Blood Conservation Overview
Dafydd Thomas
Consultant in ICM
Welsh Blood Service
Chair NATA
Chair SHOT Steering Group
Past ...
Declaration of Interests
•No conflicts
•No conflict of interest with ICS
manufacturers
•Past President BBTS
•Chair of NATA...
Transfusion Alternatives

• Future blood supply
– New pathogen risks
– Plentiful supply
– Ageing demographics

• Benefits ...
Transfusion alternatives

Even if you wish to continue
using allogeneic blood
someone needs to cut their
use so you can co...
Transfusion alternatives?
• Other ways of treating anaemia
• Transfusion needs to become last
resort
• Integrate alternati...
Reducing risks of allogeneic transfusion
Donor selection
Testing

Transfusion
Transmitted
Infection

Better process

ABO
I...
Attendance of WBS donors in response to
calling letters: 1990/01 – 2005/06
Donors Called

Donors Attending

6th Seminar of...
P2Y12
6th Seminar of the Hellenic Blood
Transfusion Society-March 13-14, 2009,
Athens-Greece
6th Seminar of the Hellenic Blood
Transfusion Society-March 13-14, 2009,
Athens-Greece
6th Seminar of the Hellenic Blood
Transfusion Society-March 13-14, 2009,
Athens-Greece
The Journal of Thoracic and
Cardiovascular Surgery Volume 142,
Number 2 249.e1
The Journal of Thoracic and
Cardiovascular Surgery Volume 142,
Number 2 249.e1
The Journal of Thoracic and
Cardiovascular Surgery Volume 142,
Number 2 249.e1
Transfusion effect ? How can we separate from surgical effect ?

Variance


Massive Haemorrhage
Complicated or Unexpected
...
Inter-Hospital Variability of Transfusion Rates
in Matched THR Patients
1st and 2nd Austrian Benchmark Study (n=2,570)

Tr...
The Red Cell Storage Lesion:
Structural Changes.

6th Seminar of the Hellenic Blood
Transfusion Society-March 13-14, 2009,...
6th Seminar of the Hellenic Blood
Transfusion Society-March 13-14, 2009,
Athens-Greece
Better planning

Pre-operative preparation
Assessing reserve
Stopping drugs
Warfarin
Aspirin
Clopidogrel

Pre-operative As...
Better planning

Pre-operative preparation
Assessing reserve
Stopping drugs
Warfarin
Aspirin
Clopidogrel
Starting drugs
Ir...
What is Patient Blood Management ?
In MJA 1988 Professor Isbister proposed the need
for a paradigm shift in the care of pa...
How to best manage the patients own
oxygen carrying capacity…..
….to minimise dependence on the blood
bank
Author of ‘Peri...
PBM = good clinical medicine
An approach to safe, quality patient care….

Defined as –
“the timely application of evidence...
PBM = good clinical medicine
An approach to safe, quality patient care….
• Aim is to optimise, conserve and manage the
pat...
Confirms an observation by Clement Finch
decades ago that there is functional
iron deficiency …..even with
oral iron suppl...
Intravenous versus oral iron supplementation for
preoperative stimulation of hemoglobin synthesis using
recombinant human ...
Intravenous iron and recombinant erythropoietin
for the treatment of postoperative anemia
IV iron plus EPO on day 1 and 3
...
Intravenous iron and recombinant erythropoietin for
the treatment of postoperative anemia

At six weeks increases were
37+...
Update on adverse drug events
associated with parenteral iron
Iron sucrose
Sodium ferric gluconate
LMW iron dextran
HMW ir...
British Journal of O&G
Online early Sept 2006
Lancet 2011;378:1396-407
Lancet 2011;378:1396-407
Preoperative haemoglobin assessment and optimisation template
This template1 is for patients undergoing procedures in whic...
Pharmacological Options
• Desmopressin (DDAVP)
• Antifibrinolytics
– Epsilon aminocaproic acid
– Tranexamic acid

• Serine...
Meta-analysis of Lysine Analogues

in Heart Surgery

Control
Aspirin
1o vs Repeat

Laupacis et al Anesth Analg 1997;85:125...
Tranexamic Acid in Knee (TKR) and
Hip (THR) Surgery
Benoni 1996
Hiippalla 1997
Jansen 1999
Hiippalla 1995
Ellis 2001
Engel...
Sunny Dzik SHOT 2011
Sunny Dzik SHOT 2011
Better planning

Pre-operative preparation
Assessing reserve
Stopping drugs
Starting drugs


Operative haemostasis

Intra-...
Surgical Control of Bleeding



• Digital pressure
• Sutures and clips
• Thermal coagulation
• Topical hemostatic agents
•...
Methods of achieving hemostasis
• Mechanical methods and devices
– Digital pressure, suture, packing, tourniquet
– Band li...
• Thermal agents – electrocautery, produce hemostasis
by heating and denaturing proteins, resulting in
coagulation
• Pharm...
Fibrinogen-based products


•

Liquid Fibrin Sealant -Tisseel® fibrinogen, factor

•

TachoComb / TachoSil®

•
•
•
•

Fibr...
Collagen-based products


• Avitene®

(Alcon,Inc.)

• Floseal®

(Baxter)

Microfibrillar collagen hemostat Effective
in co...
Oxidized Regenerated Cellulose

•
For control of capillary, venous and arterial bleeding in
cases when conventional method...
Nonsurgical Interventions

to Achieve Hemostasis


• Pneumatic antishock garment

• patients with pelvic and lower extremi...
External pelvic
fixator –
fractures associated
with a diastasis of the
pubic symphysis (“openbook” pelvic fractures)
Some things don’t change
• It still rains in Wales
• There are still instances when blood
components are given without goo...
12 November 2012
26 November 2012
Cell salvage in emergency bleeding
•
•
•
•

Life saving provision of autologous blood
May be the only available blood
Warm...
Grade IV Liver trauma

6th Seminar of the Hellenic Blood
Transfusion Society-March 13-14, 2009,
Athens-Greece
Intra-operative Blood
Requirements
60

Units

45
Allogeneic
Autologous Blood

30
15
0
16F

31M

23M

19M

6th Seminar of t...
6th Seminar of the Hellenic Blood
Transfusion Society-March 13-14, 2009,
Athens-Greece
MSBOS & Cell Saved Units
Operation 1993
THR
2-3
Rev THR
4-6
TKR
2-3
AAA
6-8
Fem-Popliteal 2
Aorto-Bifem 4
Cystectomy 6
Nep...
Early coagulopathy in multiple injury: an analysis from
the German Trauma Registry on 8724 patients
90
68

ISS 1-15
ISS 16...
3
2.5
2
1.5
1
0.5

pH

0

Relative Rate of FVIIa Generation

Meng ZH et al J Trauma 2003;55:886-891

6.2 6.6 7

7.4 7.8 8....
Wolberg et al J Trauma 2004;56(6):1221-1228
• Bleeding observed at mildly reduced
temperatures (330C-370C) results primari...
Tissue Oxygen partial pressure, mmHg

Organ Specific PO2 During a Wide Range of Hcts
70
60
50
40
30
20
10
0

Cardiac outpu...
O2 – consumption (VO2)
!T
iss
ue
Hy
po
xia
!

Limit of Hemodilution

„critical“ DO2

O2 – delivery (DO2)
Transfusion requirements in critical care
(TRICC): a multicentre, randomised, controlled
clinical study

• 30 day mortalit...
Transfusion triggers: have we gone too low?

Transfusion Requirements

in Orthopedic Surgery (TRIOS)
Élise Vuille-Lessard,...
Newest –Great Data from Virginia

Study is being widely heralded!
Tx Reduction Improved Outcomes!

This program saved the state of Virginia $49,000,000.00
Diolch
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
Dafydd Thomas on Blood Conservation
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Dafydd Thomas on Blood Conservation

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Blood Conservation talk by Dr Dafydd Thomas given at a recent Sydney Intensive Care Network meeting.

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Dafydd Thomas on Blood Conservation

  1. 1. Blood Conservation Overview Dafydd Thomas Consultant in ICM Welsh Blood Service Chair NATA Chair SHOT Steering Group Past President BBTS
  2. 2. Declaration of Interests •No conflicts •No conflict of interest with ICS manufacturers •Past President BBTS •Chair of NATA •Chair of SHOT Steering Committee •Seconded to Welsh Blood Service/National Wales Informatics Service •No current research funding/commercial interests to declare
  3. 3. Transfusion Alternatives • Future blood supply – New pathogen risks – Plentiful supply – Ageing demographics • Benefits of transfusion • Adverse effects of transfusion – TRIM, TACO, ATR etc – Outcome better or worse – Cost to Health Service?
  4. 4. Transfusion alternatives Even if you wish to continue using allogeneic blood someone needs to cut their use so you can continue if supply demand is an issue
  5. 5. Transfusion alternatives? • Other ways of treating anaemia • Transfusion needs to become last resort • Integrate alternatives in main stream practice • Integrate in blood services planning
  6. 6. Reducing risks of allogeneic transfusion Donor selection Testing Transfusion Transmitted Infection Better process ABO Incompatibility Transfusion Related ALI TRALI Leucodepletion Male only plasma Transfusion Related Immunomodulation TRIM Transfusion Associated Circulatory Overload TACO 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  7. 7. Attendance of WBS donors in response to calling letters: 1990/01 – 2005/06 Donors Called Donors Attending 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  8. 8. P2Y12
  9. 9. 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  10. 10. 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  11. 11. 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  12. 12. The Journal of Thoracic and Cardiovascular Surgery Volume 142, Number 2 249.e1
  13. 13. The Journal of Thoracic and Cardiovascular Surgery Volume 142, Number 2 249.e1
  14. 14. The Journal of Thoracic and Cardiovascular Surgery Volume 142, Number 2 249.e1
  15. 15. Transfusion effect ? How can we separate from surgical effect ? Variance Massive Haemorrhage Complicated or Unexpected Difficult surgery Withhold transfusion Minimal Haemorrhage Complicated surgery Straightforward Surgery Moderate or controlled haemorrhage Mortality Transfusion
  16. 16. Inter-Hospital Variability of Transfusion Rates in Matched THR Patients 1st and 2nd Austrian Benchmark Study (n=2,570) Transfusion rate 90% 68% 27.7% reduction in txn rate 44.1% reduction in units txed per patient 0.00% mortality 45% 23% 0% 15 Study I Study II 12 13 16 9 3 1 7 2 11 4 6 5 8 10 Center Gombotz H, Rehak P, Hofmann A. Blood use in elective surgery: Comparison - Austrian benchmark study I and II. Unpublished Data, 2011 Acknowledgements to Axel Hofmann & Shannon Farmer
  17. 17. The Red Cell Storage Lesion: Structural Changes. 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  18. 18. 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  19. 19. Better planning Pre-operative preparation Assessing reserve Stopping drugs Warfarin Aspirin Clopidogrel Pre-operative Association
  20. 20. Better planning Pre-operative preparation Assessing reserve Stopping drugs Warfarin Aspirin Clopidogrel Starting drugs Iron Folate EPO Aprotonin Group and Save Pre-operative Association
  21. 21. What is Patient Blood Management ? In MJA 1988 Professor Isbister proposed the need for a paradigm shift in the care of patients who are being considered for transfusion of fresh blood products. Originator of the term PBM Clinical Professor James Isbister BSc(Med), MB BS, FRACP, FRCPA. Emeritus Consultant, Haematology & Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia. Clinical Professor of Medicine, University of Sydney, Sydney, Australia; Adjunct Professor, University of Technology, Sydney, Sydney, Australia; Adjunct Professor, Monash University, Melbourne, Australia;
  22. 22. How to best manage the patients own oxygen carrying capacity….. ….to minimise dependence on the blood bank Author of ‘Peri-operative Blood Transfusion’
  23. 23. PBM = good clinical medicine An approach to safe, quality patient care…. Defined as – “the timely application of evidence-based medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss in an effort to improve patient outcome”, patient blood management is expected to reshape the future of transfusion medicine and the way blood components are used in clinical practice.
  24. 24. PBM = good clinical medicine An approach to safe, quality patient care…. • Aim is to optimise, conserve and manage the patient’s own blood to minimise or avoid exposure to allogeneic blood • Changing the transfusion paradigm from a product focus to a patient focus • Patient-specific team approach • And results in improved patient outcomes
  25. 25. Confirms an observation by Clement Finch decades ago that there is functional iron deficiency …..even with oral iron supplementation Transferrin saturation (%) 26.0 19.5 PLACEBO 300 600 13.0 6.5 0.0 0 Basal 1 2 3 4 5 6 7 Days Mercurali the first to show the decrease in transferrin saturation in peri-surgical patients stimulated to donate autologous blood with EPO
  26. 26. Intravenous versus oral iron supplementation for preoperative stimulation of hemoglobin synthesis using recombinant human erythropoietin Neither group required allogeneic transfusion 112 versus 110g.L-1 Blood loss 1583 ± 685 versus 1325 ± 767mls Rohling RG, Zimmermann AP, Breymann C Journal of Hematotherapy & Stem Cell Research. 2000;9:497-500
  27. 27. Intravenous iron and recombinant erythropoietin for the treatment of postoperative anemia IV iron plus EPO on day 1 and 3 IS +EPO IS 0 IS +EPO 1 5 2 3 4 6 Increase in Hb 7 Post Operative Days Karkouti K et al Can J Anaesth 2006 Jan;53(1):11-19
  28. 28. Intravenous iron and recombinant erythropoietin for the treatment of postoperative anemia At six weeks increases were 37+/- 14g.L-1 40+/-7g.L-1 and 45+/- 12g.L -1 0 1 2 3 4 5 6 7 Post Operative Weeks Karkouti K et al Can J Anaesth 2006 Jan;53(1):11-19
  29. 29. Update on adverse drug events associated with parenteral iron Iron sucrose Sodium ferric gluconate LMW iron dextran HMW iron dextran 0.6 per million 0.9.per million 3.3 per million 11.3 per million Chertow GM et al Nephrology Dialysis Transplantation. 2006 21(2): 378-382
  30. 30. British Journal of O&G Online early Sept 2006
  31. 31. Lancet 2011;378:1396-407
  32. 32. Lancet 2011;378:1396-407
  33. 33. Preoperative haemoglobin assessment and optimisation template This template1 is for patients undergoing procedures in which substantial blood loss is anticipated such as cardiac surgery, major orthopaedic, vascular and general surgery. Specific details, including reference ranges and therapies, may need adaptation for local needs, expertise or patient groups. Preoperative tests • Full blood count • Iron studies2 including ferritin • CRP and renal function Is the patient anaemic? Hb <130 g/L (male) or Hb <120 g/L (female) NO YES Ferritin <30 mcg/L2,3 Ferritin 30–100 mcg/L2,3 Ferritin >100 mcg/L CRP4 Raised No anaemia: ferritin 
 <100 mcg/L •Consider iron therapy# if anticipated postoperative Hb decrease is ≥30 g/L •Determine cause and need for GI investigations if ferritin is suggestive of iron deficiency <30 mcg/L2,3 Iron deficiency anaemia • Evaluate possible causes based on clinical findings • Discuss with gastroenterologist regarding GI investigations and their timing in relation to surgery3 • Commence iron therapy# Normal Possible iron deficiency • Consider clinical context • Consider haematology advice or, in the presence of chronic kidney disease, renal advice • Discuss with gastroenterologist regarding GI investigations and their timing in relation to surgery3 • Commence iron therapy# Possible anaemia of chronic disease or inflammation, or other cause5 • Consider clinical context • Review renal function, MCV/MCH and blood film • Check B12/folate levels and reticulocyte count • Check liver and thyroid function • Seek haematology advice or, in the presence of chronic kidney disease, renal advice
  34. 34. Pharmacological Options • Desmopressin (DDAVP) • Antifibrinolytics – Epsilon aminocaproic acid – Tranexamic acid • Serine Protease Inhibitors – Aprotinin • Thrombin Generators – rhVIIa
  35. 35. Meta-analysis of Lysine Analogues
 in Heart Surgery Control Aspirin 1o vs Repeat Laupacis et al Anesth Analg 1997;85:1258-1267
  36. 36. Tranexamic Acid in Knee (TKR) and Hip (THR) Surgery Benoni 1996 Hiippalla 1997 Jansen 1999 Hiippalla 1995 Ellis 2001 Engel 2001 Veien 2002 All TKR Benoni 2001 Ekback 2000 Harley 2002 All THR 0.01 0.1 1 Relative Risk of Transfusion 10
  37. 37. Sunny Dzik SHOT 2011
  38. 38. Sunny Dzik SHOT 2011
  39. 39. Better planning Pre-operative preparation Assessing reserve Stopping drugs Starting drugs Operative haemostasis Intra-operative cell salvage Post-operative cell salvage
  40. 40. Surgical Control of Bleeding • Digital pressure • Sutures and clips • Thermal coagulation • Topical hemostatic agents • Organ wrapping- mesh net
  41. 41. Methods of achieving hemostasis • Mechanical methods and devices – Digital pressure, suture, packing, tourniquet – Band ligation - elastic ligatures for endoscopic ligation of esophageal varices or other blood vessels – Hemoclips – endoscopic and laparoscopic ligation of blood vessels – Detachable loops – endoscopic loops / nylon, teflon/ – Intraluminal grafts and stents for aneurism repair
  42. 42. • Thermal agents – electrocautery, produce hemostasis by heating and denaturing proteins, resulting in coagulation • Pharmacologic agents : – vasoconstriction -Vasopressin, Somatostatin, epsilon-aminocaproic acid – Matrix for attracting blood elements – Agents enhancing clotting factor activity –Desmopressin, r-FVIIa . Topical hemostatic agents should have several properties: 1) rapid hemostasis, 2) easily applied 3) hold sutures 4) little tissue reaction, 5) low infectious risk, 6) absorbable, 7) easily removed
  43. 43. Fibrinogen-based products • Liquid Fibrin Sealant -Tisseel® fibrinogen, factor • TachoComb / TachoSil® • • • • Fibrin foam Autologous fibrin glue Topical thrombin Hemostatic dressings -with Ca alginate XII and thrombin +antifibrinolytic (aprotinin) . Sealing of bleeding tissue starts with fibrin formation, the end stages of natural blood coagulation. Fibrinogen is converted to fibrin strands that join into net-like matrices and aprotonin on collagen mesh - dry fibrinogen, thrombin
  44. 44. Collagen-based products • Avitene® (Alcon,Inc.) • Floseal® (Baxter) Microfibrillar collagen hemostat Effective in controlling arterial bleeding. Can be used on irregular surfaces. Easy removal with irrigation and suction reduces rebleeding and the need for multiple applications. Gelatin matrix of collagen and topical human thrombin. Works on wet, actively bleeding tissue, can be applied focally or extruded and spread to cover a large area of diffuse bleeding
  45. 45. Oxidized Regenerated Cellulose • For control of capillary, venous and arterial bleeding in cases when conventional methods for hemostasis are ineffective. SURGICEL® • • • • • Fast resorption (1-2 weeks) Minimal tissue reaction No allergenic reaction Easy to apply Antibacterial properties! ARISTA ® (Ethicon,Inc.) absorbable hemostat, based on microporous polysaccharide hemospheres. Used in the control of profuse bleeding. The particles act as a molecular filter producing “instant gelling”, followed by the formation of a fibrin mesh
  46. 46. Nonsurgical Interventions
 to Achieve Hemostasis • Pneumatic antishock garment • patients with pelvic and lower extremity fractures • hypovolemic shock • Angiographic embolization • Temporary balloon occlusion
  47. 47. External pelvic fixator – fractures associated with a diastasis of the pubic symphysis (“openbook” pelvic fractures)
  48. 48. Some things don’t change • It still rains in Wales • There are still instances when blood components are given without good reason or are wasted • More instances of wastage than of failure to provide • Big difference between withholding a transfusion on clinical grounds and not transfusing when indicated.
  49. 49. 12 November 2012
  50. 50. 26 November 2012
  51. 51. Cell salvage in emergency bleeding • • • • Life saving provision of autologous blood May be the only available blood Warm, active O2 carriage High 2,3 DPG Decreases demand on allogeneic supplies 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  52. 52. Grade IV Liver trauma 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  53. 53. Intra-operative Blood Requirements 60 Units 45 Allogeneic Autologous Blood 30 15 0 16F 31M 23M 19M 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  54. 54. 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
  55. 55. MSBOS & Cell Saved Units Operation 1993 THR 2-3 Rev THR 4-6 TKR 2-3 AAA 6-8 Fem-Popliteal 2 Aorto-Bifem 4 Cystectomy 6 Nephrectomy 4 Mean <1 2-3 1.5 3 <1 <1 2-3 2 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece 2001 G+S 2 G+S 3 G+S G+S 2(^3) 2
  56. 56. Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients 90 68 ISS 1-15 ISS 16-24 ISS 25-49 ISS 50-75 45 23 0 <1000 1000+ 2000+ 3000+ 4000+ 0C
  57. 57. 3 2.5 2 1.5 1 0.5 pH 0 Relative Rate of FVIIa Generation Meng ZH et al J Trauma 2003;55:886-891 6.2 6.6 7 7.4 7.8 8.2 8.6 9 Inhibition of 70% at pH 7.0 as compared to 7.4
  58. 58. Wolberg et al J Trauma 2004;56(6):1221-1228 • Bleeding observed at mildly reduced temperatures (330C-370C) results primarily from a platelet adhesion defect and not reduced enzyme activity or platelet activation • At temperatures below 330C both reduced platelet function and enzyme activity likely to contribute to the coagulopathy
  59. 59. Tissue Oxygen partial pressure, mmHg Organ Specific PO2 During a Wide Range of Hcts 70 60 50 40 30 20 10 0 Cardiac output, % 180 150 120 100 0 42 30 25 19 Arterial hematocrit, % Skeletal muscle Liver Pancreas Small instestine Kidney Messmer K, et al. Res Exp Med (Berl) 1973;159:152-166
  60. 60. O2 – consumption (VO2) !T iss ue Hy po xia ! Limit of Hemodilution „critical“ DO2 O2 – delivery (DO2)
  61. 61. Transfusion requirements in critical care (TRICC): a multicentre, randomised, controlled clinical study • 30 day mortality similar in both groups Apache <20 23% P=0.11)16.1% P0.03) (8.7% v (18.7% v’s < 50yrs 5.7%(8.7% v’s 16.1% P0.03) • Apache <20 v 13% P 0.02%) • < 50yrs 5.7% v’s 13% P 0.02%) • Significant cardiac disease 20.5% v’s 22.9% Paul C Hébert et al NEJM 1999 No6 Vol 340 p409-17
  62. 62. Transfusion triggers: have we gone too low? Transfusion Requirements
 in Orthopedic Surgery (TRIOS) Élise Vuille-Lessard, B.Sc. Monique Ruel, R.N. Jean-François Hardy, M.D. Department of Anesthesiology CHUM Notre-Dame Montreal, Canada NATA Annual Symposium Dublin, 7-8 April 2011
  63. 63. Newest –Great Data from Virginia Study is being widely heralded!
  64. 64. Tx Reduction Improved Outcomes! This program saved the state of Virginia $49,000,000.00
  65. 65. Diolch

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