1. There are several alternatives to blood transfusion for elective surgery that can minimize blood loss and need for transfusions, including erythropoietin therapy, IV iron substitution, adjusting pre-op medications and anesthesia techniques, and intraoperative cell salvage. 2. Effective techniques to reduce blood loss include hypotensive epidural anesthesia, acute normovolumic hemodilution, adjusting body temperature, and use of hemostatic agents. Newer blood substitutes including hemopure, perflubron and polyheme show promise but remain an attainable reality. 3. Autologous donation programs and cell salvage can collect and re-infuse a patient's own blood to

1. 1
BELLARY OBG SOCIETY
STONE CHARIOT :HAMPISTONE CHARIOT :HAMPI

2. Alternatives to blood-
transfusion
in
Elective surgery

3. Prof. (Capt.) Shankar.J.
• National subject expert - 2012 to 2014
• MCI Inspector (PG Faculty – OBG)
• PG Examiner for MD,DGO & DNB
• PG, UG Paper Setter
• Founder of Ballari OBG Society, 1998.
profcaptshankarj@gmail.com

4. Available Alternatives(Options)
1. Erythropoietin therapy
2. IV IRON substitution
3. Preop medication moderation
4. Hypotensive epidural anaesthesia
5. Body temperature adjustment
6. Intraoperative methods
7. Intra op cell salvage
8. Acute normovolumic haemodilution
9. Autologous blood transfusion
10. Blood substitute (Artificial blood)

5. Effective Blood substitutes
An attainable reality or Lost cause ?
Hemosol, hemopure, perflubron,
polyheme
Anaesthesiology 2006; 105(1); 198

6. Rule of 10:30
Haemoglobin 10gm%
Haematocrit 30%
Currently
 7-9gm% widely accepted
 6-10 gm%- packed cells
 Below 6-morbidity
Cell Salvage for minimising perioperative allogenic blood
transfusion-2010,Cochvane database, systemic review(4) ID 001888

7. Erythropoietin
Glycoprotein hormone
Precursor of erythropoiesis
Elevates haematocrit
Risk of thrombosis
Dose 100 IU/kg Twice weekly X 2weeks

8. Erythropoietin
Contraindications
Pregnancy
Lactation
Hypertension/ PIH
h/o thromoembolism
Neocytolysis
cost effectiveness of cell salvage and ailternative
methods of minimising blood transfusion, A systemic
review Health.technol.Assess, 2006

9. IV Iron Substitution
Iron is 5x more effective
Iron dextran : risks , reactions
Iron sucrose
Ferric carboxy maltose complex (FCM)
Well tolerated
Decrease reaction, infection and mortality
Works synergestically with erythropoietin

10. Ideal parental iron preparation

11. Various parenteral iron preparations

12. Pre op medications
Aspirin, clopidogrel, Vit K anticoagulants
Risk of bleeding
Antiplatelet drugs 2-20%
Aspirin + antiplatelet drugs: 30-50%
Stop aspirin if expected blood loss ≥2L
NSAIDs stop 24hrs ahead
Selective COX 2 inhibitors better
Platelet aggregation, prolonged BT
Intra op blood loss

13. Hypotensive Epidural Anaesthesia
Blood loss reduced by 25-40%
Least blockage proximal T2
Dense block of cardio-acceleratory
fibres of thoracic sympathetic chain
Low dose noradrenaline drip
Mean arterial pressure
MAP reduced to 50mm Hg
Post op drainage reduced
Nassen.S et al, 2008
“Vascular trauma”, in war surgery in Afghanistan and Iraq; a
series of cases 2003-2007 United states army publication

14. Body temperature manipulation
150
C rise =50% more blood loss
Optimise coagulation pathway
Fibrinogen, prothrombin couple, protein-C
Thrombo - elastometry
Cause of hemorrhage
Clotting process
Fibrinolysis
Platelet function

15. Acute Normovolumic Hemodilution
Blood withdrawn just before surgery
Replaced with colloids- crystalloids
Patient friendly
Economic
Easy to perform
Used up 8hrs post op

16. Acute Normovolumic Hemodilution
V = EBVX Ho-Hf
Hav
V - Volume to be removed
EBV - Estimated blood volume
Ho - Initial Haematocrit
Hf - Desired Haematocrit
Hav - Average Haematocrit
(mean of Ho and Hf)
•Pre op Hb should be 11gm and above
•ANH to be done by Anaesthesiologists

17. Thrombotic agents
Platelet gel
• Platelet derived growth factor
• Antibacterial (myeloperoxidase)
Fibrin sealants (glue)
• Produce stable clot
• 1cc glue covers 10cm2
wound area

18. NovoSeven®
Mode of Action
Eptacog alfa (activated)
Tissue factor (TF)/FVIIa,
or TF/rFVIIa interaction,
is necessary to initiatiate
haemostasis
At pharmacological
concentrations rFVIIa
directly activates FX
on the surface of locally
activated platelets.
This activation will initiate
the ”thrombin burst”
independently of FVIII
and FIX.
This step is independent
of TF.
The thrombin burst leads
to the formation of
a stable clot

19. Autologous cell capture/Transfusion
• Direct (filtered via gauze) cell salvage
• Indirect (mechanically washed) cell savage
• Drain site collection
• ? Hypotension, ? Pyrexia. ?Allergy
Contraindication
• Peritoneal contamination
• Tumour cell surgery

20. Pre op autologous blood donation
Collect 1-2 units blood
4-6 wks ahead of surgery
4 weeks of haematologic recovery
Can be used pre op/ post op
45% wastage
Declining popuarity
Cell free Hb based blood substitutes and associated
risks; A meta analysis ,JAMA 2008; 299(19) 2304-2312

21. Artificial Blood
Blood pharming
Growing red cells from haematopoietic stem cell
Hemoglobin Based Oxygen Carriers
(HBOCS)
Perflurocarbons (PFCs)
Artificial blood T. Bernier, Biomedical engineering,
University of Rhode Island, BME-281 26 Nov 2012

22. ARTIFICIAL BLOOD CELLS

23. THE QUEST TO EXPLORE
NEVER ENDS …

25. DISCLAIMER
The contents of this presentation are for academic
purposes only
The references quoted are not in any order
The author openly accepts comments and critics
J. SHANKAR
Professor in OBG
VIMS (Govt medical College)
Ballari- Karnataka

26. 26
SAFE MOTHERHOOD
ACHIVEMENT TO FAMILY, ASSET TO COMMUNITY

27. FURTHER READING…
WWW.ncbi.n/m.nih.gov/pmc/articles/pmc2738310/
www.pharmainfo.net/artificial-blood-current-review -
United States by MPA Kulkarni.
http://science.howstuffworks.com/innovation/everyday-
innovations/artificial-blood.htm
Perioperative blood conservation statergy : canadian
health services guidelines- updated 2009
Indian hemaetology and blood transfusion society
guidelines- current recommendations,2012
Internet sources(alternate to blood transfusion,artificial
blood,autologous donors…)

28. THANK YOU
profcaptshankarj@gmail.com