PRACTICE GUIDELINES FOR PERIOPERATIVE BLOOD AND BLOOD

PRACTICE GUIDELINES FOR PERIOPERATIVE BLOOD AND BLOOD

COMPONENT TRANSFUSION

Dr. R. Anandhi, Junior Consultant, Department of Anaesthesia and Intensive Care

Max Hospital, Gurgaon

These guidelines are based on the updated report by the American Society of Anaesthesiologists (ASA) task force on perioperative blood transfusion and adjuvant therapies.

PRE OPERATIVE EVALUATION

1. Review medical records.
   
2. Interview the patient and family to identify the risk factors for:
   
   1. Organ ischaemia e.g. cardiopulmonary disease.
      
   2. Coagulopathy e.g. use of warfarin, clopidogrel, asprin etc.
      
   3. Presence of congenital or acquired blood disorders e.g. Factor VIII deficiency, sickle cell anaemia, idiopathic thrombocytopenic purpura.
      
   4. Use of vitamin or herbal supplements that may affect coagulation.
      
   5. Prior exposure to drugs that may cause allergic reaction on repeat exposure e.g. aprotinin.
      
3. Review hemoglobin/ hematocrit test results.
   
4. Review coagulation profile.
   

PRE OPERATIVE PREPARATION

1. Discontinue anticoagulant drugs for sufficient time before surgery.
   
   1. Clopidogrel – 1 week prior to surgery.
      
   2. Asprin - Preferably 1 week prior to surgery, if sufficient time not available, at least 3-4 days prior to surgery.
      
   3. Warfarin - Effect may last for several days, hence discontinue at least 4 days before surgery and wait till INR normalizes for major surgeries. For moderate surgeries, INR of 1.5-1.6 is acceptable.
      
   4. Herbal medicine – To be discontinued 2-3 weeks before surgery.
      

In elective cases, surgery should be delayed until the effect of anticoagulant drugs has dissipated. PT is used as a guide.

1. Risk of thrombosis vs risk of increased bleeding should be considered when altering the anticoagulation status e.g. in the presence of coronary stent.
   
2. Assure that blood and blood components are available.
   
3. When significant blood loss is expected, e.g. repeat cardiac surgery, administer antifibrinolytics (e.g. aprotinin, €-aminocaproic acid or tranexamic acid).
   
4. Administer erythropoietin to select patients (e.g. renal insufficienty, anaemia, chronic disease or transfusion refusal)
   
5. Administration of Vit K for reversal of warfarin, to avoid potential transfusion of FFP.
   
6. Pre admission donation of autologous blood should be done to avoid or minimize allogenic transfusion.
   

ASSESSMENT FOR BLOOD / COMPONENT THERAPY

a)
Visual assessment of surgical field.

b) Laboratory monitoring for coagulopathy.

1. Platelet count
   
2. PT / INR
   
3. APTT
   
4. Others
   

   I.    Fibrinogen level
   

   II.    Platelet function
   

         III.    TEG

         IV.    D-dimer

         V.    TT.

BLOOD TRANSFUSION

Indications:

1. Hb > 10 gm% - RBC not required.
   
2. Hb 6-10 gm% - Administer RBC for:
   

   I.    Indication of organ ischemia.
   

   II.    Potential / acute ongoing bleeding.
   

   III.    Intravascular volume status maintenance.
   

   IV.    Risk factors for oxygenation (low cardiopulmonary reserve, high O₂ consumption)
   

3. Administer RBC when Hb < 6gm/dl in a young healthy patient especially when anemia is acute.
   
4. Maintain IV volume with crystalloids / colloids until criteria for RBC transfusion are met.
   

Single Unit Blood Transfusion: Not recommended anymore, as the hazards and risks of transfusion far outweigh the benefits of single unit transfusion.

COMPONENT THERAPY

Platelets:

How to assess need for transfusion

    i. Estimation of platelet count.

ii. Estimation of platelet function (if patient is having suspected/ drug induced

platelet dysfunction e.g. clopidogrel)

Indications for platelet transfusion

    a) When platelet count is > 100x 10⁹ / L, platelets are rarely indicated.

b) When platelet count is between 50-100x10⁹ / L platelet transfusion should

be based on

i. Potential for platelet dysfunction.

ii. Anticipated or ongoing bleeding.

iii. Risk of bleeding into a confined space e.g. brain or eye.

c) When platelet count is < 50,000 / cu.mm, in the presence of excessive

bleeding.

Surgery with limited blood loss may be done when platelet count is

< 50,000 e.g. vaginal delivery, minor operative procedures.

d) Platelet Dysfunction: May occur due to cardiopulmonary bypass or

antiplatelet drugs. Platelet transfusion is indicated despite a normal platelet

count.

Thrombocytopenia due to increased platelet destruction

i. Heparin induced.

ii. ITP

iii. TTP

Prophylactic platelet transfusion is not indicated and is ineffective.

Fresh Frozen Plasma (FFP):

Obtain PT / INR and APTT before giving FFP.

Indications of FFP

a) Excessive microvascular bleeding (coagulopathy - PT > 1.5, INR > 2,

APTT > 2 Normal).

b)    Excessive bleeding secondary to coagulation factor deficiency, when > 1 blood volume replaced (70ml/kg) and when PT/ INR/ APTT cannot be estimated.

c)    Urgent reversal of warfarin therapy.

d)    Known coagulation factor deficiency.

e)    Heparin resistance (antithrombin III deficiency) in a patient requiring heparin.

Dose : 10-15 ml/ kg

     5-8 ml/ kg (for reversal of warfarin therapy).

Coagulation factors provided by: 1 unit FFP is approximately = 4-5 units of platelet concentrate or 1 single donor apheresis platelet or 1 unit fresh whole blood.

Cryoprecipitate:

Estimate fibrinogen concentration.

Indications:

a) Fibrinogen concentration < 80-100 µg/dl in the presence of excessive microvascular

bleeding.

b) Excessive bleeding in massively transfused patients when fibrin levels cannot

be obtained.

c) Congenital fibrinogen deficiency.

d) Bleeding patients with von Willibrand disease, only if specific concentrate is

not available.

1 Unit of Cryoprecipitate contains 150-250 µg fibrinogen.

1 Unit of FFP contains 2-4 mg fibrinogen / ml

1 Unit FFP delivers equivalent fibrinogen as 2 Units of Cryoprecipitate.

REFERENCES

1) Practice Guidelines for Perioperative Blood Transfusion And Adjuvant Therapies.

An Updated Report By The American Society Of Anaesthesiologist Task Force On Perioperative Blood Transfusion And Adjuvant Therapies. Anaesthesioloy; 105 (1):

198-208, July 2006.

2) Current and Evolving Issues In Transfusion Practice. Indian J. Anaesthesia 2004;

48(6): 446-453.

3) Pediatric Anaesthesia – Potential Risks and Their Assessment: Part II. Pediatric

Anaesthesia 2007; 17: 3110-320.

4) Herbal – Drug Interaction – Mayo. From The Clinic.

www.mayohealth.org/mayo/0003/htm/herbdrug.htm

5) Reece R L, Beckett R.S. Epidemiology of Single Unit Transfusion: A One Year

Experience in A Community Hospital. JAMA 1965; 95: 801.

6) Cass R M, Blumberg N. Single Unit Blood Transfusion Doubtful Dogma Defeated.

JAMA 1987; 257: 628.

7) The Merck Manuals – Warfarin – Drug Information Provided By Lexi – Comp.

www.merk.com/mmpc/lexicomp/warfarin.html

8) Antiplatelet Agents in the Perioperative Period: Expert Recommendations of The

French Society of Anaesthesiology and Intensive Care (SFAR) 2001 – Summary.

Corresponding Author:

Dr. R. Anandhi

E mail: iyeranandhi@yahoo.co.in