Upload
dhritiman-chakrabarti
View
1.800
Download
16
Tags:
Embed Size (px)
DESCRIPTION
Citation preview
1
Autologous Autologous Blood Donation Blood Donation and transfusionand transfusion
2
What does ‘Autologous Transfusion’ mean?
Autologous transfusion is where the donor and recipient
are the same person.
There are different types of autologous transfusion including:•Preoperative autologous donation (PAD)•Intra-operative cell salvage•Post-operative cell salvage•Acute normovolaemic haemodilution•Directed donation
3
Aims:To demonstrate an awareness of the different techniques available as alternatives to allogeneic blood transfusion and an awareness of their appropriate use.
Objectives:•To develop an awareness of better transfusion
practice.
•Discuss different autologous transfusion techniques available.
•Identify alternative care strategies to avoid the use of allogeneic blood.
•To promote the appropriate and timely use of transfusion alternatives.
4
Although the risks of blood transfusion have been considerably minimised, the
incidents highlighted in the Serious Hazards of Transfusion (SHOT) reports
show the importance of continuing education in the appropriate use of
blood.
TRANSFUSE ONLY WHEN THE BENEFITS OUTWEIGH THE RISKS
5
Good Transfusion Practice - General Considerations
Base practice on transfusion triggers, targets set by local
guidelines, and individual patient assessment
Minimise amount of phlebotomy for
lab samples
Establish target haemoglobin
tolerable to the individual patient
6
Reducing transfusion requirements
Pre-operative procedures include:
Pre-operative surgical assessment units: blood tests should be performed
and reviewed in a timely manner for diagnosis and treatment of anaemia e.g. iron deficiency anaemia. Assessment of
patient’s previous clinical history e.g bleeding disorders.
Assessment of patient’s current medication - where possible plan to stop medications pre-operatively e.g. anti-coagulant / anti-
platelet drugs
Discuss treatment options with patient: this is of particular importance if
the patient has any strong beliefs or thoughts about blood transfusion (not just Jehovah’s Witness patients) - allow plenty
of time to plan for any specific alternatives to transfusion to be
organised.
Maximum Surgical Blood Ordering Schedule: this is a guidance schedule
developed following agreement with surgeons and anaesthetists - it should be
used as a guide/tool to indicate how many units to order for different surgical
procedures - hospital blood banks may question clinicians if a request differs from
the MSBOS.
Plan for possible cell salvage: many hospitals now provide peri or post operative cell salvage - these
techniques can be used in a variety of surgical procedures - individual patients should be assessed for
suitability pre-operatively and options discussed with the patient.
7
Reducing transfusion requirements
Module 4: Alternatives to Allogeneic Blood Transfusion
West Midlands
Intra-operative procedures include:
Careful positioning of the patient during surgery - may help
reduce blood loss by minimising venous congestion in the operating field.
Use of intra-operative cell
salvage
Maintain normothermia
(unless hypothermia is indicated) -
coagulation factors may be less effective
at lower temperatures, increasing the risk of
blood loss.
Preventing hypertension (controlled hypotension) - hypertension may lead to excessive bleeding
NOTE: this is a specialist anaesthetic technique.
Use of fibrin seals / haemostatic agents / drugs to help reduce
surgical bleeding
Appropriate use of surgical
dissecting instruments - some instruments help to
reduce blood loss e.g. diathermy knives,
lasers, ultrasonic scalpel.
8
Advantages1 Prevent transfusion TTDs2 Prevent red cell Allo - immunization3 Supplements the blood supply in BTS4 Provide compatible blood for patient with
Allo-antibodies5 Prevent adverse transfusion reactions6 Provide reassurance to patients concerned
about blood risk7 reduce postoperative risk of bacterial
infection8 reduce risk of cancer recurrence because
the fewer effect of Immuno modulation
9
Disadvantages1 Same risk of bacterial contamination2 Same risk of ABO incompatibility error3 Costlier than allogenic blood 4 Wastage of blood, if not switched over. 5 Chances of unnecessary transfusion 6 Subjects patient prone to perioperative
anemia & increase likelihood of transfusion and side effect of iron supplementation
7 same risk of clerical error8 anxiety to some patient
10
TYPES OF AUTOLOGOUS TRANSFUSION
Preoperative autologous blood donation (PABD)
Acute normovolemic hemodilution (ANH) Intra operative and post operative blood
recovery (blood salvage)
11
Preop. Autologous donation
Inclusion: Stable patients scheduled for surgical procedure in which blood transfusion is likely. Donor Pt. should qualify criteria for blood donation in surgery that bleeding is more than 1000cc.
Necessity:a. Close relation between clinician & blood bank (BB)b. Donor suitability by BB physicianc. Oral Fe one week before & many weeks after
e. at least Hb before operation is 11 * No limit of weight or aheage
12
CANDIDATES FOR P.A.B.D
Stable patients M.S.O.B.S (surgical procedure with blood loss) Major orthopedic procedure Patients with alloantibodies Vascular surgery Thoracic or cardiac surgery Total joint replacement
13
Pre-op Autologous Donation
Contraindications:1 Evidence of infection and risk of bacteremia2 Scheduled surgery to correct aortic stenosis3 Unstable angina4 Active seizure disorder5 Myocardial infarction or CVA accidents in 6 mounth6 Significant cardiac or pulmonary disease7 Cyanotic heart disease8 Uncontrolled hypertension9 Malignant diseases10 high grade main coronary artery disease 11 diarrhea12 dental operation13 skin ulcer14 Antibiotic use
14
Each blood centre or hospital that decides to conduct an autologous blood collection program must have its own policies, processes and procedures
Patient’s physician initiates the request for autologous services, which then is approved by Transfusion Medicine physician after physical evaluation
Patient advised oral supplemental iron from one week before operation
Request by physician should include the patient name, unique identifying number, number of units and kind of component required, date of scheduled surgery, nature of surgical procedure
Pre-op Autologous Donation Procedure
15
Pre-op Autologous Donation Procedure
A sufficient number of units should be drawn to avoid exposure to allogenic blood
In lower than 50 kg (weight*450cc/50)
16
It usually begins 3-5 weeks before scheduled surgery. usually 2-4 units on each occasion ,approximately 500 ml of blood are collected .patient with more than 50 kg body weight usually donate 500 ml of blood in one session .patient with less than 50 kg body weight donate smaller volumes. The volume collected shouldn’t be more than 10% of the patient’s estimated blood volume .
One donation per week is usually scheduled, although more aggressive donation schedules are possible . In theory , donation every 3 days are feasible . The last donation takes place not later than 48-72 hour before surgery . This is to allow for the equilibration of blood volume.
17
New Program
SOPs at each step Testing Protocol: Once in 30 days Separate inventory to avoid mix-ups Separate tags/ green labels to ensure
that the right unit goes to right patient X-match & Issue Discarding unused unit and not used as
allogenic because of different criteria and chances of clerical error
18
Pre-op Autologous Donation Procedure
ABO and Rh typing on labeled samples of patient. Units should have ‘green label’ with patient name
& number & marked ‘FOR AUTOLOGOUS USE ONLY’
Longest possible shelf life for collected units increases flexibility for the patient and allows time for restoration of red cell mass, between collection and surgery.
Special Autologous label may be used with numbering to ensure that oldest units are issued first.
19
PAD Complications
Anemia and hypovolemia vasovagal reaction Venous access Pediatrics- low volume challenges Donor adverse reactions Clerical errors leading to the use of regular
donors before autologous units Over transfusion
20
RISKS OF P.A.B.D
1-Mistake of transfusion 1-Mistake of transfusion 2-Human error (ABO incompatibility) 2-Human error (ABO incompatibility) 3-Bacterial contamination3-Bacterial contamination
21
PABPD CONTRAINDICATION
1-Anemia1-Anemia2-Serious cardiac disease 2-Serious cardiac disease 3-Predisposing to bacteremia 3-Predisposing to bacteremia (e.g. urinary (e.g. urinary catheter or device)catheter or device)4-HBV, HCV, HIV positive4-HBV, HCV, HIV positive
22
SAMPLE OF PROTOCOLS
Select of patient Select of patient Detection of number unitsDetection of number unitsRecommendation to interval collectingRecommendation to interval collectingUse of iron supplementsUse of iron supplementsTransport of unitsTransport of unitsReview of criteria autologousReview of criteria autologousManage of reactionManage of reactionPolicies programPolicies programAdditional informationAdditional information
23
IRON SUPPLEMNTS
Prescription of ironPrescription of ironSuitable dose for decrease GI side effectsSuitable dose for decrease GI side effectsMaybe can not store of ironMaybe can not store of iron
24
Autologous Sticker
25
Acute Normovolemic Hemodilution
Definition:It is the removal whole blood from a patient just before the surgery and transfused immediately after the surgery. It is also known as
‘preoperative hemodilution’.
26
PHYSIOLOGIC CONSIDERATION
Reduction of RBC losses Increase of perfusion’s tissues Improved oxygenation Decrease blood viscosity (The best oxygen delivery Hct 30-35%) Preservation of hemostasis
27
Acute Normovolemic Hemodilution
Properly labeled units are stored at RT for up to 8 hours, unused units must be stored within 8 hours at 1-6 C, outdates in 24h
Re infuse units in reverse order to provide maximum hemostatic functions
ANH is equivalent to PAD in radical prostatectomy, knee and hip replacement
28
CLINICAL STUDIES OF A.N.H
1-A.N.H equivalent to PAD1-A.N.H equivalent to PAD2-Minimized cost2-Minimized cost3-Elimination waste of units3-Elimination waste of units4-No inventory or testing4-No inventory or testing5-Never leaves the patient’s room 5-Never leaves the patient’s room (minimize clerical error &ABO (minimize clerical error &ABO incompatible)incompatible)
29
CRITERIA FOR SELECTION OF A.N.H
1-Likliehood of transfusion exceeds1-Likliehood of transfusion exceeds2-Preoperative Hb at least 12 g/dl2-Preoperative Hb at least 12 g/dl3-Absence of coronary, pulmonary, renal or 3-Absence of coronary, pulmonary, renal or liver diseaseliver disease4-Absence of sever hypertension 4-Absence of sever hypertension 5-Absence of infection & bacteremia5-Absence of infection & bacteremia
30
INDICATIONS FOR A.N.H
Hct>34%Hct>34%Intraoperative blood loss>1 litIntraoperative blood loss>1 litAny type of surgery with significant blood lossAny type of surgery with significant blood lossWhen the blood can be drawn after When the blood can be drawn after aneasthesia and transfusedaneasthesia and transfused
31
CONTRAINDICATION FOR ANH
1-Anemia1-Anemia2-Impaired renal function2-Impaired renal function3-C.A.D, A.S, (no compensatory 3-C.A.D, A.S, (no compensatory mechanism)mechanism)4-Limitation of cardiac or pulmonary 4-Limitation of cardiac or pulmonary functionfunction5-Untreated hypertention5-Untreated hypertention6-Coagulation disorder6-Coagulation disorder
32
PRACTICAL CONSIDERATION
1-ANH related to procedure & volume of 1-ANH related to procedure & volume of blood & target Hct blood & target Hct 2-Documented the manner 2-Documented the manner 3-Exact monitoring 3-Exact monitoring 4-Aseptic collection 4-Aseptic collection 5-Labelling 5-Labelling 6-Storage 6-Storage (room temperature=8h & (room temperature=8h & refrigirator=24h) refrigirator=24h) 7-Increase time staying in the operating 7-Increase time staying in the operating roomroom
33
TYPES OF ANH PROCEDURES
Cardiovascular Vascular Orthopedic Organ transplant Neuro Others
34
WHO IS A CANDIDATE FOR ANH?
Every one Loose >500 ml of the blood Unpredictable blood loss Need for homologous transfusion
35
WHAT ARE CONTRAINDICATIONS FOR
A.N.H? (RELATIVE)
Anemia Hct<28% Hb<10 Impaired renal function Limitation of cardiac, pulmonary function Untreated hypertension Impossible compensatory C.O. Coagulation disorder
36
WHAT ARE THE POST-OP CONCERNS FOLLOWING A.N.H?
1-Fluid overload1-Fluid overload2-High blood loss procedure2-High blood loss procedure3-Excessive hemodilution (diuretics)3-Excessive hemodilution (diuretics)
37
WHAT IS NEEDED FOR A SUCCESSFUL A.N.H PRGRAM?
38
Acute Normovolemic Hemodilution Procedure
Blood collected in ordinary blood bags with 2 phlebotomies & minimum of 2 units are collected
The blood is then stored at room temp. and re-infused in operating room after major blood loss.
Carried out usually by anesthetists in consultation with surgeons.
39
Theme behind: Patient losses diluted blood during surgery and replaced later with autologous blood.
Withdrawal of whole blood and replacement of with crystalloid/ colloid solution decreases arterial O2 content but compensatory hemo-dynamic mechanisms and existence of surplus O2 delivery capacity mechanism make ANH safe.
Acute Normovolemic Hemodilution
Procedure
40
Acute Normovolemic Hemodilution
Procedure Drop in red cell number lowers blood
viscosity, decreasing peripheral resistance and increasing cardiac output.
Administrative costs are minimized and there is no inventory or testing cost
This also eliminates the possibility of administrative or clerical error
Usually employed for procedures with an anticipated blood loss is one liter or more than 20% of blood volume.
41
Acute Normovolemic Hemodilution
Procedure
Decision about ANH should be based on surgical procedure, preoperative blood volume and hematocrit, target hemodilution hematocrit, physiologic variables
Careful monitoring of patient’s circulating volume and perfusion status
Blood must be collected in an aseptic manner
Units must be properly labeled and stored
42
procedure
For first litre compensate with 1 litre colloid after that blood must be compensated with 3 crystalloid.
For every litre of blood we must give 3 litre crystalloid.
43
Before you start you have to calculate how much blood you can safely remove from your patient you may want to use the following equation to calculate the tolerable blood loss.
ABV=EBV * (H0-HT)
(H0+HT)/2Where ABV is the autologous blood volume
to be withdrawn; H0 is the prehemodilution hematocrit(zero time);
HT is the target hemoglobin and EBV is estimated blood volume of patient.
44
AGENTS AFFECT ON WEIGHT
BODY FLUID ADULT MALE
(ml/kg)ADULT FEMALE
(ml/kg)
MUSCULAR 75 70
AVERAGE 70 65
THIN 65 60
OBESE 60 55
45
It is a matter of knowledge and experience to define a
reasonable target hemoglobin : mild (hematiocrit 20-24%) , and profound/server/extreme (hematocrit<20%) .
Some consider a target hematocrit less than 20%, in the absence of hypothermia and cardiopulmonary bypass,too risky, since it is considered to impair oxygen delivery.
46
WHAT ARE THE COMPENSATORY
MECHANISMS WHEN DILUTING THE PATIENT
Increase total & local flow rate Increase extraction of 02
Right shift of 02 diassociative curve
47
Intra-operative Blood Collection
Definition:Whenever there is blood loss and collected inside the body cavity, it
is transfused back to the patient.
48
SAMPLE PROTOCOL Phlebotomy (agreement
with surgeon The units of blood with Storage at room or
refrigerator 1 ml blood 3ml crystalloid
1ml blood 1ml colloid Salvage Transfusion Blood loss-fluid
replacements-U/O
49
Intra-operative Blood Collection
Oxygen transport properties of recovered red cell are equivalent to stored allogenic red cells
Contraindicated when pro-coagulant materials are applied.
Micro aggregate filter(40 micron) are used as recovered blood contain tissue debris, blood clots, bone fragments
50
Intra-operative Blood Collection
Hemolysis of red cells can occur during suctioning from surface (vacuum not more than 150 torr is recommended)
Indications: Blood collected in thoracic or abdominal cavity due to organ rupture or surgical procedures.
Contraindications: Malignant neoplasm, infection and contaminants in operative field.
Blood is defibrinated but it does not coagulate
51
SIDE EFFECTS OF INTRAOPERATIVE RECOVERY
Air embolous Hemolysis Higher plasma free hemoglobin Positive bacterial culture (clinical infection is rare)
52
PRACTICAL CONSIDERATION FOR INTRAOPERATIVE CELL
RECOVERY
Sterile operating field A device for intraoperative blood collection with
0.9% saline Storage (room temperature 4 h after terminating
collection) Transfusion begins 6h of initiating the collection Labeling Stored in the blood bank
53
Intra-Operative Cell Salvage (ICS)
Disadvantages Restricted to operations with high blood loss (>20 % of total blood volume). Cannot be used where wound site has an infection. Not normally used where cancer cells are in the operative field. Not suitable for patients with sickle cell disease. Requires capital outlay and trained operators - needs sufficient suitable operations to be cost effective. Only red cells are returned without platelets or plasma.
Advantages Reduction in allogeneic blood usage. Can be used regardless of patient’s medical fitness. Life saving where there is uncontrolled bleeding. System accepted by some Jehovah’s Witnesses.
54
Intraoperative Blood Collection
Complications are rare but have been reported- DIC, hemolysis due to high pressure suction and mechanical compression in roller pumps
55
Postoperative Blood Collection
Recovery of blood from surgical drain followed by re-infusion with or without processing
Shed blood is collected into sterile canister and re-infused through a micro-aggregate filter
Recovered blood is diluted, partially hemolysed and de-fibrinated and may contain high concentrate of cytokines
Upper limit on the volume(1400 ml) of unprocessed blood can re-infused
56
RECOVERED BLOOD
Dilute Partially hemolyzed Defibrinated High cytokines
57
HARMFUL MATERIAL IN RECOVERED BLOOD
Free Hb RBC Stroma Marrow fat Toxic irritant Tissue or debris Fibrin degradation product Activated coagulation factors Complement
58
Postoperative Blood Collection
Transfusion should be within 6 hours of initiating collection
Infusion of potentially harmful material in recovered blood, free Hb, red cell stroma, marrow, fat, toxic irrigant, tissue debris, fibrin degradation activated coagulation factors and complement
Most common in orthopedic procedures such as hip or knee replacement.
59
Transfusion Algorithm
Avoid Transfusion : medical and surgical Alternatives
replacement fluids: crystalloids and non plasma colloids over plasma
pharmacologic agents to reduce bleeding Autologous donation Minimize exposure to allogeneic transfusion
60
Transfusion Algorithm
It is possible to avoid transfusion ? Medical: Treat underlying cause of asymptomatic
anemias: Nutritional deficiencies-supplements Chronic GI bleeds-medications Renal failure- erythropoietin
61
Transfusion Algorithm Is it possible to avoid transfusion? Surgical: Excellent surgical skill (Factor XIV!=avoid tissue trauma, attention to hemostasis, utilize avascular plane etc) Use of topical hemostatic agents in OR Eg. Fibrin Glue- Fibrin sealant :Tisseel Collagen- platelet adhesion
62
Transfusion Algorithm
When transfusion is deemed necessary, a physician must obtain informed consent from patient.
“Informed Consent to the administration of blood and blood products involves the following: an explanation by the physician in language the patient will understand of the risks and benefits of, and options to, an allogeneic blood transfusion
63
Informed Consent- patient decides
Information provided by physician: 1. product description.
2. Benefit and potential risks. 3. Alternatives if available-including risks and benefits. 4.Risks of refusing transfusion Opportunity for questions and clarification Patient’s documentation of consent or
refusal
64
Transfusion Algorithm
Strategies to minimize exposure to allogeneic transfusion
1. replacement fluids- crystalloids and non plasma colloids
2. pharmacologic agents to reduce bleeding
3. Autologous Transfusion
65
Transfusion Algorithm
Strategies to minimize exposure to allogeneic transfusion
1. replacement fluids- crystalloids and non plasma colloids2. pharmacologic agents to reduce bleeding3. Autologous Transfusion4. Minimize allogeneic donor exposure in
neonatal transfusion
66
Red Cell Transfusion- Is a clinical decision!!!
Tissue oxygenation does NOT depend on hemoglobin concentration alone!
Cardiac performance Pulmonary function O2 Binding Coefficient Demand of Tissue (physical activity)
67
THANKS FOR YOUR ATTENTION