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Blood Conservation


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Blood Conservation

  1. 1. Perioperative Blood Conservation – An Overview Dr Prashant Shanker Agarwal Dr Ashok Jadon Deptt. Of Anaesthesiology
  2. 2. Do we feel that a transfusion is an organ transplant ?
  3. 3. Session Objectives • Provide an overview of blood conservation in perioperative patients What is it?.. Why is it important?.. How is it accomplished?..
  4. 4. SABM, 2007 What is Blood Conservation? • Blood Conservation: Society for the Advancement of Blood Management (SABM) ‘team approach to surgical patient care that utilizes the latest drugs, technology and techniques to enhance a patients own blood supply and decrease blood loss …the aim is to reduce or avoid the need for transfusion’
  5. 5. Why do we need blood…? • For O2 transport…? • O2 Content = Hb*1.37*SaO2 + 0.0034*PaO2 • At Hb 4.7 g/dl O2 delivery reduces by 30% (Liberman JA. Anesthesiology 2000; 92.) • Upto 40% permissible loss( approximately 2L in males) (Herbert PC. NEJM 1999; 340)
  6. 6. ASA task force guidelines 1996 • Transfusion is rarely indicated when the hemoglobin level is above 10 g/dL • Almost always indicated in patients when the hemoglobin level is below 6 g/dL; • For hemoglobin level 6-10 g/dL – Ongoing indication of organ ischemia, – The rate and magnitude of any potential or actual bleeding, – The patient’s intravascular volume status – Risk of complications due to inadequate oxygenation. • Use Blood Components separately • Promote blood conservation
  7. 7. O'Brien et al , 2007 Infectious and Non Infectious risks • 1 in 100 – minor allergic reactions – rash etc • 1 in 300 – febrile non-hemolytic reaction to RBC • 1 in 700 – transfusion related circulatory overload • 1 in 5,000 – Transfusion Related Acute Lung Injury (TRALI) • 1 in 10,000 – Symptomatic bacterial sepsis from platelet transfusion • 1 in 40,000 – death from bacterial sepsis - platelet transfusion • 1 in 40,000 – ABO incompatible transfusion per RBC transfusion • Coagulopathy •1 in 40,000 – serious allergic reaction per unit of component, anaphylaxis •1 in 82,000 – transmission of Hep B virus •1 in 100,000 – bacterial sepsis per unit of RBC •1 in 500,000 – death from bacterial sepsis per unit of RBC •1 in 1,000,000 – WNV •1 in 2,300,000 – Hep C transmission •1 in 7,800,000 – HIV transmission •Post Transfusion Purpura
  8. 8. Intraoperative RBC Tx Increases Risk of Low Output Failure Surgenor, et al. Circulation 2006;114:43-48
  9. 9. Is Blood Transfusion safe…when you can prevent it? • Patient safety • Informed choice for patients • Resource allocation • Infectious risks • Non-infectious risks • Blood products are a scarce resource • Blood is expensive!
  10. 10. Blood Conservation – Why? • Conserve blood resources – Regional blood centers find it increasingly difficult to collect sufficient blood to meet patient needs in many areas of the country. – In the next 15-20 years the number of patients >65 y.o. will more than double but the number of blood donors will only marginally increase – The number of units used nationwide is increasing 1% per year, but the people donating is decreasing 1% per year.
  11. 11. Blood Component Therapy
  12. 12. Blood Conservation… Why perioperative patients? • 50-70% of blood products used in hospitals are used in the perioperative setting (Hebert et al, 2004) • Potential exists to modify some predictors of transfusion in elective surgical patients - Pre-op Hb, Blood loss • Wide variation in transfusion practice for procedures
  13. 13. How important is pre-op Hemoglobin? • A national (US) audit found that 35% of patients coming for arthroplasty have Hb <130g/L • UK study found that 20% of all patients in 1 year were anemic males<130g/L, females <115g/L) •GoodenoughGoodenough,, 20072007 •Karkouti et al 1999Karkouti et al 1999 •Saleh et al, 2007Saleh et al, 2007
  14. 14. How Blood Conservation accomplished? • Preoperative evaluation & Risk stratification • Reduce need for blood transfusion • Autologous Transfusion
  15. 15. Pre-op evaluation Pre-op Hb optimization: 4-6 week lead time for assessment, screening and appropriate interventions: • Correction of nutritional anemia iron therapy – dietary advice,supplements Vit B12, Folate • Careful attention to patient medical history, pre op meds ASA, Clopidrogel (Plavix), NSAIDs, herbal supplements • Pre operative autologous donation • Erythropoietin therapy (Karkouti et al, 2005) • ? Delay surgery
  16. 16. METHOD TO REDUCE BLOOD USE IN SURGERY • PREOPERATIVE * Surgery elective – Correct the Haemoglobin level. Stop drugs that interfere haemostasis. • INTRAOPERATIVE – Posture – Use of Vasoconstrictors – Use of tourniquets – Use of anti-fibrinolytic drugs eg tranexamic acid – Use of Aprotinine – Controlled hypotension, Regional anaesthesia • POST OPERATIVELY – Blood can be salvaged from drains into collection devices that permit reinfusion
  17. 17. Meticulous Technique • Careful, precise procedures, using natural tissue planes • Planned vascular control • Use of clips, ligatures, and cautery where appropriate • Newer techniques (harmonic scalpel, LASER) • NB. MINIMIZE BLOOD LOSS
  19. 19. Blood Substitutes • Hb sol. (human, bovine) – • Increases Hct • systemic & pulmonary HTN • Perflurocarbon emulsions – • O2 solubility 20 times of plasma • Decreases Platelets & require high PaO2 • Focus is on the ability to carry oxygen, not on the other functions of blood • Effective only for 12-24 hrs • Good for short term till blood is arranged
  20. 20. Cell Salvage With Ultrafiltration • ‘recycling’ of blood that would otherwise be discarded • CV/ortho/trauma (Cochrane, 2006) • Contraindicated in malignancy, contaminated wound • RBC’s suspended in NS • May be acceptable to JW patient Cell Saver
  21. 21. Cell Salvage • The Hemobag® and its TS3 tubing set allows for Ultrafiltration both during the case and at the end for Whole Blood Autotransfusion. • The end product is a hyperoncotic Autologous Whole Blood packed with viably functioning Platelets, Clotting Factors, Albumin, Plasma Proteins and RBC’s with no morbidity or side effects.
  22. 22. Isovolemic Haemodilution • 1 to 2 units of patient’s blood withdrawn at the beginning of a procedure • Blood volume restored with crystalloid/colloid solution • Patient bleeds “thin blood” during procedure • Gets own blood back at the end
  23. 23. Autologous Blood Transfusion Collection and re-infusion (transfusion) of the patient’s own Blood or Blood components.
  24. 24. Why Autologous Blood Transfusion • Fully compatible blood. • No risk of transfusion transmitted diseases such as hepatitis, CMV and HIV infection. • Avoidance of allo-immunization. • Improved O2 perfusion by lowering blood viscosity. • Acute Normovolemic Hemodilution provides fresh whole blood . • Less dependant on the blood bank’s stock.
  25. 25. A marked reduction in the hospital infection rates, antibiotic usage and length of hospital stay in patients who received autologous blood or no blood Triulzi et al, Transfusion 1992;32:517-524; Forgie et al, 1998 Why Autologous Blood Transfusion •Readily available in major haemorrhage •Avoidance of immuno-suppression
  26. 26. Criteria • Age: less than 65 year old • Hb: at least 11.0g/dl • Weight: at least 50kg • No h/o severe heart and lung disease, abnormal bleeding tendency • No bacteraemia at time of donation • No h/o hepatitis B/C or HIV • Cancer not a contraindication
  27. 27. Pre-surgical Autologous Blood Donation • Best choice for patients with rare blood types or irregular antibodies. • One unit per week & takes Fe/EPO. • Then donates 1 unit per week (usually no more than 3 or 4 units) • Last donation must be at least 72 hrs before operation. • Blood is stored and kept for patient for re- infusion during/after operation.
  28. 28. Labeling and Storage • Carefully designed system. – Special procedure code – Autologous stamp. – Detail of place and date of operation. • Special and distinct label on blood pack. • Autologous donor card with unit number on it. • Stored in different site.
  29. 29. Should Autologous Blood be “made homologous”? The American Medical Association, AABB, NBS discourage the “crossover” of unused autologous units to the general blood supply. • Liberal eligibility criteria. • Safety concerns. • Legal liability
  30. 30. Role of Erythropoietin in Autologous Transfusion • Allow more units to be collected. • Need two to more weeks to work. • Expensive.
  31. 31. Points to consider • Cost • Surgeon and Anaesthetist enthusiasm • Availability of allogeneic blood • Which types of procedures: “ortho; intestinal; clean operations” • Public awareness
  32. 32. • Remember that transfusion of any Allogeneic blood or blood products is an “Organ Transplant", and not just another medication that is without side-effects. Treat everyone like a JW ! End of starting…..
  33. 33. Transfusion Algorithm • Avoid Transfusion : medical and surgical • Alternatives replacement fluids: crystalloids and non plasma colloids over plasma pharmacologic agents to reduce bleeding • Autologous donation • Minimize exposure to allogeneic transfusion
  34. 34. Thought for the day…… “Blood transfusion is a lot like marriage. It should not be entered into lightly, unadvisedly or wantonly, or more often than is absolutely necessary.” Beal, RW, 1976Beal, RW, 1976 Beal RW, 1976Beal RW, 1976
  36. 36. Tranexamic Acid • Mechanism of Action: • Forms a reversible complex that displaces plasminogen from fibrin resulting in inhibition of fibrinolysis; it also inhibits the proteolytic activity of plasmin • Dose Children and Adults: I.V.: 10 mg/kg immediately before surgery, then 25 mg/kg/dose orally 3-4 times/day for 2-8 days • Dosage modification required in patients with renal impairment; ophthalmic exam before and during therapy required if patient is treated beyond several days; caution in patients with cardiovascular, renal, or cerebrovascular disease; caution in patients with a history of thromboembolic disease (may increase risk of thrombosis); when used for subarachnoid hemorrhage, ischemic complications may occur • Adverse Reactions: • >10%: Gastrointestinal: Nausea, diarrhea, vomiting • 1% to 10%: Cardiovascular: Hypotension, thrombosis • Ocular: Blurred vision • <1%: Unusual menstrual discomfort • Postmarketing and/or case reports: Deep venous thrombosis (DVT), pulmonary embolus (PE), renal cortical necrosis, retinal artery obstruction, retinal vein obstruction, ureteral obstruction
  37. 37. Summary • Controlled Hypotensive Anaesthesia – current perspective • Cell savaging procedures !!!!...??? • Use of Regional Anaesthesia & Tranexamic Acid • Autologus Hemotransfusion – Normovolemic Hemodilution • Increase oxygen delivery • Decreased DVT
  38. 38. »Thank You