How much blood do you need

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How much blood do you need?

• Grand rounds
• John Welch
• 11/30/07

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Case 1

• 54 yo obese woman with hx of CHF admitted with
  DOE and edema.
• BNP 700.
• Prior EF 30. Prior Cath unremarkable.
• WBC 6.5, Hgb 9.5, Plt 250. MCV85. Cr 1.9
• CXR with possible infiltrate.

• SHx notable for being a Jehovahs Witness

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Recommendations

• Continue diuresis
• Check iron, folate, B12, TSH
• Multivitamin /- iron
• Check Epo level
• Consider treating Epo if low
• Treat possible pneumonia
• GI prophylaxis
• Respect patient autonomy

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Acute anemia in baboons
SVR
Cardiac output
oxygen extraction
Wilkerson Surgery 103 665
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Risk of mortality during cardiovascular surgery
correlates with blood loss and pre-op Hgb.
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Preop Hgb and operative mortality during cardiac
surgery.
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Meta-analysis of transfusion triggers in surgery
and critical care
Units transfused
Hct
Carson Transfusion Medicine Review 16(3) 187
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Meta-analysis of transfusion triggers in surgery
and critical care
Cardiac Outcomes
30 day All cause mortality
Carson Transfusion Medicine Review 16(3) 187
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The Blood that really saves
1961
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Parsing Hairs
Prohibited Transfusion of whole blood, red
cells, white cells, platelets or plasma.
Transfusions of pre-operative donated autologous
blood. Not promoted or encouraged Blood
donation, Transfusions of autologous blood part
of a "current therapy". Hemodilution,
Intraoperative blood salvage, Heart-Lung Machine,
Dialysis, Epidural Blood Patch Plasmapheresis,
with plasma substitution Labeling or Tagging of
RBC or WBC Hemoglobin Transplant of solid organs
and bone marrow Fractions from white blood
cells Interferons, Interleukins Fractions from
platelets Platelet factor 4 Fractions from blood
plasma Albumin, Globulins, Clotting factors,
Factor VIII and Factor IX Erythropoietin
(EPO) PolyHeme, Hemopure.

Wikepedia 2007
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Case 2

• 51 year old male presents with new AML
• WBC 3.1, Hgb 6.0, plt 7, 43 Blasts.
• Iron 108, TIBC 254, B12 and folate nl. No active
  bleeding
• Starts induction 73. EF 62.
• Day 2 Intubated. Hgb 4.1.
• Pancuronium.
• 100 FiO2 weaned to 80 after PO2 189.
• Day 4
• Hypothermia
• Bradycardia resolved with epi/atropine
• FiO2 increased to 100
• Cx grows coag negative staph
• Day 5
• HoTN Levo
• Bradycardia -gt asystole

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Tx AML daunorubicin 30 mg/m2 day 1-3,
cytarabine 100 mg/m2 5 days VP16
Amsacrine consolidation APL ATRA daunorubicin
30 mg/m2 cytarabine 100 mg/m2
ATRA, 6-MP, MTX consolidation ALL VCR, DNR, Pred
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• 44 year old woman with accelerated phase CML
  after Hydrea
• Start Epo 3 weeks prior to transplant
• Blood conservation strategies during transplant
• Condition with Fludarabine 40 mg/m2 day -9 to -6
• Busulfan 3.2 mg/kg/day day -5 to -2
• GVHD prophylaxis with Tacrolimus/MTX
• Sibling Allo transplant from sister with
  peripheral stem cell collection

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Mortality following HSCT by pre transplant Hct
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Critical care patients phlebotomy and
transfusion trends
14.6 ml/day x 51 days 744 ml
10 ml waste 5 ml CBC 7 ml CMP 5 mls coags
27 mls
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Bloodless (less blood) approachDont waste
blood!

• pediatric tubes for blood draws,
• decreased frequency (CBC, chemistry) to every
  other day, liver function tests twice weekly,
  PT/PTT once weekly,
• closed system return of the waste blood after
  blood draws,
• gastrointestinal prophylaxis with proton pump
  inhibitor,
• folic acid and iron supplementation daily,
  vitamin K once weekly,
• aminocaproic acid for platelet count below
  30,000/ml.
• oxygen support for Hgb lt 9 g/dl or symptomatic
  anemia
• oral contraceptives prior to starting chemotherapy

Bone Marrow Transplantation (2006) 37, 325327.
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Dont waste energy

• Clear discussion early concerning treatment
  options albumin, cryo, clotting factors, etc.
• Hypothermia and paralytics if intubated
• Arterial line for ABGs
• Good luck

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Other options Polyheme Phase II 1998
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Other options Polyheme phase III

• Polyheme
• Not FDA approved, but may obtain on compassionate
  basis
• Phase III trial complete in acute trauma.
• Supposedly well tolerated (as was phase II)
• Preliminary mortality data
• 13.2 PolyHeme
• 9.6 standard of care
• FDA fast track on hold
• One case of use as bridge to marrow recovery
  after sib allo transplant without significant
  side effects (Compr Ther. 2006 Fall32(3)172-5.)

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For what is a man profited, if he shall gain the
whole world, and lose his own soul?
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Rights and duties