270 likes | 875 Views
Blood Transfusion. Joanne Simpson Anaesthetic SHO. Indications. Blood Loss Bone Marrow Failure Inherited RBC disorders Acquired RBC disorders Neonatal and Exchange Transfusions. Documentation.
E N D
Blood Transfusion Joanne Simpson Anaesthetic SHO
Indications • Blood Loss • Bone Marrow Failure • Inherited RBC disorders • Acquired RBC disorders • Neonatal and Exchange Transfusions
Documentation Given the potential risks involved with blood transfusion, the indication for each transfusion should be written clearly in the patients notes The identity of the patient and the units to be transfused should be checked carefully
Risks of Allogenic Transfusion • Transmission of infections • Immunomodulation • Transfusion Reaction
Long Term Concerns • Costly • Human Errors in Transfusion • Limited supply • Viruses and Bacteria not screened for
Who will benefit? • Jehovah’s Witnesses • Patients with multiple antibodies • Patients anxious about receiving blood transfusions from unknown donors However, • Only available to selected patients in practice
Preoperative Autologous Blood Transfusion • This involves the collection of 2-4 units of blood. • The first unit is collected approx 2weeks before surgery, the second is collected around 7-10days before surgery • Iron replacement is usually given • Some centres give the patient erythropoietin to enable greater numbers of units to be collected.
Advantages • RBC’s can be stored for up to 5 weeks pre operatively • Some people are able to donate up to 4 units pre op • Many of the disadvantages of allogenic blood transfusion is avoided
Disadvantages • Patient Selection • Close collaboration between surgeon, patient and transfusion lab essential • High cost • Units may still become contaminated in storage • Patient may still require extra units • Blood may be wasted if operation is cancelled
Erythropoietin • Several studies performed showing the effectiveness of EPO • Study by De Andrande showed that by using EPO pre op the allogenic transfusion rate fell from 45% to 16% in the treated group
Erythropoietin Sign Guidelines: • Erythropoietin use should be targeted to patients aged under 70 years who are scheduled for major blood loosing surgery and who have a presenting haemoglobin of <130g/L • Erythropoietin can be used to prepare patients with objections to allogenic transfusion for surgery that involves major blood loss
Disadvantages • Cost • Risks of hypertension • Risks of thrombosis
Acute Normovolaemic Haemodilution • Removal of whole blood and the restoration of blood volume with acellular fluid shortly before anticipated blood loss • This blood may then be reinfused either in the operation or post operatively • Bryson et al in 1998 conducted a trial and concluded that ANH reduced perioperative allogenic transfusion. This has also been shown by further trials
Disadvantages • Patient Selection • Should only be undertaken where the logistics of intra operative blood removal can be undertaken without detracting from patient care • Extra paperwork in labelling Autologous blood intra operatively
Antifibrinolytic Drugs The use of Aprotinin, Tranexamic Acid or Epsilon-aminocaproic Acid to reduce intra operative bleeding and the requirement for transfusion These drugs significantly reduce blood loss (p=0.001) and transfusion requirements as found by Laupacis et al in 1997 as well as others
Disadvantages • Increased risks of thrombosis • Deterioration in renal function • Allergy • Lack of evidence for the use of antifibrinolytic drugs in certain operations
Cell Salvage Allows blood to be reinfused into patients using suction catheters and filtration systems Blood may be washed or unwashed May be reinfused intra or post operatively A study by Huet et al in 1998 confirms that cell salvage can reduce the need for allogenic transfusion
Advantages to patient and clinician • No transfusion reactions • No disease transmissions • No alloimmunisations • No immunomodulation • Safer • Readily available blood in major haemorrhage • Cheaper than using donor blood
Disadvantages • Coagulation Disorders when large volumes (>1500ml) are reinfused • Unwashed systems may give bacterial transmission • Initial set up costs
Jehovah’s Witnesses • Many refuse any type of blood transfusion based on biblical beliefs • Also refuse autologous blood transfusion • Ethical dilemmas occur in treating this patient group
Jehovah’s Witnesses • Many accept Recombinant Human Erythropoietin but not the versions with traces of human albumin • Will accept Acute Normovolaemic Haemodilution and intra operative cell salvage as long as the blood is kept in continual contact with the patients circulation • Some will accept blood transfusion and not tell members of their religion
Summary • Allogenic Transfusion is not without risks • There are feasible alternatives available to allogenic transfusion • Jehovah’s witnesses present an ethical problem when it comes to blood transfusion, but there are acceptable alternatives
References • SIGN Guideline number 54 • Oxford Handbook of Haematology • BMJ Volume 311, 28/5/95 – Management of Blood loss in Jehovah’s Witnesses • Haemoclaim, Blood Salvage Website, www.nwpgroup.com • www.urology.medsch.ucla.edu/blood_transfusions.htm
References • Huet C, Salmi LR, Fergusson D, Koopman-van Gemert AW, Rubens F, Laupacis A. A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopaedic surgery. International Study of Perioperative Transfusion (ISPOT) Investigators. Anesth Analg 1999; 89: 861-9 • Laupacis A, Fergusson D. Drugs to minimize perioperative blood loss in cardiac surgery: meta-analyses using perioperative blood transfusion as the outcome. The International Study of Peri-operative Transfusion (ISPOT) Investigators. Anesth Analg 1997; 85: 1258-67.
References • Bryson GL, Laupacis A, Wells GA. Does acute normovolemic hemodilution reduce perioperative allogeneic transfusion? A meta-analysis. The International Study of Perioperative Transfusion. Anesth Analg 1998; 86: 9-15. • de Andrade JR, Jove M, Landon G, Frei D, Guilfoyle M, Young DC. Baseline haemoglobin as a predictor of risk of transfusion and response to Epoetin alfa in orthopedic surgery patients. Am J Orthop 1996; 25: 533-42.