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Perioperative Limits of

Anemia
Sunaryo
Bagian Anestesiologi dan Reanimasi
Fakultas Kedokteran UNDIP/RS dr.Kariadi
Semarang
Defination of anaemia, lanjutan

• World Health Organization (WHO),defines


anaemia as a haemoglobin < 13 g/dl
(haematocrit < 39%) for adult males and < 12
g / dl (haematocrit < 36 % ) for adult non-
pregnant females.
• There are no universally agreed grades
of severity for anaemia during criticall
illness.
(Walsh TS,Saleh E E D.Br J Anaesth 2006;97:278-91)(P4,SN)

SN
Acute Blood Loss
• A. A Blood Loss of:
– 1. 15-30 %-should be treated with crystalloids or
colloids,not RBCs,in young,healthy patients;

– 2. 30-40%-requires rapid volume replacement,and


RBC transfusion is probably necessary;

– 3. >40%-is life-threatening and volume


replacement,including RBC transfusion,is required.
• B. Hemoglobin Concentration
– Hb after blood loss is influenced by intravenous fluid
resuscitation and time needed for equilibration.
Hemoglobin alone is an imprecise measurement
of oxygen delivery. SN
Acute Blood loss
• In contrast, physiologic responses may be
inadequate to maintain organ function and
hemodynamic stability when faced with
acute blood loss,
• Even with normal Hb,it takes time for
mobilization of extracellular fluid into the
intravascular space and or increase
erythrocyte 2,3-DPG.
• A healthy young person tolerates 500-1000 ml of acute blood loss
• 1000-2000 ml acute blood loss, can be managed with volume alone,red cell
transfsions are occasionally necessary.
• More than 2 L require red blood cell transfusion.
• Other clinical factors are important:
– Anesthesia-vasodilatory-blood loss >500 ml-require red cell transfusion-to maintain hemodynamic stability.
– Burn patient
• (Simmons ED.Transfusion Therapy.In:Bongard FS,Sue DY,editors.Current Critical Care Diagnosis & Treatment.2nd.New York :Lange Medical
Boos/McGraw-Hill Medical Publishing Division;2003.p78-95)

SN
Problems with Blood
• Disease
• Biochemical abnormalities:
– Hypernatraemia
– Acidosis
– Hyperkalaemia
– Hypocalcaemia

• Delayed effects:
– Metabolic alkalosis
– Hypokalaemia
– Immunomodulation SN
Problems with allogeneic transfusion

• Still assoc with risks (haemolysis, infection


& immunosuppression)
• Postop wound infection
• Recurrence rate of malignancy
• Unnecessary over-transf  mortality in
cardiac risk pts
•  blood product cost
SN
Transfusion Fatalities (2001-2002) in the
United States*

Bacterial 17
Contamination

TRALI 16
(transfusion related
acute lung injury)
Mistransfusion ABO 14
mismatch

*From the FDA (Oct 1, 2001 to Sept 30, 2002) SN


Risk of RBC Transfusion in United
States
• Febrile non – hemolytic RXN :1/100tx
• Minor allergic reactions :1/100-1000 tx
• Bacterial contamination :1/2,500,000
• Viral hepatitis 1/10,000
• Hemolytic tansfusion Rxn Fatal :1/50,000
• Immunosuppression : unknown
• HIV infection 1/500,000

(Doborah Tolich,RN;Alysha Fuller,BSN;India Carter RN.Blood Management,Past & Present)(2005 )(P17)


SN
Infection and Blood Transfusion
• The greater the number of red blood cell
transfusions,the greater the risk of infection.
• Shorr et al (2005).relationship between PRBC
transfusion and the development of ICU-acquired bloodstrem
infection.
• El-Masri et al.(a logistic regression analysis,number of units of
PRBC transfusion,along with the number of CVC inserted and the used of
chest tubes,were a surrogate marker for injury severity and a predictive
factor for the development of bloodstream infection.

• (American Journal of Critical Care,January 2007,volume 16,no.1) (P1)

SN
TRALI
(transfusion-related lung injury)
• TRALI is a life-threatening complication
allogenic transfusions and is the third most
common cause of transfusion-associated
death in the US.
(CHEST 2005;127:295-307) (P5)

SN
Transfusion and the Lungs
• The relationship between transfusions and
pulmonary function is complex.
• Vamvakas and Carven:
PRBC transfusion may specifically be responsible for a
prolonged need for mechanical ventilation.
.(American Journal of Critical Care,January 2007,volume 16,no.1) (P1)

SN
Compensatory mechanisms for acute
anemia

• Adequate tissue O2 does not depend


on a “normal” Hb
• Intraop blood loss replaced by
crystalloid-colloid solution
• As long as normovolemia is
maintained: anemia +  CaO2 are
compensated by  CO w/o risk of
tissue hypoxia SN
DO2=CIXCaO2
VO2=CIX(CaO2-CvO2)

Relationship between DO2 and VO2


during normovolemic hemodilution

Need for RBC- transfusion!


O2 consumption (VO2)

(1)

(2)
“ Critical DO2”

O2 delivery (DO2)

1=Supply-independent part of VO2


2=Supply-independent part of VO2 reflecting manifest tissue hypoxia SN
Factors influencing the DO2crit

• Blood volume
• Depth of anesthesia
• Muscular relaxation
• Body temperature
• FiO2
• Myocardial performance
SN
To control the immunological risk & costs

• Allogeneic transfusion completely avoided


• Minimized during op
–Intraop transf of autologous blood collected
preop (autolog blood donation, ANH) or intraop
blood salvage
– blood loss (skillful surg technique, deliberate
hypotension, adm of antifibrinolytic drug)
–Tolerance of low Hb level
SN
Remember!!!

• Acute anemia: loss of  50% BV is


tolerable in the absence of
hypovolemia, severe heart or
pulmonary disease
• Hypovolemia  30% is tolerable
SN
Evidence
RCT:
• Hb 7-9 g/dL & Hb 10-12 g/dL did not
differ in morbidity & mortality
Russell JA. Fluid Strategy in ARDS: The concept of maintaining peripheral perfusion. In H Burchardi G, GJ Dobb, J Bion, RP
Delinger (eds) WB Saunders. London 1997p; 17-42.

Multi center study:


• No improvement in morbidity & mortality
in patient who received transfusion with
Hb 8 g/dL - 10 g/dL
Carson JL et al. Perioperative blood transfusion and postoperative mortality. JAMA. 1998; 279:199-205. SN
Transfusion and oxygen Delivery
• Transfusions in septic patients do not
improve oxygen deficits in organ
systems.
• Conrad et al.(1990):increase in oxygen
consumption,but only in patients with low oxygen extration
ratios.
• Marik and Sibbald`s 1993:poorly deformable cells
cause microcirculatory occlusions,and further postulated
that these occlusions lead to tissue ischemia.
• (American Journal of Critical Care.2007;16:39-49) (P1)
SN
Transfusion in Cardiac Disease
• Patients with acute coronary
syndrome who receive transfusions
have worse outcomes.
• Yang et al. Patients receiving PRBCs had a
significantly greater risk of death alone and death
or reinfection as a combined outcome measure
than did patients not recieving blood.
• (American Journal of Critical,January 2007,volume 16,no.1).(P1)
SN
Transfusion and Truma
• A restrictive transfusion strategy is
safe and beneficial in trauma
victims.
• Malone et al.(cohort study):receiving blood were
3 times more likely to die and 3 times more
likely to be admitted to the ICU than patients not receiving
blood.(P1).
• Robinson et al.2005. The risk of death increased with
each unit of blood transfused.Hospital stays are also
longer among patients receiving transfusions.
• Dunne et al. Transfusion was an independent risk factor not
only for SIRS but for mortality and ICU admission as well.

• (American Journal of Critical Care,January 2007,volume 16,no.1) (P1) SN


APACHE 1311
Conclusion
• Overall,critically ill patients who
received red blood cell
transfusions had worst
outcomes.
• “where there`s smoke,there`s fire”.
• .(American Journal of Critical Care,January 2007,volume
16,no.1) (P1)
SN
Perioperative Transfusion
• Transfusion is rare indicated for patient
undergoing noncardiac surgery who have
hemoglobin values > 7-8 g/dl and no risk factors
for myocardial ischemia.
• Eldery patients Ht < 28 %(Hb 9 g/dl ) may be
at risk for myocardial ischemia during surgery,
especialy if tachycardia is present.
• Others at risk for myocardial ischemia a
hemoglobin < 10 g/dl.probably warrants transfusion

(Simmons ED.Transfusion Therapy.In:Bongard FS,Sue DY,editors.Current Critical Care Diagnosis &
Treatment.2nd.New York :Lange Medical Boos/McGraw-Hill Medical Publishing Division;2003.p78-95)

SN
Patient would receive transfusion,
• With one role:
• Patients were not transfused unless
their hemoglobin level was less than
9 g/dL or hematocrit was below
27%.
• NATIONAL ANEMIA ACTION COUNCIL (NAAC) ,2007
• Source :Corwin HL,at all,Journal of the American Medical Associaton,2002,vol.288,pp.2827-
2835,2884-2886.

SN
Trends in Transfusion Practice Among The
Critical ILL
• A restrictive strategy as the best practice
for most patients,including those with cardiovas
cular disease,but with possible exception of
critical ill with ongoing coronary ischemia.
• The authors concluded that the associated risk of
death was 33% for patients receiving
transfusions compared with patients not receiving
transfusions. P5,SN
(CHEST 2005;127:295-307)

SN
Blood tranfusion and outcomes
reseacrch
• Immunomodulation
• Transfusion of allogenic blood carries a number of immunomediating
compounds and activated cell lines.
• Immunosupression still exists, even if transfusions do not
transmit white cells.
• If patient is transfused during the period of colon resection, the incidence of
metastasis and early death is increase between 1.5 fold and twofold.
• Multisystem organ failure is probably an immune-mediated function,although
it could also be related to microcirculatory oxygen delivery and reduced flow-
through capillaries resulting from cell clogging of banked blood.
• The results show that transfusion remains an independent predictor of
adverse outcome even when all confounding variables are accounted.

• Blood transfusion always has strong associa-


tion with adverse outcome of multisystem
organ failure.
Bruce D.Spiess (Summer 2005 ) (P31 )
SN
Conclusion
• Concerns regarding the excess morbidity and mortality
associted with nonrestrictive transfusion strategies,coupled
with the emerging increased risk of the transmission of
newer infectious agents,and immunomodulation,should
reevaluation of current
prompt the
transfusion protocols in critical ill
patients.
• A restrictive transfusion strategy appears to
improve outcomes in critically ill patients
• Hb 7g/dL in patients without coronary disease.
(CHEST 2005;127:295-307) (P5,SN)
SN
Do not tranfuse for following
reasons ! :
• to improve general sense of well
being
• as hematinic agent
• to expand vascular volume
• as prophylaxis if there is no risk
factor
SN
Tolerable Hb level
• No universal tolerable Hb level
• Consideration must be made based on
case by case (co-morbidity)
• Healthy young adult: tolerable Ht 20%
• CRF : Ht 18 - 22%
• Septic shock : Ht 30%
• After severe shock : Ht 30 – 40%
• CAD : Ht 35%
• Severe COPD : Ht 40% SN
Guidelines for perioperative
transfusion
• Periop RBC transfusion is:
rarely indicated  Hb>10g/dL &
always indicated  Hb<6g/dL
• Young & healthy pt avoided until Hb
6g/dL (or in particular cases even lower) is
reached
• Cardiac risk pt  Hb 8-10g/dL
SN
Guidelines for perioperative
transfusion
• Every decision to transfusion based
on:
–The actual Hb
–The existence of cardiopulmonary
co-morbidity
–The appearance of physiological
transfusion triggers
–The dynamics of blood loss SN
Conclusions-Blood
• Limit transfusion
• Transfusion threshold < 7g/dL
• Maintenance level 7 – 9g/dL
• Older pts & those with ischaemic
heart disease may need higher Hb

SN
It must be the responsibility of all
doctors to ensure that blood
component therapy is given only
when clearly indicated
(McGrath et al 2001)

SN
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INFORM CONSENT
• The patient should be informed of the
benefits of transfusion, the potential
risks of transfusion, and the alternative
to transfusion.
• The patient should be given the
opportunity to ask questions about the
recommanded of transfusion.
• The consent should be obtained before.
• (Simmons ED.Transfusion Therapy.In:Bongard FS,Sue DY,editors.Current Critical Care
Diagnosis & Treatment.2nd.New York :Lange Medical Boos/McGraw-Hill Medical Publishing
Division;2003.p78-95

SN
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