This document discusses various approaches to predicting transfusion requirements before surgery. It describes strategies such as using the type of surgery and patient characteristics to estimate risk, as well as score systems that assign points to risk factors to predict probability of transfusion. It also discusses mathematical models that calculate predicted red blood cell loss based on measured patient variables and estimate transfusion needs based on the difference between predicted and tolerated blood loss. The document evaluates several studies on the accuracy of these different predictive approaches.
Six angiographic indicators of large thrombus burden by
Yip and colleagues,depending upon the angiographic morphology are
features indicated “high-burden thrombus formation”:
1. A cut-off pattern of occlusion
2. Accumulated thrombus proximal to the occlusion
3. A reference lumen diameter of the IRA of >4.0 mm
4. An incomplete obstruction with an angiographic thrombus with
the greatest linear dimension more than 3 times the reference
lumen diameter
5. The presence of floating thrombus proximal to the lesion
6. A persistent dye stasis distal to the occlusion
Dr. Sharfuddin Chowdhury: Tranexamic Acid administration in traumaShakila Rifat
Time since injury is the major factor in preventing Tranexamic Acid (TXA) use in the trauma setting: An observational cohort study from a major trauma centre in a middle income country.
SOLACI Chile Congress 2011. Dr.Ajay Kirtane. Drug-Eluting Stents for Multivessel PCI: Indications and Outcomes. Find more presentations on the web site: www.solaci.org/
Prothrombin Time/International Normalized Ratio and Thrombelastography Discor...Arthur Stem
The utility of conventional coagulation assays, such as the prothrombin time/international normalized ratio (PT/INR), for assessing coagulopathy in severely injured patients has been questioned. This is particularly true in the setting of discordant results against thrombelastography (TEG). Thrombin generation (TG) offers a unique mechanism to analyze discordances between PT/INR and TEG, given its global assessment of the end-product of the coagulation cascade. The ability to correlate PT/INR with TG is additionally important, as recent literature suggests transfusion of fresh frozen plasma based on an elevated PT/INR alone is linked to increased mortality in the setting of traumatic brain injury. We hypothesize that PT/INR reflects thrombin generation but, in the setting of a normal TEG, does not reflect altered hemostatic capacity.
Bleeding in paediatric surgery - case presentationsscanFOAM
A talk by Birgitta Romlin at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Six angiographic indicators of large thrombus burden by
Yip and colleagues,depending upon the angiographic morphology are
features indicated “high-burden thrombus formation”:
1. A cut-off pattern of occlusion
2. Accumulated thrombus proximal to the occlusion
3. A reference lumen diameter of the IRA of >4.0 mm
4. An incomplete obstruction with an angiographic thrombus with
the greatest linear dimension more than 3 times the reference
lumen diameter
5. The presence of floating thrombus proximal to the lesion
6. A persistent dye stasis distal to the occlusion
Dr. Sharfuddin Chowdhury: Tranexamic Acid administration in traumaShakila Rifat
Time since injury is the major factor in preventing Tranexamic Acid (TXA) use in the trauma setting: An observational cohort study from a major trauma centre in a middle income country.
SOLACI Chile Congress 2011. Dr.Ajay Kirtane. Drug-Eluting Stents for Multivessel PCI: Indications and Outcomes. Find more presentations on the web site: www.solaci.org/
Prothrombin Time/International Normalized Ratio and Thrombelastography Discor...Arthur Stem
The utility of conventional coagulation assays, such as the prothrombin time/international normalized ratio (PT/INR), for assessing coagulopathy in severely injured patients has been questioned. This is particularly true in the setting of discordant results against thrombelastography (TEG). Thrombin generation (TG) offers a unique mechanism to analyze discordances between PT/INR and TEG, given its global assessment of the end-product of the coagulation cascade. The ability to correlate PT/INR with TG is additionally important, as recent literature suggests transfusion of fresh frozen plasma based on an elevated PT/INR alone is linked to increased mortality in the setting of traumatic brain injury. We hypothesize that PT/INR reflects thrombin generation but, in the setting of a normal TEG, does not reflect altered hemostatic capacity.
Bleeding in paediatric surgery - case presentationsscanFOAM
A talk by Birgitta Romlin at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Debemos cambiar el paradigma! Para la reanimación del paciente politraumatizado en shock hemorrágico, debemos ser tremendamente cuidadosos y conservadores con el aporte de cristaloides o coloides!
Shock hemorrágico en el paciente politraumatizado, no debe tratarse con fisiológico, Ringer o gelatinas! Mientras más de estos productos reciban, peor pronóstico tiene nuestro paciente.
En este contexto, no debe administrarse nada que no aporte a transportar oxigeno o que colabore con la coagulación!
No más reanimación tipo ATLS, donde se recomendaba 2lt de suero fisiológico y solicitar exámenes para evaluar coagulación y ver necesidad de productos sanguíneos... NO MÁS!!!
Conceptos Claves:
- politraumatizado + shock = hemorrágico (abdomen, tórax, extremidades)
- control anatómico del sangrado es vital!
- no reanimar contra presión arterial, reanimar contra perfusión
- si necesita volumen; aportar fluidos que aporten a la coagulación o a transportar oxígeno
- recuerden calcio y ácido tranexámico
- hosp pequeño, o 1rio o 2ndario: esfuerzos en traslado
- hospital cuidado definitivo: protocolo transfusión masiva, hipotensión permisiva, cirugía control de daño, UCI
We studied the review article about Platelet Transfusion: And Update on Challenges and Outcomes, which was published in the Journal of Blood Medicine in January 2020. The journal has pointed out some common questions which clinicians need to face during transfusion. We not only organized the key points of this article but also reviewed the Nelson textbook, which provides the concept of platelet transfusion in pediatrics. Hopefully, it can be helpful to everyone who interested in this field.
Should patients with refractory anemia with excess blasts or those with oligoblastic AML receive induction therapy prior to allogeneic transplantation?
Yes: Suporn Chancharunee, MD
No: Nina Shah, MD
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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2012 anemo inghilleri - inquadramento preoperatorio del fabbisogno trasfusionale
1. Inquadramento preoperatorio
del fabbisogno trasfusionale
Giovanni Inghilleri
Servizio di Immunoematologia
e Medicina Trasfusionale
A.O. Fatebenefratelli e Oftalmico - Milano
2. In recent years, questions have been raised
about clinical outcomes after allogeneic
transfusion……In addition to these clinical
issues, economic questions about transfusion
are also being asked.
3. Strategies for allogeneic blood conservation
· Preoperative correction of anaemia
· Preoperative autologous blood donation
· rHuEPO stimulation of erythropoiesis
· Ultrasonic scalpel, argon beam coagulation
· Use procoagulant drugs
· Use of topical glues
· Acute normovolemic haemodilution
· Hypervolemic haemodilution
· Intra and post-operative blood salvage
· Use of blood substitutes
4. How Well Can Transfusion
Requirements Be Predicted?
Approaces to identify Pts at risk of requiring
blood Tx / to define Pt’s Tx requirements
1. Type of surgery (MSBOS) + some
Pts related parameters
2. Score systems
3. Mathematical approaches
5. Type of surgery (MSBOS) + some
Pts related parameters
• Much of the variability in transfusion need for a
given surgery lies with patient variables and not
with surgical variables.
• When performed by an experienced surgeon, a
given type of surgery will result in similar blood
loss for most patients, despite significant
differences in patient blood volume or starting
hematocrit.
Palmer T, Anesth Analg 2003;96:369 –75
6. • Aim of the study:
to analyse the clinical factors that would be useful in
predicting patients who would require blood transfusion.
• Evaluated parameters were:
age, gender, body weight, operation, pre-op Hb, actual blood
loss, postop Hb level, whether a patient developed symptoms
of anaemia (e.g. shortness of breath, dizziness or weakness),
whether transfusion was administered and, if so, the number
of units transfused.
• There were no autologous donations.
7. • The univariate analysis revealed a significant
relationship between postoperative blood Tx and pre-op
Hb levels (P=0.001), weight (P= 0.019) and age
(P=0.018) and not gender (P=0.47).
• However, multivariate analysis identified a significant
relationship only between the need for transfusion and
the pre-op Hb (P=0.0001) with weight (P=0.169) and age
(P=0.058) being discounted as significant factors.
8. Univariate analysis
relationship between Tx and
•Preop Hb (p = 0.0001)
•Duration of surgery (p= 0.0001)
•Weight (p= 0.002),
•Height (p = 0.019),
•Gender (p=0.0056).
Multivariate analysis
relationship only between TX and
•Preop Hb (p = 0.0001)
•Weight (p = 0.011);
% Pts transfused
• Hb < 13 g = 69%
• Hb 13-15g = 36%
• Hb > 15 g = 13%
9. Type of surgery (MSBOS) + some Pts related parameters
Cardiac Surgery
Besides preop Hb a number of clinical and surgical parameters
significantly correlate with TR (Shehata N et al Vox Sang 2007).
Magovern et al. (Ann Thorac Surg 1996) in 2000 CABG:
emergency operation, cardiogenic shock, urgent operation, catheterization-induced
coronary occlusion, low left ventricular function, low RBC mass, low body mass
index, age > 74 years, female sex, peripheral vascular disease, renal dysfunction,
redo operation, diabetes and low serum albumin.
Parr et al., J Cardiothorac Vasc Anesth 2003 in CABG pts:
increased age, preop. creatinine, low body surface and preop Hct, operative
emergency, the lowest T°on CPB and the duration of CPB.
No association for gender and prolongation of coagulation tests.
Moskowitz et al., Ann Thorac Surg 2004 in 307 CABG pts
Preop creatinine, type and the complexity of the operation (n° of vessels) and the
urgency of surgery. Moreover, the authors identified a diminished RBC mass as
one of the strongest predictors of transfusion
10. Prospective observational study in consecutive patients
undergoing primary THA or TKA. N=533 N=86 N=89
Transfusion Policy:
Pts with Hct > 39%: No PABD or EPO
Pts with Hct 37 – 39%: PABD 2 units
Pts with Hct < 37%: EPO
Results
In the group with Hct > 39% (533 out 708
pts) only 7% received allogeneic
transfusion
11. How Well Can Transfusion
Requirements Be Predicted?
Estimation of Tx requirement bbaasseedd oonn ttyyppee ooff
ssuurrggeerryy aanndd ssiinnggllee ppaattiieenntt ccoorrrreellaatteedd vvaarriiaabbllee
• Simple;
• Criteria defined in each centre;
• Most relevant parameters Hb and RBCs
mass;
• Effective in identifying Pts not requiring
Tx support;
• Not effective to define Tx requirements
(n° of units transfused).
12. British Journal of Surgery 2007; 94: 860–865
Methods: Data from 480 Pts who underwent
hepatic resection were analysed. The data set
was split randomly into a derivation set of
two-thirds and a validation set of one-third.
Univariable analysis was carried out to
determine the association between clinico-pathological
factors and blood transfusion.
Significant variables were entered into a
multiple logistic regression model, and a
transfusion risk score (TRS) was developed.
The accuracy of the system was validated by
calculating the area under the receiver–
operator characteristic (ROC) curve.
Univariable predictors of blood transfusion
Parameter P value
Male sex 0,189
Age >65 years 0,351
Associated co-morbidities 0,183
Cardiopulmonary disease 0,784
Diabetes 0,891
Cirrhosis 0,085
Weight >70 kg 0,586
Pathology 0,035
Neoadjuvant chemotherapy 0,309
Largest tumour >4 cm <0.001
Previous liver resection 0,353
Exposure of vena cava <0,001
Non-anatomical resection 0,936
Bilobar distribution of tumours 0,355
Multiple resections 0,332
Extent of liver resection 0,001
Associated procedures <0,001
ASA score >2 0,414
Haemoglobin <12,5 g/dl <0,001
Platelet count <250 × 109/l 0,390
PT-INR >1 0,008
Albumin <40 g/dl 39 ( 0,001
ALT >60 units/l 30 0,339
Total bilirubin >1,2 mg/dl 0,389
GGT >70 units/l 0,008
13. British Journal of Surgery 2007; 94: 860–865
Calculated area under the
curve was 0,89 indicating
good discrimination.
N° of units of blood transfused
correlated significantly with
the TRS.
14. Anesth Analg 2004; 99: 1239-44
Scores for each variable are added
together.
The predicted risk of allogenic Tx
based on total scores is as follows:
• score of 0–100, 10% or less;
• score of 100 –150, 10% –
30%;
• score of 150 – 200, 30%–50%;
• score more than 200, 50%.
Validation Set (934 patients)
Score % Pts in
this group
% of Pts
transfused
0-100 46 13
100-150 31 33
150-200 14 44
> 200 9 64
15. 235 Pts in derivation set; 125 Pts in validation set.
predictors significantly associated with
homologous RBC transfusion (P 0.05) in the
multivariable analysis were
Adjusted
odds ratio
4.9
6.9
6,7
19.9
Individual probability by score value:
0 = 0%; 1 = 7%; 2 = 19%; 3 = 54%; >4 = 90%
Results
Discriminating capacity of the score was
0.86 in the receiver operating
characteristics in the derivation sample and
0.83 in the validation sample.
Observed Tx rates in the validation set and
individual probabilities of RBC Tx from the
score were well correlated
(y= 0.98x+0.04; P < 0.0001).
The score was also correlated with the n° of
RBC units Tx Spearman 0.61; P < 0.0001).
Individual probability by score value:
0 = 0%; 1 = 4%; 2 = 35%; 3 = 64%; >4 = 88%
16. How Well Can Transfusion
Requirements Be Predicted?
Estimation of Tx requirement bbaasseedd oonn SSccoorriinngg
SSyysstteemmss
• Simple but require knowledge in statistics;
• Parameters and their weight must be
defined in each centre;
• Effective in defining the probability for a
Pts to requiring Tx support;
• Not effective to define Tx requirements
(n° of units transfused).
17. Mathematical approaches to Tx requirement
prediction
Define transfusion requirements taking into account
measured value of the parameters that determine TR
TTrraannssffuussiioonn RReeqquuiirreemmeenntt
RReedduuccttiioonn ooff TToottaall
BBlloooodd VVoolluummee
((BBlloooodd LLoossss))
TToolleerraatteedd BBlloooodd LLoossss
((CClliinniiccaall CCoonnddiittiioonnss ++
TToottaall BBlloooodd VVoolluummee))
HHbb rreedduucc
VVooll ooff BBlloooodd
VVooll ooff RRBBCC
HHbb rreedduucc
VVooll ooff BBlloooodd
VVooll ooff RRBBCC
18. A prospettive randomized trial of the surgical blood order
equation for ordering red cells for total arthroplasty patients.
Nuttall GA, Santrach WC Ereth MH et al. Transfusion 1998; 38: 828-33
• SBOE used to calculate the n° of RBCs units to
order, as follows:
Hb lost – (preop Hb – min HHbb)) == UUnniittss ttoo oorrddeerr
• Hb lost for THR previously measured: 3.7±1.7
• The SBOE system
– Exactly matched n° of units ordered with transfused
in 58%;
– Ordered more RBCs units than transfused in 19%
– Underordered RBCs units in 23%
19. Surgical blood order equation in femoral fracture surgery.
Kajja I, et al Transfusion Medicine 2011; 21: 7-12
• SBOE vs current order method in a case-control
study in homgeneous group of pts (n=62 each)
• SBOE used to calculate the n° of RBCs units to order, as follows:
Hb lost – (pre Hb –– MMiinn HHbb)) == UUnniittss ttoo oorrddeerr
• Hb lost for FF previously measured: 3.3±1.56
• Overall accuracy:
SBOE= 65,3%; Unaided ordering= 34,7%
20. Algorithm to help the choice of the best transfusion
strategy.
Mercuriali F, Inghilleri G Curr Med Res Opin 1996;13:465–78
Transfusion need =
predicted RBC loss - tolerated RBC loss
RBCs loss = Circulating RBC mass reduction (from presurgery
to postoperative day 5) plus the volume of RBC transfused
=PBV x (Hctpreop - Hctday 5 postop) + mL RBC transfused
Tolerated RBC loss =Volume of RBC loss to reach an
accepted minimal Hct value (according to clinical condition)
=PBV x (Hctbaseline- Hctmin acceptable)
21. Study 1
• At the preoperative anesthesia
evaluation the Pt’s estimated RBC
reserve was calculated and compared
with estimated loss (using Mercuriali &
Inghilleri formulas)
• The median RBC loss was previously
estimated to be 538 mL for THA
(range, 100–1212 mL) and 693 mL for
TKA (range, 272–1535 mL).
• PABD was indicated if RBC reserve
was < 800 mL (THA) or < 1000 mL
(TKA).
N° of Pts evaluated = 182
Pts with no expected Tx
requirement 91
Pts with no expected Tx
req. but Tx 17 (19%)
Autologous units
collected 172
Auto units Tx 93
Auto units wasted 79 (45%)
22. “Metodo per la definizione preoperatoria del fabbisogno trasfusionale nel paziente chirurgico.
Valutazione per un suo utilizzo nella selezione dei pazienti in cui adottare strategie alternative alla
trasfusione di sangue allogenico”
PROGETTI PIANO SANGUE 2008 REGIONE LOMBARDIA
Obbiettivi
verificare l’efficacia del metodo proposto nel prevedere il fabbisogno
trasfusionale di pz sottoposti ad intervento di chirurgia ortopedica maggiore
e la sua idoneità ad essere utilizzato per selezionare i pz in cui è
appropriato il ricorso tecniche alternative alla trasfusione di sangue;
Pazienti
906 Pz: PTA, PTG ed EndoPTA - Ist. Ortop.G. Pini (nov 07 - ott 08)
1° fase: Def perdite = 484 pz; 2° fase Valid. Mod. = 422
Pz
Ipotesi valutata
valore di perdita attesa = valore mediano per intervento e sesso
PTA : M = 850mL; F = 630mL . PTG M = 800 mL F = 670 mL
Hb minima accet: 9 g/dL x età < 80; 9,5 g/dL x età > 80 anni
23. “Metodo per la definizione preoperatoria del fabbisogno trasfusionale nel paziente chirurgico.
Valutazione per un suo utilizzo nella selezione dei pazienti in cui adottare strategie alternative alla
trasfusione di sangue allogenico”
PROGETTI PIANO SANGUE 2008 REGIONE LOMBARDIA
valore di perdita attesa = valore mediano per tipo intervento e sesso
PTA : M = 850mL; F = 630mL . PTG M = 800 mL F = 670 mL
Fabbisogno trasfusionale previsto
NO (Fab Neg) Si (Fab Pos) Totale
Supporto Tx
NO o 28 45 73
SI 3 128 131
Totale 31 173 204
Valore 95% CI
Prevalenza supporto Tx 64,2% 57,2% 70,8%
Sensibilità 97,7% 93,5% 99,5%
Specificità 38,4% 27,2% 50,5%
Valore Predittivo Positivo 74,0% 66,8% 80,4%
Valore Predittivo Negativo 90,3% 74,2% 98,0%
Accuratezza 76,47
24. Mathematical approaches to Tx requirement
prediction
Critical points
Which value utilize as “predicted blood loss”.
Large database for defining RBCs loss statistics.
To have adequate IT support to collect data.
Continuous updating of database and statistics
25. • Analysis of patients undergoing major non-cardiac surgery in 2008
from The American College of Surgeons’ National Surgical Quality
Improvement Program database.
• 227 425 patients, of whom 69 229 (30,44%) had preop anaemia.
• After adjustment, postoperative mortality at 30 days was higher in
patients with anaemia than in those without anaemia (odds ratio
[OR] 1,42); this difference was consistent in mild anaemia (OR 1,41)
and moderate-to-severe anaemia (OR 1,44).
• Composite postoperative morbidity at 30 days was also higher in
patients with anaemia than in those without anaemia (adjusted OR
1,35), again consistent in patients with mild anaemia (1,31) and
moderate-to-severe anaemia (1,56).
26.
27.
28. Predicting Blood Transfusion Requirements in
Surgical Patients
Conclusions
Different strategies to predict transfusion requirement
in surgical patients are currently available;
The choice of the strategy to be used depend on the
required precision and the intended use;
Reliable predictions must be based on accurate
analysis of the specific centre experience
Collaboration between different specialists involved in
the transfusion process is mandatory
Evaluation and correction of preoperative anemia
should be the first topic of a PBM program.
29. Maximum Surgical Blood Order Schedule
(MSBOS)
• In the 1970s, Friedman et al. proposed the use of
MSBOS as a way to limit outdating risk.
• The MSBOS guidelines are widely accepted and have
been repeatedly shown to decrease unnecessary
cross-matching and wastage.
• MSBOS recommends that
– RBCs units should be cross-matched only for
patients undergoing surgery with a high likelihood
of blood transfusion
– the n° of units x-matched should be twice the
median requirement for that surgical procedure
(cross-match-to-transfusion [C:T] ratio of 2:1).
30. Maximum Surgical Blood Order Schedule
(MSBOS)
• The MSBOS methods introduced the concept that
prediction should based on specific hospital
experience.
• It takes into account only “surgical variables” and
specifically the type of surgery. Patient-correlated
variable are not considered.
• Main limit is the inability to accurately predict,
for a given surgery, which patients are likely to
receive a blood transfusion.
31. Predicting Blood Transfusion Requirements in
Surgical Patients: Clinical Role
• To optimize blood inventory
management;
• To make the best use of
alternative strategies to
allogeneic blood;
32. Anesth Analg 2004; 99: 1239-44
Methods
• Univariate analysis performed to look for associations
between allogeneic Tx and each of the predictor variables.
• Predictor variables (known before surgery) showing a
significant relationship (P 0.05) were considered for
inclusion in the regression modelling process.
• The odds ratio for Tx for each predictor variable
was multiplied to yield an arithmetically convenient
integer, and these new covariates were used to create a
scoring system.
• The scores were categorized into 4 groups (transfusion
risk of 10% or less, 10%– 30%, 30% –50%, and 50%).
33. Mercuriali F, Inghilleri G. Proposal of an algorithm to
help the choice of the best transfusion strategy.
Curr Med Res Opin 1996;13:465–78
TToottaall EEssttiimmaatteedd RRBBCC LLoossss
cRBCsVpresurgery - cRBCsVday 5 postop + mL RBC transfused
Where
cRBCsV = PBV x Hct
PBV (predicted blood volume) =
Female = 0.3561 x height (m)3 + 0.03308 x weight (kg) +
0.1833
Male = 0.3669 x height (m)3 + 0.03219 x weight (kg) +
0.6041
mL RBC transfused = mL PAD RBC Tx + No of allogeneic
units Tx x 200 mL + mL of salvaged RBC
34. Mercuriali F, Inghilleri G. Proposal of an algorithm to
help the choice of the best transfusion strategy.
Curr Med Res Opin 1996;13:465–78
Transfusion requirement expressed in mL of RBCs
Difference between predicted and tolerated
RBC loss
When a negative figure is obtained:
PABD or EPO not indicated (type and screen +
stand by intraoperative salvage)
When a positive figure is obtained:
The figure represents the transfusion need
expressed in mL of RBCs