Restricting and avoiding Blood Transfusions: What Options do we have?

DR. DEEPAK SOLANKI M.D. ANAESTHESIOLOGY [email protected]

Questions to be answered
What are the implications of anemia? What are the benefits of a normal hematocrit? How do we decide when to transfuse? What are the risks of transfusion? What are the alternatives to homologous transfusion?

What are the implications of Peri operative Anemia?

DO2 =CO x CaO2 [(%sat x 1.39 x Hb) + PaO2 x0.003] Peri operative anemia usually co-exists with hypovolemia Ability to tolerate reduction in DO2 depends on the ability to increase cardiac output Myocardial contractility, HR, vascular tone with loss>15%

Problems of Peri operative Anemia

These responses are modified by: -age -co morbid illness (CAD,CNS) -pre existing Hb and plasma volume - blockers, ACE inhibitors -rapidity of loss THE PROBLEM IS TO IDENTIFY THE PATIENT AT RISK

Problems of coronary circulation and myocardium Myocardium has high O2 extraction ratio O2 delivery can be increased only by increasing flow Tachycardia compromises diastolic flow With normal coronary circulation Hb up to 7g% tolerated ECG changes of ischemia at Hb 5g% Lactate production, death at Hb 3g%

What is the urgency of replacing volume & Hb? Diversion of blood from skeletal, splanchnic beds to coronary and cerebral circulation Mucosal ischemia-starting point of MODS, sepsis Peri operative myocardial ischemia-high mortality Un replaced blood loss coagulation problems, DIC

Beneficial effects of normalisation of Hct in RBC volume, restoration of plasma volume Restoration of blood flow to GIT Restoration of viscosity in shear stress, ADP production, platelet aggregation Dispersal of platelets towards vessel wall

Anemia and NO
viscosity in anemia flow, shear stress, NO production Vasodilation at bleeding sites in cyclic GMP in platelets, inhibition of platelet function, bleeding time Hb best NO scavenger; oxidizes NO Minimum shear stress seen at Hct 3035%

Indications and Guidelines for intraoperative RBC Transfusion Based on Acute blood loss:

-15% loss in an adult(500-750 ml)-no need to transfuse -15-30%loss-crystalloids/synthetic colloids -30-40%(1500-2000ml)-rapid IV resuscitation blood ->40%-rapid volume replacement+ blood

Guidelines for Transfusion-continued

Based on Hb concentration: - Actual and anticipated Hb>10g% - Indicated when Hb7g%,at the rate of ongoing blood loss - Patients at risk trigger 8g%(consensus) Consider if patient will bleed due to coagulation abnormalities - Give appropriate coagulation factor/s

Patients at Risk
Coronary artery disease Valvular heart disease (AS) CHF H/O transient ischemic attacks Previous thrombotic stroke However, still no consensus for transfusion trigger

Transfusion Strategy for Acute Blood Loss

Signs and symptoms Requiring Transfusion

Syncope Dyspnea Postural Hypotension Tachycardia unresponsive to crystalloids Angina/ECG changes Transient ischemic attack

Patients under Anesthesia

If stable:

-assess risk of myocardial/cerebral ischemia -in the absence of risks,transfusion NOT indicated,regardless of Hb -intravascular volume to be replaced If unstable: -if at risk, transfuse -if not at risk,crystalloid+colloid initially -TRANSFUSE UNIT BY UNIT -autologous blood if available

Guidelines for Transfusion(contd)

Transfusion in the ICU:

-Overtransfusion may increase mortality -Attention to volume, inotropic support -Maintenance of BP and CO -Crystalloids preferable

Guidelines for peri operative transfusion Patient to be managed to avoid transfusion Treat anemia before elective surgery Discontinue anti platelet drugs Reverse anticoagulation Use pharmacologic agents to control bleeding Strategies of autologous transfusion

Chronic Anemia
Do not transfuse if effective alternatives exist Preferably transfuse at intervals to maintain Hb at lowest level not associated with symptoms Consider recombinant erythropoietin

-zidovudine-induced anemia,CRF -improves functional status

Risks associated with Transfusion

VIRAL INFECTIONS

lHepatitis A- 1:1,000,000 lHepatitis B- 1:50,000-1:150,000 lHepatitis C- 1:1,900,000 lWhats new: Nucleic Acid Testing (NAT) lCMV-Up to 60% transmission from blood lParvovirus B 19-Hydrops, Aplastic crisis

Risks of Transfusioncontd
Bacterial Contamination mortality Red cells 2/106 (yersinia sp) 60% Platelets 83/106 21% Hemolytic Reaction Acute 1-4/106 0.67 Delayed 1000/106 0-4 TRALI 200/106 60% Transfusion-mediated immuno modulation -good for renal transplant, recurrent abortions -increased mortality in CV, colorectal Ca

Other Hazards
Mismatched transfusion-1:14,0001:18,000 Fatality-1:800,000 units West Nile Virus-Meningitis,encephalitis Creutzfeldt-Jakob disease

Alternatives to Allogeneic (Homologous) Blood

Techniques:

-Deliberate Hypotension -Bloodless Surgery -Tourniquet where appropriate Drugs affecting coagulation -Aprotinin(1.4mg 70mg/hr) - amino caproic acid(5-10g1g/hr) -Tranexamic acid(10mg/kg1mg/kg/hr) Erythropoietin pre treatment

Autologous Blood Use

Pre operative Autologous Donation (PAD) Acute Normovolemic Hemodilution (ANH) Intra operative Cell Salvage and Reinfusion Post operative collection and Re infusion

What are the Advantages of PAD?

Avoids complications of allogeneic blood Prevents red cell alloimmunization Useful for patients with rare blood phenotypes or allo antibodies Supplements blood supply Provides reassurance to patients concerned about blood risks

Patient Selection for PAD

Hb 11.0g/dl No age or weight limits Volume 10.5 ml/kg per donation Usually once a week Last donation > 72 hours before surgery Patients with positive viral markers Selected pediatric patients

Contra indications to PAD

Surgery unlikely to require transfusion Evidence of infection/bacteremia Scheduled surgery for AS Unstable angina MI /CVA < 6 months Active seizure disorder Unstable angina, left main coronary block Cyanotic CHD Uncontrolled HT/ Pulmonary/ other medical dis. Pregnancy

Potential Problems with PAD

Risk of misidentification Infection/contamination of stored units Volume overload Increased cost of collection & storage Risk of patient becoming anemic Aggressive Phlebotomy and iron, Erythropoietin 3 weeks prior to surgery

Acute Normovolemic Hemodilution (ANH)

Blood removed shortly before surgery Volume replacement with crystalloid/colloid* Blood stored in OT at room temperature Volume= EBV (Hi-Hf) Hav Decrease in DO2, viscosity Cardiac output, systemic vascular resistance, venous return Oxygen extraction enhanced

Precautions
Hypovolemia, hypocapnia to be avoided Oxygen supplementation Reversible cognitive dysfunction in cerebral vascular disease Coronary vasodilatation important to increase O2 delivery to myocardium Store close to patient and label appropriately

Precautionscontd
Establish 2 IV lines Routine monitoring Contraindications Transfused in reverse order of collection Room temperature storage not > 8 hours Increased HR : be warned Advantages: all drawbacks of homologous blood eliminated; low cost; fresh whole blood

Red Cell Recovery and Re infusion

Blood from surgical field is collected into centrifuge bowl Suction should be low, broad tipped Large sponges rinsed in saline/RL Heparin /ACD to be added (Ca reduces deformability) Centrifuged to separate red cells from debris and WBCs Washed with saline/glycine

The Cell Salvage System

Calculation of blood loss

([Hs/Hp] x Vb xNb)/SE E.g. THR ; 5 bowls(125 ml) used HCT(bowls): 66,70,68,65,71%(av68%) HCT(patient):32,30,34,30,28%(av30.8%) Salvage efficiency 40% Blood Loss=68% x 125 x5/ 30.8% x 40% = 3450 ml

What are the potential Complications of Cell Salvage?

Poor wash quality-cell salvage syndrome (DIC, ARF) Poor salvage rate due to non-dedicated personnel Air embolism Wrong wash solution

Current Status of Artificial O2 Carriers

Necessary steps: Stabilization to prevent dissociation into dimers (intravascular retention; nephrotoxicity) Decrease O2 affinity Polymerization to increase Hb concentration at physiologic colloid oncotic pressure Emulsification of PFCs to make them watermiscible

Hemoglobin-based O2 Carriers
Exhibit a sigmoidal O2 dissociation curve Provide O2 and CO2 transport Sourced from outdated banked blood, bovine blood or genetically engineered Undergo virus inactivation and removal Protection against prion contamination Stabilised,polymerised

Difficulties and Side effects of Hb solutions

Nephrotoxicity-eliminated Vasoconstriction-systemic and pulmonary hypertension: causes-NO scavenging/increased O2 supply to arteriolar wall Abdominal pain, esophageal dysmotility due to NO modulation of smooth muscle relaxation Interference with mixed venous O2 saturation

Kinds of Artificial Hbs

Diaspirin-linked Hb (DCLHb): stopped due to jaundice,pancreatitis,mortality Human recombinant Hb (rHb 1.1,rHb 2.0): genetically expressed in E.Coli in 1990.Stopped in 2003 Polymerised bovine Hb based O2 carrier(HBOC201): used in orthopedic & cardiac trials Maleimide activated polyethylene glycol modified Hb(MP4):high mol. Wt.,oncotic pressure,Hb conc 28g/dl. Under trial.

Human Polymerised Hemoglobin (PolyHeme) From outdated banked blood Pyridoxylated and polymerized with glutaraldehyde Has been tried in trauma and urgent surgery situations 1u=50g in 500ml;171 patients with Hb<1g % survived after 20u(10l)

Per Fluoro Carbon (PFC) Emulsion (OxyGent)

Carbon fluorine compounds with high gas dissolving capacity and low viscosity Chemically and biologically inert Dose 1.8g/kg Taken up by RES;emulsion broken down,re absorbed into blood and circulates;excreted from lungs Effective transport of dissolved O2 Submicron size enhances

Nano-dimension artificial RBCs, Hb containing liposomes Purified Hb +phospholipids +cholesterol + tocopherol Lead to rapid restoration of BP,microvascular blood flow and tissue oxygenation Augmented ANH: A technique of ANH combined with administration of O2 carriers and crystalloids

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