Week 12 Part 1 - Standard 7 and Patient Blood Management Flashcards
Blood Stewardship Principles put Forward by Standard 7
Informed patient consent
Clinically appropriate blood use
Minimise blood wastage
Adverse event information is collected and managed
Facilities are accredited for quality and safety
Which Products does Standard 7 Cover?
All blood components
- packed RBCs
- fresh frozen plasma (FFP)
- platelets
- cryoprecipitate/CP depleted plasma
Plasma derivatives
- albumin
- immunoglobulins
- clotting factors
Three Pillars of Patient Blood Management (PBM)
Pillar 1
- optimise RBC mass
Pillar 2
- minimise blood loss
Pillar 3
- manage anaemia
Preoperative Planning
Likelihood of surgical blood loss
Likely tolerance of anaemia
Assessment of haemostasis
- family history, platelet count, PT/aPTT
Medications
- anti-platelet/anticoagulant, PPI’s, NSAID’s
Assessment of Hb and iron stores
Intraoperative Considerations - Surgical Techniques that Minimise Blood Loss
Controlled hypotension
Patient positioning to minimise venous/arterial pressure
Avoid hypothermia
Topical sealant (thrombin/fibrinogen/aprotinin)
Intraoperative Considerations - Cell Salvage Pros
Uses patient’s own fresh RBCs
Volume of available blood is proportional to the amount lost
Reduces exposure to allogeneic blood
Acceptable to most patients who refuse allogeneic blood
Intraoperative Considerations - Cell Salvage Cons
Bacterial contamination
Substances used that shouldn’t be infused
Administration of RBCs only
Intraoperative Considerations - Acute Normovolaemic Haemodilution
Blood is collected from patient pre-op in OT
Patient is given crystalloid (e.g. saline) or colloid (e.g. albumin) to maintain BV during surgery
Blood is re-infused as needed
Pros of Acute Normovolaemic Haemodilution
Number of RBCs lost during surgery is decreased because patient blood is diluted
Reduced risk of adverse transfusion event
Retention of plasma and platelets
Intraoperative Considerations - Use of Systemic Tranexamic Acid (TXA)
Lysine analogue that binds to the fibrin binding site of plasminogen
Inhibitor of fibrinolysis = promotes clot formation
Used when significant bleeds are anticipated
Intraoperative Considerations - ROTEM
Rotational Thromboelastometry
Used to guide administration of haemostatic agents
ROTEM Tests - EXTEM
Activator: TF
Measures: extrinsic pathway
ROTEM Tests - INTEM
Activator: ellagic acid
Measures: intrinsic pathway
ROTEM Tests - FIBTEM
Activator: TF + cytochalasin D
Measures: fibronogen contribution to clot firmness
ROTEM Tests - APTEM
Activator: TF + aprotinin
Measures: effect of fibrinolysis
ROTEM - Guiding Blood Product Administration: Tranexamic Acid
Maximum lysis (ML) > 15% in EXTEM and ↓ MCF on FIBTEM
APTEM is performed, results are compared to EXTEM
TXA given if lysis is observed in EXTEM and inhibited in APTEM
ROTEM - Guiding Blood Product Administration: Cryoprecipitate
↓ MCF in EXTEM and FIBTEM
ROTEM - Guiding Blood Product Administration: Platelets
↓ MCF in EXTEM, N MCF in FIBTEM
ROTEM - Guiding Blood Product Administration: FFP
↑ Clotting time (CT) in EXTEM
If there is an ↑ CT in INTEM, HEPTEM is performed
If HEPTEM CT is ↓, administer protamine
If the HEPTEM CT is ↑, give FFP
