76
PERIOPERATIVE ANEMIA Dr. Ion Chesov, MD, PhD, Associate Prof. Nicolae Testemitanu State University of Medicine and Pharmacy Valeriu Ghereg Department of Anesthesiology and Reanimatology 2019

Perioperative Anemia - USMF

  • Upload
    others

  • View
    8

  • Download
    0

Embed Size (px)

Citation preview

Page 1: Perioperative Anemia - USMF

PERIOPERATIVE ANEMIA

Dr. Ion Chesov, MD, PhD, Associate Prof.

Nicolae Testemitanu State University of Medicine and Pharmacy

Valeriu Ghereg Department of Anesthesiology and Reanimatology

2019

Page 2: Perioperative Anemia - USMF

Conflicts of interests

Page 3: Perioperative Anemia - USMF

Objectives

Patient blood Management (PBM)

Anemia – definition and risks

Causes

Pathophysiology

Anemia assessment

Clinical Management

Transfusion thresholds

Point of care testing

Take home messages

Page 4: Perioperative Anemia - USMF

Patient Blood Management

Patient blood management is the timely application of evidence-based medical and surgical concepts design to maintain hemoglobin concentration, optimize homeostasis and minimize blood loss in an effort to improve patient outcome.

https://www.sabm.org/, accessed on 30.11.19

Page 5: Perioperative Anemia - USMF

Patient Blood Management

Patient blood management is the timely application of evidence-based medical and surgical concepts design to maintain hemoglobin concentration, optimize homeostasis and minimize blood loss in an effort to improve patient outcome.

https://www.sabm.org/, accessed on 30.11.19

Page 6: Perioperative Anemia - USMF

PBM – Blood transfusion

Page 7: Perioperative Anemia - USMF

PBM – Blood transfusion

Page 8: Perioperative Anemia - USMF

PBM key points

Page 9: Perioperative Anemia - USMF

Anemia -WHO

Haemoglobin concentration of less than

-130 g dl1 for men

-120 g dl1 for non-pregnant women.

Page 10: Perioperative Anemia - USMF

Anemia & PBM

Page 11: Perioperative Anemia - USMF

Anemia prevalence

Up to 60% of surgical population

5–78% of patients requiringa surgical intervention

Shander A, AmJMed 2004; 116: 58S–69S

GA Hans, Continuing Education in Anaesthesia, Critical Care & Pain, 2013

Page 12: Perioperative Anemia - USMF
Page 13: Perioperative Anemia - USMF

Anemia - outcome

Page 14: Perioperative Anemia - USMF

Anemia - outcome

Higher mortality -2 times more likely to die

Higher transfusion requirements for small

haemoglobinchanges (10g/dL)

Longer hospital stays (median 2 days)

Death linked to severity of anaemia and to gender

Page 15: Perioperative Anemia - USMF

Anemia - outcome

Increase risk of AKI .

Poorer surgical outcomes.

Increase perioperative blood transfusion

Haematocrit less 39% was associated with an increased risk of 30 day postoperative mortality and cardiac events.

Arora P et, al, J Cardiothorac Vasc Anesth 2012 Browning RM et al, Aust N Z J Obstet Gynaecol 2012 David O et al Anaesth Intensive Care 2013 Klein et al. Anaesthesia June 2016 Wu W et al, J Am Med Assoc 2007; 22: 2481–8

Page 16: Perioperative Anemia - USMF

Pre-op anemia

Fowler, BJS, 2015

Page 17: Perioperative Anemia - USMF

Pre-op anemia

Leichtler, J Am Coll Sur, 2011

Page 18: Perioperative Anemia - USMF

Anemia -Transfusion

Munoz, BJA, 2015

Page 19: Perioperative Anemia - USMF

Anemia and Transfusion

Karkoutil, Can J Anesth, 2015

Page 20: Perioperative Anemia - USMF

Anemia and Transfusion

Page 21: Perioperative Anemia - USMF

Pathophysiology

DO2 COЅр1:34 Hb SaO2 Юр0:003 PaO2 Ю

Page 22: Perioperative Anemia - USMF

Pathophysiology

Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 3 2013

Page 23: Perioperative Anemia - USMF

Pathophysiology

Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 3 2013

Page 24: Perioperative Anemia - USMF

Pathophysiology

Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 3 2013

Page 25: Perioperative Anemia - USMF

Pathophysiology

Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 3 2013

Page 26: Perioperative Anemia - USMF

Causes

Microcytic anaemia:

- iron deficiency

- congenital haemoglobinopathies

- sideroblastic anaemia

- Vitamin B6 deficiency

- lead poisoning.

Macrocytic anaemia

- folate or vitaminB12 deficiency

- medication

-alcoholism.

Normocytic anaemia

- chronic disease, aplastic and sickle cell anaemia,

- haemolysis,

-pregnancy,

- riboflavin, and pyridoxine deficiency.

The most common cause in the surgical population

is iron deficiency *,**

*.World Health Organisation 2014

**. Preoperative anaemia Clevenger et al Anaesthesia 2015

Page 27: Perioperative Anemia - USMF

Iron deficiency

Page 28: Perioperative Anemia - USMF

Inflammatory diseases

Page 29: Perioperative Anemia - USMF

Causes

Page 30: Perioperative Anemia - USMF
Page 31: Perioperative Anemia - USMF

Age

Kuller, Anёsthesist, 2001

Page 32: Perioperative Anemia - USMF

Full glass

Page 33: Perioperative Anemia - USMF

Clinical approach

Page 34: Perioperative Anemia - USMF

Anemia management

Page 35: Perioperative Anemia - USMF

Have a plan

Page 36: Perioperative Anemia - USMF

Assessment

Medical history

Full blood count

Page 37: Perioperative Anemia - USMF

Alternative approach

Page 38: Perioperative Anemia - USMF

Chronic disease vs. Iron deficiency

Page 39: Perioperative Anemia - USMF

ESA - guidelines

Page 40: Perioperative Anemia - USMF

ESA - guidelines

Page 41: Perioperative Anemia - USMF

ESA - guidelines

Page 42: Perioperative Anemia - USMF

ESA - guidelines

Treat iron deficiency

Page 43: Perioperative Anemia - USMF

Iron suplementation

Page 44: Perioperative Anemia - USMF

ESA - guidelines

Page 45: Perioperative Anemia - USMF

ESA’s efficacy

Page 46: Perioperative Anemia - USMF

ESA’s efficacy

Page 47: Perioperative Anemia - USMF

ESA-guidelines

Page 48: Perioperative Anemia - USMF

Autologus blood donation

Page 49: Perioperative Anemia - USMF

ESA guidelines

Page 50: Perioperative Anemia - USMF

Iron + ESA’s

Page 51: Perioperative Anemia - USMF

Iron +ESA’s + Folate (3-4 weeks)

Page 52: Perioperative Anemia - USMF

Iron +ESAs + Folate +B12

Page 53: Perioperative Anemia - USMF

ESA guidelines

Page 54: Perioperative Anemia - USMF

ESA guidelines

Page 55: Perioperative Anemia - USMF

Post-op Iron

Page 56: Perioperative Anemia - USMF

IV iron

Page 57: Perioperative Anemia - USMF

Iron + ESA’s+ B12 + Folate

Page 58: Perioperative Anemia - USMF

ESA guidelines

Page 59: Perioperative Anemia - USMF

Post-op transfusion trigger

Page 60: Perioperative Anemia - USMF

Post-op anemia

To be consider

Page 61: Perioperative Anemia - USMF

Post-op

Page 62: Perioperative Anemia - USMF

Restrictive vs. Liberal

Page 63: Perioperative Anemia - USMF

Restrictive vs. Liberal

Page 64: Perioperative Anemia - USMF

Restrictive vs. Liberal

Page 65: Perioperative Anemia - USMF

Restrictive vs. Liberal

Page 66: Perioperative Anemia - USMF

Restrictive vs. Liberal

Page 67: Perioperative Anemia - USMF

Point of care testing

Page 68: Perioperative Anemia - USMF

Point of care testing

Page 69: Perioperative Anemia - USMF

Rotem analysisi

CT (s) CFT (s)

Amplitudinea după

CT (mm) MCF*

(mm)

Indicele de liză a

trombului (%)

10 min.

A10

20 min.

A20

30 min

CLI30

60 min

CLI60

INTEM 100-240 30-110 44-66 50-71 50-72 94-100 85-100

EXTEM 38-79 34-159 43-65 50-71 50-72 94-1000 85-100

HEPTEM 100-

240**

30-110 50-72

FIBTEM 7-23 8-24 9-25***

APTEM 38-79 34-159 50-72

Page 70: Perioperative Anemia - USMF

Conventional test vs. Rotem

Page 71: Perioperative Anemia - USMF

Conventional test vs. Rotem

Page 72: Perioperative Anemia - USMF

Active bleeding

Perfusion

Stop bleeding

Page 73: Perioperative Anemia - USMF

Stop hemorrhage

Keep patient alive

- permissive hypotension

- limit fluid infusion (dilution)

Stop hemorrhage

- early surgery, damage control

Maintain coagulation competence

- target coagulopathy

Page 74: Perioperative Anemia - USMF

Disease coagulopathy ?

FIBRINOLYSIS

Page 75: Perioperative Anemia - USMF

Disease coagulopathy

Antifibrinolitic: TxA

- 1.0 gr. i.v. over 10 min.

- if necessary after 30 min 1.0 gr. i.v./10 min

- first 3 hours

Co-factors: Ca++, Ph, Temperature control

Page 76: Perioperative Anemia - USMF

Take home messages

Anaemia and allogenic blood transfusion are

independent risk factors for poor postoperative

outcomes: morbidity and mortality.

One-third of patients are found to be anaemic on pre-

assessment.

PBM is a concept with the goal of avoiding

unnecessary blood transfusions to improve patient

outcomes and safety.

Iron deficiency requires iron supplementation.