Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus;...

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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

Transcript of Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus;...

Page 1: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

Page 2: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

Page 3: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

Page 4: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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 (

%)

Page 5: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

Page 6: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

Page 7: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

Anaemia walk-in-clinic

▪ Contact: Sabine Isik

▪ Mon–Fri: 08:00–16:00 h

▪ Tel: +49 69 6301 – 87461

▪ Email: [email protected]

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Page 8: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

Page 9: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

Page 10: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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)

Page 11: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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)

Page 12: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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)

Page 13: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

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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:

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Minimising blood loss and bleeding

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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

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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 !!!

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Fischer et al. Crit Care 2014;18(3):306

Restrictive blood sampling

16

/en

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50%

50%

50%

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Closed invasive pressure monitoring devices

Westphal et al. Anästh Intensivmed 2018;59:1–7 18

Page 19: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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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Page 20: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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])

Page 21: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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)

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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

Page 23: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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)

Page 24: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

Page 25: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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)

Page 26: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

PBM international – patient safety

PBM=patient blood management 26

Humanitarian award together with

German Prize for

Patient Safety 2016

Page 27: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

[email protected]

PBM=patient blood management 27

Page 28: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

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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

Page 30: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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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

Page 31: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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

Page 32: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute

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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

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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

Page 34: Patient blood management - new perspectivesHCV=hepatitis C virus; HIV=human immunodeficiency virus; TACO=transfusion-associated circulatory overload; TRALI=transfusion-related acute