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.

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