How much blood do you need?

Grand rounds

John Welch

11/30/07

Case 1

• 54 yo obese woman with hx of CHF admitted with DOE and edema.

• BNP 700.

• Prior EF 30%. Prior Cath unremarkable.

• WBC 6.5, Hgb 9.5, Plt 250. MCV85. Cr 1.9

• CXR with possible infiltrate.

• SHx notable for being a Jehovah’s Witness

Recommendations

• Continue diuresis• Check iron, folate, B12, TSH• Multivitamin +/- iron• Check Epo level• Consider treating Epo if low• Treat possible pneumonia• GI prophylaxis• Respect patient autonomy

Acute anemia in baboons

Cardiac outputSVR

Wilkerson Surgery 103: 665

% oxygen extractionLV lactate productionLV vascular resistance

Risk of mortality during cardiovascular surgery correlates with blood loss and pre-op Hgb.

Preop Hgb and operative mortality during cardiac surgery.

Meta-analysis of transfusion triggers in surgery and critical care

Units transfused

Hct

Carson Transfusion Medicine Review 16(3): 187

Meta-analysis of transfusion triggers in surgery and critical care

CardiacOutcomes

30 day All causemortality

Carson Transfusion Medicine Review 16(3): 187

The Blood that really saves

1961

Prohibited:Transfusion of whole blood, red cells, white cells, platelets or plasma. Transfusions of pre-operative donated autologous blood.

Not promoted or encouraged:Blood donation, Transfusions of autologous blood part of a "current therapy". Hemodilution, Intraoperative blood salvage, Heart-Lung Machine, Dialysis, Epidural Blood PatchPlasmapheresis, with plasma substitutionLabeling or Tagging of RBC or WBCHemoglobinTransplant of solid organs and bone marrow

Fractions from white blood cellsInterferons, Interleukins

Fractions from plateletsPlatelet factor 4

Fractions from blood plasma Albumin, Globulins, Clotting factors, Factor VIII and Factor IXErythropoietin (EPO)PolyHeme, Hemopure.

Wikepedia 2007

Parsing Hairs

Case 2

• 51 year old male presents with new AML– WBC 3.1, Hgb 6.0, plt 7, 43% Blasts. – Iron 108, TIBC 254, B12 and folate nl. No active bleeding

• Starts induction 7+3. EF 62%.• Day 2 Intubated. Hgb 4.1.

– Pancuronium. – 100% FiO2 weaned to 80% after PO2 189.

• Day 4– Hypothermia– Bradycardia resolved with epi/atropine– FiO2 increased to 100%– Cx grows coag negative staph

• Day 5 – HoTN: Levo– Bradycardia -> asystole

Tx:AML: daunorubicin 30 mg/m2 day 1-3, cytarabine 100 mg/m2 5 days VP16 + Amsacrine consolidationAPL: ATRA + daunorubicin 30 mg/m2 + cytarabine 100 mg/m2 ATRA, 6-MP, MTX consolidationALL: VCR, DNR, Pred

• 44 year old woman with accelerated phase CML after Hydrea•Start Epo 3 weeks prior to transplant•Blood conservation strategies during transplant•Condition with Fludarabine 40 mg/m2 day -9 to -6

•Busulfan 3.2 mg/kg/day day -5 to -2•GVHD prophylaxis with Tacrolimus/MTX•Sibling Allo transplant from sister with peripheral stem cell collection

Mortality following HSCT by pre transplant Hct

Critical care patients’ phlebotomy and transfusion trends

14.6 ml/day x 51 days = 744 ml

10 ml waste + 5 ml CBC + 7 ml CMP + 5 mls coags = 27 mls

“Bloodless” (less blood) approachDon’t waste blood!

• pediatric tubes for blood draws, • decreased frequency (CBC, chemistry) to every other

day, liver function tests twice weekly, PT/PTT once weekly,

• closed system return of the waste blood after blood draws,

• gastrointestinal prophylaxis with proton pump inhibitor, • folic acid and iron supplementation daily, vitamin K once

weekly, • aminocaproic acid for platelet count below 30,000/ml. • oxygen support for Hgb < 9 g/dl or symptomatic anemia• oral contraceptives prior to starting chemotherapy

Bone Marrow Transplantation (2006) 37, 325–327.

Don’t waste energy

• Clear discussion early concerning treatment options: albumin, cryo, clotting factors, etc.

• Hypothermia and paralytics if intubated

• Arterial line for ABGs

• Good luck

Other options: Polyheme Phase II 1998

Other options: Polyheme phase III

• Polyheme– Not FDA approved, but may obtain on compassionate

basis– Phase III trial complete in acute trauma.

• Supposedly well tolerated (as was phase II)• Preliminary mortality data:

– 13.2 %PolyHeme – 9.6 % standard of care

• FDA fast track on hold

– One case of use as bridge to marrow recovery after sib allo transplant without significant side effects (Compr Ther. 2006 Fall;32(3):172-5.)

For what is a man profited, if he shall gain the whole world, and lose

his own soul?

Rights and duties