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Tags: Haematology

Patient blood management

transfusion

blood conservation strategies

Cell salvage

3 pillars

  1. #Pre-op anaemia management
    • ↓ likelihood of Hb level that would require transfusion
  2. #Minimise intra-op blood loss
    • by optimising surgical + anaes techniques
    • avoiding & treating coagulopathy
  3. #Restrictive transfusion strategy
    • optimising patient's physiological reserve to tolerate anaemia

Pre-op anaemia management

Pre-operative anaemia is a/w ↑ rates of peri-operative morbidity

All patients undergoing surgery where blood loss is likely to be >500 ml, as well as those with a complex medical history undergoing more minor surgery, should have a full blood count (FBC) performed as early as possible in their Peri-operative journey

Minimise intra-op blood loss

#Pre-op
#Intra-op

Pre-op

plan for anti-plt / anticoagulant agents
For emergency surgery urgent reversal of the anticoagulation agents may be necessary

Warfarin can be reversed with 5 mg IV of vitamin K 6–12 hours prior to urgent surgery. If surgery cannot be delayed by 6 hours rapid reversal can be achieved using prothrombin complex concentrate (PCC) at 25–50 IU/kg

For direct oral anticoagulants (DOACs), idarucizumab is licensed for the reversal of dabigatran for urgent or emergency surgery

Andexanet alfa has recently been licenced for the reversal of rivaroxaban and apixaban during life threatening or uncontrolled bleeding, but a discussion with haematology would be prudent

Where time allows for a patient who is on a DOAC, surgery should ideally be delayed

Current guidelines DO NOT support the routine use of PCC for reversal of DOACs, however suggest a pragmatic approach to proceed with surgery and consider PCC in the event of diffuse coagulopathic bleeding

==POISE-2 ==trial found there was ↑ risk of bleeding in non-cardiac surgery when continuing aspirin, with no difference in overall cardiac events post-operatively
In the subset of patients with cardiac stents there was found to be a ↓ in post-operative MI by continuing aspirin

Clopidogrel should be stopped 5 days prior to surgery and ticagrelor 3–5 days

In patients on dual antiplatelet therapy, who are high risk for both thrombosis and surgical bleeding, consider temporarily switching clopidogrel to a short acting glycoprotein IIb/IIIa such as tirofiban

desmopressin may be of benefit to improve platelet function and is recommended in trauma patients taking aspirin

Intra-op

Permissive hypotension in Damage control surgery

avoid lethal diamond

The physiological effects of intrathoracic pressures and positioning on blood loss should also be considered
↑ PEEP may ↓ venous return and result in ↑ venous blood loss
having the operating site above the level of the heart may ↑ venous return, although one must be mindful of the risk of venous air embolism

Fibrinolytics

TXA

Aprotinin

Aprotinin was voluntarily withdrawn from the market in 2007 following the BART study which suggested an ↑ mortality with no reduced bleeding over TXA.
It has now been relicensed for patients undergoing isolated cardiopulmonary bypass graft surgery at high risk of major blood loss.

Intra-op monitoring of coagulation

VHA

Cell salvage

Restrictive transfusion strategy

Stored RBCs have a higher affinity for oxygen and therefore less readily deliver oxygen to tissues; they are less deformable which reduces transit through small capillary beds, and they may contain high concentrations of free haemoglobin

Restrictive transfusion thresholds of 7 g/dL are considered appropriate in most elective clinical settings with a number of studies demonstrating no detriment to outcome when comparing liberal to restrictive transfusion triggers

Tolerance to anaemia

optimizing a patient's physiological tolerance to anaemia

Pre-op

Intra-op

Post-op

References

Patient Blood Management and Perioperative Anaemia

Strategies to Avoid Intra-Operative Blood Transfusion - A&ICM