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Where Blood Matters

AIMSNational Scientific Meeting

Darwin Convention Centre24 – 27 September 2012

Morteza Mohajeri, MD, FRACS ( Cardiothoracic )

Senior Medical AdvisorQBMP

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National Blood AgreementNovember 2002

National Blood Agreement

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National BloodAuthorityAustralia

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National Blood Agreement

States and Territories must:• Develop & implement best practice

– Planning and management– Supply, distribution and use– Promote efficiency– Minimise waste

• Provide information and advice to NBA

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National Blood Agreement

States and Territories must:• Obtain information and advice from NBA

– Product availability– Product price

• Comply with financial arrangements– Joint funding– Commonwealth 63% : States 37%

Current Blood Matters• Variation in transfusion practices• Transfusion reactions & adverse

events• Supply & Demand• Costs

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Variation in Transfusion Practices

• Wide variation in transfusion practices based on anecdotal experience

• 12 – 87% transfusion rate for similar orthopaedic operation in 18 Austrian hospitals

Gombotz et al. Transfusion 2007;47:1468-80

• 17 – 79% transfusion rate for cardiac surgery operations in 12 Australasian hospitals

Daly et al. Anaesth Intensive Care 2007;35:760-68

Austria Queensland

Patients % Transfused Patients % Transfused Median

THR 1401 16 - 85% THR I03B 905 7 - 38% 26%

TKR 1296 12 - 87% TKR I04B 1382 0 - 27% 9%

CABG 777 37 - 63% CABG F06B 179 3 - 31% 29%

THR I03A 141 0 - 100% 63%

TKR I04A 312 9 - 55% 29%

CABG F06A 375 15 – 59% 35%

Tony Ghent, Queensland Blood Mangement Program April 2012

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All Drs 2011 - I04B Knee Replacement W/O C - 1382 Patients (168/1214)

0

10

20

30

40

50

60

70

D55 D

7D

54D

118

D18

D80

D11

2D

115

D15

D52

D79

D28

D47

D60

D37

D24

D44

D11

4D

120

D13

D27 D

5D

59D

98 D1

D86

D29

D57

D21

D82

D12

2D

16D

43D

17D

40D

46D

53D

70D

71D

92D

93D

113

D83

D99

D10 D

2D

22D

25D

36D

123

D12

4D

32D

38D

61D

26D

125

D10

6D

31D

56D

65D

121

D51

D58

D84

D10

4D

23 D9

D10

9D

14D

94D

96D

105

D11

D33

D35

D10

1D

119

D12

D90

D91

D10

7D

4D

45D

62D

69D

81D

85D

108

D30 D

6D

102

D11

0D

111

D11

6D

117

D20 D

3D

39D

48D

66D

68D

76 D8

D95

D97

Doctors

Patie

nts

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

TX. Not TX. % Tx Median 75th Percentile

Tony Ghent, Queensland Blood Management Program April 2012

2011-F06B Coronary Bypass W/O Invas-179 Patients (35/144)

0102030405060708090

E F IHospital

Patie

nts

0%

10%

20%

30%

40%

TX. Not TX. % Tx

2011 - F06B Coronary Bypass W/O Invas - 179 Patients (35/144)

0

5

10

15

20

25

D50

D51

D81

D22

D54

D21

D12

D85

D27

D46

D16

D25

D28

D23

D48

D82

D15

D20

D30

D14

D18

D19

D26

D33

D66

D67

Doctors

Patie

nts

0%10%20%30%40%50%60%70%80%90%100%

TX. Not TX. % Tx Median 75th Percentile

Tony Ghent, Queensland Blood Management Program April 2012

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Current Risk Estimates of transfusion transmitted infections

• HCV 1 : 500,000 – 1,000,000• HIV < 1 : 1,000,000• HBV 1 : 500,000 – 1,000,000• HTLV < 1 : 1,000,000• CMV 1 : 66,000• VCJD Possible, Not reported in Australia• Bacterial Sepsis

– Platelet 1 : 75,000– RBC 1 : 500,000

• Malaria < 1 : 1,000,000

Source: Australian Red Cross Blood Service, June 2011. WWW.ARCBS.com.au

Transfusion Related Adverse EventsAdverse Reaction Risk per Unit Transfused-----------------------------------------------------------------------------------------------Acute haemolytic reactions 1 : 12,000 – 77,000Delayed haemolytic reaction 1 : 4,000 – 9,000TRALI 1 : 5,000 – 190,000Anaphylaxis 1 : 20,000 – 50,000G v H disease RareTACO Up to 1% of Pts transfusedPost-Transfusion Purpura UncommonIncorrect blood component transfused UncommonFebrile transfusion reactions Common------------------------------------------------------------------------------------------------------------Source: Blood component information. Australian Red Cross Blood Servicewww.manual.transfusion.com.au/admin/file/content13/c6/BC1%202009.pdf

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Transfusion Related Adverse Events

• Pneumonia• Sugical site infection• Slow wound healing• Prolonged ventilation• Increased length of ICU stay• Increased length of hospital stay• Increased mortality

Australian Bureau of Statistics 2011, www.abs.gov.au

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Novoseven rVIIa

1 mg $1,1732 mg $2,3475 mg $5,867

Gold 1 oz $ 1,700rFVIIa 1 oz (28.3 g) $ 33.3 M

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NBA Annual Report 2010-11

NBA Annual Report 2010-11

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NBA Annual Report 2010-11

Blood Dilemma

Variations = Inappropriate use

Tx-reactions/adverse events = Unnecessary risk

Supply / Demand gap

↑↑ Costs

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Is there a solution ?

Solution:• Appropriate Transfusion / Education• Transfusion Nurse Scheme• Blood Budget devolution• Haemovigilance• Pre-operative anemia clinics• Higher Standards

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What is appropriate transfusion ?

– Evidence based• Trigers: Hb, APTT, INR, Platelet count ± function, Fibrinogen

• Symptoms• Adverse events

– Disease Process / Co-Morbidities– Alternatives to Transfusion– What is the aim of Transfusion ?

– Treating patient symptoms– Treating patient’s blood results

Transfusion Best Practice• Clinical decisions are rarely simple

• Balance Risks vs Benefits vs Costs

• NBA Patient Blood Management Guidelines aim to improve clinical outcomes by avoiding unnecessary exposure to blood products based on 3 principles:

– Optimisation of blood volume & red cells

– Minimisation of blood loss

– Optimisation of patient’s tolerance of anemia

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www.nba.gov.au

NBA Patient Blood Management Guidelines• Contributors:

– Australasian College for Emergency Medicine– Australian & New Zealand College of Anaesthetists– Australian & New Zealand Intensive Care Society– Australian & New Zealand Society of Blood Transfusion– Australian Orthopaedic Association– Australian Red Cross blood service– College of Intensive Care Medicine of Australia & New Zealand– Haematology Society of Australia & New Zealand– Royal Australian and New Zealand College of Obstetericians & Gynaecologists– Royal Australasian College of Physicians– Royal Australasian College of Surgeons– Royal College of Nursing Australia– Royal College of Pathologists of Australia– Thalassaemia Australia

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NBA Patient Blood Management Guidelines

6 Patient Blood Management Modules

• Critical Bleeding / Massive Transfusion• Perioperative• Medical• Critical Care• Obstetrics• Paediatric / neonatal

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Transfusion nurse scheme

• Role is integral in the safe & effective use of blood & in promoting best transfusion practice by:

– Introducing / promoting national transfusion guidelines– Monitoring current transfusion practice against guidelines– Multi-disciplinary transfusion audits– Providing education for healthcare professionals– Facilitating transfusion reaction incident reporting & follow up– Promoting and ensuring documentation of informed

transfusion consent

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Blood Budget Devolvement

Centrally managed budget model

• Blood is free!• Increased unnecessary risk for patients• Lack of accountability for $$$ spent on

supply of blood• Rising costs of supply of blood

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Blood Budget devolvement ( Cont. )

Blood Budget Devolution model

Price signalling / Gate Keeping

– Quality management processes– Minimising usage inline with best clinical practice

guidelines– Reducing transfusion related adverse events– Minimising wastage resulting from inappropriate

handling & storage of blood– Raising the profile of blood transfusion within the

hospital/HSD– Re-channelling any savings to other areas of service

improvements

HaemovigilanceAustralian National Haemovigilance Program– Haemovigilance Advisory Committee/ NBA

• Development and implementation of national approach to Haemovigilance

• States and territories haemovigilance systems• Transfusion safety & quality for better patient outcomes• Adverse transfusion events:

– Product & patient charactristics– Clerical & procedural errors

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State-wide Haemovigilance SystemQueensland incidents in Transfusion

QiiT2008

Drivers for haemovigilance:

Patient safety & education

National Blood Agreement

Provision of data to national haemovigilance system

NSQHS Standards/ ACSQH

QiiT data set• Febrile non-haemolytic TR• Severe allergic reaction• Anaphylaxis• Incorrect blood component transfused• TACO • TRALI• PTP• TTI• TaGVHD• Acute non-ABO HTR• Delayed HTR• ABO HTR ( Sentinel event )

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• Pre-operative anemia

– Impact on post-operative outcomes

– Management

Society of Thoracic Surgeons Blood Conservation Guideline Task ForceAnn Thorac Surg 2007;83:27-86

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Optimisation of blood Volume & red cell mass

– “High-Risk” Patients– Advanced Age– Preop. Anemia– Small Body Size– Urgency of Operation– Preop. Anticoagulation & Platelet Inhibitors– Congenital or Acquired Coagulopathies– Multiple Co-morbidities– Complexity of Operation– Naturopathic Medications

Ann Thorac Surg 2007; 83:27-86

Age• Reduced Physiologic Reserves• Cardiovascular Diseases• Cerebrovascular Diseases• Neoplastic Diseases• Anemia

– 18% Healthy Octogenerians– 24-53% Inpatient Octogenerians– Inflamatory, Renal Failure, Neoplastic: 1/3– Global Malnutrition: 1/3– Unknown: 1/3

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Studies Highlights• Anemia is common among surgical patients & independently &

significantly associated with increased 30 day adjusted mortality & morbidity

Musallam et al. Lancet 2011;378(15):1396-1407

• Anemia is very common in surgical patients & independently associated with increased mortality

Beattie et al. Anesthesiology 2009;110(3):574-81

• Even mild degrees of preop anemia is associated with increased postop mortality & cardiac events in older patients

Wu et al. JAMA 2007;297(22):2481-8

• Dose-dependent significant increase in adverse outcomes with decreasing Hb levels

• The extent of pre-existing comorbidities substantially affects periop anemia tolerance

Kulier et al. Circulation 2007;116:471-9

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Minimisation of blood lossIntraoperative Surgical blood conservation techniques

– Meticulous Surgical Technique– Intraoperative Autologous Blood Donation– Acute Normovolemic Haemodilution– Cell Salvaging / Autotransfusion– Normothermia (exception: cardiac surgery )– Antifibrinolytics– Controlled Induced Hypotension– Point-of-Care Testing of Coagulation– Biologic Glues & Topical Sealants– Minimized Cardiopulmonary Bypass Circuits– Haemofiltration

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.

©2008 by Lippincott Williams & Wilkins

Thromboelastogram• A point-of-care viscoelastic measure of clot

formation and clot dissolution that measures:– Coagulation– Platelet function– Platelet-fibrinogen interaction– Fibrinolysis

• All in one test!

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Restrictive Blood Transfusion• Anaerobic metabolism Hb < 30 – 45 g/L

Weskopf et al. JAMA 1998;279:217-21Lieberman et al. Anesthesiology 2000;92:40-7-13

• Randomised multicentre controlled prospective study comparing liberal vs restricted transfusion in > 800 ICU patients

– Liberal Tx Hb<100g/L, maintain 100-120 g/L– Restricted Tx Hb<70 g/L, maintain 70-90 g/L

• Conclusion:– No significant Mortality difference– Less ARDS and APO in restricted group– No benefit from liberal transfusion

Herbert et al. N Engl J Med 1999;340:409-17Herbert et al. Crit Care Med 2001;29:227-34

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Restricted Blood Transfusion• TRACS study 2010

– Randomised noninferiority controlled trial– Restricted Tx: 186 Pt. Hct < 24%– Liberal Tx: 195 Pt. Hct < 30%

• Conclusion– Restrictive strategy with one unit at a time is at least as

effective as and possibly superior to liberal transfusion strategy– Transfusion of 5 or more RBC units was associated with higher

mortalityHajjar et al. JAMA 2010;1304(14):1559-67

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NSQHS Std 7 – Blood and Blood Products• Governance and systems

– Safe and appropriate • Prescribing• Clinical use

• Documenting patient information– Transfusion history– Indications for use– Transfusion reactions & related adverse events

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NSQHS Std 7 – Blood and Blood Products• Managing product safety

– Storage and transport– Wastage

• Communicate with patients and carers– Information on risks and benefits– Alternatives to blood products– Informed consent

summary• Appropriate transfusion → Good outcomes

– Education– PBM Guidelines– Transfusion Nurse Scheme– Haemovigilance– Blood Budget Devolution– Higher Standards– Alternatives to Transfusion– Pre-operative Anaemia Management– Single Unit Policy– New Technology