Blood Conservation Strategies

@Patient Blood Management

Dr.Ravichandra Kumar D
Junior Resident
Outline
• Introduction.
• Aim
• Three Pillars of PBM
• Strategies
Pre operative strategies
• Pre-operative Autologous Donation
Intraoperative strategies
• Acute Normovolemic Hemodilution
Post operative strategies • Cell Salvaging
• Pharmacological Agents
Introduction
• Life saving but also has its complications
• Unnecessary blood transfusion is shown to be associated with
morbidities and prolonged hospital stays.
• Approximately 1/3rd of patients are found to be anemic on pre-
assessment.
• Strong predictor for perioperative blood transfusion requirements
• The optimization of red cell mass and erythropoiesis before Surgery is
essential.
Introduction - PBM
• Patient blood management is an international multidisciplinary
initiative that aims to reduce the unnecessary transfusion of allogeneic
blood components.

• Covers the entire course of stay from before admission into the
hospital to after treatment.

• Primary aim of PBM is to improve patient safety and clinical outcome

by appropriately utilizing patients own blood
PBM Contd..
• Quality of care and better outcomes-
restrictive transfusion has shown to
be of no harm, similar outcomes or
even better in some cases than liberal
transfusions.

• Patient in need- increasing demand

and lesser donor pool makes PBM
conserve blood for the truly needy.

• Reduced healthcare cost.

Three Pillars of PBM

• Optimizing the patient's own blood

(e.g. pre-operative optimization of
hemoglobin and hemostasis)

• Minimizing surgical blood loss

• Optimizing the patient's

physiological reserve in relation to
anemia (including use of restrictive
transfusion triggers).
Three Pillars – Optimising
PRE - OP
• Detect Anemia
• Identify underlying
cause
INTRA - OP
• Refer for further
Time Surgery POST - OP
evaluation if
with Optimise
necessary
hematological erythropoiesis
• Treat the cause like
optimisation
Iron Def anemia,
Megaloblastic
anemia, Anemia of
chronic disease
2nd Pillar – Minimise Blood Loss
• Vigilant monitoring and
management of post op
bleeding
• Meticulous • Avoid secondary
• Identify and
hemostasis and hemorrage.
manage bleeding
surgical techniques • Rapid warming/maintain
risk
• Blood sparing normothermia
• Minimising
Surgical Techniques • Autologous blood salvage
iatrogenic blood
• Anaesthetic Blood • Hemostasis/anticoagulation
loss
Conserving management
• Precise Surgical
Strategies • Prophylaxis for UGI
procedure planning
• Autologous Blood hemorrage
• Preoperative
Options • Prevent/treat infections
Autologous
• Pharmacological/He promptly
Donation
mostatic agents • Consider adverse effects of
medication
Harness and optimise physiologic reserve of
anaemia – 3rd Pillar
• Assess/optimise patients
physiological reserve and • Optimise anemia
risk factor reserve
• Optimize
• Compare estimated blood • Maximise oxygen
cardiac output
loss with patient specific delivery
• Optimise
tolerable blood loss • Minimise oxygen
ventilation and
• Formulate patient specific consumption
oxygenation
management plan using • Avoid/treat
• Restrictive
appropriate blood infections promptly
transfusion
conservation modalities • Restrictive
thresholds
• Restrictive transfusion transfusion
threshold thresholds
Pre-op Assessment
• Screening for anemia should be performed as early as 30 days prior to scheduled
surgery- for proper investigation and treatment.

• Proper history.

• CBC/Red cell indices.

• Serum Ferritin and transferrin saturation.

• Further workup based on lab results

Contd..
• I.V iron quickly corrects iron deficiency anemia.
Started as early as possible i.e. few weeks to surgery.
1000mg rises Hb by approx 2g/dl (divided dose over 3-4 weeks).

• Short pre-op regimen of erythropoietin or erythropoietin single dose + IV iron

have shown to be beneficial in reducing transfusion rate.

• Vitamin B12 - 1mg IM daily for 7 days f/b weekly IM dose/4week.

• Folic acid supplementation daily

Intraoperative strategies
• Patient position during surgery.
• Consider minimally invasive or laparoscopic surgical technique
• Point-of-care testing should be available with appropriate training.
• Consider cell salvage if blood loss > 500 ml anticipated.
• Consider giving tranexamic acid 1g if blood loss > 500 ml anticipated
• Apply restrictive transfusion threshold (Hb 7–8 mg/dl depending on
patient characteristics and hemodynamics).
• Consider use of topical haemostatic agents
Contd..
• Fluids
Crystalloid solution for routine perioperative fluid repletion in
order to maintain normovolemia and/or to replace lost blood on a 1.5:1
basis
Colloid solution to be administered on a 1:1 basis.

• Transfusion may be initiated if the hemoglobin level drops below a

certain threshold or there is bleeding at such a rate that hemoglobin
levels do not accurately reflect the patient's clinical status
 Maintenance of Normothermia
Hypothermia causes coagulopathy due to impairment of platelet
aggregation and reduced activity of enzymes in the coagulation cascade

This combination of platelet and enzyme impairment typically reduces

clot formation and increases perioperative blood loss and the need for
transfusion

Even mild (eg, 1°C) hypothermia increased blood loss by

approximately 20 percent.
Contd..
• Positioning, tourniquets, vasoconstrictors.
Keeping the surgical site higher than heart.
Infiltration of the incision sites with vasoconstrictors like adrenaline and
noradrenaline.
Use of tourniquets in extremity surgery especially on the upper and
lower limbs.

• Laproscopic surgery which restricts wound size should also be encouraged.

• Surgery staging to allow the hematological systems to recover and the blood
coagulation to become normal in complex surgeries
Controlled hypotension
• Reduction in systolic blood pressure to between 90-100mmHg or a mean arterial
blood pressure of 50-70mmHg in a normotensive patient.

• Posture- The head-up position.

• Pharmacological agents.

• Epidural and spinal anaesthesia.

• Combining normovolaemic haemodilution with hypotensive anaesthesia almost

halved the blood transfused during surgery
Postoperative Strategies
• Limiting phlebotomy related loss can decrease the incidence of
iatrogenic anemia.
• >7 day ICU stay can lead to one unit loss of blood by sampling if not
limited.
• Prevention of infections.
• Laboratory testing should be ordered only when justified and likely to
change clinical management.
• Patients on central line loose more blood to sampling.
• Steps to improve iron reserves and dietary advise
Autologous Blood Donation
Blood collected from patient for re-transfusion at later time into the
same individual is called autologous blood transfusion.

Types
Preoperative collection
Acute normovolemic hemodilution
Intraoperative collection
Postoperative collection
History
• Reinfusion of blood was employed as early as 1818 & pre-operative
donation was advocated in 1930s.

• Blood salvaging was reported during neuro-surgical & obstetric

procedures from 1936.

• Fantus in 1937 founded the first blood bank in the USA.

• During the last 20 years there is a increase in the use of ABT.

Preoperative collection - Blood is collected and stored prior to
anticipated need. (PAD)
Peri-operative collection and administration:
Acute normovolemic hemodilution:
Blood is collected at the start of surgery and then infused during or after
the procedure
Intraoperative collection:
Shed blood is recovered from the surgical field or circulatory device then
infused.
Postoperative collection:
Blood is collected from the drainage devices and reinfused to the patient
Advantages
• Prevents transfusion-transmitted disease
• Prevents red cell Allo-immunization.
• Supplements the blood bank supply.
• Prevents adverse transfusion reactions.
• Provides compatible blood for patients with allo-antibodies.
• Provides reassurance to patients concerned about blood risks.
• Individuals with rare blood groups/ irregular antibodies.
Disadvantages
• Risk of bacterial contamination.

• May results in wastage of blood.

• May subjects patients to peri-operative anemia and increased

likelihood of transfusion.

• Expensive in case of intra-operative and post operative collection

Pre-operative Autologous Donation
• Assumed that PAD is safer than allogenic blood.

• Blood is drawn and stored before anticipated need.

• Two or more units blood are drawn and stored prior to anticipated
need.

• Should be stable patients who are scheduled for a surgical procedure

in which blood transfusion is probable.
Indications of Pre-operative Autologous donation
• Major Orthopedic surgeries: Most common
(Hip & Knee replacement surgeries)

• Cardiovascular surgeries: Valve surgery

• Obstetric surgeries (hysterectomy, ovarian tumours)

• Radical prostatectomy, Mastectomy

• Gastro-surgery (Gastectomy, Splenectomy, Liver Transplant)

Contraindications
• IHD, Scheduled surgery to correct aortic stenosis
• Unstable angina
• Uncontrolled hypertension ( BP > 180/100).
• Myocardial infarction or cerebrovascular accident within 6 months of
donation.
• High grade left main coronary artery disease
• Cyanotic Heart Disease
• Evidence of infection and risk of bacteremia.
• Active Seizure Disorder
Donor Selection Criteria
Age – No limits exist.

Weight –
Donors > 60 kg or more can donate 450 ml of blood and donors weighing < 60 kg
may donate proportionately smaller volume of blood but not more than 8-9 ml/kg body
weight.

In pediatric patient of 8 years of age & weight should be 27 kg and no more than
10% of the patients blood volume should be drawn at each phlebotomy.

• Hemoglobin and hematocrit – Hemoglobin should not be less than 11.0 gm/dl and
hematocrit not less than 33%.
Blood Tests:

• ABO & Rh testing

• Test for Transfusion Transmitted Disease

Frequency of donation:
• A sufficient number of units should be drawn to avoid exposure to allogenic
blood
• Difference between two collections >72 hours.
• The last collection should be >72 hours before surgery.
Blood Bag Labeling
• Must be labeled: “Autologous Donor”.
• If any testing is reactive on a current
collection or within the last 30 days it must
also be labeled “Biohazard”.
• Untested autologous units must be labeled
“Donor Untested”.
• If the blood tested negative within the last
30 days it must be labeled “Donor Tested
Within the last 30 Days”.
Leap Frog Technique
• On day 0: unit A withdrawn.

• On day 7: unit B & C are withdrawn and unit A is retransfused.

• On day14: unit D & E are withdrawn and unit B is retransfused.

• On day 21: unit F & G are withdrawn and unit C is retransfused.

• So now unit D,E,F,G are available with us which can be given to

patient when needed.
In no circumstance the blood should be
used for another patient (Cross Over).
Acute Normovolemic Hemodilution

It is the removal whole blood from a

patient just before the surgery and
transfused immediately after the
surgery. It is also known as
‘preoperative hemodilution’.
Acute normovolemic hemodilution
• Patients who are not anemic

• Patients who can tolerate rapid withdrawal of one or several units of

blood (not exceeding 20ml/kg) before the period of blood loss.

• ANH is simpler.

• Less expensive and available to patients undergoing surgery at short

notice.
Patient eligibility Criteria
• Attending anesthetist should determine the patient’s suitability to undergo
ANH.
• Likelihood of transfusion exceeding 10%.
• Pre-op Hb of at least 12g/dL
• Absence of severe hypertension
• Patient should have near normal O2 transport capacity.
• Absence of clinically significant cardiovascular, respiratory, renal and
cerebrovascular diseases.
• Should obtain valid consent
• Absence of infection and risk of bacteremia
ANH-Advantages
• Provides fresh whole blood for transfusion.
• No biochemical alterations associated with storage.
• Removed blood is kept in the OR in room temperature, so no chance
of hypothermia.
• Platelet function is preserved.
• No reduction in oxygen carrying capacity.
• RBC loss during surgery is less as it is diluted with fluids
• Haemodilution decreases blood viscosity, which improves tissue
perfusion
ANH - Physio
Withdrawal of whole blood(in std. blood bag) and replacement with
crystalloids and colloids results in

Drop in HCT, arterial O2 content and decreased blood viscosity

Increased Cardiac output and decreased peripheral resistance

So O2 delivery to tissues is not affected

Heart Rate and Blood Pressure remains unchanged

Volume withdrawn

• Formula to estimate the possible volume to be withdrawn

• Volume withdrawn=EBV x(HCTi-HCTt)/HCTavg
EBV-estimated blood volume
HCTi - Hct before hemodilution
HCTt - targetHct after hemodilution
HCTavg - average of initial hemotocrit & minimal allowable Hct
Volume Replacement

• Blood is withdrawn from a central or peripheral vein.

• Blood is collected in standard blood bags containing Citrate anticoagulant
• Crystalloid and or colloid are infused as blood is withdrawn.
Crystalloid = 3 times the volume of blood removed
Colloids = Equal to the volume of blood removed.
• Crystalloids have the advantage of easily excreted by a diuretic at the time
of re-infusion
• Monitoring – continuous monitoring of hemodynamic variables
Labeling & Storage
With proper identification and message “For autologous use only”.
Written protocol describing policies & procedure, approved by
transfusion committee.
Keep the blood in the same operating room as the patient to preserve the
platelet function.
If it is anticipated that more than 6hrs will elapse before transfusion store
at 2-6 degree C.
Anesthetist must note on the anesthesia record ,the amount of blood
withdrawn, the amount and type of fluid infused ,amount of blood
returned, along with patient’s vital signs
Re-infusion
The units are re-infused in the reverse order of collection, so that
the first unit which has the high Hct and most clotting factors is
administered last.

Complication
Myocardial ischemia and Cerebral hypoxia are the major
potential complications, but are very rare in usual
circumstances.
Intraop and Postop Cell Salvaging
• Started nineteenth century.

• Initially used in cardiac surgery, the technique is now used in over 3,50,000 cases
every year during trauma, vascular, liver transplantation.

• Technique of collecting, processing, and reinfusing blood lost by a patient during

surgery.

• Perioperative blood conservation technique to reduce use of allogenic blood and the
risks associated with allogeneic blood exposure.

• Acceptable for use in patients that don’t consent to allogeneic or preoperative

autologous blood transfusions Eg.Jehovah’s Witnesses
AABB – General Indications for cell salvage
• Anticipated blood loss is 20% or more than the patient’s estimated
blood volume.

• Cross match-compatible blood is unobtainable.

• Patient is unwilling to accept allogeneic blood but will consent to

receive blood from intraoperative blood salvage.

• The procedure is likely to require more than one unit of RBCs.

Contd..
• With the use of special equipments the blood is collected from the
operative field and draining sites.
• Recovered blood is mixed with anticoagulant is collected in a reservoir
with a filter.
• The filtered blood is then washed with saline.
• The RBCs suspended in the saline are then pumped into a re-infusion bag.
• Most of the WBCs, platelets, clotting factors, cell fragments and other
debris are eliminated.
• Several automated devices are available for use.
Indications

• Cardiovascular Surgery.
• Ruptured spleen or liver.
• Ruptured ectopic pregnancy.
• Ruptured aneurysm.
• Traumatic penetrating injuries
Characteristics of processed blood
• HCT of processed blood is 50 – 60% and can be varied by altering the
processing parameters.

• Oxygen transport properties and survival of RBCs are equal or superior to

stored allogenic blood.

• Processed blood has a near normal 2,3-DPG level.

• pH of salvaged blood is alkaline, and potassium and sodium levels are

normal.
Procedure
• Cell salvage - collection of blood from the surgical field through a
specialized double-lumen suction tubing that delivers anticoagulant, heparin
or citrate, to the tip of the suction catheter.

• Hemolysis of red cells can occur during suctioning from surface (vacuum not
more than 150 torr is recommended)

• Processing involves specialized centrifugation that causes the lower density

plasma & anticoagulant fluid to rise up and separate from the higher density
RBCs collected at the bottom of a conical- or cylindrical-shaped bowl.
Contd..
• 500 to 700 mL of collected blood is required for processing to produce
225 to 250 mL of salvaged saline-suspended PRBCs with a Hct of 50%
to 60%.

• If saline-wash device used & if properly labeled, blood stored @ room

temperature for up to 4 hours or at 1°C to 6°C for up to 24 hours.

• Microaggregate filters (40 μm) employed during reinfusion - recovered

and processed blood contain tissue debris, small blood clots, or bone
fragments.
Complications
• Air embolism and fat embolism are important complications.

• Renal dysfunction is a possibility due to the presence of free Hb and

Fragmented RBCs.

• Sepsis is another serious problem.

• Presence of tumor cells in the operative field is considered as a

relative contraindication
Contra indication
• Procoagulant materials (e.g., topical collagen) are applied to the
surgical field because systemic activation of coagulation result.

• Parenterally incompatible chemicals (e.g., chlorhexidine, betadine,

hydrogen peroxide) in the surgical field, and use of hypotonic
solutions in the surgical field - lyse red blood cells.

• Bacterial contamination of the surgical site

• Presence of amniotic fluid

Postoperative Cell Salvage

• Recovery of blood from surgical drain followed by re-infusion with or

without processing.

• Shed blood is collected into sterile canister and re-infused through a micro-
aggregate filter.

• Recovered blood is diluted, partially hemolysed and de-fibrinated and may

contain high concentrate of cytokines.

• Upper limit on the volume(1400 ml) of unprocessed blood can re-infused

Contraindications

• Malignancy

• Perforated viscera resulting in contamination of blood with fecal

matter, urine, bile etc.

• When the rate of blood loss is less than 50ml per hour

Technique used less frequently because of lack of evidence for

effectiveness
Erythropoietin
Erythropoietin (EPO) can increase the red cell mass and therefore the
haemoglobin level potentially reducing patients exposures to allogeneic
transfusion

Indications
• Anemia secondary to chronic kidney disease
• Chemotherapy-induced anemia in patients with cancer.
• Anemia secondary to zidovudine treatment in HIV infection.
• Support in patients receiving autologous blood transfusions.
• Anemic patients undergoing elective surgery.
Contd..
• Adverse effects
Venous Thromboembolic events
Hypertension
Hypersensitivity Reactions

Dosage:
50 – 150 U/Kg/week.
600 U/Kg on Day 21,14,7 and on day of Surgery.
Tranexamic Acid
• Antifibrinolytic agent.

• Forms a reversible
complex that displaces
plasminogen from fibrin
resulting in inhibition of
fibrinolysis.

• Inhibits the proteolytic

activity of plasmin
Contd..
• Dosage:
10-15mg/kg IV

• Adverse Reactions.
Gastrointestinal: Nausea,vomiting.
Cardiovascular: Hypotension, thrombosis.
Ocular: Blurred vision
Desmopressin
• Synthetic analogue of Arginine Vasopressin.
• Induces release of stored Factor VIII and von
Willebrand’s Factor from endothelial cells.
• Increases the platelet adhesiveness.
• Prevents/controls bleeding in haemophilics, plalelet
dysfunction.
• Dose: 0.3 µg/kg IV/SC/Intranasal
• Adverse effects – Headache, Flushing, Water
Retention, Hyponatremia, Hypertension
Blood Substitutes
• Artificial Oxygen Carriers.
• Can Be used as alternatives to allogenic blood in acute blood loss.
Modified Hemoglobins.
PerFluroCarbons

Modified Hemoglobins
• Either recombinant or derived from outdated RBCs (human or bovine)
• Hemopure- From Bovine RBCs
PerFluroCarbons
• Trade Names- Oxygent, Oxycyte.
• Have the capacity to carry Oxygen and CO2 at a rate
twice that of Hemoglobin.
• Advantages-
Long Shelf Life
No risk of Transmission of Blood-borne Diseases.
• Disadvantage - Acute Lung Injury
 Summary
• Each type of autologous transfusion has potential risks and benefits.

• However when feasible the patient should have the option to use his or
her own blood.

• SOPs at each step.

• Separate inventory to avoid mix-ups.

Thank You