PDF Introduction to Patient Blood Management

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Introduction to Patient Blood Management

Dr. Salwa Hindawi

President of Saudi Society of Transfusion Medicine Director of Blood Transfusion Services,KAUH

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Patient Blood Management (PBM)

• Introduction

• ETHICS OF BLOOD MANAGEMENT

• Implementation of a PBM Program

• Policies and strategies to reduce the need for transfusion

• Management of Preoperative Anaemia

• Massive Transfusion Protocol

• Why Implementing Patient Blood Management Program

•

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Introduction

• PBM includes interventions taken early in the preparation of medical and surgical patients for treatment, as well as techniques and strategies in the preoperative, operative, and postoperative periods or completion of treatment.

• A PBM program also encompasses physician education and evaluation, alternatives to transfusion, and the

development of evidence‐based clinical practice

guidelines.

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What is Patient Blood Management

“ Right dose, right product, right patient,

right time, right reason”

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Improves the patient’s own blood and avoids unnecessary transfusions.

‘THE THREE PILLARS’

Minimise blood loss

Optimise blood volume and red

cell mass

Optimise patient’s tolerance of

anaemia

What is patient blood management

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Patient Blood Management Program (PBMP)

The program should be responsible for oversight and monitoring of:

• Physician blood ordering.

• Routine venipuncture and blood loss.

• Blood utilization.

• Preoperative anemia management

• Autologous donation.

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Patient Blood Management Program

• Intraoperative patient blood management techniques Techniques to reduce blood loss.

Use of medications to decrease blood loss.

• Normovolemic hemodilution.

• Postoperative strategies.

Blood recovery and reinfusion.

• Massive transfusion.

• Patient outcomes.

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It should include:

Evidence-based transfusion triggers and Giudelines

clinician decision support

Data collection & Audits with feedback

Education

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ETHICS OF BLOOD MANAGEMENT

• First Do No Harm

• Transfuse only when absolutely necessary

• Transfuse Only what’s Required / Sparingly

• The Freshest Components Possible

• Minimal Blood Draws Sampling.

• Avoid Waste/ Recover as much Autologous as possible.

• Use POC Labs to Justify Transfusions.

• Use Evidence Based Medicine in Decisions.

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Implementation of a PBM Program

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Implementation of a PBM Program

Considerations for Therapy:

• Does the patient need blood products.

• What are the alternative options for treatment.

• Using the product that will be most effective in providing the desired outcome.

• Minimum donor exposure.

• What is the patients view of treatment.

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Implementation of a PBM Program

• Develop a collaborative multidisciplinary group

• Identify and manage preoperative anaemia

• Manage anticoagulant and antiplatelet medication

• Adopt multiple intraoperative strategies to minimise blood loss

• Tolerance of postoperative anaemia

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So how can we manage blood better and who are the Multidisciplinary Players involved?

Primary Doctor

Admission Care Team

Pre Game Plan with the Big Three

*Surgeon, Anesthesia, Perfusion*

ICU Care Team, Nurses

Haematologist / Blood Transfusion Specialist

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Perioperative Patient Blood Management

• Preoperative anemia assessment and management

• Intraoperative blood conservation including red blood cell salvage

• Postoperative tolerance of anaemia (by transfusion decision

support)

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Policies and stratgies to reduce the need for transfusion:

Ensure a safe and adequate supply of blood and blood products

Establish a national committee on the clinical use of blood

 Develop national guidelines on the clinical use of blood

 Provide training for all clinicians, nurses, BTS/hospital blood bank staff and other personnel involved in the transfusion

process

 Establish transfusion committees in each hospital in which transfusion takes place

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Establish a system to monitor and evaluate blood usage

 Establish a national haemovigilance system to monitor, report and investigate adverse events associated with

transfusion

Prevention, early diagnosis and effective treatment of conditions that could result in the need for transfusion

Appropriate prescribing of blood and blood products in accordance with national guidelines

 Use of good surgical and anaesthetic techniques,

pharmaceuticals and medical devices to reduce blood loss

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 Availability and use of simple alternatives for volume replacement, including intravenous replacement fluids (crystalloids and colloids)

Safe pre-transfusion procedures

 Safe administration of blood and blood products.

 Management of Adverese Reaction.

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Preoperative Anaemia

Patients undergoing procedures in which substantial blood loss is anticipated such as cardiac surgery, major orthopaedic, vascular and general surgery.

Specific details:

including reference ranges and therapies, may need adaptation for local needs

Preoperative tests

• Full blood count

• Iron studies including ferritin

• CRP and renal function

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Preoperative Anaemia

• Is the patient anaemic?

• Hb <130 g/L (male) or

• Hb <120 g/L (female)

No anaemia: ferritin

<100 mcg/L

• Consider iron therapy^# if anticipated postoperative Hb decrease is ≥30 g/L

• Determine cause and need for GI investigations if ferritin is suggestive of iron deficiency <30 mcg/L

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Preoperative Anaemia

If Ferritin <30 mcg/L

Iron deficiency anaemia

•Evaluate possible causes based on clinical findings

•Discuss with gastroenterologist regarding GI investigations and their timing in relation to surgery³

•Commence iron therapy^#

If Ferritin 30–100 mcg/L

Possible iron deficiency

•Consider clinical context

•Consider haematology advice or, in the presence of chronic kidney disease, renal advice

•Discuss with gastroenterologist regarding GI investigations and their timing in relation to surgery³

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Preoperative Anaemia

Ferritin >100 mcg/L

Possible anaemia of chronic disease or inflammation, or other cause⁵

•Consider clinical context

•Review renal function, MCV/MCH and blood film

•Check B12/folate levels and reticulocyte count

•Check liver and thyroid function

•Seek haematology advice or, in the presence of chronic kidney disease, renal advice

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Senior clinician

• Request:^a

o4 units RBC o2 units FFP

•Consider:^a

o1 adult therapeutic dose platelets o tranexamic acid in trauma patients

• Include:^a

ocryoprecipitate if fibrinogen < 1 g/L

a Or locally agreed configuration

Massive transfusion protocol (MTP) template

Senior clinician determines that patient meets criteria for MTP activation

Baseline:

Full blood count, coagulation screen (PT, INR, APTT, fibrinogen), biochemistry, arterial blood gases

Notify transfusion laboratory (insert contact no.) to:

‘Activate MTP’

Bleeding controlled?

Laboratory staff

•Notify haematologist/transfusion specialist

•Prepare and issue blood components as requested

•Anticipate repeat testing and blood component requirements

•Minimise test turnaround times

•Consider staff resources

Haematologist/transfusion specialist

•Liaise regularly with laboratory and clinical team

•Assist in interpretation of results, and

OPTIMISE:

•oxygenation

•cardiac output

•tissue perfusion

•metabolic state

MONITOR

(every 30–60 mins):

•full blood count

•coagulation screen

•ionised calcium

•arterial blood gases

AIM FOR:

• temperature > 35⁰C

• pH > 7.2

• base excess < –6

• lactate < 4 mmol/L

• Ca²⁺> 1.1 mmol/L

• platelets > 50 × 10⁹/L

• PT/APTT < 1.5 × normal

• INR ≤ 1.5

• fibrinogen > 1.0 g/L

The information below, developed by consensus, broadly covers areas that should be included in a local MTP. This template can be used to develop an MTP to meet the needs of the local institution's patient population and resources

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The routineuse of rFVIIa in trauma patients is not recommended due to its lack of effect on mortality (Grade B) and variable effect on morbidity (Grade C). Institutions may choose to develop a process for the use of rFVIIa where there is:

• uncontrolled haemorrhage in salvageable patient, and

• failed surgical or radiological measures to control bleeding, and

• adequate blood component replacement, and

• pH > 7.2, temperature > 34⁰C.

Discuss dose with haematologist/transfusion specialist

• Warfarin:

• add vitamin K, prothrombinex/FFP

• Obstetric haemorrhage:

• early DIC often present; consider cryoprecipitate

• Head injury:

• aim for platelet count > 100 × 10⁹/L

• permissive hypotension contraindicated

• Avoid hypothermia, institute active warming

• Avoid excessive crystalloid

• Tolerate permissive hypotension (BP 80–100 mmHg systolic) until active bleeding controlled

•Do not use haemoglobin alone as a transfusion trigger

•Identify cause

•Initial measures:

- compression - tourniquet - packing

•Surgical assessment:

- early surgery or angiography to stop bleeding

•If significant physiological derangement, consider damage control surgery or angiography

•Consider use of cell salvage where appropriate

• Actual or anticipated 4 units RBC in < 4 hrs, + haemodynamically unstable, +/– anticipated ongoing bleeding

• Severe thoracic, abdominal, pelvic or multiple long bone trauma

• Major obstetric, gastrointestinal or surgical bleeding

Specific surgical considerations

Resuscitation Initial management of bleeding

Dosage Cell salvage

Considerations for use of rFVIIa^b Special clinical situations

Suggested criteria for activation of MTP

Platelet count < 50 x 10⁹/L 1 adult therapeutic dose

INR > 1.5 FFP 15 mL/kg^a

Fibrinogen < 1.0 g/L cryoprecipitate 3–4 g^a Tranexamic acid loading dose 1 g over 10

min, then infusion of 1 g over 8 hrs

a Local transfusion laboratory to advise on number of units

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Classification of Transfusion Reactions

Acute Hemolytic Febrile Nonhemolytic Bacteria Contamination

TRALI

Delayed Hemolytic TA-GVHD

Urticarial Anaphylactic

Circulatory Overload (TACO)

Medicated Febrile Post-Transfusion Purpura ACUTE

FEBRILE TRANSFUSION

REACTION DELAYED

ACUTE

DELAYED AFEBRILE

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Reporting Incidents/Transfusion Reactions

• Stop the Transfusion and seek Medical Input and inform the Transfusion Laboratory staff

• Check the Blood component matches the patient details

• Replace the unit and giving set with Normal Saline 0.9%

• Send the discontinued unit with giving set attached back to transfusion capped off at the end with a white venflon cap – and any previous transfused bags sealed with the blue

plugs all in biohazard bags

• Documentation (complete the checklist)

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Why Implementing Patient Blood Management

Program?

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Blood Smart BMP

• On average U.S. hospitals perform transfusions at a rate of 44 per thousand population.

• The average transfusion rate for hospitals participating in the BloodSmart Blood Management Program is 30 per thousand.

• An 8% decrease in red blood cell (RBC)use was demonstrated at hospitals implementing BMP improvement projects

compared with an increase of 4% at hospitals that are not actively managing blood use.

BloodSmart^®: Transfusion and Blood Management program

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Blood Smart BMP

• One tertiary care hospital realized $1 million in savings for blood products in its cardiac surgery service over two years, after implementation of a Blood Management Program.

• One large academic hospital saw a 9% decrease in RBC usage, a 12% decrease in platelet usage, and a 16% decrease in

plasma usage, which occurred from 2011 to 2013.

• One hospital saw almost a 90% reduction of specialised product use (typically washed RBCs which cost about

$310/unit) by implementing evidence based guidelines and recommended communications to clinicians.

BloodSmart^®: Transfusion and Blood Management program

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Blood Smart.org

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Conclusion

• PBM can be part of the Transfusion Committee

get their attention, get support from Administration, get funding, get the people, get data to get noticed •

• Patient Blood management:

Reduced Risk Reduced Cost

Improved Outcome

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Conclusion

• Patient blood management (PBM) is an evidence-based approach to optimizing the care of patients who might need transfusion.

• PBM program will result in better patient care and safe practice.

• Implementation of PBM Program will lead to better

utilization of Blood Products and add to the quality and

availability of blood.

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THANKS