Blood transfusion management BAPA refresher course€¦ · • Blood utilization review & auditing:...

MonaMOMENI,MD,PhDDepartmentofAcuteMedicine

AnesthesiologyUnit

Bloodtransfusionmanagement

BAPArefreshercourse

CliniquesuniversitairesSaint-Luc–MonaMOMENI2

Conflictsofinterest:

Speaker’sfeesMedtronic

CliniquesuniversitairesSaint-Luc–MonaMOMENI


PatientBloodManagementprograms

•  Wellrecognized&appreciatedinadults

•  Resultofevidence-basedmedicineinadults

•  Neonates&children:physiologicaldifferences:higheraverageHbconcentrations

:higherO2consumptionscomparedtoadults


•  Bloodutilizationreview&auditing:comparedwithcurrentpediatric

evidencebasedtransfusionguidelines

•  Perioperativeanemiamanagement

•  Standardproceduresformassivetransfusion

•  Maintainingahemovigilanceprogram

•  Appropriatebloodproductselection(irradiated,leukoreduces,washed,..)



Transfusionmedicinecommunity:5rights

1.   Transfusingtherightproduct2.  Transfusingintherightdose3.  Transfusingtotherightpatient4.  Transfusiongattherighttime

5.   Transfusingfortherightreason


10,7complicationsVS2,5complicationsPer1000productstransfused



•  PackedRBC•  FFP•  Plateletconcentrate

•  Fibrinogen(cryoprecipitate)•  Others:PPC,FVIIa

Transfusingtherightproduct&fortherightreason


PackedRBC

Definitionofanemia????

•  Children:≤7g/dL:≤5g/dL…..PediatricCriticalCareTransfusion&AnemiaExpertise•  Inneonates:≤8g/dL(RCTofrestrictivevsliberaltransfusion)•  Preterminfants


RisksofAnemia


Whatistheoutcomeyouarelookingat?

Restrictivevsliberaltransfusionstrategyinchildren


•  Largestmeta-analysis:KeirA,etal.Adverseeffectsofredbloodcelltransfusions

inneonates:asystematicreviewandmeta-analysis.

Transfusion.2016;56:2773-80

Nodifferenceinmortality

NodifferenceinNEC

NodifferenceinCLD

NodifferenceinROP

NodifferenceinIVH


Neurodevelopmentaloutcome?????

OngoingphaseIIItransfusionstudies:

1.  ETTNOtrial:EffectsofTransfusionThresholdonNeurocognitiveOutcomeofExtremelylowBirthWeightInfants2.TOPtrial:Transfusionofprematures

WhetherhigherHbvaluesleadto:

-  Improvementinsurvival(=primaryoutcome)

-  Ratesofneurodevelopmentalimpairmentat22-26monthsofage


Ø  Systematicreviewfrom1990–2010ofneuromonitoring&neuroprotectionstrategies

Ø  Infants<1yearØ  162manuscripts

Ø  Primaryoutcome:evidenceofstructuralbraininjuryin43%

Ø  Mostfrequentlevelofevidence:ClassIIborLevelB(42%)

Ø  TheonlypracticewithClassIIaorLevelA:avoidanceofextremehemodilution

Ø  Conclusion:levelofevidenceisinsufficienttosupporteffectivenessofcurrentneuromonitoring&neuroprotectivetechniques


Howtodetectcerebral/organhypoperfusion?

•  SurrogatemarkerofO2delivery/O2consumption

•  Combinedcerebral/somatic:usefulinformation

•  Todatenoevidence-baseddataforitsroutineuse

CBF VO2O2supply O2consumption


NIRS-basedtransfusionofRBC


ASDclosure&PAPVR;4years;preopHb=12.7g/dL

Hb=8.1g/dL:transfusion


When&howmuchRBCtotransfuse?

•  AllowableBloodloss(ABL)ABL=EBVx(Hctstarting–Hcttarget)/Hctavg•  Transfusedvolume(PRBC)=weight(kg)xdesiredHbincrease(g/dL)x5

•  10mL/kgPRBCwillincreaseHbby2g/dL


•  Ingeneraldifficulttoquantify:ventilated(maskingrespiratoryreactions)

:draping(novisualisationofurticarialreactions)

:CPB

:lackofformaluniversaldefinitionofreaction

•  Transfusionassociatedcirculatoryoverload

•  Transfusionrelatedacutelunginjury

Underdiagnosedinneonateswithrespiratorysymptoms

AdverseeffectsfromRBCtransfusion


•  HyperK&Ventricularfibrillation:

The«WakeupSafe»initiativefromSocietyofPediatricAnesthesia

recommendsthatRBCshouldbefresh(<1wold)orwashedifthepatient

is<1yoldorweights<10kg

•  TA-GVHD:veryrarewithhighmortalityrate

:Host(immuneincompetence),donorTlymphocyte,and

environmentalfactors(inflammation)

:irradiatedcellularbloodcomponents(Japan)

•  Allergicreactions:IgEmediated

AdverseeffectsfromRBCtransfusion


•  Autologousblooddonation:NO;risks>>>>benefits•  rhuEPO:veryspecificcases;guidelinesagainstroutineuse

•  AcuteNormovolemicHemodilution:veryspecificcases;olderchildren

•  Cellsalvageexceptintumorsurgery(disseminationoftumorcells)

•  Irondeficiency:exclusivebreastfeedingisariskfactor

:2–3mg/kg/doralirontopreterm/smallforgestationalage

•  Reduceblooddraws

Howtooverome/treatanemia?

!Hb/Hct:samplesfromlargerveins&arteries=lowerthancapillarysamples


FFP

•  DecisionwhethertoadministerFFPornot:easier

•  BUT……

•  EvidenceguidingtransfusionofFFPfromallbloodproductsin

theneonatesistheweakest

•  INDICATION:purpurafulminansduetoProteinC&ProteinSdeficiency

:congenitalthromboticthrombocytopenicpurpura

•  Usually10–15mL/kgwhenclinicalbleedingandstandardcoagulation

testsare1,5xnlvalues:???Notevidencebased


Standardcoagulationtestsgiveinadequateinformation:

-  Reagentsusedtoperformcoagulationtestsaresensitivetoevenminor

reductionsincoagulationfactorlevels

-  Relationshipbetweencoagulationfactorlevels&coagulationtesttimes

notlinear

-FFPoftenresultsinminimalchangesincoagulationtestresults

Point-Of-Caretests:ROTEM/TEG

FFP


GUIDELINESBSH

•  Againstroutineusetocorrectcoagulationabnormalities

•  Notroutinelyperformingcoagulationtestsinallneonates

•  Indicated:priortosurgeryifthereissignificantcoagulopathy:acutebleedingsecondarytocongenitalbleedingdisorders

wherespecificfactorreplacementisnotavailable(rare!)

:inthemanagementofactivebleeding&significant

coagulopathy

:NOTtobegivento«non-bleeding»childrenwithminor

coagulopathyevenbeforesurgery

FFP


•  Nodifferencebetweenbothgroupsintermsofbleedingortransfusionrequirements

•  Changeindailypractice


AdverseeffectsofFFP

•  Inherenttoanyallogeneicbloodproduct

•  THROMBOTICCOMPLICATIONS


Plateletconcentrate

•  Definition:mild=100–150x109/Lmoderate=50–99x109/Lsevere=<50x109/L•  Definitioninneonateslessclear:WiedmeierSEetal.Predictableincreaseinplatelets2x109/Lperweekincreasegestationalage•  Noclearrelationshipbetweenthrombocytopenia&clinicalbleeding•  NoRCTavailable•  GuidelinesBritishSocietyofHematology:stablechildren<4m:prophylacticif<30x109/Lstablechildren>4m:prophylacticif<10x109/L


-Error

-Bacterial&septicinfectionsduetostorageatroomair

-Allergicreactions

-TACO&TRALIduetotheinnateplasmacomponentofplateletproducts

Adverseeffectsplateletconcentrate


Fibrinogen

•  Hypofibrinogenemia=majorreasonforcoagulopathicbleeding

duringcomplexpediatricsurgery

(craniosynostosis,cardiac,scoliosis)

•  FFP:questionnableefficacyinrestoringfibrinogenconcentrations

•  Inadults:incaseofthrombocyotopeniaand/orplateletdysfx,fibrinogen

makesastrongercontributiontoclotfirmnessthanplatelets

Langetal.AnesthAnalg2009;108:751-8

Harretal.Shock2013;39:45-9


•  Bestwaytoanalyzefibrinogenconcentrationandfibrinpolymerization:Fibtem

•  Fibtem:eliminatestheplateletcontributionbyCytochalasinD

•  Inadults:guidelinesEurSocietyofAnaesthesiology:cutoffFibtemMCF<8mm

Fibrinogen


•  Dose:StudybyHaas90(75–120)mg/kg

•  !300mg/kg:neonateFibtemvaluesnotmeasurable

•  Ruleof10inbleedingpatient:FibtemA10<10give50mg/kgFibrinogen

•  €€€€

•  1LFFP:2.5-2.7gFibrinogen

•  Cryoprecipitate:NotinEurope:Differentdonors:VIII+Fibrinogen+Fibronectine+XIII+vWF:2pools(±200mL):4gFibrinogen

Fibrinogen



•  Fibrinogen(cryoprecipitate)•  Others:PCC,FVIIa



ProthrombinComplexConcentrate

•  Either3factors(II,IX,X)or4(II,VII,IX,X)

•  Clottingfactorconcentration25timeshigherthannormalplasma

•  Indication:VitKanatgonists(1–2mL/kg)

:congenitaldeficiencyofanyofthesefactorswhenpurified

specificcoagulationfactorsarenotavailable

•  Topreventactivationofthesefactors,mostcontainheparin

•  MayalsocontainnaturalcoagulationinhibitorsproteinC&S

•  Differenthalf–livesofthe4factors:

FII:60-72h

Others:6–24h

•  Adverseeffects:HIT–allergicreactions–thromboemboliccomplications


FactorVIIa

•  Veryexpensive•  Insufficientdatainpediatrics

•  Aprospective,randomizedtrialinpediatriccardiacsurgeryfailed

toproveasignificantdifferenceinbloodlosswhencompared

toplacebo


Antifibrinolytics:Tranexamicacid

•  Veryeffictiveinmajorsurgery&trauma

•  Optimaldosing,timingofadministration&pharmacokineticsrequirestudies

•  Adverseeffects:seizures!Athighconcentrations

InhibitionofinhibitoryglycineandGABAR;theseRhavelysinebindingsites

andaremediatorsofCNSinhibition

•  Newpharmacokineticstudies

10–15mg/kgover15minfollowedby5–10mg/Kg/hnon-cardiacsurgery


Conclusions

•  Transfusing&nottransfusing=harmful

•  MoreRCTneededtohaveevidencebaseddata

•  Focusingonspecificoutcomes

•  PatientBloodmanagementstrategies


Thankyou

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