SPEAKER: DR. BARILIN PASSAH

TRANFUSION SUPPORT IN SURGERY &

MSBOS

1

Transfusion practice in surgery

Use of blood and blood components in elective surgery

Is inconsistent

Varies between hospitals, individual doctors and

between countries

Depends upon the diagnosis, different surgical

techniques, knowledge of the clinician on the use of

blood/blood components, availability of blood

Therefore each blood transfusion service should frame

its own guidelines for appropriate use of blood and

propagate them among the clinicians

2

Most elective surgery do not result in sufficient blood loss

to require blood transfusion

Careful assessment and management ↓ patient’s morbidity and mortality

Diagnosis, investigation and treatment of anaemia

Treatment of cardiorespiratory disorders

Detection of coagulation and platelet disorders

There is rarely justification for the use of preoperative blood transfusion simply to facilitate elective surgery

3

BLOOD SPARING STRATEGIES

Operative blood loss can be significantly reduced

Meticulous surgical techniques

Use of vasoconstrictors

Anaesthetic techniques

Use of antifibrinolytic drugs

Autologous blood donations

4

AUTOLOGOUS TRANSFUSION

The collection and subsequent reinfusion of the patient’s own blood or blood components

Advantages

Elimination of the risk of disease transmission

Elimination of alloimmunization

No risk of haemolytic, febrile and allergic reaction

Provides fully compatible blood in immunized patients and patients with rare blood group

Provision of blood in remote areas

Provision of blood to patients who refuse blood from homologous donors because of religious belief.

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TYPES OF AUTOLOGOUS TRANSFUSION

1. Preoperative

2. Acute isovolemic or normovolemic haemodilution

(ANH)

3. Intraoperative blood salvage

4. Post operative blood salvage

Criteria for autologous donation

Written consent of the patient-donor

Age→ no minimum/maximum age limits

Weight→ blood drawn should be proportionate to

patient-donor weight (8-9ml/kg)

Haemoglobin→ >11gm/dl and Hct of 33%

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Preoperative autologous donation

Patient’s blood is collected and stored prior to elective

surgery

Collection should be done

weekly or

at an interval of 4 days and last donation should be at

least 72 hours before surgery

Acute isovolemic or normovolemic haemodilution (ANH)

Predetermined volume of patient’s own blood is removed

before surgery (immediately before or shortly after

induction of anesthesia)

Simultaneously replaced with colloid/crystalloid solution7

Intraoperative blood salvage

Collection of shed blood from a body cavity/wound during

surgery and its subsequent reinfusion into the same

patient

Shed blood is processed by a number of machines (cell

savers) before transfusion the patient

Can provide the equivalent of 12 units of banked blood per

hour to massively bleeding patients

Post operative blood salvage

Collection of blood from surgical drains, followed by

reinfusion

Maximum amount of blood that can be reinfused is 1400ml8

INDICATIONS FOR AUTOLOGOUS TRANSFUSION

In elective surgery with resonable probability for

transfusion

Orthopedic surgery (joint eplacement)

Plastic and reconstructive surgery

Cardio-vascular surgery

Major abdominal surgery

Obstetrics and gynaecological patients having multiple

antibodies

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MAXIMUM SURGICAL BLOOD ORDER SCHEDULE

(MSBOS)

List of surgical procedures with the number of units that will

be cross matched for each procedure

Careful audit of local surgical practice

Based on the transfusion patterns of each institute

Agreed upon by the surgeons, anesthesiologists, and

blood bank in charge

Recommended crossmatch to transfusion ratio (C:T) is 2:1

C:T ratio can be used to evaluate blood ordering practices

The ordering schedule is flexible depending on the

circumstances

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PROCEDURE

The surgery schedule should be examined prior to

performing ordered cross matching

The patient’s order is compared with MSBOS

If the patient’s order meets the recommendations of

MSBOS, cross matching is done

If the order does not meet the recommendations, the

ordering physician should be consulted

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EXAMPLE OF MSBOS

General surgery

Obstetrics/gynaecology

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Procedure Units

Breast biopsy T/S

Colon resection 2

Exploratomy laparotomy T/S

Gastectomy 2

Procedure Units

Abdomino-perineal repair T/S

Cesarean section T/S

Dilation and curettage T/S

Hysterectomy ,laparoscopic T/S

EXAMPLE OF MSBOS

Vascular surgery

Urology

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Procedure Units

Aortic bypass with graft 4

Endarterectomy T/S

Femoral-popliteal with graft 2

Procedure Units

Bladder, transurethral resection T/S

Nephrectomy, radical 3

Prostatectomy ,transurethral T/S

Renal transplant 2

BLOOD TRANSFUSION IN ACUTE BLOOD LOSS

Decision to transfuse PRBC

The Hb concentration prior to hemorrhage

The extent of haemorrhage

The presence of other conditions which may alter the

physiologic response to acute blood loss

Loss of <15% blood volume→ minimal symptoms

15% to 30%→ tachycardia

30% to 40%→ increased signs of shock

>40%→ severe shock

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RED CELL TRANSFUSION GUIDELINES

Acute blood loss:

Hb :

>10 gm/dl→ RBCs rarely needed

<6 gm/dl →usually needed

6-10gm/dl→ RBC need depends on other factors

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Loss of blood Replacement fluid

<20% blood volume none

20-30% blood volume Crystalloids/colloids

30-40% blood volume Red cells and crystalloids

> 40% of blood loss Red cells and crystalloids

TRANSFUSION SUPPORT IN BURN PATIENTS

Acutely burned patient

↓ erythrocyte function

Consumptive coagulopathy

Immunosupression

↓ red cell synthesis

Careful monitoring of coagulation status and correction of

coagulapathies is important

Administration of fresh frozen plasma, cryoprecipitate and

platelets may be required

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Several interventions may minimize transfusion

requirements in burn patients

Administration of erythropoietin

Use of conservative strategies during burn wound

excision

Use of topical hemostatic agents during burn excision

and grafting

Early excision of wound prior to bacterial infection

Minimizing blood draws

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ANAEMIA AND SURGERY

Presence of anaemia indicates an underlying pathology

exists which needs to be treated

Compensatory response to anaemia may not always be

sufficient to maintain oxygenation during surgery

Reduction in the oxygen carrying capacity due to

surgical blood loss

Cardiorespiratory depressant effects of anaesthetic

agents

Adequate Hb must be ensured preoperatively to ↓ blood

transfusion during surgery

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ANAEMIA AND SURGERY

Causes of anaemia:

Nutritional deficiencies of iron and folate

Parasitic and helminthic infestations

Anaemia should be screened and treated in elective

surgical patients and surgery should be postponed till

Hb is adequate

Haemoglobin level as a transfusion trigger→7-8 gm/dl in a well compensated and healthy individual for minor surgery

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Higher haemoglobin levels in:

Inadequate compensation for anaemia and oxygen supply to the tissues

angina, ↑ dyspnoea, dependent edema, cardiac failure

Cardiorespiratory diseases which limits the ability to compensate ↓ oxygen supply

ischaemic heart disease or obstructive airway disease

Major surgery or anticipated significant blood loss (>10ml/kg)

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SURGERY AND COAGULATION DISORDERS

Coagulation and platelet disorders can be classified as

Acquired coagulation disorders arising as a result of

disease or drug therapy

Liver diseases

Aspirin-induced platelet dysfunction

Disseminated intravascular coagulation

Congenital coagulation disorders

Hemophilia A or B

von Willebrand disease

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SURGERY AND COAGULATION DISORDERS

It is important to enquire about history

Any abnormal bleeding tendency in the patient or

his/her family

Drug intake→ aspirin, NSAIDS

To prevent excessive blood loss

Diagnosis and treatment of coagulation disorders prior to any surgical procedures

Stopping intake of drugs which interfere with platelet function 10 days before surgery

INR should be less than 2 before surgery commences

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BLOOD TRANSFUSION IN OPEN HEART SURGERY

Blood/blood components important supportive therapy

↓ requirement of blood

Preoperatively

Autologous predonation of whole blood

Pheresis of platelets

Erythropoietin

Intraoperatively

Rigourous surgical techniques

Pre-CPB normovolemic hemodilution

Retransfusion of pump blood

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Cell saver or ultrafiltration of pump blood

Drug therapy

Antifibrinolytic agents

Post operatively

Shed mediastinal blood transfusion

FFP

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BLOOD TRANSFUSION IN LIVER TRANSPLANTATION

Orthotopic liver transplantation (OLT) involves the

removal of the native diseased liver and replacing it with a

healthy liver from the donor in the same anatomic location

Extensive, complex and technically demanding

Associated with extensive bleeding→ multiple vascular

transections and anastomoses

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MECHANISM OF BLEEDING IN LIVER TRANSPLANTATION

High vascularity of the liver

End stage liver diseases

associated with portal hypertension→ risk factor for massive hemorrhage

Components of the haemostatic system may be abnormal

Chronic liver diseases → associated with anaemia and thrombocytopenia

Surgical and technical factors

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ALTERATIONS TO HAEMOSTATIC SYSTEM IN LIVER DISEASES

Thrombocytopenia

Platelet function defects

Enhanced production of nitric oxide and prostacyclin

Low levels of of factor II, V, VII, IX, X and XI

Vitamin K deficiency

Low levels of a2-antiplasmin and factor XIII

dysfibrinogenemia

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BLOOD TRANSFUSION IN RENAL TRANSPLANTATION

Blood transfusion has a beneficial effect on renal graft

survival

May result in the development of HLA antibodies which

are detected at the time of pre-transplant cross

matching

May cause immunosupression due to enhancement of

suppressor T cell activity

Rapid improvement of immunosupressive therapy suggest

no difference in graft survival between transfused and non

transufused organ recipients

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BLOOD MANAGEMENT IN OBSTETRICS AND

GYNECOLOGY

Uterine hemorrhage is normal and expected

500ml during vaginal delivery

1000ml for cesarean section

↑ 30-40% intravascular volume

↑ 20-30% red cell mass

Immediate contraction of the uterus after childbirth results in

autotransfusion of maternal blood previously sequestered in

the uterine walls

Hypercoagulable state → clotting factors function at their

maximum immediately following deliveris

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INDICATION FOR TRANSFUSION IN PREGNANCY

1. Duration of pregnancy <36 weeks

Hb ≤ 5gm/dl with or without signs of cardiac failure/hypoxia

Hb 5-7gm/dl in the presence of

Cardiac failure or clinical evidence of hypoxia

Pneumonia or any other serious bacterial infection

Malaria

Pre-existing heart disease not related to anemia

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2. 36 weeks or more

Hb 6gm/dl or less

Hb 6-8gm/dl in the presence of

Cardiac failure or clinical evidence of hypoxia

Pneumonia or any other serious bacterial infection

Malaria

Pre-existing heart disease not related to anemia

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3. Planned elective cesarean section and there is a history

of

3. Antepartum Haemorrhage

4. Postpartum Haemorrhage

5. Previous CS

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MASSIVE TRANSFUSION

Transfusion of whole blood equal to or exceeding the

person’s blood volume with 24 hours

Transfusion of 10 units of whole blood or 20 units PRBC in

24 hours

Replacement of more than 50% blood volume in 3-4 hours

in an adult

Priorities in massive blood loss

Restoring and maintaining adequate blood volume

Maintaining sufficient oxygen carrying capacity

Securing haemostasis

33

Haematological investigations in massive transfusion

Investigation Target value

Hb/HCT

Platelet count

PT

PTT

Fibrinogen

Hb 10gm/dl, Hct 0.32

> 50 X 109 /L

<1.5 X control

<1.5 X control

>0.8 gm/L

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FFP TRANSFUSION

Supplementation of FFP should be considered after one

blood volume is lost

4-5 units FFP should be given to an adult patient

Thereafter 4 units FFP should be given for every 6 units

of red cells

Coagulation factors should be maintain above the critical

level

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PLATELET TRANSFUSION

Necessary after 2 volumes of blood loss

Recent guidelines advocates the use of red cells, plasma

and platelets in1:1:1 ratio to massively bleeding patients

Laboratory parameters along with clinical considerations

should be used for effective management

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REFERENCES

1. Spiess B D, Spence R K, Shander A.Perioperative

transfusion medicine. 2ND edition

2. Makroo R.N . Principles and practice of transfusion

medicine. 1st edition

3. Saran R K. Transfusion medicine technical manual. 2nd

edition

4. Technical manual. AABB. 17th edition

5. WHO manual. Clinical use of blood.

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