Patient blood management Flashcards
Recall the different techniques that can reduce transfusion needs and which phase they fall under.
Pre-operative: Identify and treat anemia and bleeding risks. Autologous donations.
Intra-operative: Normovolemic hemodilution, cellsaver, POCT algorithms, hemostatic drugs.
Post-operative: Postop blood recovery, minimizing phlebotomy, changing physician behavior.
What hemoglobin levels define anemia, and what is its prevalence?
<13g/dL in men, <12g/dL in women
20% prevalence in men, 40% prevalence in women. Enriched in hospitalized and ill patients.
How is iron deficiency anemia treated?
Give oral or IV (iron sucrose) supplementation. Avoid using erythropoiesis stimulating agents (risk of thrombosis).
What is the role of pre-operative autologous blood donation?
Most useful for patients with rare blood and for Jehovah’s witnesses. Falling out favor due to a better allo-transfusion supply. Also increases operative bleeding and transfusion needs as well as waste.
What is the role of acute normovolemic hemodilution?
Reduce patient’s crit so they bleed fewer RBCs»_space; Hold blood at room temperature. Most helpful for high-crit patients in especially bloody surgeries.
How is intraoperative blood recovery performed?
Whole blood is collected from the operative field and the RBCs concentrated to 45-60 crit before being returned to the patient (sans plasma, etc).
What surgical and anesthesia techniques can reduce blood requirements?
Using minimally invasive approaches, elevating the operative site, preserving venous return from the operative field, lowering MAP, maintaining normothermia and optimizing fluids.
What is the role of antifibrinolytics?
Besides treating hyperfibrinolysis, helpful to reduce bleeding in settings of cardiac surgery, post-partum hemorrhage, and trauma surgery.
Note: Some association with seizure activity?
What is the role of DDAVP?
Helps reduce bleeding in settings of uremia, cirrhosis, or drug-induced dysfunction (antiplatelet therapy) and ECMO.
What is the role of post-operative blood recovery
Limited; draining blood from wounds yields a low crit (20-30%) and contains activated clotting factors. Blood may need to be washed–this method is only for high-volume complex surgical centers.
How much blood do patient’s lose to phlebotomy?
An ICU patient loses ~40mL/day due to an average of 4.6 lab draws/day. This can amount to almost a unit per week.
How can iatrogenic (phlebotomy) anemia be minimized?
Minimize draws, consolidate testing to fewer tubes, and use closed phlebotomy systems with rinseback. Note: Central lines actually worsen anemia due to requirement to dispose of dead volumes.
Distinguish between prospective, concurrent, and retrospective review/auditing
Prospective is labor intensive and toilsome, usually farmed out to residents.
Concurrent is consultative and takes place in last 12-24hrs. Need to give feedback to clinicians.
Retrospective is well after the fact. Need to give feedback to clinicians.
What is a CPOE and how can it be used to improve transfusion practices?
Computerized provider order entry (CPOE); can be set up with built-in transfusion guidelines (clinical decision support) with hard stops to promote good practices.
What is benchmarking?
Large scale data collection / data mining. Can be used to identify gaps in performance relative to other hospitals, etc.
