Patient Blood Management

1. Patient Blood Management Minh-Ha Tran, DO, FASCP UC Irvine Health Transfusion Medicine Service

2. Agenda • State the guiding principles of Patient Blood Management • Name the three phases of perioperative blood conservation • Discuss examples of modalities relevant to each phase • Define “restrictive” hemoglobin threshold • Discuss transfusion risks • Name three transfusion alternatives • Become acquainted with basic principles of platelet and plasma transfusion practice

3. Patient Blood Management • A series of ‘rights’ • Right Patient • Right Product • Right Reason • Right Time • Who defines ‘right’? • Clinical decision informed by evidence • Not all hypotension is due to anemia • Not all hypoxia is due to reduced red cell mass • Not all who are anemic require red cell transfusion

4. Perioperative Management

5. A word about PAD • Preoperative Autologous Donation • Induces Preoperative Anemia • Increases risk for allogeneic transfusion • Generates waste as most units wind up discarded • A waning practice…

6. Restrictive Transfusion Strategies • Emphasize clinical, not just laboratory indicators • Whenever possible: single unit transfusion, then reassess

7. Transfusion Risks (Allergic)

8. Anemia Management Strategies • Anemia Tolerance – General Guidelines • Acute bleeding, hypovolemic shock • Transfuse as needed • Surgical management • Chronic anemia, stable patient • Assess for symptoms • …and comorbidities • Determine cause • …and anemia treatment options • Establish timeline for correction • …is the patient preoperative?

9. Iron Deficiency Anemia

10. Iron Deficiency Anemia • Anemia severity • Endogenous erythropoietic drive • Likelihood of response • Assess for malabsorption, continued losses, anemia of inflammation, renal anemia • Slope of response • Reduced if continued ongoing losses or malabsorption

11. Treatment Considerations

12. Erythroid Stimulating Agents

13. Erythroid Stimulating Agents

14. Malabsorption • Celiac Disease • Inflammatory Bowel Disease • Roux en Y Gastric Bypass • [vegan/vegetarian]

15. General Comments • Oral Iron • Hb will rise slowly, beginning 1-2 weeks after initiation of treatment • 2 g/dL over ensuing 3 weeks • Hb deficit typically halved by 1 month, normal by 6-8 weeks • Parenteral Iron • In those unresponsive or intolerant to oral iron, or in those whose iron losses exceed absorptive capacity, IV iron is an option • Calculate an iron deficit and replenish the deficit • ESA • If ESA’s are administered for renal anemia, coordinate care with the nephrologist • In noncancer patients, ESA’s may be used to augment the erythropoietic response to iron – particularly in mild anemia or when IDA is complicated by inflammation • Always co-administer with iron to avoid functional iron deficiency

16. Calculating Iron Deficit • Example: 82 kg woman with heavy uterine bleeding presents with H/H of 6.3 g/dL and 18.9% • Total Blood Volume • 70 mL/kg x 82 kg = 5740 mL (57.4 dL) • Hemoglobin Deficit • 12 g/dL – 6.3 g/dL = 5.7 g/dL • 5.7 g/dL x 57.4 dL = 327 g • Iron Deficit • 3.34 mg Fe/g Hb • 327 g Hb x 3.34 mg Fe/g = ~1000 mg Fe

18. From the Literature • IDA treatment: • A higher and more rapid hemoglobin response with parenteral iron • Risk of infection increased with parenteral iron • Preoperative anemia: • Oral iron alone ineffective for preoperative purposes, particularly when anemia is mild • Treatment most effective with ESA containing regimen • Critical Care Patients: • ESA alone has minimal impact in transfusion avoidance among critical care patients, particularly when restrictive transfusion strategies are in place

19. The anemia we cause…

21. Platelets • Usual Adult Dose is 1 Apheresis Platelet Unit

22. Platelets

23. Platelets

24. Plasma

25. Plasma

26. PCC – first view – Tran, et al. Tran MH, GayatineaR, Albicker P, Baje M. PCC and NovoSeven for Critical Bleeds and Coagulopathy Reversal

27. PBM PI Project • PMID: 24919540

28. EBM GI Bleed Protocol

29. Utilization Review

30. Utilization Review

31. Summative Comments • Patient Blood Management • Protect the patient from unnecessary or excessive transfusions • Inform transfusion decisions not simply by hemoglobin, but by patient symptoms and comorbidities • Utilize restrictive transfusion strategies • Reduce iatrogenic anemia through reduction in both the volume and frequency of blood draws • Avoid arbitrary 2 unit transfusions • Consider transfusion alternatives for anemia management