Transfusion in Surgery

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Transfusion in Surgery

• Mark Crowther

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Why is it important?
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Outline

• Components
• Current problems
• Risks and benefits
• General approach and solutions

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Red Cell Concentrates

• The treatment of anaemia and blood loss where
  there is no other more appropriate therapy
• Not indicated for volume replacement in the
  context of active surgical bleeding

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Platelets

• The treatment and prevention of bleeding related
  to significant thrombocytopenia or platelet
  dysfunction where these problems are
  unavoidable or not amenable to other treatments.
• Not to raise platelet counts into normal range
  (10, 20, 50, 80)

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Fresh Frozen Plasma

• Single coagulation factor deficiency where no
  appropriate concentrate is available.
• Complex coagulopathies with active bleeding or
  high risk of bleeding e.g. DIC, liver disease.
• Not volume replacement or couple of FFP to see
  if bleeding stops.

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Use of Blood

• General and Vascular Surgery 18
• Orthopaedics 14
• Neurosurgery 8
• Urology 2.5
• Other Surgery 10
• Obstetrics 3
• Haematology 22
• Medicine 22

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Major Issues Facing Transfusion

• Increased red cell demand
• Decreased available donors (deferral)
• Cost of Safety (LeucoD, NAT, HTLV 1)
• Burton Judgement
• vCJD
• European regulations

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Sanguis Study

• 10 European Countries
• 43 Hospitals
• 7195 patient data
• Huge inter- and intra-hospital variation
• Guidelines little impact on practice

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Sanguis Study
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Reasons for Excess RCC Transfusion

• Easy availability
• No charge
• Old habits die hard
• Failure to consider risk-benefit

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Risks of blood transfusion
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SHOT
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SS
S
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TTI Virus

• Hepatitis A 1/10,000,000
• Hepatitis B 1/850,000
• Hepatitis C 1/51,000,000
• HIV 1/4,850,000
• HTLV I/II 1/19,000 - 80,000
• Parvo B19 1/10,000
• vCJD Others ?

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Bacterial Contamination

• RCC 1/500,000
• Platelets 1/12,000
• Y. Enterocolitica
• S. Aureus, K. Pneumonia, S. Marcescens, S.
  Epidermidis

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Risk vs Benefit

• Wrong Blood
• Delayed haemolysis
• Bacterial Infection
• Viral and other
• TRALI
• TA GVHD
• PTP

• Difficult to assess

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Summary of Risk

• Common risks Non-predictable
• Recurring
• Easily preventable
• Rare risks Non-predictable
• Non-preventable
• CHANCE OF DYING AS RESULT OF BLOOD TRANSFUSION
  VERY SMALL

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Measurements

• How do we measure the significance of anaemia?
• How do we measure the benefit of having a
  transfusion?

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Measurements

• Symptoms SOB
• Tiredness
• Changes in pulse
• Changes in cerebration
• Changes in ECG
• Hb/Hct

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Significant Observations

• 30-40 acute blood loss is easily tolerated in
  healthy young adults
• Acute isovolaemic anaemia to 5g/dl does not
  produce evidence of inadequate oxygenation in fit
  volunteers.
• CABG peri-op 8g/dl 9g/dl (Bracey et al)
• ITU 7g/dl 10g/dl (Herbert et al)

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SOLUTION

• Effective Use of Blood

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Reducing Blood Use

• A. Education
• Transfusion Protocols
• B. Detection and treatment of Anaemia
• C. Autologous Blood Use (Salvage)
• D. Others (Epo, rVIIa etc)

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Autologous pre-donation
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Peri-operative Precautions to reduce likelihood
transfusion

• Investigate and treat anaemia
• Consider stopping anti-thrombotics
• Pharmacological reduction in blood loss
• Consider autologous pre-donation ?
• Cell salvage

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Acute Blood Loss

• 15-30 Replace volume
• RCC not definitely required
• Consider co-morbidity
• gt30 RCC likely to be required
• May avoid in very fit

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Haemoglobin Concentration

• lt7 g/dl May benefit
• 7-10 g/dl No clear guideline
• Patient factors gt65yrs
• Cardiorespiratory disease
• Reduce threshold

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General Principles

• Prescriber aware of risks and benefits Tx
• Patients should be informed
• Anaemia investigated and treated
• No universal trigger
• Acute blood volume loss not treated as anaemia

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Summary

• Transfusion costs rising
• Reduction in available blood
• Unknown risks for which you are responsible