Patient Blood Management and alternatives to transfusion

Patient Blood Management and alternatives to transfusion

Patient Blood Management and the alternatives to transfusion and when these should be used Learning Outcomes Explain techniques that can be used to prevent blood transfusion Describe transfusion alternatives Describe when to use tranexamic acid Explain how point of care testing can be used to determine blood transfusion requirements Discuss the process of pre-optimisation of Haemoglobin for patients prior to procedures Discuss management of anaemia in medical patients Discuss management of iron deficiency in pregnancy Identify when to use IV iron and the expected outcomes and possible side effects

What is Patient Blood Management? Patient Blood Management is a multidisciplinary, evidence-based approach to optimising the care of patients who might need blood transfusion Patient Blood Management puts the patient at the heart of decisions made about blood transfusion to ensure they receive the best treatment and avoidable, inappropriate use of blood and blood components is reduced. Patient Blood Management needs leadership and support at every level from Trust management, health professionals in hospitals, NHS Blood and Transplant and all National and Regional Blood Transfusion Committees Launched in the UK June 2012

Patient Blood Management Alternatives to blood transfusion Spahn DR, Goodnough LT Lancet 2013 381 1855-1865

PBM in Australia and Austria Refer to 3 pillars : Optimising pre-op cell volume Reduction of peri-operative blood loss Increasing tolerance to anaemia and accurate blood transfusion triggers Adopted by WHO in 2010 to improve transfusion safety

PBM in America Limit loss through phlebotomy and testing Optimise patient s haemoglobin levels before surgery Using red cell recovery techniques Minimise peri-operative blood loss Making evidence based decisions regarding transfusion

PBM Recommendations (July 2014) Endorsed by NHS England Establishment of PBM programme and raising awareness amongst clinicians and patients Surgical PBM/Medical PBM Use restrictive transfusion thresholds In non-bleeding patients transfuse one dose of blood component then reassess Active management of anaemia Minimise volume of blood samples taken (Iatrogenic anaemia) Active management of abnormal haemostasis Empowerment of lab staff to challenge inappropriate requests National support infrastructure www.transfusionguidelines.org

Surgical PBM Detect and treat pre operative anaemia Minimise blood loss and bleeding Use cell salvage where appropriate Restrictive approach to transfusion post operatively

Limited supply Hazards of transfusion Variation in practice

The falling donor base...

RBC

Single Unit Transfusion Project 6 month baseline audit April to Sept 2014 28% single unit transfusions 68% 2 unit transfusions December 2014 55% single unit transfusions 38% 2 unit transfusions

Where Do Red Cells Go?

How do we know where blood goes? National & Regional Transfusion rates per 1000 population Issues Data from Blood Services Blood Stocks Management Scheme Data National Comparative Audit and National Surveys Clinical Benchmarking Hospital National, Regional and Local Clinical Audits Clinical Benchmarking Clinical Accounts for Blood Who and Where, but not Why Key Performance Indicators for Patient Blood Management Patient Indication and outcome documented in patient notes Clinical transfusion dataset: reason for transfusion and indication codes Transfusion rates per procedure, triggers and targets Dr. Megan Rowley Consultant HaematologistT - NHSBT and Imperial

Age and gender distribution Median age of recipients = 69 years (IQR 51-80) Males 51.6%: Females 47.4% Tinegate, H. et al (2016), Where do all the red blood cells (RBCs) go? Results of a survey of RBC use in England and North Wales in 2014. Transfusion, 56: 139 145.

Usage by broad category Tinegate, H. et al (2016), Where do all the red blood cells (RBCs) go? Results of a survey of RBC use in England and North Wales in 2014. Transfusion, 56: 139 145.

National Survey Red Cell Use It is likely that patient blood management measures such as preoperative haemoglobin optimisation will have a further effect. Attention is now also being drawn to medical anaemia, where it has been estimated that 10-20% of transfusions are inappropriate. The optimum transfusion strategy for chronic bone marrow failure syndromes is not yet known. This survey has demonstrated that 2.7% of units nationally were given to patients with iron deficiency, clearly a treatable anaemia. 2014 NHSBT National Red Cell Survey http://hospital.blood.co.uk/media/27581/anonymous-nrcs.pdf

Highest-using specialties in surgery Category Number Percentage of total Cardiothoracic 2756 6.0 Trauma 2193 4.8 Orthopaedics 1811 3.9 GI Surgery 1764 3.8 Vascular 1091 2.4 Urology 942 2.0 Solid Organ Tx 486 1.1 Neuro surgery inc injury 279 0.6 Plastic inc burns 207 0.4 ENT 194 0.4 Other surgery 595 1.3 Total 12318 26.7 Tinegate, H. et al (2016), Where do all the red blood cells (RBCs) go? Results of a survey of RBC use in England and North Wales in 2014. Transfusion, 56: 139 145.

Where do platelets go? Tinegate et al 2012 NE England N= 1937 units 25% 54% 21% Haematology 1055 Other medical 402 Surgical 479

Platelets

Intra operative cell salvage Ashworth A, and Klein A A Br. J. Anaesth. 2010;105:401-416

Intraoperative Cell salvage A Cochrane Review 2006 (Carless PA et al) highlighted a reduction in exposure to allogenic blood of 64% and a reduction by 0.82 units of blood per patient. Recommended for use: Where blood loss predicted to exceed 1000ml Patients with anaemia, rare blood types, multiple antibodies Those with objections to allogenic blood ICS should be used alongside TXA in all cases (unless there is a risk of thromboembolism Benefits Improved viability of red cells and tissue oxygen delivery Reduction in post-op infection rates Cost effective

The guideline covers the assessment for and management of blood transfusions in adults, young people and children over 1 year old. It covers the general principles of blood transfusion, but does not make recommendations relating to specific conditions. Recommendations Thresholds, targets and doses for red blood cells, platelets, fresh frozen plasma, cryoprecipitate and prothrombin complex concentrate Patient safety Patient information https://www.nice.org.uk/guidance/ng24

Iron Deficient Anaemia (IDA) For the majority of patients the aim of treatment should be to restore haemoglobin levels and MCV to normal. Replenish body stores by iron supplementation. Advice from a haematologist may be needed if this cannot be achieved Assessment and Investigation: All medical History A FBC should be obtained. A Ferritin request (A low Ferritin indicates low iron stores. However high ferritin can occur with inflammation and does not exclude iron deficiency). A sample for haematinics: Vitamin B12 and folate Oral iron: Oral iron should always be first line treatment unless the patient is known to have bowel malabsorption i.e. coeliac disease or is non-compliant.

Intra-venous Iron: IV Iron should only be used when a course of oral iron has been unsuccessful. IV iron should not be used during pregnancy unless clearly necessary and not in the 1st trimester Decision to administer IV iron (Anaemia Management pathway) Administer IV Iron in accordance with product information (Caution is needed with each administration) Patients should be closely monitored for signs of hypersensitivity Observe for anaphylactic or anaphylactoid reactions and resuscitation facilities must be immediately available. Side effects may include: Headache, dizziness, rash, nausea and vomiting, Gastrointestinal pain, breathing problems, chest pain

Anaemia Management Pathway for Surgery 1 st opportunity Check FBC and review results: If Hb: <120g/L (F) or <130g/L (M) Arrange anaemia investigations:(sequential or batch depending on local arrangements ) FBC, retics, UEC, LFT, B12, folate, ferritin, transferrin saturation, CRP Review Visit 1 Non-iron deficiency anaemia manage accordingly ** Review Anaemia Investigations Apply anaemia management algorithm Further investigation, referral, optimisation including investigation of underlying cause eg: gastroenterology referral individualised care 8 weeks before planned surgery date eg: clinically NON-urgent Iron deficiency anaemia: absolute (ferritin <30) or functional (ferritin 30-100 and transferrin saturation<20%) < 8 weeks before planned surgery date eg: clinically urgent** Review Visit 2 **If anaemia persists or surgery is urgent proceed on case by case basis following discussion with surgeon / anaesthetist Trial of oral iron Recheck Hb 4 weeks Hb normalised with oral iron: continue oral iron until surgery Anaemia persists despite oral iron Day case admission for IV iron Recheck Hb after 2 weeks Surgery 2-4 weeks depending on response to iv iron and urgency of surgery (may need repeat dose)** GP version 2014

Point of Care testing (POCT) This is a medical diagnostic testing performed outside the clinical laboratory by non-laboratory staff to where the patient is receiving care. (Near patient, bedside) The key objective of point of care testing is to generate a result quickly so that appropriate treatment can be implemented, Small sample required for test, Quick results to enable instant interventions Less invasive and laborious than other blood tests; may provide advantages in terms of time, cost and patient comfort.

How point of care testing can be used to determine blood transfusion requirements Anesthesiology 9 2012, Vol.117, 531-547 Point-of-Care Testing A Prospective, Randomized Clinical Trial of Efficacy in Coagulopathic Cardiac Surgery Patients Christian Friedrich Weber, Dr. med.,* Klaus Go rlinger, Dr. med., Dirk Meininger, P.D. Dr. med., Eva Herrmann, Prof. Dr. rer. nat., Tobias Bingold, Dr. med., Anton Moritz, Prof. Dr. med.,lawrence H. Cohn, M.D., Ph.D.,# Kai Zacharowski, Prof. Dr. med., Ph.D., F.R.C.A.** In conclusion, hemostatic therapy algorithms in conjunction with POC testing reduced the number of transfused units of packed erythrocytes when compared with conventional laboratory coagulation testing. Moreover, POC-guided therapy was associated with lower FFP and PC usage and costs as well as an improved clinical outcome in this prospective randomized singlecentre study.

Pre operative Erythropoietin Stimulating Agents 12 studies in non cardiac surgery in combination with oral or IV iron No conclusions re safety as studies were underpowered to demonstrate complications such as VTE Variable dose regimes Evidence of effect on increase in pre op Hb and reduced rate of blood transfusion Used in the Netherlands since 2003 as part of PBM programme in orthopaedics 25% reduction in blood usage Licence in Europe restricted to orthopaedic surgery and not cardiac / vascular due to question mark over risks

Tranexamic Acid (TXA) Offer TXA when moderate blood loss(>500ml) is anticipated and consider intra-operative cell salvage with Tranexamic acid when highvolume blood loss may occur. (NICE NG24 November 2015)

Tranexamic Acid (TXA)Trials: Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH 2 Study, published in 2010) assessed early administration of TXA in trauma. Mortality was significantly reduced. WOMAN(2016) study looked at whether TXA is efficacious in reducing death due to postpartum haemorrhage. TXA reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. HALT-IT trial: The Haemorrhage Alleviation with TXA Intestinal Symptoms, is currently randomising patients with acute upper GI haemorrhage CRASH -3 trial: This randomised, double-blind, placebocontrolled trial looks at the early administration of TXA of patients with trauma (brain injury)

Information for Patients Will I need a blood transfusion? Iron in your diet Receiving a plasma transfusion Children s leaflets Patient Blood Management

Posters Support from NHSBT Apps Guidance for hospital staff Safety Advice

Learning outcomes Explain techniques that can be used to prevent blood transfusion Describe transfusion alternatives Describe when to use tranexamic acid Explain how point of care testing can be used to determine blood transfusion requirements Discuss the process of pre-optimisation of Haemoglobin for patients prior to procedures Discuss management of anaemia in medical patients Discuss management of iron deficiency in pregnancy Identify when to use IV iron and the expected outcomes and possible side effects