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Putting it all together- The Role of Patient Blood Management

Putting it all together- The Role of Patient Blood Management. Disclosure. Bradford Ray, RABT Has no real or apparent conflicts of interest to report. In 1998: Allogeneic Blood Transfusion, Hospital Charges and Length of Hospitalization.

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Putting it all together- The Role of Patient Blood Management

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  1. Putting it all together- The Role of Patient Blood Management

  2. Disclosure • Bradford Ray, RABT • Has no real or apparent conflicts of interest to report

  3. In 1998: Allogeneic Blood Transfusion, Hospital Charges and Length of Hospitalization • Negative effects of transfusion have been known for years. • Vamvakas study in 1998 of 487 Colorectal Cancer Resection: • LOS: 16.7 days TX group vs 10.3 days in non-TX group • Charges: $28,101 Transfused vs $15, 978 No Transfusion Arch Pathol Lab Med Vol 122 Feb 1998 p. 145-151

  4. Blood costs continue to rise worldwide Learning from Our Transfusion-Related Data Utilization and Indications • Country> 60 yrsRBC/1000 popTrend • Canada (CBS) 18% 30.7 10.7% ↑ 2001  2006 • France 20% 31.9 7.8% ↑ 2001  2006 • Australia 17% 36.7 2.7% ↑ 2003  2005 • England+Wales 21% 40.9 12.5% ↓ 2001  2005 • Finland 22% 48.9 11.1% ↓ 2001  2006 • US (AABB Report) 17% 49.2 2.7% ↑ 2001  2004 Goldman M et al. Transfusion 2007;47:189-90A. Global Red Cell Utilization Rates: 2008-09 Devine D et al.: Vox Sanguinis 2009

  5. In 2008: Systematic Review of the Literature: RBC transfusion in the Critically ILL • 45 studies including 272,598 patients reviewed. • 42 of 45 studies the Risks of RBC transfusion outweighed the benefits. • 17 of 18 studies demonstrated RBC were an independent predictor of death. (pooled ratio in 12 of these studies was 1.7) • 22 studies examined association between RBC and nosocomial infection, (in all these studies RBC’s was independent risk factor for infection, 1.8) • Risk of multi-organ failure, (3 studies) or Acute Respiratory Distress Syndrome, (6 studies,2.5) • Marik P. Crit Care Med 2008 Vol. 36 p. 2667-2674

  6. In 2008: Intraoperative Transfusion of 1U to 2U RBC’s is Associated with Increased 30-Day Mortality, Surgical Site Infection, Pneumonia & Sepsis in General Surgery • 125,177 General Surgery patients (National Surgical Quality Improvement Program) • 1U RBC’s significantly increased Mortality (OR = 1.32) Morbidity (OR = 1.23) Pneumonia (OR = 1.24) Sepsis/shock (OR = 1.29) • 2U RBC’s, Mortality (OR = 1.38) Morbidity (OR = 1.40) • Pneumonia (OR = 1.25) Sepsis/shock (OR = 1.53) • Conclusion: Intraoperative transfusion of RBC’s increases risk for mortality and several morbidities in general surgery patients. Transfusion for mildly hypovolemic or anemic patients should be discouraged in light of these risks. • Bernard A. J Am Col SurgVol 208 May 2009 p. 931-939

  7. In 2009: Clinical Evidence of blood transfusion effectiveness • Transfusion of RBC is common in critical care medicine; 45% of critically ill patients are transfused during their ICU stay. • Transfusion of RBC’s is intended to improve tissue oxygenation & patient outcome. Whether transfusion actually meets these expectations is difficult to estimate for several reasons; • 1. Individuals can compensate for acute anemia depending on cardiac status. Efficacy only becomes apparent in presence adequate Tx trigger. • 2. Large clinical trials have yielded inconsistent results, increased M&M. • 3. Still a lack of adequate monitoring of tissue oxygenation in clinical practice. Is this a proper indicator for non-invasive hemoglobin monitoring? • Pape A. Blood Transfusion 2009 Oct 7 (4) 250-258

  8. In 2013: Impact of Perioperative Blood Transfusion on Cancer Recurrence and Survival Following Radical Cystectomy • Mayo Clinic reported results of 2060 surgical RC patients • 2 U transfused, (69 yrs≥ , worse Eastern Cooperative Oncology Group Score) • 10.9 yr follow up. Receipt of RBC associated w/ significantly worse 5 yr recurrence free survival (58% vs 64%) • Cancer specific survival (59%vs 72%) • Overall survival (45% vs 63%) • Among patients who received RBC’s, an increasing number of units transfused was independently associated with cancer specific mortality and all cause mortality. • Conclusion; We found that RBC’s is associated with significantly increased risks of cancer recurrence and mortality following Radical Cystectomy. Continued efforts to reduce the use of blood products are warranted. • Linder B. European Urology 63 2013 p. 839-845

  9. How Del Sol Med Ctr Reduced Transfusions

  10. NIH has recognized anemia as a national crisis. Many who present for surgery and/or medical treatment are, by WHO guidelines anemic. Examples; Orthopedic 30-60% Pregnant/Post Partum 20-60% Bariatric 25-50% Irratible Bowel Syndrome 25-50% Congestive Heart Failure 45-75% TherpAdv Gastro 2011 May (4) 177-184

  11. Thromboelastometry Our experience with thromboelastometry has reduced blood utilization significantly. Useful in trauma, cardiac and interventional radiology. Allows surgeons to determine clotting function prior to surgery. Blue top determines clotting profile up to 90% in 10 minutes. Saved $10K on first day of use. Do not just purchase an instrument and pray it will be accepted. Be pro-active in making it an important decision making tool.

  12. Thromboelastrometry Outcomes in Cardiac Surgery • Surgeon 1- 2011 39 cases, 38 Transfused 97.44% 2012 45 cases, 33 Transfused 73.33% 2013 49 cases, 10 Transfused 19.50% • Surgeon 2- 2011 40 cases, 29 Transfused 72.50% 2012 39 cases, 23 Transfused 58.97% 2013 36 cases, 12 Transfused 33.33% • Surgeon 3- 2011 25 cases, 25 Transfused 100% 2012 16 cases, 10 transfused 62.50% 2013 20 cases, 5 transfused 20%

  13. Accuracy of Noninvasive Hemoglobin Monitoring • Published study in Crit Care Med in 2011 compared lab reference valves to Pulse CO- Oximetry • Conclusion: When compared to laboratory reference values, hemoglobin measurement with Pulse CO- Oximetry has absolute accuracy and trending similar to widely used, invasive methods… additional advantage of providing continous measurements noninvasively. • Frasca D. Crit Care Med 2011 Oct;39 (10): 2277-82

  14. Pulse CO-Oximetry based SpHb measurement is accurate within 1.0g/dL compared with laboratory CO-OximetertHb measurement in subjects undergoing hemodilution. AnesthAnalg 2010; 111: 1424-6

  15. SpHb Monitoring Impact on Frequency of RBC Units Transfusions in Lower Blood Loss Surgery • Randomized controlled trial in 327 orthopedic surgery pts, 157-Standard Care & 170-SpHb • * p=0.03 vs. Standard Care Group; • Randomized controlled trial in 327 orthopedic surgery pts, 157-Standard Care & 170-SpHb • * p=0.03 vs. Standard Care Group; • Randomized controlled trial in 327 orthopedic surgery pts, 157-Standard Care & 170-SpHb • Randomized controlled trial in 327 orthopedic surgerypts, 157-Standard Care & 170-SpHb • * p=0.03 vs. Standard Care Group; Ehrenfeld JM et al ASA 2010 LB05 Abstract • ↓87% • Relative Reduction

  16. SpHb Monitoring Impact on Frequency of >3 RBC Unit Transfusions in High Blood Loss Surgery ↓56% Relative Reduction Prospective cohort study in 106 neurosurgery surgery pts, 61 Standard Care & 45 SpHb *p<0.01 vs. Standard Care Group Awada W et al. STA. 2013 (abstract).

  17. SpHb, Dept CO-Oximeter, Hemocue Trend Accuracy vs Lab CO-Oximeter

  18. Transfusion Reduction through Patient Blood Management and Non-Invasive Hemoglobin Monitoring • SABM Mantra has been: • Start with More • Loose Less • Measure what you’ve got • Return what you can

  19. Thank you.

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