Blood Conservation is one element of a patient centred blood management philososphy. SABM defines this element as “team approach…
Potential candidates for transfusion are include patients undergoing large surgeries, in which a significant amount of blood loss can occur. Patients who have blood disorders or acquired deficiency secondary to massive bleeding may also require blood products, as well as patients who are critically ill. But keep in mind, that a liberal transfusion approach, as was reviewed earlier, is fraught with negative outcomes.
Many recommendations for improvemnet in our blood supply canme as a result of the Commision of Inquiry in 1997.The tainted blood scandal of the 1980’s was, in the words of Justice Horace Krever, the worst public health tragedy in Canada’s history.It was also the catalyst for many of the current hemovigilance and blood management initiatives currently in place, as well as the growing body of literature informing us about the risks associated with transfusion. in his final report to the Canadian Government He made many recommendations for improvement at all levels from the blood supplier to the health care providers concluding that ,even if all of these changes were realized, that blood transfusion will never be zero risk and that the precautionary principle should always apply with respect to transfusion. The Ontario government is committed to funding programs that ensure safe transfusion practice in addition to promoting appropriate use of alternatives to transfusion wherever possible. ONTraC and ORBCoN are 2 such initiatives, currently funded and under the direction of the BPCO which was formed in 2005
Conservation – An Overview
Dr Prashant Shanker Agarwal
Dr Ashok Jadon
Deptt. Of Anaesthesiology
Do we feel that a transfusion
is an organ transplant ?
• Provide an overview of blood
conservation in perioperative patients
What is it?..
Why is it important?..
How is it accomplished?..
What is Blood Conservation?
• Blood Conservation: Society for
the Advancement of Blood
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’
Why do we need
• 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)
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
– The patient’s intravascular volume status
– Risk of complications due to inadequate oxygenation.
• Use Blood Components separately
• Promote blood conservation
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
• 1 in 5,000 – Transfusion Related
Acute Lung Injury (TRALI)
• 1 in 10,000 – Symptomatic
bacterial sepsis from platelet
• 1 in 40,000 – death from bacterial
sepsis - platelet transfusion
• 1 in 40,000 – ABO incompatible
transfusion per RBC transfusion
•1 in 40,000 – serious allergic
reaction per unit of component,
•1 in 82,000 – transmission of Hep B
•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
•1 in 7,800,000 – HIV transmission
•Post Transfusion Purpura
Intraoperative RBC Tx
Increases Risk of Low
Surgenor, et al. Circulation 2006;114:43-48
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
• Blood is expensive!
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%
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
How important is pre-op
• 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)
•Karkouti et al 1999Karkouti et al 1999
•Saleh et al, 2007Saleh et al, 2007
How Blood Conservation
• Preoperative evaluation & Risk
• Reduce need for blood transfusion
• Autologous Transfusion
Pre-op Hb optimization:
4-6 week lead time for assessment, screening and
• 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
• Pre operative autologous donation
• Erythropoietin therapy (Karkouti et al, 2005)
• ? Delay surgery
METHOD TO REDUCE BLOOD
USE IN SURGERY
* Surgery elective – Correct the Haemoglobin level.
Stop drugs that interfere
– 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
• Careful, precise
natural tissue planes
• Planned vascular control
• Use of clips, ligatures, and cautery
• Newer techniques (harmonic scalpel,
• NB. MINIMIZE BLOOD LOSS
• 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
Cell Salvage With Ultrafiltration
• ‘recycling’ of blood that
would otherwise be
• CV/ortho/trauma (Cochrane,
• Contraindicated in
• RBC’s suspended in NS
• May be acceptable to
• The Hemobag® and its TS3 tubing set
allows for Ultrafiltration both during the
case and at the end for Whole Blood
• 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.
• 1 to 2 units of patient’s blood withdrawn
at the beginning of a procedure
• Blood volume restored with
• Patient bleeds “thin blood” during
• Gets own blood back at the end
Collection and re-infusion
(transfusion) of the patient’s own
Blood or Blood components.
Why Autologous Blood
• 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
• Acute Normovolemic Hemodilution provides
fresh whole blood .
• Less dependant on the blood bank’s stock.
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
•Readily available in major haemorrhage
•Avoidance of immuno-suppression
• 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
Pre-surgical Autologous Blood Donation
• Best choice for patients with rare blood types or
• 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
• Blood is stored and kept for patient for re-
infusion during/after operation.
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.
Should Autologous Blood be
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
Role of Erythropoietin in
• Allow more units to be collected.
• Need two to more weeks to work.
Points to consider
• Surgeon and Anaesthetist
• Availability of allogeneic blood
• Which types of procedures: “ortho;
intestinal; clean operations”
• Public awareness
• 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…..
• Avoid Transfusion : medical and surgical
replacement fluids: crystalloids and non
plasma colloids over plasma
pharmacologic agents to reduce bleeding
• Autologous donation
• Minimize exposure to allogeneic
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
Beal, RW, 1976Beal, RW, 1976
Beal RW, 1976Beal RW, 1976
• 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