Basics of Blood Management - part 5 ppsx

BLUKO82-Seeber March 14, 2007 17:3 Preparation of the Patient for Surgery 153 Melagatgran Ximelagatran Abciximab Eptifibatide Tirofiban Ticlopidine Clopidogrel Dipyridamole Aspirin Flurbiprofen Direct thrombin inhibitor Direct thrombin inhibitor Blocks GPIIb/IIIa receptor of platelets GPIIb/IIIa inhibitor GPIIb/IIIa inhibitor Irreversible blockage of platelet ADP receptor Irreversible blockage of platelet ADP receptor Thrombox- ane inhibition Thromboxane inhibition May be not needed May be not needed Hemodyne analysis, modified TEG Specific platelet function tests (aggregometry or platelet count ratio) using ADP as an activator, platelet count Platelet function assay Chromogenic substrate (Chromozym), FEIBA, rFVIIa Desmopressin Dialysis, possibly desmopressin or rFVIIa, fibrinogen/ cryo-ppt Desmo- pressin, fibrinogen/ cryo-ppt Aprotinin, desmopressin, rFVIIa, plasmapherese Desmopressin, Aprotinin value is not yet fully understood. If the surgeon plans treating an anticoagulated patient, please refer to the literature for indication and dosages of the proposed agents. full-dose heparin instead of vitamin K antagonists. This permits emergency reversal with protamine if bleeding occurs. Another common anticoagulant is aspirin, an an- tiplatelet agent. It has been documented as a reason for an increased risk of perisurgical bleeding and in- creased use of transfusion [56], although this effect has not been demonstrated in other studies. The antiplatelet effect of aspirin is pronounced if the patient has taken other anticoagulants, has a preexisting problem with hemostasis, or if alcohol is taken concurrently [53]. Since aspirin irreversibly inhibits thromboxane synthesis in platelets, it is best stopped several days before surgery and the surgeon should wait until functional platelets are produced. Nowadays many other anticoagulants are used in clini- cal practice. Table 11.5 provides an overview of the existing drugs and potential reversal methods if such become nec- essary [58–79]. Avoid pharmacologic coagulopathies Many drugs are not used for anticoagulation but nevertheless affect hemosta- sis (Table 11.6) [53, 80, 81]. Whether all such drug effects translate into increased perioperative bleeding has not yet been determined. However, if at all possible, such phar- macologically induced coagulopathies should be avoided. Often it is possible to switch from one drug to another or to stop the drug altogether. Drug-induced coagulopathies can be antidoted occasionally. cardiopulmonary and general condition In coronary artery disease, the ability to increase the cardiac output is impaired, thus limiting the patient’s ability to tolerate anemia. It is important to avoid car- diac ischemia. Perioperative analgesia, anxiolytic medica- tions, normothermia, judicious beta-blockade, and close monitoring for cardiac events are recommended [82]. If Table 11.6 Examples of drugs and herbs that can cause coagu- lopathies and may increase perioperative blood loss. Nonsteroidal anti-inflammatory drugs Penicillin Some cephalosporins such as cefotaxime, moxalactam Quinidine Alteplase Protamine Nifedipine Nitroglycerine Paroxetine, fluvoxamine (vitamin C) High-dose vitamin C Valproate St John’s wort Ginger Garlic Certain hydroxyethyl starches (desmopressin) Propofol Note : The agents in parenthesis may be used to counteract pharmaco- logical coagulopathies. BLUKO82-Seeber March 14, 2007 17:3 154 Chapter 11 the patient has had beta-blockers before surgery, such should be continued to prevent withdrawal, which may otherwise cause ischemia. The perioperative risk for is- chemia can also be reduced by preoperative coronary revascularization. There are several measures available to optimize pa- tients’ pulmonary function prior to surgery. Smokers should stop smoking at least 8 weeks before surgery. In- centive spirometry before and after surgery should be en- couraged in patients with pulmonary problems. Medical therapy is at times indicated, such as bronchodilators for wheezing, and beta-agonists and atropine analogs in pa- tients with asthma and chronic obstructive pulmonary disease. A number of conditions can adversely affect anemia tolerance and counteract efforts to lower the patient’s use of donor blood. Efforts should be taken to optimize the patient’s condition preoperatively. Optimizing the surgical field In certain situations it seems prudent to optimize the sur- gical field. There are several methods for reducing the surgical field, for example, reducing the size of a tumor by preoperative chemotherapy or radiation. The vascularity of the surgical field can also be reduced. Preoperative em- bolization for primary tumors and metastases as well as for whole organs can reduce perfusion and thus blood loss [83–85]. Pharmacological therapy maybeequallyeffective in selected cases. For instance, finasteride given before be- nign prostate hyperplasia operations reduces angiogenesis in the prostate and reduces bleeding and transfusions in patients [86–88]. Patient education By definition, blood management is patient centered. This means that at all times the patient is the center of all efforts. It is crucial, therefore, to actively include him in the preparations for surgery or any other treatment. This is essential for a good patient–doctor relationship and improves patient compliance. The patient can do much to reduce exposure to donor blood. All patients should be advised not to take drugs on their own initia- tive. Help patients understand that a single aspirin for a headache or menstrual discomfort can increase blood loss. Sound habits such as healthy nutrition, sufficient sleep, and abstinence of noxae are very basic but improve pa- tients’ general condition. Moderate physical exercise may improve not only the overall condition of the patient but may also treat anemia [89]. An information book- let may be handed to the patient detailing the planned blood management procedures. It may also include a sum- mary of what the patient can do during the treatment and perisurgical period. Such a booklet may remind the pa- tient of the need to adhere to the prescribed schedule of therapy. Prepare the equipment Hours before the battle of Waterloo, Napoleon Bonaparte told his generals: “This affair will be no more serious than eating one’s breakfast.” Shortly thereafter, however, he was proven wrong. It was raining. The raindrops rendered the weapons useless, made the roads muddy and impassable for war wagons, blocked the vision of the combatants, and left the soldiers soaked to the skin. The battle at Water- loo was lost, at least in part, because proper, water-proof equipment waslacking.Somethingasinsignificant asrain- drops stopped Napoleon. Experience gained in years of campaigning was rendered useless due to the presence of rain. This drives home an important point. The most so- phisticated equipment is of little use if it is damaged or unavailable. Therefore, make sure all devices and drugs are handy before surgery. When it starts pouring and vi- sion is obscured, equipment must be readily available to master the situation. Always prepare the equipment and have the needed drugs available to ensure the patient does not meet his Waterloo. Preparation should not only involve getting ready for the intended procedure. Emergency equipment should also be made ready. One suggestion is to prepare an emer- gency tray with all that is needed to treat sudden massive bleeding [90]. The contents of such a tray can be tailored to the specialty and skills of the surgeon. It may contain tourniquets, tamponade materials, catheters to block ves- sels, special clamps, glues, mashes, balloons, etc. It may also contain copies of algorithms that guide through the management of emergent or heavy bleeding [91]. Having such a tray ready saves time in an emergency and may reduce the total blood loss. Be prepared The duration of a surgical procedure influences the degree of blood loss. Independent of otherfactors, long operation times increase blood loss. However, speeding up a proce- dure at the expense of quality does not reduce blood loss BLUKO82-Seeber March 14, 2007 17:3 Preparation of the Patient for Surgery 155 either. Rehearsing the procedure before going to the oper- ating theater is wise, because this helps the surgeon have the steps of the planned procedure fresh in mind. This may not only shorten the duration of the procedure but also improve the quality of the operation, both of which reduce blood loss. Key points r Algorithm for preparation of a patient for surgery 1 Take a thorough history and perform a physical exami- nation, paying special attention to obstacles to transfusion avoidance and matters pertaining to blood management; Review test results already available 2 Order labs and other tests if such are clearly indicated but beware of iatrogenic blood loss 3 Based on the findings of #1 and #2, calculate the allow- able blood loss, blood volumes, and determine the lowest tolerable hematocrit. 4 Formulate a plan of care (with a timetable). It should include the allowable blood loss and the expected blood loss. Record: ◦ How the patient’s medical problems will be treated, e.g., coagulation problems ◦ How to optimize the hemoglobin level ◦ What surgery is to be done and what preparations are necessary ◦ What measures will be taken to reduce blood loss ◦ What emergencies can be expected and how such will be dealt with. Further, list all additional personnel, items, and drugs required. 5 Prepare the patient and the equipment, and make personal preparation in accord with the plan of care. Questions for review r Which steps are vital to prepare a patient for surgery in a blood management program? r How do drugs influence the blood management of patients? r What measures need to be taken to work up a patient with anemia and with a coagulopathy? r What preparations are required for surgery in a blood management program? Suggestions for further research Compile a list of drugs that have an impact on surgical blood loss. List laboratory tests of coagulationandevaluatetheirvalue as predictors for surgical blood loss. Exercises and practice cases Answer the following questions: r A patient does not complain of any signs of a bleeding disorder. During the physical examination petechiae and a splenomegaly are found. Which laboratory tests should be ordered for the patient? r Last week, a patient presented with a Quick of 28. He was treated with appropriate doses of vitamin K. Today, he presents with a Quick of 35. What needs to be done? r A female patient complains of heavy menstrual bleeding although no obvious anatomic pathology is found in a gynecologic exam. Otherwise, she is healthy. Her Quick is 114%, her aPTT is 24 seconds, her platelet count is 250, and her hematocrit is 28. What tests should be ordered? r A male patient presents for elective hip replacement. He is scheduled for surgery in 3 weeks. On questioning, he states that he usually takes up to 2.5 g of aspirin per day about once a week for tension headache. Otherwise he is healthy. What tests should be ordered? Introduce Miss B to a colleague. Discuss in a multidis- ciplinary fashion how her treatment should be continued and write a plan of care for Miss B. Miss B is 70 years old; she has been sent by her family doctor for bilateral hip replacement. She suffers from a long-standing arthrosis. She has never had an operation before. Miss B lives alone on the third floor of an apartment building and has increasing difficulty climbing stairs. Her friend Millie used to have the same trouble. Once she got artificial joints, the patient says, she was again able to go for extended walks in the park. Miss B wants to join her friend and asks for the same procedure. Among other information the letter from Miss B’s doc- tor contains the following: Her height is 1.60 m and weight 55 kg Miss B takes the following drugs: r Cordarone tablets 200 mg per os 1-0-0-0 r Coumarin tablets 3 mg per os depending on the INR r Ibuprofen tablets 400 mg per os 1-1-1-1 Current laboratory test results: BLUKO82-Seeber March 14, 2007 17:3 156 Chapter 11 Table 11.7 Proposal for emergency hemorrhage equipment used in obstetrics and gynecology. Plastinated emergency informationDrugs/glues Equipment Remarks Tranexamic acid, desmopressin, conjugated estrogens, aprotinin, oxytocin, ergot derivative, prostaglandin analogues (Carboprost, Misoprostol), anticoagulant for cell salvage (heparin, citrate), vasopressin and glues for enhancement of packing, other topical hemostatics (gelatin, collagen, etc.) packing (5-yard roll), balloon device for uterine tamponade (Foley, Sengstaken- Blakemore), straight (10 cm) eyed-needles and large curved eyed-needles for use with No. 1 suture, 3 Heaney vaginal retractors, 4 sponge forceps, container and suction for cell salvage diagrams + instructions for the various types of compression sutures and tamponade techniques; Algorithm for nonblood management of postpartum hemorrhage, phone number of radiology dept. (embolization), pharmacy (rhFVIIa), dosage and indications for mentioned drugs Determine storage time, sterilization, responsible persons, intervals of checks, training Hematocrit 0.30; hemoglobin 10 g/dL (red cell in- dices: mean corpuscular volume and mean corpuscu- lar hemoglobin content decreased); leukocytes 8000; platelets 250000; electrolyte profile, liver, and kidney panel unremarkable. Experience shows that implanting a single artificial hip joint causes the loss of 1000 mL of whole blood. What is the allowable blood loss for patients with the fol- lowing characteristics: r 66 kg male with a minimum tolerable hematocrit of 20 and a current hematocrit of 45 r 100 kg male with a minimum tolerable hematocrit of 30 and a current hematocrit of 33 r 40 kg female with a minimum tolerable hematocrit of 25 and a current hematocrit of 37. Homework Take a focused history of three surgical patients in the hospital; be sure to get all the data needed for the patients’ blood management. Go to the hospital laboratory and find out whether platelet function tests are available. If so, obtain more in- formation on them. Find out what the three most common congenital and three most common acquired bleeding disorders are in your field of practice. Following the example of Table 11.7, draw up a list of contents for an emergency hemorrhage tray or chart for at least one of the following departments: Emer- gency department (acute trauma care), gastroenterology, urology, operating room for unexpected major bleeding, pediatrics, ENT, any other you prefer. References 1 Drager, L.F., et al. Impact of clinical experience on quantifi- cation of clinical signs at physical examination. JInternMed, 2003. 254(3): p. 257–263. 2 Keating, E.M. Preoperative evaluation and methods to re- duce blood use in orthopedic surgery. Anesthesiol Clin North America, 2005. 23(2): p. 305–313, vi–vii. 3 Scott, B.H., et al. Blood use in patients undergoing coro- nary artery bypass surgery: impact of cardiopulmonary by- pass pump, hematocrit, gender, age, and body weight. Anesth Analg, 2003. 97(4): p. 958–963, table of contents. 4 Khanna, M.P., P.C. Hebert, and D.A. Fergusson. Review of the clinical practice literature on patient characteristics associ- ated with perioperative allogeneic red blood cell transfusion. Transfus Med Rev, 2003. 17(2): p. 110–119. 5 Scott, B.H., F.C. Seifert, and P.S. Glass. Does gender influence resource utilization in patients undergoing off-pump coro- nary artery bypass surgery? J Cardiothorac Vasc Anesth, 2003. 17(3): p. 346–351. 6 Tzilinis, A., A.M. Lofman, and C.D. Tzarnas. Transfusion requirements for TRAM flap postmastectomy breast recon- struction. Ann Plast Surg, 2003. 50(6): p. 623–627. 7 Koscielny, J., et al. A practical concept for preoperative iden- tification of patients with impaired primary hemostasis. Clin Appl Thromb Hemost, 2004. 10(3): p. 195–204. 8 Kadir, R.A., et al. Frequency of inherited bleeding disorders in women with menorrhagia. Lancet, 1998. 351(9101): p. 485– 489. BLUKO82-Seeber March 14, 2007 17:3 Preparation of the Patient for Surgery 157 9 Rapaport, S.I. Preoperative hemostatic evaluation: which tests, if any? Blood, 1983. 61(2): p. 229–231. 10 Saito, T., et al. Coagulation and fibrinolysis disorder in mus- cular dystrophy. Muscle Nerve, 2001. 24(3): p. 399–402. 11 Noordeen, M.H., et al. Blood loss in Duchenne muscular dys- trophy: vascular smoothmuscle dysfunction? JPediatr Orthop B, 1999. 8(3): p. 212–215. 12 Franchini, M. Hemostasis and thyroid diseases revisited. J Endocrinol Invest, 2004. 27(9): p. 886–892. 13 Ouattara, A., et al. Identification of risk factors for allogeneic transfusion in cardiac surgery from an observational study. Ann Fr Anesth Reanim, 2003. 22(4): p. 278–283. 14 Bergquist, S. and R. Frantz. Pressure ulcers in community- based older adults receiving home health care. Prevalence, incidence, and associated risk factors. Adv Wound Care, 1999. 12(7): p. 339–351. 15 Dobson, M. World Health Organization Haemoglobin Colour Scale: a practical answer to a vital need. Anesthesia, 2002. 15 : Article 18. 16 Asaf, T., et al. The need for routine pre-operative coagulation screening tests (prothrombin timePT/partialthromboplastin time PTT) for healthy children undergoing elective tonsillec- tomy and/or adenoidectomy. Int J Pediatr Otorhinolaryngol, 2001. 61(3): p. 217–222. 17 Gewirtz, A.S., K. Kottke-Marchant, and M.L. Miller. The pre- operative bleeding time test: assessing its clinical usefulness. Cleve Clin J Med, 1995. 62(6): p. 379–382. 18 Gewirtz, A.S., M.L. Miller, and T.F. Keys. The clinical useful- ness of the preoperative bleeding time. Arch Pathol Lab Med, 1996. 120(4): p. 353–356. 19 Peterson, P., et al. The preoperative bleeding time test lacks clinical benefit: College of American Pathologists’ and American Society of Clinical Pathologists’ position article. Arch Surg, 1998. 133(2): p. 134–139. 20 Zwack, G.C. and C.S. Derkay. The utility of preoperative hemostatic assessment in adenotonsillectomy. Int J Pediatr Otorhinolaryngol, 1997. 39(1): p. 67–76. 21 Derkay,C.S.A cost-effectiveapproach forpreoperativehemo- static assessment in children undergoing adenotonsillectomy. Arch Otolaryngol Head Neck Surg, 2000. 126(5): p. 688. 22 Eckman, M.H., et al. Screening for the risk for bleeding or thrombosis. Ann Intern Med, 2003. 138(3): p. W15–W24. 23 DeLoughery, T.G. Management of bleeding with uremia and liver disease. Curr Opin Hematol, 1999. 6(5): p. 329–333. 24 Dempfle, C.E. Perioperative Gerinnungsdiagnostik. Anaes- thesist, 2005. 54: p. 167–177. 25 Hu, S.S. Blood loss in adult spinal surgery. Eur Spine J, 2004. 13(Suppl 1): p. S3–S5. 26 Senthil Kumar, G., O.A. Von Arx, and J.L. Pozo. Rate of blood loss over 48 hours following total knee replacement. Knee, 2005. 12(4): p. 307–309. 27 Yuasa, T., et al. Intraoperative blood loss during living donor liver transplantation: an analysis of 635 recipients at a single center. Transfusion, 2005. 45(6): p. 879–884. 28 Cushner, F.D., et al. Blood loss and transfusion rates in bilateral total knee arthroplasty. J Knee Surg, 2005. 18(2): p. 102–107. 29 Surgenor, D.M., et al. The specific hospital significantly af- fects red cell and component transfusion practice in coronary artery bypass graft surgery: a study of five hospitals. Transfu- sion, 1998. 38(2): p. 122–134. 30 NATA. TAB: Transfusion Medicine and Alternatives to Blood Transfusion. 2000. Edition. Available on http://www.nataonline.com/CONNATTex2.php3. 31 Surgenor, D.M., et al. Determinants of red cell, platelet, plasma, and cryoprecipitate transfusions during coronary artery bypass graft surgery: the Collaborative Hospital Trans- fusion Study. Transfusion, 1996. 36(6): p. 521–532. 32 Despotis, G.J., et al. Factors associated with excessive postop- erative blood loss and hemostatic transfusion requirements: a multivariate analysis in cardiac surgical patients. Anesth Analg, 1996. 82(1): p. 13–21. 33 Parr, K.G., et al. Multivariate predictors of blood product use in cardiac surgery. J Cardiothorac Vasc Anesth, 2003. 17(2): p. 176–181. 34 Moskowitz, D.M., et al. Predictors of transfusion require- ments for cardiac surgical procedures at a blood conservation center. Ann Thorac Surg, 2004. 77(2): p. 626–634. 35 Criswell, K.K. and R.L. Gamelli. Establishing transfusion needs in burn patients. AmJSurg, 2005. 189(3): p. 324–326. 36 Grosflam, J.M., et al. Predictors of blood loss during total hip replacement surgery. Arthritis Care Res, 1995. 8(3): p. 167– 173. 37 Nilsson, K.R., et al. Preoperative predictors of blood trans- fusion in colorectal cancer surgery. J Gastrointest Surg, 2002. 6(5): p. 753–762. 38 Mariette, D., et al. Preoperative predictors of blood transfu- sion in liver resection for tumor. Am J Surg, 1997. 173(4): p. 275–279. 39 Hunt, P.S. Bleeding ulcer: timing and technique in surgical management. AustNZJSurg, 1986. 56(1): p. 25–30. 40 Forest, R.J., et al. Repair of hypoplastic left heart syndrome of a 4.25-kg Jehovah’s Witness. Perfusion, 2002. 17(3): p. 221– 225. 41 Lawry, K., J. Slomka, and J. Goldfarb. What went wrong: multiple perspectives on an adolescent’s decision to refuse blood transfusions. Clin Pediatr (Phila), 1996. 35(6): p. 317– 321. 42 Bolan, C.D., M.E. Rick, and D.W. Polly, Jr. Transfusion medicine management for reconstructive spinal repair in a patient with von Willebrand’s disease and a history of heavy surgical bleeding. Spine, 2001. 26(23): p. E552–E556. 43 de Andrade, J.R., et al. Baseline hemoglobin as a predictor of risk of transfusion and response to Epoetin alfa in orthopedic surgery patients. Am J Orthop, 1996. 25(8): p. 533–542. 44 Hansen, M.E. and S. Kadir. Elective and emergency em- bolotherapy in children and adolescents. Efficacy and safety. Radiologe, 1990. 30(7): p. 331–336. BLUKO82-Seeber March 14, 2007 17:3 158 Chapter 11 45 Chou, M.M., et al. Internal iliac artery embolization before hysterectomy for placenta accreta. J Vasc Interv Radiol, 2003. 14(9, Pt 1): p. 1195–1199. 46 Tsirikos, A.I., et al. Comparison of one-stage versus two-stage anteroposterior spinal fusion in pediatric patients with cere- bral palsy and neuromuscular scoliosis. Spine, 2003. 28(12): p. 1300–1305. 47 Matin,S.F.,et al.Evaluationof age andcomorbidity asrisk fac- tors after laparoscopic urological surgery. JUrol, 2003. 170(4, Pt 1): p. 1115–1120. 48 Karski, J.M., et al. Etiology of preoperative anemia in patients undergoing scheduled cardiac surgery. Can J Anaesth, 1999. 46(10): p. 979–982. 49 Dix, H.M. New advances in the treatment of sickle cell dis- ease: focuson perioperative significance.AANAJ, 2001.69(4): p. 281–286. 50 Mankad, V.N. Exciting new treatment approaches for pathy- physiologic mechanisms of sickle cell disease. Pediatr Pathol Mol Med, 2001. 20(1): p. 1–13. 51 Weigert, A.L. and A.I. Schafer. Uremic bleeding: pathogenesis and therapy. AmJMedSci, 1998. 316(2): p. 94–104. 52 Krishnan, M. Preoperative care of patients with kidney disease. Am Fam Physician, 2002. 66(8): p. 1471–1476, 1379. 53 George, J.N. and S.J. Shattil. The clinical importance of ac- quired abnormalities of platelet function. NEnglJMed, 1991. 324(1): p. 27–39. 54 Chou, R. and T.G. DeLoughery. Recurrent thromboembolic disease following splenectomy for pyruvate kinase deficiency. Am J Hematol, 2001. 67(3): p. 197–199. 55 Papers to Appear in Forthcoming Issues. Gynecol Oncol, 1998. 68(2): p. 218. 56 Ferraris, V.A., et al. Preoperative aspirin ingestion increases operative blood loss after coronary artery bypass grafting. Ann Thorac Surg, 1988. 45(1): p. 71–74. 57 Chu, M.W., et al. Does clopidogrel increase blood loss follow- ing coronary artery bypass surgery? Ann Thorac Surg, 2004. 78(5): p. 1536–1541. 58 Kessler,C.M.Currentand futurechallenges ofantithrombotic agents and anticoagulants: strategies for reversal of hemor- rhagic complications. Semin Hematol, 2004. 41(1, Suppl 1): p. 44–50. 59 van Aart, L., et al. Individualized dosing regimen for pro- thrombin complex concentrate more effective than standard treatment in the reversal of oral anticoagulant therapy: an open, prospective randomized controlled trial. Thromb Res, September 20, 2005. 60 Levi, M., N.R. Bijsterveld, and T.T. Keller. Recombinant fac- tor VIIa as an antidote for anticoagulant treatment. Semin Hematol, 2004. 41(1, Suppl 1): p. 65–69. 61 Freeman, W.D., et al. Recombinant factor VIIa for rapid re- versal of warfarin anticoagulation in acute intracranial hem- orrhage. Mayo Clin Proc, 2004. 79(12): p. 1495–1500. 62 Hanslik, T. and J. Prinseau. The use of vitamin K in patients on anticoagulant therapy: a practical guide. Am J Cardiovasc Drugs, 2004. 4(1): p. 43–55. 63 Baker, R.I., et al. Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis. Med J Aust, 2004. 181(9): p. 492–497. 64 Chang, L.C., et al. PEG-modified protamine with improved pharmacological/pharmaceutical properties as a potential protamine substitute: synthesis and in vitro evaluation. Bio- conjug Chem, 2005. 16(1): p. 147–155. 65 Stafford-Smith, M., et al. Efficacy and safety of heparinase I versus protamine in patients undergoing coronary artery bypass grafting with and without cardiopulmonary bypass. Anesthesiology, 2005. 103(2): p. 229–240. 66 Schick, B.P., et al. Novel design of peptides to reverse the anti- coagulant activities ofheparin and otherglycosaminoglycans. Thromb Haemost, 2001. 85(3): p. 482–487. 67 Warkentin, T.E. and M.A. Crowther. Reversing anticoagu- lants both old and new. Can J Anaesth, 2002. 49(6): p. S11– S25. 68 Stratmann, G., et al. Reversal of direct thrombin inhibition after cardiopulmonary bypass in a patient with heparin- induced thrombocytopenia. Anesth Analg, 2004. 98(6): p. 1635–1639, table of contents. 69 Bodendiek,I., etal. Chromogenic substrateas antidoteagainst the thrombin inhibitor Melagatran. Hamostaseologie, 2003. 23(2): p. 97–98. 70 Elg, M., S. Carlsson, and D. Gustafsson. Effect of activated prothrombin complex concentrate or recombinant factor VIIa on the bleeding time and thrombus formation during anticoagulationwitha directthrombin inhibitor. Thromb Res, 2001. 101(3): p. 145–157. 71 Reiter, R.A., et al. Desmopressin antagonizes the in vitro platelet dysfunction induced by GPIIb/IIIa inhibitors and as- pirin. Blood, 2003. 102(13): p. 4594–4599. 72 Li, Y.F., F.A. Spencer, and R.C. Becker. Comparative ef- ficacy of fibrinogen and platelet supplementation on the in vitro reversibility of competitive glycoprotein IIb/IIIa (alphaIIb/beta3) receptor-directed platelet inhibition. Am Heart J, 2001. 142(2): p. 204–210. 73 Akowuah, E., et al. Comparison of two strategies for the man- agement of antiplatelet therapy during urgent surgery. Ann Thorac Surg, 2005. 80(1): p. 149–152. 74 Nacul, F.E., et al. Massive nasal bleeding and hemodynamic instability associated withclopidogrel. PharmWorld Sci,2004. 26(1): p. 6–7. 75 Samama, M.M., et al. Biochemistry and clinical pharma- cology of new anticoagulant agents. Pathophysiol Haemost Thromb, 2002. 32(5–6): p. 218–224. 76 Lubenow, N.andA.Greinacher. Drugs for the prevention and treatment of thrombosis in patients with heparin-induced thrombocytopenia. Am J Cardiovasc Drugs, 2001. 1(6): p. 429–443. BLUKO82-Seeber March 14, 2007 17:3 Preparation of the Patient for Surgery 159 77 Dyke, C.M., et al. Preemptive use of bivalirudin for urgent on-pump coronary artery bypass grafting in patients with po- tential heparin-induced thrombocytopenia.Ann ThoracSurg, 2005. 80(1): p. 299–303. 78 Greilich, P.E., et al. Near-site monitoring of the antiplatelet drug abciximab using the Hemodyne analyzer and modified thrombelastograph. J Cardiothorac Vasc Anesth, 1999. 13(1): p. 58–64. 79 Tanaka, K.A., et al. Clopidogrel (Plavix) and cardiac surgical patients: implications for platelet function monitoring and postoperative bleeding. Platelets, 2004. 15(5): p. 325–332. 80 Tielens, J.A. Vitamin C for paroxetine- and fluvoxamine- associated bleeding. Am J Psychiatry, 1997. 154(6): p. 883– 884. 81 Winter, S.L., et al. Perioperative blood loss: the effect of val- proate. Pediatr Neurol, 1996. 15(1): p. 19–22. 82 Nierman, E. and K. Zakrzewski. Recognition and manage- ment of preoperative risk. Rheum Dis Clin North Am, 1999. 25(3): p. 585–622. 83 Wirbel, R.J., et al. Preoperative embolization in spinal and pelvic metastases. J Orthop Sci, 2005. 10(3): p. 253–257. 84 Chatziioannou, A.N., et al. Preoperative embolization of bone metastases from renal cell carcinoma. Eur Radiol, 2000. 10(4): p. 593–596. 85 Layalle, I., et al. Arterial embolization of bone metastases: is it worthwhile? J Belge Radiol, 1998. 81(5): p. 223–225. 86 Li, G.H., et al. Effect of finasteride on intraoperative bleeding and irrigating fluid absorption during transurethral resection of prostate: a quantitative study. Zhejiang Da Xue Xue Bao Yi Xue Ban, 2004. 33(3): p. 258–260. 87 Hagerty, J.A., et al. Pretreatment with finasteride decreases perioperative bleeding associated with transurethral resec- tion of the prostate. Urology, 2000. 55(5): p. 684–689. 88 Crea, G., et al. Pre-surgical finasteride therapy in patients treated endoscopically for benign prostatic hyperplasia. Urol Int, 2005. 74(1): p. 51–53. 89 Dimeo, F., et al. Endurance exercise and the production of growth hormone and haematopoietic factors in patients with anaemia. Br J Sports Med, 2004. 38(6): p. e37. 90 Baskett, T.F. Surgical management of severe obstetric hemor- rhage: experience with an obstetric hemorrhage equipment tray. J Obstet Gynaecol Can, 2004. 26(9): p. 805–808. BLUKO82-Seeber March 14, 2007 17:0 12 Iatrogenic blood loss A number of patients are transfused after they developed anemia or a coagulopathy, due to surgery or trauma with major blood loss or due to an underlying medical con- dition. However, there is another group of patients who, although not belonging to the above, are transfused any- way. Many of these patients lost blood as a result of medi- cal interventions. A series of small iatrogenic blood losses can add up resulting in patients becoming anemic. This chapter will address seven of the major causes of such ia- trogenic blood loss and describe methods that minimize these losses. Objectives of this chapter 1 List different ways in which a medical caregiver causes blood loss. 2 Describe methods how iatrogenic blood loss is minimized. 3 Explain the vital role of minimizing iatrogenic blood loss in a comprehensive blood management program. Definitions Iatrogenic bloodloss : Theword “iatrogenic” stemsfrom the word “iatros” which is Greek and means “physician,” and “genesis,” which means “origin” or “cause.” “Iatrogenic” therefore means “caused by a physician.” All blood losses that are, directly or indirectly, caused by a physician’s in- tervention are summarized under the phrase “iatrogenic blood loss.” Actually, iatrogenic blood loss is not caused by physicians only. Every member of the care team can cause blood loss. In turn, every member of the medical care team can also help to reduce iatrogenic blood loss. Causes of iatrogenic blood loss You may ask: “How can a physician (or any medical care- giver) be the culprit?” and, “What ways are there to cause iatrogenic blood loss?” Well, almost everything a medical team does has the potential to cause blood loss. Not only have thesurgeonscausedblood loss bytheiroperation. No, every specialty can causebloodloss—directly orindirectly. Blood loss may be caused simply by the fact that a patient has to see a physician. The patient may be so stressed by the very thought of seeing a doctor that he develops a stress ulcer and bleeds internally. Patients prescribed bed rest soon show a lowered red cell count. Many diagnos- tic procedures cause blood loss. Some of them to such an extent that physicians are moved to transfuse. Also, many therapeutic interventions cause blood loss. This holds true for drug therapy as well as for more invasive approaches, such as dialysis and other forms of extracorporeal circu- lation (ECC). Nevertheless, all of these interventions can be adapted so that iatrogenic blood loss is minimized. Problem 1: phlebotomy—laboratory testing causes blood loss Blood loss by phlebotomy is not a new phenomenon. For ages, phlebotomy in the form of blood letting was a le- gitimate “cure” for all kinds of ailments, including ane- mia. While beneficial in selected cases, phlebotomy to the extent of blood letting more often than not harmed the patient, even resulting in his death. Blood losses by to- day’s phlebotomists are more subtle, yet clearly detectable as well. They have a great impact on patient care and also on transfusion practice. Since laboratory results are an important tool to achieve a diagnosis and to guide med- ical care, a certain amount of blood usually is required to get the needed information. However, a great quantity of blood drawn for laboratory testing is drawn needlessly. One major problem is that laboratories are drawn with- out good reason, drawn too often, or drawn despite not being indicated. Some members of the care team ordering blood tests are not aware of the significance of the results obtained. Often, laboratory results do not influence pa- tient’s care at all. So, what is the point of obtaining them? 160 BLUKO82-Seeber March 14, 2007 17:0 Iatrogenic Blood Loss 161 Table 12.1 Average phlebotomy-induced blood loss in critically ill patients. Average Reporting phlebotomy-induced country Setting blood loss United States Cardiothoracic ICU Avg. 377 mL/day United States General surgical ICU Avg. 240 mL/ day United States Medical surgical ICU Avg. 41.5 mL/day Great Britain First day in ICU Avg. 85.3 mL/day Great Britain Following days Avg. 66.1 mL/day Europe Medical ICUs Avg. 41.1 mL/day ICU, intensive care unit; Avg., average. Another problem with phlebotomy is that excessive blood volumes are drawn. A study in a neonatal intensive care unit (ICU), for instance, indicated that almost 20% of the blood drawn was not needed in the laboratory to perform the requested tests [1]. Whenbloodis drawn fromindwelling arterial or venous lines, a certain amount of blood (“dead space volume”) is withdrawn to clear the line, before the actual phlebotomy volume is drawn. This is done in order to reduce the mix- ing of the catheter flushing solution with the blood sam- ple. The drawn dead space volume is usually discarded. Depending on local custom, the discarded volume differs between 2 and 10 mL per blood draw [2]. The total daily amount of blood drawn for laboratory tests differs, depending on the pathology and the length of stay. Sicker patients experience more blood loss than those less sick, placing the sicker patients at higher risk for anemia. Table 12.1 demonstrates how substantial the total daily amounts of blood drawn from one patient can be [2]. Possible solution: reduction of phlebotomy-induced blood loss Strategies to reduce phlebotomy-induced blood loss exist and are usually employed in patients at high risk for ane- mia, such as neonates, pediatric patients, the critically ill, and patients for whom transfusions are not an option. Reduction of the amount of phlebotomy Reducing the amount of blood for phlebotomy starts with the plain avoidance of unnecessary phlebotomy. Thought- less ordering of a variety of parameters does not contribute to your value as a caregiver, nor does it help your patient. Ask yourself: What would change in the care of the patient if I do or do not have the result? If there is no clear indi- cation for a blood test, it is most probably not indicated and a waste of blood and money. Standing orders (“Mr. Miller is going to have his liver function test every other day, no matter what”) should bereconsidered and in many instances eliminated. When you know what laboratory values are needed, think whether batching the requests is possible. One spec- imen is often sufficient to obtain several values at a time. Then, make sure that you know how much blood is needed to perform the requested tests. Phlebotomy overdraw can be substantial. Especially in small children, small amounts of blood, drawn unnecessarily, matter. Collection tubes with fill lines should help in this regard [1]. Drawing the blood up to the fill line prevents overdraw, either caused by drawing too much blood for one sample or by draw- ing blood for the same test twice. The latter may be the case when insufficient blood is drawn into the container resulting in a wrong mixing ratio of blood and the addi- tive provided in the container (e.g., anticoagulant). In this case, blood has to be drawn again, resulting in unnecessary blood loss. Patients at high risk for anemia will probably bene- fit from further means to reduce blood draws. The use of neonatal tubes, with a smaller fill volume, reduces blood loss and at the same time provides the needed re- sults (Table 12.2). A switch from adult to pediatric-sized tubes may reduce the diagnostic blood loss by over 40% [3]. A more blood-saving method is microsampling. Only few microliters of blood are needed to obtain required information, e.g., 150 μ L for blood gases, electrolytes, hemoglobin and hematocrit, and the blood sugar. De- vices for point-of-care testing [4] often require only small blood volumes. Some point-of-care devices are even able Table12.2 Phlebotomyvolumes ofcommercially available blood tubes. Neonatal/ Regular Pediatric microsampling Hematology 3.5–9 mL 2.6–3.0 Serology 4.9–10 mL 2–2.7 mL 250 μ L–1 mL Coagulation 4–10 mL 2.9–3.0 mL Blood sugar 2.6–3.0 mL 20–50 μ L (or less) Sedimentation rate 2 mL Blood gases 1–3 mL 100–500 μ L BLUKO82-Seeber March 14, 2007 17:0 162 Chapter 12 to return the drawn blood directly back to the patient after it has been analyzed [5]. In areas where rather expensive point-of-care devices are not available, color scales may help to obtain fairly accurate laboratory results, using only one drop of the patient’s blood [6, 7]. Keeping track of the amount of phlebotomy of indi- vidual patients is especially helpful in high-risk patients (neonates, severely anemic). It sensitizes the members of the personnel (physicians, nurses, phlebotomists, labo- ratory technicians) to take greatest care in their efforts of blood conservation. Therefore, it may be beneficial to mark such high-risk patients, to alert personnel to be es- pecially careful. Having every member of the care team who orders or executes phlebotomy sign a special sheet may also be of help, especially in the initial phase of estab- lishing blood saving techniques. Practice tip Place a sheet of paper next to all patients in the ICU and have all persons who draw blood list the total volume of blood drawn. After the patient leaves the unit, add all losses up and present them to the health-care team for discussion. Reduction and elimination of discard volume Dead space volume drawn before obtaining the blood sample is usually discarded. It was shown that a volume of only twice the catheter dead space is sufficient to gain the required accuracy of the drawn laboratory values [8]. Whatever goes beyond this volume is a wasted resource. To avoid discard volume as a source of iatrogenic blood loss altogether, several methods are used. The simplest one is probably just to return the sterile dead space vol- ume once the blood sample is drawn. Discard volume is completely eliminated when a passive extracorporeal ar- teriovenous backflow is used [9]. For this technique, a double-stopcock-system connects the central line and the arterial line. When the appropriate stopcocks are opened, blood from the arterial line flows back, through the tub- ing, toward the venous line. The blood is allowed to flow a certain distance (which equals the usual discard volume) past a sampling port. Then, the blood sample is drawn through the sampling port and the blood is directed back to the patient. Additionally, special systems, using a reservoir that is meant tobeincludedin an arterial line, areavailable for the withdrawal of dead space volume and subsequent retrans- fusion. Adapting arterial blood draws, by using a closed system, reduces the blood loss by about 50% [10]. Replacement of phlebotomy by “bloodless” monitoring Another way to eliminate the need for blood draws is the use of methods that deliver the needed information with- out a blood draw. Some values (e.g., pH,partial pressure of carbon dioxide (PCO 2 ), partial pressure of oxygen (PO 2 ), arterial oxygen saturation (SaO 2 ), bicarbonate, base ex- cess) can be obtained, with satisfying accuracy, using in- dwelling measuring catheters with photochemical sensors [11]. The catheter can either be inserted into an ECC [11] or directly into the vascular system [12]. Photochemical sensors can be placed intravascular for continuous mea- surement, or extravascular for on-demand-measurement. To obtainsomebloodvalues,direct contactbetween blood and a measuring device is not always necessary. Skin sen- sors may be placed on patients who are at high risk for ia- trogenic blood loss. The sensors measure the partial pres- sures of carbon dioxide and oxygen in the blood and the blood glucose level through the skin, obviating the need for serial blood draws. Education Educating members of the team on techniques for reduc- ing unnecessary blood loss, e.g., ordering only essential blood tests, exercising the greatest care in infants, prac- ticing drawing blood samples into syringes, etc., may also help. While studies to evaluate the effect of education on the appropriate use of phlebotomy did not show a signif- icant change in practice, the introduction of mandatory policies and guidelines for laboratory use did. Problem 2: resting patients lose blood Even patients who do nothing at all may lose blood. One reason for this is that inactivity and bed rest elicit physio- logical responses that lead to anemia [13]. Another prob- lem of bed-resting patients may be the development of de- cubital ulcers, leading to so-called “pressure sore anemia” [14]. Anemia due to decubital ulcers is characterized by mild to moderate anemia with low serum iron and normal or increased ferritin in combination with hypoproteine- mia and hypoalbuminemia. Anemia probably develops because of the chronic inflammatory state caused by the presence of pressure ulcers. [...]... exposure [24, 27, 36, 45, 46, 52 55 ] The essence of the studies is that many of the above-described methods for cutting reduce blood loss when compared to the conventional scalpel [13, 55 ] Some of these studies are listed in Table 13.2 The use of laser can either increase or decrease blood loss, depending on the type of laser used Carbon dioxide laser incisions are reported to be less bloody than scalpel... improvement Diagnostic blood loss is a major determinant of anemia in adult and neonatal ICUs, accounting for substantial amounts of transfused blood [1, 50 ] In fact, in the ICU setting, the total amount of diagnostic blood loss is a significant predictor of allogeneic transfusion [28] As shown above, comprehensive blood management effectively reduces phlebotomy-induced blood loss [51 , 52 ] and such attempts... transfusions [5, 53 ] Apart from phlebotomy, there are many other items under the control of a medical care team that affect the blood count of a patient In many instances, attention to detail helps to avoid unnecessary blood loss [7, 54 , 55 ] Even if there are not many randomized controlled studies demonstrating that attention to every one of the abovementioned details translates into reduction of transfusions... Chilvers Arterial blood sampling practices in intensive care units in England and Wales Anaesthesia, 2001 56 (6): p 56 8 57 1 50 Corwin, H.L., K.C Parsonnet, and A Gettinger RBC transfusion in the ICU Is there a reason? Chest, 19 95 108(3): p 767–771 51 MacIsaac, C.M., et al The influence of a blood conserving device on anaemia in intensive care patients Anaesth Intensive Care, 2003 31(6): p 653 – 657 52 Dech, Z.F... 95( 5): p 1432–1436, table of contents 55 Singer, A.J., et al Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial Ann Emerg Med, 20 05 45( 2): p 134– 139 13 The physics of hemostasis Sufficient hemostasis is vital to reduce the number of allogeneic transfusions A basic knowledge of the methods is essential to enable a blood manager to critically... impact of blood loss caused by the insertion of a central line is obvious when an untrained individual performs the insertion Often, blood flows back freely, pouring out on to the drapes and is lost Quantifying such blood losses is difficult One study on iatrogenic blood loss mentioned the insertion of arterial and central venous catheters as source of blood loss, but did not determine the amount of blood. .. laparoscopic surgery Chirurg, 1996 67 (5) : p 54 6 55 1 47 Basting, R.F., N Djakovic, and P Widmann Use of water jet resection in organ-sparing kidney surgery J Endourol, 2000 14(6): p 50 1 50 5 48 Oertel, J., M.R Gaab, and J Piek Waterjet resection of brain metastases—first clinical results with 10 patients Eur J Surg Oncol, 2003 29(4): p 407–414 49 Shekarriz, H., et al Hydro-Jet-assisted laparoscopic cholecystectomy:... mastectomy Am Surg, 1988 54 (5) : p 284–286 56 Smyrniotis, V.E., et al Selective hepatic vascular exclusion versus Pringle maneuver in major liver resections: prospective study World J Surg, 2003 27(7): p 7 65 769 57 Makuuchi, M., et al Safety of hemihepatic vascular occlusion during resection of the liver Surg Gynecol Obstet, 1987 164(2): p 155 – 158 58 Quan, D and W.J Wall The safety of continuous hepatic... solution: minimizing blood loss due to ECC The use of an ECC inevitably causes blood loss Happily, the extent of these changes depends on a variety of factors, 166 Chapter 12 most of which can be altered to reduce the effect of the ECC on the blood In former times, patients on an ECC, such as the cardiopulmonary bypass, were transfused with a lot of blood Even the ECC was primed with donor blood Today, this... to estimate the blood loss he suffers during his stay in the ICU All blood draws are taken from the central line, except the ones for the blood cultures, which are taken directly from the vein Before a blood sample is drawn into the sampling tubes from the central line, 10 mL of the blood is discarded Before blood is drawn from the arterial line, 5 mL of the blood is discarded The blood tubes used . the blood sugar. De- vices for point -of- care testing [4] often require only small blood volumes. Some point -of- care devices are even able Table12.2 Phlebotomyvolumes ofcommercially available blood tubes. Neonatal/ Regular. comprehensive blood management effectively re- duces phlebotomy-induced blood loss [51 , 52 ] and such attempts reduce the patient’s exposure to allogeneic trans- fusions [5, 53 ]. Apart from phlebotomy,. tube con- tamination. Anesth Analg, 2002. 95( 5): p. 1432–1436, table of contents. 55 Singer, A.J., et al. Comparison of nasal tampons for the treat- ment of epistaxis in the emergency department: