how to reduce blood transfusion at elective surgery in obg

1

BELLARY OBG SOCIETY

STONE CHARIOT :HAMPISTONE CHARIOT :HAMPI

Alternatives to blood-transfusion in Elective surgery

Prof. (Capt.) Shankar.J.

• National subject expert - 2012 to 2014• MCI Inspector (PG Faculty – OBG)• PG Examiner for MD,DGO & DNB • PG, UG Paper Setter• Founder of Ballari OBG Society, 1998.

profcaptshankarj@gmail.com

Available Alternatives(Options)

1. Erythropoietin therapy

2. IV IRON substitution

3. Preop medication moderation

4. Hypotensive epidural anaesthesia

5. Body temperature adjustment

6. Intraoperative methods

7. Intra op cell salvage

8. Acute normovolumic haemodilution

9. Autologous blood transfusion

10. Blood substitute (Artificial blood)

Effective Blood substitutes

An attainable reality or Lost cause ?Hemosol, hemopure, perflubron,

polyheme

Anaesthesiology 2006; 105(1); 198

Rule of 10:30

Haemoglobin 10gm%Haematocrit 30%

Currently

7-9gm% widely accepted 6-10 gm%- packed cells Below 6-morbidity Cell Salvage for minimising perioperative allogenic blood

transfusion-2010,Cochvane database, systemic review(4) ID 001888

Erythropoietin

Glycoprotein hormonePrecursor of erythropoiesisElevates haematocritRisk of thrombosisDose 100 IU/kg Twice weekly X 2weeks

Erythropoietin

Contraindications PregnancyLactationHypertension/ PIHh/o thromoembolismNeocytolysis

cost effectiveness of cell salvage and ailternative methods of minimising blood transfusion, A systemic review Health.technol.Assess, 2006

IV Iron Substitution

Iron is 5x more effectiveIron dextran : risks , reactionsIron sucroseFerric carboxy maltose complex (FCM)Well toleratedDecrease reaction, infection and mortalityWorks synergestically with erythropoietin

Ideal parental iron preparation

Various parenteral iron preparations

Pre op medicationsAspirin, clopidogrel, Vit K anticoagulantsRisk of bleeding

Antiplatelet drugs 2-20%

Aspirin + antiplatelet drugs: 30-50%Stop aspirin if expected blood loss ≥2LNSAIDs stop 24hrs aheadSelective COX 2 inhibitors betterPlatelet aggregation, prolonged BTIntra op blood loss

Hypotensive Epidural Anaesthesia

Blood loss reduced by 25-40%Least blockage proximal T2 Dense block of cardio-acceleratory

fibres of thoracic sympathetic chainLow dose noradrenaline dripMean arterial pressureMAP reduced to 50mm Hg Post op drainage reduced

Nassen.S et al, 2008 “Vascular trauma”, in war surgery in Afghanistan and Iraq; a

series of cases 2003-2007 United states army publication

Body temperature manipulation 150 C rise =50% more blood loss

Optimise coagulation pathway Fibrinogen, prothrombin couple, protein-C

Thrombo - elastometry Cause of hemorrhage

Clotting process

Fibrinolysis

Platelet function

Acute Normovolumic Hemodilution

Blood withdrawn just before surgeryReplaced with colloids- crystalloidsPatient friendlyEconomicEasy to performUsed up 8hrs post op

Acute Normovolumic Hemodilution

V = EBVX Ho-Hf

HavV - Volume to be removed

EBV - Estimated blood volume

Ho - Initial Haematocrit

Hf - Desired Haematocrit

Hav - Average Haematocrit

(mean of Ho and Hf)

•Pre op Hb should be 11gm and above•ANH to be done by Anaesthesiologists

Thrombotic agents

Platelet gel• Platelet derived growth factor• Antibacterial (myeloperoxidase)

Fibrin sealants (glue)• Produce stable clot• 1cc glue covers 10cm2 wound area

NovoSeven® Mode of ActionEptacog alfa (activated)

Tissue factor (TF)/FVIIa,or TF/rFVIIa interaction,is necessary to initiatiate haemostasis

At pharmacological concentrations rFVIIa directly activates FX on the surface of locally activated platelets.

This activation will initiatethe ”thrombin burst”independently of FVIII and FIX. This step is independent of TF.

The thrombin burst leads to the formation of a stable clot

Autologous cell capture/Transfusion

• Direct (filtered via gauze) cell salvage• Indirect (mechanically washed) cell savage• Drain site collection• ? Hypotension, ? Pyrexia. ?Allergy

Contraindication• Peritoneal contamination• Tumour cell surgery

Pre op autologous blood donation

Collect 1-2 units blood4-6 wks ahead of surgery4 weeks of haematologic recoveryCan be used pre op/ post op45% wastageDeclining popuarity

Cell free Hb based blood substitutes and associated risks; A meta analysis ,JAMA 2008; 299(19) 2304-2312

Artificial Blood

Blood pharming Growing red cells from haematopoietic stem cell

Hemoglobin Based Oxygen Carriers (HBOCS)

Perflurocarbons (PFCs)

Artificial blood T. Bernier, Biomedical engineering, University of Rhode Island, BME-281 26 Nov 2012

ARTIFICIAL BLOOD CELLS

THE QUEST TO EXPLORE

NEVER ENDS …

DISCLAIMER

The contents of this presentation are for academic purposes only

The references quoted are not in any order

The author openly accepts comments and critics

J. SHANKAR Professor in OBG

VIMS (Govt medical College)

Ballari- Karnataka

profcaptshankarj@gmail.com

26

SAFE MOTHERHOOD

ACHIVEMENT TO FAMILY, ASSET TO COMMUNITY

FURTHER READING…WWW.ncbi.n/m.nih.gov/pmc/articles/pmc2738310/www.pharmainfo.net/artificial-blood-current-review -

United States by MPA Kulkarni.http://science.howstuffworks.com/innovation/everyday-

innovations/artificial-blood.htmPerioperative blood conservation statergy : canadian

health services guidelines- updated 2009Indian hemaetology and blood transfusion society

guidelines- current recommendations,2012Internet sources(alternate to blood transfusion,artificial

blood,autologous donors…)

THANK YOU

profcaptshankarj@gmail.com