perioperative anemia - usmf
TRANSCRIPT
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PERIOPERATIVE ANEMIA
Dr. Ion Chesov, MD, PhD, Associate Prof.
Nicolae Testemitanu State University of Medicine and Pharmacy
Valeriu Ghereg Department of Anesthesiology and Reanimatology
2019
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Conflicts of interests
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Objectives
Patient blood Management (PBM)
Anemia – definition and risks
Causes
Pathophysiology
Anemia assessment
Clinical Management
Transfusion thresholds
Point of care testing
Take home messages
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Patient Blood Management
Patient blood management is the timely application of evidence-based medical and surgical concepts design to maintain hemoglobin concentration, optimize homeostasis and minimize blood loss in an effort to improve patient outcome.
https://www.sabm.org/, accessed on 30.11.19
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Patient Blood Management
Patient blood management is the timely application of evidence-based medical and surgical concepts design to maintain hemoglobin concentration, optimize homeostasis and minimize blood loss in an effort to improve patient outcome.
https://www.sabm.org/, accessed on 30.11.19
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PBM – Blood transfusion
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PBM – Blood transfusion
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PBM key points
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Anemia -WHO
Haemoglobin concentration of less than
-130 g dl1 for men
-120 g dl1 for non-pregnant women.
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Anemia & PBM
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Anemia prevalence
Up to 60% of surgical population
5–78% of patients requiringa surgical intervention
Shander A, AmJMed 2004; 116: 58S–69S
GA Hans, Continuing Education in Anaesthesia, Critical Care & Pain, 2013
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Anemia - outcome
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Anemia - outcome
Higher mortality -2 times more likely to die
Higher transfusion requirements for small
haemoglobinchanges (10g/dL)
Longer hospital stays (median 2 days)
Death linked to severity of anaemia and to gender
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Anemia - outcome
Increase risk of AKI .
Poorer surgical outcomes.
Increase perioperative blood transfusion
Haematocrit less 39% was associated with an increased risk of 30 day postoperative mortality and cardiac events.
Arora P et, al, J Cardiothorac Vasc Anesth 2012 Browning RM et al, Aust N Z J Obstet Gynaecol 2012 David O et al Anaesth Intensive Care 2013 Klein et al. Anaesthesia June 2016 Wu W et al, J Am Med Assoc 2007; 22: 2481–8
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Pre-op anemia
Fowler, BJS, 2015
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Pre-op anemia
Leichtler, J Am Coll Sur, 2011
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Anemia -Transfusion
Munoz, BJA, 2015
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Anemia and Transfusion
Karkoutil, Can J Anesth, 2015
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Anemia and Transfusion
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Pathophysiology
DO2 COЅр1:34 Hb SaO2 Юр0:003 PaO2 Ю
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Pathophysiology
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 3 2013
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Pathophysiology
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 3 2013
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Pathophysiology
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 3 2013
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Pathophysiology
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 3 2013
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Causes
Microcytic anaemia:
- iron deficiency
- congenital haemoglobinopathies
- sideroblastic anaemia
- Vitamin B6 deficiency
- lead poisoning.
Macrocytic anaemia
- folate or vitaminB12 deficiency
- medication
-alcoholism.
Normocytic anaemia
- chronic disease, aplastic and sickle cell anaemia,
- haemolysis,
-pregnancy,
- riboflavin, and pyridoxine deficiency.
The most common cause in the surgical population
is iron deficiency *,**
*.World Health Organisation 2014
**. Preoperative anaemia Clevenger et al Anaesthesia 2015
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Iron deficiency
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Inflammatory diseases
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Causes
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Age
Kuller, Anёsthesist, 2001
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Full glass
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Clinical approach
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Anemia management
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Have a plan
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Assessment
Medical history
Full blood count
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Alternative approach
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Chronic disease vs. Iron deficiency
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ESA - guidelines
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ESA - guidelines
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ESA - guidelines
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ESA - guidelines
Treat iron deficiency
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Iron suplementation
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ESA - guidelines
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ESA’s efficacy
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ESA’s efficacy
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ESA-guidelines
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Autologus blood donation
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ESA guidelines
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Iron + ESA’s
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Iron +ESA’s + Folate (3-4 weeks)
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Iron +ESAs + Folate +B12
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ESA guidelines
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ESA guidelines
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Post-op Iron
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IV iron
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Iron + ESA’s+ B12 + Folate
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ESA guidelines
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Post-op transfusion trigger
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Post-op anemia
To be consider
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Post-op
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Restrictive vs. Liberal
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Restrictive vs. Liberal
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Restrictive vs. Liberal
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Restrictive vs. Liberal
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Restrictive vs. Liberal
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Point of care testing
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Point of care testing
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Rotem analysisi
CT (s) CFT (s)
Amplitudinea după
CT (mm) MCF*
(mm)
Indicele de liză a
trombului (%)
10 min.
A10
20 min.
A20
30 min
CLI30
60 min
CLI60
INTEM 100-240 30-110 44-66 50-71 50-72 94-100 85-100
EXTEM 38-79 34-159 43-65 50-71 50-72 94-1000 85-100
HEPTEM 100-
240**
30-110 50-72
FIBTEM 7-23 8-24 9-25***
APTEM 38-79 34-159 50-72
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Conventional test vs. Rotem
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Conventional test vs. Rotem
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Active bleeding
Perfusion
Stop bleeding
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Stop hemorrhage
Keep patient alive
- permissive hypotension
- limit fluid infusion (dilution)
Stop hemorrhage
- early surgery, damage control
Maintain coagulation competence
- target coagulopathy
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Disease coagulopathy ?
FIBRINOLYSIS
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Disease coagulopathy
Antifibrinolitic: TxA
- 1.0 gr. i.v. over 10 min.
- if necessary after 30 min 1.0 gr. i.v./10 min
- first 3 hours
Co-factors: Ca++, Ph, Temperature control
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Take home messages
Anaemia and allogenic blood transfusion are
independent risk factors for poor postoperative
outcomes: morbidity and mortality.
One-third of patients are found to be anaemic on pre-
assessment.
PBM is a concept with the goal of avoiding
unnecessary blood transfusions to improve patient
outcomes and safety.
Iron deficiency requires iron supplementation.