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1、Patient Blood Management Donat R. Spahn,Patient Blood Management (PBM),What is Patient Blood Management ? Why Patient Blood Management ? Benefits and challenges of PBM Significance of the three pillars of PBM Preoperative anemia treatment (iv iron, EPO, Vit B12, Folic acid) Reduction of perioperativ
2、e RBC loss Restrictive Transfusion triggers Harnessing tolerance of anemia Transfusion outcome Clinical outcome (patients) Consequences / benefits for hospitals,Spahn D. R. et al. Lancet (2013) 381: 1855,Conflict-of-Interest,Consulting for B. Braun, CSL Behring, Vifor International ABC / ABC trauma
3、faculty, managed by Thomson Physicians World GmbH (unrestricted educational grant - Novo Nordisk, CSL Behring, LFB Biomdicaments) In the past 5 years I received honoraria / travel support for occasional consulting / lecturing:,Honoraria / travel support for occasional consulting / lecturing,RBC tran
4、sfusion can be life-saving,Severe malaria induced anemia in children Major trauma with exsanguination Major surgery in severely anemic patients without possibility of preoperative anemia correction Very severe intra- / postoperative anemia with signs of cardiovascular insufficiency,Lackritz, E. M. e
5、t al. Lancet (1992) 340: 524 English M. et al. Lancet (2002) 359: 494 Meremikwu M. et al. Cochrane Database Syst Rev 2000:CD001475 Spahn D. R. et al. Crit Care (2013) 17:R76 Spahn D. R. et al. Lancet (2013) 381: 1855 Wu W. C. et al. Ann Surg (2010) 252: 11,RBC transfusions result in,Mortality Length
6、 of hospital stay Organ dysfunction Lung injury (TRALI, TACO) Renal impairment Stroke Myocardial infarction Infection Transfusion reactions Tumor growth promotion Costs Non-Hodgkin lymphoma ,Spahn D. R. et al. Lancet (2013) 381: 1855,The real problems,Incidence of anemia is high (30%) and per se Mor
7、tality (+ 40%) Major Morbidity (+ 30%) Predisposes for RBC transfusions Major blood loss per se Mortality (3-fold) Major Morbidity (3-fold) Predisposes for RBC transfusions RBC transfusion per se Mortality Major Morbidity ,Musallam K. M. et al. Lancet (2011) 378: 1396 Ranucci M. et al. Ann Thorac Su
8、rg (2013) 96: 478 Spahn D. R. et al. Lancet (2013) 381: 1855,Problems solutions / actions,Incidence of anemia is high (30%) and per se Mortality (+ 40%) Major Morbidity (+ 30%) Predisposes for RBC transfusions Major blood loss per se Mortality (3-fold) Major Morbidity (3-fold) Predisposes for RBC tr
9、ansfusions RBC transfusion per se Mortality Major Morbidity ,Musallam K. M. et al. Lancet (2011) 378: 1396 Ranucci M. et al. Ann Thorac Surg (2013) 96: 478 Spahn D. R. et al. Lancet (2013) 381: 1855,Multidisciplinary team approach To improve patient outcome,Anaemia,Blood loss & bleeding,Transfusion,
10、Courtesy of Dr. A. Hofmann,http:/www.aabb.org/pbm/Pages/default.aspx http:/www.blood.gov.au/patient-blood-management-pbm#whatispbm,http:/www.blood.gov.au/patient-blood-management-pbm#whatispbm,WHO urges member states to promote the availability of transfusion alternatives including, where appropriat
11、e, autologous transfusion and patient blood management“,http:/apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R12-en.pdf,Patient Blood Management publications per year (2015-08),Preoperative anemia,Kassebaum N. J. et al., Blood (2014) 123: 615,30%,Mild anemia Male: Hb 120 - 129 g/L Female: Hb 110 - 119 g/
12、L,Moderate anemia Male: Hb 90 - 119 g/L Female: Hb 80 - 109 g/L,Kassebaum N. J., et al. Blood (2014) 123: 615 Camaschella C., New Engl J Med (2015) 372: 1832,Blood loss, iron absorption ,Microcytic Anemia = Small RBC Small size of RBC due to reduced production of Hb (= predominant constituent of RBC
13、) Globin production (Thalassemia) Iron delivery to heme (Anemia of inflammation) Lack of iron delivery to heme (Iron deficiency anemia) Defects in heme production (Sideroblastic anemia),DeLoughery T., New Engl J Med (2014) 371: 1324,DeLoughery T., New Engl J Med (2014) 371: 1324,Iron restricted anem
14、ia,Iron restricted anemia Anemia of inflammation (Hepcidin iron unavailable for erythropoiesis, Erythropoietin ) Iron deficiency anemia (Iron iron is lacking for erythropoiesis) Iron deficiency Iron content in food (heme iron, absorption 10 times ) Tea reduces iron absorption by 90% Vitamin C improv
15、es iron absorption Following bariatric surgery (iron absorption ),DeLoughery T., New Engl J Med (2014) 371: 1324,Iron treatment,Oral 100 - 325 mg ferrous sulphate (ev. lower dose) With meat (iron absorption ) no tea ! Vitamin C (500 U) If there is sufficient time response in 4 weeks Intravenous If o
16、ral iron is inefficacious / not tolerated (GI side effects) Only short time available for anemia correction like in most preoperative situations (1-2 weeks) Mind formulations with high-molecular-weight dextran (allergic reactions) Anemia of inflammation,DeLoughery T., New Engl J Med (2014) 371: 1324 Camaschella C., New Engl J Med (2015) 372: 1832,Iv iron treatment,Camaschella C. New Engl J Med (2015) 372
