1. Module 8: Alternative strategies to transfusion Transfusion Training Workshop KKM 2012

2. Avoid blood transfusion if possible Strategies to avoid blood transfusion works Make it a good clinical practice Gain experience Increase confidence

3. 3 basic principles 1.Tolerance of anaemia 2.Optimising RBC mass 3.Minimising blood loss

4. 1. Tolerance of anaemia Lower transfusion threshold trigger

5. Adaptive mechanisms to avoid tissue hypoxia When Hb falls,  Cardiac output increases  Blood viscosity decreases  Peripheral vasoconstriction occurs  Redistribution of blood flow  Increase O2 tissue extraction To maintain O2 delivery to tissues

6. Herbert PC, NEJM 1999

7. 2. Optimising red cell mass Pre-op planning

8. Bleeding risk – take a good bleeding history Baseline Hb – investigate and correct anaemia Medications – discontinue aspirin, anticoagulants if possible Underlying medical illness Estimate surgical blood loss Tolerance to blood loss

9. Optimising red cell mass Treat underlying anaemia Keep HCT 45 – 50%  IV iron sucrose  Folic acid, vitamin B12  Erythropoeitin

10. Case 1 80 year-old man Referred from IJN for anaemia Planned for CABG Hb 9.8

11. Case 1 – anaemia of inflammation Hb 9.6MCV 97 TW 5.2Plt 161 Crea 55Bil 6.0 Blood film: normochromic normocytic, no dysplasia Medications:  Simvastatin  Ticlopidine  Amlodipine  Perindopril  Pharmaton (hematinics)

12. Case 1 – s/c erythropoeitin 28/8/099/10/096/11/098/1/1030/4/10 9.610.611.413.012.4 CABG Feb 2012 No transfusions Post-op Hb 10 OGDS: antral erosions Colonoscopy: diverticular dis No active bleeding Started on proton pump inhibitors s/c Erythropoeitin 10,000 IU Once weeklyTwice weekly HCT 48%

13. Case 2 15 year-old boy Acute Lymphoblastic Leukaemia Blood group: AB Rh neg Rx: chemotherapy Difficulty getting blood s/c erythropoeitin 4000 IU 2x/weekly + iron tabs Hb maintained >8 g/dL No tx required

14. 3. Minimising blood loss

15. Minimising blood loss Meticulous surgery Haemostatic agents Cell salvage Quick trauma response  Damage control surgery Normothermia Prompt arrest of bleeding Judicious volume resuscitation Restrict diagnostic phlebotomy

16. Meticulous surgery Positioning of patient  Avoid venous compression Least traumatic approach Minimize duration of surgery Maintain normothermia

17. Cell salvage Saves 50% of blood loss Indication: estimated blood loss >1 L Cell salvage device  Recover the shed blood  Filter debris  ± Wash red cells

18. Haemostatic agents Tranexamic acid Topical fibrin glues (fibrinogen + thrombin)  Generates instant clot Oozing Leaks Tissue fixation

19. Lancet 2010 CRASH-2

20. Quick Trauma Response Damage control surgery  Do not wait to stabilize patient first  Avoid excessive fluid resuscitation Rapid rewarming

21. Avoid transfusion whenever possible Transfusion has its risks

22. What would you do? 26/ F G7 P6 @ 36 weeks Hb 5.4 MCV 58 fL

23. IV venofer Mean rise in Hb by 2.2 g/dL in 1 week (post- partum patients) with IV venofer 200 mg NHS 2008 Gravier A, J Gynecol Obst Reprod Biol 1999

24. The end Thank you