Anesthesiology. Goodhough LT, Shander A. 2012 June;116(6):1367-1376. Patient Blood Management
It is
the collaboration of a multidisciplinary team consisting of transfusion
medicine specialists, surgeons, anesthesiologists, and critical care specialist
to optimize the appropriate use of blood and blood components for patients when
needed. Multiple steps are outlined to guide clinicians the decision to transfuse
keeping in mind the risks of exposing the patient to known blood risks, unknown
blood risks, preservation of the national blood inventory, and constraints from
escalating costs. The multimodal decision to transfuse are based on, but not
limited to, 1) appropriate anemia management and work-up in the pre operative
setting; 2) blood availability and compatibility testing; 3) blood
administration and documentation; 4) alternatives to allogeneic blood; and 5)
indications for blood transfusion.
A
thorough anemia workup must be complete before (at least 30days) scheduled
elective surgery. Anemia can be due to iron deficiency secondary to occult
blood loss or malignancy, chronic inflammation, chronic kidney disease, Vitamin
B12/Folic acid deficiency.
If the
patient is suspected to undergo transfusion, preparation must include a
completed type and screen/cross. To ensure availability of the blood products,
clinicians should confirm that the appropriate blood work is completed before
proceeding to the operating room.
In order
to decrease error of blood product administration, blood products must have a
patient identification with transfusion order confirmed, date and time of
transfusion, and vitals before and after transfusion.
To help
with decreasing the introduction of allogeneic blood, autologous transfusions
are a good option for patients, but not without risks. In preoperative
autologous donation, patients donate their own blood over a period of weeks,
but risks include acquired storage lesions, depletion of 2,3-DPG, and impaired
ability for erythrocytes to unload oxygen to tissues. Acute normovolemic
hemodilution allows preoperative dilution of blood loss, most effective in
procedures with large blood loss, but efficacy on its use is mixed due to low
acceptance secondary to the lack of standardized protocols, variations in
target hemoglobin, types of fluids used, heterogeneity in surgical blood losses
by procedure, and patient selection criteria. Lastly cell salvage helps with
the reduction of allogeneic blood transfusions but can increase loss of
platelets and plasma in washed blood leading to dilutional coagulopathy or
thrombocytopenia, and is a relative contraindication in patients with cancer or
obstetric/bowel surgeries involving contamination.
Consensus
for blood transfusion has been debated, using hemoglobin levels as a threshold.
Generally,
transfusion is not of benefit when hemoglobin is greater than 10 g/dl, and are
beneficial when less than 6 g/dl. Multiple trials show that patients can
tolerate hemoglobin between 7 and 8 g/dl, with equivalent clinical outcomes,
and a higher threshold for elderly patients with coronary risks undergoing surgery
with anticipated blood loss.
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