Basics of Blood Management Petra Seeber MD Department of Anesthesiology Critical Care Medicine Pain Management, Emergency Medicine HELIOS Klinik Blankenhain Wirthstr. 5 99444 Blankenhain Germany Aryeh Shander MD, FCCM, FCCP, Chief Department of Anesthesiology, Critical Care Medicine Pain Management and Hyperbaric Medicine Englewood Hospital and Medical Center 350 Engle Street Englewood, NJ 07631 and Clinical Professor of Anesthesiology, Medicine and Surgery Mount Sinai School of Medicine, Mount Sinai Hospital, New York first edition Basics of Blood Management Basics of Blood Management Petra Seeber MD Department of Anesthesiology Critical Care Medicine Pain Management, Emergency Medicine HELIOS Klinik Blankenhain Wirthstr. 5 99444 Blankenhain Germany Aryeh Shander MD, FCCM, FCCP, Chief Department of Anesthesiology, Critical Care Medicine Pain Management and Hyperbaric Medicine Englewood Hospital and Medical Center 350 Engle Street Englewood, NJ 07631 and Clinical Professor of Anesthesiology, Medicine and Surgery Mount Sinai School of Medicine, Mount Sinai Hospital, New York first edition C 2007 Petra Seeber and Aryeh Shander Published by Blackwell Publishing Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First published 2007 1 2007 Library of Congress Cataloging-in-Publication Data Seeber, Petra. Basics of blood management / Petra Seeber, Aryeh Shander. – 1st ed. p. ; cm. Includes bibliographical references and index. ISBN: 978-1-4051-5131-3 1. Transfusion-free surgery. 2. Blood–Transfusion. 3. Bland banks. I. Shander, Aryeh. II. Title. [DNLM: 1. Blood Substitutes–therapeutic use. 2. Blood Banks–organization & administration. 3. Blood Loss, Surgical–prevention & control. 4. Blood Transfusion. WH 450 S451b 2008] RD33.35.S44 2008 617–dc22 2007005030 ISBN: 978-1-4051-5131-3 A catalogue record for this title is available from the British Library Set in 9.25/11.5 Minion by Aptara Inc., New Delhi, India Printed and bound in Singapore by Fabulous Printers Pte Ltd Development Editor: Rebecca Huxley Commissioning Editor: Maria Khan Editorial Assistant: Jennifer Seward Production Controller: Debbie Wyer For further information on Blackwell Publishing, visit our website: http://www.blackwellpublishing.com The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. Blackwell Publishing makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check that any product mentioned in this publication is used in accordance with the prescribing information prepared by the manufacturers. The author and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this book. Contents Preface to the first edition, vii Acknowledgments, viii Introduction, ix 1 History and organization of blood management, 1 2 Physiology of anemia and oxygen transport, 9 3 Anemia therapy I: erythropoiesis stimulating proteins, 21 4 Anemia therapy II (hematinics), 35 5 Growth factors, 50 6 Fluid therapy, 65 7 The chemistry of hemostasis, 77 8 Recombinant blood products, 96 9 Artificial blood components, 110 10 Oxygen therapy, 125 11 Preparation of the patient for surgery, 139 12 Iatrogenic blood loss, 160 13 The physics of hemostasis, 172 14 Anesthesia—more than sleeping, 191 15 The use of autologous blood, 200 16 Cell salvage, 211 17 Blood banking, 227 18 Transfusions. Part I: cellular components and plasma, 243 19 Transfusions. Part II: plasma fractions, 265 20 Law, ethics, religion, and blood management, 287 21 Step by step to an organized blood management program, 299 Appendix A: Detailed information, 322 Appendix B: Sources of information for blood management, 329 Appendix C: Program tools and forms, 334 Appendix D: Teaching aids: research and projects, 346 Appendix E: Address book, 350 Index, 376 v Preface to first edition The benefit-to-risk ratio of blood products needs con- The benefit-to-risk ratio of blood products needs con- stant evaluation. Blood products, as therapeutic agents, stant evaluation. Blood products, as therapeutic agents, have had the test of time but lack the evidence we ex- have had the test of time but lack the evidence we ex- pect from other medicinals. Blood, an organ, is used as pect from other medicinals. Blood, an organ, is used as a pharmaceutical agent by the medical profession, due to a pharmaceutical agent by the medical profession, due to the achievements in collection, processing, banking, and the achievements in collection, processing, banking, and distribution. The fact that the most common risk of blood distribution. The fact that the most common risk of blood transfusionisblooddeliveryerrorsupportsthenotionthat transfusionisblooddeliveryerrorsupportsthenotionthat blood is handled as a pharmaceutical agent. Over the last blood is handled as a pharmaceutical agent. Over the last few decades, the risk of blood transfusion and associated few decades, the risk of blood transfusion and associated complications has raised concerns about safety of blood complications has raised concerns about safety of blood by both the public and health-care providers. At the same by both the public and health-care providers. At the same time, experience with patients refusing blood and data on time, experience with patients refusing blood and data on blood conservation brought to light the real possibility of blood conservation brought to light the real possibility of other modalities to treat perisurgical anemia and to avoid other modalities to treat perisurgical anemia and to avoid it with blood conservation methods. In addition to risks it with blood conservation methods. In addition to risks and complications, data became available demonstrating and complications, data became available demonstrating the behavioral aspect of transfusion practice versus an the behavioral aspect of transfusion practice versus an evidence-based practice. In this book, the authors address evidence-based practice. In this book, the authors address many aspects of modern transfusion medicine, known many aspects of modern transfusion medicine, known blood conservation modalities, and new approaches to the blood conservation modalities, and new approaches to the treatment of perisurgical anemia, as well as special clinical treatment of perisurgical anemia, as well as special clinical considerations. This approach, now termed “blood man- considerations. This approach, now termed “blood man- agement” by the Society for the Advancement of Blood agement” by the Society for the Advancement of Blood Management, incorporates appropriate transfusion prac- Management, incorporates appropriate transfusion prac- tice and blood conservation to deliver the lowest risk and tice and blood conservation to deliver the lowest risk and highest benefit to the patient. In addition, it brings all highest benefit to the patient. In addition, it brings all these modalities to the patient’s bedside and above all is a these modalities to the patient’s bedside and above all is a patient-centered approach. Blood management is a mul- patient-centered approach. Blood management is a mul- tidisciplinary, multimodality concept that focuses on the tidisciplinary, multimodality concept that focuses on the patient by improving patient outcome, making it one of patient by improving patient outcome, making it one of the most intriguing and rewarding fields in medicine. the most intriguing and rewarding fields in medicine. vii Acknowledgments We thank the following individuals for their review David Grant, Renate Lange, Gregg Lobel, MD, FAAP, and valuable comments: Philip Battiade, Dr Charles and David Moskowitz, MD, Barbara Shackford, CRNA, MS, Nicole Beard, Prof. Dr Jochen Erhard, Shannon Farmer, Mark Venditti, MD, and Prof. Max Woernhard. viii Introduction The benefit-to-risk ratio of blood products needs con- various techniques. This publication introduces the reader stant evaluation. Blood products, as therapeutic agents, to blood management and explains how to improve medi- have had the test of time but lack the evidence we expect cal outcomes by avoiding undue blood loss, enhancing the from other medicinals. Blood, an organ, is used as a phar- patient’s own blood, and improving tolerance of anemia maceutical agent by the medical profession, due to the and coagulopathy until any of these underlying conditions achievements in collection, processing, banking, and dis- are successfully remedied. tribution. The fact that the most common risk of blood This introduction to blood management is intended for transfusion is blood delivery