Patient Blood Management Marisa B. Marques, MD UAB Department of Pathology November 17, 2016
Learning Objectives Upon completion of the session, the participant will: 1) Differentiate between the various risks of transfusions. 2) Describe the evidence for proper utilization of red blood cell transfusions. 3) Name alternatives to transfusion and when they should be employed.
Table 3: Transfusion-Associated Fatalities by Complication, FY2011 FY2015 173 total deaths = 35 per year
Must be aware of diagnosis Transfusion-Related Acute Lung Injury (TRALI) Dyspnea, hypotension, hypoxia, pulmonary infiltrates Acute transient leukopenia in CBC Treatment: supportive 100% require supplemental O 2 72% require mechanical ventilation Most patients recover in 3-7 days Screen donor for HLA and antibodies to neutrophils (HNA) If present, donor deferred permanently Type recipient to check for antigen-matching
PRBCs can cause TRALI Total: 8 27 3 9 1 19 http://www.fda.gov/downloads/biologicsbloodvaccines/safetyavailability/reportapr oblem/transfusiondonationfatalities/ucm518148.pdf
More dangerous than you may think! Perhaps the most preventable serious reaction Contributing factors Transfusion-Associated Circulatory Overload (TACO) Patient-specific: cardiac/renal function, age, fluid status Product-specific: number of units, volume, rate of infusion, other fluids Dyspnea, hypertension, hypoxia, pulmonary infiltrates Treatment: Diuretics Essential to explain to nursing staff importance of rate of infusion
Table 3: Transfusion-Associated Fatalities by Complication, FY2011 FY2015 173 total deaths = 35 per year
Hemolytic Transfusion Reactions ABO-related When recipient has anti-a or anti-b that attacks donor PRBCs Most commonly due to clerical error lack of proper patient identification at the time of the transfusion May happen if blood from someone else is sent to BB in patients without historical blood type Non-ABO-related When recipient has antibodies to other RBC antigens that attack donor PRBCs Preventable by performing Type & Screen prior to transfusion If screen negative, no antibodies in plasma History of antibodies must be honored if when antibody screen is negative
Acute Hemolysis Laboratory workup Clerical check Plasma color very sensitive for intravascular hemolysis Positive DAT (also called direct Coombs) RBCs collected from patient post-reaction are coated with IgG and/or C3 Free urine hemoglobin Post-transfusion Pre-transfusion
Table 3: Transfusion-Associated Fatalities by Complication, FY2011 FY2015 173 total deaths = 35 per year
Fever ( 2 F), chills, rigors, shock Management: Stop transfusion Platelets are the most common blood product to be contaminated Send remaining of unit for culture Get cultures from patient Start broad spectrum antibiotics
AHTR = acute hemolytic transfusion reaction, FNHTR = febrile nonhemolytic transfusion reaction, IV = intravenous, TACO = transfusionassociated circulatory overload, TRALI = transfusion-related acute lung injury. Cancer Control. January 2015, Vol. 22, No. 1
Is there anything else? Zika virus etc
Blood donors positive for Zika virus in Puerto Rico
Ct denotes the threshold cycle (indicated by the values in parentheses) at which the result on RT-PCR assay was positive. The positive result on day 51 was obtained in a sample that had four times the starting volume on RT-PCR.
http://www.cdc.gov/zika/transmission/bloodtransfusion.html August 26, 2016 US FDA issued revised guidance to prevent the spread of Zika virus through the blood supply. Called for blood collection centers in the United States to screen all donated blood for Zika virus.
What can be done to avoid risks of transfusion? PBM: Patient Blood Management is the answer The scientific use of safe and effective medical and surgical techniques designed to prevent anemia and decrease bleeding in an effort to improve patient outcome. http:www.sabm.org 21
Pre-operative measures to avoid transfusions 1.Erythropoiesis optimization Identification, evaluation, and treatment of anemia Erythropoiesis-stimulating agents if nutritional anemia excluded 2.Minimization of blood loss Identification/management of bleeding risk (past/family history) Review of medications (antiplatelet, anticoagulation therapy) Minimization of iatrogenic blood loss Procedure planning and rehearsal 3.Management of anemia Comparison of estimated blood loss with patient-specific tolerable loss Assessment/optimization of patient s physiologic reserve Management plan with appropriate blood conservation modalities to manage anemia Goodnough and Shander. Anesthesiology 2012; 116:1367-76.
Intra-operative measures to avoid transfusions 1.Erythropoiesis optimization Surgical timing with optimization of RBC mass 2.Minimization of blood loss Meticulous hemostasis and surgical techniques Blood-sparing surgical techniques Anesthetic blood conserving strategies: acute normovolemic hemodilution, cell salvage/reinfusion Pharmacologic / hemostatic agents (antifibrinolytics, recombinant factor VIIa) 3.Management of anemia Optimization of cardiac output, ventilation and oxygenation Evidence-based transfusion strategies
Post-operative measures to avoid transfusions 1. Erythropoiesis optimization Management of nutritional/correctable anemia (e.g., avoid folate deficiency, iron-restricted erythropoiesis); EPO therapy, if appropriate Awareness of drug interactions that can cause anemia (e.g., ACE inhibitor) 2.Minimization of blood loss Monitoring/management of bleeding Maintenance of normothermia (unless hypothermia indicated) Autologous blood salvage Hemostasis/anticoagulation management Awareness of adverse effects of medications (e.g., acquired vitamin K deficiency) Minimization of iatrogenic blood loss
Iatrogenic blood loss is a common cause of hospital-acquired anemia Fischer et al. Critical Care 2014, 18:306
The impact of one change to decrease blood wasted when collected for tests 2007 UAB consultants audit result: ICU patients lost ~69 ml of blood/day for tests and waste January 2008: Changed requirement for Type & Screen from inpatients 4 ml instead of 14 ml single pink top tube January 2017: 9 years x 34,000 tests/year x 10 ml (not collected) = 3,060 liters or > 805 gallons of blood saved! 26
HAA is not a new problem! 28
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Post-operative measures to avoid transfusions 3.Management of anemia Maximization of oxygen delivery Minimization of oxygen consumption Avoidance/treatment of infections promptly Evidence-based transfusion strategies
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Total number of PRBCs transfused per year at UAB Hospital 1997-2016 42500 40000 37500 35000 32500 30000 27500 25000 22500 20000 Enforcement of restrictive transfusion approach started in 2007 25% reduction from 2007 baseline
Number of PRBCs transfused per patientdischarged at UAB Hospital 1997-2016 0.95 0.85 0.75 0.65 0.55 0.45 0.35 0.25 2007 2008 2009 2010 2011 2012 2013 2014* 2015 2016 35% reduction from 2007 baseline * - inpatient definition changed to include 2-midnights