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OUTLINE
INTRODUCTION
INTRODUCTION
Bloodless Medicine and Surgery(BMS) is relatively new Medicine has searched for alternatives to allogeneic blood The term (BMS) is defined as the avoidance of allogeneic blood The practice of BMS entails more Balance - Benefits and risks Homologous blood transfusion
Knowledge of broad spectrum of techniques and methods Employment of those techniques and methods(condition&harm)
Founded in 1884 in Western Pennsylvania as a Bible Study Group Grown into a worldwide organisation comprising over 7 million adherents
in over 200 countries
The Witnesses belief is that God views blood as sacred and holy. They cite some biblical passages to support their claims. Leviticus 17:10-12, God says to Moses:
As for any man of the house of Israel or some alien resident who is residing as an alien in their midst who eats any sort of blood, I shall
certainly set my face against the soul that is eating the blood, and I
shall cut him off from among his people. Genesis 9:1-4, God says to Noah after the flood: Every moving animal that is alive may serve as food for you. As in the case of green vegetation, I do give it all to you. Only the flesh with its soul, its blood, you must not eat.
Bible does not speak of blood transfusion The decree that Christians must abstain from taking blood covers the
taking of blood into the body, whether through the mouth or directly into the bloodstream.
Initially, J.W. adamant refusal of blood and blood products was met with
much controversy and frustration.
Doctors viewed J.W. position as one that prevented them from rendering
adequate care under certain circumstances
In those days, most open-heart surgeries required 20-30 units of blood It was the genesis of the bloodless medicine and surgery However the programme BMS was officially launched in 1997 at USC
University Hospital and USC Norris Cancer Hospital California in consultation with the local hospital liaison committee for J.W.
Highlights of the USC Programme include: The 1st adult-to-adult living-related live-donor liver transplant in a Jehovahs
Witness patient without blood products in June,1999.
Followed up with paediatric liver-donor liver transplant Others include bloodless o Radical nephrectomy o Cystectomy o Hip/Knee surgery o Ortho-spine surgery o Heart transplants o Cardiac bypass and valve replacement surgery
Currently there about 100 BMS centres in the United States The medical community is learning that bloodless medicine and surgery
has some benefits: 1.Helps Patients avoid problems such as Risks of contracting blood-borne diseases HIV, Hep A,B,C Blood transfusion reactions Shortage of blood 2. Patients also recover more quickly from surgical procedures
(immunomodulation - down regulation of cellular immunity by allogeneic blood). Extensive data showing that it enhances renal allograft tolerance
3. Significantly reduce medical costs A study conducted by members of Cleveland Clinics Anaesthesiology Department concluded that using a bloodless surgery protocol 50% of the time, could save the health care industry in the US up to $3.7 billion a year.
INTRAOPERATIVE STRATEGIES
PRE-OPERATIVE MANAGEMENT
This involves appropriately Assessing, Investigating and Preparing patients
prior to surgery to aid in reducing or avoiding allogeneic blood transfusion
This is a multidisciplinary approach: Blood bank technician(PABD) Physician (hypertension) Haematologist (haematological disorders) Surgeon (surgical approach or composition of team) Anaesthetist (intraoperative technique that can be used)
Cardio-respiratory disorders
SIGNIFICANCE OF ANAEMIA
Definition: Haemoglobin concentration in blood that is below the expected
value with respect to certain factors such as age, gender, pregnancy and altitude
The unit of measure is g/dl value dependent on ratio between Total amount of circulating Hb in RBC (numerator) Plasma volume (denominator)
Hence treating pathology and/or associated anaemia will improve the patients pre-operative condition
Decreased oxygen reserve in the body Surgical blood loss or cardio-respiratory depression due to anaesthetic
agents leads to decreased oxygen carrying capacity of the blood
Hence the body tries to maintain tissue oxygenation by falling on oxygen reserves in the body. However in anaemic patients their oxygen reserves are diminished and hence are at a higher risk of decompensation
This depends on the balance between oxygen delivery to the tissue and
oxygen demand (consumption requirement) by the tissue
* (n = CV)
n = (CaO2).(CO)
+
+
Since our Cardiac output = 5000ml/min (on the average for an adult)
maximum amount of O2/min that can be extracted body under basal conditions
5000ml x 15 100ml
750ml O2/min
DO2 critical
It is the minimum amount of O2 required to maintain tissue oxygenation Below this threshold, tissue hypoxia sets in The most rigorous clinical study found a threshold value of 4ml O2 /min/ kg (3-4g/dl Hb) The(4ml O2/ min/kg) value isn't accurate because: The DO2 critical measures is based on the average anaerobic threshold for the whole body at rest Different organs in the body have different anaerobic thresholds which may vary significantly from the bodys average Also metabolic demands are increased in various diseased states
Right Heart
Lungs
Left Heart
Venous side
Normovolaemia Hypovolaemia
Arterial side
Normovolaemia
Pre-capillary arteriole
Microcirculation
*Normovolaemia *Hypovolaemia-shunting
T I S S U E
capillary flow
*Normovolaemia - flow leads to recruitment of previously closed capillaries *Hypovolaemia decreased flow due to viscosity
O2 extraction Due to shift of oxyhaemoglobin curve 2,3 diphosphoglycerate levels increases after 12-36hrs with declining Hb level
HISTORY
Look out for common causes of Anaemia, Bleeding disorders and Cardiorespiratory disorders
1. Anaemia
Production Erythrogenesis renal disease leading to EPO Factory BM failure (haematological failure) Raw materials Iron bleeding from orifices (menorrhagia, haematuria, bleeding PR) Folate - utilisation of folate (metformin, phenytoin, methotrexate) Vitamin B12 lack of IF (post gastrectomy (uncommon)) Breakdown Haemolysis Haemoglobinopathies (SCD seasonal joint pains, jaundice) Malaria(Enemic region)
2. Bleeding disorders
Congenital Family history of bleeding disorders e.g. haemophilia A or B, Von Willebrand
disease
Warfarin (stop 3 days prior to surgery and check INR) Heparin (stop at least 6 hours prior to surgery)
3. Cardiorespiratory disorders
Some diseases are contraindicated in certain blood conservation methods: IHD Hypertension
NB: Severe hypertension predisposes to severe bleeding during surgery. Hence BP needs to be controlled before surgery
Thrombotic strokes
PHYSICAL EXAMINATION
1. General Examination
Pallor (and degree) Conjunctivae Tip of tongue Nail beds Sole of feet Palm
2. Cardiorespiratory System - For any abnormality which will affect oxygen delivery 3. Abdomen
Hepatomegaly Splenomegaly
Haemoglobinopathies Haematological malignancy
(Haematologist consult)
INVESTIGATION
* Blood tests should not be routine to blood loss
1.
Baseline FBC, Sickling test, BUE & Cr, CRP, ferritin Platelet count 100 x 109/L Hb: 7-8g/dl is acceptable in well compensated and otherwise healthy
individual presenting for minor surgery However higher preoperative Hb is indicated before elective surgery in the following Anaemia Signs of decompensation (eg. angina, dyspnoea) Blood loss major surgery/ significant blood loss expected(>10ml/kg)
(due to oxygen carrying capacity of blood)
Co-existing significant cardio-respiratory disease It may limit ability to further compensate for reduction in oxygen supply due to operative blood loss, cardio-respiratory depressant effects of anaesthetic agents
2.
Specific Blood film comment, LFTs, folic acid and B12 level Clotting profile for coagulation disorders
TREATMENT OR CORRECTION
1. Anaemia
EPO (renal disease) recombinant human EPO folate folic acid Iron Iron supplements EPO Malarial antimalarials Helminthic infestation e.g. hookworm deworming (Albendazole)
2. Bleeding Disorders
Need haematologist consult
3. Cardio-respiratory Disorders
Need physician consult
Route: IM/ SC/ IV (gives higher plasma levels) Dose varies but iron supplementation required
Mechanism of action Causes committed stem cells to be converted to RBC lines Dose dependent increase in reticulocyte count, Hct and Hb
Adverse Effects More common in patients with renal insufficiency Hence unclear if adverse effects are due to renal disease/
EPO therapy/ Both CNS seizures, CVA, hypertensive encephalopathy CVS: MI, hypertension Others: hyperkalaemia, thrombosis
INTRAOPERATIVE STRATEGIES
PATIENT POSITIONING(POSTURE) ANAESTHESIA TECHNIQUE
BP effect
going below heart going above heart 0.77mmHg per centimetre of vertical distance at the density of normal blood
Blood volume
with BP (arterial/ venous) with BP (arterial/ venous) NB: because the veins are more compliant than arteries (i.e. c V/P); a small change in pressure in venous system leads to significant accumulation of blood) 1mmHg pressure increase in circulatory system can lead to accumulation of blood in the venous system up to 8 times the volume in the arterial system
increases blood flow (due to BP) venous drainage (due to congestion) Combination of the two leads to blood loss
Level of the operative site should be a little above the level of the heart This will lead to
blood flow to the operative site and reduces venous congestion
Trendenlenburg position (head down) most appropriate for abdominal, pelvic, lower limb procedures
Reverse Trendenlenburg position (head up) most appropriate for head and neck surgery
NB: in the head up position
Pressures in the veins above the level of the heart are subatmosphereic Hence if a large vein above the level of the heart is opened to the atmosphere during surgery, there is potential of air to enter the circulation causing an air embolus This complication is rare and can be avoided with careful surgery
ANAESTHESIA TECHNIQUE
SPINAL ANAESTHESIA Systemic vasodilatation
GENERAL ANAESTHESIA
GENERAL ANAESTHESIA
Blood flow to surgical site (Q) Determinants MAP prevents episodes of hypertension and tachycardia due to
sympathetic overactivity by causing adequate levels of anaesthesia and analgesia Peripheral resistance prevent widespread vasodilatation due to hypercarbia (CO2 retention) by controlling ventilation (need for capnograph monitoring)
Venous drainage from site Impaired by Cough (impair venous drainage) Straining Patient movement
Adequate muscle relaxation to prevent unnecessary manoeuvre
This is the deliberate reduction in the blood pressure to facilitate surgery and it improves the surgical field and may reduce blood loss between 3050% Contraindications include HPT, IHD or Valvular Heart DX, RF, previous CVA.
Hypotensive agents
B-blockers: Labetolol 2-10mg bolus. Infusion 2.5-30ug/kg/min Esmolol, 50-250ug/kg/min Vasodilators Hydrallazine, 2-5mg boluses Na nitroprusside, 0.3 0.5ug/kg/min
Classification
Acute Hypervolaemic Haemodilution Acute Normovolaemic Haemodilution Periopertaive Blood Salvage) PABD (Preoperative Autologous Blood Donation)
Synonyms Acute isovolaemic haemodilution Acute normovolaemic anaemia Controlled normovolaemic exsanguination
Specific
Accident centre: Orthopaedic surgery: joint replacement procedure Cardio: cardiac surgery/ vascular surgery (major reconstructive vascular surgery) Ground floor: Neurosurgery (major back procedures) 1st floor GU: urologic surgery nephrectomy; cystectomy; prostatectomy General surgery major bowel resection; cancer resection Eye: ENT: MFU:
Contraindication
Anaemic Level
Initial Hct 36% (Hb 12g/dl) (* values as low as 24% may be acceptable Hb 8g/dl)
Blood coagulation disorders Because dilution of blood with asanguinous fluid also dilutes
coagulation factors eg. platelets
Coexisting disorder CNS significant cerebrovascular disease : cannot tolerate lower Hct
value
CVS severe hypertension/ underlying cardiac disorder (severe aortic stenosis/ unstable angina) : cannot tolerate lower Hct value, impaired ability to compensate for anaemia Resp severe pulmonary disease : impaired ability to compensate for anaemia
Persistence/ presence of foetal Hb leads to leftward shift of oxyhaemoglobin dissociation curve which impairs oxygen release at tissue level to compensate for iatrogenic dilutional anaemia
Elect Target Hb = 10g/dl EBV = 90 x 75 = 6750ml Average Hb = (14+10)/2 = 12 Volume of blood to be collected = (14-10)/ (12 x 6750) = 2250ml
NB: max no. of units of blood removed is 3
INTRAVENOUS ACCESS a) Arterial line Adv: arterial pressure serves as a pressure head that pumps the
blood into collection bag Disadv: inability to do invasive blood pressure monitoring; to monitor beat to beat BP b) Venous access Adv: invasive BP monitoring possible Disadv: blood sequestration is a passive process and its speed is influenced by gravity Types:
a)
b)
Central ( + large bore peripheral IV) most reliable and effective because lack of venous valves to slow down flow and cause sludging; most popular sites are internal jugular and subclavian (but can be placed anywhere) 2 large bore peripheral most popular but has sludging risks; needs at least 18G cannula; 2 large cannulae are inserted in opposite arms to aid flow)
Emptying
Patient 3 way tap attached to cannula opened for blood to flow into tubin Blood should be seen flowing through tubing of collection bag Must ensure that blood doesnt lump and coagulate in the tube
leading to flow obstruction Tubing shouldnt be too long to minimize tubing dead space Flushing of tubing periodically with N/ Saline
Collection bag Add mixture of blood and CPD anticoagulant as blood flows into collection
bag to prevent sludging/ clumping off RBCs or platelets.(automatic or manual)
Blood quantity typically 450ml of whole blood is collected into each bag. Subjective: experienced eye to adjudge whether collection bag is overfilled or underfllled Objective: weighing (1ml of blood weighs 1g) Advantage: to accurately calculate amount of asanguinous fluid is required to maintain normal blood volume for adequate volume resuscitation
Labelling
Patient info: Name; Age; Sex; Hospital number
Storage
Room temperature (20C) Must be re-infused (after haemostasis controlled) within 6hrs as haemolysis takes place after 6 hours at room temperature 1st unit salvaged is given last Refrigerant (0C) To be used if not going to be re-infused within 6hrs Must be re-infused within 24hrs Disadv: decease or inactivate platelet function
Fluid resuscitation
2)Colloids
Advantages Stay in intravascular space [1:1 replacement ratio] Less risk of tissue oedema Disadvantages Expensive Not easily diuresed Most colloids have a half life longer than 4hrs and may not be rapidly diuresed
from body Therefore there is at least the theoretical risk of hypervolaemina and fluid overload if the sequestered blood is re-infused rapidly after haemostasis has been achieved
Types Short acting [t1/2 < 4 hours] Pentastarch; Dextran 40 Intermediate acting [t1/2 4-24hrs] Dextran 70 Long acting [t1/2 >24 hrs] - albumin, high molecular weight HES e.g. Hetastarch
MONITORING
Basic
ECG continuous HR (gives idea of volume replacement + urine output), ST segment info (ischaemic changes) Pulse oximeter oxygen saturation BP invasive BP preferred as it gives beat to beat blood pressure Capnography adequacy of circulation
Additional
CVP (central venous pressure) assess volume status and oxygen delivery PAP (pulmonary arterial pressure) Transoesophageal echocardiography real time assessment of ventricular and valvular performance
Haemodynamic consideration
In future
Whole blood collection circuit and fluid resuscitation system have to remain continuous with patients intravascular compartments
Once blood collection in patient has been achieved it should be allowed to trickle slowly back into patient to resemble venous flow
NB: If all the whole blood cannot be administered in the operating room, reinfusion can continue in the recovery room. However when patients emerge from anaesthesia they and their families need to be prepared that the whole blood is autologous and it is the end phase of the ANH technique
Advantages
1.
RBC (Hb) Fewer loss of RBC & Hb per given volume of blood loss E.g. A - Starting at Hb=14g/dl blood loss volume = 1000ml amount of Hb loss = 140g (1000ml 14g) B - Starting Hb 10g/dl (after ANH) blood volume loss = 1000ml amount of Hb loss = 100g (1000ml 10g) Difference between A & B = 40g of Hb Platelets and coagulation factros Provision of fresh supply durng re-infusion
2.
A. B. C. D. E.
Anaemia/ haemodynamic change during blood collection period leads to BP and HR Blood clumping in tubing and collection bag slows collection process Collection bag overfilled/ underfilled Distraction conduct of anaesthetist OR blood collection process OR both Entering allogenic blood pool in blood bank
Definition
Acute (process is conducted relatively rapidly over minutes) Hypervolaemic: blood volume of patient is increased Haemodilution: blood of patient is diluted with asanguinous fluid
infusion
Pitfalls
This technique is not as widespread as ANH and is relatively new There is not enough data about its use and safety
Similar to ANH
Calculation of amount of volume expansion required to achieve Hct of 20-25% Subjective 20-40ml/kg IV fluids fast Objective (Kumar et al proposed equation)
EF expansion factor
x EF
Definition: depends on ability of fluid used for haemodilution to expand plasma volume of patient
e.g. Fluid with volume effect of 80% (i.e. 80% of fluid stays in intravascular space) will have EF = 100/80 = 1.25
Hence its is important to choose fluid that has an intravascular residence time similar to the time of surgery. This is in order to maintain hypervolaemia during surgery. Colloids are preferable HES, dextran 40, gelatin
Definition
Process of Collection + anticoagulation Filtration centrifugation and washing Reinfusion of shed blood into the same patient
Classification
Timing of collection of blood Intraoperative period Post operative period Unprocessed blood (not washed)/ Processed blood (washed)
Indication General Anticipated blood loss >20% of circulating blood volume Current blood loss is significant to require blood transfusion Blood type transfusion rare and adequate amounts of allogenic
blood cannot be found
Specific Elective cardiothoracic procedures Emergencies Ruptured ectopic gestation Ruptured spleen
initiates intravascular coagulation B. Bacteria contamination due to bowel contents/ infected wounds/ urine C. Cancer surgery (controversial) Theoretical risk of dissemination of tumour cells because standard filtration and washing does not remove malignant cells Risk is decreased by Using specific filters (leucocyte depletion filter) Irradiation of salvaged blood to inactivate cancer cells NB: There as been no established difference in prognosis in oncology cases between patients who had blood salvaged and those that did not.
D.
Debris contamination (cells/ haemostatic agents protamine and thrombin]) may initiate intravascular coagulation Erythrocyte destruction (Haemolysis) shed blood of more than 6hrs should NOT be re-infused since haemolysis of RBCs s likely to be complete Fat contamination
E.
F.
This is often seen in orthopaedic surgery due to the marrow fat in wound blood This is associated with fat embolism and related pulmonary endothelial damage NB: even after filtration and washing or salvaged RBCs a s significant amount of fat remains in blood
Sickle cells occur when Hb is deoxygenated. However in cell salvage blood id in contact with air and therefore Hb is oxygenated
Anticoagulants(why)
blood collected from operation site comes into contact with tissue
factors leading to activation of clotting cascade with FDPs formed; leading to reduced levels of fibrinogen in salvaged blood ( 1g/L)
Anticoagulants(Types)
Heparin avoid in patents with platelet dysfunction or heparin
induced thrombocytopaenia (HIT)
CPD (citrate-phosphate-dextrose)
Citrate chelates calcium
Adv: improves platelet function Disadv: hypocalcaemia in hepatic insufficiency
Anticoagulant It is added manually via port on canister (reservoir) Filtration blood and anticoagulant filtered through a micro filter (20150m) to remove large particles and cellular debris from blood, into a rigid reservoir with a disposable liner or collection bag
washing: blood washing device Reinfusion: processed or unprocessed using standard blood transfusion
set
Filtration: anticoagulated blood is filtered into a disposable reservoir Washing: filtered blood is then centrifuged this separates denser RBCs from plasma and dissolves
solutes (WBC, platelets, anticoagulants, cellular debris, RBC free Hb and other contaminants)
washed with saline- This dilutes plasma and dissolves solute and
discarded.
complications
More likely to occur when using large volumes of unwashed blood Advisable NOT to salvage more than 1500ml of unwashed blood
A. B. C. D. E. F.
Air embolism Breathlessness (pulmonary insufficiency) Coagulopathy and calcium derangement Disease (sepsis) Electrolyte imbalance and acid-base disturbance Fat embolism
G.
H.
GU renal dysfunction
haemolysis
A.
Air embolism a) Aetiology reinfusion of blood done under pressure (rare complication) b) Effect mortality
B.
Pulmonary dysfunction a) Aetilogy - debris/ fatty acid (toxic) damage pulmonary vasculature b) Effect pulmonary oedema etc.
C.
Coagulopathy a) Aetiology
anticoagulant usage heparin/citrate may be re-infused in large amounts if washing of salvaged RBCs is not done properly washing technique washing of large volumes of salvaged blood (>2L) can lead to loss of platelets and clotting factors into waste bag. Monitoring of clotting profile is indicated when large volumes of RBCs are salvaged DIC (intracellular components of blood activate coagulation cascade)
b)
Effect - bleeding
C.
a)
Aetiology
b) D.
entry large volumes of blood salvaged ( amounts of CPD) exit hepatic insufficiency slow citrate metaboliism
E.
Electrolyte imbalance
a) b)
Aetiology dilutional due to re-suspension of salvaged RBCs in saline for transfusion Effect depends on electrolyte
E.
Acid-base disturbance
a) b) F. G.
a)
Aetiology haemolysis due to: High suction level Aspiration causing excessive mixing of air with blood
b)
Effect
Turbulence of air shear stress n RBC membrane destruction of RBCs free Hb excess free Hb (Hb 150mg/dl exceeds binding capacity of haptoglobin) haemoglobinuria ARF NB: if adequate diuresis is maintained (until urine free of Hb) Hb can be excreted without renal duysfunction
If tubing from the reservoir bag to the cell saver analyser is inadvertently clamped, pressure builds up in the tubing and this will cause tubing to disconnect from analyser and spray blood throughout operating room
Such problems mandate the need for personnel involved in the use of cell saver devices to be educated and familiar with the equipment prior to operating the device
D donation B of blood
A by a patient
P in the elective preoperative period and subsequently re-infused into the same patient if operative blood loss necessitates blood transfusion
Indication
Surgical blood loss likely to result in transfusion ( 20% circulating blood volume)
Contraindication
A. B. C. D.
NB: Age and weight are no longer a restriction Paediatric age group do not donate more than 10% of blood volume Weight < 50kg do not donate more than 9ml/kg
Process
A.
Awareness of patient : Benefits of procedure Risk of procedure (including possibility of homologous transfusion Consent form signed Minimum criteria for autologous BP at the time of each donation
B.
Collection Onset: about 5 weeks prior to surgery Duration: in adults about 1 unit of blood (450ml) is collected weekly (7 days) but last unit is collected at least 5 days prior to surgery Reason allows time for the Hct to increase and time for plasma proteins to normalise intravascular volume prior to surgery Effect 4-5 units of blood may be available for use by the date of surgery
Problems
Crossover technique into homologous pool Leapfrog technique serial re-transfusion of stored blood starting with the oldest donated blood. Then fresh unit of blood donated later.
Fridge storage
Blood should be stored in a refrigerator at 4C (up to 35 days) in a section of the refrigerator separate from the homologous blood pool Blood should be clearly labelled with name, age, sex, hospital number, blood group, AUTOLOGOUS BLOOD INSCRIPTION.
GXM
ABO grouping is required for patient identification Other tests on blood donated are mandatory if cross over s going to occur e.g. transfusion transmitted disease 48hrs prior to surgery, fresh blood sample of patients is taken to ensure ABO compatibility because of increased risk of procedural errors leading to incorrect identification
Haemotransfusion indication
This should be based on same criteria used for the transfusion of homologous blood and should not be merely given because it is available
This is because of the risks of incorrect identification and possible bacterial contamination with banked blood.
Advantages
Decreases need for homologous blood and its problems Crossover effect - provided donor has met all the criteria for
homologous blood donation ( donor blood pool)
Disadvantages
Bacterial contamination of blood id possible Cost is higher than allogeneic blood transfusion Disability may lead to ineligibility to donate e.g. severe cardiac
disease
Classification Procoagulants encourage clot formation rVIIa DDVP Antifibrinolytics slows down clot dissolution Tranexamic acid Aprotinin
COAGULATION CASCADE
TPA + fibrinogen
I.
(route) intravenously (IV) dose varies (20-40g/kg over 3 minutes) Dynamics: Factor VII plays a key role in extrinsic pathway (requiring tissue damage) by activating Factor X which then enters common pathway of coagulation cascade
II.
Deamino-8-D-arginine vasopressin (DDAVP)/ Desmopressin Definition: synthetic analogue of arginine vasopressin (ADH)
D deamino demination of hemicysteine at position 1 (one) of ADH (AVP) Adv: protects DAVP from peptidase degradation hence prolongs t1/2 to 55-60 minutes D arginine this substitutes L arginine at position 8 (eight) of AVP Adv: limits activity of DDAVP on V1 receptors found on smooth muscle CVS hypertension Resp broncho-constriction GIT cramps Uterus - cramps
Route: intravenously (IV), subcutaneously, intranasally (both equally effective as IV but plasma concentration peaks after 1 hour)
Rapid administration causes endothelial cells to release prostaglandin which causes systemic vasodilatation and hypotension
III.
Definition
They are -amino carboxylic acid analogue of lysine (-ACL)
Route: oral/ IV (preferred in perioperative period) Bioavailability (dose) EACA loading: 100-150mg/kg; maintenance dose 1015mg/kg/hr TXA loading: 10mg/kg; maintenance 1mg/kg/hr lower doses than EACA becaue 7-10x more potent
Excretion
EACA: 90% is excreted in urine within 4-6hrs of administration TXA: 90% is excreted in urine within 24hrs of administration
Route: oral/ IV (preferred in perioperative period) Bioavailability (dose) EACA loading: 100-150mg/kg; maintenance dose 10-15mg/kg/hr TXA loading: 10mg/kg; maintenance 1mg/kg/hr
MECHANISM OF ACTION
Competitive inhibition binds to fibrinogen (at lysine potion) and this prevents TPA from binding to fibrinogen. Hence TPA is degraded rapidly. This reduces rate of conversion of plasminogen to plasmin (fibrinolysis) to lyse clots
Adverse effects
Increases perioperative thrombotic events Nausea, vomiting, diarrhoea, hypotension (when administered rapidly IV)
Aprotinin
Distribution Rapidly redistributed into extracellular fluid Rapid accumulation in renal tubular epithelium Rapid lysosomal degradation Hence need for continuous infusion to maintain adequate
plasma concentration
SURGICAL TECHNIQUE
The training, experience and care of the surgeon performing the procedure
is the most crucial factor in reducing operative blood loss
Preoperative planning Surgical team composition: an enlarged team helps reduce operating
time hence reduce operative blood loss
Appropriate surgical technique Non-invasive procedures No blood loss e.g lithotripsy (sound waves to break up kidney
stones into smaller bits allowing it to pass out of the urinary tract without creating an incision or cut
Minimally invasive procedures Little blood loss e.g. laparoscopy (key hole surgery), endoscopy
Invasive procedures
Use of Tourniquet Meticulous heamostasis: Sutures Devices: electrocautery, argon beam coagulator Microwave coagulating scalpel
POSTOPERATIVE MANAGEMENT
Blood loss and hypovolaemia can still occur in postoperative period Hence it is important to try and prevent it. But if it still occurs, detect it early and treat Preventative measures
Leading to tissue hypoxia Hence it is important to give supplementary oxygen to all patients
recovering from GA and monitoring O2 saturations sing pulse oximeter
Vitals monitoring ECG ST segment changes to indicate ischaemia Pulse & BP Tachycardia could be due to hypovolaemia Need to regularly check wound and drains for bleeding/
haematoma
Intervention
Secure haemostasis (early surgical re-exploration) This is indicated where significant blood loss continues to occur in
the postoperative period and there is no treatable disturbance of the coagulation status of the patient
Blood transfusion Indication based on Anaemia postoperative Hb Baseline general condition of patient (whether surgery of
inadequate tissue oxygenation)
Older oxygen therapeutic agents have existed since 1930s using lysed RBC; however although they demonstrated oxygen carrying properties they were nephrotoxic in nature. Other side effects were attributed to dissociation of the Hb tetramer into dimers and polymers
Used in patients with severe injuries led to reduction in overall 30-day mortality and reduction in allogenic blood use overall as well as a reported reduction in incidence of multi-organ failure
Prepared from is prepared from outdated human RBCs. The cells are washed to remove plasma proteins and lysed (gently) filtered and pasteurised and finally purified using chromatography Added to ringers lactate to produce product with Hb concentration 10g/dl Has been trialled in patients undergoing coronary artery bypass graft in conjunction with ANH. Overall patients had increased transfusion avoidance and reduction in units of allogenic blood transfused
Lower oxygen affinity compared to Human Hb so facilitates easier oxygen unloading in tissue Does not require refrigeration and is stable at room temperature for 2 years Clinical trials have demonstratd reduction in transfusion requirements
Recent development of newer tetrameric rHb that do not cause vasoconstriction when infused and have fewer side effects eg. Hemozye, MP4 ( a tetramer combined with polyethylene glycol to create larger molecule to stay in intravascular space)
Definition
carbon fluorine compounds characterized by a high gas dissolving capacity (oxygen and carbon dioxide) low viscosity and chemical and biological inertness.
Unlike haemoglobin with sigmoid shaped dissociation curve, there is a liner relationship between oxygen partial pressure and oxygen content
Must be given with supplemental oxygen to maintain relatively high arterial oxygen partial pressures, which are necessary to maximize the oxygen transport capacity of fluorocarbon emulsions.
Intravascular perfluorocarbon solutions loaded with oxygen at a PaO2 of 200 mmHg can deliver 5 vol% of oxygen per decilitre of perfluorocarbon
Perfluorocarbons release 80% of their carried oxygen so can deliver approximately four times the oxygen that would be delivered by the same volume of Hb.
Giving 120 ml of Oxygent to a 70-kg patient is equivalent to 500 ml transfusion of whole blood
CONCLUSION
Patients should be given the option of choosing autologous blood transfusion They have the choice of PABD, ANH or soon Blood salvage ANH provides warm, platelets and Factor VIII rich blood Combination of PABD and ANH is possible It is relatively easy to perform and reasonably safe Erythropoietin is an accepted therapy for the increase in the Hb for autologous blood transfusion EPO is worth its price when one thinks about HIV and this is accepted among Jehovah's witnesses Properly planned rare blood groups can be easily done Other blood conservation methods must be employed before thinking about allogenic blood A patient who needs just a unit of blood probably does not need it
REFERENCES
1. 2. 3.
Cardiovascular Physiology Concepts Myocardial oxygen extraction: www.cvphysiology.com/CAD/CAD008.htm (Richard E Klabunde PhD) Review of physiologic mechanism I response to anaemia: Paul C Herbert (MD, FRCPC, mHSc), Ling Qun Hu, George Bird Acute normovolaemic anaemia: Physiological and practical concerns: P. Van der Linden (Dept. of Anaesthesiology, CHU Brugmann, Brussels, Belgium)
4.
5. 6. 7. 8. 9.
Anaemia and red blood cell transfusion in the critically ill patient: S.A. McLellan, D.B.L. McClelland, T.S. Walsh
Network for advancement of Transfusion alternative (NATA) Oxygen delivery and consumption: Ilene M. Roben MD, Scott Manaker MD Critical care medicine tutorials (oxygen) Oxygen delivery: Nathan W Peterson, Lisa Moses Acute Normovolaemic Haemodilution: Larry Eitel
Role of the red blood cell in Nitric oxide homeostasis and hypoxic vasodilatation: Mark T Gladwin Peri-operative anaemia management: consensus statement on the role of intravenous iron www.nba.gov.au/guideline/module2 medicine for residents- Iron and iron deficiency anaemia- quick recap A Physicians Guide to oral iron supplements (www.anemia.org) Perooperative blood conservation www.schulich.vwo.ca/anaesthesia/perioperativeblood-conservation WHO clinical use of blood pdf Iron metabolism wikipedia Oxygen content of blood: Anaesthesia UK (www.frca.co.uk/article)
30. ANH policy in surgical patients 31. Global Blood safety Initiative (autologous transfusion in developing countries) 32. Transfusion alternatives for Jehovahs Witnesses (St Georges Healthcare) 33. Cardiovascular pharmacology concepts vasopressin analogues
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