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Transfusion Free Medicine – Outdated Practice or Revolutionary Science

Transfusion Free Medicine – Outdated Practice or Revolutionary Science. Randy Henderson Director Transfusion Free Surgery/Patient Blood Management Keck Medical Center of USC Sherri Ozawa, RN Clinical Director, Patient Blood Management Englewood Hospital and Medical Center

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Transfusion Free Medicine – Outdated Practice or Revolutionary Science

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  1. Transfusion Free Medicine – Outdated Practice or Revolutionary Science Randy Henderson Director Transfusion Free Surgery/Patient Blood Management Keck Medical Center of USC Sherri Ozawa, RN Clinical Director, Patient Blood Management Englewood Hospital and Medical Center Director, Society for the Advancement of Blood Management

  2. Dinosaurs vs. Transfusion-Free Outdated Outdated??? - TBD

  3. Is “Transfusion-Free” or “Bloodless” a prototype for Patient Blood Management? The word prototype comes from the Latin words proto, meaning original, and typus, meaning form or model. In a non-technical context, a prototype is an especially representative example of a given category In hardware design, a prototype is a "hand-built" model that represents a manufactured (easily replicable) product sufficiently for designers to visualize and test the design.

  4. Early Pioneers of “Bloodless” Surgery In 1957, Cooley pioneered open-heart surgery without blood support leading a team of cardiovascular surgeons who performed thousands of operations on adults and children. In those days, most open-heart surgeries required 20 to 30 units of blood and as many as 12 units of blood were used just to prime the heart-lung bypass machine. Dr. Cooley and his colleagues used innovative methods to prime the bypass machine with non-blood fluids. In 1995, Dr. Hiram C. Polk Jr., editor-in-chief of the American Journal of Surgery, recognized Dr. Cooley’s outstanding accomplishments. He commented on the trailblazing efforts of Dr. Cooley in performing some 1,250 “bloodless” open-heart surgeries on patients who requested it due to their religious beliefs. He stated that “Dr. Cooley’s blood conservation techniques are applicable to every operation and, therefore, meaningful to all 17,000 readers of The American Journal of Surgery.” Denton Cooley, M.D.

  5. Early Pioneers of “Bloodless” Surgery 1970s-1980s – Operated on Jehovah’s Witness patients in scenarios where others would not First effort at collection of patient data in Bloodless Surgery (PBM) Pioneer efforts in publishing early writings on seminal nature of transfusion medicine and surgery Richard Spence, M.D.

  6. Some History 1960s-1970s – Early pioneers accomplish successful heart surgery on Jehovah’s Witness patients 1980s – Jehovah’s Witness organization forms organizational structure to inform/educate health care professionals/hospital in “BLOODLESS” surgery 1980s – HIV crisis forces reconsideration of current transfusion practices 1990s – Handful of US hospitals form “BLOODLESS PROGRAMS” to cater to needs of patients for whom blood is not an option 2001- Formation of SABM – intended to promote Optimal Patient Blood Management as a standard of care for all patients 2013- Recognition of PBM by WHO, TJC, AABB, multiple references in peer reviewed journals, chapters, textbooks

  7. Hospital Profile • 525 Bed Medical Center – Academic Affiliate of Mt. Sinai School of Medicine • Teaching program for Internal Medicine, Vascular Surgery • Training site: Surgery, Pediatrics, Critical Care • Level II Trauma • Level III NICU • All Medical Surgical Services except Transplants, PICU • 18 Years of Comprehensive PBM Program across all specialties • Worked with 100 hospitals in program development

  8. Some History • Hospital Administration was approached by members of Jehovah’s Witness community (1993) • Intent was to provide same standard of care but without use of blood transfusions • Hospital participation for ethical and business reasons

  9. Standard of Care? Birth of “Bloodless Programs” led to uneven Standard of Care and the larger philosophical question: Why should Optimal Blood Management be limited to patients who refuse blood??

  10. Hospital Wide Patient Blood Management Bloodless Program

  11. Blood Transfusion: Who is at risk The 1-3units of RBC transfused Shander A. Submitted A&A 2012

  12. Unsafe Blood • 43% of 191 WHO members test their blood for HIV, HBV, and HCV. • > 13 million units per year are transfused WITHOUT these tests • Annual estimates • 8 - 16 million transmission of HBV • 2.3 - 4.7 million of HCV • 80,000 - 160,000 of HIV Lancet 2003;361(9352)161-169

  13. A CLINICIAN’S PERCEPTIONS • Safety of BLOOD - high • Risk of BLOOD - low • Risk of Anemia - unknown • Risk of Surgical Bleeding – low • Transfusions- rare

  14. The Reality… • Transfusions are risky • A host of infectious and non-infectious risks • Association with worse patient outcomes • Transfusions are costly • A complex process (more tests & processing on the way) • True cost significantly higher than what hospitals pay to blood centers • Blood supply is limited • Marginal supply likely to worsen due to aging population (less donation; more demand) • Constant threat of emerging pathogens COBCON – Shander et al. Best Pract Res ClinAnaesthesio 2007

  15. Transfusion Medicine In American Undergraduate Medical Education Transfusion is the most common procedure in hospitals N = 86 American medical schools surveyed (AAMC) 83% administrators reported - didactic lectures 48% of medical schools providing 1 or 2 hours of lectures Handful reported small group sessions on transfusion medicine (6%) 92% administrators were unfamiliar with the 1989 or the 1995 TMAA curricula. Karp JK. et al. Transfusion. 2011 Nov;51(11):2470-9

  16. Transfusion Practice • Influence of knowledge and attitudes on the quality of physicians' transfusion practice • Amount of transfused products was inversely • proportional to physician knowledge of • transfusion medicine • Attending MD - lower knowledge scores, • greater confidence than residents • >60% of residents inappropriate transfusion due • attending pressure (once a month) • Salem-Schatz SR, Avorn J, Soumerai S B. JAMA 1990

  17. Principles ofPatient Blood Management • 94% of transfusions in surgical patients can be attributed to: • low preoperative hemoglobin levels • excessive surgical blood loss, and/or • inappropriate transfusion practices Shander A, Javidroozi M, Perelman S, Puzio T, Lobel G. Mt Sinai J Med. Jan-Feb 2012

  18. Some resist cultural change

  19. NATIONAL SUMMIT ON OVERUSE • SEPTEMBER 24, 2012 • Elective PCI • Myringotomy and Tubes • Early C – section • Antimicrobials in URI • Blood transfusion CHOOSING WISELY CAMPAIGN ABIM 2012

  20. Outcome of Patients Who Refuse Transfusion After Cardiac Surgery • N= 322 Witnesses and 87 453 non-Witnesses ( N = 48 986 transfused) • Witnesses – fewer complications and shorter LOS • Witnesses had better 1-year survival (P = . 007) • Similar 20-year survival (P = . 90) • Blood management strategies do not appear to place patients at heightened risk for reduced long-term survival Pattakos G, et al. Arch Intern Med 2012;172:1154-60.

  21. N = 500 (Group A vs. Group B = before and after blood conservation respectively) • 30 days mortality was 3% in group A vs. 1% in group B despite greater operative risk factors • Factors contributing to the low morbidity-mortality in group B: • Preoperative erythropoietin to attain a minimal hgb value of 14 g/dl • Warm blood cardioplegia • Implementation of blood conservation protocol • Fast track extubation J Cardiothorac Surg. 2012 Sep 27;7(1):95

  22. Mending the Problem • Are we asking the right question? • Liberal vs. Restrictive transfusion practice • Asking the same question over and over and expecting different answers? • More guidelines FOR TRANSFUSION • Who follow and why should they? • Changing culture • Can be done but resources and urgency are needed

  23. From Bloodless Medicine and Surgery to Patient Blood Management • The goal is not merely to avoid or withhold transfusions but: • To apply evidence-based medical and surgical approaches to manage anemia • optimize hemostasis • minimize blood loss and blood transfusion • The newer PBM concept places more emphasis on preventive measures that will obviate the need for transfusions Shander A, Javidroozi M, Perelman S, Puzio T, Lobel G. Mt Sinai J Med. Jan-Feb 2012

  24. Patient Blood Management

  25. Patient Blood Management

  26. Patient Blood Management

  27. Patient Blood Management

  28. Patient Blood Management

  29. Patient Blood Management

  30. The USCexperience(REPRINTED) ARCH SURG/VOL 141, SEP 2006 WWW.ARCHSURG.COM • Impact of a Transfusion-Free Program on Non–Jehovah’s Witness Patients Undergoing Liver Transplantation- Nicolas Jabbour, MD; Singh Gagandeep, MD; Haimesh Shah, MD; Rod Mateo, MD; Maria Stapfer, MD; Yuri Genyk, MD; Linda Sher, MD; Monika Zwierzchoniewska, MD; Rick Selby, MD; Gary Zeger, MD • Background: Examined the impact of the initiation of a transfusion-free program in January 2000 for Jehovah’s Witnesses (JWs) on the overall use of blood products in non-JW patients undergoing OLT. • Design: Retrospective review of OLT from January 1997 through December 2004.

  31. The USCexperience(REPRINTED) ARCH SURG/VOL 141, SEP 2006 WWW.ARCHSURG.COM • Impact of a Transfusion-Free Program on Non–Jehovah’s Witness Patients Undergoing Liver Transplantation- Nicolas Jabbour, MD; Singh Gagandeep, MD; Haimesh Shah, MD; Rod Mateo, MD; Maria Stapfer, MD; Yuri Genyk, MD; Linda Sher, MD; Monika Zwierzchoniewska, MD; Rick Selby, MD; Gary Zeger, MD • Patients:Total of 272 OLTs were performed on non-JW adults including 216 (79.4%) deceased donor and 56 (20.6%) living donor liver transplantations. • Thirty-three OLTs were performed before January 2000 (ie, before the initiation of a transfusion-free program) (group 1), and 239 OLTswereperformed after January 2000 (group 2). I • In group 2, all patients underwent OLT using cell-scavenging techniques and acute normovolemichemodilution (ANH) whenever feasible.

  32. The USCexperience(REPRINTED) ARCH SURG/VOL 141, SEP 2006 WWW.ARCHSURG.COM • Impact of a Transfusion-Free Program on Non–Jehovah’s Witness Patients Undergoing Liver Transplantation- Nicolas Jabbour, MD; Singh Gagandeep, MD; Haimesh Shah, MD; Rod Mateo, MD; Maria Stapfer, MD; Yuri Genyk, MD; Linda Sher, MD; Monika Zwierzchoniewska, MD; Rick Selby, MD; Gary Zeger, MD • Results: In comparing group 2 with group 1, the mean MELD score was statistically significantly higher (P<001), whereas the mean number of intraoperative PRBC and FFP transfusions was significantly lower (P=.03 and P=.004, respectively). The number of preoperative and postoperative PRBC, FFP, and platelet transfusions between the 2 groups was not statistically different.

  33. The USCexperience(REPRINTED) ARCH SURG/VOL 141, SEP 2006 WWW.ARCHSURG.COM Conclusion:The development of a transfusion-free surgical program for JW patients has had a positive impact on reducing the overall blood use in non-JW patients undergoing OLT, despite the increase in MELD score.

  34. LDLT IN ADULT JWRecipient Intra-Operative Data

  35. LDLT IN ADULT JW Recipient Post-Operative Course

  36. Blood Management in Cardiac Sx2000-2013 YTD • 3211 Total Cases • (valves, CABG, aneurysm, and combination) • More complicated case mix than other hospitals • LOWEST transfusion rate in State • LOWEST mortality rate in State

  37. Cardiothoracic Surgery &Patient Blood Management 2000-2013 YTD N=2861

  38. CABG &Patient Blood Management • 1375 Total Surgeries in 13 years • Overall Mortality – 7 (0.56%), Zero for past six years • Much lower than expected rates for: • Post Op Bleeding • Sternal Infection • Sepsis • Pneumonia • Stroke

  39. CABG &Blood Management Average Transfusion Rate nationally at 40-

  40. CABG outcomesPBMP vs non-PBMP N=586 Moskowitz DM et al. Ann ThoracSurg2010;90:451–8

  41. n=25

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