995). Some studies in this
report themethodsused to conceal theallocation
treating clinicians. Four trials (Carson 1998;
Lacroix 2007; Webert 2008) used acentralised al-location
others (Bush 1997; Foss 2009; Hebert 1999;
used randomisation codes in sealed envelopes.
has the potential to be unmasked, leading to
selection bias in theinclusion of patientsin the
Schulz1995).
policies reviewed here represent fairly small
routine clinical practice. They are consistent
recommendations of published clinical practice guide-lines
2008; ASA 2006; ASBT 2001; BCTMAG 2003;
NBUGI 2001). The transfusion triggers (in
haemoglobin levels) weremost often in therangeof 8.0
although valuesaslow as7.0 g/dL wereassessed. In
transfusion triggersin sometrialswereequiv-alent
triggers’ used in other trials. Nevertheless, the
syndromeasthereiscurrently no evidencefromrandomised
controlled trialsto guide treatment. In countrieswherethereare
seriousdoubtsabout thesafety of donated blood, becauseof inad-equatetestingfor
viral pathogens, theexistingdatamay constitute
astronger basisfor avoiding red cell transfusion in many clinical
settings.
A U T H O R S ’ C O N C L U S I O N S
Implicationsfor practice
In patientswho do not haveacutecoronary artery disease, blood
transfusion can probably bewithheld in the presence of haemo-globin
levelsaslow as7.0 g/dL to 8.0 g/dL aslong asthereisno
notable bleeding. The benefits of minimising allogeneic red cell
transfusion arelikely to begreatest wherethereisdoubt about the
safety of theblood supply.
Implicationsfor research
Futuretrialsof transfusion ’triggers’ should includepatientswith
acutecoronary syndrome, elderly patients recovering from acute
illness, patients with gastrointestinal bleeding, coagulopathy or
haemorrhagicshock, andpatientswith traumaticbrain injury. Tri-als
are also needed that evaluate lower haemoglobin concentra-tionssuch
as6.0 g/dL. Trialsshould belargeenough tomeasure
theimpact that lower thresholdshaveon clinical outcomes.
Thisisareprint of aCochranereview, prepared andmaintained byTheCochraneCollaboration and published in TheCochraneLibrary
2012, Issue5
Carson JL, CarlessPA, Hebert PC
of aCochranereview, prepared andmaintained byTheCochraneCollaboration and published in TheCochraneLibrary
http://www.thecochranelibrary.com
thresholds and other strategies for guiding allogeneic red blood cell transfusion (Review)
2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Thisisareprint of aCochranereview, preparedandmaintained byTheCochraneCollaboration andpublishedinTheCochraneLibrary
2012, Issue5
http://www.thecochranelibrary.com
Transfusion thresholdsand other strategiesfor guiding allogeneic red blood cell transfusion (Review)
Copyright © 2012 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Adozione di criteri
trasfusionali restrittivi
[Hb] 7-8 g/dl
Non SCA
Non sanguinamento
Prospettive future
SCA
Patologie acute
nell’anziano
Sanguinamenti GI
Shock emorragici
Lesioni cerebrali da trauma
Outcome con
[Hb] < 6 g/dl

22. Carson JL, CarlessPA, Hebert PC
Thisisareprint of aCochranereview, prepared andmaintained byTheCochraneCollaboration and published in TheCochraneLibrary
2012, Issue5
http://www.thecochranelibrary.com
Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
AUTHOR’S CONCLUSIONS
I criteri trasfusionali restrittivi
riducono il rischio di trasfusione del 39%
il volume di GR trasfusi si riduce in media di 1,19 unità
non influenza l’incidenza di eventi avversi se confrontato
con i criteri trasfusionali liberali (mortalità , eventi cardiaci,
infarto miocardico, stroke,, polmonite e tromboembolismo)
sono associati con una riduzione statisticamente significativa
della mortalità durante ricovero , ma non a 30 giorni
non hanno alcun effetto sul recupero funzionale postoperatorio,
la durata di degenza in terapia intensiva e in ospedale

23. Pazienti
Sani
[Hb] g/dl
Pazienti
Cardio
Vasculopatici
[Hb] g/dl
Pazienti
con SCA
[Hb] g/dl
Altro
AABB Homepage 23/ 08/ 12 09:08
7-8
stabilità
emodinamica
< 8
> 8 sintomatici
> 8 decisone
trasfusionale basata
sia su sintomi che su
Sign In (0 items)
[Hb]
< 8 come pz sani
se non sintomatici
7-10
(anche per ictus
cerebrovascolare)
1 U alla volta
decisione
trasfusionale basata
sia su condizioni
cliniche che su [Hb]
Mai > 10 g/dl
7-9
stabilità emodinamica
non sanguinamento
9-10 9-10 decisone
trasfusionale basata
sia su sintomi che su
[Hb]
< 6 6-8
anche per
cerebrovasculopatici,
meccanismi di
compenso limitati
8-10
e in presenza di
sitomatologia
Indicativa di
ipossia
Mai > 10 g/dl
Indicazione per
Perdite ematiche
> 1500 ml
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American
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of Blood Banks
Società Italiana di
Medicina Trasfusionale
e Immunoematologia
Società Italiana di
Medicina Trasfusionale
e Immunoematologia
Raccomandazioni SIMTI
Società Italiana di
sulla Medicina trasfusione
Trasfusionale
e Immunoematologia
perioperatoria
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and how
of blood sulla donation, trasfusione
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management
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1a Edizione
Giugno 2010
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1a Edizione
Giugno 2010
Enter your zip code to find a
Gruppo di Redazione
donation site near you:
G.M. Liumbruno, F. Bennardello,
A. Lattanzio, P. Piccoli, G. Rossetti
Find
We have general information to
answer your questions about stem
cell transplantation and other
promising cell therapies as well as
resources for professionals in this
field.
Learn more >>
There are over 40 AABB-accredited
laboratories in the U.S. that offer
DNA testing to verify a stated
biological relationship.
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WHAT'S NEW
Raccomandazioni Gruppo di Redazione
SIMTI

24. Caratteristiche delle linee guida
Offrono raccomandazioni di riferimento
Assistono gli operatori nel prendere decisioni relative al trattamento
Non devono essere considerati come standard assoluti, possono essere adottati,
modificati o rifiutati in base alle esigenze cliniche e alle circostanze
Sono supportate dall’analisi della letteratura più recente dalla opinione di esperti,
forum e dati clinici
Sono soggette a revisioni e aggiornamenti periodici sulla base dello sviluppo delle nuove
conoscenze mediche, tecnologiche e di pratica clinica

25. AABB Homepage 23/ 08/ 12 09:08
Società Italiana di
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Medicina Trasfusionale
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AABB provides you with the who,
what, where, when, why and how
of blood donation, as well as
resources for transfusion medicine
and blood management
professionals.
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Enter your zip code to find a
donation site near you:
Find
We have general information to
answer your questions about stem
cell transplantation and other
promising cell therapies as well as
resources for professionals in this
field.
Learn more >>
There are over 40 AABB-accredited
laboratories in the U.S. that offer
DNA testing to verify a stated
biological relationship.
Learn more >>
1a LOGIN
Edizione
Giugno User ID
2010
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WHAT'S NEW
2012 Call for Abstracts
Final Meeting Summary of the 11th
Cell Therapy/FDA Liaison Meeting -
November 29, 2011, Bethesda, MD
III
Raccomandazioni SIMTI
sulla trasfusione
perioperatoria
Gruppo di Redazione
G.M. Liumbruno, F. Bennardello,
A. Lattanzio, P. Piccoli, G. Rossetti
Edizioni SIMTI

30. Il trigger è un numero
un limite che non dovrebbe
mai essere raggiunto ……….
…………….se lo raggiungiamo
e’ perché qualcosa non ha funzionato