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ONTraC presentation Plus random slides after (28 MB). Note: this presentation contains custom animation and with some slides you need to wait until this takes effect. With particular thanks to Dr James Isbister of Sydney, Australia. Blood Transfusion:

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Ontrac presentation plus random slides after 28 mb

ONTraC presentation

Plus random slides after

(28 MB)

Note: this presentation contains custom animation and with some slides you need to wait until this takes effect

With particular thanks to Dr James Isbister of Sydney, Australia


Ontrac presentation plus random slides after 28 mb

Blood Transfusion:

An expensive & potentially hazardous alternative to

Blood Management

John Freedman

Director, Transfusion Medicine

St Michael’s Hospital

University of Toronto


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I won’t keep you long

As Henry VIII said to each of his 6 wives


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Objectives of this presentation

To gain an understanding of:

  • Risks of allogeneic transfusion

    • Infectious

    • Immunologic (TRALI, immunomodulation)

    • Errors

  • Blood conservation/transfusion alternatives

  • An Ontario approach to blood conservation


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Blood will immerse you in a world of horror unlike any you've experienced before. Brace yourself for a nightmarish battle against the bloodthirsty minions of an ancient, forgotten god bent on wiping humanity from the face of the earth

WWW.BLOOD.COM

With thanks to

Dr James Isbister, Sydney, SABM 2005


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Blood you've experienced before. Brace yourself for a nightmarish battle against the

הואבדםהבשרנפשכי

ויקרא Leviticus 17

(‘the life/soul of the flesh is in the blood’)

Blood transfusion: other than

as a scarce and expensive resource, who cares?

Adverse effects

Errors

1:18,000 units to wrong pt


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Patients you've experienced before. Brace yourself for a nightmarish battle against the think blood transfusion is special and beneficial, but have difficulty accepting small risks they can’t control.

Blood Donorsbelieve their contribution is a gift to the community that will be used appropriately and safely

Cliniciansthink blood is ordinary, take blood transfusion for granted, benefit is assumed and risks regarded as minimal.

Governmentsview blood as a commodity and transfusion medicine as an expensive support service which should be regulated and funded in a cost-effective manner.

Blood transfusion


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1997 you've experienced before. Brace yourself for a nightmarish battle against the Krever Commission: Recommendation #9:

“It is recommended that ….. promote appropriate use of, and alternatives to, blood components and blood products.”

1996 Gallup Poll indicates that only 7% of respondents would want to receive donated blood; 82% think patients should have the right to make final decision


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Virus TTI you've experienced before. Brace yourself for a nightmarish battle against the

Residual risk

HIV1:10 million

HCV1:3 million

HBV1:72,000 (no NAT)

HTLV 1:1.1 million

Per unit

Risk of death from:

(actuarial tables)

MVA 1: 9,000

Home accident 1: 10,000

Murdered in Canada 1: 85,000

General anaesthesia 1: 20-50,000

Lightning 1: 3,000,000

Chiavetta et al, CMAJ, 169:67-73, 2003


Standard collection pouch

bacterial you've experienced before. Brace yourself for a nightmarish battle against the

contamination

bacterial survival in component

febrile

reaction

severe

reaction

fatality

106

105

104

102

103

Bacterial contamination

Standard collection pouch

Skin fragment


Bacterial contamination of platelets
Bacterial contamination of platelets you've experienced before. Brace yourself for a nightmarish battle against the

N plt type % positive

Blajchman (1995) 15,838 RDP 0.04%

Risk of receiving BCP 50-250-fold > combined risk from virus TTI.

Estimated that BCP kill ≈15 Canadians/yr


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The BSE threat, vCJD & transfusion you've experienced before. Brace yourself for a nightmarish battle against the

UK


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vCJD (variant Creutzfeldt-Jakob) you've experienced before. Brace yourself for a nightmarish battle against the

First case in UK in 1996; annual increase; ? peaked

167 cases of vCJD worldwide; 1 in Canada

Human cases about 5 yrs after BSE epidemic

Growth hormone, corneas, ---

?No transfusion-transmitted cases

Currently no screening test for vCJD

Geographic exclusion criteria for donor exclusion

2003

1994

Llewelyn et al: Lancet 363:417-421, 2004

Peden et al: Lancet 364:527-529, 2004


Trali transfusion related acute lung injury
TRALI: you've experienced before. Brace yourself for a nightmarish battle against the Transfusion-related acute lung injury

leading cause of transfusion-related death

Anti-leukocyte antibody, usually in the donor blood product


Trali cases canada
TRALI cases: Canada you've experienced before. Brace yourself for a nightmarish battle against the

  • Age – median 68 years, range 16-94 years

  • Sex – female 45%, male 55%

  • Blood pressure – 30% hypotension, 24% hypertension,

  • 75% perioperative (CVS), haem/onc, trauma patients


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TRALI: you've experienced before. Brace yourself for a nightmarish battle against the

  • New acute lung injury; bilateral pulmonary infiltrates

  • Within 6 hours of plasma-containing transfusion

  • Acute respiratory distress

  • . ●Hypoxemia

  • PaO2 of 30 – 50 torr;

    • PaO2/FIO2 <300 mm Hg;

    • O2 saturation < 90% on room air

  • Fever (1 to 2 oC)

  • No evidence of circulatory overload


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  • TRALI: you've experienced before. Brace yourself for a nightmarish battle against the

  • often difficult to know if X-ray image that of noncardiogenic pulmonary edema

  • Rales and diminished breath sounds

  • Normal jugular venous pressure

  • Normal/low pulmonary wedge pressure

  • Does not respond to diuretics

  • Hypotension does not respond to intravenous fluids

  • Absent S3


Trali patients
TRALI you've experienced before. Brace yourself for a nightmarish battle against the patients

  • 17% died

  • 48% mechanical ventilation (70% of those who died)

  • Donor α-leukocyte antibodies in 63%

    α-PMN in 54% of those who died vs in 25% of patients who recovered;

    sicker patients also frequently received components containing α-HLA,

    particularly class II


Donors
Donors you've experienced before. Brace yourself for a nightmarish battle against the

  • Overall, 18 % of donors had anti-HLA

    (29% female vs 7% male)

  • 9 % of donors had anti-PMN

    (equal frequency female & male)

  • ?? Remove suspect donors from the donor pool;

  • ?? Remove female blood donors

  • Many donors implicated had donated many times before (in one case >200 times) without a previously reported TRALI reaction


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Donor blood products with α-leukocyte antibodies you've experienced before. Brace yourself for a nightmarish battle against the

implicated in TRALI cases


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Antibody to WBC you've experienced before. Brace yourself for a nightmarish battle against the

TRALI

Pulmonary damage

Ag/Ab reaction

Capillary leak syndrome

C’ activation

Pulmonary endothelial damage

Leukosequestration

Pulmonary endothelium

primed PMN sequester on EC, adhere, cytoskeletal change, rigid, trapped in microvasculature

Immunogenic TRALI: Classical theory, anti-leukocyte antibody,

but antibody not always found.

Activation of EC

Hyper-reactive PMN

adhesion molecules

chemokines

Silliman et al: Non-immunogenic TRALI.2 stage process.

i. Susceptible patient: sepsis, surgery, trauma,

ii. Transfusion

Release enzymes

PMN primed

2

1

  • Transfusion:

  • BRMs:

  • Lipids (Lyso-PCs)

  • Cytokines

  • Antibodies

  • Susceptible patient

  • Sepsis

  • Surgery (CPB)

  • Trauma


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  • 1 you've experienced before. Brace yourself for a nightmarish battle against the Susceptible pt: sepsis, surgery, trauma

  • Activated EC

  • Chemokines

  • Adhesion molecules on EC

O2-

Capillary leak

2Transfusion (BRM)

Lipids (lyso-PCs)

Cytokines

(antibodies, microvesicles, cell fragments)

Attraction Tethering

Firm Adhesion

Activation EC damage

Primed PMN

Rigid

Trapped . in mv

Hyper-reactive

enzymes

Pulmonary endothelium

TRALI

Lung damage


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Transfusion-induced you've experienced before. Brace yourself for a nightmarish battle against the immunomodulation

  • Renal allograft survival [Opelz & Terasaki, 1981]

  • Graft one year survival rates

    • 23% in patients not transfused

    • 87% in patients receiving > 10 transfusions

transfusion-induced immunosuppression (allogeneic leukocytes)


Transfusion induced immunomodulation due to allogeneic leukocytes some potential mechanisms
Transfusion-induced immunomodulation you've experienced before. Brace yourself for a nightmarish battle against the (due to allogeneic leukocytes)Some potential mechanisms:

  • Clonal deletion or anergy (of CTLs)

  • Induction of suppressor cells

  • Production of antiidiotypic antibody

  • Suppression of NK cell activity

  • Polarization of cytokine response


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Infections & perioperative transfusion you've experienced before. Brace yourself for a nightmarish battle against the

10/16 observational studies and 4/5 randomized trials showed statistically significant reduction in postoperative infections with autologous versus allogeneic transfusions.

Even more true for no transfusion versus allogeneic transfusion


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In various surgical settings, no variable was more you've experienced before. Brace yourself for a nightmarish battle against the

consistently associated with postoperative infection

than was perioperative allogeneic transfusion

  • For each allogeneic RBC unit given, 1.5 fold increase in nosocomial infection.

  • Translates into potential morbidity, mortality and LOS.

    (Koval et al, J Orthop Trauma, 1997, 11:260)


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SHOT, UK, annual report 2000-01 you've experienced before. Brace yourself for a nightmarish battle against the

Adverse effects of transfusion

TRALI 4.8%

TTI 1.9%

TA-GvHD 0.3%

PTP 1.0%

Delayed HTR 12.7%

Acute HTR 11.7%

IBCT 67.6%

Incorrect blood component transfused (IBCT): “Wrong blood” is, without exception, an avoidable error


Shot 1996 97 to 2001 01
SHOT 1996/97 to 2001/01 you've experienced before. Brace yourself for a nightmarish battle against the

  • Blood centre 2%

  • Transfusion laboratory 28%

  • Collection, administration 55%

  • Prescription, sampling, request 13%

  • Other 1%

  • Unknown<1%

.

68%

Wards


Cbs projections collections vs demands
CBS Projections: Collections vs Demands you've experienced before. Brace yourself for a nightmarish battle against the


Cost of blood transfusion in us 1998
Cost of Blood Transfusion (in US$, 1998) you've experienced before. Brace yourself for a nightmarish battle against the

Mean Overall Cost: $491-$545 per unit.

  • Overhead = facility cost

  • Variable direct labour = lab technologists, phlebotomists, nurses

  • Fixed direct labour = administrators, etc.

  • Direct material = supplies, blood, tests

Ontario blood budget:

$420 million per year

.

Cremieux P-Y, Barrett B, Anderson K, Slavin MB. J Clin Oncol 18:2755, 2000


Costs incurred in provision of blood
Costs incurred in provision of blood you've experienced before. Brace yourself for a nightmarish battle against the

  • Recruitment and collections

  • Infectious disease testing

  • Manufacturing, shipping, handling, labelling

  • Pre-transfusion testing

  • Transfusion costs

  • Post-transfusion sequelae

  • Regulatory and legal costs


Hospital charges
Hospital charges you've experienced before. Brace yourself for a nightmarish battle against the

  • Blood type ABO $ 156

  • Blood type Rh 85

  • Antibody screen 182

  • Crossmatch, immediate spin 350

  • Crossmatch, antiglobulin (Coombs) 391

  • Red cell antigen screening, per antigen 108

  • Fresh frozen plasma thawing 156

  • Crypoprecipitate pooling 43

  • Handling 86

  • Surcharge 15%

    Zeger, Jabbour (USC): Transfusion-free medicine and surgery, 2005, Blackwell


Costs adult open heart surgery
COSTS: Adult open heart surgery you've experienced before. Brace yourself for a nightmarish battle against the

Jabbour, 2005


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It is clear that: you've experienced before. Brace yourself for a nightmarish battle against the

1) the demand for blood outweighs the supply

2) there are real risks associated with blood transfusion

3) blood is not ‘free’


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Blood transfusion is a lot like marriage. you've experienced before. Brace yourself for a nightmarish battle against the

It should not be entered into lightly,

unadvisedly or wantonly,

or more often

than is absolutely necessary.

[Beal RW: Aust N Z J Surg 46:309, 1976]


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Blood is Good????? you've experienced before. Brace yourself for a nightmarish battle against the


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1960 you've experienced before. Brace yourself for a nightmarish battle against the

1971


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Blood you've experienced before. Brace yourself for a nightmarish battle against the

  • Enough

  • In the right place

  • At the right time

  • And not too much

Most people in this room will depart Earth as a result of not maintaining one or more of these functions of the blood

J Isbister, SABM 2005


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Blood Conservation: you've experienced before. Brace yourself for a nightmarish battle against the Aims

Management

  • Allogeneic transfusion avoidance

  • Transfusion reduction


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Goals: Minimize Anemia and Avoid Allogeneic Blood Transfusion.

Risk

Anemia

(Reduced

Hematocrit)

Allogeneic

Transfusion

Transfusion has risks,

but bleeding to death is fatal !


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Anemia is common: 30% patients preop Transfusion.

In the ICU, most patients anemic at time of admission.

Hb typically declines by at least 0.5 g/dL/day in first 3 d

of ICU stay. Continues to decline if sepsis/severe illness.

These patients particularly may be at risk from anemia

(cardiovascular, respiratory, metabolic compromise).

Etiology of anemia multifactorial:

phlebotomy, GI bleeding, coagulopathy, blood loss from

vascular procedures, renal failure, nutritional deficiencies,

marrow suppression, impaired erythropoietin response, etc


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Blood Transfusion.

Conservation??

Office of the Director of Medical Services

“I need you to find a radically innovative new way to keep everything exactly the same”


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Blood conservation approaches in surgery Transfusion.

Autologous blood (PAD, cell salvage, ANH)

Erythropoietin (EPO, Eprex)

Other pharmacologics (e.g. antifibrinolytics)

Fibrin glues (e.g. Tisseel)

Hemostatic/harmonic scalpels

Blood substitutes

Controlled hypotension; positioning

Minimally invasive surgery

Transfusion trigger (level of Hb)

rFVIIa

etc


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Preoperative Autologous Donation (PAD) in primary hip surgery:No PAD, 29% had allogeneic transfusionPAD, 6% had allogeneic transfusion(B Feagan; 2001/2002); 28 Ontario sites; 3352 pts

Is blood conservation approach effective in avoiding allogeneic transfusion?


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Pre-operative surgery:EPO for Orthopaedic Surgery

Feagan BG et al. Ann Intern Med 133:845-854, 2000.

Allogeneic Blood Transfusions

45% in placebo group

23% in low dose EPO (p<0.003)

11% in high dose EPO (p< 0.001)

Significant requirement for supplemental iron

Monitor serum ferritin, transferrin saturation


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Initial Hb level predictive of transfusion. surgery:

Hb pre-op% transfused

< 130 53 %

> 130 20 %

But, if

Hb done in PAF

< 130

> 130

BC Capital Health Region

EPO

Iron

B12, folate

15%

5%


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Transfusion trigger: surgery:How much Hb do you need?

Operative mortality increases with untreated anemia.

Preop Hb Mortality

< 60 g/L 62%

61 - 80 33%

81 - 100 0%

> 100 7%

Carson, Am J Surg 170:6A:32S, 1995

Adjusting for APACHE II score: Post-op,2.5X increase inodds of death for each 10 g/L decrease in Hb below 80 g/L

(Carson et al: Transfusion 42:812, 2002)


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Crude in-hospital survival rate of patients with different preoperative haemoglobin concentrations

.

Preoperative haemoglobin >100g/L

.

Preoperative haemoglobin ≤100g/L

So level of Hgb important, but at what trigger should one transfuse?

Lancet, Vol 369, May 18, 2002

.


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So how many red cells do you need? preoperative haemoglobin concentrations

“The bad news is, you have only one red blood cell.

The good news is, he’s a workaholic!”


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H preoperative haemoglobin concentrations ébert et al; NEJM 340:409, 1999: ICU patients (TRICC)

Transfusion trigger randomized by Hb(70 vs 100 g/L)restrictiveliberal

Units transfused 2.6 5.4

Mean Hb values 85 107

Hospital morbidity 22% 28%

ICU mortality 14% 16%

30 day mortality 19% 23%

Organ failure score 8.3 8.8

Trend to improved survival in restricted group (p=0.10)


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1940’s – 80’s: preoperative haemoglobin concentrations Hb 100g/L

1980’s – 2005: Hb 80g/L

Transfusion trigger

70g/L

60g/L

70g/L

Blood Management


What hgb level
WHAT HGB LEVEL? preoperative haemoglobin concentrations

  • SAFE PREOPERATIVE HGB WILL VARY FROM ONE PATIENT TO THE NEXT, AND

  • SAFE PREOPERATIVE HGB WILL VARY FOR THE SAME PATIENT DEPENDING ON CLINICAL CIRCUMSTANCES


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When Does Anemic Organ Injury Occur? preoperative haemoglobin concentrations

Activation of

Protective Mechanisms

Tissue

Hypoxia

Clinical Evidence

Of Harm

90 g.L-1

70 g.L-1

30 g.L-1

100 g.L-1

Hemoglobin Concentration


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90 g preoperative haemoglobin concentrations .L-1

70 g.L-1

30 g.L-1

100 g.L-1

Hemoglobin Concentration

What is the Optimal Transfusion Threshold ?

Anaerobic

Metabolism

Co-

Morbidities

No Co-

Morbidities

?

???


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. preoperative haemoglobin concentrations

.

.

Hb decrease 2 – 3.9 g/dL

Hb decrease > 4 g/dL

Hb decrease 2-3.9 g/dL +CVD

Adjusted odds ratio for mortality according to preoperative hemoglobin concentration in patients refusing red blood cell (RBC) transfusions.

While cardiovascular disease (CVD) increases the risk of mortality, increased blood loss during surgery (resulting in a decrease in Hb) are also associated with an important rise in the risk of death.

Adapted from Carson JL et al. Lancet 348: 1055, 1996.


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  • Blood Management preoperative haemoglobin concentrations is all about

  • Oxygen

  • Hemostasis


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Arsenal FC preoperative haemoglobin concentrations

Tour de France

J Isbister, SABM 2005

Modified from James Isbister, SABM 2005


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O2 Availability preoperative haemoglobin concentrations

O2 Diffusion

O2 Release

O2 Uptake

Inspired PO2Lung Fn (Diffusion)

InterstitialSpace

Red Cell, HbEndothelial Fn

Red Cell& Hb Function

O2 Convection

Cardiac & Vascular Fn

O2 Consumption

TissueMetabolism

ATP

Oxygen delivery

O2 Consumption

O2 Delivery DO2

HbO2

HbO2

Hemoglobin

O2

O2

O2

Myoglobin

Hemoglobin

HbO2

CO2

O2

O2

With thanks to James Isbister, SABM 2005 (modified)


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Limit transfusion to appropriate need. Transfuse unit by unit.

There is no single Hb value optimal for all patients:

consider factors such as:

Cardiac output

Heart rate, stroke volume, contractility

Peripheral vascular resistance

Increased O2 release from red cell

Decreased blood viscosity

Dilution

  • Assessing Efficacy

  • Red cell survival

  • Hemoglobin level

  • Patient symptoms

  • Doctor feels better


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MOH unit.

DEVELOPING A NETWORK of

ONTARIO TRANSFUSION COORDINATORS

Enhance transfusion practice outside of the Blood Bank

* ‘clinical bridge’ between Transfusion Service & rest of hospital

Interact with physicians, nurses & patients to promote . blood conservation & alternatives to allogeneic transfusion

Anticipated a 5 to 10% reduction in red cell use

.

Susan Gagne; Niagara Health System; 905-684-7271 ext 46570


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Pre-operative approach unit.

  • assess at pre-admission clinic (3-5 weeks before surgery)

  • identify patients at risk of transfusion ahead of surgery

  • discuss informed consent and transfusion alternatives

  • investigate, diagnose and treat anemia

  • (family doctor, surgeon, anesthetist, hematologist)

  • erythropoietin and / or iron

  • predonation of autologous blood (with hematinics + EPO)

  • stop anticoagulants/antiplatelet drugs if safe to do so

  • minimize blood taken for lab testing


Progress

10 unit.

HSC, MSH, UHN, TEGH, SJH, SWCHC, SMH, BrH, Tr,

Progress

23 hospitals chosen based on blood utilization & geography

  • At specific time periods, collect detailed anonymized patient information for a defined number of all consecutive patients admitted for the designated procedures

  • Evaluations: Baseline (Jan 2002), 12, 18 & 24 months

  • Aggregate data for Ministry of Health of Ontario; Site-specific data for each institution

10

[Guelph General Hospital, Hamilton Health Sciences Centre, Hospital for Sick Children (Toronto), Kingston General Hospital, Lakeridge Health (Oshawa), London Health Science Centre, Mt Sinai Hospital (Toronto), Niagara Health System, North Bay General Hospital, Peterborough Regional Health Centre, Sault Area Hospitals (Sault St Marie), Scarborough General Hospital, St Joseph’s Health Centre (Toronto), St Mary’s General Hospital (Kitchener), St Michael’s Hospital (Toronto), Sudbury Regional Hospital, Sunnybrook & Women’s College Health Sciences Centre (Toronto), The Ottawa Hospital, Toronto East General Hospital, Trillium Health Centre (Mississauga), University Health Network (Toronto), Windsor Regional Hospital]


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White unit.= pre-ONTraC

Blue = at 6 mos

Yellow = at 16 mos

Red= at 24 mos

Education in-services in

previous 6 mos:

Pre-Ontrac = < 20

At 6 mos = > 140

At 16 mos = > 250

At 24 mos = > 290


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Three targeted surgical procedures unit.

Knee arthroplasty:

19 hospitals; 1150 patients at each time point

AAA surgery:

17 hospitals; 300 patients at each time point

CABG surgery (primary):

4 hospitals; 300 patients at each time point


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Aggr unit.


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Non-autologous pts unit.

Autologous pts


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. unit.



Red cells
Red Cells unit.


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J Surg Research 2002;102:237-244 unit.

Prospective data from 6301 non-cardiac surgical procedures 1995-2000

Transfusion PRBCs > 4 units

Odds Ratio:

Death 2.84

Infection 9.28

P<0.001 for both



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Pre-op Hb versus number of units transfused unit.

Pre-op Hb (g/L)

Pre-op Hb

Pre-op Hb

Mean Pre-op Hb

P < 0.0001


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Compared to NO transfusion: unit.

Knee CABG AAA

Every ↓ in pre-op Hb of 10 g/L increases chance of allogeneic transf by 1.839 (84%) 1.847 1.433

Every ↓ in nadir Hb of 10 g/L increases chance of allogeneic transf by 4.31 (430%) 4.502 3.534

As age increases by 10 yrs, the odds of an allogeneic transfusion  by 1.515 1.558 1.818

As BSA decreases by -0.25, the odds of an allogeneic transfusion  by 1.466 2.288 1.598

Being female increases the odds of receiving allogeneic transfusion by 1.445 6.820 1.987

Having an allogeneic transfusion odds of postoperative infection by 2.653 2.681 1.950

Each additional allogeneic unit the chance of infection by a factor of 1.587 1.524 1.488


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Increased risk of unit.postoperative infection per allogeneic units RCC transfused

Increased risk of LOS per allogeneic units RCC transfused


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At 12 months unit.,

  • For Ontario, estimate for the 3 targeted procedures only:

  • Red cell product (at $400/unit) 8,640,000

  • Reduced LOS 5,300,000

  • Reduced work in hospitals 650,000

  • Total savings per year: $14,950,000

  • In addition: greater patient satisfaction and safety

  • Cost of program per year: $ 1,800,000

  • Expansion to other procedures & other conservation measures should result in even greater savings


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DEMAND unit.

SUPPLY

What’s best for the blood supply?

What’s best for the patient?


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G unit.

4

T

A

Formula for “Scientific” Medical Opinion

Volume of hot air

Years from graduation

V

=

x

Distance from regular patient contact

Academic rank (Professor =1 , Lecturer = 4)

J Isbister, SABM, 2005


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CLINICAL DECISION MAKING unit.

Clinical Experience

Repeating one’s own mistakes with increasing confidence over time

Evidence Based Medicine

Minimal variation inclinical practice with people perpetuating the mistakes of others

Nothing is black and white, medicine ispracticed in the context of constant uncertainty


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Law unit.

Politics

Perception

Transfusion Medicine

Practice

Evidence

Science

Decisions

J Isbister


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Paradigm Shift unit.

  • Relace transfusion with

  • Blood conservation =

  • Bloodless medicine =

  • Bloodless surgery =

  • Blood management

Thomas S. Kuhn 1922-1996


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Paradigm Shift unit.

Bloodless Surgery

Ott DA, Cooley DA. Cardiovascular surgery in Jehovah's Witnesses. Report of 542 operations without blood transfusion. JAMA 238:1256-8, 1977.

Jehovah's Witnesses who require operation represent a challenge to the physician because of the patients' refusal to accept blood transfusion. We report a 20-year experience with a consecutive series of 542 Jehovah's Witness patients ranging in age from 1 day to 89 years who underwent operation. Early mortality (within 30 days after operation) was 9.4%. In 362 patients requiring temporary cardiopulmonary bypass, early mortality was 10.7%. Mortality was 13.5% among 126 patients who had single- or double-valve replacement. The only deaths among patients who had aortic valve replacement or repair of a ventricular septal defect occurred in those who had some serious complication before operation. Preoperative or postoperative anemia was a contributing factor in 12 deaths, and loss of blood was the direct cause of three deaths. Cardiovascular operations can be performed safely without blood transfusion.


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Ontrac presentation plus random slides after 28 mb

Why “bloodless medicine”…? unit.

There are many bloodless medicine programs …and the number is growing. Even in remote areas of Siberia, physicians and patients know about bloodless medicine.

If one types “bloodless medicine” into an internet search engine,

> 12,000 hits are obtained.…

[from T Kickler, Johns Hopkins, Transfusion 43:550, May 2003]


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Bloodless medicine (or blood conservation) unit.

Requires coordination of services across a variety of departments….

cooperation between outpatient scheduling, surgical and

anesthesia physicians and their clinic personnel, operating room

scheduling, intensivists and hematologists to get the patient

prepared, …the billing office….

This is in contrast to a transfusion, which can usually be accomplished with one phone call….

[from T Kickler, Johns Hopkins, Transfusion 43:550, May 2003]


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Some institutions market their bloodless medicine programs by pointing out the complications and adverse effects of allogeneic transfusion, as a way to lower hospital expenses or length of hospital admissions.

May be so, but careful outcomes research needed before making this the only argument to establish bloodless medicine program.

The strongest argument for having a bloodless medicine program is to respect the rights of patients…. based on the ethical value of autonomy or self-determination, and medical institutions have a responsibility to respond to this need.

A plethora of new techniques and therapies are available …and their relative merits, alone and in combination, still needs to be investigated,but it is becoming standard of practice.


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3 year renewable contract signed; to 2009 by pointing out the complications and adverse effects of allogeneic transfusion, as a way to lower hospital expenses or length of hospital admissions.

5 new coordinators; 3 new sites

New targeted procedures


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Individual sites by pointing out the complications and adverse effects of allogeneic transfusion, as a way to lower hospital expenses or length of hospital admissions.

mean

Aggr


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Nadir hemoglobin levels as surrogate by pointing out the complications and adverse effects of allogeneic transfusion, as a way to lower hospital expenses or length of hospital admissions.

measure of transfusion trigger

Radical prostatectomy:

Non-autologous 83.29

Autologous 89.47

  • Nadir hemoglobins higher for autologous than for allogeneic transfusions

  • Progressive reduction in hemoglobin level trigger for transfusions

  • Trigger hemoglobin higher in knee surgery than in CABG !!

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20% of Pts had autologous blood collected, of whom 47% received their autologous blood; only 3.47% also received allogeneic blood.

42% of autologous units collected were transfused.


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Transfusion Medicine received their autologous blood;

Anesthesi-ologist

Hematologist

Opinion Leader

Cooordinator

PatientBlood Management

Bureaucrat

Surgeon

ICU &Wards


The best transfusion is the transfusion not given
The best transfusion is the transfusion not given! received their autologous blood;

Allogeneic blood transfusion should only be used as therapy when there is evidence for potential benefit, there are no alternatives, a quality product is available and the risks are appropriately considered and balanced against the benefits.

Paradigm Shift

Thank you


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Procedures employed: received their autologous blood;

PAD

EPO

Overall EPO use per month

  • Increase in pre-operative autologous donation in CABG & AAA patients

  • Progressive increase in use of erythropoietin after first year

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Other blood conservation procedures (% of patients) received their autologous blood;

Cell saver

antifibrinolytics

Fibrin glue

hypotension

DDAVP

Limited use of other procedures; specific for type of surgery

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Miscellaneous slides received their autologous blood;


Pharmacologic agents costs
Pharmacologic agents: costs received their autologous blood;

  • Cost per dose Cost per course

  • Eprex 588 2,350

  • Darbopoietin 132 530

  • Amicar 18 46

  • Aprotinin 540 1,000

  • DDAVP 144

  • Tranexamic acid 73

  • rFVIIa 7,056 (4.8 mg)

  • Jabbour


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    Transfusion trigger received their autologous blood;

    Restrictive vs Liberal


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    Consider: received their autologous blood; PADEPOcell saver

    Hb > 130 g/L  N/A

    Hb >100 - <130 g/L N/A

    Surgery 2 to 4 weeks awayN/A

    >10% likely to require transfusion  

    Anticipated blood loss (units) 1-2 1-5 >1;

    >20% BV

    Need for Fe supplement 

    Not within 72 h of surgery 


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    Factors to consider in the surgical transfusion decision received their autologous blood;

    Clinical history

    Cardiopulmonary disease

    Existing coagulopathy

    Anemia

    Trauma classification (mechanism of injury)

    Medications

    Antiplatelet drugs; Anticoagulants

    Clinical symptoms

    Dyspnea on exertion; Angina

    Hemoglobin/hematocrit level

    Oxygen delivery/consumption

    Surgical procedure(elective vs emergency; laparoscopic vs open)

    Estimated blood loss

    Jehovah’s Witness


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    • Independent predictors for transfusion: received their autologous blood;

    • Preoperative factors:

    • Red blood cell mass

    • Type of operation

    • Urgency of operation

    • Number of diseased vessels

    • Serum creatinine > 1.3 mg/dL

    • Preoperative prothrombin time

      Postoperative factors:

    • Cardiopulmonary bypass time

    • Three or fewer bypass grafts

    • Lesser volume of ANH removed

    • Total crystalloid > 2500 ml

    Moskowitz et al


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    Identifying patients for blood conservation strategies received their autologous blood;

    • 24,509 consecutive adult surgical patients; 14 procedures (not neuro or cardiac)

    • Type of procedure

    • Age

    • Sex

    • Emergency surgery

    • Preoperative autologous donation

    • Preoperative hemoglobin level

    Identifying patients for blood conservation strategies. Van Klei et al, Br J Surg 89:1176, 2002


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    • Preoperative autologous donation (PAD) received their autologous blood;

    • Consider when:

    • Preoperative hemoglobin >130 g/L

    • > 10% of patients undergoing procedure

    • require transfusion

    • Elective surgery scheduled 2 to 4 weeks away

    • Patient on iron supplement

    • Not within 72 h of surgery

    • no severe cardiovascular or hemodynamic problems


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    Autologous blood donation received their autologous blood;

    AdvantagesDisadvantages

    Prevents transfusion-transmitted disease No effect on risk of bacterial contamination

    Prevents red cell alloimmunization No effect on risk of ABO incompatibility error

    Supplements the blood supply Costs more than allogeneic blood?

    Provides compatible blood for pts with alloabs Wastes blood not transfused

    Prevents some adverse reactions Possible adverse reactions from donation

    Reduces likelihood of allogeneic transfusion May subject patient to preoperative anemia


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    Autologous donation deferral received their autologous blood;

    • evidence of infection or bacteremia

    • severe aortic stenosis

    • unstable angina

    • myocardial infarction or cerebrovascular accident in past 6 months

    • high grade left main coronary artery disease

    • cyanotic heart disease

    • active seizure disorder

    • uncontrolled hypertension

    Br J Anaesth 78:768, 1997


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    PAD received their autologous blood;

    observational

    42 studies

    RR 0.31

    [Carless et al

    Transf Med 14:123, 2004]


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    PAD received their autologous blood;

    randomized

    8 studies

    RR 0.37


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    Autologous Donation: received their autologous blood;

    In contrast to autologous blood donation under standard

    conditions, in “aggressive” autologous blood phlebotomy

    (twice weekly for 3 weeks beginning 25-35 days before surgery)

    endogenous erythropoietin levels do increase.*

    Can be further stimulated by exogenous erythropoietin.**

    * Goodnough et al: J Lab Clin Med 236:57, 1995

    **Goodnough et al: N Engl J Med 336:933, 1997


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    • Erythropoietin received their autologous blood;

    • Consider when:

    • Anticipated loss of two to five units

    • Preoperative hemoglobin >100 to < 130 g/L

    • Elective surgery scheduled 2 to 4 weeks away

    • Patient on iron supplement


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    Different Formulations of Recombinant Erythropoietin received their autologous blood;

    Estimated total number of cases of PRCA is about 250

    Possibly related to formulation and increased incidence with sq administration

    Never seen if EPO is administered IV

    Since 1998- 1.7/10,000 cases in France, 0.26/10,000 cases in Germany


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    CABG: received their autologous blood;

    .

    .

    .

    .

    .


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    • Cell Salvage received their autologous blood;

    • Consider when:

    • Blood loss likely >20% of blood volume

    • > 10% of patients undergoing procedure

      require transfusion

    • Mean transfusion requirement exceeds one unit


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    • ANH received their autologous blood;

    • Consider when:

    • Blood loss likely >20% of blood volume

    • Preoperative hemoglobin >100 g/L

    • Absence of severe cardiac disease


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    • Before planned surgery received their autologous blood; :

    • Assessment at preadmission clinic

    • Correcting treatable anemia

    • Stopping anticoagulants and antiplatelet drugs,

    • if safe to do so

    • Erythropoietin and /or iron

    • Pre-donation of blood, with hematinics + erythropoietin

    • Minimizing blood taken for laboratory samples


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    • During surgery received their autologous blood; :

    • Losing less blood through optimal surgical & anesthetic technique

    • Keeping patient warm

    • Using measured hematocrit or blood loss as guide to red cell replacement

    • Using rapid hemostasis testing to guide blood component replacement

    • Antifibrinolytics to reduce bleeding in selected cases

    • Intraoperative cell salvage


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    • After surgery received their autologous blood; :

    • Postoperative cell salvage

    • Using a protocol to trigger re-exploration at a specified level of blood loss

    • Use of a protocol to guide when hemoglobin should be checked

    • Use of a protocol stating blood transfusion thersholds and targets

    • Minimizing blood taken for laboratory samples


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    • At surgery: received their autologous blood;

    • Meticulous dissection:

    • Develop avascular planes

    • Stop all small bleeders as encountered

    • Reduction of regional vascular pressure

    • Appropriate patient position

    • Blood inflow control

    • Limb exsanguination & proximal tourniquet

    • Prevention of hypothermia

    • Optimal use of cell salvage-


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    “Haemostatic” dissecting instruments: received their autologous blood;

    mechanismdisadvantagesapplications

    Monopolar diathermy heat transmission collateral thermal damage; most procedures

    interferes with pacemakers;

    ignition of flammable fluid/gas

    Bipolar diathermy heat cannot “cut” tissues; where need ignition flammable gas/fluid precise dissection

    Argon beam heat collateral thermal damage; hepatobiliary interferes with pacemakers; surgery

    ignition of flammable gas/fluid

    Laser (e.g. Nd-YAG, CO2) heat as above according to laser type

    Ultrasound dissector mechanical cost solid organ

    disruption; some heat surgery

    Water-jet dissector mechanical cost solid organ surg


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    • Key points: received their autologous blood;

    • surgical technique is most important determinant of blood loss

    • simple physical methods result in significant reduction in blood loss

    • minimally invasive surgery can contribute to blood conservation

    • modern ‘haemostatic’ surgical instruments can contribute to bloodless dissection, especially with solid organ surgery

    • topical haemostatic agents, particularly fibrin sealants, help when bleeding not controlled by more straightforward means


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    • Pharmacologics: received their autologous blood;

    • High dose aprotinin reduces red cell and component use in cardiac, hepatic transplant and major orthopedic (but not vascular) surgery

    • Tranexamic acid inconsistent in reduction of red cells and no effect on component use

    • Tranexamic acid no proven benefit in patients taking antiplatelet drugs

    • EACA does not reduce allogeneic transfusion

    • DDAVP after cardiac surgery may be useful in proven platelet dysfunction

    • rFactor VIIa: await evidence from randomized placebo-controlled studies


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    • Potential difficulties: received their autologous blood;

    • Clinical/diagnostic criteria not detailed enough

    • Clinical information often missing/difficult to interpret

    • Donor samples difficult to retrieve; donor recall delayed

    • Shipping of samples: time, conditions

    • Crossmatch samples availability rare

    • Sensitivity of tests:

      • inherent

      • panel antigen coverage

      • false positives and negatives

      • technique specific


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    Factors to consider in the surgical transfusion decision received their autologous blood;

    Clinical history

    Cardiopulmonary disease

    Existing coagulopathy

    Anemia

    Trauma classification (mechanism of injury)

    Medications

    Antiplatelet drugs; Anticoagulants

    Clinical symptoms

    Dyspnea on exertion; Angina

    Hemoglobin/hematocrit level

    Oxygen delivery/consumption

    Surgical procedure(elective vs emergency; laparoscopic vs open)

    Estimated blood loss

    Jehovah’s Witness


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    Identifying patients for blood conservation strategies received their autologous blood;

    • 24,509 consecutive adult surgical patients; 14 procedures (not neuro or cardiac)

    • Type of procedure

    • Age

    • Sex

    • Emergency surgery

    • Preoperative autologous donation

    • Preoperative hemoglobin level

    Identifying patients for blood conservation strategies. Van Klei et al, Br J Surg 89:1176, 2002


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    K Sazama, Vox Sang 92:95-102, 2007. received their autologous blood;


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    K Sazama, Vox Sang 92:95-102, 2007. received their autologous blood;