Patient Blood Management in the Surgical Setting


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also        

    Anaemia

    Iron deficiency
    Blood product prescription 
    The Australian Red Cross Blood Service anaemia and haemostasis overview
    Intravenous iron

    Key Points

    Patient Blood Management (PBM) aims to improve clinical outcomes by avoiding unnecessary exposure to blood components. 

    Background

    • Anaemia and iron deficiency may be seen prior to paediatric surgery and are risk factors for adverse clinical outcomes and red cell transfusion.
    • It is good clinical practice to identify and treat pre-operative anaemia prior to elective surgery associated with significant blood loss, with the aim of reducing a patient’s risk of needing a red cell transfusion. 

    Assessment

    Red Flags:   Iron deficiency and/or anaemia

    Any patient undergoing elective surgery and at risk of requiring a red cell transfusion intra- or post-operatively should be assessed with regard to PBM.

    Considerations:

    • Patients requiring a blood group and antibody (BGAB) for surgery
    • Nature and length of surgical procedure
    • Concurrent anti-platelet or anticoagulant medications
    • Bleeding risk of surgery
    • Previous operative history
    • Previous red cell transfusion audit data 

    Three Pillars of PBM applied to the surgical patient

    • Pre-operative
      • Optimise a patient’s red cell volume and red cell mass
        • Identify and treat iron deficiency with or without anaemia prior to surgery
        • Review medications and consider ceasing prior to surgery
    • Intra-operative
      • Minimise intra-operative blood loss
        • Surgical/anaesthetic techniques; use of antifibrinolytics and cell salvage where appropriate
        • Maintenance of normothermia
        • Minimise unnecessary blood tests
      • Avoid unnecessary transfusions
    • Post-operative
      • Minimise post-operative blood loss
        • Minimise unnecessary blood tests
      • Optimise a patient’s tolerance of anaemia
        • Optimise oxygen delivery to tissues
      • Avoid unnecessary transfusions

    Management 

    Pre-operative anaemia and iron deficiency assessment and optimisation algorithm

    Pre operative anaemia


    Pre-operative

    • Detection, evaluation and management of anaemia and iron deficiency
      • Treatment with oral iron +/- IV iron
    • Optimising haemostasis
      • Discontinue or reverse anti-coagulants
      • Vitamin K supplementation
    • Review indications for anti-platelet agents and the need to continue leading up to surgery
    • BGAB prior to surgery to allow allocation of red blood cell (RBC) units 
      • Units cross matched for surgery

    Intra-operative

    • Maintenance of normothermia (Temp> 36°C)
    • Meticulous surgical and perioperative haemostasis to minimise blood loss
    • Intravenous anti-fibinolytics (e.g. tranexamic acid or aprotinin)
    • Cell salvage
    • Acid base balance status (pH > 7.2 and ionised Ca2+ > 1.1 mmol/L)
    • Optimise tissue oxygenation and perfusion, as well as cardiac output
    • Minimise frequency and volume of blood sampling
    • Point of care testing including viscoelastography
    • Restrictive transfusion triggers
    • Single unit RBC transfusion in stable, non-bleeding patients with reassessment of Hb between units 

    Post-operative

    • Maintenance of normothermia (Temp > 36°C)
    • Optimise tissue oxygenation and perfusion, as well as cardiac output
    • Acid base balance status (pH > 7.2 and ionised Ca2+ > 1.1 mmol/L)
    • Restrictive transfusion triggers
      • Hb <70g/L; A RBC transfusion is often indicated, however lower thresholds may be acceptable in patients without symptoms and where specific therapy (e.g. iron) is available
      • Hb <70-90g/L; A RBC transfusion may be indicated, depending on the presence of bleeding and clinical signs or symptoms of anaemia
      • Hb >90g/L; RBC transfusion is often unnecessary and may be inappropriate
      • NOTE: higher thresholds may be indicated for specific situations (e.g. pre-term neonates, children with cyanotic congenital heart disease and extracorporeal life support (ECLS))
    • Tranexamic acid
    • Single unit RBC transfusion with reassessment of Hb between RBC units
    • Minimise frequency and volume of blood sampling
    • Early removal of sampling lines when patient is stable and frequent sampling no-longer required
    • Clinical pathways for surgical specialities that inform regarding routine post-operative blood tests
    • Blood conservation strategies

      • Reducing laboratory ordering, rationalising and consolidating laboratory blood testing
      • Use of neonatal collection tubes
      • Strict adherence with minimum volume analyte volumes for pathology tests
      • Early removal of sampling lines
      • Returning of discard volumes
      • Point of care testing devices
      • Extended expiry BGABs in neonates less than 4 months and surgical patients 

      Consider consultation with local paediatric team when:

      Red flags identified 

      Consider transfer when:

      Children requiring care beyond the level of comfort of the local hospital. 

      For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

       

       Information specific to RCH and Monash Children’s Hospital

       Consider discussion with clinical haematology




               

            Last updated January 2019