1 / 39

Blood Day: The Role of the Anesthesiologist/Perioperative Physician

Blood Day: The Role of the Anesthesiologist/Perioperative Physician. Scott Wolfe, MD, FRCPC Department of Anesthesia and Perioperative Medicine University of Manitoba. Blood Day 2011. Part 1: Transfusion Considerations Complications of transfusion Transfusions and outcomes

merrill
Download Presentation

Blood Day: The Role of the Anesthesiologist/Perioperative Physician

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Blood Day: The Role of the Anesthesiologist/Perioperative Physician Scott Wolfe, MD, FRCPC Department of Anesthesia and Perioperative Medicine University of Manitoba

  2. Blood Day 2011 • Part 1: Transfusion Considerations • Complications of transfusion • Transfusions and outcomes • When to transfuse (transfusion triggers)

  3. Blood Day 2011 • Part 2: Case Discussion- (Application Blood Conservation Strategies) • Correction of anemia preoperatively • Iron/Epo • PAD • Cell salvage • ANH/Hypovolemic sequestration • Tranexamic acid • Regional Data- WRHA Blood Conservation Program

  4. 3rd edition 2011

  5. PART 1 Transfusion Considerations • Provide a framework of concepts which translate in the pattern of practice seen in perioperative transfusion medicine

  6. The potential hazards of Transfusion • Acute hemolytic transfusion reaction • ABO mismatch/incompatibility • TRALI- transfusion related acute lung injury • TACO- transfusion associated circulatory overload • Anaphylaxis • Infectious- HIV, Hep C, bacterial, unknown/untested pathogens

  7. Transfusion-Related Fatalities in the United States, 2004-2006 American Blood Center Newsletter, 2007

  8. Complications of Transfusion • Changes in Oxygen Transport of RBC • Impaired from preservation process and age of blood • Difficult to release O2 to tissues immediately after transfusion • Coagulopathy (from Massive Transfusion) • Dilutional thrombocytopenia +/or coagulation factors • Disseminated Intravascular Coagulation • Hypothermia • Electrolyte abnormalities (hyperkalemia, hypocalcemia) • Acid-Base abnormalities (pH 6.7-6.9, citratebicarbonate)

  9. Other associated conditions/outcomes from transfusion • Immunomodulating effects • Increased risk of nosocomial infections • Acute lung injury • Development of autoimmune diseases later in life • Recurrence of malignancy • Length of hospital stay

  10. Transfusion trigger • Threshold or lower limit when to transfuse patients • Studies have led to guidelines established on transfusion triggers for given patient populations • Shown equal if not improved outcomes in the restricted transfusion practice versus the more liberal transfusion groups

  11. Massive transfusion and coagulopathy: pathophysiology and implications for clinical management. Hardy JF et al. CJA 2006

  12. So What Does This Mean to the perioperative health care team? • Reasonable data to avoid if possible the use of blood products • In General, we can adapt lower limit for transfusion than in the past • These two conclusions have made “Blood Conservation Strategies” more attractive in the last decade

  13. PART 2 • Case presentation • Application of perioperative blood conservation strategies

  14. Case: Mr. X • 50 yo male • PMhx • Spinal Stenosis, Anemia Hbg 100g/l, low Fe stores • Rest of history and labs are normal • Wt 70 kg • Scheduled for a multilevel spine instrumentation and fusion booked for 8 hours • Estimated Blood Loss range 1000-3000ml

  15. Preoperative period • Allows for optimization of patients health status and correction of anemia • Maximum blood loss calculation (MABL): • MABL= (starting Hb- transfusion trigger) x pt blood volume starting Hgb • For Hbg 100 could lose 1400 ml’s before trigger Hgb of 70 • For Hgb 140 could lose 2400 ml’s before trigger Hbg 70

  16. Optimizing Preoperative Hbg:

  17. Preoperative anemia • IV or oral Iron therapy

  18. I.V. Iron TherapyIndications When oral Fe not tolerated Urgent pre-op correction of anemia Low hgb when transfusion may be imminent

  19. IV Iron Therapy

  20. Erythropoetin (EPO) • Hormone that regulates red blood cell production • Perioperative Indications: • Anemia of chronic disease (including renal disease) • Adjunct to iron therapy • When there is limited endogenous production (hgb 105-120) • Occasionally adjunct to PAD • Usually given weekly for 2-3 weeks preoperatively • FDA cautions in patients with Cancer

  21. Erythropoietin therapy 2010

  22. Preoperative autologous blood donation (PAD): • Institution dependent across Canada • Winnipeg • reserved for revision Orthopedic (hip) surgery, • patients with rare blood types, • Benefits: ?possibly reduces post op infections • Reduces demand on allogenic blood supplies • Reduces transmission of some infections • Prevents some adverse transfusion reactions

  23. Preoperative autologous blood donation (PAD) Risks: Donation: • 12 fold higher risk of severe reaction at time on donation • Lost unit • Cancelled OR and outdated autologous unit Transfusion • Bacterial contamination • ABO mismatch (wrong blood given) • Transfusion of allogenic blood when autologous available Overall reduces chance of allogenic transfusion but increases likelihod of all transfusion, NOT been shown to be safer… Poor Cost-effectiveness

  24. Mr.X: The Day of Surgery • Preop: • Investigated anemia • Gave IV iron sucrose x 2 doses • Hbg 140 • Now the day of the OR • What can we do?

  25. Mr. X: Intraop • Surgical technique • ANH • Cell Salvage • Antifibrinolytics

  26. Acute NormovolemicHemodilution

  27. ANH for Mr. X • Starting Hgb 140 g/l • No ANH: if loses 1000ml  140 g’s of Hb lost • Undergo ANH to starting hgb of 100 • If loses 1000ml  100 g’s of Hb lost • End of case the whole blood taken off at beginning given back • Both augmenting Hgb conc. and fresh supply of coagulation factors and platelets • Very little data on the efficacy and safety of ANH and its widespread use at this time cannot be recommended. • (ASA I and Jehovah’s Witnesses)

  28. Cell salvage

  29. Intraoperative cell salvage. Kuppurao L , Wee M Contin Educ Anaesth Crit Care Pain 2010;10:104-108

  30. ‘Hypovolemic sequestration’ • Variant of ANH and cell salvage • Slight reduction in circulating volume ‘hypovolemia’ • Intermediary Hgb 140125 • Higher hgb thought to increase yield from cell salvage • Retain benefits of fresh supply of Hgb, plt and coag factors at end of the case

  31. Tranexamic acid • An Antifibrinolytic that inhibits degradation of the fibrin, basic framework for formation of a clot  clot stabilizer • Hemostatic effects have been shown to reduce blood loss in orthopedic, hepatic and cardiac (Cochrane review Henry et al.) • Also shown to decrease mortality in trauma patients with mild to moderate bleeding given within the first 3 hours • Variable dosing in literature • 15-30mg/kg usual dose (+/- repeat in 6-8 hours) • Relatively safe, side effects  GI upset, seizures • Relative Contraindications: patients at elevated risk for thrombosis Henry DA et al. Anti- fibrinolytic use for minimising perioperative allogeneic blood transfusion. [Systematic Review] Cochrane Injuries Group Cochrane Database of Systematic Reviews. 2011

  32. Case Summary: Mr X OPTION 1 Standard  Preop Hgb 100  Intraop 1.5 l blood loss  Postop Hgb 70 OPTION 2 BLOOD CONSERVATION  Preop hgb 140 with IV Fe  Intraop Cellsaver, ANH 1.5 l blood loss  Postop Hgb 100

  33. Conclusion • Further studies show more restrictive transfusion practice improves outcomes • Known risks of transfusion • Limited blood supply • Current information locally via database  warrants further research oppurtunities • Blood conservation strategies will have a larger and larger role in perioperative medicine.

  34. The Ten Commandments of TransfusionQUESTIONS?‘Bloody Easy 3’ JL Callum et al. 2011

More Related