Dr Lulseged B. AlemuConsultant General Surgeon

Member of Hospital liaison committee for Jehovah’s witnesses ,Botswana

Strategies to Avoid Blood Transfusion in

Critically ill patient

History of Bloodless Medicine and Surgery

Until19th century blood letting rather than blood transfusion was the

standard practice in medicine

History of Bloodless cont.

Virtually all surgeries prior to the 20th century were essentially ‘bloodless’, and some were remarkably successful.

Theodore Kocher, for instance, did his first thyroidectomy in 1872, and by the end of his career he had done 5000 thyroidectomies with only 1% mortality.

1628 William Harvey discovered the circulation of blood

In 1900 Landsteiner’s discovered ABO blood groups

In 1915 Richard Lewisohn introduced anticoagulation with sodium citrate

In 1937, Bernard Fantus set up the first hospital based blood bank in Chicago, USA

From then on blood transfusion became a universal practice in medicine

History of Bloodless cont.

BMS started as an attempt by some dedicated surgeons in the 1960s to accommodate patients who declined blood transfusion, notably Jehovah’s Witnesses.

Their religious belief is based on passages from the Bible, such as: “You are to abstain from … blood” – Acts Ch. 15 v. 29 (New English Bible)

On May 18th, 1962 Denton Cooley, performed the first bloodless open-heart surgery on one of Jehovah’s Witnesses

In 1977 Ott and Cooley published a pioneer report of 542 open-heart surgeries without allogeneic blood transfusion in patients ranging in age from one day to 89 years

The advent of HIV/AIDS in 1981 forced a reconsideration of blood transfusion practices and a desire for BMS

History of Bloodless cont.

Many other Pathogens old and new that are transmitted by blood and many non-infectious hazards received renewed attention and prominence

The cost of making blood “safe” rose astronomically while the supply of “safe” blood shrank.

Recently the focus has shifted from the hazards to efficacy.

* The Canadian Critical Care Trials Group study on Transfusion Requirements in Critical Care (TRICC) by Hérbert and co-workers in 1999 was a landmark prospective randomized study of 838 ICU patients comparing a liberal (<10gm%)transfusion versus restricted (<7gm%)transfusion policy. It revealed better results with the restricted transfusion group: lower ICU mortality, lower hospital mortality, lower 30-day mortality, and a trend towards decreased organ failure.

History of Bloodless cont.

The Government of Western Australia is the first in the world to implement Patient Blood Management as an official policy starting from 2008.

A retrospective study on 605,046 patient from 2008-2014 is published in ‘ Transfussion volume 00. 2017’. ” there is significant reduction in hospital mortality; length of stay, RBC,FFP and Platelet transfusions and marked cost reduction”

* In 2010 the 63rd World Health Assembly of the World Health Organization officially recognized and adopted the “pillars” of Patient Blood Management.

BMS is therefore the universal standard of future ethical practice of medicine!

Why ….?

Patient choice

Demand outstripping supply

Risk vs. Benefit

Cost

Legal / Ethical issues

Sound medical practice

Principles

A: Physiology of compensation

A1: Tolerance of Anemia.Tissue Oxygen consumption remains the same over a wide range of Hemoglobin level

• Oxygen Carrying Capacity

1.34-1.39ml/ gmHgb

1.34mlx15gm/100ml = 20ml/100ml Blood

= 1000ml at any given time ( adult)

• Oxygen Consumption

110-160ml/m2/min

= 200-250ml/m

Extraction ratio= 25%

Principles: Physiology cont.

Slide 9

A2: Body’s response to blood loss

I: Increased CO: Stroke Volume x heart rate

-Decreased blood viscosity -Decrease SVR

-Increase VR

-Increased sympathetic stimulation ( increase HR)

II: Decreased Oxygen affinity of Hemoglobin

-Increase Tissue extraction of oxygen from blood.

III: Redistribution of blood flow and improved

microcirculation.

Principl

es:

physiolo

gy cont

H+

T

2,3-DPG

C02

Principles

B: Strategies to avoid transfusion

Slide 11

1: Optimize RBC mass: - Erythropoesis, Hematinics, Nutrition

2: Minimize RBC Loss: - Permissive moderate hypotension during bleeding

- Normothermia

- Microsampling

- Prophylaxis of UGIB

- Prophylaxis/ treatment of Infection- Autotransfussion/ Blood cell salvage

- Hemostatic agents: Topical & sytemic

- Expeditious Angiographic embolization

3: Increase oxygen delivery - Augment cardiac output

-Supplemental oxygen

-Minimization of oxygen consumption

I- Optimize RBC mass

A-Erythropoietin

Slide 12

Critical illness is associated with deficient erythropoietin production

and a blunted response to endogenous erythropoietin

Irrespective of the endogenous serum EPO level, the erythropoietic

system in critically ill patients remains responsive to high-dose

erythropoiesis-stimulant

Concomitant anabolic androgen therapy may potentiate response by

sensitizing erythroid progenitor cells

May produce an increase 2,3-DPG content of RBC

A transient dose dependent rise in platelet count

Anti-inflammatory, anti-apoptosis and cardioprotective

effects (non-haemopoietic effects) .

Has been used in all ages, including infants with minimal side effect

Optimize RBC Mas Count….

B: Hematinics

Slide 13

In critical illness, iron metabolism is

abnormal ( low iron levels, normal or

elevated serum ferritin...)

Functional or absolute deficiency...

IV iron therapy can be administered safely in

all age group.

Iron sucrose, ferric carboxymaltose

(Rapid high dose without test dose)

iron sorbitol, Irone dextran

Nutrition:Early enteral feeding, as tolerated

Protein supplementation to support

erythropoesis

B12, FA

II: Minimize blood lossA: Prevention and arrest bleeding

Rapid Diagnosis and Control of haemorrhage.

High index of suspicion!

1- Maintenace of Normothermia.

Heat loss occurs by various route.

-convection, radiation, and evaporation

- active and passive warming strategies

2- Prophylaxis of Upper Gastrointestinal hemorrhage

3- Prophylaxis and Prompt Management of Infection

Blood transfusion has not been shown to improve oxygen consumption in

septic patients

4- Attend to unusual source of bleeding: Menstruation,

5- Permissive Moderate Hypotension During bleeding.

6- Auto transfusion/Blood cell salvage

Minimize blood loss;

Prevention and arrest bleeding Cont.7-Hemostasis:

Topical:Technique: Local compression/TorniquetAgents: Tissue adhesives, oxidized cellulose, collagen based.. Thermal/energy. Electrocoutery, Argon beam coagulator, laser... Systemic. -Vitamin K ( Phytonadion) - Prothrombine complex concentrate - Recombinant coagulation factor VIIa- Desmopressin,Aprotonin, Tranexamic acid Conjugated

estrogens ( eg Premarin)

8-Expeditious Angiographic Embilization. Prompt arrest of bleeding Preemptive embolization of potential bleeder

Slide 16

9-Damage control Surgery

-Surgical Management of the unstable Hypovolemic

patient

Lethal Triad Hypothermia

temperature < 35,4oC

Acidosis

pH < 7.20

Coagulopathy

Slide 17

Stages of DCS

Short surgical intervention

• Haemorrhage control

• Limit contamination

Postoperative resuscitation in “ICU”

• Rewarming

• Restoration of haemodynamics & oxygenation

• Correction of coagulopathy

Re-operation

• Definitive repair

DCS has proven itself clinically as the most successful approach to the exsanguinating,dying patient

Minimize blood loss cont...B:Minimization of Iatrogenic Blood Loss

1- Restrict Diagnostic Phlebotomy. Perform only essential tests Coordinate and consolidate blood tests. Minimize volume of diagnostic blood sampling. –Pediatric tubes for adult, Microsampling

2- Cautious Thromboembolic prophylaxis. Consider alternatives Mechanical prophylaxis (e.g., intermittent pneumatic compression devices, graduated compression stockings, inferior vena cava filters) alone or in combination with low dose anticoagulant .

3- Drug side effect: (e.g., NSAIDs, beta blockers, calcium channel blockers, and furosemide ).cephalosporin/penicillin antibiotics, lipid-lowering medications, corticosteroids, herbal preparations , may potentiate the effects of anticoagulation medications

III: Optimization of Oxygen Delivery

Assess perfusion and tissue oxygenation Evaluate index of global perfusion: oliguria, diminished sensorium, lactic acidosis, base excess/deficit, and tachycardia. Also assess oxygen delivery (DO2), oxygen consumption (VO2), mixed venous oxygen saturation (SvO2), tissue CO2 tension (PCO2) Evaluate index of regional perfusion: Evidence of myocardial ischemia (ST-segment abnormalities), Renal dysfunction (decreased urine output and an increased blood urea nitrogen to creatinine ratio) Central nervous system dysfunction (altered mental state)

Optimization of Oxygen Delivery cont.

1-Augment cardiac output

Require understanding of pathophysiological process and knowledge

of the patient’s cardiac performance

Microcirculatory blood flow and tissue oxygenation are not

always dependent on blood pressure in critically ill patient

Use of Pressor agents in Critically ill patient

Eg. In septic patient with a low systemic vascular resistance

Fluid resuscitation must be Individualized.

Att. dextrans are associated with increased bleeding tendency (

inhibit platelet aggregation, reduce VIIa, promote fibrinolysis)

Optimization of oxygen delivery cont.

2-Early enhancement of oxygenation Promote oxygen delivery ( dissolved + Hgb bound)

The dissolved amount is directly proportional to PO2

O2=α PO2, where α = 0.003Eg. 100% O2 at 3 atmospheres, dissolved O2 = 5.7 ml/dl= 285ml/5lit

Supplemental oxygen

Mechanical ventilation:

Hyperbaric oxygen ( HBO) therapy. If other methods fail to attain adequate oxygenation. Employ intermittent air breaks as required by HBO protocol Consider adjunctive antioxidant therapy ( eg tocopherol) Monitor closely to determine appropriate HBO dosage and onset of adverse effects (e.g., pulmonary or CNS function)

Artificial O2 carriers! ?

Optimization of oxygen delivery cont.3- Minimization of oxygen consumption

Appropriate Analgesia

Sedation and muscle relaxants.

Administer lowest effective dose for the shortest duration of

analgesia and sedation.

Consider Neuromuscular blockade

Mechanical Ventilation.

NB -Nitrous oxide may cause transient inhibition of platelet

adhesion.

Thermal Management.

Actively warm hypothermic patient. Cool febrile patient.

Consider therapeutic hypothermia( 32-33celcius)

Strategies to avoid transfusion Summary

Multidisciplinary &multimodality approach

Slide 23

Postpone Elective

Surgery

Optimize

Blood Count

Preoperative

Planning

Hemodilution

(ANH)

NormovolemiaPatient

Positioning

Meticulous

Surgery

Minimize Bleeding

Intraoperative Auto-transfusion/

Cell Salvage

Hemostatic

Agents

Normothermia

(Patient Warming)

Supplemental

Oxygen

Multimodality

Approach

Avoiding transfusion in critically ill patient is

Slide 24

Attainable

Safe

Cost effective

Sound medical practice

SURGERY

CRITICAL CARE

GI BLEEDING

OBSTETRICS & GYNECOLOGY

Clinical Strategies for Avoiding Transfusion