23 Fazakas Periop Blood Saving
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Transcript of 23 Fazakas Periop Blood Saving
Options for blood saving,
peri-operative blood collection
János Fazakas MD , PhDSemmelweis University
Department of Transplantation and Surgery, Budapest
Why do we need …?Options for blood saving, peri-operative blood collection
Options for blood saving,
peri-operative blood collection
Predeposit autologous donation (PAD)
Acute normovolemic hemodilution (ANH)
Intraoperative cell salvage (ICS)
Postoperative cell salvage (PCS)
•Autologous predeposit - full blood donation
•Autologous predeposit - full blood donation and separation
•Autologous predeposit - mechanical components donation
Predeposit autologous
donation (PAD)
Predeposit autologous
donation (PAD)
•* HIV epidemic of the early 1980s.
Patients with rare blood groups or multiple blood group antibodies
Allogenic donor blood is difficult to obtain
Serious psychiatric risk → anxiety about exposure to donor blood
Patients who refuse donor blood transfusion, but accept PAD
• assessed by a ‘competent clinician’, usually a transfusion medicine specialist
• the same rules of hemovigilieance (adverse reaction-events reported)
Predeposit autologous
donation (PAD)
Blood Safety and Quality Regulations:
PAD must be performed in a licensed blood establishment setting
PAD RBC storage-life of 35 days at 4°C (CAPD)
Healthy patients can donate up to 1-3 red cell units before elective surgery
Patients should be given iron supplements, folate, B12, EPO
•* HIV epidemic of the early 1980s.
Fundamental principles - PAD
Donor = Recipient
� Only in the case of general indication of transfusion
� Unused blood = hazardous waste
Advantage
� No allo-immunization
� Complication ↓
� No transfusion transmitted
infectious diseases
� No blood transfusion reaction
� Allogenic blood consumption ↓
To be considered
� Bacterial infections
� Technical faults
� Administration faults
� Expires
� Complex organization
Indications - PAD
Surgical procedures
� Before elective surgical
procedures
� Significant blood loss
may occur
Others0
� Rare blood group
� Hyperimmunization
� Tissue or organ donor
� Religion
Contraindications - PAD
• Acute surgical
procedures
• Significant
blood loss may
not occur
• Infection
• Severe heart disease
• Impaired blood
components
• Risk of micoaggregate
formation
• Warm and cold auto-
antibodies
• Direct Coombs
positivity
• HBV, HCV, HIV-1/2,
HTLV I/II, syphilis
• Hb less than 11 g/L
• Cardiovascular disorders
The Informed Consent Form - PAD
� Possibility
� Risk / benefit
� Significant blood loss may occur
� MedDRA System Organ Class
� ≥ 1/10 very common
� ≥ 1/100 to < 1/10 common
� ≥ 1/1000 to < 1/100 uncommon
� The informed consent documents must be clearly
written and understandable to donor/recipient!
PAD – questionnaire/registration form
Initiating procedure of PAD
� In written form! – questionnaire + registration form
� With medical records - laboratory tests
- internist’s expert report
physician’s request
BTS local institution
contracting hospital departments
� Blood tests can be performed only by BTS blood
suppliers.
BTS: Blood Transfusion Service
Preliminary tests before PAD
In Blood Transfusion Service lab
� Hgb
� ABO and Rh(D)
� testing for antibodies� enzymatic
� indirect Coombs
� direct Coombs
� HBV antigen and HCV, HIV 1-2, treponema antibody
→ in case of positivity the patient must be excluded
from analogous blood donation!
Suitability for PAD
� Internal examination
� Laboratory test
� Written request from the
institution sending the
patient (appendix I:
„Autologous blood donation
registration form”)
� BTS examination
� Transfusiologist’s
examination (every occasion)
� tapping liver, spleen, lymph
node
� circulation and respiratory
examinations
� blood pressure, pulseVerifying
suitability !
Identifying donor/recipient -PAD
� Photo identification document + authority ID (residential
address card)
photograph, full name, date of birth
� Health insurance card (TAJ in Hungary), EU card
� In case of children: 2 parents/authorized representatives
� Written (appendix II: „Informed consent form VAGY Information sheet”)
and oral information
� Medical record and general state of health (appendix III:
„Autologous blood donation questionnaire”)
� Patient’s assent to
� examination of blood sample
� autologous blood donation
� patient registries
Administration - PAD
� If suitable
→ making arrangements for blood tests before operation
→ patient registry – physician’s signature, stamp- collected blood volume
- blood substitute solution (which? how much?)
- RR, HR
� If not suitable
→ informing the patient in written form
→ informing the physician who sent the patient in written form
Blood collection - PAD
� Autologous Homologous blood collectiontype and quality of bag system type and quality of bag system
� The rules of autologous blood collection
The rules of homologous blood collection
+ direct supervision of a physician
+ ± substituting with infusion
+ collected blood volume (on one occasion) 450 ml (±10%)
≤ 12% of the patient’s blood volume (65-75 ml/ttkg x 0,12)
+ in case of apheresis:
thrombocytes, RBC, plasma
=
=
Labeling autologous blood
1. „Autotransfusion” label
2. The donor/recipient’s
name
3. The donor/recipient’s
date of birth
4. The donor/recipient’s
health insurance
number (TAJ)
� age 18-65 years
� weight > 10 kg
� pulse 50-110/min
� blood pressure systole: 100-180 Hgmm
diastole: < 100 Hgmm
� Hgb > 110 g/l
� Hct > 33%
PAD procedure
7 days 7 days 7 days 3 days
1 E back 1 E back
Medication - PAD
physician ≠ transfusiologist
1. checking iron level, oral iron
supplementation for autologous donor- one week before the first blood collection
- for 3 months after the last one
2. EPO ?
procedures for
homologous blood
PAD - blood products*
→ RBC concentrate, resuspended
→ Fresh Frozen Plasma (FFP)
→ RBC concentrate, from apheresis,
resuspended in solution with adenine content
→ Platelet concentrate from apheresis
Autologous
blood
What to do before retransfusion
� The recipient has to be identified unequivocally
- recognizing signature
� Check the identifying codes of blood preparation
� Perform AB0 and Rh(D) identification at bedside (recipient/preparation)
Personal data� name
� birth name
� address
� date of birth
� mother’s name
� health insurance
number (TAJ)
Registry – for 30 years
Contact�address� telephone numbers�e-mail address
Hospital/physician treating the patient
�name, address, department ofthe hospital
�physician’s name, telephone number, stamp number
Medical record�anamnesis� laboratory test results� internist’s opinion
Examinations before blood collection�weight�blood pressure, pulse�current Hgb
BTS laboratory tests�Hgb�AB0,Rh(D)�antibody testenzymatic, direct and indirect Coombs
�HBV antigen and HCV, �HIV 1-2, treponema antibody
Blood collection data�dates of each stages
�dates of blood
collections
� identification numbers
of blood/blood
components
• Bags of blood being removed
immediately before the initiation of
surgery,
• The infusion of volume expanders to
maintain normovolemia.
• Bags of blood being re-infused
during and/or immediately after the
surgery is completed.
Acute normovolemic
hemodilution (ANH )
Acute normovolemic
hemodilution (ANH )
1-3 units of whole blood are collected and the patient’s blood volume is maintained by the simultaneous infusion of crystalloid or colloid fluids.
• The blood is stored in the operating theatre at room temperature
• Reinfused at the end of surgery or if significant bleeding occurs
Risk of fluid overload, cardiac ischemia
Systematic reviews + trials → no significant reduction to transfusions
• other blood conservation techniques: ICS
Intraoperative cell salvage (ICS)the collection and reinfusion of blood spilled during surgery
Blood lost into the surgical field is anticoagulated with heparin or citrate and aspirated into a collection reservoir
Sponge filtration remove particulate debris
the salvaged blood can be centrifuged and washed in a closed, automated system.
Red cells suspended in sterile saline solution are produced, which must be transfused to the patient within 4 hours of processing.
the reinfusion bag should be labelled in the operating theatre with the minimum patient identifiers derived from the patient’s ID band
The red cells are transfused through a 200 µm screen filter, after 800 ml a leucodepletion filter is indicated (C3a-C5a)
� Patients who needs ICS → give informed consent
� The transfusion → documented and the patient monitored in the same way as
for any transfusion
Indications for ICS in adults
and children
Surgery + anticipated blood loss is >20% of the patient’s BV
Elective or emergency surgery + major hemorrhage
risk factors for bleeding and low preoperative Hb concentration.
Patients with rare blood groups or multiple blood group antibodies for whom it may be difficult to provide donor blood.
Patients who do not accept donor blood transfusions but are prepared to accept, and consent to, ICS (this includes most Jehovah’s Witnesses
• concerns about cancer cell reinfusion and spread,
• manufacturers do not recommend ICS in patients having surgery for
malignant disease.
• Extensive clinical experience suggests this is not a significant risk
• Reinfuse the red cells through a leucodepletion filter
• concerns about amniotic fluid embolism
• the harvested red cells should be reinfused through a leucodepletion filter
CONTRAINDICATIONS� Sepsis
� Malignant tumour *
� Contamination:• betadine, hydrogen-peroxide, alcohol
• distilled water, water
• non-parenteral antibiotics
• fibrin gel, collagen based hemostasis
• meconium, amniotic fluid *
• urine
• stomach content
• bile
Intraoperative cell salvage
* Reinfuse the red cells through a leucodepletion filter
Diagram of the set up of a
standard cell salvage circuit
A. Ashworth, and A. A. Klein Br. J. Anaesth. 2010;105:401-416
Intraoperative cell salvage
� Hemocinetics ®
Cell Saver
� C.A.T.S.®
(Continuous
Auto
Transfusion
System )
HAEMONETICS
CELLSAVER
Collection
Wash
Concentration
8-10 min
FRESENIUS C.A.T.S.
Spiral pipe system
Continuous collection,
separation,
resuspendation,
concentration
Intraoperative cell salvage
Intraoperative cell salvage
In 1976, was introduced
by Haemonetics Corp.
and is known commonly
as "Cell Saver"
0 in 1995 Fresenius
introduced a continuous
autotransfusion system0
Intraoperative cell salvage
A. Ashworth, and A. A. Klein Br. J. Anaesth. 2010;105:401-416
Intraoperative cell salvage
C.A.T.S.
WASHING PROGRAMS
20 - 45 ml/minQuality Wash
100 ml/minEmergency Wash
30 - 70 ml/minHigh Flow Wash
25 ml/minLow Volume Wash
20 - 40 ml/minHigh Quality Wash
Flow rateWashing programQuality
anticoagulation: Na-heparin 15000 NE/500 ml + 0,9 % NaCl solution
C.A.T.S. ® (Fresenius)
Advantages� 2,3-DPG level↑
� Normothermia
� Normal pH
� Potassium ion ↓
(compared to vvs
concentration)
Elimination� Plasma
� Platelets
� WBC
� Free Hgb
� Cell debris
� Activated factors
� Intracellular enzymes
coagulopathy
ICS - evidence
A. Ashworth, and A. A. Klein Br. J. Anaesth. 2010;105:401-416
Postoperative cell salvage (PCS)
� Orthopedic procedures (knee or hip replacement) and in scoliosis surgery
� The filtration systems for reinfusion of unwashed red cells are used when expected blood losses is 500 →→→→ 1000 ml
� Blood is collected from wound drains and then either filtered or washed in an automated system before reinfusion to the patient
� Collection of salvaged blood must be completed within 6 hours
� Clinical staff must be trained and competency assessed to use the device
� Accurately document the collection and label the pack at the bedside.
� The reinfusion must be monitored and documented in the same way as donor transfusions.
� * Is acceptable to most Jehovah’s Witnesses.
PCS - device
� HemovacOrthopedic and cardiac surgery
45 mmHg vacuum
230 micron macro filter
� Bellovacorthopedic and spine surgery
90 mmHg vacuum
200 micron macro-filter in the bag
80 and 40 micron micro-filter - transfusions set
Maximum 6 hours (700 -1500 ml); do not filter bacterial contamination
Mental competence and
refusal of transfusion
� 0unless there is clear evidence of prior refusal such as an Advance Decision Document. The patient record should document the indication for transfusion and thepatient should be informed of the transfusion when mental capacity is regained (and their future wishes should be respected)
� 0the parents or legal guardians of a child under 18refuse blood transfusion, the opinion of the treating clinician is life-saving or essential for the well-being of the child, a Specific Issue Order (or national equivalent) can be rapidly obtained from a court0
� 0all hospitals should have policies that describe how to do this, without delay, 24 hours a day0
• Altered consciousness0, critically ill patients with temporary incapacity
clinicians must give life-saving treatment, including blood transfusion
Thank you for your attention!