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MINIMIZING INTRA-OP TRANSFUSION REQUIREMENTS

MINIMIZING INTRA-OP TRANSFUSION REQUIREMENTS. DR. NYAMARI FACILITATOR: DR. BHOYYO KIBET. RATIONALE. To minimize hazards associated with blood transfusion Hazards include infection, immunologic reactions, hypothermia, volume overload, dilutional coagulopathy,

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MINIMIZING INTRA-OP TRANSFUSION REQUIREMENTS

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  1. MINIMIZING INTRA-OP TRANSFUSION REQUIREMENTS DR. NYAMARI FACILITATOR: DR. BHOYYO KIBET

  2. RATIONALE • To minimize hazards associated with blood transfusion • Hazards include infection, immunologic reactions, hypothermia, volume overload, dilutional coagulopathy, • Conservation and optimal use of blood resources due to perennial blood shortage • To improve outcomes in patients objecting blood transfusion for religious/personal reasons

  3. TRANSFUSION THRESHOLD • ABLEBV • EBV • Premature neonates 95mL/kg • Full term neonate 85mL/kg • Infants 80mL/kg • Adult men 75mL/kg • Adult women 65mL/kg

  4. STRATEGIES • Patient optimization • Minimization of blood losses • Alternatives to allogeneic blood

  5. PATIENT OPTIMIZATION • Correction of anemia, thrombocytopenia • Optimize hemostatic function; stopping anti-coagulant therapy early, NSAIDs, correction of coagulopathies • Minimizing diagnostic phlebotomy • Pre-operative Autologous Donation(PAD)

  6. PAD • This involves a patient scheduled for elective surgery donating blood prior to surgery • Hb≥ 11g/dl or HCT ≥33% (AABB standards) • Donation done weekly at 10.5ml/kg • Efficacy is dependent on the patient’s intrinsic increase in erythropoiesis • Endogenous erythropoietin response is sub optimal resulting in only 11% expansion of RBC volume • Recombinant erythropoietin and daily iron supplements aid.

  7. PAD ADVANTAGES • Limits transfusion transmitted diseases • Prevents red cell alloimmunization • Provides compatible blood • Provides patient reassurance

  8. PAD DISADVANTAGES • Doesn’t reduce risk of contamination • May result in wastage of blood not transfused(5%) • Risk of perioperative anemia • More expensive

  9. PAD CONTRAINDICATIONS • Evidence of infection • Scheduled surgery for aortic stenosis • Unstable angina, MI, CVA, Cyanotic heart dx • Uncontrolled hypertension

  10. MINIMIZING BLOOD LOSS • Acute NormovolemicHemodilution(ANH) • Intra-operative cell salvage • Surgical technique • Anesthetic technique • Pharmacologic manipulation

  11. ANH • Removal of whole blood from a patient while restoring the circulating volume with acellular fluid shortly before significant blood loss • End point is a Hct of 27%-33% • Blood collected in standard blood bags, stored at room temperature • Re-infused during surgery after major blood loss ceases( within 8hrs) • Re-infusion is done in reverse order.

  12. ANH • The chief benefit is the reduction of RBC losses. • Concomitant decrease in arterial oxygen capacity • Compensatory increase in Cardiac output and reduction in peripheral resistance.

  13. ANH CRITERIA • Likelihood of transfusion exceeds 10% • Absence of cardiac, hepatic or renal dx • Absence of hypertension • Absence of infection

  14. ANH v/s PAD

  15. INTRA-OP BLOOD SALVAGE • Involves the collection of blood from the surgical field into a cell salvage device. • The cell salvage device: • Filters the collected blood(40nm filters) i.e. bone fragments, tissue debris • Anti-coagulates the blood • Separates RBCs from other cellular and liquid elements • Washes salvaged RBCs extensively with saline • The RBCs are then re-infused suspended in saline

  16. CELL SALVAGE MACHINE

  17. INTRA-OP BLOOD SALVAGE INDICATIONS • Aortic reconstruction • Spinal instrumentation • Joint arthroplasty • Liver transplantation • Resection of A-V malformations • Trauma patients

  18. INTRA-OP BLOOD SALVAGE CONTRAINDICATIONS • Infection • Malignant cells • Urine and bowel contents in operating field • Amniotic fluid • Procoagulant material used in surgical field

  19. INTRA-OP BLOOD SALVAGE COMPLICATIONS • Massive air embolism • Dilutional coagulopathy • Nephrotoxicty by free Hb ( limit suction pressures to 150mmHg)

  20. ANAESTHETIC TECHNIQUE • Maintainance of normothermia • Use of regional anesthesia when possible e.g. TJR surgery • Patient positioning • Avoiding high intra-thoracic pressures • Controlling blood pressure • Permissive hypotension • Controlling and maintaining a normal pCO2

  21. SURGICAL TECHNIQUE • Meticulous surgical hemostasis • Use of diathermy, laser scapel • Use of tourniquet where applicable • Minimally invasive procedures if possible

  22. PHARMACOLOGIC AGENTS • Serine protease inhibitors e.g. Aprotinin that are direct plasmin inhibitors • Lysine analogues e.g. Tranexamic acid that inhibit conversion of plasminogen to plasmin • Desmopressin that stimulates the release of vWF promoting primary haemostasis • Recombinant activated factor VIIa • Fibrin glue

  23. ALTERNATIVES TO BLOOD • Substances used to mimic and fulfill functions of biological blood especially oxygen ‘carrying’ • Hemoglobin based oxygen carriers • Perfluorocarbon based oxygen carriers

  24. CONCLUSION • Adhere to protocols on transfusion of blood and its products • Where protocols are non-existent, develop the protocols • Pre-operative assessment and work-up of patients

  25. REFERENCES • Miller’s anesthesia, 7th edition Autologous Transfusion, Recombinant Factor VIIa, and Bloodless Medicine Lawrence T. Goodnough,Terri G. Monk • Clinical Anesthesia, 6th Edition Hemostasis and Transfusion Medicine Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.; Stock, M. Christine

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