1. Putting you first

2. The Waikato PBM Team Who are we? Nurse Coordinator – Lucia Best
Speciality Clinical Nurses –Ruth Ireland & Gill Archer
Clinical Lead: Dr Scott Robinson – Chair of the Hospital Transfusion Committee
Dr Antony Aho – PBM doctor/Anaesthetist

3. What is Patient Blood Management
Patient Blood Management improves patient outcomes by improving the patient’s medical and surgical management in ways that boost and conserve the patient’s own blood. As a consequence of better management, patients usually require fewer transfusions of donated blood components thus avoiding transfusion-associated complications.

4. What guides us…..
We’re based on the Australian National Blood Authority Guidelines and the 3 pillars help guide our work. For example Optimise red blood cell mass where anaemia and iron deficiency is detected and treated – which Ruth will explain in more detail shortly. Optimising haemagolbin, Minimize Blood Loss by reducing phlebotomy and using cell salvage and lastly Managing Anaemia by estimating a patients tolerance for blood loss.

5. Why Patient Blood Management
A patients own blood is the BEST blood for them and it works BEST when it stays in their arteries, veins and capillaries
Blood transfusion is not without RISK and should only be used when there is not a better alternative and the RISKS of not transfusing outweigh the RISKS transfusing
Reduces unnecessary blood loss i.e. phlebotomy and cell saver
Optimizing patients before surgery to boost their blood – Pre-operative Anaemia service
Reduces hospital-acquired complication and infection
Reduces hospital costs

6. Optimise Red Blood Cell Mass
Pillar I
Optimise Red Blood Cell Mass
Before surgery we try to optimise a patient’s red blood cell mass by detecting and treating anaemia and iron deficiency through our pre-op anaemia service.
BUT Why do anything about anaemia pre-op……
(Anaemia – a disease condition due to decreased amounts of RBC. Iron Deficiency Anaemia – a nutritional deficiency and the leading cause of anaemia in the world.)

7. Pre-operative anaemia service
Ruth Ireland - SCN

8. Pre-operative anaemia is BAD!
Anaemic patients are more likely to require a blood transfusion
Transfusions increase risk of morbidity and mortality
Increased risk of post-operative complications
Increased length of hospital stay (especially cardiac patients)
Treating anaemia helps:
Patients generally feel better
Reduces potential need for blood transfusion
Reduces blood transfusion associated risks
References:
World Health Organization. (2017). Blood safety and availability . Retrieved from
National Blood Authority. (2012). Patient Blood Management Guidelines: Module 2 – Perioperative. Canberra, Australia: National Blood Authority.
Pre-op anaemia is BAD!
Evidence shows that anaemic patient’s undergoing surgery have a higher risk of morbidity and mortality.
You’re more likely to need a transfusion
Anaemia can lead to longer hospital stays
Can even increase the risk of reoccurrence of certain cancers (colorectal)
FIX
Pt‘s feel much better
It reduces the need for a blood transfusion
Reduces risks associated with transfusion

9. Prevention vs. treatment
Another study which looked at over cardiac surgical patients concluded that there was an increased risk of infection, MI, hospital stay, mortality and cost when patients received red blood cell transfusions. There are many other studies – and a quick google search will find more than you can read.
Obviously in some cases, red blood cell transfusion is absolutely necessary and effective and saves lives, and our service is heavily involved in the use of RBC’s in trauma for example.
But the message we are trying to put across here is that transfusion is NOT always the answer as it exposes patients to increased risks, and that the need transfusions can often be prevented by anaemia being treated pre-operatively.
“Red blood cell transfusion in patients having cardiac surgery is strongly associated with both infection and ischemic postoperative morbidity, hospital stay, increased early and late mortality, and hospital costs.”
Murphy, Reeves, Rogers, Rizvi, Culliford & Angelini (2007).

10. Anaemia increases mortality rates
Condition
% Mortality (at 30 days)
Baseline
0.27
Age >=65
2.19
Age>=65 plus anaemia
7.08
0.62
Cardiac disease
3.45
Cardiac disease plus anaemia
8.44
0.65
COPD
4.02
COPD plus anaemia
11.1
There is an ever increasing body of evidence to show that patient’s going into operations anaemic do worse.
They have higher complication rates, high mortality, longer lengths of stay and more infections.
This table here is from data published in the Lancet where 227,425 patients from the US veterans database were analysed. There were almost 70,000 patients with anaemia and extensive multivariate regression analysis was undertaken to attempt to exclude confounders. Increased risk with anaemia across the board.
Ref: Mussallam et al. (2011).

11. Another study… *7759 patients undergoing major non-cardiac surgery
* 39% had pre-operative anaemia
Ref: Beattie, Karkouti, Wijeysundera & Tait (2009).
Red bar is relative risk of mortality if the patient was anaemic, blue is non-anaemics and as you can see risk of death is over 4 and a half times greater if you go into an operation whilst anaemic.
On the right is same data but with all other risk factors taken into account, and you can see the risk is still almost 2 and a half times.
Authors of this study concluded that going into major surgery with anaemia increases mortality, and it is also associated with an increased requirement for transfusion

12. Patients are referred to PBM who are having major surgery expected to have a blood loss of >600mls and with an Hb of <130 for MEN and 120 for WOMEN.
We use an algorithm to determine if patient would benefit from intervention from our team. Around a THIRD of all pre-operative patients are found to be anaemic.
When we receive a referral, we assess patient with regards to their medical and surgical history, co-morbidities and any other health issues. We assess their CBC and ferritin, but in more complex cases we will request full iron studies including iron saturations & transferrin and also renal results to determine the cause of anaemia and if IV iron would be beneficial.
At times when the cause of anaemia is not clear and not related to reason for surgery, we will refer back to GP for further investigation of cause of anaemia, and patient will be placed on hold until cause is found and addressed.

13. Iron therapy
If the patient has more than two months before their surgery date, we will often recommend oral tablets (ferrous fumerate) with a repeat Hb after one month. If there has been a poor response to oral iron or the patient is not tolerating tablets we will then recommend IV iron.
If we have less than 2 months until surgery or oral iron is not likely to be affective then we recommend IV iron.
The product we provide as part of our service is ferric carboxymaltose – Usually 1g Fast infusion (15 mins), low risk of adverse affects or reaction, easy to prepare and administer.
We organise IV iron through a patient’s GP, through our infusion clinic at Waikato Hospital, and at times will even see a patient in our Anaesthetic Assessment clinic to provide an IV iron infusion if time is limited.
We aim to give IV Iron at least 4 weeks prior to surgery to ensure patient is well optimised. After a month we follow up and if patient surgery date still hasn’t been confirmed we will repeat bloods to ensure they are still optimised.
If time is limited and we receive referral a few days out from surgery we will recommend anaesthetists to give IV iron intra-operatively – which again reduces need for a blood transfusion and reducing transfusion-related risks.

14. Given IV Ferric Carboxymaltose 1g on 16th October 2018
Case example
71 year old male referred to PBM for anaemia management prior to R)TKJR
Blood tests:
4th Oct 2018– Hb 92, Ferritin 17
14 May 2018– Hb 109, Ferritin 17
Given IV Ferric Carboxymaltose 1g on 16th October 2018
Repeat blood tests:
19 Nov 2018– Hb 115, Ferritin 36
27 Feb 2019– Hb 143, Ferritin 120

15. Minimise blood loss/Surgical strategies
Pillar II
Minimise blood loss/Surgical strategies

16. PBM Surgical Strategies
Optimize patients Hb before surgery
Correct anaemia & reduce phlebotomy
Keep the patient warm and well oxygenated
Stop medications or supplements that can increase blood loss
Utilize surgical techniques and devices to control bleeding
Blood salvage techniques
TEG - Thromboelastography

17. Cell Saver machine
Cell salvage is a way of collecting a patient's own blood lost during or after surgery. This blood can then be recycled by infusing it back to the same patient

18. Cell Salvage benefits
Safer blood transfusion, patient’s own blood is used
Reduces allogeneic/donor red cell requirements
An alternative for patients with rare blood groups or
antibodies where obtaining allogeneic/donor blood
may be difficult
An option for patients who refuse blood transfusions
(e.g. Jehovah’s Witness)
References: Guidance For The Provision Of Intraoperative Cell Salvage
(Guidance for Australian Health Providers)
Intraoperative Cell Salvage Education Workbook

19. Cell Salvage savings Total savings OCT – DEC 2018 $107,124.00
Serial Number
October 2018
November 2018
December 2018
Volume reinfused
Total Cases
Total
Average
BO23034 M13 20
11085
889 24
14440
602 16
10346
690
BO23126 M13
11170
858
12129
551 15
11239
749
BO21095 F12
13339
702 8
3192
456 13
9174
706
BO23035 M13 9
1655
327 10
1808
362 6
2472
412
BO23036 M13
2661
505 5
2014
504 2
400
Overall 81
39910
656 71
35583
495 52
33631
Cost Savings Total
$ ,910.00 $
35,583.00
$ ,631.00
Slide of savings – using cell salvage pt own blood vs donated blood
1 ml of salvaged blood ≈ $ 1
Total savings OCT – DEC 2018 $107,124.00
Total savings since April 2015: $1,751,825.00

20. Thromboelastography (TEG)
A TEG machine will give you a snapshot of which products the patient is deficient in. Giving the clinician an overall snapshot of whole blood clotting, gives the ability to quickly detect surgical bleeding caused by coagulopathy. This means that we only give the patient the products they require rather than causing further coagulopathy by giving lots of red blood cells. We now have 2 TEG 6S machines one in ICU and one in theatre along with a TEG5000 which is for cardiac patient use only.

21. Proportions (%) of cardiac surgical patients transfused by blood product in Waikato before and after implementation of TEG algorithm.
Cost saving per cardiac patient is around $500

22. Other areas we focus on…..
Promotion of the core PBM Team
Continuing education for Clinicians, Nurses, HCA’s and Attendants
Blood conservation policies and protocols – Single unit policy/Transfusion Thresholds
Massive Transfusions Protocol
Wastage investigation
Audits – G&S, blood testing, WBIT
Foster and maintain relationships with staff, departments and NZBS
Design and update all forms relating to blood
In the first year that PBM started at Waikato we saved the DHB $2.4 million dollars. To achieve this we focused on the following….

23. Everything Blood

25. Summary and Questions
PBM is about helping patients to make their own blood, minimizing blood loss and using blood only when the evidence says we should
Waikato has the first PBM team in New Zealand
Anaemia pre-op is bad
Transfusion can be bad
Many transfusions are avoidable or not evidence based
Blood is expensive
Everything blood is a useful resource for blood related things