Patient Blood Management
Minh-Ha Tran, DO, FASCP
UC Irvine Health
Transfusion Medicine Service
Agenda

State the guiding principles of Patient Blood Management

Name the three phases of perioperative blood conservation

Discuss examples of modalities relevant to each phase

Define “restrictive” hemoglobin threshold

Discuss transfusion risks

Name three transfusion alternatives

Become acquainted with basic principles of platelet and plasma transfusion
practice
Patient Blood Management

A series of ‘rights’
◦ Right Patient
 Right Product
 Right Reason
 Right Time

Who defines ‘right’?
◦ Clinical decision informed by evidence
 Not all hypotension is due to anemia
 Not all hypoxia is due to reduced red cell mass
 Not all who are anemic require red cell transfusion
Perioperative Management
Preoperative
Intraoperative
Postoperative
Medication review and targeted
bleeding history
Acute normovolemic hemodilution
when appropriate
Iron supplementation
Management plan for congenital
bleeding disorders
Use of antifibrinolytics when
appropriate
Reduction of iatrogenic blood loss
Evaluation and treatment of
preoperative anemia
Application of minimally invasive
surgical techniques
Medical optimization
Intraoperative cell salvage
Utilization of restrictive transfusion strategies throughout the perioperative period
Anemia tolerance, utilization of transfusion alternatives when possible
A word about PAD

Preoperative Autologous Donation
◦ Induces Preoperative Anemia
 Increases risk for allogeneic transfusion
 Generates waste as most units wind up discarded
 A waning practice…
Restrictive Transfusion Strategies
Study
Patient Population
Arms
Primary Outcome
TRICC
838 Critical Care patients
7 g/dL (n=418) vs
30 Day ACM: (18.7% vs 23.3%, p = 0.11)
NEJM 1999
[RCT]
9 g/dL (n=420)
TRACS
502 Cardiac Surgery with
8 g/dL (n=249) vs 10 g/dL
NI margin for 30 day ACM predefined at -8%: Observed between group
JAMA 2010
Cardiopulmonary Bypass
(n=253)
difference 1% [95% CI, -6% to 4%], p = 0.85.
[RCT, NI study]
FOCUS
2016 Patients with CAD/Risk
< 8 g/dL (n=1009) vs
Death or inability to walk across room unassisted at 60 days: Abs Risk
NEJM 2011
of CAD after Hip Fracture
10 g/dL (n=1007)
Difference 0.5 percentage points [95% CI, -3.7 to 4.7]
Surgery
[RCT]
Acute UGI Bleed
921 Patients with severe
< 7 g/dL (n=461) vs
45 Day ACM: 91% restrictive vs 95% liberal; HR for death with
NEJM 2013
Upper GI bleeding
< 9 g/dL (n=460)
Restrictive Strategy 0.55 [95% CI: 0.33 to 0.92], p = 0.02.
[RCT]
Emphasize clinical, not just laboratory indicators
 Whenever possible: single unit transfusion, then reassess

Transfusion Risks
(Allergic)
Anemia Management Strategies

Anemia Tolerance – General Guidelines
◦ Acute bleeding, hypovolemic shock
 Transfuse as needed
 Surgical management
◦ Chronic anemia, stable patient
 Assess for symptoms
 …and comorbidities
 Determine cause
 …and anemia treatment options
 Establish timeline for correction
 …is the patient preoperative?
Iron Deficiency Anemia
Iron Deficiency Anemia

Anemia severity
◦ Endogenous erythropoietic drive

Likelihood of response
◦ Assess for malabsorption, continued losses, anemia of
inflammation, renal anemia

Slope of response
◦ Reduced if continued ongoing losses or malabsorption
Treatment Considerations
Enteral Formulations
Iron Salts
Unit Dose (mg)
Elemental Iron (mg)
Ferrous Sulfate
325
65
Ferrous Gluconate
325
36
Ferrous Fumarate
325
106
Notes
Iron salts are similarly tolerated; adverse effects
generally attributable to elemental iron content.
Non-Salts
Carbonyl Iron
45
45
Carbonyl iron microspheres derived by heating
gaseous iron pentacarbonyl; absorption dependent
on solubilization by gastric acid
Parenteral Formulations
Concentration
Dextran Stabilized
(mg elemental iron/mL)
Vial
Notes
LMW Iron Dextran
(INFed)
50
100 mg/2 mL
Watson Pharma, Inc, Corona, CA
Iron Sucrose
(Venofer)
20
100 mg/5 mL;
200 mg/10 mL
American Regent, Inc, Shirley, NY
12.5
62.5 mg/ 5 mL
Watson Pharma, Inc, Corona, CA
Ferumoxytol
(Feraheme)
30
510m g/17 mL
AMAG Pharmaceuticals, Lexington, MA
Ferric Carboxymaltose
(Injectafer)
50
750 mg/15 mL
Luitpold Pharmaceuticals, Shirley, NY
Sodium Ferric Gluconate Complex in Sucrose
solution
(Ferrlecit)
Erythroid Stimulating Agents
Erythroid Stimulating Agents
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
300 U/Kg
Mon
Tues
Wed
Thurs
Fri
Sat
300 U/Kg
Sun
600 U/kg
600 U/kg
600 U/kg
600 U/kg
Malabsorption
Celiac Disease
 Inflammatory Bowel
Disease
 Roux en Y Gastric
Bypass
 [vegan/vegetarian]

General Comments

Oral Iron
◦ Hb will rise slowly, beginning 1-2 weeks after initiation of treatment
◦ 2 g/dL over ensuing 3 weeks
◦ Hb deficit typically halved by 1 month, normal by 6-8 weeks

Parenteral Iron
◦ In those unresponsive or intolerant to oral iron, or in those whose iron losses exceed
absorptive capacity, IV iron is an option
◦ Calculate an iron deficit and replenish the deficit

ESA
◦ If ESA’s are administered for renal anemia, coordinate care with the nephrologist
◦ In noncancer patients, ESA’s may be used to augment the erythropoietic response to iron –
particularly in mild anemia or when IDA is complicated by inflammation
◦ Always co-administer with iron to avoid functional iron deficiency
Calculating Iron Deficit

Example: 82 kg woman with heavy uterine bleeding
presents with H/H of 6.3 g/dL and 18.9%

Total Blood Volume
◦ 70 mL/kg x 82 kg = 5740 mL (57.4 dL)

Hemoglobin Deficit
◦ 12 g/dL – 6.3 g/dL = 5.7 g/dL
◦ 5.7 g/dL x 57.4 dL = 327 g

Iron Deficit
◦ 3.34 mg Fe/g Hb
◦ 327 g Hb x 3.34 mg Fe/g = ~1000 mg Fe
From the Literature

IDA treatment:
◦ A higher and more rapid hemoglobin response with parenteral iron
◦ Risk of infection increased with parenteral iron

Preoperative anemia:
◦ Oral iron alone ineffective for preoperative purposes, particularly when
anemia is mild
◦ Treatment most effective with ESA containing regimen

Critical Care Patients:
◦ ESA alone has minimal impact in transfusion avoidance among critical
care patients, particularly when restrictive transfusion strategies are in
place
The anemia we cause…
Platelets

Usual Adult Dose is
1 Apheresis Platelet
Unit
Platelets
Platelets
Plasma
Plasma
PCC – first view – Tran, et al.
PreTreatment INR vs Delta INR in PCC Group
12.00
11.00
10.00
y = 0.8727x - 1.2166
R² = 0.9304
Delta INR (Pre-Post)
9.00
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
-1.00
0
1
2
3
4
5
6
7
8
9
10
PreTreatment INR
Delta INR
Linear (Delta INR)
Tran MH, Gayatinea R, Albicker P, Baje M.
PCC and NovoSeven for Critical Bleeds and Coagulopathy Reversal
11
12
13
PBM PI Project
PMID: 24919540
EBM GI Bleed Protocol
Utilization Review
Utilization Review
Summative Comments

Patient Blood Management
◦ Protect the patient from unnecessary or excessive transfusions
◦ Inform transfusion decisions not simply by hemoglobin, but by patient
symptoms and comorbidities
◦ Utilize restrictive transfusion strategies
◦ Reduce iatrogenic anemia through reduction in both the volume and
frequency of blood draws
◦ Avoid arbitrary 2 unit transfusions
◦ Consider transfusion alternatives for anemia management