patient blood management
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Patient Blood ManagementMinh-Ha Tran, DO, FASCPUC Irvine HealthTransfusion Medicine Service
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
Patient Blood ManagementA 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
Perioperative Management
Preoperative Intraoperative PostoperativeMedication review and targeted bleeding history
Acute normovolemic hemodilution when appropriate
Iron supplementation
Management plan for congenital bleeding disorders
Use of antifibrinolytics when appropriate
Reduction of iatrogenic blood loss
Evaluation and treatment of preoperative anemia
Application of minimally invasive surgical techniques
Medical optimization Intraoperative cell salvage
Utilization of restrictive transfusion strategies throughout the perioperative period
Anemia tolerance, utilization of transfusion alternatives when possible
A word about PADPreoperative Autologous Donation
◦Induces Preoperative Anemia Increases risk for allogeneic transfusion
Generates waste as most units wind up discarded A waning practice…
Restrictive Transfusion Strategies
Emphasize clinical, not just laboratory indicators Whenever possible: single unit transfusion, then reassess
StudyPatient Population
Arms Primary Outcome
TRICC
NEJM 1999
838 Critical Care
patients [RCT]
7 g/dL (n=418) vs
9 g/dL (n=420)
30 Day ACM: (18.7% vs 23.3%, p = 0.11)
TRACS
JAMA 2010
502 Cardiac Surgery
with Cardiopulmonary
Bypass [RCT, NI study]
8 g/dL (n=249) vs 10
g/dL (n=253)
NI margin for 30 day ACM predefined at -8%: Observed
between group difference 1% [95% CI, -6% to 4%], p =
0.85.
FOCUS
NEJM 2011
2016 Patients with
CAD/Risk of CAD after
Hip Fracture Surgery
[RCT]
< 8 g/dL (n=1009) vs
10 g/dL (n=1007)
Death or inability to walk across room unassisted at 60
days: Abs Risk Difference 0.5 percentage points [95% CI, -
3.7 to 4.7]
Acute UGI Bleed
NEJM 2013
921 Patients with severe
Upper GI bleeding
[RCT]
< 7 g/dL (n=461) vs
< 9 g/dL (n=460)
45 Day ACM: 91% restrictive vs 95% liberal; HR for death
with Restrictive Strategy 0.55 [95% CI: 0.33 to 0.92], p =
0.02.
Transfusion Risks
(Allergic)
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?
Iron Deficiency AnemiaAnemia 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
Treatment ConsiderationsEnteral Formulations
Iron Salts Unit Dose (mg) Elemental Iron (mg) Notes
Ferrous Sulfate 325 65 Iron salts are similarly tolerated; adverse effects generally attributable to elemental iron content.
Ferrous Gluconate 325 36
Ferrous Fumarate 325 106
Non-Salts
Carbonyl Iron 45 45
Carbonyl iron microspheres derived by heating gaseous iron pentacarbonyl; absorption dependent on solubilization by gastric acid
Parenteral Formulations
Dextran Stabilized Concentration(mg elemental iron/mL) Vial Notes
LMW Iron Dextran(INFed) 50 100 mg/2 mL Watson Pharma, Inc, Corona, CA
Iron Sucrose(Venofer) 20 100 mg/5 mL;
200 mg/10 mL American Regent, Inc, Shirley, NY
Sodium Ferric Gluconate Complex in Sucrose solution
(Ferrlecit)12.5 62.5 mg/ 5 mL Watson Pharma, Inc, Corona, CA
Ferumoxytol(Feraheme) 30 510m g/17 mL AMAG Pharmaceuticals, Lexington, MA
Ferric Carboxymaltose(Injectafer) 50 750 mg/15 mL Luitpold Pharmaceuticals, Shirley, NY
Erythroid Stimulating Agents
Erythroid Stimulating Agents
Sun Mon Tues Wed Thurs Fri Sat
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
Sun Mon Tues Wed Thurs Fri Sat
600 U/kg
600 U/kg
600 U/kg
600 U/kg
Malabsorption
Celiac DiseaseInflammatory
Bowel DiseaseRoux en Y
Gastric Bypass[vegan/
vegetarian]
General CommentsOral 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
Calculating Iron DeficitExample: 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
From the LiteratureIDA 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
The anemia we cause…
PlateletsUsual Adult Dose
is 1 Apheresis Platelet Unit
Platelets
Platelets
Plasma
Plasma
PCC – first view – Tran, et al.
0 1 2 3 4 5 6 7 8 9 10 11 12 13-1.00
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
11.00
12.00
f(x) = 0.87265707126853 x − 1.21662810391693R² = 0.93037900284288
PreTreatment INR vs Delta INR in PCC Group
Delta INR Linear (Delta INR)
PreTreatment INR
Delt
a I
NR
(P
re-P
ost)
Tran MH, Gayatinea R, Albicker P, Baje M.PCC and NovoSeven for Critical Bleeds and Coagulopathy Reversal
PBM PI Project
PMID: 24919540
EBM GI Bleed Protocol
Utilization Review
Utilization Review
Summative CommentsPatient 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
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