how to reduce blood transfusion at elective surgery in obg
TRANSCRIPT
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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.
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
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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…)
