Professional Documents
Culture Documents
79]||ClickheretodownloadfreeAndroidapplicationforthisjournal
Review Article
Key words: Anaemia, blood conservation, cell salvage, patient blood management, perioperative
How to cite this article: Manjuladevi M, Vasudeva Upadhyaya KS. Perioperative blood management. Indian J Anaesth 2014;58:573-80.
improve the quality of care. Hence, this article focuses coagulation profile, prothrombin time[PT], activated
on achieving goals of PBM in the perioperative period. partial thromboplastin time[aPTT], international
normalised ratio[INR], bleeding time, clotting
PREOPERATIVE APPROACH time[CT], platelets, fibrinogen, Ddimer).[14] Evaluation
and optimization of other parameters like nutrition,
Perioperative anaemia is not uncommon in patients blood pressure and ventilation will also help in
presenting for major surgery. It is presently evident reducing transfusion requirement.
that correction of anaemia with BT may not improve
patient outcome[11,12] Patients undergoing elective Preoperative patient optimisation improves not
surgery with potential for large blood volume loss only blood loss and transfusion requirements, but
need early screening for anaemia. Even though no also morbidity and mortality in the perioperative
clear universal Hb threshold has been identified, period. Anaemia should be treated with iron
algorithm based management recommended by PBM supplementation [Figure 2] preoperatively.[16] Additional
strategy can reduce the transfusion requirement in the erythropoietin/erythropoiesis stimulating agents (ESA)
perioperative period.[13] is helpful in selected patients (e.g. chronic kidney
disease, anaemia of chronic disease).[17] Discontinuation
A preoperative visit should also have an adequate
of anticoagulant therapy (e.g. warfarin, anti Xa
assessment to detect and correct abnormalities in
drugs, antithrombin agents) should be considered
haematological homeostasis.[14] History of abnormal
before elective surgery with appropriate specialist
bleeding tendencies in the past(e.g.following bruises,
consultation. Whenever possible antiplatelet agents
trivial injuries and previous surgeries), prior BTs,
(e.g. clopidogrel, ticagralor, prasugrel) except aspirin
congenital coagulopathy, thrombotic events(e.g.deep
should be discontinued for a sufficient time prior to
vein thrombosis, pulmonary embolism), and family
history should be elicited. Drugs such as antiplatelet surgery. Patients with insitu vascular stents may require
and/or anticoagulant agents(e.g.aspirin, clopidogrel, continuation of drugs. Selected patients may require
warfarin), vitamin supplements, nonsteroidal shorter acting drugs(heparin, lowmolecularweight
antiinflammatory drugs, selective serotonin reuptake
inhibitor antidepressants(e.g.fluoxetine, paroxetine),
herbal medicines(e.g.ginko, ginseng, garlic) can
adversely affect bleeding.[15] Signs of increased
bleeding tendency(e.g.ecchymoses, petechiae, pallor)
and diseases associated with abnormal bleeding have
to be evaluated in physical examination. Risk factors
for organ(e.g.heart, brain) ischaemia which may
ultimately influence transfusion trigger for BT should
also be evaluated.[12]
heparin) for transition. In emergency surgeries, and replacing losses including surgical site losses.
reversal of anticoagulants (prothrombin complex Choice of fluid (crystalloids, colloids and blood
concentrates [PCC], Vitamin K, Fresh frozen plasma components) and quantity administered is based on
[FFP]) and antifibrinolytics to minimize blood loss monitored haemodynamic parameters.
maybe instituted.[14]
Use of regional anaesthesia
In patients at high risk of bleeding, preoperative Central neuraxial blocks such as spinal/epidural
multidisciplinary team meetings(anaesthetist, surgeon, anaesthesia are associated with a reduction in blood
haematologist, and radiologist) may help to discuss loss during surgery(approximately 25-30%), the benefit
the correct surgical approach. This should include extending to the postoperative period too(e.g.pelvic,
feasibility of less invasive(laparoscopic or radiological orthopaedic, vascular procedures).[24,25] Systemic
interventions), staging procedures(performed in two hypotension induced by sympathetic blockade and
stages as in corrective spinal surgery) or a decision to decreased venous tone is responsible for blood saving
use larger operating team thus reducing duration of effect by neuraxial anaesthesia.
surgery.[11,15]
Positioning[15,19]
Preoperative autologous blood donation[14,18] The surgical position of the patient can significantly
Patients can be considered for preoperative autologous influence intraoperative bleeding (if patient is
blood donation(PAD) when they are scheduled for incorrectly positioned, obstruction of venous return
elective procedures in which they are likely to receive produces venous engorgement). Elevating the
transfusion. Patients donate a unit of blood per week operative site above level of the right atrium facilitates
from a month prior to their operation and donations can venous drainage and decreases local venous pressure.
be more than once a week but the last one should be 72h Twisting the neck interferes with jugular venous
prior to surgery. Such a system is labour intensive and drainage(e.g.head and neck surgery) causing pooling
depends on good organization, both of collection and of blood at surgical site and should be avoided. In
storage of blood and coordination of operating lists with the prone position, pressure on the abdominal wall
guaranteed operating dates. It is expected that patient should be avoided(so as to minimise the compression
will generate additional red cells between the time of on inferior vena cava) to reduce blood flow through
donation and time of surgery. Iron supplementation and collateral vertebral venous plexus. In the supine
erythropoietin/ESA therapy to enhance erythropoiesis position left side tilt avoids compression on inferior
with PAD has been considered. Cost effectiveness is vena cava in selected patients.
low mainly because of a high proportion of discarded
units. The predonated units are stored, in the same Ventilation[15,19]
way, as allogenic blood and have depletion of Positive pressure ventilation under general anaesthesia
2,3diphosphoglycerate(2,3DPG) and impaired ability can hamper venous return. Minimizing mean
for erythrocytes to unload oxygen to tissues. intrathoracic pressure during controlled ventilation
with minimal use of positive end expiratory pressure
INTRAOPERATIVE STRATEGIES[15,19] and low tidal volume increases venous return, helps
in reducing blood loss.
Patient blood management measures during surgery
generally focus on reducing blood loss and/or on Controlled hypotensive techniques[15,19]
collecting and reinfusing the patients own shed blood. Reducing mean arterial pressure to 50-75mmHg is
achieved by various drugs such as inhalational agents,
Maintenance of intravascular volume[2023] propofol, beta blockers, alpha blockers, calcium
In general, intravenous fluids(IVF) are administered channel blockers, direct arterial/venous vasodialators,
according to protocols based on tradition, ganglion blockers, adenosine and prostaglandins E1.
expert opinion and often with limited evidence. This method mandates continuous haemodynamic
Individualised goaldirected therapy is necessary to monitoring and has been employed in hip, spinal
optimise intravascular volume and microcirculation, and open prostate surgeries. Coronary artery disease,
thereby maintaining adequate tissue perfusion. Fluid uncontrolled hypertension, cerebrovascular disease
administration is aimed at providing basal metabolic and anaemia are contraindication to controlled
requirements, compensate for preoperative deficits hypotensive techniques.
compared to liberal transfusion threshold(Hb>9g/dL) and expected blood loss. Monitoring for perfusion
and therefore recommended to target Hb concentration of vital organs using standard American Society of
of 7-9g/dL during active bleeding.[14] Transfusion of Anesthesiologists recommendations includes heart
platelets, FFP, cryoprecipitate, fibrinogen, factor XIII, rate, blood pressure, oxygen saturation, capnography
factor VIIa and PCC for prophylaxis and treatment and urine output in addition to clinical evaluation.
of excessive bleeding is based appropriately on Visual assessment of the surgical field for the presence
abnormalities in monitored parameters.[31] of any excessive bleeding has to be noted. Quantitative
measurement includes estimation of blood loss
POSTOPERATIVE STRATEGIES including checking suction canisters, surgical sponges
and surgical drains. Hb/Hct monitoring, arterial blood
Bleeding can continue after surgery into the gas analysis is based on clinical signs and estimated
postoperative period. Strategies used in the blood loss. More extensive continuous haemodynamic
intraoperative period such as maintenance of monitoring is based on blood loss, haemodynamic
normothermia, antifibrinolytics and red CS can instability and comorbidities. Invasive arterial blood
continue during this period. pressure, central venous pressure and pulmonary
artery catheter based parameters monitoring have to
Drain management[15]
be individualised. Additional monitoring may include
Use of postoperative drains is to diminish hematoma and
mixed venous oxygen saturation, echocardiography
compression of vital structures. Closed suction drainage
and cerebral monitoring(cerebral oximetry and near
after lower limb arthroplasty increases the blood
infrared spectroscopy).
transfusion rate by>40% when compared to the control
group without drains.[32] Reinfusion of blood from wound
Monitoring is becoming less invasive with advances
drain, with or without processing is used in cardiac and
in technology. Devices using pulse contour analysis
orthopaedic surgery. This is safe only if volume<1 litre,
(pulseinduced contour cardiac output, lithium
and the process is completed within 6h.[19]
dilution cardiac output and volume view) to determine
Cell salvage[14,19,27] cardiac output(CO), stroke volume variation(SVV)
Postoperative CS and reinfusion, with or without and pulse pressure variation(PPV) are commercially
washing, has been shown to be effective in decreasing available.[34] CO and SVV can also be measured using
perioperative blood loss after total knee arthroplasty, Flotrac and esophageal Doppler. Predicting preload
total hip arthroplasty and instrumented spine surgery. responsiveness and optimizing strategies driven
This is restricted to elective procedures with significant by SVV/PPV/CO help in optimising transfusion
anticipated postoperative blood loss through drains in requirement and tissue perfusion.
the first 6h.
Coagulation monitoring[19,35]
Lower transfusion threshold The aim of intraoperative coagulation monitoring is
Laboratory investigation are based on clinical to prevent and treat the pathological mechanisms of
evaluation of estimated blood loss, and blood increased perioperative bleeding.
components are transfused accordingly.[14]
Clinical monitoring includes periodic visual assessment
INTRAOPERATIVE AND POSTOPERATIVE PATIENT of the surgical field and communication with the
MONITORING surgical team as standard practice to detect impending
or established coagulopathy. This entails an assessment
Intraoperative and postoperative patient monitoring of the amount of blood lost and the presence of
for PBM consists of monitoring for perfusion of vital microvascular bleeding from mucosal lesions, serosal
organs, blood loss, anaemia, coagulopathy and adverse surfaces, catheter insertion sites and wounds. Further,
effects of transfusion. temperature is monitored to maintain normothermia.
Perfusion of vital organs monitoring[19,33,34] In susceptible patients, blood gas analysis will aid the
The goal of continuous haemodynamic monitoring is to detection of acidosis, anaemia and hypocalcaemia.
ensure adequate tissue perfusion and oxygen delivery, Routine coagulation parameters like INR, aPTT,
to predict instability and to institute therapy. Level of PT, platelet count and fibrinogen levels are to
monitoring is based on the extensiveness of surgery be individualised. Activated clotting time (ACT)
monitoring is recommended when high dose of heparin Monitoring adverse effects of transfusion[37]
is used intraoperatively. Patients with inherited During and after transfusion, patient should be
coagulation defects may exsanguinate with trauma or periodically monitored for hypoxaemia, respiratory
major surgery necessitating second level coagulation distress, elevated peak airway pressure, urticaria,
tests for specific factor replacement(such as factor hypotension and signs of hypocalcemia, hyperthermia,
VIII, IX and von Willebrand factor concentrate). haemoglobinuria and microvascular bleeding.
18. SingbartlG. Preoperative autologous blood donation: Clinical perioperative allogeneic blood transfusion. Cochrane Database
parameters and efficacy. Blood Transfus 2011;9:108. Syst Rev 2011:CD001886.
19. SuzanneET, MichaelHC. Clinical strategies to avoid blood 31. TanakaKA, KorDJ. Emerging haemostatic agents and
transfusion. Anaesth Intensive Care Med 2013;14:4850. patient blood management. Best Pract Res Clin Anaesthesiol
20. De BackerD, Corts DO. Characteristics of fluids used for 2013;27:14160.
intravascular volume replacement. Best Pract Res Clin 32. ParkerMJ, LivingstoneV, CliftonR, McKeeA. Closed suction
Anaesthesiol 2012;26:44151. surgical wound drainage after orthopaedic surgery. Cochrane
21. MarshC, BrownJ. Perioperative fluid therapy. Anaesth Database Syst Rev 2007:CD001825.
Intensive Care Med 2012;13:5947. 33. IijimaT, BrandstrupB, RodheP, AndrijauskasA, SvensenCH.
22. StrundenMS, HeckelK, GoetzAE, ReuterDA. Perioperative The maintenance and monitoring of perioperative blood
fluid and volume management: Physiological basis, tools and volume. Perioper Med(Lond) 2013;2:9.
strategies. Ann Intensive Care 2011;1:2. 34. CoveME, PinskyMR. Perioperative hemodynamic monitoring.
23. ChappellD, JacobM, HofmannKieferK, ConzenP, RehmM. Best Pract Res Clin Anaesthesiol 2012;26:45362.
Arational approach to perioperative fluid management. 35. KozekLangeneckerSA. Perioperative coagulation monitoring.
Anesthesiology 2008;109:72340. Best Pract Res Clin Anaesthesiol 2010;24:2740.
24. Mauermann WJ, Shilling AM, Zuo Z. A comparison of 36. WeberCF, ZacharowskiK. Perioperative point of care
neuraxial block versus general anesthesia for elective coagulation testing. Dtsch Arztebl Int 2012;109:36975.
total hip replacement: A metaanalysis. Anesth Analg 37. ClevengerB, KelleherA. Hazards of blood transfusion in adults
2006;103:101825. and children. Contin Educ Anaesth Crit Care Pain 2014;14:1128.
25. RichmanJM, RowlingsonAJ, MaineDN, CourpasGE, Weller 38. SpiessBD. Perfluorocarbon emulsions: Artificial gas transport
JF, WuCL. Does neuraxial anesthesia reduce intraoperative media. In: Spiess BD, Spence RK, ShanderA, editors.
blood loss? A metaanalysis. JClin Anesth 2006;18:42735. Perioperative Transfusion Medicine. 2nded. Philadelphia:
26. RajagopalanS, MaschaE, NaJ, SesslerDI. The effects of mild Lippincott Williams and Wilkins; 2006. p.27486.
perioperative hypothermia on blood loss and transfusion 39. CabralesP, IntagliettaM. Blood substitutes: Evolution from
requirement. Anesthesiology 2008;108:717. noncarrying to oxygenand gascarrying fluids. ASAIO J
27. KuppuraoL, WeeM. Perioperative cell salvage. Contin Educ 2013;59:33754.
Anaesth Crit Care Pain 2010;10:1048. 40. RobertsDJ, ProwseCV. Blood substitutes. In: MurphyMF,
28. CarlessPA, HenryDA, MoxeyAJ, OConnellD, BrownT, PamphilonDH, editors. Practical Transfusion Medicine. 4thed.
FergussonDA. Cell salvage for minimising perioperative West Sussex, UK: Wiley Blackwell; 2013. p.399409.
allogeneic blood transfusion. Cochrane Database Syst Rev 41. GregoryMT, DavidCM. Haemoglobin based oxygen carriers.
2010:CD001888. In: SpiessBD, SpenceRK, ShanderA, editors. Perioperative
29. GoodnoughLT, ShanderA. Current status of pharmacologic Transfusion Medicine. 2nded. Philadelphia: Lippincott
therapies in patient blood management. Anesth Analg Williams and Wilkins; 2006. p.25471.
2013;116:1534.
30. HenryDA, CarlessPA, MoxeyAJ, OConnellD, StokesBJ,
Source of Support: Nil, Conflict of Interest: None declared
FergussonDA, etal. Antifibrinolytic use for minimising
Announcement