Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus;...
Transcript of Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus;...
Professor Kai Zacharowski, MD PhD ML FRCA
Director: Department of Anaesthesiology, Intensive Care
Medicine & Pain Therapy, University Hospital Frankfurt
Vice-President: European Society of Anaesthesiology
Patient blood management
- new perspectives
The Frankfurt PBM Team
COIDuring the last 3 years I have received research grants, consultant/speaker honoria as well asfinancial support for continious education of my department :
German Research Foundation (ME 3559/1-1, ME 3559/3-1, SFB 834 B4, SFB 815 A17, KFO TP07), ECCPS, LOEWE
TP 6, European Union
Abbott GmbH &Co KG AbbVie Deutschland GmbH & Co. KG
Aesculap Akademie GmbH AQAI GmbHAstellas Pharma GmbH AstraZeneca GmbHAventis Pharma GmbH B. Braun Melsungen AGBaxter Deutschland GmbH Biosyn GmbHBiotest AG Bristol-Myers Squibb GmbHCSL Behring GmbH Dr. F. Köhler Chemie GmbHDräger Medical GmbH Essex Pharma GmbHFresenius Kabi GmbH Fresenius Medical CareGambro Hospal GmbH GileadGlaxoSmithKline GmbH Grünenthal GmbHHaemonetics Hamilton Medical AGHCCM Consulting GmbH Heinen+Löwenstein GmbHHexal AG Janssen-Cilag GmbHmed Update GmbH Medivance EU B.V.MSD Sharp&Dohme GmbH Novartis Pharma GmbHNovo Nordisk Pharma GmbH P. J. Dahlhausen&Co. GmbHPfizer Pharma GmbH Pulsion Medical Systems S.E.Siemens Healthcare Teflex Medical GmbHTEM International Teva GmbH TopMed Medizintechnik GmbHVerathon Medical Vifor Pharma GmbH
Werfen
Triad of
independent
risk factors
for
adverse
outcomes
Anaemia is a disease in itself
Farmer et al. Best Pract Res Clin Anaesthesiol 2013;27(1):43–58; Meybohm et al. Ann Surg 2016;264(2):203–211;
Zacharowski & Spahn. Best Pract Res Clin Anaesthesiol 2016;30(2):159–169 3
Blood loss
& bleedingTransfusion
Anaemia
Problem: pre-operative anaemia
Hb=haemoglobin
Musallam et al. Lancet 2011;378(9800):1396–1407 4
Retrospective study: 227,425 patients
0.78
3.52
10.17
0
2
4
6
8
10
12
No anaemia(n=158,196)
Mild anaemia (Hb 9–12 g/dL)
(n=57,870)
Severe anaemia(Hb <9 g/dL)(n=11,359)
30
-da
y m
ort
alit
y (
%)
Bill Gates Foundation: leading 30 global health problems
AP=Asia Pacific; Cent=central; CKD=chronic kidney
disease; Eur=Europe; G6PD=glucose-6-phosphate
dehydrogenase; hemog=hemoglobinemia; HI=high
income; IDA=iron deficiency anaemia; LA=Latin America;
NA=North America; NA/ME=North Africa/Middle East;
NTD=neglected tropical diseases; South=Southern;
SE=Southeast; SSA=sub-Saharan Africa;
YLD=years lived with disability
GBD 2015 Disease and Injury Incidence and Prevalence
Collaborators. Lancet 2016;388(10053):1545–1602;
Kassebaum et al. Blood 2014;123(5):615–624 5
Iron-deficiency anaemia
(=green) is a global problem!
▪ 20–30% of humans
have anaemia
▪1/3 IDA
▪2/3 other causes
Three pillars of PBM
PBM=patient blood management 6
1. Management of pre-operative anaemia
►Screening and diagnosis
►Treatment
2. Minimising blood loss and bleeding
3. Restrictive use of blood units
Anaemia walk-in-clinic
▪ Contact: Sabine Isik
▪ Mon–Fri: 08:00–16:00 h
▪ Tel: +49 69 6301 – 87461
▪ Email: [email protected]
7
WHO anaemia definition
WHO=World Health Organization 8
9.8 g/dL 6.9 g/dL
1500 mL
13.0 g/dL
6 L
12.0 g/dL
3.5 L
Haem
oglo
bin
leve
l
Pre-operative phase
Surgery
Post-operative phase
Frankfurt anaemia definition
9
13.0 g/dL
9.8 g/dL 7.5 g/dL
13.0 g/dL
1500 mL6 L
3.5 L
Haem
oglo
bin
level
Pre-operative phase
Surgery
Post-operative phase
Pre-operative algorithm V4.0
CKD=chronic kidney disease; Hb=haemoglobin; ICU=intensive care unit; IV=intravenous 10
Management of
pre-operative anaemia
NO iron
deficit
optimal
IV iron Further
diagnostics of
anaemia
NO iron
deficit
Iron deficiencyTransferrin saturation <20%
or
Ferritin <100 ng/mLFerritin <300 ng/mL
If heart failure/CKD
Iron status Iron status
♀ ♂ Hb <13 g/dL♀ ♂ Hb ≥13 g/dL
Transfusion probability
>10%
Planned surgery (next day)
Pre-operative algorithm V4.0
CKD=chronic kidney disease; Hb=haemoglobin; ICU=intensive care unit; IV=intravenous 11
Transfusion probability
<10%
Management of
pre-operative anaemia
NO iron
deficit
optimal
IV iron Further
diagnostics of
anaemia
NO iron
deficit
Iron deficiencyTransferrin saturation <20%
or
Ferritin <100 ng/mLFerritin <300 ng/mL
If heart failure/CKD
Iron status Iron status
♀ ♂ Hb <13 g/dL♀ ♂ Hb ≥13 g/dL
Transfusion probability
>10%
Planned surgery (next day)
Pre-operative algorithm V4.0
CKD=chronic kidney disease; Hb=haemoglobin; ICU=intensive care unit; IV=intravenous 12
Emergency
Transfusion probability
<10%
Management of
pre-operative anaemia
NO iron
deficit
optimal
IV iron Further
diagnostics of
anaemia
NO iron
deficit
Iron deficiencyTransferrin saturation <20%
or
Ferritin <100 ng/mLFerritin <300 ng/mL
If heart failure/CKD
Iron status Iron status
♀ ♂ Hb <13 g/dL♀ ♂ Hb ≥13 g/dL
Transfusion probability
>10%
Planned surgery (next day)
OR=odds ratio
1. Beattie et al. Anesthesiology 2009;110(3):574–581; 2. Fowler et al. Br J Surg 2015;102(11):1314–1324; 3. Musallam et al. Lancet 2011;378(9800):1396–1407
*Retrospective single-centre cohort study of consecutive patients >18 years undergoing non-cardiac surgery between March 2003 and June 2006 (N=7,759). Shown are the propensity-
matched values for variables that are potential confounders in the relationship between anaemia and post-operative mortality (N=2,090)1
§Systematic review and meta-analysis of observational studies exploring associations between pre-operative anaemia and post-operative outcomes (24 studies; N=949,445)2
†Retrospective cohort study of major non-cardiac surgery in 2008 (a prospective validated outcomes registry from 211 hospitals worldwide, N=227,425). OR presented had an extended
adjustment for a large number of clinically relevant variables3
Pre-operative anaemia
13
2x increased risk of
infection
(OR=1.93, p=0.01)§2
4x increased risk of
kidney injury
(OR=3.75, p<0.001)§2
3x increased risk of
mortality
(OR=2.90, p<0.001)§2
5x increase in
transfusions
(18.5% vs 4.7%, p<0.01)§2
22% longer hospital stay
(11 vs 9 days, p=0.0001)*1
Pre-operative anaemia
is associated with:
Minimising blood loss and bleeding
14
1. Management of pre-operative anaemia
2. Minimising blood loss and bleeding
► Blood sparing techniques
► Haemostasis
► Intra-operative blood salvage
► Coagulation management
3. Restrictive use of blood units
Hospital-acquired anaemia
Data (N=1,867 cardiac surgery patients; 221,498 lab tests)
Koch et al. Ann Thorac Surg 2015;99(3):779–784 15
5 litres !!!
Fischer et al. Crit Care 2014;18(3):306
Restrictive blood sampling
16
/en
17
50%
50%
50%
Closed invasive pressure monitoring devices
Westphal et al. Anästh Intensivmed 2018;59:1–7 18
1. Management of pre-operative anaemia
2. Minimising blood loss and bleeding
3. Restrictive use of blood units
► Monitoring tolerance of anaemia
► Restricted transfusion trigger
Restrictive use of blood units
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International guidelines
1. Carson JL, Grossman BJ, Kleinman S, et al.
Red blood cell transfusion: a clinical practice
guideline from the AABB*. Ann Intern Med
2012; 157 (1): 49–58.
2. Guidelines of the German Medical Association
regarding the use of blood and blood
components. 2014; 1–137.
3. Retter A, Wyncoll D, Pearse R, et al. Guidelines
on the management of anaemia and red cell
transfusion in adult critically ill patients. Br J
Haematol 2013; 160 (4): 445–464.
4. Padhi S, Kemmis-Betty S, Rajesh S, et al.;
Guideline Development Group. Blood
transfusion: summary of NICE guidance. BMJ
2015; 351: h5832.
5. ...
6. ...
ECG=electrocardiogram; Hb=haemoglobin; RBC=red blood cell 20
Transfusion trigger checklistList has to be filled for each RBC unit
(Exception: massive bleeding)
Hb <6 g/dL
■ Independent of any compensation possibility
Hb 6–8 g/dL
■ Clinical symptoms for anaemic hypoxia
(tachycardia, hypotension, ischaemic ECG
changes, lactate acidosis)
■ Limited compensation, existing risk factors
(e.g., coronary artery disease, heart failure,
cerebrovascular insufficiency)
■ (Other indication: …………………………………)
Transfusion in case of Hb >8 g/dL are related to
an unclear risk–benefit balance
■ Hb >8 g/dL (only indicated in individual cases;
very low recommendation level [2C])
Most wanted treatment…
AABB=American Association of Blood Banks; CDC=Centers for Disease Control and Prevention; RBC=red blood cell
Carson et al. N Engl J Med 2017;377(13):1261–1272 21
54.6
48.2
43.941.7 41.5 41.0
38.136.1 35.3 35.3 34.5 33.8 33.2
29.928.0 27.0
0
10
20
30
40
50
60
Tra
nsfu
sio
n r
ate
s
(RB
C u
nits p
er
1,0
00
pe
op
le)
Risks of transfusion versus…
AHTR=acute haemolytic transfusion reaction; DHTR=delayed haemolytic transfusion reaction; FNHTR=febrile non-haemolytic transfusion reaction; HBV=hepatitis B virus;
HCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute lung injury
Carson et al. N Engl J Med 2017;377(13):1261–1272 22
Infectious and non-infectious adverse effects of red-cell transfusions
as compared with other, unrelated risks
PBM study
Patients from four University Hospitals (Bonn, Frankfurt, Kiel, Münster)
IM=implementation of PBM; PBM=patient blood management
Meybohm et al. Ann Surg 2016;264(2):203–211 23
2013
Centre 1 Control PBM
Centre 2
Centre 3
2014
IM
Control PBMIM
Control PBMIM
* * * * * *
Centre 4 Control PBMIM
01.07 01.07 01.0701.01 01.01 01.07
201501.01
2012
* * * * *
* * * *
* * *
Pre-PBM(n=54,513 patients)
PBM (n=75,206 patients)
PBM study results
PBM=patient blood management; RBC=red blood cell
Meybohm et al. Ann Surg 2016;264(2):203–211 24
2019: >40%
A omplicationsC A ostsC
>17%
Pre-PBM
A ransfusionsT
>10%
Pre-PBM
6.2%6.4%
Pre-PBM
PBM networks
PBM=patient blood management 25
German PBM network (2014 founded)
More than 160 hospitals worldwide
✓ Participation free
✓ Support with implementation
✓ Marketing & education
European
PBM network(Founded 2016)
Global
PBM network(Founded 2017)
PBM international – patient safety
PBM=patient blood management 26
Humanitarian award together with
German Prize for
Patient Safety 2016
PBM=patient blood management 27
Multimodal PBM program based on a three-pillar strategy
▪ Systematic review and meta-analysis
▪ Studies had to address each of the three PBM pillars with at least one
measure per pillar, e.g., pre-operative anaemia management + cell
salvage + rational transfusion strategy
▪ Study protocol: registered with PROSPERO (CRD42017079217)
▪ 17 studies with 235,779 surgical patients (100,886 pre-PBM group and
134,893 PBM group)
PBM=patient blood management
Althoff et al. Ann Surg 2019;269(5):794–804 2816
Transfusion rate
CI=confidence interval;
PBM=patient blood management
Althoff et al. Ann Surg 2019;269(5):794–804 2916
Orthopaedic surgery
Heart surgery
Vascular surgery
General surgery
Total
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Number of RBC units per patient
CI=confidence interval;
PBM=patient blood management; RBC=red blood cell
Althoff et al. Ann Surg 2019;269(5):794–804 30
Orthopaedic surgery
Heart surgery
Vascular surgery
General surgery
Total
Length of hospital stay
CI=confidence interval;
PBM=patient blood management
Althoff et al. Ann Surg 2019;269(5):794–804 3116
Orthopaedic surgery
Heart surgery
Vascular surgery
General surgery
Total
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Number of complications
CI=confidence interval;
PBM=patient blood management
Althoff et al. Ann Surg 2019;269(5):794–804 32
Orthopaedic surgery
Heart surgery
Vascular surgery
General surgery
Total
16
Mortality
CI=confidence interval;
PBM=patient blood management
Althoff et al. Ann Surg 2019;269(5):794–804 33
Orthopaedic surgery
Heart surgery
Vascular surgery
General surgery
Total