Journal reading

Practice Guidelines for Perioperative Blood ManagementAmerican Society of AnesthesiologistsTask Force on Perioperative Blood Management Anesthesiology V 122 • No 2, Feb., 2015

Present by R1蘇府蔚Instructor : Dr.王審之

Introduction

• Guideline to improve perioperative management – Blood transfusion– Adjuvant therapies.– Reduce adverse outcomes of transfusions,

bleeding, or anemia.• To Update guideline published in 2006– Exclude neonates, infants, <35kg children, patients

not undergoing procedures.

Outline of Guidelines

• I. Patient evaluation• II. Preadmission preparation• III. Preprocedure preparation• IV.

Intraoperative and postoperative management

I. Patient evaluation

1. Review previous medical recordsa) Congenital / acquired diseases ; history of

transfusion reaction.b) E.g. sickle-cell, clotting factor def., hemophilia,

liver disease, hx of thrombotic events

2. Conducting interviewa) Inform risk and benefits of transfusion

3. Review existing laboratory test result4. Order additional lab tests

Risk of transfusion

• Prolonged hospital stay– Infection– Transfusion-related organ damage– Transmission of pathogen–論文內好像有提到這部分，再麻煩您看看是否有遺漏

II. Preadmission preparation

1. Treatment of anemia ?2. Discontinuation of anticoagulants and

antiplatelet ?3. Preadmission autologous blood donation

II.-1. Treatment of anemia

• WHO definition : (g/dl)– 6m-5 y/o : 11 ; 5-12 y/o : 11.5 ; 12-15 y/o : 12– >15 y/o Non-preg. Women : 12 ; Pregnant women :

11g/dl– >15 y/o Men : 13 g/dl

• Treatment : EPO / iron supplement– EPO +/- iron vs. placebo: ↓vol. of trans.(LoE: A1-B)– EPO+ iron vs. EPO alone: insufficient evidence– Iron vs. placebo : equivocal on Hgb level/ vol.

transfusion. (LoE : A2-E)

II.- 2. Discontinuation of anticoagulants and antiplatelet ?

• Stop warfarin LMWH vs. pt. no warfarin : – One observational study : equivocal (LoE: B1-E)

• Stop aspirin vs. continue use : – insufficient evidence

• + Aspirin before op. vs. placebo : equivocal– No difference on peri-op. blood loss, transfusion,

MI, major bleeding (LoE : A2-E, 2 RCTs)

II. Preadmission preparation

1. Treatment of anemia ?a) CKD, Anemia of chronic disease, refusal of transfusion : EPO +/-

iron (but takes weeks, $$)b) Iron-def. anemia : iron supplement (takes time)

2. Discontinuation of anticoagulants and antiplatelet ?a) Consult specialist : stop anticoagulant (e.g. warfarin, anti-Xa) for

elective OP, shift to heparin/LMWHb) Except pt. had PCI stop non-aspirin antiplt. (e.g. clopidogrel,

ticagrelor.) sufficient time before opc) Pt. had PCI + stent : dual anti-plt. 3m for BMS, 1yr for DES

3. Preadmission autologous blood donationa) Offer the opportunity if adequate of time

III. Preprocedure preparation

1. Blood management protocols2. Reversal of anticoagulants3. Antifibrinolytics for prophylaxis of excessive

blood loss4. Acute normovolemic hemodilution (ANH)

III.-1. Blood management protocols

a) Multimodal protocols/algorithmsb) Restrictive vs. Liberal transfusion criteriac) Avoidance of transfusiond) Massive transfusion protocole) Maximal surgical blood order schedules

III.2-Reversal of anticoagulants

a) Preprocedure administration of prothrombin complex concentrates(PCCs)– Observational study : (LoE: B4-E)

Pre-op 4-factor單位是不是有問題 ? PCC : INR↓Thromboembolic event : 0.003% of pts.

b) Administration of FFP– Insufficient study to evaluate impact.

c) Preprocedure administration of vitamin K– Immediately-pre-op Vit. K vs. placebo :

equivocal for transfusion requirement (LoE: B3-E)

III.-3 Antifibrinolytics for prophylaxis of excessive blood loss

• Tranexamic acid– RCTs ( vs. placebo) no dif. in stroke, MI, AKI, mortality (LoE:

A2-B)– Meta-analyses of placebo-controlled RCTs

• Prophylaxis of excessive bleeding ( pre-op +/- intra-op)↓ pt. of transfusion & blood loss & vol. of transfusion (LoE : A1-B )

– Meta-analyses of RCTs • Prophylactic use in THA/TKA, before tourniquet deflation :↓ vol. of blood loss ( LoE : A1-B )

– One RCT : tranexamic acid in cardiac surgery• No efficacy after cardiac surgery and continue to 12H. (LoE : A3-E)

III. Preprocedure preparation1. Blood management protocols

a) No single algorithm can be recommended at this timeb) Restrictive RBC transfusion protocolc) Hgb 6-10g/dl : bleeding condition, volume status, organ ischemia,

cardiopulmonary reserve

2. Reversal of anticoagulantsa) Warfarin urgent reversal : FFP / consult specialist use PCCb) Non-urgent : Vit. K.

3. Antifibrinolytics for prophylaxis of excessive blood lossa) For prophylaxis if undergoing CPBypassb) Consider use in certain Ortho op (e.g. TKA)c) Consider use in liver op / if risk of excessive bleeding

4. Acute normovolemic hemodilution (ANH)a) Major cardiac, orthopedic, thoracic, liver surgery

IV. Intraoperative and postoperative management of blood loss

1. Allogeneic RBC transfusion2. Reinfusion of recovered RBC3. Intraoperative and postoperative monitoring4. Treatment of excessive bleeding

IV.-2. Reinfusion of recovered RBC

• Intraoperative RBC recovery– Meta-analyses of RCTs : Effectively ↓ vol. of

allogeneic blood transfusion ( LoE : A1-B )• Postoperative RBC recovery– RCTs : Major orthopedic surgery

Effectively ↓ frequency of allogeneic blood transfusion ( LoE : A2-B )

IV. -3. Intraoperative and postoperative monitoring

a) Monitoring for blood lossb) Monitoring for perfusion of vital organsc) Monitoring for anemiad) Monitoring for coagulopathye) Monitoring for adverse effects of transfusions

IV.3-b. Monitoring for perfusion of vital organs

• Standard ASA monitoring.• Additional : cerebral oximetry, near infrared

spectroscopy, ABG, mixed-venous saturation.• Insufficient literature to evaluate efficacy

IV.3.-d.Monitoring for coagulopathy

• Portable laser photometer as PoC test for PT/aPTT : good correlation with traditional lab, ↓ time for results ( LoE : B2-B)

• Platelet count test during CPBypass : predict excessive bleeding (Se: 83%, Sp: 58%) LoE : B2

• TEG / ROTEM : single RCT showed equivocal for transfusion requirement (???)

IV.-4. Treatment of excessive bleeding

a) Transfusion of plateletsb) Transfusion of FFPc) Transfusion of cryoprecipitated) Pharmacologic treatment

① Desmopresin② Antifibrinolytics③ Topical hemostatics

e) Prothrombin complex concentratesf) Coagulation factor concerntratesg) Treatment for hypofibrinogenemia

IV.4.-a. Transfusion of platelets

• Insufficient literature to evaluate of platelet transfusion on resolution of coagulopathy.

• Survey response : – obtaining platelet count / function test first.

IV.4.-b. Transfusion of FFP

• ? Blood loss / ? RBC transfused / FFP ? No FFP ? – RCTs inconsistent findings

• Survey response : – obtain coagulation test before FFP transfusion

IV.4.-c. Transfusion of cryoprecipitate

• Intra-op/ post-op. cryoprecipitate to manage coagulopathy : Insufficient literature

• Survey : – fibrinogen level test when excessive bleeding

before cryo. transfusion.

IV. Intraoperative and postoperative management of blood loss

1. Allogeneic RBC transfusiona) Without considering blood storage duration : okb) Leukocyte-reduced: for purpose to↓complication

2. Reinfusion of recovered RBC : intraoperative blood-sparing intervention3. Intraoperatve and postoperative monitoring

a) Visual assessment (drains, suction, sponge) / Vital organs ( standard monitors + PE)

b) May use add. monitor (TEE, Br.oximetry, U/O, ABG, ScvO2)c) If suspect anemia : check EBL/PEd) If suspect coagulopathy : check INR, aPTT, fibrinogen, or TEG/ROTEM, plt count.

4. Treatment of excessive bleedinga) Check plt, plt function, PT/INR, aPTT, fibrinogen before transfusionb) Desmopressin may be use when excessive bleeding and plt dysfunction.c) Consider topical hemostatics , antifibrinolytics, fibrinogen concentrated) PCC may be used with excessive bleeding and INR ↑e) If treatment options exhausted, consider recombinant act. Factor VII.

Difference from current practice

• Emphasis of preop. pts/risks assessment • Use of adjunct medication– Erythropoietin for anemia– PCC for urgent warfarin reversal– Anifibrinolytics for cardiac/high bleeding risk op.

• Advocate the use of transfusion algorithms– Real-time monitoring– Blood ordering schedules– Restrictive transfusion strategies

個人心得• 需要各部門之間整合並有共識• 文章中多處使用籠統與含蓄用語• 考量現實可用之資源，發展新進技術• 可配合輔助藥物減少輸血

Further question/discussion

• Choice of intraoperative lab tests / Monitoring tool ? Target of INR/HgB ?– TEG/ROTEM as monitor tool vs. TEG/ROTEM-based

algorithm : different evidence.– Vital organ monitoring

• Preoperative routine tests for patients with risks of excessive bleeding ?

• Intraoperative use of laser photometry for INR/APTT ? Check fibrinogen/plt (not only ABG?)

• VGHTPE transfusion algorithm ?

THANK YOU FOR YOUR ATTENTION