Patient Blood Management (PBM)

Abteilung für Anästhesiologie und Intensivmedizin, AKH Linz

Patient Blood Management

H. Gombotz


„Patient Blood Management (PBM)“ ist ein multidiziplinäres, evidenzbasiertes

Behandlungsmodell, welches zum Ziel hat, durch optimale Behandlung des

patientInneneigenen Blutvolumens die Verabreichung von Fremdblut- und

Fremdblutprodukten bei akzeptablem Anämierisiko auf ein Minimum zu

reduzieren oder gar zu vermeiden.

Mit dem PBM Konzept können Transfusionen nicht ganz vermieden, aber –

geht man vom derzeitigen Verbrauch aus – deutlich reduziert werden.

Damit werden nicht nur die Nebenwirkungen der Bluttransfusion verhindert,

sondern auch die Risiken einer vorbestehenden oder neu auftretenden

Anämie auf ein Minimum reduziert.

3

Patient blood management

Adamson J.W. New Engl J Med (2008) 358: 1225


To implement this resolution, the WHO Blood Transfusion Safety Programme

(WHO/BTS), in collaboration with Sharjah Blood Transfusion and Research Centre and

the Government of United Arab Emirates (UAE), is planning to organize the

WHO Global Forum for Blood Safety:


on 13-14 March 2011 in Dubai, UAE. The aim of this forum is to provide a mechanism

for information exchange, fostering collaboration, involving international partners in

the implementation of resolution WHA63.R12 on availability, safety and quality of

blood products, particularly on patient blood management system.

Western Australian PBM ProjectRationale for patient blood management

There are compelling reasons for implementing

Patient blood management:

• Blood supply pressures

• Cost of blood

• Transfusion practice variability

• Transfusion safety and effectiveness


Helm et al: Ann Thorac Surgery 98: 65, 125-136

Prä

opera

tiv

• Prophylaktische Gabe von Eisen

• Stimulation der Erythropoiese wenn

notwendig

genaue Überwachung von Blutungen

rasche Korrektur von Gerinnungs-

störungen

rasche Reoperation

Aufrechterhaltung der Normodermie

Retransfusion von Wundblut

Erhöhung und Ausschöpfung der

Anämietoleranz

• Zeitliche Planung des Eingriffes

entsprechend der Optimierung des

Erythrozytenvolumens

Exakte Blutstillung und spezielle

chir. und anästhesiologische

Techniken (minimal invasiv)

Blutsparmethoden

optimales Gerinnungsmanagement


Anämietoleranz

Strenge Indikationsstellung zur

Bluttransfusion

• Anämieerkennung

• Identifizieren der Grunderkrankung

• ev. Zuziehen von Konsiliarärzten

• Behandlung der Grunderkrankung

• Behandlung der Anämie

• NB: eine unbehandelte Anämie stellt

eine Kontraindikation für einen

elektiven Eingriff dar

Abschätzen des Blutungsrisikos

Minimierung des diagnostischen und

interventionellen Blutverlustes

interdisziplinäre Planung des

Eingriffs

...


Anämietoleranz

Intra

opera

tivPosto

pera

tiv

2. SäuleReduktion des Blutverlustes auf

ein Minimum

3. SäuleErhöhung und Ausschöpfung

der Anämietoleranz

1. SäuleOptimierung des


Evaluierung des aktuellen Blutverbrauchs

Bestellpraxis

Erstellung von Richtlinien

Planung des operativen Vorgehens

Re-Evaluierung


Hb g/dL0 4,0 6,0 8,0 10,0 12,0 14,02,0

Clinician‘sTransfusion-Trigger Hb Pre-op Hb

Patient 1

ExpectedNadir HbPatient 1

Blood loss1,800ml

Scenario 1 –

Patient

treated

w/o PBM

Hb g/dL0 4,0 6,0 8,0 10,0 12,0 14,02,0


Pre-op HbPatient 1

Blood loss1,800ml

•Fe•B12

•Folic Acid•ESAs

Clinician‘sTransfusion-Trigger Hb

Scenario 2 –

Patient

treated

w/ PBM

Hb g/dL0 4,0 6,0 8,0 10,0 12,0 14,02,0

© Axel Hofmann Vienna Vifor 09-2010


Pre-op HbPatient 1

Blood loss1,800ml

•Meticulous surgical hemostasis,•Topical hemostatic agents•Systemic hemostatic agents•Anesthesiological

techniques•Normothermia•Induced hypotension•etc.

Blood loss1,000ml


Scenario 2 –

Patient

treated

w/ PBM

Hb g/dL0 4,0 6,0 8,0 10,0 12,0 14,02,0

© Axel Hofmann Vienna Vifor 09-2010


Pre-op HbPatient 1

•Keep pt. normovolemic•FiO2 100%•Minimising metabolicdemand

Blood loss1,000ml


Scenario 2 –

Patient

treated

w/ PBM

Implementing PBM

Predictors of Transfusion

• Type of surgery/surgeon

• Baseline hemoglobin and RBC mass

• Actual blood loss

• Co-morbidities

• Tolerable blood loss and transfusion trigger

(individual)

ESTIMATED AND CALCULATED BLOOD LOSS IN DIFFERENT TYPES OF SURGERY

Hip Knee Spine General CAGB Urologic





• Co-morbidities


(individual)

Red blood cell (RBC) mass versus transfusion rate

Moskowitz et al: Ann Thorac Surg 2004;77:626 –34

Measures to optimize the use of blood components in selected surgical procedures in Austrian hospitals

Predictors of RBC transfusions

Procedure THR TKR CABG

IndependentVariable

Odds ratio(95% CI)

Odds ratio(95% CI)

Odds ratio(95% CI)

Hemoglobin preop.(%)*

0.65 (0.60;0.70) 0.68 (0.63;0.73) 0.69 (0.63;0.75)

Min. hemoglobin postop. (%)*

1.50 (1.38;1.64) 1.48 (1.35;1.63) 1.52 (1.36;1.70)

Lost RBC -volume (%) **

1.82 (1.64;2.01) 1.81 (1.62;2.02) 1.81 (1.58;2.07)

Center rank‡ 1.34 (1.24;1.46) 1.35 (1.25;1.46) -

Correctly classified (%)

97.4% 97.2% 97.0%

* Percentage of WHO cut-off values** Percentage of the preoperatively circulating RBC volume

‡ Centers ranked according to the mean perioperative RBC lossGombotz et al: TRANSFUSION 2007;47:1468-1480.





• Co-morbidities

• Tolerable blood loss ând transfusion trigger

(individual)

A standardized method for calculating blood loss

Brecher et al: Transfusion 37, 1070, 1997

The influence of baseline hb concentration on toleranceof anemia in cardiac surgery

Karkouti et al: TRANSFUSION 2008;48:666-672.

The relationship between maximum decrease in Hb

concentrationand adverse outcomes was independently associated

with increased risk!!





• Co-morbidities


(individual)

Comorbidities of Anemic Patients

Beattie et al. Anesthesiology 2009; 110:574–81

Risk for perioperative myocardial

infarction and mortality in

patients undergoing hip or knee

arthroplasty: the role of anemia

Mantilla et al: TRANSFUSION 51, 82-91 :2011

Type of surgery (surgeon) and baseline hemoglobin

Sex, body weight, BMI

Baseline RBC mass, expected blood loss

Individual transfusion trigger and comorbidities

Probability of Transfusion

70-80% (estimated)

+

+

+

MercurialiAlgorithm

Calculation of RBC mass to be transfused or generated

Transfusion Algorithm(Mercuriali F., Inghilleri G.: Curr. Med. Res. Opin. 13, 465-478, 1996)

Transfusion needs = Predicted RBC loss - tolerable RBC loss

Predicted RBC loss = C-RBC-Vpreop - C-RBC-VPOD5 + RBC transfused

Tolerable blood loss = (PBVx hctbaseline) - (PBV x hctmin. acc)

Tolerable Blood Loss

SurgicalBlood Loss

Transfusion Requirement

Predictability of Patient Specific Transfusion Requirements

ROC Curve of ATR ROC Curve of baseline hct

ROC = Receiver Operating Characteristics

Hackl et al: EJA , 20, Suppl 30, A-303, 2003

Components of PBM

Evaluation of the actual blood usage (data management)

Optimising blood ordering schedules

Increasing tolerance of anemia

3 pillar strategy

– Optimising preoperative red cell mass

– Minimising perioperative blood loss

– Reducing transfusion trigger

Total units transfused per month

682

601 606

1065

969 980

360381

425

271249

272

90 109 102

186 184 166

0

200

400

600

800

1000

1200

Jun.05 Jul.05 Aug.05

RBC Site 1 RBC Site 2 FFP Site 1 FFP Site 2 Plts Site 1 Plts Site 2

Data Management

Components of PBM




3 pillar strategy




Measures to optimize the use of blood components in selected surgical procedures in Austrian hospitals

Ordered and not transfused(61%)

Ordered and transfused(28%)

Not ordered and transfused(11%)

Preoperative blood request

C/TR ratio 2,2 : 1

MSBOSMaximum Blood Ordering Schedule

Authors Type of surgery CTR before CTR after

Rogers et al. 2006 Orthopedics 3.21 : 1 1.62 : 1

Mehra et al. 2004 Knee replacement 4.90 : 1 1.70 : 1

Foley et al. 2003 Gynecology 2.25 : 1 1.71 : 1

Richardson et al. 1998 Various 1.80 : 1 1.80 : 1

1.7: 1 = reduction of ....€

Single RBC unit txns vs total units txd

Example from EMMC USA

Data Management

Components of PBM




• 3 pillar strategy




Prä

opera

tiv



notwendig



störungen

rasche Reoperation




Anämietoleranz







Blutsparmethoden



Anämietoleranz


Bluttransfusion













Eingriffs

...


Anämietoleranz

Intra

opera

tivPosto

pera

tiv


ein Minimum


der Anämietoleranz




Bestellpraxis



Re-Evaluierung


Transfusion Needs

Patients for elective surgery should present at the preoperative ambulance as soon a possible (4 weeks before their surgery).

PBM PLANNING

Präop. Aufklärung AKH Linz

"Sollten Sie unter Anämie leiden, weisen wir Sie darauf hin,

dass eine präoperative Anämiebehandlung diverse Risiken,

die mit der Operation verbunden sind (z.B erhöhte

Transfusionsrate, erhöhte Infektionsrate und Infarktrate und

damit verbunden ein längerer Krankenhausaufenthalt),

wesentlich reduzieren würden. Aus diesem Grund empfehlen

wir bei allen elektiven, also nicht ganz dringlichen Eingriffen

eine entsprechende Behandlung."

Hgb < 120 g/L for femalesHgb < 130 g/L for males

ferritin < 30 mcg/L and/or TSAT < 15-

20%

ferritin 30-70 mcg/Land/or TSAT > 20%

Normal

Ferritin? TSAT?

Serum creatinineGFR

Anemia of chronic disease

Low Vitamin B12

and/or folic acid

ferritin > 70 mcg/Land/or TSAT > 20%

NormalChronic kidney disease (CKD)

Low

R/O iron deficiency

Inflammation/ chronic disease

Iron deficiency Referral to

gastroenterologist to R/O malignancy

Folic acid and/orVitamin B12 therapyESA TherapyIron Therapy

1 – Oral iron in divided doses2 – IV iron in divided doses

if patient cannot tolerate oral iron,intestinal absorption problems, or

short timeline

Refer to nephrologist

No response

No action required

Evaluation necessary

Goodnough et al: Nata guidelines, BJA in print

Empfehlungen II

Circulation 2005;112;1681-1683

Prä

opera

tiv



notwendig



störungen

rasche Reoperation

Aufrechterhaltung der Normothermie



Anämietoleranz







Blutsparmethoden



Anämietoleranz


Bluttransfusion













Eingriffs

...


Anämietoleranz

Intra

opera

tivPosto

pera

tiv


ein Minimum


der Anämietoleranz




Bestellpraxis



Re-Evaluierung


General standards and advanced measures

Modify Surgery??

Up to 50% reduction of blood loss!!!

Management of mini-cardiopulmonary bypass devices: is it worth the energy?

Ranucci et al: Current Opinion in Anaesthesiology 2009, 22:78–83

Tranexamic Acid and Aprotinin in Primary Cardiac Operations: An Analysis of 220 Cardiac Surgical Patients Treated with

Tranexamic Acid or Aprotinin

Incidence of allogeneic red blood cell transfusion and 24 h drainage loss.

Dietrich et al: Anesth Analg 2008;107:1469 –78)

A Randomized Controlled Trial of Cell Salvage in Routine Cardiac Surgery

Klein et al: Anesth Analg 2008;107:1487–95)

Modified ultrafiltration after cardiopulmonary bypass is associated with a lower prevalence of early morbidity and lower blood transfusion requirements. The impact on length of hospital stay needs further analysis.Routine application of modified ultrafiltration after adult cardiac operations is warranted.

Rotem®

basierter Algorithmus

Jambor C.Management des massiven peri-operativen Blut-Verlusts. InFrietsch T, Weiler-Lorentz A.2009

Prä

opera

tiv



notwendig



störungen

rasche Reoperation




Anämietoleranz







Blutsparmethoden



Anämietoleranz


Bluttransfusion













Eingriffs

...


Anämietoleranz

Intra

opera

tivPosto

pera

tiv


ein Minimum


der Anämietoleranz




Bestellpraxis



Re-Evaluierung


Relation of VO2/DO2

DO2 (Whole Body)

VO

2(w

ho

le B

od

y)

VO2 vs DO2Dependency

VO2 vs DO2Independency

VO2 vs DO2Dependency

Critical DO2

Dysoxia-Hibernation Steady State Metabolic Activity

Difficult to detect!!

Perioperative myocardial ischemic episodes are related to hematocrit level in patients undergoing radical prostatectomy

<28% >28% <28%+T >28%+T <28% >28% <28%+T >28%+T0%

10%

20%

30%

40%

intraoperative postoperative

Pts

. wit

h is

che

mia

(%

)

Hogue et al.: Transfusion 38:924-931, 1998

Recommendations Regarding Indications for RBC Transfusion in the General Critically Ill Patient (1)

1. RBC transfusion is indicated for patients with evidence of hemorrhagic shock. (Level 1)

2. RBC transfusion may be indicated for patients with evidence of acute hemorrhage and hemodynamic instability or inadequate oxygen delivery. (Level 1)

3. A “restrictive” strategy of RBC transfusion (transfuse when Hb 7 g/dL) is as effective as a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients with hemodynamicallystable anemia, except possibly in patients with acute myocardial ischemia. (Level 1)

4. The use of only Hb level as a “trigger” for transfusion should be avoided. Decision for RBC transfusion should be based on an individual patient’s intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters. (Level 2)

5. In the absence of acute hemorrhage RBC, transfusion should be given as single units. (Level 2)

6. Consider transfusion if Hb 7g/dL in critically ill patients requiring mechanical ventilation (MV). There is no benefit of a “liberal”transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients requiring MV. (Level 2)

Napolitano et al: Crit Care Med 2009; 37:3124 –3157

Recommendations Regarding Indications for RBC Transfusion in the General Critically Ill Patient (2)

7. Consider transfusion if Hb 7 g/dL in resuscitated critically ill trauma patients. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in resuscitated critically ill trauma patients. (Level 2)

8. Consider transfusion if Hb 7 g/dL in critically ill patients with stable cardiac disease. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients with stable cardiac disease. (Level 2)

9. RBC transfusion should not be considered as an absolute method to improve tissue oxygen consumption in critically ill patients. (Level 2)

10. RBC transfusion may be beneficial in patients with acute coronary syndromes (ACS) who are anemic (Hb 8 g/dL) on hospital admission. (Level 3)

Napolitano et al: Crit Care Med 2009; 37:3124 –3157

Transfusion thresholds and other strategies for guiding

allogeneic red blood cell transfusion

• Restrictive transfusion strategies reduced the risk of receiving a red

blood cell (RBC) transfusion by a relative 42%. This equates to an

average absolute risk reduction (ARR) of 40%.

• The volume of RBCs transfused was reduced on average by 0.93 units.

• However, heterogeneity between these trials was statistically

significant (p<0.00001) for these outcomes.

• Mortality, rates of cardiac events, morbidity, and length of hospital stay

were unaffected. Trials were of poor methodological quality.

Hill SR, et al: The Cochrane Library, Issue 4, 2003.

0

10

20

30

40

50

60

70

80

90

100

1

% patients transfused

Baseline (2003)

Evaluation (2003)

Guidelines (2004)

Individual approach (2004-2005)

Plus preop treatment (2005)

Goal

Gombotz H. et al. Unpublished data.

AKH Linz Experience

Primary Hip and Knee Replacement

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

50,0%

69,5%

22,4%

26,6%

8,0%

15,9%

3,2%4,3%

U.S. Multi-CenterReports

EHMC

0,00%

0,50%

1,00%

1,50%

2,00%

2,50%

3,00%

3,50%

4,00%

2,89%

3,54%

2,48%

1,23%

Expected Mortality

Actual Mortality

Retrospektiver Vergleich bei anämischen PatientInnen mit einseitigem Hüftgelenksersatz

%

Unpublished data.

n = 2x50 Patientinnen

0

1

2

3

4

5

0 2 4 6

Hb

-An

stie

g (g

/dL)

Behandlungszeit (Wochen)

Hb-Anstieg vs. Behandlungszeit

Retrospektiver Vergleich bei anämischen PatientInnen mit einseitigem Hüftgelenksersatz

0

10

20

30

40

50

60

70

80

90

100

PBM ohne PBM

%

Unpublished data.

n = 2x50 Patientinnen

Study evaluating PBM Outcomes

Compared a cohort of 586 pts undergoing

isolated CABG at an institution with a

developed PBM Program (PBMP) with a

propensity-score matched cohort of 586

pts from institutions without a PBMP

Isolated CABG includes elective & urgent and primary & redo procedures


PBM strategies used:

1. Preop haemoglobin optimisation

2. Intraop ANH and Intra & Postop cell salvage

3. Meticulous surgical technique

4. Endovascular vein harvesting

5. Point-of-care coagulation testing

6. Targeted haemostatic therapy

7. Tolerance of perioperative anaemia (60 – 70 g/L depending on patient-specific physiology)


CABG Outcomes PBMP vs Non-PBMP

Outcome PBMP cohort (n=586)

Non-PBMP cohort (n=586)

P-value

% Transfused 10.6% 42.5% <0.0001

Mortality 0.8% 2.5% 0.02

Serious complication 11.1% 18.7% 0.0002

Moskowitz et al. TheThe impact of blood conservation on outcomes in cardiac surgery: is it safe and effective?

Ann Thorac Surg 2010;90:451-9


Postgraduate Hochschulkurs Universität GRAZ

Dauer: 3 Semester einschließlich PBM-Project

Kosten: 20 Ek‘s pro Semester u. Teilnehmer

Leiter: Gombotz, Kurz, Lanzer

Beginn: Herbst 2011

Patient Blood Management (PBM)

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