1. Perioperative Blood
Conservation – An Overview
Dr Prashant Shanker Agarwal
Dr Ashok Jadon
Deptt. Of Anaesthesiology

2. Do we feel that a transfusion
is an organ transplant ?

3. Session Objectives
• Provide an overview of blood
conservation in perioperative patients
What is it?..
Why is it important?..
How is it accomplished?..

4. SABM, 2007
What is Blood Conservation?
• Blood Conservation: Society for
the Advancement of Blood
Management (SABM)
‘team
approach to surgical patient
care that utilizes the latest
drugs, technology and
techniques to enhance a
patients own blood supply and
decrease blood loss …the aim
is to reduce or avoid the
need for transfusion’

5. Why do we need
blood…?
• For O2 transport…?
• O2 Content =
Hb*1.37*SaO2 + 0.0034*PaO2
• At Hb 4.7 g/dl O2 delivery reduces by 30%
(Liberman JA. Anesthesiology 2000; 92.)
• Upto 40% permissible loss( approximately
2L in males) (Herbert PC. NEJM 1999; 340)

6. ASA task force guidelines 1996
• Transfusion is rarely indicated when the
hemoglobin level is above 10 g/dL
• Almost always indicated in patients when the
hemoglobin level is below 6 g/dL;
• For hemoglobin level 6-10 g/dL
– Ongoing indication of organ ischemia,
– The rate and magnitude of any potential or actual
bleeding,
– The patient’s intravascular volume status
– Risk of complications due to inadequate oxygenation.
• Use Blood Components separately
• Promote blood conservation

7. O'Brien et al , 2007
Infectious and Non Infectious risks
• 1 in 100 – minor allergic reactions
– rash etc
• 1 in 300 – febrile non-hemolytic
reaction to RBC
• 1 in 700 – transfusion related
circulatory overload
• 1 in 5,000 – Transfusion Related
Acute Lung Injury (TRALI)
• 1 in 10,000 – Symptomatic
bacterial sepsis from platelet
transfusion
• 1 in 40,000 – death from bacterial
sepsis - platelet transfusion
• 1 in 40,000 – ABO incompatible
transfusion per RBC transfusion
• Coagulopathy
•1 in 40,000 – serious allergic
reaction per unit of component,
anaphylaxis
•1 in 82,000 – transmission of Hep B
virus
•1 in 100,000 – bacterial sepsis per
unit of RBC
•1 in 500,000 – death from bacterial
sepsis per unit of RBC
•1 in 1,000,000 – WNV
•1 in 2,300,000 – Hep C
transmission
•1 in 7,800,000 – HIV transmission
•Post Transfusion Purpura

8. Intraoperative RBC Tx
Increases Risk of Low
Output Failure
Surgenor, et al. Circulation 2006;114:43-48

10. Is Blood Transfusion
safe…when you can prevent it?
• Patient safety
• Informed choice for patients
• Resource allocation
• Infectious risks
• Non-infectious risks
• Blood products are a scarce
resource
• Blood is expensive!

11. Blood Conservation – Why?
• Conserve blood resources
– Regional blood centers find it increasingly difficult to
collect sufficient blood to meet patient needs in many
areas of the country.
– In the next 15-20 years the number of patients >65
y.o. will more than double but the number of blood
donors will only marginally increase
– The number of units used nationwide is increasing 1%
per year, but the people donating is decreasing 1%
per year.

12. Blood
Component
Therapy

13. Blood Conservation…
Why perioperative patients?
• 50-70% of blood products used in
hospitals are used in the perioperative
setting (Hebert et al, 2004)
• Potential exists to modify some predictors
of transfusion in elective surgical patients
- Pre-op Hb, Blood loss
• Wide variation in transfusion practice for
procedures

14. How important is pre-op
Hemoglobin?
• A national (US) audit found that 35% of patients coming for
arthroplasty have Hb <130g/L
• UK study found that 20% of all patients in 1 year were anemic
males<130g/L, females <115g/L)
•GoodenoughGoodenough,, 20072007
•Karkouti et al 1999Karkouti et al 1999
•Saleh et al, 2007Saleh et al, 2007

15. How Blood Conservation
accomplished?
• Preoperative evaluation & Risk
stratification
• Reduce need for blood transfusion
• Autologous Transfusion

16. Pre-op evaluation
Pre-op Hb optimization:
4-6 week lead time for assessment, screening and
appropriate interventions:
• Correction of nutritional anemia
iron therapy – dietary advice,supplements
Vit B12, Folate
• Careful attention to patient medical history, pre op meds
ASA, Clopidrogel (Plavix), NSAIDs, herbal
supplements
• Pre operative autologous donation
• Erythropoietin therapy (Karkouti et al, 2005)
• ? Delay surgery

17. METHOD TO REDUCE BLOOD
USE IN SURGERY
• PREOPERATIVE
* Surgery elective – Correct the Haemoglobin level.
Stop drugs that interfere
haemostasis.
• INTRAOPERATIVE
– Posture
– Use of Vasoconstrictors
– Use of tourniquets
– Use of anti-fibrinolytic drugs eg tranexamic acid
– Use of Aprotinine
– Controlled hypotension, Regional anaesthesia
• POST OPERATIVELY
– Blood can be salvaged from drains into collection
devices that permit reinfusion

18. Meticulous
Technique
• Careful, precise
procedures, using
natural tissue planes
• Planned vascular control
• Use of clips, ligatures, and cautery
where appropriate
• Newer techniques (harmonic scalpel,
LASER)
• NB. MINIMIZE BLOOD LOSS

19. Volume Expanders
• ACUTE VOLUME REPLACEMENT
• HYDROXYETHYL STARCH (HES)
• DEXRAN 70
• DEXTRAN40
• UREA-BRIDGED GELATIN
(HAEMACCEL)
• Blood substitutes

20. Blood Substitutes
• Hb sol. (human, bovine) –
• Increases Hct
• systemic & pulmonary HTN
• Perflurocarbon emulsions –
• O2 solubility 20 times of plasma
• Decreases Platelets & require high PaO2
• Focus is on the ability to carry oxygen, not on
the other functions of blood
• Effective only for 12-24 hrs
• Good for short term till blood is arranged

21. Cell Salvage With Ultrafiltration
• ‘recycling’ of blood that
would otherwise be
discarded
• CV/ortho/trauma (Cochrane,
2006)
• Contraindicated in
malignancy,
contaminated wound
• RBC’s suspended in NS
• May be acceptable to
JW patient
Cell Saver

22. Cell Salvage
• The Hemobag® and its TS3 tubing set
allows for Ultrafiltration both during the
case and at the end for Whole Blood
Autotransfusion.
• The end product is a hyperoncotic
Autologous Whole Blood packed with viably
functioning Platelets, Clotting Factors,
Albumin, Plasma Proteins and RBC’s with
no morbidity or side effects.

23. Isovolemic Haemodilution
• 1 to 2 units of patient’s blood withdrawn
at the beginning of a procedure
• Blood volume restored with
crystalloid/colloid solution
• Patient bleeds “thin blood” during
procedure
• Gets own blood back at the end

24. Autologous Blood
Transfusion
Collection and re-infusion
(transfusion) of the patient’s own
Blood or Blood components.

25. Why Autologous Blood
Transfusion
• Fully compatible blood.
• No risk of transfusion transmitted diseases
such as hepatitis, CMV and HIV infection.
• Avoidance of allo-immunization.
• Improved O2 perfusion by lowering blood
viscosity.
• Acute Normovolemic Hemodilution provides
fresh whole blood .
• Less dependant on the blood bank’s stock.

26. A marked reduction in the hospital infection
rates, antibiotic usage and length of hospital
stay in patients who received autologous blood
or no blood
Triulzi et al, Transfusion 1992;32:517-524;
Forgie et al, 1998
Why Autologous Blood
Transfusion
•Readily available in major haemorrhage
•Avoidance of immuno-suppression

27. Criteria
• Age: less than 65 year old
• Hb: at least 11.0g/dl
• Weight: at least 50kg
• No h/o severe heart and lung disease,
abnormal bleeding tendency
• No bacteraemia at time of donation
• No h/o hepatitis B/C or HIV
• Cancer not a contraindication

28. Pre-surgical Autologous Blood Donation
• Best choice for patients with rare blood types or
irregular antibodies.
• One unit per week & takes Fe/EPO.
• Then donates 1 unit per week (usually no more
than 3 or 4 units)
• Last donation must be at least 72 hrs before
operation.
• Blood is stored and kept for patient for re-
infusion during/after operation.

29. Labeling and Storage
• Carefully designed system.
– Special procedure code
– Autologous stamp.
– Detail of place and date of operation.
• Special and distinct label on blood pack.
• Autologous donor card with unit number on it.
• Stored in different site.

30. Should Autologous Blood be
“made homologous”?
The American Medical Association,
AABB, NBS discourage the
“crossover” of unused autologous
units to the general blood supply.
• Liberal eligibility criteria.
• Safety concerns.
• Legal liability

31. Role of Erythropoietin in
Autologous Transfusion
• Allow more units to be collected.
• Need two to more weeks to work.
• Expensive.

32. Points to consider
• Cost
• Surgeon and Anaesthetist
enthusiasm
• Availability of allogeneic blood
• Which types of procedures: “ortho;
intestinal; clean operations”
• Public awareness

33. • Remember that transfusion of any
Allogeneic blood or blood products is
an “Organ Transplant", and not just
another medication that is without
side-effects. Treat everyone like a JW !
End of starting…..

34. Transfusion Algorithm
• Avoid Transfusion : medical and surgical
• Alternatives
replacement fluids: crystalloids and non
plasma colloids over plasma
pharmacologic agents to reduce bleeding
• Autologous donation
• Minimize exposure to allogeneic
transfusion

35. Thought for the day……
“Blood transfusion is a lot like
marriage. It should not be
entered into lightly,
unadvisedly or wantonly, or
more often than is absolutely
necessary.”
Beal, RW, 1976Beal, RW, 1976
Beal RW, 1976Beal RW, 1976

36. THANK YOUTHANK YOU

37. Tranexamic Acid
• Mechanism of Action:
• Forms a reversible complex that displaces plasminogen from fibrin resulting
in inhibition of fibrinolysis; it also inhibits the proteolytic activity of plasmin
• Dose Children and Adults: I.V.: 10 mg/kg immediately before surgery, then
25 mg/kg/dose orally 3-4 times/day for 2-8 days
• Dosage modification required in patients with renal impairment; ophthalmic
exam before and during therapy required if patient is treated beyond several
days; caution in patients with cardiovascular, renal, or cerebrovascular
disease; caution in patients with a history of thromboembolic disease (may
increase risk of thrombosis); when used for subarachnoid hemorrhage,
ischemic complications may occur
• Adverse Reactions:
• >10%: Gastrointestinal: Nausea, diarrhea, vomiting
• 1% to 10%: Cardiovascular: Hypotension, thrombosis
• Ocular: Blurred vision
• <1%: Unusual menstrual discomfort
• Postmarketing and/or case reports: Deep venous thrombosis (DVT),
pulmonary embolus (PE), renal cortical necrosis, retinal artery obstruction,
retinal vein obstruction, ureteral obstruction

39. Summary
• Controlled Hypotensive Anaesthesia
– current perspective
• Cell savaging procedures !!!!...???
• Use of Regional Anaesthesia &
Tranexamic Acid
• Autologus Hemotransfusion
– Normovolemic Hemodilution
• Increase oxygen delivery
• Decreased DVT

40. »Thank You