Blood: Blood: A Conversation A Conversation

about Conservationabout Conservation(aka Patient Blood Management)(aka Patient Blood Management)

Dr Biddy RidlerDr Biddy RidlerBlood Conservation Specialty DoctorBlood Conservation Specialty Doctor

Exeter Surgical SocietyExeter Surgical Society3rd October 20133rd October 2013

Blood Conservation:Blood Conservation:[‘[‘Preservation, protection…prevention Preservation, protection…prevention of wasteful use of a resource’ OED]of wasteful use of a resource’ OED]

• Why conserve bloodWhy conserve blood

• Current laws / guidelinesCurrent laws / guidelines

• Strategies - present Strategies - present

• Strategies - futureStrategies - future

Patient Blood Management (PBM)Patient Blood Management (PBM)

Donor Blood Transfusion is Donor Blood Transfusion is

no longer the default optionno longer the default option

Stock Level on 08 Oct 2013 Total

Should we be worried about the donor Should we be worried about the donor blood supply - if so why?blood supply - if so why?

• Diminishing donor poolDiminishing donor pool• Demand and wDemand and wasteaste• Cost Cost • Potentially avoidable problems: Potentially avoidable problems:

Clerical errorClerical error InfectionInfection ImmunosuppressionImmunosuppression (‘liquid transplant’)(‘liquid transplant’)

Why is there a shortage of blood?Why is there a shortage of blood?

Supply: Supply:

• Volunteer donorsVolunteer donors

Recruiting and retaining: Recruiting and retaining:

• 4% of adults currently donors 4% of adults currently donors

• 50% give 75% of donations50% give 75% of donations

• 15% turnover of donors annually 15% turnover of donors annually

• 250,000 250,000 newnew donors/yr required donors/yr required

http://www.blood.co.uk/

Are there concerns about infected Are there concerns about infected blood – if so why?blood – if so why?

Donors lost – safety and testingDonors lost – safety and testing

• HIV, hepatitis, syphilis and moreHIV, hepatitis, syphilis and more

• vCJD vCJD exclusion if previous transfusion (> 3.5%)exclusion if previous transfusion (> 3.5%) screening test for vCJD announced 3.2.11screening test for vCJD announced 3.2.11 donors may fear the implications of a donors may fear the implications of a

positive testpositive test

• Malaria, West Nile virusMalaria, West Nile virus

• What else is out there?What else is out there?

Why conserve blood – Why conserve blood – are there any national references?are there any national references?• Blood conservation / shortageBlood conservation / shortage

• Patient Blood ManagementPatient Blood Management

• Clinical care / changing perceptionsClinical care / changing perceptions

• Consensus conferencesConsensus conferences

• Serious Hazards Of Transfusion (SHOT)Serious Hazards Of Transfusion (SHOT)

• UK Government edictsUK Government edicts BBT3 HSC 2007-01 (transfusion practice)BBT3 HSC 2007-01 (transfusion practice) EU Directive 2005 (traceability)EU Directive 2005 (traceability)

Blood components commonly wastedBlood components commonly wasted

• Emergency Group O NegEmergency Group O Neg

• Out of fridge > 30 minsOut of fridge > 30 mins

• FFP or Vitamin K ?FFP or Vitamin K ?

• PlateletsPlatelets

AllAllLOW STOCKSLOW STOCKS

Cost of blood products 2012/2013

Red cells

Platelets

FFP (UK)

FFP (US) [for U16s,

soon for All]

£123.31

£209.30

£27.46

£171.54

Current Guidelines: red cellsCurrent Guidelines: red cells

BCSH guidelines & endorsed by NBTCBCSH guidelines & endorsed by NBTC(NICE consultation 2013 )(NICE consultation 2013 )

• Acute blood lossAcute blood loss up to 30% blood loss – crystalloid/colloidup to 30% blood loss – crystalloid/colloid 30% loss - RBC usually required30% loss - RBC usually required

• Peri-operative – assuming normovolaemiaPeri-operative – assuming normovolaemia Hb < 7g/dlHb < 7g/dl Hb < 8g/dl if known CVD/risk factors for CVDHb < 8g/dl if known CVD/risk factors for CVD

Upper GI haemorrhage

• 1/1000 adults per year

• High mortality (10-30%)

• Increasing incidence: Alcohol related

• Uses 14% of all donated blood supply

• Potential problem for blood management

Current strategies #1Current strategies #1

• Anaemia managementAnaemia management• Cell salvageCell salvage• Coagulation correctionCoagulation correction

NB recombinant factor VIIaNB recombinant factor VIIa

• Surgical techniquesSurgical techniques harmonic scalpelharmonic scalpel swab washingswab washing

• Anaesthetic techniquesAnaesthetic techniques hypotensionhypotension warming (Bair huggers/IVI warmers)warming (Bair huggers/IVI warmers)

Anaemia ManagementAnaemia Management

• IronIron

• Erythropoietin Erythropoietin but tumour growthbut tumour growth

• Aprotinin Aprotinin withdrawn 2007 (BART Trial)withdrawn 2007 (BART Trial)

• Tranexamic acidTranexamic acid

• Haemostatic sealantsHaemostatic sealants

New UK TrialNew UK Trial

• Randomised double blind phase III Randomised double blind phase III

• Major abdominal surgeryMajor abdominal surgery

• Preop clinic/endoscopyPreop clinic/endoscopy

• One dose iv Ferinject vs placeboOne dose iv Ferinject vs placebo

• Primary endpoint - ? Reduction transfusionPrimary endpoint - ? Reduction transfusion

• Secondary endpoints - health related quality of Secondary endpoints - health related quality of life, post-operative morbidity, safety and length life, post-operative morbidity, safety and length of hospital stayof hospital stay

Patient Blood Management (PBM)Patient Blood Management (PBM)

We have learned a lot from the MilitaryWe have learned a lot from the Military

Damage Control Resuscitation forPatients with Major TraumaJansen et al, BMJ 2009

Patient Blood Management (PBM)Patient Blood Management (PBM) The lethal triad and The lethal triad and

the golden hour/platinum five minutesthe golden hour/platinum five minutes

Patient Blood Management (PBM)Patient Blood Management (PBM)

Permissive hypotension (not for brain injury)Permissive hypotension (not for brain injury)

Patient Blood Management (PBM)Patient Blood Management (PBM)

Tranexamic acid (TXA) – good evidenceTranexamic acid (TXA) – good evidence

Lancet 2010 Jun 15; (http://dx.doi.org/10.1016/S0140-6736(10)60835-5

)

BMJ 2012;345:e5839

Patient Blood Management (PBM)Patient Blood Management (PBM)Massive Haemorrhage/Blood Loss protocolMassive Haemorrhage/Blood Loss protocol

Blood products:

Warm crystalloid initially & Send urgent G&S

1 unit of FFP / unit of blood( O -ve blood in ED and theatre fridges, group specific available withi n 10 min & fully cross-

matched within 45 min)

Tranexamic acid 1g IV over 10 min then 1g over 8 h infusion

Platelets >75 (100 if brain or spinal injury)

2 units of cryoprecipitate if fibrinogen < 1.5g/dL-1

ROTEM to guide

Cell Salvage

Blood products:

Warm crystalloid initially & Send urgent G&S

1 unit of FFP / unit of blood( O -ve blood in ED and theatre fridges, group specific available withi n 10 min & fully cross-

matched within 45 min)

Tranexamic acid 1g IV over 10 min then 1g over 8 h infusion

Platelets >75 (100 if brain or spinal injury)

2 units of cryoprecipitate if fibrinogen < 1.5g/dL-1

ROTEM to guide

Cell Salvage

Reassess every 6 units

transfused:Send clotting, FBC and

fibrinogen

Check calcium and magnesium

Reassess every 6 units

transfused:Send clotting, FBC and

fibrinogen

Check calcium and magnesium

NONO

Patient stabilised?No evidence continued blood loss

Pulse < 100

BP > 100mmHg systolic

CVP > 5

Urine output > 30ml/hr -

Falling serum lactate

HB > 7

Patient stabilised?No evidence continued blood loss

Pulse < 100

BP > 100mmHg systolic

CVP > 5

Urine output > 30ml/hr -

Falling serum lactate

HB > 7

YESYESRecombinant factor seven

(rVIIa/novoseven)Discuss with haematology consultant

Requires fibrinogen to work so correct first1:30 incidence of arterial thrombosis (caution in

arteriopaths)

Recombinant factor seven (rVIIa/novoseven)

Discuss with haematology consultant Requires fibrinogen to work so correct first

1:30 incidence of arterial thrombosis (caution in arteriopaths)

Alert the laboratory and switchboard that the Massive Blood Loss Protocol is being

stood down

Alert the laboratory and switchboard that the Massive Blood Loss Protocol is being

stood down

Massive Blood Loss150ml/min-1 blood loss or

50% circulating volume loss within 3 hours* or

Class III / IV shock with ongoing blood loss

Massive Blood Loss150ml/min-1 blood loss or

50% circulating volume loss within 3 hours* or

Class III / IV shock with ongoing blood loss

Switchboard & Transfusion 2466“I am triggering the

MASSIVE BLOOD LOSS PROTOCOL”and state the site e.g. Emergency Department

Switchboard & Transfusion 2466“I am triggering the

MASSIVE BLOOD LOSS PROTOCOL”and state the site e.g. Emergency Department

Initial management

A B CDo not delay definitive management e.g. surgery

Initial management

A B CDo not delay definitive management e.g. surgery

Nominate staff member to communicate with transfusionNominate staff member to communicate with transfusion

Patient Blood Management (PBM)Patient Blood Management (PBM)

Shock packs 1:1:?1Shock packs 1:1:?1

BeriplexBeriplex

Patient Blood Management (PBM)Patient Blood Management (PBM)Blood – components/products:Blood – components/products:

O neg, Group specific, full XMO neg, Group specific, full XM

Rf VIIa (not licensed for MH)Rf VIIa (not licensed for MH)

Current strategies #2 PeopleCurrent strategies #2 People

• Transfusion Practitioners (TPs)Transfusion Practitioners (TPs)

• Hospital Transfusion TeamsHospital Transfusion Teams

• Hospital Transfusion CommitteesHospital Transfusion Committees

• Regional Transfusion CommitteesRegional Transfusion Committees

• Regional TP GroupsRegional TP Groups

• National Blood Transfusion CommitteeNational Blood Transfusion Committee

• International SocietiesInternational Societies

3 pillars of patient blood management3 pillars of patient blood management(Hofmann A, Friedman D, Farmer S, 2008)(Hofmann A, Friedman D, Farmer S, 2008)

The future #1The future #1• Further decrease in blood stocksFurther decrease in blood stocks

• Further decrease for surgeryFurther decrease for surgery Minimal blood orderingMinimal blood ordering Cell salvage, sealantsCell salvage, sealants Minimal invasive surgeryMinimal invasive surgery

Increase for medicine Increase for medicine AUGIB, Haemo-oncologyAUGIB, Haemo-oncology

The future #2

• AB, B,A Group conversion to O

• Embryonic stem cellsO neg

• Oxygen carrying solutions

- Haemoglobin derived

- Perfluorocarbons

• ‘Quikclot’

International concerns International concerns about blood transfusionabout blood transfusion

• Availability

• Economics

• Obsession with safety but not efficacy

• Preoperative anaemia carries risks……

• …….But so does transfusion

• PBM is emotional rather than rational

• PBM should be pre-emptive

• Increase for AUGIB and Haem-oncology

How can How can youyou can help? can help? • Consider the need for blood productsConsider the need for blood products• Be aware of the problemsBe aware of the problems

training, competencies, policiestraining, competencies, policies• Optimise patients earlyOptimise patients early – on referral – on referral

• Use blood wiselyUse blood wisely Clinical indicationsClinical indications Current HbCurrent Hb Risks/benefitsRisks/benefits Consider alternativesConsider alternatives

• Audit your blood useAudit your blood use

Patient Blood Management (PBM)Patient Blood Management (PBM)

A multidisciplinary, evidence-based approach to optimising the care of

patients who might need

blood transfusion.

Patient Blood Management:Patient Blood Management:The ReferenceThe Reference

Transfusing blood safely and Transfusing blood safely and appropriately Murphy M et al appropriately Murphy M et al

BMJ 2013;347:f4303 BMJ 2013;347:f4303

Take Home MessageTake Home MessagePatient Blood ManagementPatient Blood Management

““The optimal use of this scarce, expensive The optimal use of this scarce, expensive and potentially infectious resource is of and potentially infectious resource is of

international importance”international importance” McGill N et alMcGill N et al BMJ 2002;324(7439):1299BMJ 2002;324(7439):1299