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Dafydd Thomas on Blood Conservation
The document discusses blood conservation strategies in transfusion medicine, highlighting the importance of patient blood management (PBM) principles to optimize and minimize the use of allogeneic blood. It emphasizes integrating transfusion alternatives, preoperative assessment, and planning to improve patient outcomes while addressing potential risks associated with blood transfusions. The author, Dafydd Thomas, advocates for a paradigm shift in transfusion practices, focusing on the patient's needs and safety over the traditional product-centric approach.
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Dafydd Thomas on Blood Conservation
- 1. Blood Conservation Overview DafyddThomas Consultant in ICM Welsh Blood Service Chair NATA Chair SHOT Steering Group Past President BBTS
- 2. Declaration of Interests •Noconflicts •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. Transfusion Alternatives • Futureblood 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. Transfusion alternatives Even ifyou wish to continue using allogeneic blood someone needs to cut their use so you can continue if supply demand is an issue
- 5. Transfusion alternatives? • Otherways of treating anaemia • Transfusion needs to become last resort • Integrate alternatives in main stream practice • Integrate in blood services planning
- 7. Reducing risks ofallogeneic 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
- 9. Attendance of WBSdonors 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
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- 12. 6th Seminar ofthe Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
- 13. 6th Seminar ofthe Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
- 14. 6th Seminar ofthe Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
- 15. The Journal ofThoracic and Cardiovascular Surgery Volume 142, Number 2 249.e1
- 16. The Journal ofThoracic and Cardiovascular Surgery Volume 142, Number 2 249.e1
- 17. The Journal ofThoracic and Cardiovascular Surgery Volume 142, Number 2 249.e1
- 18. 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
- 21. Inter-Hospital Variability ofTransfusion 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
- 22. The Red CellStorage Lesion: Structural Changes. 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
- 23. 6th Seminar ofthe Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
- 24. Better planning Pre-operative preparation Assessingreserve Stopping drugs Warfarin Aspirin Clopidogrel Pre-operative Association
- 25. Better planning Pre-operative preparation Assessingreserve Stopping drugs Warfarin Aspirin Clopidogrel Starting drugs Iron Folate EPO Aprotonin Group and Save Pre-operative Association
- 26. What is PatientBlood 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;
- 27. How to bestmanage the patients own oxygen carrying capacity….. ….to minimise dependence on the blood bank Author of ‘Peri-operative Blood Transfusion’
- 28. PBM = goodclinical 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.
- 29. PBM = goodclinical 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
- 32. Confirms an observationby 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
- 33. Intravenous versus oraliron 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
- 34. Intravenous iron andrecombinant 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
- 35. Intravenous iron andrecombinant 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
- 36. Update on adversedrug 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
- 37. British Journal ofO&G Online early Sept 2006
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- 41. Preoperative haemoglobin assessmentand 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
- 42. Pharmacological Options • Desmopressin(DDAVP) • Antifibrinolytics – Epsilon aminocaproic acid – Tranexamic acid • Serine Protease Inhibitors – Aprotinin • Thrombin Generators – rhVIIa
- 43. Meta-analysis of LysineAnalogues in Heart Surgery Control Aspirin 1o vs Repeat Laupacis et al Anesth Analg 1997;85:1258-1267
- 45. Tranexamic Acid inKnee (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
- 46. Sunny Dzik SHOT2011
- 47. Sunny Dzik SHOT2011
- 48. Better planning Pre-operative preparation Assessingreserve Stopping drugs Starting drugs Operative haemostasis Intra-operative cell salvage Post-operative cell salvage
- 50. Surgical Control ofBleeding • Digital pressure • Sutures and clips • Thermal coagulation • Topical hemostatic agents • Organ wrapping- mesh net
- 51. Methods of achievinghemostasis • 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
- 52. • 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
- 53. Fibrinogen-based products • Liquid FibrinSealant -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
- 54. 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
- 55. Oxidized Regenerated Cellulose • Forcontrol 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
- 56. Nonsurgical Interventions to AchieveHemostasis • Pneumatic antishock garment • patients with pelvic and lower extremity fractures • hypovolemic shock • Angiographic embolization • Temporary balloon occlusion
- 57. External pelvic fixator – fracturesassociated with a diastasis of the pubic symphysis (“openbook” pelvic fractures)
- 58. Some things don’tchange • 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.
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- 61. Cell salvage inemergency 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
- 62. Grade IV Livertrauma 6th Seminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
- 63. Intra-operative Blood Requirements 60 Units 45 Allogeneic Autologous Blood 30 15 0 16F 31M 23M 19M 6thSeminar of the Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
- 64. 6th Seminar ofthe Hellenic Blood Transfusion Society-March 13-14, 2009, Athens-Greece
- 65. MSBOS & CellSaved 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
- 66. Early coagulopathy inmultiple 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
- 67. 3 2.5 2 1.5 1 0.5 pH 0 Relative Rate ofFVIIa 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
- 68. Wolberg et alJ 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
- 71. Tissue Oxygen partialpressure, 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
- 73. O2 – consumption(VO2) !T iss ue Hy po xia ! Limit of Hemodilution „critical“ DO2 O2 – delivery (DO2)
- 75. Transfusion requirements incritical 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
- 76. Transfusion triggers: havewe 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
- 83. Newest –Great Datafrom Virginia Study is being widely heralded!
- 84. Tx Reduction ImprovedOutcomes! This program saved the state of Virginia $49,000,000.00
- 88.