BEST TRANSFUSION

may often be
NO TRANSFUSION

Patient blood management (PBM)

 Definition

• Timely application of evidence-based medical and surgical concepts

• Designed to maintain Hb conct.

• Optimize hemostasis

• Minimize blood loss

• Improve patient outcome

 History

• 1st bloodless medicine & surgery: Jehovah’s Witness patients (1980s).

• Outcomes treated without allogeneic transfusion equivalent / sometimes better

• several adverse outcomes were published associating allogeneic transfusion

• Bloodless medicine and surgery might be good for all patients  PBM arose.
 Aim

• Allogeneic transfusion may be lifesaving

• Like any medical therapy, associated with risks.

• Should be reserved for circumstances in which there is clear benefit

 Restrictive Or Liberal

• TRICC (Transfusion requirement in Critical care) trial: Late 1990’s.

Objective:- To determine which approach of transfusion is better

Transfusion to 10g/dl Hb was a common practice in critical care.

Methodology:- Randomized 838 critically ill non-bleeding patients

Restrictive (7g/dl) with target Hb 7-9g/dl)
Liberal(10g/dl) with target Hb 10-12g/dl
 Result

50% in RBC Tx in restrictive group: no overall difference in 30-day mortality.

MI & Pulmonary Edema common in liberally transfused group.

Restrictive Tx maybe superior in lower illness severity score pts (APACHE II

score < 21) & pts <55 years age.

However:- Uncertainty in transfusion of critically ill patients with shock.

APACHE II Score
 TRISS(Transfusion requirement in septic shock)

Objective:- Liberal Hb target VS Restrictive transfusion

Methodology:- Randomized 1005 patients with septic shock

Restrictive(<7g/dl) Liberal(<9g/dl)

Result:- Restrictive group received approx. 50% fewer RBC Tx with similar 30-
day survival and requirements for oxygen support.

Conclusion:- Restrictive transfusion safe in septic shock.

 Restrictive Or Liberal In Perioperative
Setting ?

• PREVENTT trial demonstrate that IV iron successfully increased Hb but no effect

on transfusion requirement or perioperative mortality.

• Carson & colleagues: Random trial on 2016 patients with anemia following hip
surgery.
Restrictive(8g/dl) Liberal(10g/dl).

Result:- Substantial reduction in RBC Tx with no difference in mortality or

functional outcome at 60 days.
 TRICS-III trial
Objective:- Random trial of over 5000 patients undergoing cardiac surgery

Restrictive(7.5g/dl) Liberal(8.5g/dl)

Outcome basis:- Death, MI, Stroke, Renal failure by day 28.

Result:- No difference in outcome & substantial reduction in RBC Tx.

Ducrocq et al Trial
• Backround:- Random trial on 668 patients with acute MI

Restrictive(<8g/dl) Liberal(<10g/dl)

•
 Robertson et al Trial
• Background:- Randomized trial of 200 head-injury pts

Restrictive(7g/dl) Liberal(10g/dl).

• Result:- No difference in disability at 6 months. Higher rate of thromboembolism in

liberal Tx.

Frankfurt Consensus Conference on PBM (2018):

Threshold for post-op ICU patient: 7g/dl (Strong recommendation)

Threshold for pts following cardiac surgery: 7.5g/dl (Strong recommendation)

Strategies
 Computerized Physician Order Entry
Systems to Guide Evidence-Based Transfusions
• Restrictive use of allogeneic blood results in no difference in pt outcome  leads to
avoidance of certain complications a/w Tx & reduced cost of care

• Similar results in ICU pts, pediatric and geriatric patients, pts with hip fracture, GI
bleeding, cardiac surgery, septic shock and TBI.

• Restrictive Tx significantly cardiac events, re-bleed, bacterial infection, mortality

• Little benefit from transfusing pts with Hb levels > 7–8 g/dL range.

• Allogeneic Tx is costly, provides no benefit to aggressive transfusion  drive clinicians

 Computerized Physician Order Entry
(CPOE)
• introduction of electronic medical records and CPOE systems has facilitated compliance
with accepted standards.

• Allow for prospective monitoring of transfusion orders, as well as facilitating a process for
monitoring transfusions that do not meet an institutional standard.
 Reduce All Forms of Waste Related
to Blood Transfusion Practices
• Provides a significant opportunity for cost savings

• Research suggest: PAD Tx. 50% unused  many centres do not use PAD for surgical
pts

• Cross-matching too many pts: General standard: CT ratio < 2. Computer cross-
matching for pts without antibodies allows blood availability rapidly (< 5 mins).

• Maximum Surgical Blood Ordering Schedule (MSBOS): CT ratio. Developed to

arrange adequate blood during OR. Originally was derived by consensus of surgeons.
 Reduce All Forms of Waste Related
to Blood Transfusion Practices
• Excessive phlebotomy: Approx 30% Tx in ICU d/t excessive phlebotomy. Starts
with ‘rainbow draw’ at admission. Excessive phlebotomy extends hospital stay 
routine phlebotomy occurs. Only to order when clinical question to be answered.

• Blood mishandling: Can be significantly reduced by educating clinicians. Blood

center releases blood based on a physician order, may be the nurse is in charge to
transfuse the unit, may have multiple other patients to care for. Distribution
process driven by nurse reduced 79% platelet wastage (1 study).

• Unnecessary ordering of blood to OR: most goes unused.

 Reduce All Forms of Waste
Related to Blood Transfusion
Practices
 Promote Alternative Blood Transfusion
Methods and Systems

• Multilevel spine fusion / open thoraco-abdominal aneurysm repair heavy blood

loss highly probable.

• Cell salvage: Collection of shed blood from surgical field  concentrate, wash,
filter & re-administered  60% of lost cells can optimally be returned. 
multiple complete blood volumes can be processed prior to allogeneic RBC
supplementation.
• Normovolaemic haemodilution: withdrawal of autologous blood prior to start of the
surgery and replacing volume with asanguineous IVF  creates relative anemia so that
intra-op shed blood contains reduced number of RBCs  Blood loss diminished,
harvested cells returned to pt.
• Disadvantage: Does not work very well to prevent red cell transfusion. The savings
attributable to normovolaemic haemodilution are estimated at 100–200 mL, hardly
enough to significantly reduce allogeneic exposure.
• The value of haemodilution relates to its ability to treat coagulopathy that might develop
during a major blood loss procedure. Intraoperative blood salvage allows for allogeneic
red blood cell avoidance up to two to three blood volumes, while sequestered plasma and
platelets from normovolaemic haemodilution protect the patient when a dilutional or
consumption coagulopathy occurs. In general, removal of a litre of whole blood through
normovolaemic haemodilution, and then reinfusion, is adequate for platelet and plasma
 Promote Anaemia Management Strategies

• Pre-op anemia: Ranges from 5% in female geriatric hip fracture pts to over 75% in
colon cancer patients. 34% of non-cardiac surgery patients and 35% of those
undergoing total knee or hip replacement.

• Greatest risk factor for perioperative transfusion. higher mortality rates in surgical
patients.

• Optimisation of Hb: Iron, vitamins and occasionally using erythropoietin.

 Limit Iatrogenic Blood Loss

• Point-of-care testing devices: Blood gas, electrolyte, glucose level, Hb and

coagulation function tests  Require microlitres of blood rather than the
standard 3–4 mL

• In cardiac surgery, where point-of-care testing has been implemented blood use
has been reduced by up to 70%.

• hospitals can use paediatric vacutainer tubes for routine laboratory testing 
aspirate 0.5–1 mL of blood.
 Provide Blood Management Education,
Awareness and Auditing for Clinicians

• Variability relates to surgeon differences in tolerability of anemia, surgical

approach, DVT prevention practices and use of anti-fibrinolytics.

• By developing such reports and publicly sharing them, surgeons will self-regulate
their transfusion behavior.
Three pillar nine matrix of perioperative PBM
 PLATELET TRANSFUSION

• Prevent bleeding in thrombocytopenic and pts who are on antiplatelet meds.

• Approx. 8-66% ICU pts are thrombocytopenic, 9% of these receive PLT Tx.

• 1 apheresis unit / pool of 6 RDP units:- PLT count by 30±15x10⁹/L in afebrile,

non-obese, non-bleeding patients.

• For general surgery:- PLT count at least 50x10⁹/L

• For closed space bleeding:- PLT count raised to 100x10⁹/L

• Restrictive threshold for PLT transfusion:- 10x10⁹/L

• ESICM guidelines:-

Extrapolates from trials on patients with haematological malignancy.

Advise platelet transfusion if< 10x10⁹/L for a non-bleeding critically ill patient

Threshold of 50x10⁹/L may be appropriate for invasive procedure(tracheostomy, CVC )

International interventional radiology guidelines:-

• Platelet transfusion for a high risk procedure if count < 50x10⁹/L

• For all procedures, if count < 20x10⁹/L.

General accepted threshold for PLT transfusion in major abdominal surgery: 50x10⁹/L.

Surgery in critical sites (intracranial, spinal, ocular): threshold 100x10⁹/L.

 WHO Bleeding Score For Assessment Of Therapeutic/Prophylactic PLT Tx
Gr Type of bleeding
Gr Type of bleeding

1 •Petechiae/purpura, localized to 1-2 dependent sites 3
or sparse/non-confluent
•Oro-pharyngeal bleeding, epistaxis: < 30 min
2 •Melena, hematemesis, hemoptysis, fresh blood in
stool, musculoskeletal bleeding, soft tissue bleed not
requiring PRBC Tx within 24 h of onset & without
hemodynamic instability.
•Profuse epistaxis / oro-pharyngeal bleeding >30 min. 4
•Symptomatic oral bleed / causing major discomfort.
•Multiple bruises, each >2 cm / any >10 cm.
•Visible blood in urine
•Abnormal bleeding from procedure sites
•Bleeding requiring PRBC Tx specifically for support
of bleeding within 24 h of onset & without
hemodynamic instability.
•Bleed in body cavity, fluids grossly visible.
•Cerebral bleed on CT without neurological signs
and symptoms.
•Debilitating bleed (retinal bleed; visual impairment)
•Non-fatal cerebral bleed + neurological signs and
symptoms.
•Bleed a/w hemodynamic instability
•Fatal bleed from any source
Prophylactic Transfusion Of Platelets
 Therapeutic Transfusion Of Platelet
INDICATION TRANSFUSE PLATELET AT

WHO bleeding score >2 and severe life-threatening bleeding No trigger, manage individually according to the
symptoms and maintain platelet count >50,000/ μl

Multiple trauma, traumatic brain injury or spontaneous ICH <100,000/ μl

Non severe and/ or non-life-threatening bleed <30,000/ μl

Platelet Transfusion In Immune Thrombocytopenia

INDICATION TRANSFUSE PLATELET AT

No Bleeding <5,000/ μl

Invasive procedure or surgery Transfuse 1 adult/ paediatric dose prior to the intervention or
peri-interventional period. Any threshold count may not be
achievable and is unnecessary
Serious and or life-threatening bleeding >2 adults/ paediatric dose of PLT + co-administration of IVIG
 FFP Transfusion
• Usually to treat bleeding (usually guided by abnormal laboratory coagulation test)

• One 250ml unit increases plasma coagulation factors by 2.5%

• 6-8 units are needed for a 15-20% correction in critically ill or injured patient.
BCSH guidelines recommendation
• No evidence of prophylactic use of FFP in a non-bleeding patients with abn coagulation test.

• Impact of using FFP to correct clotting results/reducing bleeding risks is very limited, particularly
when PT ratio/INR is between 1.5-1.9

• Vitamin K administration should be done in patients with prolonged PT.

• During major blood loss, may contribute to support circulating vol but shouldn’t be used for
 ESIC Guidelines(2020)
Clinical scenario Suggested strategy Strength of recommendation

Elevated PT in a critically •Reverse anticoagulant if indicated Conditional recommendation,

ill non-bleeding patient •Administration of Vit K if suspicion of Very low certainty
deficiency
•No prophylactic Tx of FFP

Elevated PT in a non- •Reverse anticoagulant if indicated Weak recommendation

bleeding patient •Administration of Vit K if suspicion of
undergoing high risk deficiency
invasive procedure •FFP transfusion(target INR < 1.5-1.8
 Cryoprecipitate
• 10%, 20%, 30% decline in factor VIII is seen at 2, 4, 6 hours respectively.

• One 5 U pool deliver 1.5g of fibrinogen and fibrinogen conct. by 0.3-0.4g/L.

• Transfusion dose in adults:- Two 5 U (equivalent to 10 single donor units)

BSH guidelines
• Administered at dose 10-20ml/kg/h (or 30-60 minutes per 5 unit pool)
 Massive Transfusion (DGHS)
≥10 blood unit transfusion within 24 hours / Transfusion of ≥4 blood units in 1
hour / Replacement of 50% of blood volume in 3-4 hours / A rate of loss of blood
≥ 150 ml/hour.

• CTVS surgery(1/3 of all massive bleeding) > Transplant surgery(20%) > Trauma(15-
16%) > Medical cause(10%) > Maternal haemorrhage(2%)
 Massive transfusion protocol
• Provide rapid blood replacement for patients with massive blood loss.

BCSH
o In trauma patients guidelines
 1:1:1 ratio of platelets: plasma: red cells (If apheresis unit available:- 1:6:6)

 Tranexemic acid infusion ASAP

o In obstetric patients
 1:1:1 ratio of platelets: plasma: red cells. Cryoprecipitate, if fibrinogen<2gm/dl

 Tranexamic acid may be considered

 Latest recommendation:-
 Conclusion
• The variety and volume of data that can be collected to support a PBM programe are
almost limitless.

• BT is most common billable procedure: 1 of 5 most overused procedures  managing

use has great potential to reduce risks, cost & improve outcomes.

• Quality / cost = value  successful PBM asset to hospital / health system.

Reference
• Practical Transfusion Medicine

• Transfusion Medicine Technical Manual. DGHS

Thank you!!!