Lección inaugural: “Patient Blood Management: concepto, componentes e implementación” Prof A. Herrera “CURSO DE ACTUALIZACIÓN EN PATIENT BLOOD MANAGEMENT”. Taller CASTYM (Control Avanzado del Sangrado en Trauma y Cirugía Mayor). Tercera Edición

1. CURSOS EXTRAORDINARIOS de
VERANO 2018
PATIENT BLOOD MANAGEMENT
Prof. Herrera

2. ¿QUIÉNES ME HAN ENSEÑADO?
• Prof.Manuel Muñoz Dr. García Erce

3. ¿QUÉ ES PATIENT BLOOD
MANAGEMENT ?
• CAMBIO DE ESTRATEGIA Y DE MENTALIDAD
POR PARTE DEL CIRUJANO
• CLASICAMENTE : GRAN CIRUJANO-GRAN
INCISION . ACTUALMENTE CIRUGIA M.I.S
,CUIDADOS EN CAMPO OPERATORIO ,
HEMOSTASIA CUIDADOSA . PREPARACION
PRE-OPERATORIA
• SI SANGRA QUE LO TRANSFUNDAN
• ANESTESISTA : HAY SANGRE , PODEMOS
OPERAR

4. CAMBIOS
• AFORTUNADAMENTE HEMOS PASADO DEL
“ESTUDIO DOBLE CIEGO” A CONOCER LA
ERITROPOYESIS Y EL METABOLISMO DEL
HIERRO
• LA CIRUGÍA NO ES SOLO EL ACTO
QUIRÚRGICO
• A ESCUCHAR Y A APRENDER DE LOS ERRORES
• A TRABAJAR EN EQUIPO Y RESPETAR A LOS
OTROS ESPECIALISTAS

5. ¿POR QUÉ ES IMPORTANTE , ESTE
CAMBIO?
• C.O y T : Cirugía con importante sangrado entre 1.5-
2 l , superficies cruentas muy vascularizadas
• 20-40% Pacientes tienen anemia pre-operatoria .
Influencia en infección , calidad de vida ,
recuperación , mortalidad , estancia….

6. OTRAS ESPECIALIDADES
• CIRUGÍA CARDIACA
• CIRUGÍA ABDOMINAL
TUMORAL
• CIRUGÍA GINECOLOGICA
• CIRUGÍA TORACICA

7. TRANSFUSIÓN SANGRE
ALOGENICA
• PROBLEMAS CLINICOS , LOGISTICOS Y
ECONOMICOS
• REACCION HEMOLITICAS
• EDEMA DE PULMÓN
• SOBRECARGA CIRCULATORIA
• INFECCIONES
• INMUNOMODELACION
• ETC

8. PATIENT BLOOD MANAGEMENT
• CAMBIO DE MENTALIDAD , BASADO EN EL
CONOCIMIENTO
• ENSEÑANZAS POR EL HEMATOLOGO Y
ESPIRITU DE COLABORACION
• CAMBIOS DE MENTALIDAD DEL ANESTESISTA
• EQUIPO MULTIDISPLINAR INTEGRADO
• PERCEPCION DE BENEFICIOS
• ESCEPTICISMO CONVERSO
PREDICACION

9. 4 ESTRATEGIAS
• 1) USO DE CRITERIOS RESTRICTIVOS
DE TRANSFUSIÓN
• 2)ESTIMULACIÓN DE LA
ERITROPOYESIS
• 3) REDUCCIÓN DEL SANGRADO
• 4) TRANSFUSIÓN DE SANGRE
AUTÓLOGA

10. MEDIDAS A ADOPTAR
• IDENTIFICACION Y TRATAMIENTO DE LA
ANEMIA PRE-OPERATORIA
• CRITERIOS RESTRICTIVOS DE TRANSFUSION
• HEMOSTASIA INTRA-OPERATORIA .USO DE
AGENTES HEMOSTATICOS
• TRANSFUSION DE SANGRE HOMOLOGA
• AUTOTRANSFUSION INTRA Y POST-
OPERATORIA
• TRATAMIENTO ANEMIA POST-OPERATORIA

11. ANEMIA PRE-OPERATORIA
• MUY FRECUENTE
• 20-70% DE LOS PACIENTES
• IDENTIFICACIÓN DE LA
ETIOLOGÍA : FERROPENICA
,INFLAMATORIA O AMBAS
ASOCIADAS

13. EXAMEN PRE-OPERATORIO
• MINIMO : 1 MES
• PACIENTES EN ALTO PORCENTAJE CON
COMORBILIDADES , POLIMEDICADOS Y > 65 a
• EVALUACION CLINICA Y AJUSTE DE
MEDICACION
• HEMOGRAMA CON RETICULOCITOS ,
FERRITINA , SATURACIÓN DE TRANSFERRINA ,
PROTEÍNA C-REACTIVA , CREATININA Y
NIVELES DE VITAMINA B-12 Y FOLATOS

14. DIAGNOSTICO
• A.FERROPENICA: Sat.Trans. < 20%
Ferr.<30ng/ml,HCM <27pg
• A.T.C : Sat Trans<20% , Ferr.>100ng/ml .
P.C.R ,Creatinina ,Niveles de eritropoyetina
• A.MIXTA : Sat .Trans<20%, Ferr. 30-
100ng/ml,
A.T.C y ferropenia
* A.Macrocitica : Niveles de Vit.B12 y A .Folico
* A.Mielodisplasica o desconocida

15. ANEMIA
• SATURACIÓN DE TRANSFERRINA<20%
Ferritina <30 μg/l Ferritina Ferritina
+ HCM <27 pg 30 - 100 μg/L >100 μg/L
Anemia Anemia Inflamatoria Anemia Inflamatoria
Ferropénica + Ferropenia

16. PRE-OPERATORIO
• ANEMIA A.T.C o D.P.S.A : Hi . i.v
• Hi . Carboxi-maltosa : 1.000 mg/sem.
• Hi . Sacarosa : 600 mg/sem.
• rHuEPO . 40.000 U.I
• CORREGIR DEFICIT Vit B12 y A.FOLICO
• PERMITE DPSA Y EVITA TSA

17. ACTO QUIRÚRGICO
• ABORDAJE QUIRÚRGICO , TRATAMIENTO DE
LOS TEJIDOS
• HEMOSTASIA CUIDADOSA
• USO DE RECUPERADORES DE SANGRE
• USO DE SELLANTES
• ACDO. TRANEXÁMICO
• DRENAJES
• VENDAJE POST-OPERATORIO

18. ACTO QUIRÚRGICO
• CIRUGÍA MIS
10 cm

19. RECUPERADORES INTRA Y ATX
• RECUPERADORES INTRA : CIRUGÍAS CON
GRANDES EXPOSICIONES Y ABUNDANTE
SANGRADO : RECAMBIOS PROTESICOS
ESCOLIOSIS Y CIRUGÍA TUMORAL?
• ATX : PRE-OPERATORIO , INTRA-
OPERATORIO ,INTRA-OPERATORIO Y POST-
OPERATARORIO
• ORAL , INTRAVENOSO : BOLUS O
INFUSIÓN,TÓPICO

20. RECUPERADORES INTRA
• Horstmann WG, Slappendel R, Van Hellemondt GG,
Castelein RM, Verheyen CCPM. Safety of retransfusion of
filtered shed blood in 1819 patients after total hip or knee
arthroplasty. Tranfus Altern Tranfus Med. 2010;11:57-64.
• Muñoz M, Slappendel R, Thomas D. Laboratory
characteristics and clinical utility of post-operative cell
salvage: washed or unwashed blood transfusion. Blood
Transfus. 2011;9:248-61

21. ATX TÓPICO
• CIRUGÍA ARTROPLASTIA TOTAL DE CADERA ,
USO DE ATX TÓPICO : INYECTADO POR EL
DRENAJE PROFUNDO
• ESTUDIO DE 125 PACIENTES CON ATX TÓPICO
Y 129 PACIENTES GRUPO CONTROL
• DISMINUCIÓN DE LA TASA DE PACIENTES
TRANSFUNDIDOS : 63.2%
• NO COMPLICACIONES TROMBOEMBOLICAS

22. PERI-OPERATORIO
• CONTROL Hb . DETECTAR HEMODILUCION
• SANGRADO INTRA y POST-OPERATORIO y
PROCESO INFLAMATORIO : IL-1 / IL-6
PRODUCCION DE HEPCIDINA
• TRATAMIENTO : Hi . i.v , valorar uso
rHuEPO
• CRITERIO RESTRICTIVO TRANSFUSION : 7-8 gr
Hb . CRITERIOS CLINICOS
• RECUPERAR SANGRADO POR DRENAJES

23. RECUPERADORES POST-
OPERATORIOS
• Muñoz M, Iglesias D, Garcia-Erce JA, Cuenca J, Herrera
A, Martin-Montañez E, Pavia J. Utility and cost of low-
vacuum reinfusion drains in patients undergoing
surgery for subcapital hip fracture repair .A before
and after cohort study . Vox Sang. 2014 Jan;106(1):83-
91
• The subgroup of patients with admission Hb < 13
g/dl, the use of Bellovac ABT reduced postoperative
ABT rates (16% vs. 46%, for groups 2 and 1,
respectively; P = 0001)

24. CRITERIOS RESTRICTIVOS
• Transfusion theresholds and other strategies for guiding allogenic red blood cell
transfusion.Carson JL, Stanworth SJ, Roubinian N, Fergusson DA, Triulzi D, Doree C, Hebert
PC. Cochrane Database Syst Rev. 2016 Oct 12;10:CD002042. Review.
• Transfusing at a restrictive haemoglobin concentration of between 7 g/dL to 8 g/dL decreased the
proportion of participants exposed to RBC transfusion by 43% across a broad range of clinical
specialities. There was no evidence that a restrictive transfusion strategy impacts 30-day mortality or
morbidity (i.e. mortality at other points, cardiac events, myocardial infarction, stroke, pneumonia,
thromboembolism, infection) compared with a liberal transfusion strategy. There were insufficient data
to inform the safety of transfusion policies in certain clinical subgroups, including acute coronary
syndrome, myocardial infarction, neurological injury/traumatic brain injury, acute neurological
disorders, stroke, thrombocytopenia, cancer, haematological malignancies, and bone marrow failure.
The findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most
patients with haemoglobin thresholds above 7 g/dL to 8 g/dL.
• Brunskill SJ, Millette SL, Shokoohi A, Pulford EC, Doree C, Murphy MF, Stanworth S. Red blood cell
transfusion for people undergoing hip fracture surgery ..Cochrane Database Syst Rev. 2015 Apr 21;
(4):CD009699. doi: 10.1002/14651858.CD009699.pub2. Review
• We found low quality evidence of no difference in mortality, functional recovery or postoperative
morbidity between 'liberal' versus 'restrictive' thresholds for red blood cell transfusion in people
undergoing surgery for hip fracture. Although further research may change the estimates of effect, the
currently available evidence does not support the use of liberal red blood cell transfusion thresholds
based on a 10 g/dL haemoglobin trigger in preference to more restrictive transfusion thresholds based
on lower haemoglobin levels or symptoms of anaemia in these people

25. CRITERIOS RESTRICTIVOS
• Roubinian NH, Carson JL.Restrictive red blood cell transfusion strategies
appear safe in most clinical satting . Evid Based Med. 2015
Oct;20(5):170. doi:10.1136/ebmed-2015-110218
• Substantial progress has been made in generating data to make
evidence-based recommendations for red blood cell (RBC) transfusion.
Findings from clinical trials suggest that in most clinical settings, a
restrictive transfusion strategy, where RBCs are transfused once
haemoglobin levels fall below either 7 or 8 g/dL, does not impact
mortality compared with liberal transfusion where RBCs are transfused
when haemoglobin levels fall below 9–10 g/dL.1 This meta-analysis,
incorporating data from five recently published clinical trials, was used
to compare the overall risk of death and other adverse events of liberal
and restrictive transfusion strategies.

26. OTRAS MEDIDAS
• Adecuado soporte nutricional
• Reducción del número y/o volumen la extracciones sanguíneas con
fines diagnósticos (especialmente en críticos).
• Supresión, disminución de dosis y/o cambio de agente en paciente con
anticoagulación oral o tratamiento antiagregante plaquetario.
• Adecuado posicionamiento del paciente para evitar la congestión
venosa.
• Mantenimiento de la normotermia para evitar alteraciones de la
coagulación.
• Uso de fármacos que disminuyen el sangrado (e.g., ácido tranexámico
(ATX) , ácido épsilon aminocaproico (ACA)

27. FUNDAMENTAL

28. PERSONALIZAR
• Mirski MA, Frank SM, Kor DJ, Vincent JL,
Holmes DR Jr. Restrictive and liberal red cell
transfusion strategies in adult patients :
reconciling clinical data with best practice.
Crit Care. 2015 May 5;19:202
• Current evidence suggests that in many
clinical settings a restrictive RBC transfusion
strategy is cost-effective, reduces the risk of
adverse events specific to transfusion, and
introduces no harm

29. RESULTADOS
• Theusinger's study data . Transfus 2014; 12: 195-203.
• In conclusion, this study shows that the implementation of a PBM programme
for elective hip,knee, and spine surgery leads to a significant reduction of
immediate pre-operative anaemia, intra-operative RBC mass loss as well as the
blood volume loss, and transfusion needs

30. RESULTADOS
• Ten year follow up on Dutch orthopaedic blood‑ ‑
management (DATA III survey)
• M. C. Struijk Mulder · W. G. Horstmann ·‑
• C. C. Verheyen · H. B. Ettema. Arch Orthop Trauma
Surg. 2013
• The combined use of multiple blood-saving
methods is much more effective than a single
technique . With a blood management algorithm,
allogeneic red blood cell transfusions can be
reduced up to 80 %

31. RESULTADOS
• Cuenca J, García-Erce JA, Martínez F, Cardona R, Pérez-Serrano L, Muñoz M.
Preoperative haematinics and transfusion protocol reduce the need for
transfusion after total knee replacement ..Int J Surg. 2007 Apr;5(2):89-94. Epub
2006 Apr 27.
• RESULTS: Compared to those in Group 1, patients in Group 2 presented a lower
transfusion rate (5.8% vs. 32%, for Group 2 and Group 1, respectively; p<0.01)
• García-Erce JA, Cuenca J, Haman-Alcober S, Martínez AA, Herrera A, Muñoz M.
Efficacy of preoperative recombinant human erythropoietin administration for
reducing transfusion requirements in patients undergoing surgery for hip fracture
repair. An observational cohort study . Sang. 2009 Oct;97(3):260-7. doi:
10.1111/j.1423-0410.2009.01200.x.
• CONCLUSIONS: In anaemic hip fracture patients managed with perioperative
intravenous iron and restrictive transfusion protocol, preoperative administration
of rHuEPO is associated with reduced ABT requirements. However, appropriate
training, education and awareness are needed to avoid protocol violations and to
limit further exposure to ABT and ABT-related risks

32. RESULTADOS
• Muñoz M, García-Erce JA, Cuenca J, Bisbe E, Naveira E; AWGE (Spanish Anaemia Working
Group). On the role of iron therapy for reducing allogenic blood transfusion in orthopaedic
surgery .Blood Transfus. 2012 Jan;10(1):8-22. doi: 10.2450/2011.0061-11
• - Peri-operative intravenous iron reduces the frequency and volume of allogeneic blood
transfusion in orthopaedic and trauma surgery, and may hasten the recovery from post-
operative anaemia, while preserving iron stores. These effects seem to be increased by the
addition of a single dose of recombinant human erythropoietin.
• - Intravenous iron seems to decrease infection rate or mortality. Nevertheless, despite the
absence of definitive clinical data, intravenous iron should not be given to patients with
ongoing bacteraemia or iron overload.
•
• Muñoz M, Iglesias D, Garcia-Erce JA, Cuenca J, Herrera A, Martin-Montañez E, Pavia J.
Utility and cost of low-vacuum reinfusion drains in patients undergoing surgery for
subcapital hip fracture repair . A before and after cohort study . Vox Sang. 2014
Jan;106(1):83-91. doi: 10.1111/vox.12071.
• The use of Bellovac ABT reduced postoperative ABT rates (16% vs. 46%, for groups 2 and 1,
respectively; P = 0·001

33. RESULTADOS
• P.B.M ES COSTE-EFECTIVO
• MEJORA EL POST-OPERATORIO
• REDUCE EL NUMERO DE UNIDADES , SI SE
TRANSFUNDE
• MENOS INFECCION
• MENOS MORTALIDAD
• MENOR ESTANCIA

34. MUCHAS GRACIAS POR SU
ATENCION