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Module 8: Alternative strategies to transfusion
Transfusion Training WorkshopKKM 2012
Avoid blood transfusion if possible Strategies to avoid blood transfusion
works Make it a good clinical practice Gain experience Increase confidence
3 basic principles
1. Tolerance of anaemia
2. Optimising RBC mass
3. Minimising blood loss
1. Tolerance of anaemia
Lower transfusion threshold trigger
Adaptive mechanisms to avoid tissue hypoxia When Hb falls,
Cardiac output increases Blood viscosity decreases Peripheral vasoconstriction occurs Redistribution of blood flow Increase O2 tissue extraction
To maintain O2 delivery to tissues
Herbert PC, NEJM 1999
2. Optimising red cell mass
Pre-op planning
Pre-op planning
Bleeding risk – take a good bleeding history Baseline Hb – investigate and correct
anaemia Medications – discontinue aspirin,
anticoagulants if possible Underlying medical illness Estimate surgical blood loss Tolerance to blood loss
Optimising red cell mass
Treat underlying anaemia Keep HCT 45 – 50%
IV iron sucrose Folic acid, vitamin B12 Erythropoeitin
Case 1
80 year-old man Referred from IJN for anaemia Planned for CABG Hb 9.8
Case 1 – anaemia of inflammation Hb 9.6 MCV 97
TW 5.2 Plt 161 Crea 55 Bil 6.0 Blood film:
normochromic normocytic, no dysplasia
Medications: Simvastatin Ticlopidine Amlodipine Perindopril Pharmaton
(hematinics)
Case 1 – s/c erythropoeitin
28/8/09 9/10/09 6/11/09 8/1/10 30/4/10
9.6 10.6 11.4 13.0 12.4
CABG Feb 2012No transfusionsPost-op Hb 10
OGDS: antral erosionsColonoscopy: diverticular disNo active bleedingStarted on proton pump inhibitors
s/c Erythropoeitin 10,000 IUOnce weekly Twice weekly
HCT 48%
Case 2
15 year-old boy Acute Lymphoblastic
Leukaemia Blood group: AB Rh
neg Rx: chemotherapy Difficulty getting
blood
s/c erythropoeitin 4000 IU 2x/weekly + iron tabs
Hb maintained >8 g/dL
No tx required
3. Minimising blood loss
Minimising blood loss
Meticulous surgery Haemostatic agents Cell salvage Quick trauma
response Damage control
surgery
Normothermia
Prompt arrest of bleeding
Judicious volume resuscitation
Restrict diagnostic phlebotomy
Meticulous surgery
Positioning of patient Avoid venous compression
Least traumatic approach Minimize duration of surgery Maintain normothermia
Cell salvage
Saves 50% of blood loss Indication: estimated blood loss >1 L Cell salvage device
Recover the shed blood Filter debris ± Wash red cells
Haemostatic agents
Tranexamic acid Topical fibrin glues (fibrinogen +
thrombin) Generates instant clot
Oozing Leaks Tissue fixation
Lancet 2010
CRASH-2
Quick Trauma Response
Damage control surgery Do not wait to stabilize patient first Avoid excessive fluid resuscitation
Rapid rewarming
Avoid transfusion whenever possible
Transfusion has its risks
What would you do?
26/ F G7 P6 @ 36 weeks Hb 5.4 MCV 58 fL
IV venofer
Mean rise in Hb by 2.2 g/dL in 1 week (post-partum patients) with IV venofer 200 mg
NHS 2008
Gravier A, J Gynecol Obst Reprod Biol 1999
The end
Thank you