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9/15/2011 1 How to avoid unnecessary blood transfusion

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9/15/2011
Chines e charac ter of blood
“The sacrifice on the plate”
How to avoid unnecessary
blood transfusion?:
perioperative view
รองศาสตราจารยวราภรณ เชื้ออินทร
ภาควิชาวิสัญญีวทิ ยา
ประชุมวิชาการประจําป 2553 ครั้ง ที่ 26 คณะแพทยศาสตร
เมื่อ 13 ตุลาค ม 2553 ณ หองบรยาย 4
คณะแพทยศาสตร มหาวิท ยาลัยขอนแกน
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Indications for Blood Transfusion*
Physiologic Transfusion trigger
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In OR or in ICU
PO or in Ward
Relative hypotension (MAP < 70 to 80%of baseline or 60 mm Hg)
Yes
Yes
Relative tachycardia (rate > 120 to 130% to baseline or
110 to 130 beats/min)
New ST-segment depression > 0.1 mV
Yes
Yes
Yes
Yes
New ST-segment elevation > 0.2 mV
Yes
Yes
New wall motion abnormality in transesophageal / transthoracic
echocardiography
Mixed venous oxygen partial pressure (PvO2), mm Hg
Yes
Yes
<32
NA
Oxygen extraction rate, %
>40
NA
Mixed venous oxygen saturation (SvO2), %
<60
NA
Decrease in oxygen consumption (VO2), %
<10
NA
*ใชเมื่อเกิดภาวะซีดจ ากโรคเดิมของผูปว ย (underlying cause) และตองรักษาระดับการไ หลเวีย นใ หได normovolemia, รักษาภ าวะ
tachycardia และ optimizing anesthesia (Shander A. Vas cular 2008;16 (Suppl. I):S39.)
Risks of transfusion-related transmission of
HIV, HBV and HCV in USA
Complications of transfusion
Acute
Delayed
Acute hemolytic transfusion reaction
Delayed hemolytic transfusion reactions
Febrile non-hemolytic transfusion
Transfusion-related immmunomodulation
reactions
Microchimerism
Transfusion-related acute lung injury
Transfusion-transmitted diseases
Allergic reactions
Post-transfusion graft-versus-host
Bacterial sepsis
disease
Hypocalcemia a
Post-transfusion purpura
Hyperkalemia a
Infection; variant Creutzfeldt-Jakob
Acidosis a,b
disease (CJD), SARS, avian influenza
Hypothermia a,b
Dilutional coagulopathy a,b Perkins JG, et al.. Crit Care Med 2008; 36:[Suppl.]: S326.
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Shander A. Crit Care Med 2003 ; 31 (Suppl.) :S710.
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9/15/2011
Incidents are classified under
the following headings:
Summar y of outcome variable analysis
Variable
Transfused
patients (n = 45)
Patients not
transfused (n = 20)
Infectious morbidity (%)
40% (18/45)
30% (6/20)
Postpartum hospitalization (days)
Average of 8 days
Average of 7 days
Ventilatory support (h)
Average of 4 h
Average of 4 h
Disseminated intravascular coagulopathy (%) 4.4% (2/45)
Nil
Maternal death (%)
12% (3/20)
15.6% (7/45)
Chigbu B, et al. Arch Gynecol Obstet 2009;279: 471.
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How Can W e Reduce the Use of Allogeneic Blood?
• Multidisciplinary effort
• Chain from OPD to D/C from hospital
• Knowledge with respect to
• Anti-D cases
• Right blood to right patient (RBRP)
• Acute non-haemolytic transfusion reaction (ATR)
• Haemolytic transfusion reaction: Acute and
Delayed (HTR)
• Transfusion associated graft-versus-host-disease
(TA-GVHD)
• Transfusion-related acute lung injury (TRALI)
• Post-transfusion purpura (PTP)
• Transfusion transmitted infection (TTI)
• ‘Near miss’ events
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General principles of blood
conservation
• Devising an individual plan of care
• Using a multidisciplinary treatmen t
approach
• Anticipating and addressing
complications
– haemostatic
– blood conservative techniques
– treatment of anemia
– transfusion trigger
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• Incorrect blood component transfused (IBCT)
• Practices based on clinical judgment
• Screening, investi gating, and
treating anemia, before surgery
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Overview of perioperative blood conservation strategies
General principles of blood conservation
(cont.)
• Minimizing iatrogenic blood loss
• Restrictive transfusion strategy
• Limiting preop. use of anticoag.
and antiplatelet agents
• Consulting specialists
• Rapidly controlling hemorrhage
and transferring
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Preoperative
Intra-operative
Post-operative
1.Screen for anemia and
manage it and its
underlying causes
2. Use ESAs, iron, and
folate if anemic
3. Reassess the use of
anticoagulant and
antiplatelet agents
4. Minimize phlebotomy
5. Consider PAD (if
requested by patient or if
absolutely needed)
1. Use refined surgical
techniques and
meticulous hemostasis
2. Perform ANH
3. Perform cell salvage
4. Use hemostatic agents
5. Maintain normovolemia
6. Avoid hypothermia
7. Consider controlled
hypotension
1. Monitor and control
bleeding (re-explore if
necessary)
2. Continue cell salvage
3. Maintain normovolemia
4. Screen for and manage
anemia and underlying
causes
5. Use ESAs, iron, and
folate if anemic
6. Reassess the use of
anticoagulant and
antiplatelet agents
7. Minimize phlebotomy12
Shander A. Vascular 2008;16(Suppl. I):S43.
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9/15/2011
Preoperative optimization
Advances in bloodless surgery
• Preoperative optimization
• Intraoperative reduction of
losses
• Postoperative optimization
Hofland J, Henny CP. Dig Surg 2007;24:267.
Shander A. Crit Care Med 2003; 31:S708–S714.
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Practice standards :
• effective means of assessing a patient’s anaemia
before surgery and take appropriate corrective
action where necessary.
• Patients assessed in the pre-assessment clinic
have their anaemia managed effectively.
Performance indicators :
• Preoperative Hb > 12 g/dl
• The percentage of patients transfused.
• Average number of red cell units transfused
/procedure.
Grant-Casey J, Madgwick K. Nursing Standard. 2010;24:43-6.
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Preoperative optimization
Preoperative optimization
• Preoperative autologous donation
(PAD)
• Other recom binant drugs to
stim ulate platelets or various white
blood cells: (r)interleukin-11,
(r)Hthrombopoietin, GM-CSF, G-CSF,
M-CSF, rFVIIa, FVIII, FIX
Increasing red blood cell m ass:
ØUse of (i.v.) iron
ØRecom binant human
erythropoietin
ØErythropoiesis-stimulating
protein
Hofland J, Henny CP. Dig Surg 2007;24:267.
Shander A. Crit Care Med 2003; 31:S708–S714.
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Methods of blood conservation
Method
Acute normovolaemic
haemodilution
Advantages
Autologous blood
Method
Haemodynamic instability during
venesection
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Mechanism
Advantages
EBM
To prevent subacute anemia
Reducing blood loss fr om
diagnostic testing
Closed blood sam pling
Techniques
Reduction in allogeneic Perioperative anaemic
blood transfusions
Whole blood
Mis-transfusion due to clerical errors
Up to 50% of predonated blood is
unused
Potential bacterial contamination of Bl
Optimiz e haemoglobin Expensive, Education
Reduces inappropriate Time-consuming
allogeneic blood Tx
Con-(low dose rHuEPO+iron IV in-OR)2
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Ashwor
th A,
Klein A. Br J Anaesth 2010;105 (4): 401–16. W Chau-in Avoid Bl Tx
2 Na HS,et al. Tr ansfusion 2010
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Methods of blood conservation
Disadvantages
Reduction in allogeneic Additional training required
blood transfusions
Whole blood,
Inexpensive
Preoperative autologous Autologous blood (up Logistical planning
donation (none in UK) to 4 units)
Preoperative
erythropoietin
Hofland J, Henny CP. Dig Surg 2007;24:267.
Shander A. Crit Care Med 2003; 31:S708–S714.
17
Sm all-volum e sam ple
tubes
Point-of-car e
m icr oanalysis
Er ythr opoietin
Restr ictive r ed blood cell
tr ansfusion tr igger *
Reduction of iatr ogenic
blood loss fr om diagnostic
testing
Reduction of iatr ogenic
blood loss fr om diagnostic
testing
Reduction of iatr ogenic
blood loss fr om diagnostic
testing
Incr eased pr oduction of
r ed blood cells in bone
m ar r ow
• Incr ease in hem oglobin level
RCT
• Elim ination of “discar d” blood loss
befor e testing in patients with indwelling centr al catheter s
• Reduced r isk of bacter ial
contam ination of catheter hubs and
blood-str eam infections
• Reduced blood loss
RCT
Exper t opinion
RCT
• Shor t tur nar ound tim e for test r esults Exper t opinion
• Reduced per sonnel tim e
• Incr ease in hem oglobin level and
possible
r educed need for tr ansfusion
• Possible r eduction in m or tality
am ong tr aum a patients†
Raised hem oglobin
• Reduced need for blood tr ansfusion
thr eshold for r ed blood cell without incr ease in m or bidity or
tr ansfusion
m or tality in m ost cr itically ill patients
Ashwor th A, Klein A. Br J Anaesth 2010;105 (4): 401–16.
Na HS, et al. Tr ansfusion 2010
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RCT; m etaanalysis
RCT subgr oup
analysis
RCT
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Intraoperative reduction of losses
Intraoperative reduction of losses
• Hemodilution and Critical Hemato crit
• Modification of surgical technique:
ØLaparoscopy
ØEndoscopy
ØRobotic surgery
ØTranscatheter surgical techniques
ØUltrasonic scalpel
ØArgon beam coagulator
ØSurgical packing material
• Hemodilution and Critical Hematocrit
Ø Acute normovolemic hemodilution (ANH)
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Ø Critical Hematocrit
a restrictive approach to RBC transfusion by
maintaining Hb 6- 9 g/dL or at 10 to 12 g/dL3
normal pt at 6 g/dL,
elderly pt S- coronary HD at 7 g/dL,
cardiac dz at 9 g/dL
Hofland J , Henny CP. Dig Surg 2007;24:267.
Shander A. Crit Care Med 2003; 31:S708–14.
3 Mos k owitz DM,et al. Ann Thorac Surg2010;90:451–9
Hofland J, Henny CP. Dig Surg 2007;24:267.
Shander A. Crit Care Med 2003; 31:S708–S714.
19
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Contraindication for
Acute Normovolemic Hemodilution (ANH)
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• Renal dysfunction (Cr >1.8 mg/dL)
• Abnormal coagulation parameters (INR >1.5
not on warfarin and/or plt <100,000)
• Presence of active infection
• Evidence of hepatic metabolic disorder
(bilirubin >2 mg/dL or ALT >75 U/L)
• Preoperative autologous blood donation
Oct 13,2 010
• Modification of anesthetic technique:
Epidural anesthesia
Spinal anesthesia
Controlled Hypotension
Avoidance of Hypothermia
Optimization of monitoring devices to
manipulate hemodynamics, blood oxygen
levels, actual coagulation
Ø Acute normovolemic hemodilution
Ø Cell Salvage
Ø Use of artificial oxygen carriers
Ø
Ø
Ø
Ø
Ø
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Hofland J, Henny CP. Dig Surg 2007;24:267.
23
Shander A. Crit Care Med 2003; 31:S708–S714.
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Avoidance of Hypothermia
Intraoperative reduction of losses (cont.)
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Contraindication for ANH (cont.)
• Active coronary artery disease (exceptions
for cardiac stress study showing no
reversible ischemia within 30 d)
• History of cerebrovascular disease
• History of congestive heart failure
• Uncontrolled hypertension
• Restrictive or obstructive pulmonary
disease (COPD)
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• Even mild hypothermia (<1°C)
significantly increases blood loss by
approximatel y 16% (4–26%) and
• Increases the relative risk for
transfusion by approximatel y 22% (3–
37%). 1
• Each BT 1 o C decline, there is a 10%
reduction in the coagulation facto r
activity21 Rajagopalan S,et al. Anesthesiology 2008; 108:71–7
2 Johansson P I. Acta Anaesthesiol Scand 2010; 54: 1039–49
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9/15/2011
Methods of blood conservation
Method
Mechanism
Advantages
Cell salvage
EBM
To r educe acute blood loss
Antifibrinoly tic a ge nts
Im prov e d he m os ta s is
Tra ne x a m ic a c id or
e ps ilon a m inoc a proic a c id
• Re duc e d ris k of re c urre nt ble e ding a nd de a th
M e ta -a na ly s is
a s s oc ia te d with ga s trointe s tina l ble e ding†
Ve rm a e t a l . BM C
Su rg e ry 2 0 1 0 , 1 0 :1 3
M e ta -a na ly s is
• Re duc e d ris k of pe riope ra tiv e ble e ding a nd
ne e d for re ope ra tion in c a rdia c s urge ry pa tie nts
• Unde r inv e s tiga tion for us e in tra um a pa tie nts
Aprotinin
Im prov e d he m os ta s is
• Re duc e d ris k of pe riope ra tiv e ble e ding a nd
M e ta -a na ly s is
ne e d for re ope ra tion in c a rdia c s urge ry pa tie nts
De s m opre s s in
Im prov e d he m os ta s is from
• Re duc e d ris k of ble e ding in pa tie nts with
Obs e rv a tiona l
inc re a s e d fa c tor VIII a nd
v on Wille bra nd le v e ls
c onge nita l c oa gula tion de fe c ts (pla tele t
dy s func tion, v on Wille bra nd’s dis e a se , m ild
s tudie s
he m ophilia A) a nd thos e with re na l fa ilure
Re c om bina nt a c tiv a te d
Im prov e d he m os ta s is
• Pos s ible be ne fit in s e le c te d c as e s re fractory to
Ca s e re ports ;
fa c tor VII
Artific ia l ox y ge n c a rrie rs
Inc re a s e d ox y ge n tra ns port
s ta nda rd s urgic a l a nd m e dic a l tre a tm e nt†
• Pos s ible re duc tion in ne e d for tra ns fus ion†
e x pe rt opinion
RCT
(m odifie d he m oglobin
s ubs titute s ,
without blood tra ns fus ion;
inc re a s e d a bility to pe rform
• Prolonge d s he lf-life
• Produc ts c a n be s tore d a t room te m pe ra ture
pe rfluoroc a rbons )
a c ute norm ov ole m ic
he m odilution
• No ris k of dis e a s e tra ns m is s ion
• No im m unologic e ffe c ts
Pos tope ra tiv e blood re c ov e ry Re turn of blood c olle c te d
• Re duc e d ne e d for pe riope ra tiv e blood
te c hnique s (c e ll s a lv a ge )
tra ns fus ion in orthope dic s urge ry but not in
c a rdia c s urge ry
Oct 13,2 010
in s urgic a l dra ins
Ashwor th A, Klein A. Br J Anaesth 2010;105 (4): 401–16.
Na HS,et al. Tr ansfusion 2010
M e ta -a na ly s is
W Chau-in Avoid Bl Tx 25
• the process of collecting a patient’s own blood
during surgery for transfusion back into the
patient, is an alternative to reliance on donor
blood when a transfusion is required.
• sufficient evidence to support the use of cell
salvage in cardiac and orthopaedic surgery.
Cell salvage does not appear to cause any
adverse clinical outcomes.
Carless PA, et al.Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD001888.DOI:
10.1002/14651858.CD001888.pub4.
Oct 13,2 010
Diagram of the set up of a standard
cell salvage circuit.
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Cell salvage
• Reduces the requirement for allogenic blood
transfusion.
• It should be considered for surgery with an
anticipated blood loss of 1000 ml.
• It can be used in cancer surgery, but a leucocyte
depletion filter is recommended.
• Evidence from cardiac and orthopaedic surgery
is reasonable but is limited for other surgery.
• There is still a need for large prospective RCT.
As hworth A, Klein A. Br J Anaes th 2010;105 (4): 401–16.
Oct 13,2 010
As hworth A, Klein A. Br J Anaes th 2010;105 (4): 401–16.
27
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Intraoperative reduction of losses (cont.)
• Recycling of drain blood
• Strict transfusion triggers
• Low threshold for re-intervention in case of
postoperative bleeding
– Re-operation
– Angiography combined with arterial
embolization Hofland J, Henny CP. Dig Surg 2007;24:267.
Ø Aprot inin
Ø Antifibrinoly tics
Ø Desmopres sin
Ø Fibrin glues
Ø rFVIIa
• Strict transfusion triggers
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Hofland J, Henny CP. Dig Surg 2007;24:267.29
Shander A. Crit Care Med 2003; 31:S708–S714.
28
Postoperative optimization
• Pharm acological
interventions
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Shander A. Crit Care Med 2003; 31:S708–S714.
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9/15/2011
Potential risks and disadvantages associated with
blood conservation strategies (cont.)
Over view of pharmaco logic agents
Strategy
Reduction of blood loss
associated with diagnostic
testing
Closed blood sampling
techniques
Small-volume sample tubes
Agents
Antifibrinoly tic
Aminoc aproic ac id
Tranex amic ac id
Topic al
Thrombin
Gelatin s ponges
Fibrin, Fibrin glues
Proc oagulant
Des mopres s in
Rec ombinant c oagulation fac tor
Rec ombinant fac tor VIIa
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Potential risks and disadvantages associated with
blood conservation strategies
Str ategy
Potential r isks and disadvantage s
Antifibrinolytic agents
• Thrombosis
• Possible increased risk of death with use of
aprotinin
Desmopressin
• Thrombosis
Recombinant activated factorVII • Thrombosis
• No benefit with routine use in cases of trauma or
massive bleeding
Artificial oxygen carriers (modified • Short half-life
hemoglobin substitutes,
• Interference withlaboratory measures with use of
perfluorocarbons)
hemoglobin substitutes
• Vasoreactivitywith use of hemoglobin substitutes
• Use of 100% oxygen to provide effective
oxygenation with use of perfluorocarbonsmay
cause lung injury
• Limited applicability to most critical care patients
• Reduced quality of reinfused blood (hemolyz ed,
diluted, cytokines [e.g., interleukins])
Erythropoietin
• Thrombosis
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Tinmouth AT, et al. CMAJ 2008;178:49-57. W Chau-in Avoid Bl Tx
Tinmouth AT, et al. CMAJ 2008;178:49-57.
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Transfusion trigger
permissive anemia
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Blood conservative
techniques
Haemostatic
Perioperative blood transfusion
Multidisciplinary
team
Policy
postoperative M&M
Oct 13,2 010
long-term survival
W Ch a u -i n Av o i d Bl Tx
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ขอบคุณ คะ
Conclusion
การลดการใชเ ลือดตองเริ่มจากการวางแผนการ
รักษาที่เ หมาะสมในผูปวยแตละรายโดยอาศัยแนวทาง
การใชเ ลือดตามขอบงชีร้ วมกับการเฝาระวังอาการและ
อาการแสดงของผูปวยเมื่อเริ่มมีการเปลี่ยนแปลงของ
ระบบไหลเวียนเลือดอยางใกลชิดระวังภาวะช็อคและ
hemodilution และการทํางานเปนทีมสหสาขาวิชาชีพ
ถือเปนกุญ แจสูความสําเร็จของกลยุทธหลีกเลี่ยงการใช
เลือด
32
W Chau-in Avoid Bl Tx
Perioperative blood conservation
strategy
Postoperative blood recovery
techniques (cell salvage)
Oct 13,2 010
• Retrograde arterial embolization
• Potential for insufficient volume for
diagnostic testing
Point-of-care microanalysis • Variable accuracy and precision
(need for ongoing quality assurance
and calibration)
Restrictive blood transfusion • Possible risk of death among patients
trigger
with active cardiac disease
Gurusamy KS, et al. Cochrane Database of Systematic Reviews 2009, Issue 4.
Art. No.: CD008085.
31
Oct 13,2 010
Potential risks and disadvantages
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