module 8: alternative strategies to transfusion transfusion training workshop kkm 2012

Module 8: Alternative strategies to transfusion

Transfusion Training WorkshopKKM 2012

Avoid blood transfusion if possible Strategies to avoid blood transfusion

works Make it a good clinical practice Gain experience Increase confidence

3 basic principles

1. Tolerance of anaemia

2. Optimising RBC mass

3. Minimising blood loss

1. Tolerance of anaemia

Lower transfusion threshold trigger

Adaptive mechanisms to avoid tissue hypoxia When Hb falls,

Cardiac output increases Blood viscosity decreases Peripheral vasoconstriction occurs Redistribution of blood flow Increase O2 tissue extraction

To maintain O2 delivery to tissues

Herbert PC, NEJM 1999

2. Optimising red cell mass

Pre-op planning

Pre-op planning

Bleeding risk – take a good bleeding history Baseline Hb – investigate and correct

anaemia Medications – discontinue aspirin,

anticoagulants if possible Underlying medical illness Estimate surgical blood loss Tolerance to blood loss

Optimising red cell mass

Treat underlying anaemia Keep HCT 45 – 50%

IV iron sucrose Folic acid, vitamin B12 Erythropoeitin

Case 1

80 year-old man Referred from IJN for anaemia Planned for CABG Hb 9.8

Case 1 – anaemia of inflammation Hb 9.6 MCV 97

TW 5.2 Plt 161 Crea 55 Bil 6.0 Blood film:

normochromic normocytic, no dysplasia

Medications: Simvastatin Ticlopidine Amlodipine Perindopril Pharmaton

(hematinics)

Case 1 – s/c erythropoeitin

28/8/09 9/10/09 6/11/09 8/1/10 30/4/10

9.6 10.6 11.4 13.0 12.4

CABG Feb 2012No transfusionsPost-op Hb 10

OGDS: antral erosionsColonoscopy: diverticular disNo active bleedingStarted on proton pump inhibitors

s/c Erythropoeitin 10,000 IUOnce weekly Twice weekly

HCT 48%

Case 2

15 year-old boy Acute Lymphoblastic

Leukaemia Blood group: AB Rh

neg Rx: chemotherapy Difficulty getting

blood

s/c erythropoeitin 4000 IU 2x/weekly + iron tabs

Hb maintained >8 g/dL

No tx required

3. Minimising blood loss

Minimising blood loss

Meticulous surgery Haemostatic agents Cell salvage Quick trauma

response Damage control

surgery

Normothermia

Prompt arrest of bleeding

Judicious volume resuscitation

Restrict diagnostic phlebotomy

Meticulous surgery

Positioning of patient Avoid venous compression

Least traumatic approach Minimize duration of surgery Maintain normothermia

Cell salvage

Saves 50% of blood loss Indication: estimated blood loss >1 L Cell salvage device

Recover the shed blood Filter debris ± Wash red cells

Haemostatic agents

Tranexamic acid Topical fibrin glues (fibrinogen +

thrombin) Generates instant clot

Oozing Leaks Tissue fixation

Lancet 2010

CRASH-2

Quick Trauma Response

Damage control surgery Do not wait to stabilize patient first Avoid excessive fluid resuscitation

Rapid rewarming

Avoid transfusion whenever possible

Transfusion has its risks

What would you do?

26/ F G7 P6 @ 36 weeks Hb 5.4 MCV 58 fL

IV venofer

Mean rise in Hb by 2.2 g/dL in 1 week (post-partum patients) with IV venofer 200 mg

NHS 2008

Gravier A, J Gynecol Obst Reprod Biol 1999

The end

Thank you