Obstetrics and Maternity Patient Blood Management

How do you manage your obstetric and maternity patients with anaemia? Here are some scenarios to consider.

Nancy Chan, age 32 is 4 months pregnant. She had a history of iron deficiency anaemia in her last pregnancy. Her Hb is 123 g/L and her ferritin is <5 µg/L.

What treatment, if any would you recommend?

Sally Johnson, age 29, is in her third trimester of pregnancy. She has iron deficiency anaemia. She was not able to tolerate the oral iron you prescribed, despite decreasing the dose and frequency, so stopped taking it. Her Hb has dropped further and she is scheduled for a LUSC in two weeks due to placenta praevia.

Do you prescribe more steak dinners?

Tell her to persist with oral iron?

Give her a shot of intramuscular iron?

Or schedule some intravenous iron ASAP?

Kaylee Jones, age 31, is 7 months pregnant with her third child. She is feeling short of breath walking down the street. Her haemoglobin is 61 g/L. She is pale and tachycardic.

Do you transfuse her? How many units?

Find out the answers and learn more in our latest Transfusion Q&A topic Obstetrics and Maternity Patient Blood Management Guidelines part 1: Anaemia

All cases are based on the National Blood Authority Patient Blood Management Guidelines and the explanations provide links to the guidelines and other resources.

Dr Sandy Minck, the author of this post, is a Medical Officer at the Australian Red Cross Blood Service and a member of the Transfusion Practice and Education team.

Obstetrics and Maternity Patient Blood Management Guidelines released

The fifth in a series of six evidence-based patient blood management (PBM) guidelines, the Obstetrics and Maternity module was approved by the National Health and Medical Research Council (NHMRC) in December 2014, and released on 23 March 2015.

The module contains a series of recommendations based on evidence from the systematic review; practice points developed through consensus decision making by the Clinical/Consumer Reference Group (CRG) where there was insufficient high quality data; and thirdly, unique so far to the fifth module, expert opinion points to guide practice in areas outside the scope of the systematic review.

Evidence from the systematic review led to four recommendations. Firstly, routine administration of iron supplementation to all pregnant women is not recommended. The administration of iron to pregnant women with iron deficiency is recommended, but not the routine addition of folic acid. Finally, ESAs should not be routinely used in maternity patients. Further guidance regarding anaemia and iron therapy is provided in the form of practice points.

The module also covers blood group and screen during pregnancy; planning for when transfusion is not an option; transfusion in women who are not actively bleeding, and when there is critical bleeding including the use of massive transfusion protocol. The use of modified blood components (CMV negative and phenotyped); transfusion support for maternity care/services; guidance for coagulopathic patients at risk of bleeding; and the use of recombinant activated factor VIIa, cell salvage, interventional radiology also feature.

To learn more about obstetric and maternal patient blood management and the PBM guidelines, why not register to attend Transfusion Update: Obstetric and Maternal Patient Blood Management either in person or by webinar. This session will cover PBM in maternity care including iron deficiency anaemia, indications for blood product support during pregnancy, the needs of the growing fetus and critical bleeding.

Wednesday 13 May, 1.30pm – 3.00pm (Sydney time), at The Royal Women’s Hospital, 20 Flemington Rd, Parkville, or by webinar.
Presented by Dr Helen Savoia, Head of Haematology, The Royal Children’s Hospital, Dr Wendy Pollock, Critical Care Nurse and Midwife, Mercy Hospital for Women, and Dr Shelley Rowlands, Obstetrician and Fetal Maternal Specialist, Royal Women’s Hospital. The session is Chaired by Mr Leigh McJames, General Manager, National Blood Authority.

Dr Sandy Minck, the author of this post, is a Medical Officer at the Australian Red Cross Blood Service and a member of the Transfusion Practice and Education team.

Demand for red cells is falling. What’s going on?

Demand for red cells is declining in Australia and internationally. In Australia, demand for red cell units dropped by 4.8 percent from 2011/12 to 2012/13, 7.9% in 2013/14, and is expected to decline by a further 3% in 2014/15. In the UK demand started to decline sharply in October 2012, with a reduction of 2.7% in 2012/13, a further 4.8% in 2013/14, and the trend forecast to continue over the medium term. Sanquin Blood Services in the Netherlands saw a greater than 20% reduction in demand from 2009 to 2013. In New Zealand the clinical use of red cell components has reduced significantly over the last decade with transfusion rates falling by almost 25% from 29.6 red cells per 1000 population in 2006 to a projected 22.3 per 1000 by the end of 2014. The US estimates 8.2% fewer transfusions in 2011 compared to 2008, with transfusion rates falling from 48.4 units per 1000 to 44.0/1000.

All organisations report that the decline in red cell demand is likely due to the growing adoption of programs to reduce wastage and improve appropriate use. In Australia, the National Blood Authority (NBA) has implemented the National Blood and Blood Product Wastage Reduction Strategy 2013-17 to facilitate improved inventory management and logistics. The NBA and other blood sector stakeholders have also been focussed on practice improvement, including improving appropriate use through the publication and implementation of Patient Blood Management Guidelines. The Australian Red Cross Blood Service has developed a transfusion education curriculum and numerous resources to promote patient blood management principles including appropriate and safe transfusion practices.

New Zealand specifically attribute the initial decrease in demand as being driven by blood conservation programs such as “Why use two when one will do?” emanating from Canterbury District Health Board and increasingly rolled out across the country. Australia is encouraging a similar theme with the single unit transfusion guide. Increasing awareness of the importance of maximising patient’s haemoglobins prior to surgery has also contributed to the fall in clinical use. Pre-operative assessment identifies many patients who are iron deficient, treatment of which improves haemoglobin levels prior to surgery with a consequent reduction in the need for transfusion. Additionally, improved surgical techniques and other patient blood management (PBM) strategies – such as cell salvage – have contributed.

What does the decline in red cell demand mean? The upside is the benefit to patients and healthcare facilities – reduced transfusion rates results in decreased adverse outcomes, such as decreased morbidity, mortality and length of stay; and decreased cost.

The downside is the impact on the blood services – the costs of the blood supply chain are relatively fixed in nature and it is challenging to reduce costs at the same rate as volume reduction. As capacity is reduced in line with longer term trends in demand, blood services remain dependent on their donors to be able to respond to short term demand pressures. In addition, there is the need to increase the proportion of rare blood group donors, especially of O negative. In managing this environment we can sometimes be seen as presenting conflicting messages to our donors.

If you would like to find out more about how the Blood Service aligns supply and demand, You can head along to the Melbourne Processing Centre, 100 – 154 Batman Street, West Melbourne on Wednesday 8 April at 1.30pm. You can also join this session by webinar, or catch up with a recorded version after the event. Register at Transfusion Online Learning on transfusion.com.au.

Some other useful resources:

Understanding red cell decline: a global challenge for blood services.
National Blood Authority Australia Annual report 2013-14.
The 2011 National Blood Collection and Utilization Survey Report. Department of Health and Human Services, USA.
NHS Blood and Transplant Annual Report and Accounts 2013/14.
New Zealand Blood Service Annual Report 2013/2014.
Sanquin Blood Supply Annual Report 2013.

Dr Sandy Minck is a Medical Officer at the Australian Red Cross Blood Service and a member of the Transfusion Practice and Education team.

Latest study debunks age of red cell advantage

Results from the ABLE (Age of Transfuse Blood in Critically Ill Adults) study have just been published in the New England Journal of Medicine.

This study is an important milestone in the debate around the value of “fresh blood”. For several years now there has been increasing evidence of differences in stored blood with time: the longer red cells are stored, the more measurable changes occur. It has been assumed that this red cell storage lesion has negative clinical consequences. Indeed, several observational studies strongly suggested that older blood had deleterious effects.

The ABLE study compared key outcomes –  in particular 90-day mortality –  for critically ill patients in 64 hospitals across Canada and Europe. Patients were randomised to receive <7 day old blood or standard transfusion. The patient groups were very closely matched and the groups received either 6.1 day old or 22 day old red cells for transfusion. The primary outcome found no difference in the 90-day mortality between the groups. Secondary outcomes such as major illness, length of stay, transfusion reactions etc also found no difference between the study groups.

The ABLE study now sits beside the other large randomised trials in this area: the ARIPI study (Fergusson et al), which found no advantage of fresh blood in sick premature babies and the RECESS study (Steiner et al), which found no difference in cardiac surgical patients.

Together these studies are building evidence that the red cell storage lesion is not very important in some clinical situations. We should note that only very sick patients have been studied in these large trials and the results may not be generalisable.

There are other high quality studies still ongoing in this field, in particular the Australian TRANSFUSE study and the Canadian-Australian INFORM study.

For my clinical practice, I am becoming progressively reassured that I don’t need to ask for young blood compared to standard, especially in the setting of ICU.

Dr Ben Saxon is the National Transfusion Specialist at the Australian Red Cross Blood Service and haematologist at the Women’s and Children’s Hospital, Adelaide.

Quick transfusion quiz for busy health professionals

Transfusion Q&A is a database of questions, grouped by topic, designed to test your knowledge of safe transfusion practices and patient blood management. We made it specifically for the time poor (that would be all of us, then).

You can access Transfusion Q&A at qanda.transfusion.com.au. Alternatively you can access individual topics on Transfusion Online Learning on transfusion.com.au.

You choose how you complete a topic: all in one hit as a “quick quiz”; or enrol to get sent questions over time. You choose the device on which you access the education – PC, laptop, mobile phone, or tablet.

If you enrol, the system sends notifications when questions are due to be answered. During enrolment you choose to receive these via email or SMS. You can also choose to customise delivery notifications, indicating how many questions you want to receive with each notification and how often you get the notifications.

But don’t worry if you can’t be bothered with the customisation – we have pre-set a delivery schedule for you.

Every time you answer a question you get feedback on your response and an explanation with links to the relevant information about the topic.

If you want to receive a certificate for CPD purposes, enrol in a topic. You’ll need to get each question correct twice to be awarded a certificate – there are no rewards for random guessing in this game.

If you think you already know your stuff, but just want to confirm this, do a quick quiz. You’ll still get instant feedback on the answers to your questions and a score at the end, but no certificate.

Once you log into Transfusion Q&A, your dashboard will list the topics you are currently enrolled in and those you have completed, with links to your certificate.

 

– Dr Sandy Minck

Intraoperative cell salvage and the ROTEM system – what’s the benefit?

A recent webinar on cell salvage and the ROTEM system hosted by the TPE team at the Blood Service was a great opportunity to come up to speed on new patient blood management techniques.

This joint presentation was given by Peter Frantzis, Head Perfusionist at the Royal Adelaide Hospital and Associate Professor David Roxby, Head of SA Pathology Transfusion Services at Flinders Medical Centre.

Here’s some of the key information from the session:

What is cell salvage?
Intraoperative cell salvage (ICS) is performed as a blood conservation technique and is frequently used in cardiothoracic and vascular surgery as these areas traditionally have high levels of blood usage. It has been gaining more attention lately as transfusion risks have become more fully appreciated, patient blood management (PBM) guidelines have been released and the National Blood Authority of Australia has recently implemented guidelines for intraoperative cell salvage (March 2014).

What happens during the cell salvage process?
During the process, the surgeon aspirates any bleeding into a collection reservoir, the blood is filtered and anticoagulant is added in order to remove debris and prevent clotting. The blood is then centrifuged and washed to produce separated red blood cells (RBC) with a high Hct, suspended in 0.9% normal saline for re-infusion to the patient (autotransfusion).

What are the benefits of cell salvage?
Cell salvage helps to reduce the requirement for allogenic blood transfusion during cardiothoracic and vascular surgery and when combined with improved bypass circuitry/techniques and haemofiltration, patients can even have elevated Hb levels post-surgery. ICS is also very useful for Jehovah witness patients who refuse blood transfusions as a circuit is set up between the patient, heart lung machine and the autotransfusion device providing continuity and ensuring all their red blood cells are returned.

What is the ROTEM system?
The ROTEM (rotational thromboelastometry) system is actually a modified version of thromboelastography [TEG], probably a more familiar term to many of us. The ROTEM system provides real-time measurement of the interactions of coagulation factors, inhibitors and cellular components during the phases of clotting and subsequent lysis over time. The aim of this method is to mimic the sluggish flow of blood in veins.

What are the benefits of ROTEM?
The ROTEM system provides a point of care (POC) test and is proving to be an extremely useful source of information. Clinicians are able to assess their patients before surgery (to determine if coagulopathies are present), during surgery (to determine if coagulopathies are developing) and after surgery (when trying to establish the cause of bleeding). It can also be located in either the operating theatre, transfusion laboratory or networked between these areas. ROTEM results are also available much quicker than traditional coagulation tests like INR, APTT, Fibrinogen and platelet count and enable the treating clinician to discriminate between coagulation related conditions in a more efficient manner.

The benefits of coagulation POC testing have also been highlighted in an article in Anesthesiology, where the randomised clinical trial was terminated 6 months early as initial results demonstrated that haemostatic therapy based on POC testing significantly reduced patient exposure to allogenic blood products and provided significant benefits with respect to clinical outcomes.

Additional information and extra reading
The Blood Service clinical website transfusion.com.au contains excellent information about PBM, blood conservation and the PBM guidelines. In fact, the PBM guidelines: Module 2 Perioperative actually state that ICS is recommended for adult patients undergoing surgery in which substantial blood loss is anticipated and also mentions that TEG and TEG-based POC tests should be considered in adult patients undergoing cardiac surgery.

If you would like more information on these topics, this joint webinar was recorded for educational purposes and can be accessed in Transfusion online learning.

– Tanya Raison, Project Officer, TPE