bleeding and transfusion in the operating room - sabm · bleeding and transfusion in the operating...

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Bleeding and Transfusion in the Operating Room

Richard K. Spence MD, MHA, FACS

2

New Rationale: John Bell, Textbook of Surgery, 1812

“ Is not this fear of hemorrhage uppermost in the minds of young surgeons? Were this one danger removed, he would go forward in his profession, almost without fear.”

3

TOPICS

BLEEDING IN THE OR - HOW OFTEN, WHICH PATIENTS, WHY ?

TREATMENT IS TRANSFUSION THE ANSWER?

RISK/BENEFIT EQUATION OF TRANSFUSION

PREVENTION AND REDUCTION OF TRANSFUSION

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INCIDENCE OF HEMORRHAGE IN THE OPERATING ROOM

Japanese Society of Anesthesiologists (JSA) annual survey (2003) - 1,367,790 pts from 782 hospitals Life-threatening hemorrhage (LTH) reported in

1,011 pts = 0.074% Irita K et al. Masui, 2005;54(1):77-86

Hemorrhagic complications in elective surgery - COMPARE™ data: N = 130,641

Incidence = 960/130,641 = 0.075% Data on file, COMPARE™, Haemonetics®

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SOURCES OF LIFE-THREATENING HEMORRHAGE IN THE OPERATING ROOM

Main sources of bleeding were abdominal aorta (15.4%)

thoracic aorta (14%)

liver (12.6%)

intracranial (8.2%)

pelvic organs (8%)

coeliac/mesenteric artery (7.8%) and

lung (7.1%). Irita K et al. Masui, 2005;54(1):77-86

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WHY DO PATIENTS BLEED IN THE OPERATING ROOM?

1. “IT’S A PART OF THE PROCEDURE.”

2. INADVERTENT INJURY: THE “OOPS” FACTOR?

3. MICROVASCULAR BLEEDING

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HIGH-RISK PROCEDURES FOR TRANSFUSION FROM THE LITERATURE

Cardiac Surgery Shehata et al, Vox Sang,

2007

Head & Neck for Squamous Ca

Jecker et al, Hno, 2005

Liver transplantation Bertelli et al, Transplant

Proc, 2005

Joint replacement Nelson C et al, Clin Orthop,

1998

Spine Vitale et al, Spine J, 2002

Abdominal surgery in cirrhotic pt Garrison et al, Ann Surg,

1984

AAA repair Healy et al, Ir J Mede Sci,

2007

TAA repair Conrad et al, Ann Thorac

Surg, 2007

C-section for placental abnormalities Imberti et al, Acta Anaesthesiol

Belg, 1990

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Hemorrhagic Complications: Incidence by Procedure Group

0

0.5

1

1.5

2

2.5

% PTS

% PTS 2.3 2.1 2 2 1.8 1.8 1.7 1.5 1.5 1.5 1.2 1.2 0.8

ENDO MALE GEN ENT NEURO GU HEMLYM\P MS RESP FEM GEN CVS GI SKIN BREAST

N = 130,641 pts. P 0.0001 across groups

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Hemorrhagic Complications: Incidence by Specific Procedure - Top 15

0

2

4

6

8

10

12

14

16

18

% PTS

% PTS 16.7 12.5 11.1 11.1 9.1 6.4 5.3 4.7 4.6 4.5 4.1 3.7 3.6 2.8 2

ENDO

BILIARYVAD

PANC

CYSTCBDE

PULM

VALVE

LIVER

TXP

TOTAL

PANCTAH AAA

EXC LGE

INTTAA

DISTAL

PANC

ABD

VASCMVR AVR

N = 130,641 pts. P <.0001 across groups

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THE “OOPS” FACTOR?

629 injuries trocar injuries from 1993 - 1996. 408 (65%) vascular, primarily aorta and vena cava.

Bhoyrul S et al. J Am Coll Surg.2001;192(6):677-83

FDA report of 1384 trocar injuries cited surgical technique, device problems and patient characteristics as contributing factors.

Fuller J et al. J Minim Invasive Gynecol, 2005;12(4):302-7

“Approximately 75% to 90% of intraoperative and early postoperative bleeding is due to technical factors.”

Marietta M et al.Transplant Proc.2006;38(3):812-4

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THE “OOPS” FACTOR?

Up to 40% of all splenectomies are done for iatrogenic injury. Most common with left hemicolectomy, open anti-reflux procedures and left nephrectomy.

Cassart K & Munro A. J R Coll Surg Edinb,2002;47(6):731-41

7/404 (1.7%) vascular injuries during major renal and adrenal retroperitoneoscopic surgery

Meraney AM et al. J Urol. 2002;168(5):1941-4

54/480 (11% ) spine patients with intraoperative vascular injury. 45/54 (83%) minor. 83% involved exposure of L4-5.

Hamden AD et al. J Vasc Surg, 2008;48(3):650-4

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LIFE-THREATENING HEMORRHAGE IN THE OPERATING ROOM: ASSOCIATED FACTORS

Factors associated with LTH Delayed decision making (15.6%)

Delayed admission to OR for surgery (16.3%)

Anesthesia management problem (28.1%)

Delayed arrival of blood products (25.5%)

Surgical management problem (16.3%). Irita K et al. Masui, 2005;54(1):77-86

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High-Risk Surgery in the JW

Cardiovascular surgery in Jehovah's Witnesses. Report of 542 operations without blood transfusion

Ott DA & Cooley DA, JAMA,1977;238(17):1256-8

Major gynecologic and obstetric surgery in Jehovah's Witnesses (N = 165)

Bonakdar MI et al. Obstet Gynecol, 1982; 60(5):587-90

Total hip arthroplasty in Jehovah's Witnesses without blood transfusion (N = 89).

Nelson CL & Bowen WS. J Bone Joint Surg [Am], 1986;68(3):350-3

Preoperatively assessing and planning blood use for elective vascular surgery (N = 120)

Spence RK et al. Am J Surg, 1994;168(2):192-6

Transfusion free surgery: single institution experience of 27 consecutive liver transplants in Jehovah's Witnesses

Jabbour N et al. J Am Coll Surg, 2005;201(3):412-7

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PROCEDURE AND ERROR-RELATED BLEEDING

1. Procedures that involve cutting into the cardiovascular system may involve more risk, and errors do occur in the best of circumstances, but REMEMBER

2. Shed blood can be recovered, processed and returned to the patient for ALL these procedures, and

3. ALL these procedures can and have been done with minimal blood loss by using careful technique and meticulous hemostasis.

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MICROVASCULAR BLEEDING AND OOZING - WHAT’S GOING ON ?

Quantitative and/or Qualitative problems with Platelets and/or Coagulation Factors

Drug effects and Interactions

Massive transfusion - dilution

Transfusion reaction Melting Ice Cream Truck sculpture by "The

Glue Society”, Australia

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Platelets and Coagulation Factors - Quantitative Disorders

Hereditary Fanconi, Alport, Bernard-Soulier syndromes

Factor deficiencies - Hemophilia, Von Willebrand’s disease

Decreased production Vitamin B12 deficiency

Leukemia, Myelodysplastic syndrome

Sepsis

Liver failure

Increased destruction ITP, TTP, DIC, SLE, HUS

Dilutional Massive transfusion

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Platelets and Coagulation Factors - Qualitative Disorders

Medications Heparin/Warfarin - prophylaxis

COX inhibitors Aspirin/NSAIDs

Glycoprotein IIb/IIIa inhibitors Abciximab, Epifibitide, Tirofiban

ADP inhibitors Clopidogrel, Ticlopidine

Chemotherapeutic agents

Valproic acid

Herbals

Von Willebrand’s disease

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Risk of Bleeding with Prophylactic Anticoagulation

Rivaroxaban v. enoxaparin in TKR % THR: Major bleeding TKR = 0.6%; 0.5%; THR = 0.3%; 0.1%

Lassen MR et al. N Engl J Med.2008;358(26):2776-86

Erikkson BI et al. N Engl J Med.2008;358(26):2765-75

Bleeding incidence = 6.7% with LMWH v. 2.7% with conventional heparin but all MINOR

Bergqvist D et al. Br J Surg. 1988;7599):888-91

High risk orthopedic surgery - no major bleeding in trial of LMWH v. UFH

Simmoneau G et al. Arch Intern Med.1993;153(13):1541-6

426 pts - all general anesthesia, all LMWH: 1/426 (0.2%) bleeding

Howard A et al. Br J Surg. 2004;91(7):842-7

Incidence of

MAJOR bleeding

less than 1%

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Herbal Medicines with Coagulation Effects

Ginkgo biloba

Licorice root

Ginger

Garlic

Gingseng

Clove

Fenugreek

Feverfew

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Preoperative Strategies

Identify and record patient’s medications

Stop meds before surgery if possible…and safe

Convert from long acting/irreversible drug to reversible drug Coumadin to Heparin

Use smaller dose Pre-operative aspirin increases post-operative bleeding, but

this may be avoided by the use of aspirin doses <325 mg/day.

Sun JC et al. Eur Heart J, 2008;29(8):1057-71

Correct nutritional deficiencies

Use specific factors for hereditary disorders

Desmopressin for von Willebrand’s

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What About Patients on Dual Therapy after PCI and Stenting?

Dual therapy = Clopidogrel and ASA

Risk of stent thrombosis increased if therapy is discontinued early, especially if surgical pt,

Silber S et al. Herz, 2008; 33(4):244-53

Chassot PG et al. Br J Anaesth. 2007;99(3):316-28

Best evidence says MUST continue therapy until stents are endothelialized

3 mos for bare metal stents; up to 1 yr for drug-eluting stents

Rate of bleeding and transfusion for CABG similar with/without cessation of clopidogrel Song SW et al. Circ J. 2008;72(4):626-32

Consider converting from irreversible drug (Clopidogrel) to reversible drug (Eptifibitide)

Consult the cardiologist!!!

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Trauma, Transfusions and Recombinant Factor VIIa

380 patients in Level I & II trauma centers at risk of death from hemorrhage

Mean time from admission to rFVIIa = 4.6 hrs.

Average 18 units RBCs before rFVIIa

Death from hemorrhage = 30%

Predictors of poor response pH <7.2

Platelet count <100,000

Blood pressure </= 90mm Hg

“Precise role of rFVIIa in traumatic hemorrhage is unclear.”

“First, correct shock, acidosis and thrombocytopenia.”

Knudson MM et al, 2011, J Amer Coll Surg, 22:1, 87-95

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Blood Loss and Transfusion are NOT the Same!

www.usaccc.org

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Why Do We Transfuse? Historical Transfusion Standards

James Blundell (1812): transfuse only following life-threatening hemorrhage

Multiple authors (19th century - 1940’s): transfuse only following life-threatening hemorrhage or to treat severe anemia

Adams and Lundy (1941): transfuse to an H/H of 10/30 before surgery

Received knowledge (1941-1988): transfuse as deemed needed

NIH Consensus Conference(1988): transfuse based on clinical evidence and Hgb < 8 gm/dL

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Rationale for Transfusion Over Time

1667 - Correct mental disturbances

Jean Baptiste Denis and surgeon Paul Emmerez transfused lamb’s blood into a 16 yr old boy to correct his “dull and lumpish spirit.”

Antoine Mauroy had “escaped from his wife’s control.”

Deaths and lawsuits lead to ban for 150 years.

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Rationale for Transfusion Over Time

1818 - Preventing death from active blood loss James Blundell

performs 1st allogeneic human blood transfusion on post-partum women - 50% successful

1818 and on - Uncertainty We are “all at sea” on

this subject

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Rationale for Transfusion 1880 - 1900

Reports on 243 transfusions for “severe hemorrhage” -

Life-saving in 40.9%.

Experiments in transfusion for “severe hemorrhage”

Jennings - Transfusion: 1884 Geo Crile, Sr. - Hemorrhage and Transfusion: 1899

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Bernheim, Blood Transfusion, Hemorrhage and the Anemias, 1917

Death from hemorrhage can be prevented by transfusion

Surgery made possible by transfusion

BUT, only anecdotal evidence

Rationale for Transfusion 1880 - 1900 - II

•Risk of reaction = 1:2 or 3

•Success = volume and use of fresh, whole blood

•Cult of itinerant “surgical” transfusionists develops

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Military experience with

fresh, whole blood

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Immediate Life-Threatening Condition…AND Hemoglobin!

BLEEDING CARDIOPULMONARY COMPROMISE

STILL POSSIBLE

IV ACCESS CONTROL PAIN

TREAT HYPOTHERMIA CORRECT PH TO > 7.20

1. BOLUS 20 ML/KG RL/NS, repeat X 2 2. TRANSFUSE TO HBG > 10 G/Dl 3. FIND AND CONTROL BLEEDING SITES

Scientific American Handbook of Trauma, 2000

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Immediate Life-Threatening Condition…AND Hemoglobin!

http://www.trauma.org/archive/resus/massive.html

If Hb > 10g/dl transfusion is rarely indicated.

If Hb < 7g/dl transfusion is usually necessary.

If Hb between 7 and 10 g/dl, clinical status, PvO2 and ER are helpful in defining transfusion requirements

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WHY DO YOU TRANSFUSE?

1. THE PATIENT “NEEDS”, “REQUIRED” A TRANSFUSION BECAUSE

1. “THE HEMOGLOBIN WAS LOW.”

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2. “HE WAS ANEMIC.”

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3. “SHE NEEDED MORE OXYGEN.”

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4. “WE’D LOST A LOT OF BLOOD.”

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5. “SHE WAS DIZZY AND LIGHT-HEADED.”

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6. “THIS IS WHAT I WAS TAUGHT TO DO.”

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7. “I ALWAYS TRANSFUSE THIS TYPE OF PATIENT.”

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8. “THE NURSE CALLED AND TOLD ME HE NEEDED BLOOD.”

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9. “THE ANESTHESIOLOGIST/HOSPITALIST/ PA/ NP/ RESIDENT/PRIMARY CARE DOC DID IT - NOT ME!”

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9. “THE ANESTHESIOLOGIST/HOSPITALIST/ PA/ NP/ RESIDENT/PRIMARY CARE DOC DID IT - NOT ME!”

10. “I WAS ONLY FOLLOWING ORDERS.”

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WHAT DETERMINES RBC TRANSFUSION? THE “USUAL SUSPECTS”?

Blood loss? Most literature discusses

TRANSFUSION not BLOOD LOSS - they are not the same!!

Patient status Co-morbidities

Urgency of operation

Surgeon - experience, training and choice

Hemoglobin/Anemia

Female gender

Advanced age

BSA

Captain Renault: “Major Strasser

has been shot. Round up the

usual suspects.” (Casablanca, 1942)

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FACTORS ASSOCIATED WITH RBC TRANSFUSION

N = 130,171 elective surgical patients

FACTOR OR CI P

GENDER (F) 1.7 1.6 - 1.8 <.0001

ANEMIC ON ADM 0.6 0.56 - 0.65 <.0001

HX ANEMIA 1.75 1.6 - 1.9 <.0001

ANY HEART DISEASE

1.18 1.1 - 1.3 <.0001

CHARLSON 0.19 0.15 - 0.23 <.0001

NADIR HGB 13944 9198 - 21148 0.0000

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ADMISSION HGB GROUP - NUMBER PATIENTS BY GROUP

0

1000

2000

3000

4000

5000

6000

7000

N PTS

N PTS 230 464 1446 2435 3701 5389 6569 6325 4805 2957 1564 1583

5 6 7 8 9 10 11 12 13 14 15 16

67%

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RBC Transfusion by Admission and Nadir Hemoglobin

0

10

20

30

40

50

60

70

NADIR ADM

NADIR 50 66 58 52 34 17 12 10 9.6 10 9 9 9.2

ADM 48 66 57 50 38 27 23 17 14 14 15 14 17

4.1-5 5.1-6 6.1-7 7.1-8 8.1-9 9.1-1010.1-

11

11.1-

12

12.1-

13

13.1-

14

14.1-

15

15.1-

16

16.1-

17

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RBC Transfusion in Patients with AHD

by Hemoglobin Group - % transfused

0

10

20

30

40

50

60

70

80

AHD YES AHD NO

AHD YES 33.3 58 53.3 50 42 31 27 20.3 16.8 16.8 14.6 15.1 20.8 19.1 14.4

AHD NO 60.3 71.4 60.2 49.5 35.6 25.1 20.2 15.3 12.1 12.1 16.1 13.1 13.7 15.8 14.4

<5 5.1-6 6.1-7 7.1-8 8.1-99.1-

10

10.1-

11

11.1-

12

12.1-

13

13.1-

14

14.1-

15

15.1-

16

16.1-

17

17.1-

18>18

P <.0006

P <.03

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0

1

2

3

4

5

6

7

8

9

% RBCS YES % RBCS NO CHARLSON

% RBCS YES 0 0 2.5 4 3.7 1.3 2.8 3.3 4 3.4 4.15 4.4 4.3 2.1 2.2

% RBCS NO 5.9 8 2.4 2.6 4.5 1.6 0.84 0.88 0.78 0.84 0.84 0.79 1.2 1.2 0.34

CHARLSON 1.6 2 1.5 1.4 1.5 1.4 1.35 1.3 1.2 1.3 1.4 1.5 1.3 1.2 1

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

P <.0001

HGB RANGE

Impact of RBCs on mortality in elective, non-cardiac surgery patients with any heart disease -

Plenary Session presentation, AABB Annual Meeting, 2008, Montreal

RBC Transfusion and Mortality in

Elective, Non-Cardiac Surgery

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RBC Transfusion Incidence by Procedure Group

0

5

10

15

20

25

% PTS RBCS

% PTS RBCS 20 18 22 20 21 18 22 19 20 21 20 20 17 20.5

CVS ENDO ENT EYEFEM

GENGI GU

HEML

YM\P

MALE

GENMS

NEUR

ORESP SKIN MISC

N = 130,641 pts. P <.0001 across groups

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RBC TRANSFUSION VARIABILITY - THE AUSTRIAN STUDY

N = 1401 THR, 1296 TKR, 777 CABG Gombotz H et al, Transfusion, 2007;47(8):1468-80

0

50

100

% P

TS

T

RA

NS

FU

SE

D

PROCEDURE TYPE

HIGH LOW

HIGH 85 87 63

LOW 16 12 37

THR TKR CABG

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RBC TRANSFUSION VARIABILITY BY HOSPITAL - JOINT REPLACEMENT

0

10

20

30

40

50

60

70

80

% PTS

% PTS 32 22 16.7 7.3 28 74 64.5 32 38.5 45 16.5 39 1.5

A B C D E F G H I J K XXX EBS

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RBC TRANSFUSION VARIABILITY BY SURGEON - COLECTOMY

A B C D E F G H I J K L M N O P Q

% PTS RBCS

0

10

20

30

40

50

60

70

% PTS RBCS

% PTS RBCS 67 50 31 17 33 40 0 33 29 25 0 20 60 14 13 20 40


N = 2,056 pts.

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RBC TRANSFUSION VARIABILITY BY SURGEON - LYSIS OF ADHESIONS


% PTS RBCS

0

10

20

30

40

50

60

70

80

90

% PTS RBCS

% PTS RBCS 25 0 0 25 0 60 60 20 20 0 40 33 17 86 14 25 78


N = 2,136 pts.

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RBC TRANSFUSION VARIABILITY BY SURGEON - BREAST


% PTS RBCS

0

10

20

30

40

50

60

70

80

90

% PTS RBCS

% PTS RBCS 20 60 20 0 40 0 0 83 67 17 43 71 14 0 11 10 27


N = 2,080 pts.

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When Are RBCs Transfused? Transfusion by Perioperative Day

0

10

20

30

40

50

60

% P

TS

TR

AN

SF

US

ED

0

50

100

150

200

250

% PTS N UNITS

% PTS 9 50 26 14 11 5 1 2 2 9

N UNITS 48 199 94 51 40 19 4 9 12 32

PREOP OP POD 1 POD 2 POD 3 POD 4 POD 5 POD 6 POD 7POD

>1 WK

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Risk versus Benefit in Blood Transfusion: Known Risks of Blood Transfusion

Reactions

TTD

Microchimerism

TRIM

TRALI

TACO

Cytokine infusion

Human error

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Risk Vs. Benefit is in the Eyes

of the Beholder

BUT, known risks should outweigh

perceived benefits every time

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Studies of RBC Transfusion Association with Infection

A. Taylor - Orthopedics: Y = 14.3%; N = 5.8%

A. Crit Care Med,2006;34(9):2302-8

B. Innerhofer - Orthopedics: Y = 12%; N = 6.9%

A. Transfusion, 2005;45(1):103-10

C. Dunne - Trauma/combat: Y = 69%; N = 18%

A. Am Surg, 2006;72(7):619-25

Hill - 23 peer-reviewed articles (1986 to 2000)- 13,152 pts. (5,215 transfused; 7,937 non-transfused

OR of postoperative bacterial infection with RBCS =as 3.45

(range, 1.43-15.15), p < or = 0.05

Hill, Gary E et al. J Trauma 2003 May;54(5):908-14.

0

10

20

30

40

50

60

70

% P

TS

WIT

H IN

FE

CT

ION

A B C

AUTHORS

WITH RBCS W/O RBCS

These results provide overwhelming

evidence that ABT is associated with a

significantly increased risk of

postoperative bacterial infection in the

surgical patient.

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Allogeneic Blood Transfusion, Cancer Recurrence and Survival

Author Cancer N Pts Year Survival Recurrence

Drezner Esoph 235 2000 NA

Balachandran Ampullary 113 2007 NA

Dhar Gastric 640 2000 NA

Pysz Breast 863 77-95

Van de

Watering

Colorectal* 657 2001

Kaibori Hepatic 285 2007

Amato Colorectal 12,127 2006 NA

Jensen Colorectal** 740 2000

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The RBC Storage Lesion

Decreased oxygen delivery Loss of 2,3, diphosphoglycerate (2,3 DPG) shifts O2 dissociation curve to left = hemoglobin

attracts oxygen and holds onto it but doesn’t release it well. Suttner, Anesth Analg, 2004

Deformed cells RBCs lose flexibility and cannot get into the capillaries, thereby decreasing delivery of

oxygen to cells in need. Chin-Yee I and Spence RK, Blood Storage in: Perioperative Transfusion Medicine, 2006, eds. Spiess, Shander, Spence. P.

199-210.

Accelerated RBC death Stored RBCs die more quickly than fresh cells. They release free hemoglobin, a potent

vasoconstrictor. Vasoconstriction of capillaries decreases oxygen delivery to tissues. Luten M., Cell Mol Biol, 2004

Affects both Allogeneic and Autologous RBCs Ghio M et al, Transfusion, May 6 2008

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Koch C et al., Duration of Red-Cell Storage and

Complications after Cardiac Surgery.

N Engl J Med, 2008, 358(12):1229-1239

The Older the Blood, the Worse the Outcome

Multiple studies in a variety of patients have shown that the age of the transfused blood has a negative impact on patient outcomes.

Pneumonia Van de Watering, Transfusion,

2006

ICU patients Tinmouth, Transfusion, 2006

Cardiac surgery Vamvakas, Transfusion, 1999

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Giving MORE Blood Does NOT Improve Outcomes

The TRICC Trial: 357 ICU pts. randomized to maintenance of either 8 gm/dL (restrictive group) vs. 10 gm/dL (liberal group)

• Hébert et al. N Engl J Med. 1999;340:409-417

The PINT Trial: ELBW infants randomly assigned within 48 hrs of birth to maintenance of low or high Hgb transfusion thresholds.

Kirpalani H, J Pediatr, 2006;149(3):301-307

RBC transfusion to 8 gm/dL vs. 10 gm/dL in severe brain injury patients

George et al, Neurocrit Care, 2008;Feb 14

For ALL THREE TRIALS: Transfusion rate lower in restrictive groups

No statistically significant differences between groups in primary outcomes.

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Benefit of Blood Products - What Can We Conclude?

Evidence of benefit from RBC transfusion is hard to find

Most benefit is assumed and not scientifically proven

Some patients will benefit from blood transfusion but we need to do a better job of identifying who they are

No prospective, randomized trials have ever been done to establish the life-saving benefit of RBC transfusion

Giving MORE blood is NOT better

As a result, many RBC transfusion are probably unnecessary

Patients transfused without need get RISK, not BENEFIT

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All Blood Products Carry Risk

FFP PLATELETS

65

FFP and CRYO GUIDELINES

DO USE FFP FOR Single or multiple specific, diagnosed coagulation

factors deficiencies

DIC with bleeding

DO NOT USE FFP FOR Warfarin reversal

Vitamin K deficiency

To correct INR/PT/PTT in the absence of bleeding

Hypovolemia

DIC without bleeding

DO USE CRYO FOR Documented fibrinogen deficiency

DIC with bleeding

66

How Do I Prevent and/or Reduce Blood Loss?

• Halstedian principles

• Temporary vascular occlusion

• Stop bleeding, don’t use it as a guide to transfusion!

• “I HAD TO DO THIS QUICKLY, SO I IGNORED THE BLEEDING”

• Anatomic dissection • “IF IT BLEEDS WHEN YOU CUT

IT, IT’S A VESSEL!’

• CLAMP, THEN CUT!

• Experienced hands • SLOW BAD, FAST BAD, FAST

GOOD

• Preop embolization

• Staging of procedures

• CUSA, cautery, LASER, etc.

• Fibrin glues, etc.

• Laparoscopic and lap-assisted surgery

• Image-guided surgery

• Robotics

• Minimally-invasive, endovascular, etc.

67

Halsted’s Surgical Principles

Handle tissue gently

Dissect along anatomic planes

Maintain hemostasis

Use fine sutures

Use sharp dissection

68

“Next, an example of the very same procedure when done correctly!”

Know

The

Procedure!!

The surgeon has many tools available to control bleeding.

Know them and use them wisely.

70

THE MAIN REASONS WE TRANSFUSE

TO TREAT ANEMIA AND RAISE H&H

PHYSICIAN CHOICE

71

Blood Loss in Surgery - Basic Concepts

Most general surgical procedures can be done with minimal blood loss

Reducing surgical blood loss improves outcomes by reducing RBC transfusion

Allogeneic blood carries risk that can be avoided

Preoperative planning is essential for blood avoidance

72

WHAT CAN WE CHANGE IN OUR TRANSFUSION PRACTICE?

1. PREVENTION - WORDS HAVE POWER, SO STOP SAYING THE PATIENT “NEEDS” OR “REQUIRED” A TRANSFUSION

1. WHERE’S THE PROOF? WHY DID THE PT “NEED” A TRANSFUSION?

2. IF YOU CHOSE TO TRANSFUSE USE CLINICAL CRITERIA AND DOCUMENT BOTH YOUR REASONS AND RESULTS

1. ADD TO SURGICAL TIME-OUT?

3. IF ARE YOU TREATING A NUMBER, NOT A PATIENT

1. WHO FEELS BETTER - YOU OR THE PATIENT?

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TREAT ANEMIA PREOP

Treatable anemia

should be a CONTRAINDICATION

to elective surgery.

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Perioperative Blood Management Policies

Tolerate asymptomatic anemia

Transfuse on a case-by-case basis Document both rationale and results

Transfuse one unit at a time

Right blood to the right patient at the right time

Prevent and control blood loss

Use fresh, not stored, autologous blood

Maximize oxygen delivery

Restore RBC preop

Involve the patient

Follow policies and procedures

Track, measure and monitor

Listen, learn and share Spence RK, Surgical Red Blood Cell Transfusion Policies. Am J

Surgery, 1995; 170, [6A] (Suppl)

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Any Questions?

bleeding and transfusion in the operating room - sabm · bleeding and transfusion in the operating...

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