Transfusion Medicine Updates & Considerations
(Optimize & Protocolize)Michelle Zeller MD FRCPC MHPE DRCPSC
McMaster University & Canadian Blood ServicesSept 21, 2019
DisclosuresØ Pfizer Advisory BoardØ Research funding through Canadian Blood Services
Disclosures
Learning Objectives
• Review principles of Patient Blood Management (PBM)• Apply strategies for implementing PBM
– Hemoglobin optimization– Restrictive use of red blood cell transfusion
• Review principles of Massive Hemorrhage Protocol (MHP)• Recognize challenges & benefits of implementation
PATIENT BLOOD MANAGEMENT (PBM)Part One
Optimize Optimize Optimize! Don’t Give TOO Much (Make your own)!!
• Definition:– Patient blood management (PBM) is an evidence-based, multidisciplinary
approach to optimizing the care of patients who might need transfusion (AABB Definition)
• Effective PBM requires:– Multi-disciplinary approach– Appropriate transfusion indications
• Minimize blood loss• Optimize patient red cell mass
• Promotes judicious use of blood products to optimize patient outcomes and decrease adverse events.
Pre-op Peri-op Post-op
Society for the Advancement of Blood Management (SABM) 2014; Meybohmet al. Perioperative Medicine (2017) 6:5
Patient Blood Management (PBM)
Any patient who might need a transfusion
Four Principles of PBM
1. Anemia management/Optimize hemoglobin 2. Minimize blood loss/Optimize coagulation3. Limit transfusion/Blood conservation
strategies4. Patient-centered decision
Shander et al. Anesthesia & Analgesia Oct 2016 • Vol 123 (4)
Why Reduce Blood Utilization?• Hives (1 in 100)• Fever (1 in 300*RBC) (1 in 20*Plt)• Volume overload (1 in 100)
Most Common
• ABO Incompatible (1 in 40 000)• Delayed hemolytic reaction (1 in 7,000)• Anaphylaxis/Severe Allergic (1 in 40,000)• Acute lung injury (1 in 10,000)
Non-infectious
• Symptomatic bacterial contamination (1 in 250 000*RBC); (1 in 10,000* PLT) death (1 in 500 000*RBC)
• HIV (1 in 21 mil.)Infectious
Risk Vs.
BenefitRisk
Bloody Easy 4
Evidence in Support of PBM• Reduces perioperative blood loss and transfusion• Reduces perioperative morbidity • Reduces mortality • Reduced length of hospital stay• Reduced costEndorsed by WHO since 2010 (WHA63.12)• Bleeding • Transfusion • Anemia
Meybohm et al. Perioperative Medicine (2017) 6:5 [Leahy et al. 2017; Goodnough et al. 2014a; Moskowitz et al. 2010 Trentino et al. 2015]; Murphy. 2015 Transfus Clin Biol.
Improved Patient
Outcomes
Poor Patient
Outcomes
Preoperative Anemia Recommendations
Mueller JAMA 2019; Zeller JAMA 2019
How to Optimize Patient Red Cells
• Minimum 4-6 weeks • Investigation of etiology
Early Identification
• Oral (>6 wks) or IV iron (
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Muñoz M, International consensus statement on the perioperative management of anaemia and iron deficiency. Anaesthesia. 2017;72(2):233–247.
Who
Nee
ds W
hat
ORBCoN & ONTraC• Ontario Regional Blood Coordinating Network (ORBCoN)
– Integrates blood management in Ontario through engagement of hospitals and Canadian Blood Services since 2006
• Ontario Transfusion Coordinators (ONTraC) Program– Provincial blood conservation program– Promotes alternatives to blood transfusion in surgical patients– Formed in 2002, supported by MOH LTC– 25 Ontario hospitals– Multidisciplinary & multifaceted blood conservation on targeted
surgeries• TKA, THA, CABG, valves, radical prostatectomy, gynecologic surgery
Transfusionontario.org
HHS RCC Utilization Total Hip Arthroplasty2015** 2014 2013 2012
# of patients 487 606 714 5570 units RCC 97% 94% 89% 80%1-2 units 2% 4% 9% 17%
3 or more units 1% 2% 2% 3%
Total Knee Arthroplasty
2015** 2014 2013 2012# of patients 757 869 1010 9140 units RCC 99% 97% 92% 83%1-2 units 1% 3% 7% 15%
3 or more units 0% 0.2% 1% 2%
HHS CABG only*
2017 2016
# of patients 906 836
0 units RCC 57% 52%
1-2 units 23% 28%
3-4 units 11% 16%
5 or more units 8% 10%
* HHS CABG only patients. Excludes all patients having valves, hemiarch and ascending aorta procedures performed at time of CABG, OR priority 1 and 2 patients, and patients involved in the TRICS study (due to predetermined transfusion trigger).
** Data for 2015 arthroplasty gathered from January 1 to September 30 only.
Data C/O Linda Pickrell
Effective Preoperative IV Iron Delivery
Essentials:• Identification and lead time• Prescriber comfort and access• Product funding• Chair access• Institutional buy-inChallenge:• Product limitations
Perioperative PBM Strategies
• Cell salvage• Antifibrinolytics• Surgical Techniques
– Minimally invasive procedures where appropriate (stent/laparoscopic procedures).
– Meticulous attention to hemostasis (Factor XIV).
Carless. 2010 Cochrane Database of Systematic Reviews; Wang 2009 Anesth Analg; Fergusson 2008 NEJM; Henry 2001 Cochrane Database of Systematic Reviews.
Postoperative Restrictive Blood Transfusion
Mueller JAMA 2019; Zeller JAMA 2019
Carson et al. NEJM 2017; 377 (13)
Rest
rictiv
e vs
. Lib
eral
Red Blood Cell IndicationsHemoglobin Level (g/L)/Patient Population Transfusion Recommendations
Any Hb with associated IDA Iron repletion in hemodynamically stable patients
Less than 70 Likely appropriate, 1 unit and reassess
Less than 75 Appropriate for patients undergoing cardiovascular surgery
Less than 80 Consider in patients with pre-existing cardiovascular disease or evidence of impaired tissue oxygenation. Transfuse 1 unit, reassess
80 - 90 Probably inappropriate, unless symptomatic or evidence of impaired tissue oxygenation. Transfuse 1 unit and reassess
Greater than 90 Most likely inappropriate, unless symptomatic or evidence of impaired tissue oxygenation. Transfuse 1 unit and reassess
Bleeding Reasonable to maintain Hb > 70 (80 for cardiovascular disease)
Inpatients with hematologic malignancy No strong recommendation to support restrictive or liberal; institutional variation 70-80/titrate to symptomsOutpatient
Carson JL et al. Ann Int Med 2012;157(1);49-58. NAC Companion Document to: “Red Blood Cell Transfusion: A Clinical Practice Guideline from the AABB” 2014. www.nacblood.ca; Choosing Wisely Canada www.choosingwiselycanada.org .
http://www.nacblood.ca/
MASSIVE HEMORRHAGE PROTOCOL (MHP)Part Deux
Protocolize, Protocolize, Protocolize! Make Sure to Give ENOUGH (of the right stuff)!
MHP Principles
• Rapid, protocolized treatment of massively bleeding patient• Early recognition and treatment of acute coagulopathy of trauma• Rapid identification and treatment of bleeding source• Rapid definitive surgical intervention• Access to hemostatic agents
– Reversal agents, TxA
Kahn, Injury, Int. J. Care Injured 44 (2013) 587–592, Milligan. Emerg Med J 2011;28:870-2, Callum CMAJ Open 2019
This Photo by Unknown Author is licensed under CC BY-SA
https://askhematologist.com/https://creativecommons.org/licenses/by-sa/3.0/
MHP Benefits
• Improved blood product administration • Improved patient outcomes
– reduction in multiorgan failure and infectious complications– increase in ventilator- free days
• Decreased variability of treatment• Reduced blood component wastage• Facilitates interprofessional communication • Tracking of CQI metrics
Kahn, Injury, Int. J. Care Injured 44 (2013) 587–592, Milligan. Emerg Med J 2011;28:870-2, Callum CMAJ Open 2019
Interdisciplinary Team
MHPTM
Lab
Trauma Team Sx/IR
Paging
Porter
Provincial MHP Recommendations
• Callum et al. employed a modified Delphi consensus technique to generate 42 statements and 8 quality indicators
• Participants included 36 content experts and represented diverse backgrounds; stakeholder input incorporated
• Basis for an MHP toolkit that will be available through ORBCoN
Callum 2019 CMAJ Open: http://cmajopen.ca/content/7/3/E546.figures-only
http://cmajopen.ca/content/7/3/E546.figures-only
Callum 2019 CMAJ Open
The Downside• Group AB plasma is the universal plasma group
– 73% transfused to non-AB• With increased MHP adoption there has been concurrent, disproportionate
increase in AB plasma use • In an international multicentre study, plasma transfused in the ER accounted for
the highest percentage of group AB plasma units transfused to non-AB recipients• Only 3% of Canadians are group AB
Yazer 2013 Transfusion; Zeller 2018 Transfusion
Percentages of Blood Groups in Canada (%)
O A B AB
46 42 9 3https://blood.ca/en/blood/facts-about-whole-blood
https://blood.ca/en/blood/facts-about-whole-blood
Plasma Distribution Trends
Q4 2017/18 (Source: Canadian Blood Services)
Group A plasma instead of AB?
• Retrospective studies of trauma patients report no significant difference in outcomes between ABO-compatible and incompatible plasma transfusions
• Survey of 61 trauma centres showed 63% use Group A plasma in initial phase of resuscitation for group unknown patients
• STAT study – retrospective study of 17 trauma centres reported on 1163 trauma patients– No significant difference in in-hospital mortality
• Use of Group A plasma in MHPs is not yet standard of care • Evidence remains retrospective and observational
Dunbar, Transfusion. 2017;57(8); Stevens J., Trauma Acute Care Surg. 2017;83(1); Dunbar, Transfusion. 2016;56(1):125–129.
Take Home Points
PBMOptimize patient’s
own red cells
Judicious use of blood products
MHPRapid
identification & treatment
Hemostatic agents
Inter-disciplinary
Team
Fe
TxA
TxA
FC
35°C
Helpful Links
1. https://professionaleducation.blood.ca/en2. http://transfusionontario.org/en/documents/?cat=bloody_easy3. https://www.ontracprogram.com/Public.aspx
https://professionaleducation.blood.ca/enhttps://www.ontracprogram.com/Public.aspxhttps://www.ontracprogram.com/Public.aspx
Thank you
Prepared with Linda Pickrell, RN, OnTRAChttp://www.hamiltonhealthsciences.ca/documents/Patient%20Education/IronPillChoosing-th.pdf
Iron
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https://fhshc.csu.mcmaster.ca/owa/redir.aspx?SURL=oOarai7-_-0JqP9wszPeD2coD64oR9uiOzF4wNOsIwZ5AgfE51XTCGgAdAB0AHAAOgAvAC8AdwB3AHcALgBoAGEAbQBpAGwAdABvAG4AaABlAGEAbAB0AGgAcwBjAGkAZQBuAGMAZQBzAC4AYwBhAC8AZABvAGMAdQBtAGUAbgB0AHMALwBQAGEAdABpAGUAbgB0ACUAMgAwAEUAZAB1AGMAYQB0AGkAbwBuAC8ASQByAG8AbgBQAGkAbABsAEMAaABvAG8AcwBpAG4AZwAtAHQAaAAuAHAAZABmAA..&URL=http://www.hamiltonhealthsciences.ca/documents/Patient%20Education/IronPillChoosing-th.pdf
Compound Brand Name Recommended amount per dose
Infusion Time*
Availabiliy
Iron Dextran Dexiron® 100-1000g 6 hrs(+test dose)
$30/100mg
Iron Sucrose Venofer® 200-300mg 100mg/hr $40/100mgFerrous Gluconate Ferrlecit® 125mg 10 min $55/125mg
Ferumoxytol Feraheme® 510mg 15 min $40/100mgNo longer available in Canada
FerricCarboxymaltose (FC)
Injectafer®Ferinject®
500-1000mg 15 min Not yet available in Canada
Iron isomaltoside Monoferric® 1000mg >15 min HC approved
EAP Reimbursement Criteria
Ministry of Health and Long-term Care Exceptional Access Program (EAP) EAP Reimbursement Criteria for Frequently Requested Drugs
Updated: December 22, 2016
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