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Blood Products andBloodless MedicineSujani Surakanti MDDuke UniversityHospital Medicine Hematology Medical Oncology. Bloodless Medicine Objection to blood products Religious Personal Challenges with taking blood products. Adverse reactions Allo antibodies Question 1What Blood Products are not acceptable to all Jehovah sWitnesses .A Whole Blood Packed RBCsB Platelets FFPC Cryoprecipitate IVIGD A B and CE A and B. For the Jehovah sThe Annals of Thoracic Surgery 2012 93 19 25DOI 10 1016 j athoracsur 2011 06 ... Copyright 2012 The Society of Thoracic Surgeons Terms and Conditions Blood ComponentSeparation Apheresis for platelets or plasma .Centrifuge Plateld Red RichBlood PlasmCentrifugePlatelet Fresh.Concentrate FrozenCentrifugeCryoprecipitat Components Plasma components. Fresh Frozen Plasma Cellular Cryoprecipitate Cryopoor plasmaComponents Stored plasma. Red Cell Platelets Plasma Derivatives Albumin Granulocytes Immunoglobulin. Coagulation Factors Whole Blood Unit 450ml No functional platelets No labile coagulation factors. Rarely used exception massivetransfusion protocol acute trauma withblood loss Red Cell Concentrates aka Packed Platelets and plasma removed. Unit 200 250ml Hct 60 Stored at 4 C for up to six weeks One unit expected to raise Hgb by 1g dL Hct by 3 in average size adult Packed Red Blood Cells. Indication symptomatic anemia Common triggers Hgb 7 mg dL or symptomatic Hgb 10 mg dL for cardiac or pulmonary disease Hemorrhage with 30 total blood loss. Sickle cell anemia Transfusion or exchange to decrease Hgb S 30 Platelets Random donor 4 6 units of platelets from multiple Apheresis Single donor. Stored at room temperature for up to 5 days Cold storage decreases platelet function Long storage time increases infection risk Raise plate count by 20 000 30 000 L Platelets. Indications decreased platelet count and or function Common triggers Plts 10 000 Plts 20 000 with fever or sepsis Plts 50 000 prior to major surgery. Plts 100 000 prior to neurosurgery or ophthalmologic Active bleeding with known platelet dysfunction Frozen within 8 hours ofcollection at 18 C Stored up to 1 year. Volume 200 ml 1 IU ml of each factor To increase factor levels by 20 30 give 10 to 20 ml kg 4 to 6 Cryoprecipitate. Cold insoluble portion of plasmacontaining high molecular weightglycoproteins Stored at 18 C for 1 year Unit is 25 ml. 150 mg fibrinogen 80 IU of Factor VIII 30 of factor XIII of original plasma 10 units to raise fibrinogen 100 mg dL Cryoprecipitate. Indications decreased or dysfunctional fibrinogen vWF Factor XIII Factor VIII Common triggers Fibrinogen 100 mg dL Dysfibrinogenemia. Factor XIII deficiency Uremic platelet dysfunction with bleeding vWD if DDAVP contraindicated type 2B or type 3 and active Conversation ConservationThe Annals of Thoracic Surgery 2012 93 19 25DOI 10 1016 j athoracsur 2011 06 ... .Copyright 2012 The Society of Thoracic Surgeons Terms and Conditions Blood Conservation Blood conservation may provide particular benefit to Blood refusal patients Patients with sickle cell disease or other hematologic.disorders hemolytic anemia Transplant recipients or patients waiting for transplants Question 2You are the nocturnist called on a 32 yo female patient withvasoocclusive crisis with Hgb SS A page from RN states that the.patient developed a fever to 38 1 hypotensive to 80 50 and severerespiratory distress with RR of 30 min and SPO2 of 81 Before goingto evaluate you review her last progress note Her baseline Hgb runsabout 6 g dL She has ongoing problems with iron deficiency frommenorrhagia from multiple large uterine fibroids Now during this.admission she is actively menstruating Her hemoglobin dropped to 3g dL and she was lethargic and dizzy She was given her 1U RBCearlier today with improvement in symptoms You go evaluate thepatient and her sats continue to drop and her breathing is very labored Question 2 cont .You call an RRT She is intubated What will she need next A Continue Supportive careB DiureticsC RBC exchange.D IV antibiotics Benefits of Transfusion Avoidance Infectious risks TRALI TACO Immune suppression. Administration error transfusion Limited resource Cost of Blood Products Acquisition Costs American RedCross 2016. PRBCs 212 73 Platelet pheresis unit 514 00 FFP 49 98 Cryoprecipitate pool 5 bags Cost of Transfusion. Tasks and resource consumption materials labor third party services capital related to bloodadministration RBC unit costs averaged 761 294 Did not include treatment of complications.associated with transfusion transmissible disease litigation or reimbursement indemnification foradverse eventsShander A et al Transfusion 2010 50 753 765 Restrictive Transfusions.Hebert et al A MC RCT of Transfusion Requirements in CC NEJM No GPS Yet Growing number of BloodlessMedicine and Surgery programsacross the nation. No standard established guidelines Not many studies to inform optimal Common Methods Minimizing lab testing Low volume microtainers for.phlebotomy Tolerating lower Hgb levels Dx and treat anemia and othercytopenias Preoperative. Perform thorough history and physical exam to evaluate forpotential causes of anemia or blood loss Referral back to PCP or GI for colonoscopy if suspected GI bleed iron deficiency Hematology referral for complex anemia hemolysis neutropenia.or thrombocytopenia etc Delay surgery to allow for treatment of anemia Early evaluation Hold anticoagulants appropriately Consultation of cardiologist neurologist as needed. Intraoperative Treatment Surgical techniques Minimally invasive techniques tissue coagulants minimize Ensure maximum hemostasis Perfusion Techniques. RAP smaller circuit volume Normovolemic hemodilution Cell salvage Pharmacotherapy DDAVP Antifibrinolytics etc Minimize crystalloid. Hemodilution of clotting factors NormovolemicHemodilution Cell Saver Question 3.Neurosurgery consulted you for medical co management on a 65 yo male withHTN admitted to undergo elective lumbar spinal fusion He is a Jehovah sWitness His surgery goes well Post op day 2 the patient is hypotensive andmildly dyspneic You note in the Anesthesia log that Factor VIIa was not givenduring the case The OP note says that hemostasis was judiciously.maintained Preadmission testing Hgb was 9 g dL Today Hgb is 5 8 g dL You page the primary team to recommend the following A Reassess your patient and consider taking back to the ORB Call Hematology to get recombinant Factor VIIa approved to give nowC Start IV iron and erythropoeitin.D Check CBC coags and DIC panel q6hours and replete factors accordingly Postoperative Early recognition of surgical bleeding Low tolerance to re operate Labs to recognize and correct coagulopathy point .of care testing ACT inadequate heparin reversal TEG ROTEM Minimize blood draws Minimize myocardial demand Tolerance of anemia. Optimizing Coagulation Assess for coagulopathy early Utilize point of care tests ROTEM By avoiding treating coagulopathy maytransfuse less total products overall. Minimize hemodilution of plateletsand clotting factors For massive transfusion aim for 1 1 1ratio to mimic whole blood Pharmacotherapy. Prevent fibrinolysis improve plateletfunction provide clotting factors PharmacotherapyPreoperative Perioperative IV or oral Iron Tranexamic acid. B12 folate Epsilon aminocaproic acid Recombinant factor VIIa Prothrombin complex If vWD concentrate ex Kcentra . Desmopressin DDAVP cryoprecipitate Calcium optimize ionizedHumate P calcium 1 2 1 3 Hgb based O2 Carriers HBOCs .HBOC 201 hemoglobin glutamer 250 bovine Hemopure Biopure Corporation HBOC 201 Hemopure Carries and off loads oxygen demonstrated efficacy in a variety of animal models. does not require crossmatching stored at room temperature up to 3 years proof of efficacy in clinical trials has been lessconsistent limited intravascular half life generally 1 day. challenging trial design either continued therapy orreplacement with erythrocytes Postpone vs Eliminate Need RCT single blind multinational study Q can HBOC 201 eliminate the need for PRBC transfusion.in adults undergoing elective orthopedic surgery 688 patients mean age 61 with hemoglobinconcentrations 10 5 g dL who required transfusionsrandomized treatment with HBOC 201 or. PRBCs J Trauma 2008 Jun 64 1484 HBOC group loading dose of 65 g of hemoglobin infused in 500 mL equivalent to 1U PRBCs additional doses were administered for up to 6 days to a maximum of 325 g 2500. after which need for additional oxygen carrying capacity was met by transfusion of subsequent transfusions if at least one present P 100 bpm SBP 90 mmHg ECG evidence of myocardial ischemia base deficit 4 acute blood loss 7 mL kg within 2 hours oliguria and significant weakness or dizziness Overall 59 of patients in the HBOC group did not require PRBC transfusion . The HBOC group had significantly higher rates of AEs elevated blood pressure RR 8 5 vs 5 9 per patient cardiac events and strokes RR 0 34 vs 0 25 per patient risk greatest in patients 80 yo had volume overload and were undertreatedJ Trauma 2008 Jun 64 1484. Non surgicalMullon et al NEJM 2000 Because it is in its experimental stages the drug is only available underinvestigational status through the FDA.expanded access program to qualifyingpatients under specific circumstances Touse it U S institutions must get approvalfrom HbO2 Therapeutics the localHuman Safety Institutional Review.Board and the US Food DrugAdministration The institution and thetreating physician must follow a specifictreatment protocol and they mustsubmit an Investigational New Drug form. Question 4Your work day today includes seeing new admits to a rehab center You see a 71 yo femalewith h o ITP s p prednisone in past She was recently given IVIG as an inpatient with goodresponse to her platelet count now about 50K PT and OT consulted and suggested rehabgiven ongoing steroid myopathy and general weakness from prior treatments When you.see her at rehab she is icteric and Hgb is 5 and has dropped by 3 g dL in last 24 hours Platelets are about 40K and she has no active sign of bleeding You arrange for transportto ED with plans for transfusion but in ED she refuses a transfusion and is quitedisagreeable She says she is done with blood products The ED calls you saying theydon t see the point of admission and plan to let her discharge AMA unless rehab will take.her back in this state You state that she should still be admitted You advise the ED to A Review the smear for shistocytes this now looks more like TTPB Send a G6PDC Call the blood bank and see if they carry Hemopure.D Send a Coomb s test and if positive supportive management alone Outcomes of Protocol Driven Care of Critically IllSeverely Anemic Patients for Whom Blood Transfusion IsNot an Option Shander Aryeh Javidroozi Mazyar MD PhD .Gianatiempo Carmine Gandhi Nisha Lui John Califano Frank Kaufman Margit Naqvi Sajjad Syed Faraz Aregbeyen OshuareCritical Care Medicine 44 6 1109 1115 June 2016 DOI 10 1097 CCM 0000000000001599.Figure 2 Mortality rates in propensity score matchedtransfused and bloodless patients according to the lowesthemoglobin Hb level within first 24 hr of ICU admission A and lowest Hb level during ICU stay B In eachcolumn the lower light gray part represents mortality.during ICU stay and the upper dark gray part representsmortality occurring during hospital stay out of ICU Numbers in parentheses are the total number of cases ineach category Star symbol indicates p 0 5 comparingtotal mortality rate between the bloodless and transfused.Copyright by 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health Inc All Rights Reserved 2Question 2. You are the nocturnist, called on a 32 yo female patient with vasoocclusive crisis with Hgb SS. A page from RN states that the patient developed a fever to 38.1, hypotensive to 80/50, and severe respiratory distress with RR of 30/min and SPO2 of 81%.