Blood Conservation Techniques and Perioperative … · K.R Part 9 of Helping Hands of Blood Conservation Techniques, May 2001 Page 1 Clinical Strategies for Avoiding Blood Transfusion

K.R Part 9 of Helping Hands of Blood Conservation Techniques, May 2001 Page 1

Clinical Strategies for Avoiding Blood Transfusion in Obstetrics and Gynecology Hospital Information Services(Canada)for Jehovah's Witnesses

Helping Hands for Blood Conservation Techniques and Perioperative Planning Part 9 May 2001

Table of Contents

OUICK REFERENCE (QR) 3/99(Revised Version June 2000) ................................................................ 5 Jehovah's Witnesses General Aspects (QR) Part 1 ..................................................................................... 5

Religious and Ethical Position on Medical Therapy, Child Care, and Related Matters .............................. 5 Abortion .................................................................................................................................................. 5 Adoption and Foster Care ....................................................................................................................... 5 Advance Directives ................................................................................................................................. 5 Alcohol, Narcotics, Medications ............................................................................................................. 6 Alternatives to Blood Transfusion........................................................................................................... 6 Alternatives to Blood Transfusion (cont.) ............................................................................................... 6 Autotransfusion ....................................................................................................................................... 6 Blood Transfusions ................................................................................................................................. 6 Burial of a Fetus ...................................................................................................................................... 6 Child Discipline, Neglect, and Abuse ..................................................................................................... 6 Circumcision ........................................................................................................................................... 7 Decision-Making and Treatment Information ......................................................................................... 7 Dietary Laws and Beliefs ........................................................................................................................ 7 Dissection and Autopsies ........................................................................................................................ 7 Drugs....................................................................................................................................................... 7 Euthanasia ............................................................................................................................................... 7 Handicapping Conditions (Birth Defects) ............................................................................................... 7 Heart Bypass ........................................................................................................................................... 7 Hemodialysis........................................................................................................................................... 7 Hemodilution........................................................................................................................................... 7 Immunoglobulins, Vaccines .................................................................................................................... 7 "Living Will"/Substitute Decision-Maker/ Power of Attorney for Medical Decisions............................ 8 Medications............................................................................................................................................. 8 Narcotics ................................................................................................................................................. 8 Organ Donation and Transplantation ...................................................................................................... 8 Prolongation of Life and Right to Die ..................................................................................................... 8 Religion and Healing Processes(Faith Healing) ...................................................................................... 8 Religious Sacraments, Ordinances,Rituals, and Customs........................................................................ 8 Serums..................................................................................................................................................... 8 Transplants .............................................................................................................................................. 8 Vaccinations............................................................................................................................................ 8

Strategies for Avoiding and Controlling Hemorrhage and Anemia Without BloodTransfusion (QR) PART 2(Revised Version June 2000) ............................................................................................................ 9

1. Surgical Devices and Techniques to Locate and Arrest Internal Bleedling......................................... 9 a. Electrocautery/Electrosurgery......................................................................................................... 9 b. Laser Surgery.................................................................................................................................. 9 c. Argon Beam Coagulator ................................................................................................................. 9 d. Stereotactic Radiosurgery............................................................................................................... 9 e. Microwave Coagulating Scalpel ..................................................................................................... 9 f. Ultrasonic Scalpel ........................................................................................................................... 9 g. Endoscope ("keyhole surgery") ...................................................................................................... 9 h. Arterial Embolization ..................................................................................................................... 9 i. Tissue Adhesives............................................................................................................................. 9



2. Techniques and Devices to Control External Bleeding and Shock ..................................................... 9 a. For Bleeding: .................................................................................................................................. 9 b. For Shock: ...................................................................................................................................... 9

3. Operative and Anesthetic Techniques to Limit Blood loss During Surgery........................................ 9 a. Hypotensive Anesthesia.................................................................................................................. 9 b. Induced Hypothermia ..................................................................................................................... 9 c. Intraoperative Hemodilution........................................................................................................... 9 d. Hypervolemic Hemodilution ........................................................................................................ 10 e. Intraoperative Blood Salvage ....................................................................................................... 10 f. Mechanical occlusion of bleeding vessel ...................................................................................... 10 g. Reduce blood flow to skin ............................................................................................................ 10 h. Meticulous hemostasis.................................................................................................................. 10 i. Preoperative planning:................................................................................................................... 10

4. Blood-Oxygen Monitoring Devices and Techniques that Limit Blood Sampling ............................. 10 a. Transcutaneous Oximeter ............................................................................................................. 10 b. Pulse Oximeter ............................................................................................................................. 10 c. Pediatric microsampling equipment.............................................................................................. 10 d. Multiple tests per sample.............................................................................................................. 10

5. Volume Expanders ............................................................................................................................ 10 a. Crystalloids................................................................................................................................... 10 b. Colloids ........................................................................................................................................ 10 c. Perfluorocarbons........................................................................................................................... 10

6. Hemostatic Agents for Bleedling/Clotting Problems ........................................................................ 10 a.Topical:.......................................................................................................................................... 10 b. lnjectable: ..................................................................................................................................... 10 c. Other Drugs: ................................................................................................................................. 11

7. Therapeutic Agents and Techniques for Managing Anemia.............................................................. 11 a. Stop any bleeding ......................................................................................................................... 11 b. Oxygen support ............................................................................................................................ 11 c. Maintain intravascular volume...................................................................................................... 11 d. Hematinics (iron, folic acid, Vitamin B12) .................................................................................. 11 e. Erythropoietin............................................................................................................................... 11 f. Nutritional support ........................................................................................................................ 11 g. lmmunosuppressive agents if indicated ........................................................................................ 11 h. Perfluorocarbons .......................................................................................................................... 11 i. Granulocyte-Colony Stimulating Factor........................................................................................ 11 j. Hyperbaric Oxygen Therapy ......................................................................................................... 11 k. 10/30 rule has no scientific basis .................................................................................................. 11

CLINICAL STRATEGIES for managing HEMORRHAGE and ANEMIA without BLOOD TRANSFUSION in the ICU (QR) PART 3(Revised Version June 2000) ............................................... 12

GENERAL NONBLOOD MANAGEMENT PRINCIPLES ........................................................... 12 GENERAL THERAPEUTIC PRINCIPLES 1,2,3,4 ........................................................................ 12

1. MINIMIZE HEMORRHAGIC BLOOD LOSS5................................................................................... 12 A. Avoid hypertension and hypervolemia 6,7.............................................................................. 12 B. Avoid severe hypotension ....................................................................................................... 12 C. Maintain extra vigillance......................................................................................................... 12 D. Avoid delay............................................................................................................................. 12 E. Blood salvage .......................................................................................................................... 12 F. Maintain normothermia ........................................................................................................... 13 H. Hemostatic agents for bleeding/clotting problems 30,31......................................................... 13 I. Prophylaxis of upper gastrointestinal hemorrhage 48,49 ........................................................... 13 J. Avoid/treat infections promptly ............................................................................................... 13

2. REDUCE IATROGENIC BLOOD LOSS............................................................................................. 13 A. Restrict Phlebotomy 57,58 ........................................................................................................ 13 B. Review adverse effects of current medications (NSAIDs, e.g.,............................................... 13

3. MAXIMIZE OXYGEN DELIVERY..................................................................................................... 14 A. Maintain intravascular volume................................................................................................ 14 B. Maintain cardiovascullar support 86,87.................................................................................... 14 C. Maintain Ventilation and Oxygenation ................................................................................... 14



4. MINIMIZE OXYGEN CONSUMPTION ............................................................................................. 14 A. Adequate and appropriate analgesia ....................................................................................... 14 B. Sedation; ................................................................................................................................. 14 C. Mechanical ventilation ............................................................................................................ 14 D. Maintain/restore normothermia............................................................................................... 14

5. IMPROVE BLOOD COUNT ................................................................................................................ 14 A.Therapy for Hematinic Deficiencies: ....................................................................................... 14 B. Prophylactic hematinic therapy to maximize stores and optimize........................................... 15 C. Recombinant Erythropoietin (r-HuEPO) Therapy .................................................................. 15 E. Nutritional Support.................................................................................................................. 15

6. PREOPERATIVE WORKUP / CLINICAL EVALUATION................................................................ 15 A. Medical History and Physical Examination 129,130................................................................. 15 B. Laboratory Assessment/Screening 135,136,137 ............................................................................ 15 C. Management of bleeding risk/therapy for coexisting disease. l39,140......................................... 16 D. Correct anemia and optimize preoperative hemogIobin level (See 5. A»-C.) ............................ 16

7. SURGICAL/ANESTHETIC BLOOD CONSERVATION TECHNIQUES.......................................... 16 A. Surgical procedure(s) to specifically avoid and prevent bloodloss ......................................... 16 B. Arterial Embolization.............................................................................................................. 16 C. Meticulous Hemostasis 165, 166, 167 ............................................................................................ 16 D. Mechanical occlusion of bleeding vessel 168 ........................................................................... 16 E. Electrocautery.......................................................................................................................... 16 F. Ultrasonic Scalpel 169............................................................................................................... 16 G. Argon beam coagulator 170,171 .................................................................................................. 16 H. Tissue Adhesives .................................................................................................................... 16 I. Intraoperative Blood Salvage 174, 175 ......................................................................................... 16 J. Hemodilution 176, 177 ................................................................................................................. 16 K. Platelet-rich plasma sequestration 178, 179 ................................................................................. 16 L. Induced hypothermia ............................................................................................................... 16 M. Hypotensive anesthesia 180...................................................................................................... 16

Clinical Strategies for Avoiding and controlling Hemorrhage and Anemia without Blood Transfusion in Obstetrics and Gynecology .......................................................................................................................... 22 (QR) PART 4(Reviced June 2000) .............................................................................................................. 22

General Principles of Nonblood OB/GYN Management ........................................................................... 22 General TherapeuticPrinciples................................................................................................................... 22 1.Clinical Evaluation/Preoperative Planning1,2 ...........................................................................................22

A. Medical history and physical examination3........................................................................................22 B. Laboratory assesment/screening 8,9,10 .................................................................................................23 C. Opimize blood count .........................................................................................................................23 D. Management of Menorrhagia and Bleeding Risk ..............................................................................23

2. SURGICAL AND ANESTHETIC BLOOD CONSERVATION TECHNIQUES43,44,45 ........................24 A. Insert two large-bore intravenous catheters prior to major surgery; warming of fluids and the patient will avoid hypothermia and coagulopathy............................................................................................. 24 B. Enlarged surgical team/minimal time................................................................................................ 24 C. Meticulous hemostasis...................................................................................................................... 24 D. Uterine Thermal Balloon Ablation Therapy54,55 ............................................................................... 24 E. Transcervical or hysteroscopic endometrial ablation56,57 .................................................................. 24 F. Spinal/epidural/general anesthesia58,59 .............................................................................................. 24 G. Normovolemic hemodilution60,61,62................................................................................................... 24 H. Controlled hypotension63.................................................................................................................. 24 I. Intraoperative blood salvage64,65,66,67.................................................................................................. 24 J. Considerations for cesarean section: ................................................................................................. 24 K. Management of surgical Hemorrhage/shock..................................................................................... 24

3. NONBLOOD VOLUME EXPANDERS................................................................................................24 A. Crystalloids ....................................................................................................................................... 24 B. Colloids ............................................................................................................................................. 24

4. HEMOSTATIC AGENTS FOR BLEEDING/CLOTTING PROBLEMS..............................................25 A. Topical .............................................................................................................................................. 25 B. Injectable .......................................................................................................................................... 25

5. OBSTETRIC HEMORRHAGE117,118,119,120 ............................................................................................25



A. Antepartum........................................................................................................................................ 25 B. Postpartum........................................................................................................................................ 25

1. Anticipation and prevention; Postpartum Hemorrhage Risk Factors122,123 ....................................25 2. Active management of third stage of labour123,124..........................................................................25 3. Control of postpartum hemorrhage127 ............................................................................................25 4. Prevention and Management of Disseminated Intravascular Coagulation (DIC)143,144,145 .............26

7. MANAGEMENT OF PROFOUND ANEMIA146,147,148,149 .................................................................... 26 A. Stop any bleeding.............................................................................................................................. 26 B. Restrict laboratory blood testing....................................................................................................... 26 C. Maximize oxygen delivery ............................................................................................................... 26 D. Minimize oxygen consumption ........................................................................................................ 26 E. Improve blood count152,153,154 (See 1.C.) ........................................................................................... 26



OUICK REFERENCE (QR) 3/99(Revised Version June 2000) Hospital Information Services (Canada) for Jehovah's Witnesses ! [email protected] ! Information/Referral # 1-800-265-0327 # ! 24-Hour Hot Line

Jehovah's Witnesses General Aspects (QR) Part 1

Hospital Information Services (Canada) for Jehovah's Witnesses ! [email protected] ! Information/Referral # 1-800-265-0327 # ! 24-Hour Hot Line

Religious and Ethical Position on Medical Therapy, Child Care, and Related Matters

Abortion

Deliberately induced abortion simply to avoid the birth of an unwanted child is the wilIful taking of human life and hence is unacceptable to jehovah's Witnesses. 1f, at the time of childbirth, a choice must be made between the life of the mother and that of the child, it is up to the individuals concerned to make that decision.

Adoption and Foster Care Every effort is made to assist the natural parent(s) to care for their children and to preserve, to the extent possible, the integrity of the family. lf custodial care by others is necessary, the best physical, emotional, and spiritual environment is desirable and encouraged. Witness families have provided adoptive and foster care for both Witness and non-Witness children.

Advance Directives Jehovah's Witnesses carry on their person an Advance Medical Directive/Release that directs no blood transfusions be given under any circumstances, while releasing physicians/hospitals of responsibility for any damages that might be caused by their refusal of blood. When entering the hospital, release forms should be signed that state matters similarly and deal more specifically with the hospital care needed. Witness patients request medical alternatives to blood transfusion.

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mailto:[email protected]



Alcohol, Narcotics, Medications Moderate use of wine and other alcoholic beverages is not prohibited by the Bibie. (Deuteronomy 14:26; Ephesians 5:18; 1 Timothy 5:23) Similarly, Bibie principles of moderation and respect for one's life and mental faculties would rule out taking drugs for "highs" and thrills or to produce a form of drunkenness. The taking of mindaltering medications and drugs, inciuding narcotics for severe pain, under the supervision of a physician, would be a matter for personal decision. though one would not want to resort too quickly or without good cause to drugs that were addictive or hallucinatory if other effective methods of treatment were available or if endurance of temporary pain would be the wise and preferable course, 2 Corinthians 7:1.

Alternatives to Blood Transfusion Use of allogeneic (donor) blood transfusion can be avoided by the systematic use of appropriate clinical strategies for managing hemorrhage and anemia without blood transfusion. These strategies use combinations of drugs, medical clevices, and surgicai/medical techniques to conserve the patient's own blood and to help his/ her body act as its. own blood bank. (Piease refer to overview on page 4.) This is called blood conservation or "bIoodless" medicine and surgery.

Alternatives to Blood Transfusion (cont.) For example, hemostatic scalpels can simultaneously cut tissue and stop bleeding. The patient's shed blood may be filtered and returned to the patient using a cell salvage or "autotransfusion" clevice. Hemostatic agents enhance or promote clotting. Medications can be used to stimulate the body to produce replacement blood cells more quickly and abundantly than usual. (For example, a drug called erythropoietin stimulates the body's production of red blood cells.) Modified anesthetic and surgical techniques (e.g., hemodilution) are employed to limit blood loss during an operation. Blood sampiing for lab tests is minimized to reduce blood loss.

Autotransfusion Autotransfusion is acceptable to many of jehovah's Witnesses (this being a matter of conscience) when the equipment is arranged in a closed circuit that is constantly linked to the patient's circulatory system and there is no storage of the patient's blood. jehovah's Witnesses do not accept preoperative collection, storage, and later reinfusion of blood.

Blood Transfusions Jehovah's Witnesses believe that blood transfusion is prohibited by Biblical passages such as: "Only flesh with its soul-its blood-you must not eat" (Genesis 9:3, 4); "[Youl must in that case pour its blood out and cover it with dust" (Leviticus 17:13, 14); and "Abstain . . . from fornication and from what is strangied and from blood." (Acts 15:19-21) While these verses are not stated in medical terms, Witnesses view them as ruling out transfusion of whole blood, packed red blood cells, white blood celis, plasma, and platelets. However, Witnesses' religious understanding cloes not absolutely prohibit the use of minor blood fractions, such as albumin, clotting factors, and immune globulins. -See ImmunogIobulins, Vaccines." Refusing blood cloes not make jehovah's Witnesses anti-medicine. There are many effective nonblood medical alternatives to allogeneic blood. For example, nonblood volume expanders are acceptable, and reinfusion of their own blood is permitted by many Witnesses when the blood is not stored and when the equipment is arranged in acircuit that is constantly linked to the patient's circulatory system. (See page 4.)

Burial of a Fetus The decision is a personal one to be made by the couple or the wornan involved.

Child Discipline, Neglect, and Abuse Child neglect or abuse has no justification. Discipline in the sense of instruction, training, and balanced correction are vital in molding the lives of young children. The Bible speaks approvingly of using the "rod"



of parental authorityin correcting children, which may include appropriate but moderate physical chastisement at times. -Proverbs 13:24; 29:15, 17.

Circumcision Under Christian law, whether one is or is not circumcisecl has no spiritual value. (1 Corinthians 7:19) This is a personal matter for the parents to decide on behalf of their child.

Decision-Making and Treatment Information The patient (or parents/guardians of young children) should be fully informed on diagnosis, prognosis, and treatment recommendations so that informed health care decisions can be made. Parents have the natural and legal right to make such decisions for their children. In a rare emergent situation where doctors may feel the need to get a court order to impose medical care to which the parents have not given consent (such as administering a blood transfusion), the parents should be informed of such intended action as early as possibie so that they can also be represented in court.

Dietary Laws and Beliefs Christians are required to abstain from eating blood and meat of animals from which blood has not properly been drained. (Acts 15:28, 29) Aside from this Bibie injunction, there is no restriction on what is to be eaten.

Dissection and Autopsies Unless there is compelling reason, such as when an autopsy is required by a governmental agency, Jehovah's Witnesses generally prefer that the body of a beloved relative not be subjected to a postmortern dissection. The appropriate relative(s) can decide if a limited autopsy is advisable to determine cause of death and the like.

Drugs See "Alcohol, Narcotics, Medications."

Euthanasia See "Prolongation of Life and Right to Die."

Handicapping Conditions (Birth Defects) See comments under "Prolongation of Life and Right to Die."

Heart Bypass Some Witness patients permit the use of a heart-lung machine when the pump is primed with nonblood fluids and blood is not stored in the process.

Hemodialysis Hemodialysis is a matter for each Witness patient to decide conscientiously if a closed circuit is employed, if no blood prime is used, and if there is no blood storage.

Hemodilution Induced hemodilution is a matter for the Witness patient to decide according to his conscience when a closed circuit is used and no blood storage is involved. jehovah's Witnesses do not accept preoperative collection and storage of blood and its later transfusion.

Immunoglobulins, Vaccines The religious understanding of Jehovah's Witnesses cloes not absolutely prohibit the use of minor blood fractions such as albumin, immune globulins, and hemophiliac preparations. Each Witness must decide individually whetherhe/she can accept these. Accepting vaccines from a nonblood source is strictly a medical decision to be madeby each patient.



"Living Will"/Substitute Decision-Maker/ Power of Attorney for Medical Decisions Each patient will decide what is appropriate for him/her according to his/her circumstances and the provisions of the law.-See "Decision-Making and Treatment Information."

Medications See "Alcohol, Narcotics, Medications."

Narcotics See "Alcohol, Narcotics, Medications."

Organ Donation and Transplantation While the Bible specifically forbids consuming blood, no Biblical command pointedly forbids the taking in of tissue or bone from another human. Therefore, whether to accept an organ transplant is a personal, medical decision. The same would be true of organ donation.

Prolongation of Life and Right to Die Life is sacred and the willful takin of life under any health care circumstance w d be wrong. For this reason, reasonable and humane effort should be made to sustain and prolong life. However, the Scriptures do not require that extraordinary, complicated, distressing, and costly measures be taken to sustain a person, if such, in the general consensus of the attending physicians, would merely prolong the dying process and/or leave the patient with no quality of life. Any advance directions by the patient that speciflcally defined what was or was not wanted should be respected.

Religion and Healing Processes(Faith Healing) Jehovah's Witnesses have faith in God but do not believe in faith healing today. Miraculous healing was God's arrangement for a limited time.

Religious Sacraments, Ordinances,Rituals, and Customs

Jehovah's Witnesses do not have special rituals that are to be performed for the sick or for those dying. Every reasonable effort should be made to pro e medical assistance, comfort, and spiritual care needed by the sick patient.

Serums Serums are not forbidden; however, an individual Witness may still conscientiously refuse them. The same applies to albumin as a minor component of blood.

Transplants

See "Organ Donation and Transplantation."

Vaccinations

See Immunoglobulins, Vaccines."

Volume Expanders

Nonblood expanders are acceptable to Witness patients. In BCT May 2000 Part 9



Strategies for Avoiding and Controlling Hemorrhage and Anemia Without

BloodTransfusion (QR) PART 2(Revised Version June 2000) 1. Surgical Devices and Techniques to Locate and Arrest Internal Bleedling

a. Electrocautery/Electrosurgery

b. Laser Surgery

c. Argon Beam Coagulator

d. Stereotactic Radiosurgery

e. Microwave Coagulating Scalpel

f. Ultrasonic Scalpel

g. Endoscope ("keyhole surgery")

h. Arterial Embolization

i. Tissue Adhesives

2. Techniques and Devices to Control External Bleeding and Shock

a. For Bleeding: (1) Direct Pressure (2) Ice Packs (3) Elevate body part above level of heart (4) Hemostatic Agents (see below) (5) Prompt surgery (6) Tourniquet (7) Controlled Hypotension

b. For Shock: (1) Trendelenburg/shock position (patient supine with head lower than legs) (2) Medical Antishock Trousers (M.A.S.T.) (3) Appropriate volume replacement after bleeding controlled

3. Operative and Anesthetic Techniques to Limit Blood loss During Surgery

a. Hypotensive Anesthesia

b. Induced Hypothermia

c. Intraoperative Hemodilution



d. Hypervolemic Hemodilution

e. Intraoperative Blood Salvage

f. Mechanical occlusion of bleeding vessel

g. Reduce blood flow to skin

h. Meticulous hemostasis

i. Preoperative planning: (1) Enlarged surgical tearn/Minimal time (2) Surgical positioning (3) Staging of complex procedures

4. Blood-Oxygen Monitoring Devices and Techniques that Limit Blood Sampling

a. Transcutaneous Oximeter

b. Pulse Oximeter

c. Pediatric microsampling equipment

d. Multiple tests per sample

5. Volume Expanders

a. Crystalloids (1) Ringer's Lactate (2) Normal Saline (3) Hypertonic Saline

b. Colloids (1) Dextran (2) Gelatin (3) Pentastarch/Hetastarch

c. Perfluorocarbons

6. Hemostatic Agents for Bleedling/Clotting Problems

a.Topical: (1) Avitene (2) Gelfoam (3) Oxycel (4) Surgicel (5) Many others

b. lnjectable: (1) Desmopressin (2) e-Aminocaproic Acid (3) Tranexarnic Acid (4) Vitamin K



c. Other Drugs: (1) Vasopressin (2) Conjugated Estrogens (3) Aprotinin (4) Viricristine

7. Therapeutic Agents and Techniques for Managing Anemia

a. Stop any bleeding

b. Oxygen support

c. Maintain intravascular volume

d. Hematinics (iron, folic acid, Vitamin B12)

e. Erythropoietin

f. Nutritional support

g. lmmunosuppressive agents if indicated

h. Perfluorocarbons

i. Granulocyte-Colony Stimulating Factor

j. Hyperbaric Oxygen Therapy

k. 10/30 rule has no scientific basis NOTE: Current references from respected peer-reviewed medical journals are available upon request from Hospital Information Services (Canada) for jehovah's Witnesses. Hospital Information Services facilitates, at no cost to the physician, ac:cess to current and clinically relevant information regarding strategies to avoid allogeneic blood transfusion in medicine and surgery. Local representatives of the Hospital Liaison Committee Network for jehovah's Witnesses are also available to support physicians and Witness patients, at the patient's request, by arranging consultations with physicians and medical teams experienced in the use of medical alternatives to blood transfusion.

Hospital Information Services (Canada) for Jehovah's Witnesses ! [email protected] ! Information/Referral # 1-800-265-0327 # ! 24-Hour Hot Line In BCT May 2000 Part 9



CLINICAL STRATEGIES for managing HEMORRHAGE and ANEMIA without

BLOOD TRANSFUSION in the ICU (QR) PART 3(Revised Version June 2000)

GENERAL NONBLOOD MANAGEMENT PRINCIPLES 1. Formulate a comprehensive plan of care for avoiding allogeneic blood, integrating a combination of blood conservation modalities. 2. Anticipate and be prepared to address potential risiks. 3. Employ a mulitispeciality team approach. 4. Maintain frequent, close observation for hemorrhage. Early recognition and prompt intervention to prevent/control abnormal bleeding

is the cornerstone of effective care for patients who will not accept allogeneic blood. In general, avoid a "watch and wait" approach to the bleeding patient.

5. Exercising clinical judgment, be prepared to modify routine practice when appropriate. 6. Consult prompfly with senior specialists experienced in nonblood management if complications arise. 7. Transfer a stabilized patient, if necessary, to a major centre before the patient's condition deteriorates. 8. Discuss risks (both short- and long-term), benefits and alternatives to proposed interventions with the patient/farnily.

GENERAL THERAPEUTIC PRINCIPLES 1,2,3,4 1. Control or avoid hemorrhagic and iatrogenic blood loss. 2. Optimize cardiac and respiratory support by maximizing oxygen delivery (volume replacement, oxygenation, vasoactive agents)

and minimizing oxygen consumption (analgesia, sedation, mechanical ventilation). 3. Restore/improve blood count by stimulating hematopoiesis.

1. MINIMIZE HEMORRHAGIC BLOOD LOSS5

A. Avoid hypertension and hypervolemia 6,7 1. lf active bleeding present, consider tolerating mild hypotension (i.e., reduced systolic blood pressure in the range of 90- 100 mm

Hg for a normotensive patient) until hemorrhage is prompfly controlled, using a combination of blood conservation modalities.8,9,10

2. Hypertension and hypervolemia may inhibit spontaneous hemostasis, accentuate hemorrhage, or disrupt effective thrombus. Excess fluids may also promote hemorrhage by diluting coagulation factors and lowering blood viseosity.

3. Allow a slow, gradual return to normal blood pressure after bleeding is controlled. 11 4. In resuscitation from shock state avoid circulatory overload. Fluid administration by protocol without ongoing clinical judgment

should be avoided. 5. Use vasodilators to manage hypertension with/without automated control of transient hypertension.12

B. Avoid severe hypotension 1. Use vasoactive drug therapy to control marked hypotension not responcing to fluid therapy. 2. In severe head trauma, maintain appropriate level of cerebral perfusion pressure (70-80 mm Hg).13,14 Resuscitation of

head-injured, muitiply-traumatized patients with lactated Ringer's, hypotonie, or dextrose-containing solutions may be detrimental.15.16

C. Maintain extra vigillance

to detect and treat ongoing bleeding and other complications. 17 Note: Continuous low-level bleeding (e.g., from smali vessels and capillaries) could become significant if tolerated for a prolonged

period of time.

D. Avoid delay.

Do not defer surgery if active bleeding cannot be controlled nonoperatively.18,19. (e.g., pharmacologic, endoscopic, angiographic)

E. Blood salvage 20,21,22 (i.e., postoperative)



F. Maintain normothermia unless hypothermia is indicated 23

Notes: 1. External active warming may be superior to passive warming. 2. Coagulation proteins may be less effective at lower temperatures, increasing risk of bloodloss.24 3. Hypothermia is associated with higher infection rates.25 4. Controlled hypothermia may be considered for severe anemia or cerebral protection.26, 27

G. Adequate and appropriate heparin/protamine dosing 28,29

H. Hemostatic agents for bleeding/clotting problems 30,31 1. Tranexamic acid 32.33 2. Epsilon-aminocaproicacid 34 3. Desmopressin 35.36,37 (use trial dose to assess response)38 4. Aprotinin 39.40,41 Note: Aprotinin or Desmopressin may reduce bleeding due to drug-induced platelet dysfunction (e.g., due

to ASA, NSAIDs, beta-lactam antibioties, antithrombotics).42 5. Conjugated estrogens 43,44 6. Vasopressin 41 7. Appropriate drugs to control gynecological hemorrhage (e.g., hormone manipulation) 8. Vitamin K 46.47 Notes: 1. Consider prophylactic parenteral administration of vitamin K. 2. Causes of vitamin K deficiency include: a. Inadequate dietary intake, limited absorption or synthesis b. Antibiotics c. Anticoagulants (e.g., nicoumalone, warfarin) d. Other drugs (e.g., salicylates) 9. Treatment for congenital or acquired hemorrhagic disorders: a. Clotting factor replacement therapy Note: Faetors V11a,

Vlll, lX are available as recombinant products. b. Cryoprecipitate

I. Prophylaxis of upper gastrointestinal hemorrhage 48,49 1. Cytoprotective agents (e.g., sucralfate) 50 2. Enteral nutrition 51 3. Proton pump inhibitors 52 4. H2 blockers 53 (associated with thrombocytopenia and pancytopenia in some patjents; may reduce iron solubility due to

increase in gastric pH)

J. Avoid/treat infections promptly 1. Prophylaxis of infection54,55,56 2. Thorough assessments of wounds; avoid secondary contamination (e.g., colon or rectal)

2. REDUCE IATROGENIC BLOOD LOSS

A. Restrict Phlebotomy 57,58 1 Perform only essentiai tests 2. Eliminate duplication/perform muitiple tests per sample 59 3. Pediatric phlebotomy tubes 60 4. Point-of-care whole blood microsampling 61,62,63,64 5. PuIse oximetry 6. Transcutaneous oximetry 7. End-tidal CO, monitoring 8.In-line blood reservoirs; eliminate purge discard volume 61,66 9. In-line arterial blood gas monitors 67

B. Review adverse effects of current medications (NSAIDs, e.g.,

Ketorolac; Antibioties, e.g., cephalosporins, penicillins) and drug reactions and interactions that may increase risk of iatrogenic anemia, hypoprothrombinemia, bleeding or suppress erythropoiesis 1. Consider dosage reduction, discontinuation, or substitution with alternative medication. Continue monitoring for adverse reactions.

2. Judicious prophylaxis of thromboembolism. Closely monitor patients treated with anticoagulants/antiplatelet drugs. Risk of hemorrhage is related to dosage, duration of therapy, and predisposing conditions where risk of hemorrhage is present.



3. MAXIMIZE OXYGEN DELIVERY

A. Maintain intravascular volume 68 (stop any bleeding-see 1. A.-1.)

1. Judicious use of asanguineous fluids: a. Crystalloids i. i. Ringer's lactate n. ii. Normal saline in. iii. Hypertonic saline 69 b. Co11oids i. Pentastarch 70,71 ii. Hetastarch (may adversely affect coagulation-see note 3 below) iii. Gelatin

72 iv. Dextran (may adversely affect coagulation-see note 3 below) c. Perfluorochemicais (oxygen-carrying blood substitutes) Notes: 1 .Normovolemic anemia can be tolerated in hemodynamically stable patientS.73,74,75,76,77 2. Avoid circulatory overload, especially in profoundly anemic patients. Closely monitor fluid balance and vitai signs. 3. The clinician should judiciously choose the solution(s) for volume expansion.78.79.80.81,82,83 (See aiso 1. A.) 4. If jndicatecl (clinical examination anei noninvasive investigation provide inadequate data), use invasive monltoring 84 (e.g., pulmonary artery catheter,

central venous line, arterial catheter, antiseptic-impregnated catheters) to guide the management of patients. 5. Bleeding should be suspected and diagnosis sought when a patient shows evidence of hypovolemia despite reasonable hydration. Avoid aggressive fluid

replacement to normalize blood pressure. Adequate perfusion can be obtained at lower pressure. Simple measurement of vitaf signs is a poor indicator of blood volume loss.

6. Albumin therapy may be detrimentai to the shocked patient. 85

B. Maintain cardiovascullar support 86,87 1. Closely monitor and assess oxygen utilization/hypoxia (e.g., clinical signs, pH and lactate, urine output), hemodynamics (e.g., cardiac output, pulmonary

artery wedge pressure) 2. Maintain/improve tissue perfusion and cardiac output (inotropes) 88 3. Maintain blood pressure (vasopressors)

C. Maintain Ventilation and Oxygenation 89. 1. Appropriate and adequate ventilatory support for optimal oxygenation and C02 elimination 90 (e.g., PEEP, IPPV, CPAP)

Note: Nitric oxide and hypercapnia may inerease risk of bleeding. 2. Ongoing monitoring and assessment of the adequacy of ventilation and oxygenation (clinical assessment, arterial blood gas analysis

and/or pulse oximetry, capnometry, oximetric pulmonary artery catheter) to allow for early and appropriate intervention 3. Hyperbaric Oxygen Therapy (H130) 91,92,93,94

a Indications for HB0 therapy: i. Adequate oxygen transport and metabolism (arterial and mixed venous blood gas analysis) cannot be achieved using conventional

mechanical ventilation ii. Tissue hypoxia (e.g., mental obtundation, abnormal vital signs, decreased urine output, metabolie acidosis) in the presence of

adequate fluid resuscitation and perfusion b. Use ongoing monitoring to determine appropriate HB0 dosage b. and onset of adverse effects (e.g., pulmonary and CNS function) 95 c. Use intermittent HBO therapy and antioxidants to minimize oxygen toxicity or barotrauma 96,97 d. Provide concomitant therapy with i.v. r-HuEPO, and iron, folate, and nutrition to support hematopoiesis

4. MINIMIZE OXYGEN CONSUMPTION

A. Adequate and appropriate analgesia

B. Sedation; consider neuromuscular blockade (i.e., to prevent muscle shivering, agitation, anxiety)

1. To minimize adverse effects, use lowest dose and shortest duration of analgesia and sedation necessary" 2.Closely monitor degree of blockade (e.g., perjpheral nerve stimulation) and adjust drug doses to determine minimum appropriate dosage

to allow faster recovery of neuromuscular function and spontaneous ventilation; avoid standard dosing 99

C. Mechanical ventilation

D. Maintain/restore normothermia unless hypothermia is indicated.

Actively rewarm postoperative patients. Cool febrile patients

5. IMPROVE BLOOD COUNT

A.Therapy for Hematinic Deficiencies: 1. i.v. iron I00,101 (use test dose l02.103) 2. Folic acid 104 3. Vitamin B12 105



Notes: 1. Intravenous route of administration improves bioavailability, rapidly increases stores, avoids potential malabsorption or gastric irritation (e.g., oral iron). 2. Concomitant administration of ascorbic acid and oral iron may enhanee absorption from the gastrointestinal tract. 3. Oral iron is known to interact with many commonly used drugs.

B. Prophylactic hematinic therapy to maximize stores and optimize response to erythropoietin 106

C. Recombinant Erythropoietin (r-HuEPO) Therapy (107,108 .109,110) 1. Subcutaneous injection or intravenous administration 111,112 2.Faetors that may delay or attenuate response to r-HulEIPO induce: 113,114

a. Iron deficiency 115,116,117 b. Chronic infection, inflammation, or malignant process c. Occult blood loss d. Bone marrow disease e. Vitamin deficiencies (folate, B12) f. Poor subcutaneous absorption of r-HuEPO g. Hemolysis h. Aluminum intoxication (e.g., medications, dialysate fluid) i. Osteitis fibrosa cystica (hyperparathyroidism)

Notes: 1. Endogenous EPO production is proportional to degree of anemia. For severe anemia, r-HuEPO should be used for rapid restoration of red cell mass. 2. A high endogenous EPO level does not preclude response to r-HuEPO. 118 3. Rate of response to r r-HuEPO is dose dependent and varies among patients. Therapy may need to be individualized. Monitor and escalate dosage or change route of administration to improve response.119,120,121,122 4. Consider pretreatment investigation to identify and correct, if possibie, any faetor that could mediate erythropoietin resistance. If not correctable use higher dose.123 5. Hyperoxic ventilation (a high Pa02) or critical illness may blunt endogenous EPO production in response to acute anemia. 6. r-HuEPO administration up to 2,000 U/kg/day in divided doses has been reported to be well tolerated.124 7. Monitor for hypertension, which may induce bleeding, and consider initiation or increases in antihypertensive therapy. 8. r-HuEPO may procuee a moderate dose-dependent rise in the platelet count, within the normal range, during treatment.125,126

D. Other Hematopoietic Growth Factors (e.g., G-CSF, GM-CSF, IL-11)

E. Nutritional Support

127 (oral/parenteral)

6. PREOPERATIVE WORKUP / CLINICAL EVALUATION

Thorough patient assessment is essential to formulating a comprehensive risk faetor-based plan of care incorporating multiple blood conservation measures in an optimal manner.128

A. Medical History and Physical Examination 129,130 1. History of anemia 2. Congenital/acquired bleeding clisorders131 (known from birth, circumcision, frequent nose bleeds, easy bruising without trauma,

tonsilleetomy, dental extraction, menorrhagia, prolonged bleeding after minor skin lesion, previous surgery, pregnancy, etc.) a. Personal history b. Family history

3.End-organ disease/injury (esp. renal or hepatic) 4.Previous surgery (biood loss may be increased with repeat surgery) 5.ldentify medications that may adversely affect hemostasis 132 (e.g., ASA, NSAIDs, anticoagulants, platelet aggregation inhibitors,

antibioties, dietary supplements). Also ensure that additional prescription and nonpreseription drugs containing ASA or NSAIDs are not jnadvertently taken by patients. 133,134

6. Physical examination (e.g., purpuric lesions, petechiae, ecchymosis, hepatomegaly, splenomegaly)

B. Laboratory Assessment/Screening 135,136,137 1. Establish baseline parameters: a. Compiete blood count (incIuding red blood cell and platelet counts) b. Serum ferritin

c. Serum folate d. Serum vitamin B12 e. PT, PTT, template bleeding time (as indicated) 2. Additional investigation as indicated by history and degree of hemostatie challenge: a. Coagulation tests ?. i. Platelet funetion,

adhesion, aggregation tests ii. Fibrinogen concentration iii. Fibrin degradation products (FDP) iv. Specific coagulatjon faetor assays v. Assay for ristocetin cofactor activity (von Willebrand disease, Bernard-Soulier synerome) b. Liver function c. Renal function (creatinine) d. Point-of-care coagulation monitoring (e.g., thrombelastogram, Sonoclot)138

Note: Minimize iatrogenic bloodloss. (See 2. A.)



C. Management of bleeding risk/therapy for coexisting disease. l39,140

1 . Consider discontinuing medications associated with increased postoperative bleeding complications (from 3 to 14 days preoperatively) and temporary substitution with alternate therapy( alternate therapy (e.g., NSAIDs with short half-Iives, heparin):141

a. ASA (at least 7 days before surgery) b. NSAIDs (10 days or more for NSAIDs with long half-Iives) c. Anticoagulants, platelet inhibitors (e.g., warfarin, ticlopidine) d. Antibioties (e.g., ticarcillin)

2. Treatment for congenital and inuced hemorrhagic disorders142 (See 1. H)

3. Consider preoperative prophylactic optimjzation of tissue perfusion by augmentation of cardiac output 143,144 (patients with coexisting pathology and poor cardiac function)

D. Correct anemia and optimize preoperative hemogIobin level (See 5. A»-C.) Note: Consider preoperative use of r-HuEIPO in surgical patients where there is risk of significant blood loss, even if not

anemic.145,146,147,148

7. SURGICAL/ANESTHETIC BLOOD CONSERVATION TECHNIQUES

149,150,151,152,153

A. Surgical procedure(s) to specifically avoid and prevent bloodloss 154,155

1. Minimally invasive techniques (endoscopic/laparoscopic surgery) 2. Enlarged surgical team minimal time 156 3. Surgical positioning to minimize bleeding 157,158 4. Staged surgery for complex procedures 159.

B. Arterial Embolization 160,161,162 (including preoperative)163,164

C. Meticulous Hemostasis 165, 166, 167

D. Mechanical occlusion of bleeding vessel 168

E. Electrocautery

F. Ultrasonic Scalpel 169

G. Argon beam coagulator 170,171

H. Tissue Adhesives

I. Intraoperative Blood Salvage 174, 175

J. Hemodilution 176, 177

K. Platelet-rich plasma sequestration 178, 179

L. Induced hypothermia

M. Hypotensive anesthesia 180. Note: Regardless of the choice of anesthesia (regional, narcotic, etc.) the anesthetic technique must be well-pIanned and executed

so as to minimize blood loss (e.g., positioning, ventilation, deliberate hypotension). Avoid increases in arterial or venous pressure.181



This table reflects current clinical and scientific knowledge and is subject to change. The strategies do not indicate an exclusive course of treatment. Clinical judgment may suggest modification, depending on the specific circumstances and patient wishes.



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Recombinant human erythropoietin for a Jehovah's Witness with anemia of thermal injury. Am J Hem 199 1;37(1)53-4. 119. Kaufman JIS, Reda D.1, Fye C1-, et al. Subcutaneous compared with intravenous elpoetin in patients receiving hemodialysis. N Engl J Med 1998;339(9):578-83. 120. Schreilber S, Howaldt S, Schnoor M, et al. Recombinant erythropoietin for the treatment of anemia in inflammatory bowel disease. N Engl J Med 1996;334(10):619-23. 12 1. Faris PIVI, Rtter MA, Albels RI, et al. The effects of recombinant human erythropoietin on perioperative transfusion requirements in patients having a major orthopaedc operation. J Bone Joint Surg 1996;78A(1):62-72. 122. Busuttil D, Copplestone A. Management of blood loss in Jehovah's Witnesses. BMJ 1995;311:115-6. 123. Danielson B. R-HuEPCI hyporesponsiveness-who and why? Nephrol Dial Transplant 1995; 10 (Suppl 2):69-73. 124. Niemeyer CM, Baumgarten E, Holldack J, et al. Treatment trial with recornbinant human erythropoietin in ehiidren with congenital hypoplastic anemia. Contrib Nephrol 199 1;88:276-80. 125. Epoetin alfa erythropoiesis regulating hormone product monograph. Compendiurn of Pharmaceuticals and Speciaities. 32ncl ed. Ottawa: Canadian Pharmaceutical Association; 1997. p. 540-4. 126. Porter JC, Leahey A, Polise K, et al. Recombinant human erythrooetin reduces the need for erythrocyte and platelet transfusions in pediatric patients with sarcoma: a rancornized double-bIind, placebo-controlled trial. J Pediatr 1996; 129(5):656-60. 127. Dudrick SJ, 0'Donnell .-1, Raleigh DP, et al. Rapid restoration of red blood cell mass in severely anemic surgicai patients wino refuse transfusion. Arch Surg 1985; 120:721-7. 128. Helm RE, Rosengart TK, Gomez M, et al. Comprehensive muitimodality blood conservation: 100 consecutive CABG operations without transfusion. Ann Thorac Surg 1998 Jan;65(1):125-36. 129. Mclntyre AJ. Blood transfusion and haemostatic management in the penoperative penod. Can J Anaesth 1992;39(5 PI: 2):R101-R1 14. 130. Colon-Otero G, Cockerill KJ, Bowie EI How to diagnose bleeding disorders. Postgrad Med 1991;90(3):145-50. 131. Hampton KK, Preston FE. ABC of elinicai hematology. Bleeding disorders, thrombosis, and anticcagulation. BMJ 1997;314:1026-9. 132. Spiess Bl). Coagulatbn function in the operating room. Anesthesiol Clin North Am 1990 Sep;8(3):481-99. 133. Brigden M, Smith RE. Acetylsalieylic-aci~ontaining drugs and nonsteroidal anti-inflammatory drugs available in Canada. Can Med Assoc, J 1997; 156(7):1025-8. 134. Hylek EM, Heiman H, Skates S-1, et al. Acetaminophen and other risk faetors for excessive warfarin anticcogulatioin. JAMA 1998;279(9):657-62. 135. Malhotra N, Roizen MF. Laboratory testing. Prob Anesth 1991 Dec;5(4):575-90. 136. Feldman Ml), McCrae KR. Clinical coagulation laboratory evaluation of hemostasis in the perioperative period. In: Lake CL, Moore RA, editors. Blood: Hernostasis, Transfusion, and Alternatives in the Perioperative Period. New York: Raven Press; 1995. p. 153-78. 137. Bowie EJW, Owen CA Jr. Clinical and laboratory djagnosis of hemorrhagie disorders. In: Ratnoff OD, Forbes CD, editors. Disorders of Hemostasis. 3rd ed. Philadelphia: Saunders; 1996. p.53-78. 138. Dorman BIH, Sonale FG, Bailey MK, et al. Identification of patients at risk for excessive bood loss curing coronary artery bylpass surgery: thrornboelastogralphy versus coagulation screen. Anesth Analg 1985;64:888-96. 139. Czinn EA, Chediak R Ccagulation and hemostasis. In: Salem MR, editor. Blood Conservation in the Surgical Patient. Baltimore: Williams & Wilkins; 1996. p. 45-78. 140. Kitchens CS. Surgery and hemostasis: the influence of one on the other. In: Ratnoff OD, Forbes CD, editors. Disorders of Hemostasis. 3rcl ed. Philadelphia: Saunders; 1996. p.53-78. 141. Medication management before surgery. Compendiurn of Pharmaceuticals and Specialties. 32nc! ed. Ottawa: Canadian Pharmaceutical Association; 1997. p. L38-L4 1. 142. Spence RK. Management of surgical patients with special proloems. In: Petz LD, Swisher SN, Kleinman S, et al, editers. Ciinicai Practice of Transfusion Medicine. 3rd ed. New York: Churchill Livingstone; 1996. p. 595-606. 143. Boyd 0, Bennett ED. Enhancement of perioperative tissue perfusion as a therapeutic strategy for major surgery. New Honz 1996;4(4):453-65. 144. Shoemaker WC, Appel PL, Kram HB. Hemodynamic and oxygen transport responses in survivors and nonsurvivors of hgh-risk surgery. Crit Care Med 1993;21(7):977-90. 145. Dubois RW, Lim D, Häsbert P, et al. The development of indications for the preoperative use of recombinant erythropoietin. Can J Surg 1998;41(5):351-65.



146. Shimpo H, Mizumoto T, Onoda K, et al. Erythropoietin in peciatric cardiac surgery. Clinical efficacy and effective dose. Chest 1997; 111(6):1565-70. 147. Rothstein P, Roye D, Verdisco L, et al. Preoperative use of erythropoietin in an adolescent Jehovah's Witness. Anesthesioi 1990;73(3):568-70. 148. Canadian Orthopedic Perioperative Erythropoiietin Study Group. Effectiveness of perioperative recombinant human erythropoietin in elective hip replacement. Lancet 1993;341:1227-32. 149. Salem MR, editor. Blood Conservation in the Surgical Patient. Baltimore: Williams & Wilkins; 1996. 150. Spence RK. Biood saving strategies in surgical patients. In: Petz LD, Swisher SN, Kleinman S, et al, editors. Clinical Practice of Transfusion Medicine. 3rd ed. New York: Churchill Livingstone; 1996. p. 521-37. 151. Kreiger KI-1, Isorn OW, editors. Blood Conservation in Cardiac Surgery. New York: Springer-Veriag; 1998. 152. Tawes RL Jr, editor. Autotransfusion: Therapeutie Prineiples and Trends. Detroit: Apoeton; 1997. 153. de Andrade JIR. Prudent strategies for red blood celi conservation in orthopedic surgery. Am J Med 1996; 10 1 (Suppl 2A): 1 6S-21 S. 154. Cooley DA. Conservation of blood curing cardiovascular surgery. Am J Surg 1995; 170(6A Suppl):53S-59S. 155. Nelson C1-, Fontenot J. Ten strategies to reduce blood loss in orthopecic surgery. Am J Surg 1995; 1 70(6A Suppl):64S-68S. 156. Brodsky JW, Dickson JH, Erwin WD, et al. Hypotensive anesthesia for scollosis surgery in Jehovah's Witnesses. Spine 199 1; 16(3):304-6. 157. Milani JIC. Blood preservation in spine surgery: an overview. Spine: State Art Rev 1991;5(1):17-27. 158. Murphy JM. Anesthetic considerations in lumbar sonal surgery. Spine: State Art Rev 1991;5(1):29-33. 159. Bragg LE, Thompson JIS. Management strategies in the Jehovah's Wilmess patient. Contemp Surg 1990; 36:45-9. 160. Hansen ME, Kadir S. Bective and emergency embolotherapy in chiidren and adolescents. Efficacy and safety. Radioioge 1990;30(7):331-6. 161. Appleton DS, Sibiey GN, Doyle PT. Intemal iliac artery embolisation for the control of severe blaccler and prostate haemorrhage. Br J Urol 1988;61 (1):45-7. 162. Sciafani SJA, Shaftan GW, Scalea TM, et al. Nonoperative salvage of computed tomogralahy-ciagnosed spienic irjunes: utilization of anglogralphy for triage and embolization for hemostasis. J Trauma Injury Infect Crit Care 1995;39(5):818-27. 163. Broacclus WC, Grady MS, Delashaw JB Jir, et al. Preoperative superselective artenolar ernbolizartion: a new approach to enhance resectalbility of spinal tumors. Neurosurgery 1990;27(5): 755-9. 164. Mitty HA, Steräng KM, Nvarez M, et al. Obstetric hemorrhage: prophyactic and emergency artenal catheterizartion and embolotherapy. Radiology 1993 Jul; 188(1):183-7. 165. Vihuela F, Canalis RF, Hartz RS, et al. Surgical hemostasis and blood conservation. In: Salem NIR, editor. Blood Conservation in the Surgical Patient. Baltimore: Williams & Wilkins; 1996. p. 386-424. 166. Seu P, Neelankata G, Csete M, et al. Liver transplantation for fulminant hepatie failure in a Jehovah's Witness. Clin Transpiant 1996; 10(5):404-7. 167. Spence RK, Carson J, Poses R, et al. Elective surgery without transfusion: influence of preoperative hemoglobin level and bood loss on mortality. Am J Surg 1990; 159(3):320-4. 168. lshiwata Y, Inomori S, Fujitsu K, et al. A new intracranal silastie encireling clip for hemostasis. J Neurosurg 1990;73(4):638-9. 169. Rees M, Plant G, Wells J, et al. One hundred fifty helpatic resections: evolution of technique towards bloocless surgery. BrJ Surg 1996;83(11):1526-9. 170. Ward PH, Castro DJI, Ward S. A significant new contribution to radical heacl and neck surgery. The argon beam coagulator as an effective means of limiting blood loss. Arch Otolaryngol Head Neck Surg 1989; 115(8):921-3. 17 1. Dunham CM, Cornwell EE, Militello P. The role of the argon beam coagulator in soenic salvage. Surg Gynecol Obstet 199 1; 173(3):179-82. 172. Kram HB, Ragu CN, Stafford F-1, et al. Filbrin glue achieves hemostasis in patients with coagulation disorders. Arch Surg 1989; 124:385-87. 173. Radosevich M, Goubran HA, Bumouf T. Filbrin sealant: scientific rationale, production methods, properties, and current clinical use. Vox Sang 1997;72(3):133-43. 174. Stehling L. Autologous transfusion. Int Anesthesioi Clin 1990 Fall;28(4):190-6. 175. Spain DA, Miller FB, Bergamini TIVI, et al. Quality assessment of intraoperative blood salvage and autotransfusion. Am Surg 1997;63(12):1059-63. 176. Grubbs PE Jr., Marini CP, Fleischer A. Acute hemodilution in an anemic Jehovah's Witness curing extensive abccminal wali resection and reconstruction. Ann Plast Surg 1989;22(5):448-52. 177. Kafer ER, Collins ML. Acute intraoperative hemodilution and perioperative blood salvage. Anesthesiol Clin North Am 1990 Sep;8(3):543-67. 178. Stehling L, Zauder HL, Vertrees R. Altematives to allogeneic transfusion. In: Petz LD, Swisher SN, Kleinman S, et al, editors. Clinical Practice of Transfusion Medicine. 3rd ed. New York: Churchill Livingstone; 1996. p. 539-6 1. 179. Ereth MH, Oliver WC Jr, Santrach P.I. Intraoperatve techniques to conserve autologous blood: red-cell salvage, platelet-rich plasma, and acute normovolemic hemodilution. In: Spiess BD, Counts RB, Gould SA, editors. Perioperative Transfusion Medicine. Baltimore: Williams & Wilkins; 1998. p. 309-23. 180. Petrozza PH. Induced hypotension. Int Anesthesiol Clin 1990 Fall;28(4):223-9. 181. Salem IVIR, Manley S. Blood conservation techniques. In: Salem MIR, editor. Blood Conservation in the Surgical Patient. Baltimore: Williams & Wilkins; 1996. p. 92-106.




Clinical Strategies for Avoiding and controlling Hemorrhage and Anemia without Blood

Transfusion in Obstetrics and Gynecology

(QR) PART 4(Reviced June 2000)

General Principles of Nonblood OB/GYN Management 1. Prepare an individualized management plan to facilitate rapid decicion making. Be prepared to utilize a

combination of interventions to minimize blood loss. 2. Ensure availability of experienced personnel, appropriate drugs, and equipment to prevent and promptly

manage hemorrhage. without blood transfusion. 3. Communicate plan to involved medical and nursing personnel to avoid treatment delays. 4. Maintain close observation for hemorrhage.The clinical urgency of unspectacular low-level persistent

bleeding may not be recognized until compensatory mechanisms fail and blod pressure falls. Early recognition and prompt intervention to prevent / control abnormal bleeding is the cornerstone of effective care for patients who will not accept allogenic blood. In general, avoid a " watch and wait" approach to the bleeding patient.

5. Adopt a multidisciplinary team approach to patient care.Involve other specialists in planning, if necessary.

6. Transfer a stabilized patient, if necessary , to a major centre before the patient's condition deteroriates. 7. Obtain informed consent to nonblood management. Discuss the options and the risks and benefits (both

short- and long-term) of proposed interventions with the patient / family.

General TherapeuticPrinciples 1. Optimize red blood cell count preoperatively and during pregnancey. 2. Timely recognition and expeditious control of hemorrhage must be the first objective of

treatment in the hemorrhaging patient who refuses blood transfusion. In the face of severe hemorrhage, definitive measures are required.

3. Maintain appropriate fluid resusciatation. Until hemorrhage is controlled, avoid attempts to normalize blood pressure; permit mild hypotension.

4. Prevent or treat coagulation disorders promptly. 5. Minimize the amount of blood drawn for laboratory testing.

1.Clinical Evaluation/Preoperative Planning1,2

A. Medical history and physical examination3 1. History of anemia 2. Hereditary or acquired bleeding disorders 4,5

a. Personal history b. Family history

(1) easy bruising (2) frequent nose bleeds or unexplained bleeding from the gums (3) bleeding after tooth extractions (4) postoperative bleeding (e.g., after tonsillectomy, adenoidectomy) (5) menstrual history, especially of menorrhagia6

(6) postpartum bleeding at previous pregnancy 3. End-organ disease or injury (esp. renal or hepatic) 4. Determine drug allergies. Take an inventory of medications used by the patient. Identify current prescription or nonprescription drugs that may

adversely affect hemostasis (e.g., anticoagulants, platelet aggregation inhibitors, preparations containing ASA or NSAIDs, or antibiotics)7



6. Physical exam (e.g., purpuric lesions, petechiae, ecchymosis, hepatomegaly, splenomegaly)

Note: Clinicians should have a high index of suspicion of a bleeding disorder in women with persistent menorrhagia sufficient to cause iron deficiency or a history of bleeding after hemostatic challenge.

B. Laboratory assesment/screening 8,9,10

1. Complete blood count (including red cell and platelet counts) 2. Additional investigation as indicated by history and degree of hemostatic challenge:

a. Template bleeding time (to detect platelet dysfunction) b. PT, PTT c. Serum ferritin level d. More detailed coagulation studies to identify clotting disorders, including specific coagulation factor assays, e.g., for von Willebrand disease e. Liver function f. Renal function (creatinine)

Notes:

1. Thorough history taking and judicious laboratory testing improve the estimation of risks and help guide clinical decision making. 2. Women with mild coagulation abnormalities in early labour may need special attention regarding the risk of postpartum hemorrhage. 3. Minimize the volume of blood drawn for laboratory analysis throughout the perinatal or perioperative period. Combine laboratory blood tests. Use

pediatric-sized blood collection tubes,11 point-of-care blood testing and microsampling.12 4. In preparation for obstetric emergencies, the obstetrician should seek early collaboration with the anesthetist, anticipate which parturients are at higher risk, and develop a plan of care to facilitate decisive intervention.

C. Opimize blood count 1. Hematinics (maximize store)

a. Oral13 or parenteral14,15 iron b. Folic acid16 (oral/parenteral) c. Vitamin B12

17,18 (parenteral/oral) Notes:

1. Bioavailability of oral iron may be improved with concomitant administration of ascorbic acid.19 2. Iron absorption may de decreased by concurrent use of milk products, egg yolks, coffee, tea, antacids, fiber, and soy protein. 3. Administration of H2 blockers (cimetidine, ranitidine), proton pump inhibitors (omeprazole), and other drugs may decrease the absorption of iron. 4. Parenteral iron should be considered for patients with low iron stores, intolerance to oral iron, inadequate absorption, noncompliance, or patients with chronic or

severe blood loss.20 It is reported that intravenous iron as a total dose infusion is able to replenish iron stores more efficiently and faster than oral iron therapy.21,22

2. Recombinant Erythropoietin (r-HuEPO)23,24,25 a. Provide supplemental iron, folate, and B12 to support erythropoiesis. b. Consider use of r-HuEPO during pregnancy and preoperatively for anemic patients and also preoperatively for non-anemic surgical patients where

there is risk of significant blood loss.26,27,28 c. Rate of respons to r-HuEPO is dose dependent and varies among patients. Monitor and escalate dosage or change route of administration to improve

response.29,30 d. Consider factors that may diminish or delay response to r-HuEPO therapy.31,32 e. Monitor for hypertension and consider initiation of antihypertensive therapy.

3. Anabolic Androgenic Hormones33,34 (to stimulate erythropoiesis if r-HuEPO unavailable) Note: Anabolic steroids may cause suppression of clotting factors II, V, VII, and X and increase in prothrombin time.

4. Protein Nutrition35 (oral/tube/parenteral)

D. Management of Menorrhagia and Bleeding Risk 1. Emergency treatment for menorrhagia36

a. I.V. Conjugated Estrogens b. High dose Oral Contraceptive preparation q.6.h. for 24 to 48 hours c. Emergency Hysteroscopy and Curettage, or Hysterectomy37

2. Preoperative preparation for elective surgery or for chronic bleeding38 a. Tranexamic acid 39,40

b. Prostaglandin inhibitors (may cause GI bleeding c. Combined Oral Contraceptives d. Progesterone (e.g., levonorgestrel41) e. Danazol (reported to be more effective in patients over 45) f. GnRH analogue42

3. Discontinue/substitute medications that can affect platelet aggregation or are associated with bleeding complications a. Anticoagulants, platelet inhibitors (If a patient is at high risk or a diagnosis of thromboembolism is established, monitor anticoagulants closely or

substitute with low molecular weight heparin.) b. Aspirin or NSAID-containing preparations c. Antibiotics

4. Consider discontinuation of oral contraceptive at least one month before major elective surgery due to risk of thromboembolic complications. Note: In addition to gynecologic disorders, menorrhagia may reflect an underlying defect in hemostasis.



2. SURGICAL AND ANESTHETIC BLOOD CONSERVATION TECHNIQUES43,44,45

A. Insert two large-bore intravenous catheters prior to major surgery; warming of fluids and the patient will avoid hypothermia and coagulopathy

B. Enlarged surgical team/minimal time

C. Meticulous hemostasis 1. Electrosurgery/Electrocautery 2. Laser surgery 3. Microwave coagulating scalpel46 4. Ultrasonic scalpel47,48,49 5. Mechanical occlusion of bleeding vessels50

6. Arterial embolization51,52,53 (including preoperative) (See also 2.K.4.)

D. Uterine Thermal Balloon Ablation Therapy54,55

E. Transcervical or hysteroscopic endometrial ablation56,57

F. Spinal/epidural/general anesthesia58,59

G. Normovolemic hemodilution60,61,62

H. Controlled hypotension63

I. Intraoperative blood salvage64,65,66,67

J. Considerations for cesarean section: 1. Intracesarean blood salvage/recovery with precautions68,69,70

2. Spontaneous placental delivery at cesarean section71

K. Management of surgical Hemorrhage/shock 1. Hemorrhage should be immediately controlled 2. Elevate legs/apply blood pressure cuffs 3. Appropriate volume replacement after bleeding controlled. Avoid aggressive intravenous fluid replacement and uncontrolled hemorrhage72

4. Angiographic arterial embolization73,74 including prophylactic75 5. Prompt laparoscopy/surgery/uterine or internal iliac artery ligation 6. Medical Antishock Trousers (M.A.S.T.)76

Notes: 1. Involve anesthetists and operating room staff in preoperative planning. 2. Regardless of the choice of anesthesia drug (general, regional) the anesthetic technique must be well planned and executed so as to minimize blood loss.

Avoid increases in arterial or venous pressure.

3. NONBLOOD VOLUME EXPANDERS A. Crystalloids

1. Ringer's lactate 2. Normal saline 3. Hypertonic saline77

B. Colloids 1. Gelatin 2. Pentastarch78/Hetastarch79,80 (preferable low molecular weight) 3. Dextran (anticoagulant effect opposable with desmopressin)81

Notes:

1. In active bleeding or oozing, permit mild hypotension (systolic blood pressure of 90-100 mm Hg in a normotensive patient) while taking prompt measures to control the hemorrhage.82,83

2. Appropriate volume replacement, judiciously choosing the solution(s) for volume expansion.84,85 Adequate perfusion can be obtained with deliberate underresuscitation and mild hypotension.

3. Avoid hypertension. Aggressive fluid resuscitation may inhibit spontaneous hemostasis, accentuate hemorrhage, or disrupt clots. Excess fluids may also promote hemorrhage by diluting coagulation factors and lowering blood viscosity.

4. Allow a slow, gradual return to normal blood pressure after bleeding is controlled. Permit mild hypotension during the early postoperative hours.86

5. Avoid circulatory overload, especially in severely anemic patients. Closely monitor fluid balance and vital signs. Use pulmonary artery catheter or CVP line, if indicated.



6. Normovolemic anemia can be tolerated in hemodynamically stable patients.87,88,89 10/30 rule for minimum hemoglobin/hematocrit level has no scientific basis.90

4. HEMOSTATIC AGENTS FOR BLEEDING/CLOTTING PROBLEMS

A. Topical 1. Collagen Avitene 2. Gelatin Gelfoam 3. Oxidized Cellulose (Oxycel, Surgicel) 4. Tissue adhesives91,92

5. Uterine packing93,94 6.. Vaginal/abdominal/pelvic packing95 7. Vasopressin96 (infiltration or soaked uterine packing97,98) 8. Thrombin99

Notes:

1. If packing is used, care must be taken to ensure it does not conceal substantial hemorrhage. It may be used as a temporary measure before surgical intervention to repair major vascular injuries.

2. Consider combining hemostatic methods (e.g., vasopressin and tourniquet for myomectomy).

B. Injectable 1. Vitamin K100,101 (consider prophylactic administration) 2. Tranexamic acid102

3. Epsilon-aminocaproic acid103

4. Desmopressin104,105,106,107 (in elective case, use trial dose to assess response)108 5. Aprotinin109,110,111

Note: Aprotinin or desmopressin may be used for control of bleeding due to drug-induced platelet dysfunction (e.g., due to ASA, NSAIDs, beta-lactam antibiotics, and antithrombotics).112

6. Conjugated estrogens113,114

7. Replacement therapy for congenital/induced hemorrhage disorders115 (with specific patient consent) a. Clotting factor replacement therapy

Note: Recombinant preparations of Factors VIIa, VIII, IX are available.116

b. Cryoprecipitate

5. OBSTETRIC HEMORRHAGE117,118,119,120 A. Antepartum

1. Prompt evacuation of uterus (if indicated) 2. Timely, appropriate drug therapy (See 4.B.) 3. Anticipate postpartum hemorrhage

B. Postpartum

1. Anticipation and prevention; Postpartum Hemorrhage Risk Factors122,123 a. Previous history of postpartum hemorrhage, manual removal of the placenta, or retained products b. Nulliparity c. Maternal age, obesity, and/or grand multiparity d. Abruptio placentae or Placenta previa e. Multiple pregnancy f. Intrauterine death g. Prolonged labour with/without induction h. Mid-forceps extraction or forceps rotation i. Breech presentation j. Cesarean section/prior cesarean delivery k. Birthweight of 4 kg or more

2. Active management of third stage of labour123,124 a. Thirty seconds to deliver anterior shoulder b. Immediate prophylactic synthetic oxytocin � I.V. or I.M. c. Thirty seconds to deliver posterior shoulder d. Deliver body slowly/head down e. Deliver placenta by controlled cord traction/displace uterus upwards by suprapubic pressure f. Prompt extraction or manual removal of placenta if hemorrhage occurs. Consider i.v. nitroglycerine to aid manual extraction of retained

placenta125, 126 g. Consider prophylactic ergometrine administration � I.M. h. Monitor vital signs and observe for hemorrhage one hour post delivery i. Never leave bleeding postpartum patient

3. Control of postpartum hemorrhage127 a. Uterine massage b. Transabdominal aortic compression128



c. Bimanual uterine compression d. Stimulate nipple manually/suckle infant e. Oxytocic drugs (may loose potency in hot climate)

(1) Oxytocin and/or Ergometrine (2) Prostaglandin analogous

i. Carboprost127,128 including intramyometrial injection129 ii. Misoprostol130 iii. Gemeprost pessaries131, 132 (with uterine compression)

f. Nonblood volume expanders (See 3.) g. Drain bladder with catheter h. Remove retained secundines i. Repair lacerations cervix/vagina j. Uterine packing/oxytocin drip (See 4.A.6. to 4.A.9.) k. Prophylactic I.V. antibiotics l. High low uterine/ovarian artery ligations133,134 m. Timely single-stage total uterine devascularization135 n. Subtotal hysterectomy136,137

Notes: 1. Be prepared to use a combination of interventions to arrest hemorrhage. 2. The presence of an experienced obstetrician is important to make an early decision to operate before the patient's condition deteriorates. 3. The most important factor determining the choice of procedure to arrest hemorrhage is the skill and experience of the surgeon. Other factors include the

extent of hemorrhage and condition of the patient.138. Transfer a stable patient that cannot be managed surgically to a larger centre prior to deterioration of the patient's condition.

5. Provide frequent monitoring in the early postpartum period and postoperatively. Assess hematocrit, coagulation profile, hemodynamics, volume status, urine output, ventilatory status, and core temperature.139

6. Considerations in the management of placenta percreta140and accreta.141, 142

4. Prevention and Management of Disseminated Intravascular Coagulation (DIC)143,144,145 a. Identify and treat the underlying pathologic process without delay. Consult promptly with a hematologist or internist. b. Causes: gram-negative infections, amniotic fluid embolism, abruptio placentae

7. MANAGEMENT OF PROFOUND ANEMIA146,147,148,149 A. Stop any bleeding

1. Avoid hypertension and excessive fluid administration 2. Do not defer surgery if active bleeding cannot be controlled nonoperatively 3. Maintain normothermia (hypothermia is associated with increased blood loss)

B. Restrict laboratory blood testing

C. Maximize oxygen delivery 1. Maintain intravascular volume 2. Mechanical ventilation/hyperbaric oxygen therapy150,151

D. Minimize oxygen consumption 1. Adequate and appropriate analgesia and sedation

E. Improve blood count152,153,154 (See 1.C.) This table reflects current clinical and scientific knowledge and is subject to change. Clinical judgement, taking into account individual circumstances and patient wishes, may require adjustments.

References

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