Strategies to Optimise Blood Use

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Strategies to Optimise Blood Use Dr Mickey
Koh Deputy Director Centre for Transfusion
Medicine Consultant Haematologist Stem Cell
Transplant Programme Singapore General Hospital
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Optimise Blood Use, Not Reduce

• Appropriate Clinical Use of Blood
• Main aim for Transfusionists Optimal Use of
  Blood Products rather than merely reducing blood
  usage
• Minimally Invasive Surgery vs Complex Ones that
  require blood support
• Clinical Transfusion Medicine

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Why The Need For Clinical Guidelines

• Blood and blood components are a precious,
  limited resource- SUPPLY
• SAFETY of Blood- No blood is completely safe
• Is the blood transfusion required?- INDICATION
• Adverse and Immunomodulatory effects of blood
  transfusion- EFFECT
• first do no harm
• reduce allogeneic blood exposure

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EVIDENCE BASED MEDICINE

• Evidence based medicine is the conscientious,
  explicit and judicious use of current best
  evidence in making decisions about the care of
  individual patients. This practice means
  integrating individual clinical experience with
  the best available external clinical evidence
  from systematic research
• Sackett et al., BMJ, 1996, 312, pp.72-3

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EVIDENCE BASED HEALTHCARE

• Evidence-based healthcare is the conscientious
  use of current best evidence in making decisions
  about the care of individual patients or the
  delivery of health services. Current best
  evidence is up-to-date information from relevant,
  valid research about the effects of different
  forms of health care, the potential for harm from
  exposure to particular agents, the accuracy of
  diagnostic tests, and the predictive power of
  prognostic factors
• National Institute of Public Health, Oslo,
  Norway, 1996

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INTERNATIONAL CONSENSUS GUIDELINES

• American Society of Anesthesiologists
  Anesthesiology 1996, 84 732-747
• British Committee for Standards in Haematology
  British Journal of Haematology 2001, 113 24-31
• Canadian Medical Association
  Canadian Medical Assoc Journal 1997, 156 (11
  Suppl) S1
• Clinical Practice Guidelines Use of Blood and
  Blood Products. Consultation draft April 2001 by
  National Health and Medical Research Council
  (NHMRC) and the Australasian Society of Blood
  Transfusion

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LOCAL CONSENSUS GUIDELINES

• Adapted from international guidelines
• Modified for local use
• Working Group Haematologists, Transfusion
  Specialists. Endorsed by Surgeons, Physicians,
  Anaesthetists
• Assist the physician in deciding the appropriate
  clinical situations where blood component support
  is deemed necessary
• Not didactic. Aid in decision making not to
  restrict individual clinical judgement

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UNIQUE TO LOCAL SCENARIO

• Haemaglobinopathies Sickle Cell Anaemia a
  problem in certain countries Locally Thalassemia
• Rhesus positive and negative blood is an issue
  due to multi-ethnicity
• What are your urgent needs and your national
  priorities?
• Hospital guidelines vs regional guidelines vs
  national guidelines.

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GUIDELINES VEIN TO VEIN

• Guidelines should exist from the phlebotomy of
  blood to the bedside administration of blood
  products.
• GMP/ ISO. The entire process of blood and
  component processing is under tight quality
  control.
• Loose cannons are the CLINICIANS!
• How do we rein them in?
• Clinicians as GODS vs Sympathetic Clinicians
• Haematologists. Surgeon who understands

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How EBM works

• Hebert P C et al. A multicenter, randomised,
  controlled clinical trial of transfusion
  requirements in critical care. The New England
  Journal of Medicine 1999, 340(6) 409-417
• ICU patients. Transfused at Hblt7 g/dl (liberal)
  or at Hblt 10 g/dl (conservative)
• No difference in mortality.
• Other comparative studies End result may be
  difficult to intepret.
• Blood transfusion only one modality of treatment.

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RBC TRANSFUSION GUIDELINES

• There is no fixed transfusion trigger
• When Hb gt10g/dL - very little indication for red
  cell transfusion
• When Hb lt7g/dL - red cells transfusion probably
  beneficial but not always required
• When Hb is between 7-10g/dL - transfusion guided
  by the clinical signs and symptoms, coexisting
  medical problems and other risk factors (e.g.
  cardiovascular disease, respiratory disease etc)

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Red Cell Transfusion in the Peri-operative
setting

• Autologous blood donation should be considered
  where indicated
• Correction of haemoglobin before surgery with
  measures other than red cell transfusion (e.g.
  iron replacement or erythropoietin) should be
  considered where appropriate.
• Blood conseravtion strategies actively promoted
• Pre-operative transfusion is rarely required when
  Hb gt 10g/dL, frequently required when Hb lt 7g/dL
• Management of peri-operative bleeding - as for
  acute blood loss

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Red Cell Transfusion for Chronic Anaemias

• Transfuse to maintain Hb just below lowest
  concentration which is asymptomatic
• The cause of anaemia should be established
• Other pharmacological agents (iron, vitamin B12,
  folate) should be used when indicated to correct
  anaemia in order to reduce patientss exposure to
  allogeneic transfusion
• Erythropoietin should be considered when it is
  indicated, e.g. chronic renal failure, anaemia of
  chronic illness
• ?Phenotype matched blood

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Massive Transfusion

• Not about replacement of blood only
• Coagulation factors, acidosis etc

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PLATELET TRANSFUSION GUIDELINES

• When platelet counts is lt 10,000/?L in patients
  with impaired bone marrow function with no other
  risk factors
• When platelet count is lt 20,000/?L in patients
  with impaired bone marrow function with other
  risk factors (e.g. sepsis, rapid fall of platelet
  count or coagulation abnormalities or dengue)
• For patients undergoing surgery or invasive
  procedures if platelet count lt 50,000/?L with no
  other coagulopathies
• Neurosurgical procedures may benefit from higher
  prophylactic platelet transfusion threshold
  (100,000/?L)
• For patients with platelet count lt 50,000/?L in
  massive blood transfusion (usually gt1.5BV).
• In patients with a) significant bleeding and b)
  platelet count lt 50,000/?L or qualitative
  platelet dysfunction.

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MAXIMUM SURGICAL BLOOD ORDER SCHEDULE (MSBOS)

• MSBOS widely used to improve blood ordering
  practices and prevent inventory outdating. Local
  transfusion committees from each hospital should
  review their own blood usage practices and
  establish a schedule agreeable by both hospital
  physicians and the blood provider.
• Surgeries lt 30 likelihood of requiring blood
  transfusion no crossmatch done. A type and
  screen approach more appropriate where the blood
  group of the patients are determined and their
  serum screened for antibodies prior to the
  surgeries. A properly developed MSBOS should have
  a crossmatch and transfusion ratio (CT ratio) of
  less than 21. To be reviewed every year.

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Clinical Services

• Clinical consultation
• to clinical colleagues on management of patients
  requiring blood/component therapy, including
  management of complications (DIC, perisurgical)
• professional advice to hospitals and overseas
  blood banks on matters related to transfusion
  medicine and blood safety issues
• work with the haematologists, hospital blood
  banks and the Hospital Transfusion Committees
• Strengthen the clinical transfusion interface
• training of medical officers, haematology
  trainees and nurses
• Evidence based medicine

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Role of Clinicians

• Clinician within the Blood Service
• Hospital clinicians who are end users
• How do we define and refine this clinical
  interface?

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Strengthening the Clinical Transfusion Interface

• working with other clinical disciplines on
  management pathways management of post partum
  haemorrhage, DIC etc
• Development of clinical guidelines
• Joint clinical appointments in hospital and blood
  bank
• encourage doctors, hospital blood banks to speak
  to transfusion specialist if in doubt
• Clinicians must shift their perception of the
  blood bank as mere supplier of products to role
  player in the management of their patients
• Accreditated training

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Hospital Transfusion CommitteesTerms of Reference

• Promote best practice through local protocols
  based on national guidelines-vein to vein
• Carry out multi-disciplinary audits on
  transfusion practice and make this known to
  hospital staff
• Investigate the undesirable effects of
  transfusion and, where necessary, institute
  corrective measures
• Assist the Centre for Transfusion Medicine in
  blood procurement efforts
• Promote continuing education in transfusion
  medicine for the hospital staff.
• Have the authority toimprove existing
  protocolsogue You dont have to do this alone.
  Involve the end users. Share the reponsibilities
  and involve them as users of blood products

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Thank you