Blood Management Strategies – No Bones About it.

1. Blood Management Strategies – No Bones About it. By Andrea C. Peters, AA, BS, CPBMT Perfusion.com, Inc. St. Francis Hospital, Columbus, GA September 10,2011

2. Purpose • Identify and promote safe, appropriate and evidence-based interventions that are likely to be helpful in blood management. • Encompass all aspect of blood management from patient evaluation, through clinical indicators and management of a decision-making process.. • Establishing guidelines that provide balance between efficacy, safety, and regulatory constraints.

3. The Magnitude of Blood Management One in twenty American’s will receive a transfusion at some point in their lives. About 12 million units of red blood cells and whole blood, 8 million platelet units and 3 million plasma units are transfused annually. Every three seconds someone needs blood. People older than 65 use 43 percent of all donated blood. The demand for blood will increase as the population ages. Approximately 40,000 units of blood are used each day in the United States http://www.bloodtransfusion.com/facts.asp

4. What is Blood Management? • Blood management is a comprehensive, multidisciplinary process that is designed to promote the optimal use of blood products thoughoutthe hospital. • The goal of blood management is to ensure the safe and efficient use of the many resources involved in the complex process of blood component therapy.

5. What is Blood Management? • More than • Tightening of transfusion practice • Bloodless medicine • An approach to medical treatments where the patient’s blood is managed thereby reducing or eliminating the need for blood transfusion.

6. Advantages of Blood Management • By using the patient’s own blood reduces risk of infection, autoimmune and or hemolytic reactions • Reduced rate of complications reduces possible hospital stay • Reduction in cost for the patient, their insurance company and the hospital.

7. Why is This Important? Increases your facility’s competitive advantage Reduces out-of-pocket expense to patients Reduces cost to payers Attracts patients who prefer not to receive banked blood Red blood cell products are continually becoming more scarce and more expensive Blood transfusions are not consistently reimbursed It is safer for the patient to receive salvaged autologous blood than pre-deposited autologous or banked blood Donor blood does not carry oxygen for the first 24 hours after transfusion, and transfused patients consistently experience immuno-suppression

8. The more allogeneic blood you give, the greater the risk of complications

9. The more allogeneic blood you give, the greater the risk of infection

10. The more allogeneic blood you give, the greater the risk of increased length of stay

11. Stored allogeneic blood is an imperfect substitute for endogenous hemoglobin! • Ineffective Exchange • Impaired tissue oxygen delivery due to storage defects • Excess Baggage • Adverse effects and immune system changes as a consequence of allogeneic transplantation

12. Techniques • Manage blood • Control bleeding • Stimulate growth of new blood cells • Minimize blood sampling

13. 2 Applied Blood Management • Ensure that every unit of blood transfused is appropriate • Minimize transfusion, complications and anemia • Efficient use of all resources (drugs, devices) • Organizational principles • Attention to detail • Multidisciplinary approach • Utilization of evidence-based guidelines and clinical best practices1 • Reduce risk exposure • Proactive patient management systems2

14. The Role of Blood Utilization in Blood Management • Transfusion safety is much more than blood safety • Efforts to reduce blood demand should parallel efforts to increase the blood supply • Blood utilization committees are the key to optimal blood management • Right patient • Right product • Right dose

15. A Smart Approach to Blood Management Patient centered, evidence-based, systems oriented, data driven

16. Strategies for Change

17. Creating an Environment • This is centered around teamwork & communication. • It helps maintain consistent and standardized practices in blood management therapy. • It is essential for managing the complexities of transfusion processes – complexities that often exceed the capabilities of individual clinical disciplines in the organization • It improves patient safety by allowing departments to learn from each other’s mistakes and proactively implement necessary improvements consistently across the organization .

18. Multidisciplinary Blood Management Team

19. Blood Management & Action Items

20. Blood Management & Action Items

21. Blood Management & Action Items

22. Blood Management Overview in the Orthopedic Surgical Arena I have been asked to provide an orthopedic surgeon's point of view and perspective on blood management for this newsletter issue. I am a hip and knee surgeon with a large total joint arthroplastic practice in a community-based hospital and serve as a director of the The American Osteopathic Academy of Orthopedics (AOAO).  Over the last 12-18 months, I have become very interested in developing and implementing a comprehensive blood conservation program to decrease surgical blood loss and reduce blood transfusions after total joint surgery. Patients undergoing total hip and knee surgery often sustain a significant blood loss related to surgery, secondary to multiple reasons. The postoperative anemia may have numerous deleterious effects on the patients to include delayed rehabilitation, higher complication rates, limited pain control, and poor postoperative outcomes. The ability to limit postoperative bleeding may reduce this problems and ultimately result in better patient satisfaction and a more positive surgical result. With this in mind, we have taken into account preoperative, intraoperative, and postoperative measures to develop a multimodal blood conservation strategy to decrease complications, increase patient safety, and improve our postsurgical results.

23. Unwashed Autotransfusion Disadvantages Low Hematacrit Product: Approximately 30% Biologic Response Modifiers: Source: ActaOrthop. Scand 1995;66:334-8

24. Unwashed Autotransfusion Disadvantages (cont.) Consequences of Biologic Response Modifiers: • Fever1 • Acute respiratory failure2 • Hypotension3 • Upper airway edema4 Sources: 1Clement S.D.H., Sculco T, et al J Bone Joint Surg (Am) 1992;74:646-51 2Wixson RL, Kwaan H, Spies S, et al. J Arthroplasyt 1994;9:351-8 3Heath K, McFadzean W. JR Army Med Corps 19956;141:105-106 4Woda R, Tetzlaff JE, Can J Anaesth 1992; 39:290-2

25. Brat2 with Blood Management

26. Post-op blood salvage via wound drain

27. Original Study to Utilize as a Base for an Evaluation “Platelet-Rich Plasma Application During Closure Following Total Knee Arthroplasty” By William J. Berghoff, MD; William S. Pietrzak, PhD; Richard D. Rhodes, MD ORTHOPEDICS 2006; 29:590 July 2006 Platelet treatment appears to improve several short-term outcomes following total knee arthroplasty. Total knee arthroplasty (TKA) is one of the most common orthopedic procedures performed, restoring function and reducing pain in the arthritic knee.1 In general, results are excellent with reported survival rates as high as 90%-95% at 10-15 year follow-up.2 Complications are infrequent, with reoperations occurring in approximately 1% of patients per year.3 With an aging population, elective TKA rates are steadily increasing. In addition, there is a trend toward earlier hospital discharge during a more acute phase of recovery in an effort to reduce hospital costs. . .

28. PRP Evaluation Data Sheet

29. Staff Education & Patient Communication • To insure competency, in-servicing should be completed and signed off by each individual involved in their respective areas. • Review patient chart for labs, current medications and medical history. • Discuss with the patient why you are doing this blood draw. • Benefits • Results • Answer questions from the patient

30. Angel with processed products

31. OR Staff Communication • Once the patient is in the room and before decanting, verify correct product and patient with the circulating nurse. • Explain applicator assembly as tech is drawing up components. • Don’t accidently mix components to prevent clotting the tip of the applicator. Wipe away any excess. • Gently agitate syringes to re-suspend platelets just before application.

32. PRP/PPP with Recothrom/Ca Ready for Application

33. PRP Completed Eval Data

34. A Champion for Success • Utilizing Platelet Rich and Platelet Poor Plasma …”We were able to show a significantly less use of narcotics, a higher functional range of motion, and had better postoperative hemoglobins and a significant decrease in the need for blood transfusions. We believe the use of autologous platelet gels and fibrin sealants has enhanced the efficacy of our total joint arthroplasty surgeries.” • Dr. George W. Zimmerman, D.O. • Orthopedic Surgeon, specializing in Knee and Hip

35. Quality Issues: Failure to Adopt Evidence-based Transfusion Guidelines “A restrictive strategy of red cell transfusions is at least as effective as and possibly superior to a liberal strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction or unstable angina.”1 Ranked as the #1 landmark study that has changed the practice of transfusion medicine2but how many physicians are familiar with it? 1 Hébert et al- NEJM 1999;340(6) 2 Blajchman- Transfusion 2005:45

36. A multicenter, randomized controlled clinical trial of transfusion strategies in critical careHebert et al, NEJM 1999:340(6) • Results • Overall, the adjusted multi-organ dysfunction score and in-hospital mortality were significantly higher in the liberal transfusion group than in the restrictive transfusion group. • No sub-group of these critically ill patients demonstrated an added benefit of higher Hbg levels, and most patients in the liberal transfusion group had worse outcomes.

37. Variations in Transfusion Practices • Transfusion rates of plasma and platelets have been reported to vary from 0% to 100% of bypass patients. • Among 18 tertiary-care institutions • 8 transfused 10% or less patients with platelets • 4 transfused > 50% of patients with platelets • 28% of patients platelet-related risk factors received platelets • 17% of patients without platelet-related risk factors received platelets • In addition to intra-institution variability in transfusion practice, it has been reported that 26% of perioperative transfusions are given inappropriately.

38. The “Transfusion Trigger” Controversy Transfusion trigger: “a particular hemoglobin level of discomfort in the prescribing physician, not defined by clear physiologic parameters”1 10/30? 8.5/26? 7/21? Transfusion paradigms 1 Spiess, Ann Thorac Surg 2002;74

39. Establishing Evidence-based Transfusion Trigger • “All in all, I feel the most significant alteration in our practice that has decreased the use of blood products, is an alteration in our perioperative transfusion trigger. We have employed strict evidence-based transfusion criteria and have gone from the "10/30 rule" to a more aggressive hemoglobin of 7 and hematocrit of 20 before transfusion. With our alterations in practice and our blood conservation means preoperatively, intraoperatively, and postoperatively, we have significantly decreased the blood product usage at our institution.”

40. Orthopedic Amicar Review

41. Incorporating Additional Therapies: Tranexamic Acid • “We have begun administering 20 mg per kg 1 time intravenous bolus dose before surgery to our "high-risk for postoperative anemia" patients, but now consider providing this pharmacologic agent to all patients undergoing total joint surgery.”

42. Benefits • More blood collected perioperatively may reduce reliance on stored blood • Less reliance on stored blood may reduce hospital costs

44. High Quality RBC Product • High hematocrit RBC product • High RBC recovery • High free hemoglobin removal • High albumin removal • High heparin removal

46. Transfusion Costs • “Hanging costs” are substantially more than the cost of acquisition • Total cost to the hospital includes accounting for a variety of resources that are consumed: • Direct Materials • Variable Labor • Fixed Labor • Overhead

47. RBC Year Over Cost Savings for PerioperativeAutotransfusion DIRECT COST SAVINGS Average Monthly Savings $37,776 COBCON Cost Savings Average Monthly Savings $219,400

48. Blood Product Costs RBC PPH FFP

49. Additional Strategies to Incorporate

50. TEGPlateletMappingAssay Plateletfunction, prothromboticstateandplatelet inhibition