Patient Blood Management. vs. Dr. Petro-Lize Wessels PBM Consultant SANBS August 2018
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1 Patient Blood Management vs. Dr. Petro-Lize Wessels PBM Consultant SANBS August 2018
2 Overview Definition 3 Predictors of negative clinical outcomes 3 Pillars of patient blood management What is my role?
3 but first a reminder of 4 important facts.. Fact 1 Delivery of oxygen to the body depends on: Arterial oxygen content X Cardiac output Arterial oxygen content depends on: Number of red cells x saturation of haemoglobin with oxygen DO 2 = % saturation x 1,39 x Hb x Cardiac Output
4 Fact 2 Anaemia is the enemy Global burden of disease study in 2015 (Lancet, October 2016): Billion people was affected by anaemia. - The prevalence of iron-deficiency anaemia was 1.46 billion.
5 Fact 3 Randomized controlled trials showed red cell transfusions to be associated with increased morbidity and mortality dosedependant. Increased morbidity = increased costs and lower quality of life
6 Fact 4 Active donor panel in South Africa < Require 1% of a population to be blood donors to sustain supply. Patients die before they can receive blood/ receive enough blood.
7 What is Patient Blood Management? PBM is an evidence-based, multi-disciplinary approach to optimizing the care of patients who may need transfusions. Covers all aspects of patient evaluation and clinical management surrounding the transfusion decision-making process. This includes: Application of appropriate indications, minimizing blood loss and optimizing the patient s red blood cell mass. - AABB
8 3 Predictors of negative clinical outcomes (slide adapted from Prof. Axel Hoffman) Anaemia and iron deficiency Induces or worsens anaemia Blood loss and Bleeding Triad of independent Risk Factors for Adverse Outcomes Associated with re-bleeding Triggers transfusion Transfusion
9 3 Pillars of PBM to address 3 Risk factors Anaemia and iron deficiency Blood loss and Bleeding Transfusion Optimise patient s own red cell mass Minimize blood loss and bleeding Harness and optimise physiological reserves
10 Optimize Erythropoiesis Minimize Blood Loss Optimize physiological reserves Patient Blood Management National Provincial Facility Societies DOH Private SANBS NHLS Pre- Operative Intra- Operative Post- Operative Co-ordinated Monitored
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12 Optimize erythropoiesis Minimize blood loss Harness & Optimize physiological reserves P R E Identify anaemia and aetiology. Treat anaemia.? Autologous donation. Consider iron or ESA. Refer if needed. Identify bleeding risks (drugs, history) & manage Review medication. Minimize sampling. Plan & discuss procedure. Estimated blood loss vs. tolerable blood loss. Optimize physiological reserves. Develop a patient specific management plan. I N T R A Do not schedule elective surgery unless pre-operative anaemia has been corrected. (Surgeon and anaesthetist roles). Meticulous haemostasis Anaesthesia techniques. ANH / Cell salvage Fibrin glue. Patient positioning. Pharmacological Rx. Optimize cardiac output. Optimize ventilation and oxygenation. Follow evidence-based transfusion triggers. P O S T Manage nutritional anaemia (iron, folate). Know your drugs interactions! Consider ESA. Manage bleeding early. Maintain normothermia Maintain normovolemia Blood salvage (drains) Minimize sampling. Haemostatic drugs. Adverse drug effects. Avoid hypertension. Adequate oxygenation. Minimize O 2 consumption. Treat infections promptly. Evidence-based transfusion triggers. Tolerate normovolemic anaemia.
13 Donor Blood Management Users: Clinically appropriate use, BLUCs SANBS: Services, Education, Data Use donor blood data to monitor PBM program Patient Blood Management Users: Anaemia management, Skills, PBMCs Patient rights groups: Public info SANBS::Education, Advisory, Monitoring,?Accreditation,? Cell salvage
14 Take home message Multi-disciplinary Diagnose anaemia primary healthcare level is crucial. Treat anaemia adequately. Minimise blood loss in all ways possible. Optimize your patient s physiological reserves. Monitor, monitor, monitor! Transition from Hospital transfusion committees/ guidelines to Patient blood management committees/ guidelines a.s.a.p.
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