Blood conservation strategies
Preop
Applicable for elective cases
Optimisation
- Screen and correct coagulation defects
- Stop anti-platelet / anticoagulant Rx
- Consider
- Iron Rx
- EPO
- Haematology referral if anaemia
Surgical planning
- Staged procedure
- Smallest procedure possible
- Experienced surgeon
- Arterial embolisation ... by interventional radiologist
Others
- Autologous blood transfusion
- Logistics may be difficult
- 1 unit per week for 4/52
Minimise bleeding
- Permissive hypotension
- Avoid in head injury
- Positioning patient to reduce venous pressure in surgical field
- ?Neuraxial blockade (instead of GA)
Surgical techniques
➤ Minimise arterial bleed:
- Clamps to arteries
- Limb tourniquet (with limb exsanguination before tourniquet inflation)
➤ Minimise wound bleeding:
- Use of diathermy / harmonic scalpel
- Direct compression
- Packing
- Use of topical agents
- e.g. thrombin, collagen, fibrin glue / fibrin sealant
Rx of coagulopathy
- Avoid hypothermia and acidosis
Anti-fibrinolytics
- Tranexamic acid
- 1g over 10 min ... followed by 1g over 8 hours
- ε-aminocaproic acid
Coagulation factors
- FFP
- Cryoprecipitate
- Prothrombinex
- Recombinant factor VIIa
- i.e. Novoseven
- 50 mcg/kg at PAH
- Desmopressin
- i.e. DDAVP
- 0.3 mcg/g
- NOT recommended for routine use unless congenital bleeding disorder (Cochrane 2008)
Others
- Platelets
Other options
- Cell salvage
- Intraop cell saver
- Postop auto-trainsfusion drains
- Acute normovolaemic haemodilution