Transfusion free medicine outdated practice or revolutionary science
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Transfusion Free Medicine – Outdated Practice or Revolutionary Science. Randy Henderson Director Transfusion Free Surgery/Patient Blood Management Keck Medical Center of USC Sherri Ozawa, RN Clinical Director, Patient Blood Management Englewood Hospital and Medical Center

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Transfusion free medicine outdated practice or revolutionary science

Transfusion Free Medicine – Outdated Practice or Revolutionary Science

Randy Henderson

Director

Transfusion Free Surgery/Patient Blood Management

Keck Medical Center of USC

Sherri Ozawa, RN

Clinical Director, Patient Blood Management

Englewood Hospital and Medical Center

Director, Society for the Advancement of Blood Management


Dinosaurs vs transfusion free

Dinosaurs vs. Transfusion-Free

Outdated

Outdated??? - TBD


Is transfusion free or bloodless a prototype for patient blood management

Is “Transfusion-Free” or “Bloodless” a prototype for Patient Blood Management?

The word prototype comes from the Latin words proto, meaning original, and typus, meaning form or model. In a non-technical context, a prototype is an especially representative example of a given category

In hardware design, a prototype is a "hand-built" model that represents a manufactured (easily replicable) product sufficiently for designers to visualize and test the design.


Early pioneers of bloodless surgery

Early Pioneers of “Bloodless” Surgery

In 1957, Cooley pioneered open-heart surgery without blood support leading a team of cardiovascular surgeons who performed thousands of operations on adults and children. In those days, most open-heart surgeries required 20 to 30 units of blood and as many as 12 units of blood were used just to prime the heart-lung bypass machine. Dr. Cooley and his colleagues used innovative methods to prime the bypass machine with non-blood fluids.

In 1995, Dr. Hiram C. Polk Jr., editor-in-chief of the American Journal of Surgery, recognized Dr. Cooley’s outstanding accomplishments. He commented on the trailblazing efforts of Dr. Cooley in performing some 1,250 “bloodless” open-heart surgeries on patients who requested it due to their religious beliefs. He stated that “Dr. Cooley’s blood conservation techniques are applicable to every operation and, therefore, meaningful to all 17,000 readers of The American Journal of Surgery.”

Denton Cooley, M.D.


Early pioneers of bloodless surgery1

Early Pioneers of “Bloodless” Surgery

1970s-1980s – Operated on Jehovah’s Witness patients in scenarios where others would not

First effort at collection of patient data in Bloodless Surgery (PBM)

Pioneer efforts in publishing early writings on seminal nature of transfusion medicine and surgery

Richard Spence, M.D.


Some history

Some History

1960s-1970s – Early pioneers accomplish successful heart surgery on Jehovah’s Witness patients

1980s – Jehovah’s Witness organization forms organizational structure to inform/educate health care professionals/hospital in “BLOODLESS” surgery

1980s – HIV crisis forces reconsideration of current transfusion practices

1990s – Handful of US hospitals form “BLOODLESS PROGRAMS” to cater to needs of patients for whom blood is not an option

2001- Formation of SABM – intended to promote Optimal Patient Blood Management as a standard of care for all patients

2013- Recognition of PBM by WHO, TJC, AABB, multiple references in peer reviewed journals, chapters, textbooks


Hospital profile

Hospital Profile

  • 525 Bed Medical Center – Academic Affiliate of Mt. Sinai School of Medicine

  • Teaching program for Internal Medicine, Vascular Surgery

  • Training site: Surgery, Pediatrics, Critical Care

  • Level II Trauma

  • Level III NICU

  • All Medical Surgical Services except Transplants, PICU

  • 18 Years of Comprehensive PBM Program across all specialties

  • Worked with 100 hospitals in program development


Some history1

Some History

  • Hospital Administration was approached by members of Jehovah’s Witness community (1993)

  • Intent was to provide same standard of care but without use of blood transfusions

  • Hospital participation for ethical and business reasons


Standard of care

Standard of Care?

Birth of “Bloodless Programs” led to uneven Standard of Care and the larger philosophical question:

Why should Optimal Blood Management be limited to patients who refuse blood??


Transfusion free medicine outdated practice or revolutionary science

Hospital Wide Patient Blood Management

Bloodless Program


Transfusion free medicine outdated practice or revolutionary science

Blood Transfusion: Who is at risk

The 1-3units of RBC transfused

Shander A. Submitted A&A 2012


Unsafe blood

Unsafe Blood

  • 43% of 191 WHO members test their blood for HIV, HBV, and HCV.

  • > 13 million units per year are transfused WITHOUT these tests

  • Annual estimates

    • 8 - 16 million transmission of HBV

    • 2.3 - 4.7 million of HCV

    • 80,000 - 160,000 of HIV

Lancet 2003;361(9352)161-169


Transfusion free medicine outdated practice or revolutionary science

A CLINICIAN’S PERCEPTIONS

  • Safety of BLOOD - high

  • Risk of BLOOD - low

  • Risk of Anemia - unknown

  • Risk of Surgical Bleeding – low

  • Transfusions- rare


The reality

The Reality…

  • Transfusions are risky

    • A host of infectious and non-infectious risks

    • Association with worse patient outcomes

  • Transfusions are costly

    • A complex process (more tests & processing on the way)

    • True cost significantly higher than what hospitals pay to blood centers

  • Blood supply is limited

    • Marginal supply likely to worsen due to aging population (less donation; more demand)

    • Constant threat of emerging pathogens

COBCON – Shander et al. Best Pract Res ClinAnaesthesio 2007


Transfusion medicine in american undergraduate medical education

Transfusion Medicine In American Undergraduate Medical Education

Transfusion is the most common procedure in hospitals

N = 86 American medical schools surveyed (AAMC)

83% administrators reported - didactic lectures

48% of medical schools providing 1 or 2 hours of lectures Handful reported small group sessions on transfusion medicine (6%)

92% administrators were unfamiliar with the 1989 or the 1995 TMAA curricula.

Karp JK. et al. Transfusion. 2011 Nov;51(11):2470-9


Transfusion free medicine outdated practice or revolutionary science

Transfusion Practice

  • Influence of knowledge and attitudes on the quality of physicians' transfusion practice

  • Amount of transfused products was inversely

  • proportional to physician knowledge of

  • transfusion medicine

  • Attending MD - lower knowledge scores,

  • greater confidence than residents

  • >60% of residents inappropriate transfusion due

  • attending pressure (once a month)

  • Salem-Schatz SR, Avorn J, Soumerai S B. JAMA 1990


Principles of patient blood management

Principles ofPatient Blood Management

  • 94% of transfusions in surgical patients can be attributed to:

    • low preoperative hemoglobin levels

    • excessive surgical blood loss, and/or

    • inappropriate transfusion practices

Shander A, Javidroozi M, Perelman S, Puzio T, Lobel G. Mt Sinai J Med. Jan-Feb 2012


Transfusion free medicine outdated practice or revolutionary science

Some resist cultural change


Transfusion free medicine outdated practice or revolutionary science

  • NATIONAL SUMMIT ON OVERUSE

  • SEPTEMBER 24, 2012

  • Elective PCI

  • Myringotomy and Tubes

  • Early C – section

  • Antimicrobials in URI

  • Blood transfusion

CHOOSING WISELY CAMPAIGN

ABIM 2012


Outcome of patients who refuse transfusion after cardiac surgery

Outcome of Patients Who Refuse Transfusion After Cardiac Surgery

  • N= 322 Witnesses and 87 453 non-Witnesses ( N = 48 986 transfused)

  • Witnesses – fewer complications and shorter LOS

  • Witnesses had better 1-year survival (P = . 007)

  • Similar 20-year survival (P = . 90)

  • Blood management strategies do not appear to place patients at heightened risk for reduced long-term survival

Pattakos G, et al. Arch Intern Med 2012;172:1154-60.


Transfusion free medicine outdated practice or revolutionary science

  • N = 500 (Group A vs. Group B = before and after blood conservation respectively)

  • 30 days mortality was 3% in group A vs. 1% in group B despite greater operative risk factors

  • Factors contributing to the low morbidity-mortality in group B:

    • Preoperative erythropoietin to attain a minimal hgb value of 14 g/dl

    • Warm blood cardioplegia

    • Implementation of blood conservation protocol

    • Fast track extubation

J Cardiothorac Surg. 2012 Sep 27;7(1):95


Mending the problem

Mending the Problem

  • Are we asking the right question?

    • Liberal vs. Restrictive transfusion practice

      • Asking the same question over and over and expecting different answers?

    • More guidelines FOR TRANSFUSION

      • Who follow and why should they?

    • Changing culture

      • Can be done but resources and urgency are needed


From bloodless medicine and surgery to patient blood management

From Bloodless Medicine and Surgery to Patient Blood Management

  • The goal is not merely to avoid or withhold transfusions but:

    • To apply evidence-based medical and surgical approaches to manage anemia

    • optimize hemostasis

    • minimize blood loss and blood transfusion

  • The newer PBM concept places more emphasis on preventive measures that will obviate the need for transfusions

Shander A, Javidroozi M, Perelman S, Puzio T, Lobel G. Mt Sinai J Med. Jan-Feb 2012


Patient blood management

Patient Blood Management


Patient blood management1

Patient Blood Management


Patient blood management2

Patient Blood Management


Patient blood management3

Patient Blood Management


Patient blood management4

Patient Blood Management


Patient blood management5

Patient Blood Management


The u s c experience reprinted arch surg vol 141 sep 2006 www archsurg com

The USCexperience(REPRINTED) ARCH SURG/VOL 141, SEP 2006 WWW.ARCHSURG.COM

  • Impact of a Transfusion-Free Program on Non–Jehovah’s Witness Patients Undergoing Liver Transplantation- Nicolas Jabbour, MD; Singh Gagandeep, MD; Haimesh Shah, MD; Rod Mateo, MD; Maria Stapfer, MD; Yuri Genyk, MD; Linda Sher, MD; Monika Zwierzchoniewska, MD; Rick Selby, MD; Gary Zeger, MD

    • Background: Examined the impact of the initiation of a transfusion-free program in January 2000 for Jehovah’s Witnesses (JWs) on the overall use of blood products in non-JW patients undergoing OLT.

    • Design: Retrospective review of OLT from January 1997 through December 2004.


The u s c experience reprinted arch surg vol 141 sep 2006 www archsurg com1

The USCexperience(REPRINTED) ARCH SURG/VOL 141, SEP 2006 WWW.ARCHSURG.COM

  • Impact of a Transfusion-Free Program on Non–Jehovah’s Witness Patients Undergoing Liver Transplantation- Nicolas Jabbour, MD; Singh Gagandeep, MD; Haimesh Shah, MD; Rod Mateo, MD; Maria Stapfer, MD; Yuri Genyk, MD; Linda Sher, MD; Monika Zwierzchoniewska, MD; Rick Selby, MD; Gary Zeger, MD

    • Patients:Total of 272 OLTs were performed on non-JW adults including 216 (79.4%) deceased donor and 56 (20.6%) living donor liver transplantations.

      • Thirty-three OLTs were performed before January 2000 (ie, before the initiation of a transfusion-free program) (group 1), and 239 OLTswereperformed after January 2000 (group 2). I

      • In group 2, all patients underwent OLT using cell-scavenging techniques and acute normovolemichemodilution (ANH) whenever feasible.


The u s c experience reprinted arch surg vol 141 sep 2006 www archsurg com2

The USCexperience(REPRINTED) ARCH SURG/VOL 141, SEP 2006 WWW.ARCHSURG.COM

  • Impact of a Transfusion-Free Program on Non–Jehovah’s Witness Patients Undergoing Liver Transplantation- Nicolas Jabbour, MD; Singh Gagandeep, MD; Haimesh Shah, MD; Rod Mateo, MD; Maria Stapfer, MD; Yuri Genyk, MD; Linda Sher, MD; Monika Zwierzchoniewska, MD; Rick Selby, MD; Gary Zeger, MD

    • Results: In comparing group 2 with group 1, the mean MELD score was statistically significantly higher (P<001), whereas the mean number of intraoperative PRBC and FFP transfusions was significantly lower (P=.03 and P=.004, respectively). The number of preoperative and postoperative PRBC, FFP, and platelet transfusions between the 2 groups was not statistically different.


The u s c experience reprinted arch surg vol 141 sep 2006 www archsurg com3

The USCexperience(REPRINTED) ARCH SURG/VOL 141, SEP 2006 WWW.ARCHSURG.COM

Conclusion:The development of a transfusion-free surgical program for JW patients has had a positive impact on reducing the overall blood use in non-JW patients undergoing OLT, despite the increase in MELD score.


Ldlt in adult jw recipient intra operative data

LDLT IN ADULT JWRecipient Intra-Operative Data


Ldlt in adult jw recipient post operative course

LDLT IN ADULT JW Recipient Post-Operative Course


Blood management in cardiac sx 2000 2013 ytd

Blood Management in Cardiac Sx2000-2013 YTD

  • 3211 Total Cases

    • (valves, CABG, aneurysm, and combination)

  • More complicated case mix than other hospitals

  • LOWEST transfusion rate in State

  • LOWEST mortality rate in State


Cardiothoracic surgery patient blood management 2000 2013 ytd

Cardiothoracic Surgery &Patient Blood Management 2000-2013 YTD

N=2861


Cabg patient blood management

CABG &Patient Blood Management

  • 1375 Total Surgeries in 13 years

  • Overall Mortality – 7 (0.56%), Zero for past six years

  • Much lower than expected rates for:

    • Post Op Bleeding

    • Sternal Infection

    • Sepsis

    • Pneumonia

    • Stroke


Cabg blood management

CABG &Blood Management

Average Transfusion Rate nationally at 40-


Transfusion free medicine outdated practice or revolutionary science

CABG outcomesPBMP vs non-PBMP

N=586

Moskowitz DM et al. Ann ThoracSurg2010;90:451–8


Transfusion free medicine outdated practice or revolutionary science

n=25


Conclusion

Conclusion

  • Bloodless was the start – applied knowledge

  • Social, medical and economic drivers for PBM

  • PBM emphasizes the use of a multimodality approach and is adopted universally

  • Emerging data support that:

  • PBM is safe and effective in providing better care and improving patients’ outcomes while reducing transfusion of allogeneic blood components

Shander A, Javidroozi M, Perelman S, Puzio T, Lobel G. Mt Sinai J Med. Jan-Feb 2012


Thank you

Thank you


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