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Blood Day: The Role of the Anesthesiologist/Perioperative Physician. Scott Wolfe, MD, FRCPC Department of Anesthesia and Perioperative Medicine University of Manitoba. Blood Day 2011. Part 1: Transfusion Considerations Complications of transfusion Transfusions and outcomes

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blood day the role of the anesthesiologist perioperative physician

Blood Day: The Role of the Anesthesiologist/Perioperative Physician

Scott Wolfe, MD, FRCPC

Department of Anesthesia and Perioperative Medicine

University of Manitoba

blood day 2011
Blood Day 2011
  • Part 1: Transfusion Considerations
    • Complications of transfusion
    • Transfusions and outcomes
    • When to transfuse (transfusion triggers)
blood day 20111
Blood Day 2011
  • Part 2: Case Discussion- (Application Blood Conservation Strategies)
    • Correction of anemia preoperatively
    • Iron/Epo
    • PAD
    • Cell salvage
    • ANH/Hypovolemic sequestration
    • Tranexamic acid
    • Regional Data- WRHA Blood Conservation Program
slide5

PART 1 Transfusion Considerations

  • Provide a framework of concepts which translate in the pattern of practice seen in perioperative transfusion medicine
the potential hazards of transfusion
The potential hazards of Transfusion
  • Acute hemolytic transfusion reaction
    • ABO mismatch/incompatibility
  • TRALI- transfusion related acute lung injury
  • TACO- transfusion associated circulatory overload
  • Anaphylaxis
  • Infectious- HIV, Hep C, bacterial, unknown/untested pathogens
transfusion related fatalities in the united states 2004 2006
Transfusion-Related Fatalities in the United States, 2004-2006

American Blood Center Newsletter, 2007

complications of transfusion
Complications of Transfusion
  • Changes in Oxygen Transport of RBC
    • Impaired from preservation process and age of blood
    • Difficult to release O2 to tissues immediately after transfusion
  • Coagulopathy (from Massive Transfusion)
    • Dilutional thrombocytopenia +/or coagulation factors
    • Disseminated Intravascular Coagulation
  • Hypothermia
  • Electrolyte abnormalities (hyperkalemia, hypocalcemia)
  • Acid-Base abnormalities (pH 6.7-6.9, citratebicarbonate)
other associated conditions outcomes from transfusion
Other associated conditions/outcomes from transfusion
  • Immunomodulating effects
    • Increased risk of nosocomial infections
    • Acute lung injury
    • Development of autoimmune diseases later in life
  • Recurrence of malignancy
  • Length of hospital stay
transfusion trigger
Transfusion trigger
  • Threshold or lower limit when to transfuse patients
  • Studies have led to guidelines established on transfusion triggers for given patient populations
  • Shown equal if not improved outcomes in the restricted transfusion practice versus the more liberal transfusion groups
slide14

Massive transfusion and coagulopathy: pathophysiology and implications for clinical management.

Hardy JF et al. CJA 2006

so what does this mean to the perioperative health care team
So What Does This Mean to the perioperative health care team?
  • Reasonable data to avoid if possible the use of blood products
  • In General, we can adapt lower limit for transfusion than in the past
  • These two conclusions have made “Blood Conservation Strategies” more attractive in the last decade
part 2
PART 2
  • Case presentation
  • Application of perioperative blood conservation strategies
case mr x
Case: Mr. X
  • 50 yo male
  • PMhx
    • Spinal Stenosis, Anemia Hbg 100g/l, low Fe stores
  • Rest of history and labs are normal
  • Wt 70 kg
  • Scheduled for a multilevel spine instrumentation and fusion booked for 8 hours
  • Estimated Blood Loss range 1000-3000ml
preoperative period
Preoperative period
  • Allows for optimization of patients health status and correction of anemia
  • Maximum blood loss calculation (MABL):
  • MABL= (starting Hb- transfusion trigger) x pt blood volume

starting Hgb

  • For Hbg 100 could lose 1400 ml’s before trigger Hgb of 70
  • For Hgb 140 could lose 2400 ml’s before trigger Hbg 70
preoperative anemia
Preoperative anemia
  • IV or oral Iron therapy
i v iron therapy indications

I.V. Iron TherapyIndications

When oral Fe not tolerated

Urgent pre-op correction of anemia

Low hgb when transfusion may be imminent

erythropoetin epo
Erythropoetin (EPO)
  • Hormone that regulates red blood cell production
  • Perioperative Indications:
    • Anemia of chronic disease (including renal disease)
    • Adjunct to iron therapy
    • When there is limited endogenous production (hgb 105-120)
    • Occasionally adjunct to PAD
  • Usually given weekly for 2-3 weeks preoperatively
  • FDA cautions in patients with Cancer
preoperative autologous blood donation pad
Preoperative autologous blood donation (PAD):
  • Institution dependent across Canada
  • Winnipeg
    • reserved for revision Orthopedic (hip) surgery,
    • patients with rare blood types,
  • Benefits: ?possibly reduces post op infections
          • Reduces demand on allogenic blood supplies
          • Reduces transmission of some infections
          • Prevents some adverse transfusion reactions
preoperative autologous blood donation pad risks
Preoperative autologous blood donation (PAD) Risks:

Donation:

  • 12 fold higher risk of severe reaction at time on donation
  • Lost unit
  • Cancelled OR and outdated autologous unit

Transfusion

  • Bacterial contamination
  • ABO mismatch (wrong blood given)
  • Transfusion of allogenic blood when autologous available

Overall reduces chance of allogenic transfusion but increases likelihod of all transfusion, NOT been shown to be safer…

Poor Cost-effectiveness

mr x the day of surgery
Mr.X: The Day of Surgery
  • Preop:
    • Investigated anemia
    • Gave IV iron sucrose x 2 doses
    • Hbg 140
  • Now the day of the OR
  • What can we do?
mr x intraop
Mr. X: Intraop
  • Surgical technique
  • ANH
  • Cell Salvage
  • Antifibrinolytics
anh for mr x
ANH for Mr. X
  • Starting Hgb 140 g/l
  • No ANH: if loses 1000ml  140 g’s of Hb lost
  • Undergo ANH to starting hgb of 100
    • If loses 1000ml  100 g’s of Hb lost
  • End of case the whole blood taken off at beginning given back
    • Both augmenting Hgb conc. and fresh supply of coagulation factors and platelets
  • Very little data on the efficacy and safety of ANH and its widespread use at this time cannot be recommended.
    • (ASA I and Jehovah’s Witnesses)
slide34

Intraoperative cell salvage.

Kuppurao L , Wee M Contin Educ Anaesth Crit Care Pain 2010;10:104-108

hypovolemic sequestration
‘Hypovolemic sequestration’
  • Variant of ANH and cell salvage
  • Slight reduction in circulating volume ‘hypovolemia’
  • Intermediary Hgb 140125
  • Higher hgb thought to increase yield from cell salvage
  • Retain benefits of fresh supply of Hgb, plt and coag factors at end of the case
tranexamic acid
Tranexamic acid
  • An Antifibrinolytic that inhibits degradation of the fibrin, basic framework for formation of a clot  clot stabilizer
  • Hemostatic effects have been shown to reduce blood loss in orthopedic, hepatic and cardiac (Cochrane review Henry et al.)
  • Also shown to decrease mortality in trauma patients with mild to moderate bleeding given within the first 3 hours
  • Variable dosing in literature
  • 15-30mg/kg usual dose (+/- repeat in 6-8 hours)
  • Relatively safe, side effects  GI upset, seizures
  • Relative Contraindications: patients at elevated risk for thrombosis

Henry DA et al. Anti- fibrinolytic use for minimising perioperative allogeneic blood transfusion. [Systematic Review] Cochrane Injuries Group Cochrane Database of Systematic Reviews. 2011

case summary mr x
Case Summary: Mr X

OPTION 1

Standard

Preop Hgb 100

Intraop

1.5 l blood loss

Postop Hgb 70

OPTION 2

BLOOD CONSERVATION

Preop hgb 140 with IV Fe

Intraop Cellsaver, ANH

1.5 l blood loss

Postop Hgb 100

conclusion
Conclusion
  • Further studies show more restrictive transfusion practice improves outcomes
  • Known risks of transfusion
  • Limited blood supply
  • Current information locally via database  warrants further research oppurtunities
  • Blood conservation strategies will have a larger and larger role in perioperative medicine.