Methods to reduce blood transfusion

Alternative Therapies to Reduce Blood Transfusion

Blood Conservation
Preop –
Intra op –
Post op –

Pre Op

Assessment of patient, review blood results.
Drug treatment.
Donation of Autologous blood.
Relatively fit patients with Hb >10g/dl.
Up to 4 units.
Needs a good team, funding for programme.
Decline in popularity.

Pre Op
Iron – deficiency 14% women and 3% men.
iron – iron sucrose and iron dextran preparations.
iv bolus or iv infusion.
Can reduce blood transfusions and prepare patients for surgery in anticipation of blood loss.
Erythropoietin.
Acute normovolaemic haemodilution.

Anaesthetic Techniques

Deliberate Hypotension
Arterial pressure
Patient selection
Various agents, techniques
Invasive monitoring
MAP – 55 to 60 mm hg
Venous Pressure
Patient positioning- elevate op site, avoid obstruction to venous drainage,coughing, straining.
IPPV, PEEP and CPAP.
Avoid Hypervolemia in certain cases.


Hypothermia

T< 35.5 C – impairs haemostasis.
Reduce heat loss – inc ambient temp, keep patient covered, short procedures, minimally invasive surgery.
Increase heat input – warm fluids, skin warming.
Monitor temperature.
Pre, intra op, post op warming.


General Vs Regional Anaesthesia

Regional – low arterial BP,CVP, peripheral venous pressure.
Evidence is equivocal.


Fluid Therapy

Effect on coagulation – dilutional
Crystalloids less effect than colloids
Gelatins less effect than starches and dextran

Surgical Methods

Operative Techniques
Avascular planes
Progressive haemostasis
Patient position
Limb exanguination
Minimally invasive procedures- endovascular AAA repair, laproscopic surgeries, laser prostatectomy etc

Surgical Haemostasis

Diathermy
Lasers
Ultrasound dissectors
Water - jet dissectors
Haemostatic swabs
Fibrin sealents
Cell Salvage
Surgical blood loss anticoagulated, filtered and collected.
Separated concentrated and washed.
Re suspended in saline and re infused.
Best if loss > 1 litre.
Major vascular, orthopaedic and trauma, hepatic surgeries.
Capital costs, disposables, training.
Aprotinin
Reversible inhibitor of serine proteases.
Antifibrinolytic – inhibitory action on plasmin by directly binding to plasmin.
Supresses inflammation by inhibiting kallikrein.
Uses - orthopedic surgeries.
Reduction in blood loss ~ 50%.
Tranexamic Acid
Binds to lysine binding sites of plasminogen.
Blocks its binding to fibrin.
Prevents plasminogen activation.
Delays fibrinolysis.
Uses – joint replacement surgeries specially revision surgeries.
Post Op
Drain salvage.

Transfusion trigger.
Drug therapy – iron, erythropoietin,tranexamic acid.

Summary
Assess patients – optimise conditon.
Reduce blood loss.
Conserve blood.
Reduce threshold.

Team effort – consult hematologist.

Thank You