Perioperative Blood Conservation

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Perioperative Blood Conservation Anita Lamond RN
BScN Blood Conservation Program Hamilton Health
Sciences Hamilton, Ontario
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Session Objectives

• Provide an overview of blood conservation in
  perioperative patients
• What is it?..
• Why is it important?..
• How is it accomplished?..
• Provide an overview of the Ontario Nurse
  Transfusion Coordinators (ONTraC) program

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What is Blood Conservation?

• Blood Conservation Society for the Advancement
  of Blood Management (SABM) team approach to
  surgical patient care that utilizes the latest
  drugs, technology and techniques to enhance a
  patients own blood supply and decrease blood loss
  the aim is to reduce or avoid the need for
  transfusion
• Why is blood conservation important?
• a little historical background!

• SABM(2007)

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TransfusionA historical perspective

• Pre 20th Century
• Blood was thought to contain mystical healing
  powers
• Transfusion often led to death for the donor and
  recipient!
• 20th Century Major Advances
• ABO grouping
• Blood Banking
• Recognition of transfusion transmitted disease
• 1971 Hepatitis B (HBV) testing
• 1985 Human Immunodeficiency Virus (HIV)
  antibody testing
• 1999 Nucleic Acid Testing for HIV and
  Hepatitis C virus (HCV)

• Commission of Inquiry on the Blood System (1997)

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Why is Blood Conservation Important?

• Krever Report recommendations
• precautionary principle
• For elective surgical patients
• Informed consent rerisks and benefits of blood
  transfusion and available alternatives
• Increase awareness and availability of autologous
  blood donation programs
• Peer review of transfusion practices as a
  requirement for hospital accreditation

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Why is Blood Conservation Important?..

• Patient safety
• Informed choice for patients
• Resource allocation

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Why is Blood Conservation Important?

• Patient Safetythe bigger picture
• Increasing awareness about broader concerns
  regarding our blood supply
• Other Infectious risks
• Non-infectious risks
• Blood products are a scarce resource
• Blood is expensive!

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Infectious and Non Infectious risks

• 1 in 100 minor allergic reactions rash etc
• 1 in 300 febrile non-hemolytic reaction to RBC
• 1 in 700 transfusion related circulatory
  overload
• 1 in 5,000 Transfusion Related Acute Lung
  Injury (TRALI)
• 1 in 10,000 Symptomatic bacterial sepsis from
  platelet transfusion
• 1 in 40,000 death from bacterial sepsis -
  platelet transfusion
• 1 in 40,000 ABO incompatible transfusion per
  RBC transfusion

• 1 in 40,000 serious allergic reaction per unit
  of component, anaphylaxis
• 1 in 82,000 transmission of Hep B virus
• 1 in 100,000 bacterial sepsis per unit of RBC
• 1 in 500,000 death from bacterial sepsis per
  unit of RBC
• 1 in 1,000,000 WNV
• 1 in 2,300,000 Hep C transmission
• 1 in 7,800,000 HIV transmission
• OBrien et al, 2007

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Why is Blood Conservation Important?

• Resource Allocation
• Demand for RBCs in North America is estimated to
  increase from 12 20 million units from 1990 to
  2030
• Shrinking inventory and increased demand -aging
  of baby boomers -?donor pool
• Cost ? due to advanced technology for testing

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Other concerns

• Blood transfusion associated with
• Longer hospital stay
• Increased infection rates
• Growing body of literature demonstrates extreme
  variation in transfusion rates for similar
  procedures under similar conditions suggesting
• Underutilization of available conservation
  strategies
• Opportunity to align physician practice (Feagan,
  2002)

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How is Blood Conservation accomplished?

• Identify at risk population
• Krever recommendations
• Consider transfusion alternatives for elective
  surgical patients (gt10 risk of transfusion)
• Why perioperative patients?
• 50-70 of blood products used in hospitals are
  used in the perioperative setting (Hebert et al,
  2004)
• Potential exists to modify some predictors of
  transfusion in elective surgical patients
• Pre-op Hb, Blood loss
• Wide variation in transfusion practice for
  procedures

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How important is pre-op Hemoglobin?

• A national (US) audit found that 35 of patients
  coming for arthroplasty have Hb lt130g/L
• UK study found that 20 of all patients in 1 year
  were anemic maleslt130g/L, females lt115g/L)

• Goodenough, 2007

• Saleh et al, 2007

• Karkouti et al 1999

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How is Blood Conservation accomplished?

• Pre-op Hb optimization
• 4-6 week lead time for assessment, screening and
  appropriate interventions
• Correction of nutritional anemia iron therapy
  dietary advice,supplements Vit B12, Folate
• Careful attention to patient medical history, pre
  op meds
• ASA, Clopidrogel (Plavix), NSAIDs, herbal
  supplements
• Pre operative autologous donation (PAD) Acute
  normovolemic hemodilution (ANH)
• Erythropoietin therapy
• ? Delay surgery

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Pre-operative Autologous Donation (PAD)

• Available at CBS, HQ some hospitals
• 21-34 days prior to surgery
• Avoidance of viral transmission, TRALI etc
• Reduces allogeneic (donor) transfusion but
  increases likelihood of all transfusion
  (autologous allogeneic in randomized studies
  (Forgie et al, 1998)
• Directed donation
• Not an option for JW patients

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Erythropoietin

• Erythropoietin produced by renal cortex in
  reponse to hypoxia stimulates erythropoiesis
• Rh EPO recombinant form of endogenous hormone
• Reduces allogeneic tx rates in elective surgical
  patients (Karkouti et al, 2005)
• Approved subject to ICR(MOH) for elective
  surgical patients Hb 100-130g/L with/without PAD

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How is Blood Conservation Accomplished?

• Intraoperative/post-operative strategies
  reduce blood loss
• Good surgical technique
• Cell salvage
• Pharmaceutical agents- Antifibrinolytics, DDAVP,
  topical hemostatic agents
• Controlled hypotension, Regional anaesthesia
• Adherence to Transfusion guidelines

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Cell Salvage

• recycling of blood that would otherwise be
  discarded
• CV/ortho/trauma (Cochrane, 2006)
• HHS stats AR of allogeneic transfusion 23 in
  elective AAA repair
• Contraindicated in malignancy, contaminated wound
• May be acceptable to JW patient

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How is Blood Conservation Accomplished?

• For ALL patients
• Avoid inappropriate transfusion
• Consensus Transfusion Guidelines
• Evidence based transfusion triggers
• Standardize approach to transfusion decision,
  empower team, nurses have a role to play in the
  transfusion decision!
• Put evidence based guidelines at point of care
• Transfuse to alleviate symptoms
• Blood products administered in therapeutic dose
  ( eliminate 2 units standard transfusion order)

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Blood Conservation at HHS
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Blood Conservationgetting started in Ontario
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Ontario Nurse Transfusion Coordinator (ONTraC)
Program

• ONTraC Program
• Facilitate transfusion avoidance and optimize
  blood management in elective surgical patients
• Placement of 27 coordinators in 25 hospitals
  across Ontario with the intent to enhance
  transfusion practice outside of blood bank
  interact with physicians, nurses and patients to
  promote blood conservation and alternatives to
  transfusion
• Evaluate impact of program Direct monitoring
  of red cell transfusion rates in target
  populations Indirect monitor implementation
  of transfusion committees, informed consent
  policies etc

• Participating hospital CEO signs participation
  agreement with ONTraC Program re
• Hiring of coordinator
• designate supporting and reporting mechanisms for
  the coordinator within the hospital
• Provision annual REB approval for anonymized data
  collection, transfer and analysis
• Facilitate and support coordinator role profile
  within the hospital 50 - Management of blood
  conservation program patient assessment and
  intervention 25 - Patient/Staff education 20
  - Data Management 5-10 - Other related
  activities

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Blood Conservation at HHSGetting started

• Formation of Multidisciplinary Blood Conservation
  Committee
• Start up activities HHS
• Needs assessment
• Development of algorithms to guide
• patient management
• Development of blood conservation
  program with corporate direction
• ONTraC responsibilities
• Pre op patient management
• Data collection and analysis
• Education and liaison

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Barriers to progress

• Challenges
• Getting the message out
• Demand for level 1 evidence few RCTs, lots of
  expert opinion and guidelines
• Reluctance to change, identification of champions
  is key!
• Financial constraints perception that blood is
  free, alternatives cost money!

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Costs associated with alternatives

• Pre-op alternatives
• Iron, (oral, IV)
• PAD, inconvenience to patient
• Erythropoietin more visits pre-op, increased
  cost related to serial sampling

• Intra-op/post-op alternatives
• Cell salvage intra-op 200 per patient if blood
  collected and reinfused
• Pharmaceuticals antifibrinolytics, fibrin
  sealants
• Micro sampling techniques more labour intensive
  for the labs

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The Good News.
ONTraC
ONTraC
CBS, 2007
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• Thought for the day
• Blood transfusion is a lot like marriage. It
  should not be entered into lightly, unadvisedly
  or wantonly, or more often than is absolutely
  necessary.

Beal, RW, 1976
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• Thank you for your attention!
• Visit the ONTraC website www.ontracprogram.com
  
• www.transfusionontario.org

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References

• Callum, J.L. Pinkerton P.H. (2005). Bloody Easy 2
  Toronto Sunnybrook and Womens College Health
  Sciences Centre
• Feagan B, Wong, C., Johnson, W.C.,Arellano R.,
  Colterjohn N., Karkouti, K., et al (2002).
  Transfusion Practices for elective orthopedic
  surgery.Canadian Medical Association Journal,
  166(3), 310-314
• Forgie, M.A., Wells, P.s., Laupacis, A, et al
  (1998). Preoperative autologous donation deceases
  allogeneic transfusion but increases exposure to
  all red blood cell transfusions. Archives of
  Internal Medicine. 158, 610-616
• Freedman, J., Luke K., Escobar, M., Vernich, L.,
  Chiavetta, A. (2008). Experience of a network of
  transfusion coordinators for blood conservation.
  (Ontario Transfusion Coordinators ONTraC).
  Transfusion 48, 237-250.
• Hebert, P.C., Wells,G., Blajchman, M.A.,
  Marshall, J., Martin C., Pagliarello, G., et al
  (1999). A multicentre randomized controlled
  clinical trial of transfusion requirements in
  critical care. New England Journal of Medicine
  340(6),
• Karkouti, K., McCluskey, S.A., Evans L.,
  Mahomed, N., Ghannam, M., Davey R. (2005).
  Erythropoietin is an effective modality for
  reducing RBC transfusion in joint surgery.
  Canadian Journal of Anesthesia, 52(4), 362-368.
• Saleh, E., McLelland, D.B.L.,Hay, A., Semple, D.,
  Walsh, T.S. (2007). Prevalence of anemia before
  major joint arthroplasty nad the potential
  impact of preoperative investigation and
  correction on perioperative blood transfusions.
  British Journal of Anesthesia, 99(6), 801-808