Download Blood Management: - Pfiedler Enterprises

Blood Management:
Providing Patient Choices
An Online Continuing
Education Activity
An Online Continuing Education Activity
Sponsored By
Funded By
Stryker CMF
Welcome to
Blood Management:
Providing Patient Choices
(An Online Continuing Education Activity)
CONTINUING EDUCATION INSTRUCTIONS
This educational activity is being offered online and may be completed at any time. We suggest you take the following
steps for successful completion:
1. Read the overview and objectives to ensure consistency with your own learning needs and objectives.
2. Review the content of the activity, paying particular attention to those areas that reflect the objectives.
3. Complete the Test Questions and compare your responses with the answers provided.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. A certificate of completion will be available for you to print at the conclusion. Pfiedler Enterprises will maintain a
record of your continuing education credits and provide verification, if necessary, for 7 years.
If you have any questions, please call: 720-748-6144.
CONTACT INFORMATION
2101 S. Blackhawk Street, Suite 220
Aurora, CO 80014-1475
Phone: 720-748-6144
Fax: 720-748-6196
Website: www.pfiedlerenterprises.com
© Pfiedler Enterprises - all rights reserved 2012
OVERVIEW
Blood management is an evidenced-based, multidisciplinary process that is designed to promote the optimal use of blood
products throughout a health care facility. A blood management program is designed and implemented to ensure the safe
and efficient use of the many resources involved in the complex process of blood component therapy. This continuing
education activity will explore blood and blood components. Safer and more effective options rather than blood transfusion
will be discussed. In addition, health care facilities must be prepared to respect a patient’s personal and religious beliefs or
convictions regarding the acceptance of blood transfusion alternatives.
LEARNER OBJECTIVES
After completing this continuing education activity, the participant should be able to:
1. Explain the difference between allogeneic and autologous transfusions.
2. Describe blood and blood components.
3. Identify reasons to develop a blood management program.
4. Define the benefits of blood transfusion alternatives.
5. Identify safer, more effective options to blood transfusions.
INTENDED AUDIENCE
This continuing nursing education activity is intended for use by perioperative nurses and surgical technologists who are
interested in learning more about blood management and the impact on patient choices.
CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for
1.0 contact hour(s).
Obtaining full credit for this offering depends upon completion, regardless of circumstances, from beginning to end.
Licensees must provide their license numbers for record keeping purposes.
The certificate of course completion issued at the conclusion of this course must be retained in the participant’s
records for at least four (4) years as proof of attendance.
IACET
Pfiedler Enterprises has been accredited as an Authorized Provider by the International Association for Continuing
Education and Training (IACET).
CEU Statements
• As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs that qualify under the ANSI/
IACET Standard.
• Pfiedler Enterprises is authorized by IACET to offer 0.1 CEUs for this program.
IAHCSMM
The International Association of Healthcare Central Service Materiel Management has approved this educational offering for
1.0 contact hour to participants who successfully complete the program.
Page 1
RELEASE AND EXPIRATION DATE
This continuing education activity was planned and provided in accordance with accreditation criteria. This material was
originally produced in January 2012 and revised in June 2014 and can no longer be used after June 2016 without being
updated; therefore, this continuing education activity expires in June 2016.
DISCLAIMER
Accredited status as a provider refers only to continuing nursing education activities and does not imply endorsement of any
products.
SUPPORT
Funded by Stryker CMF.
Author/PLANNING committee/REVIEWer
Elizabeth Deroian, RN, BA
Program Manager/Author/Planning Committee
Pfiedler Enterprises
Aurora, CO
Julia Kneedler, RN, MS, EdD
Program Manager/Reviewer
Pfiedler Enterprises
Aurora, CO
Judith Pfister, RN, BSN, MBA
Program Manager/Planning Committee
Pfiedler Enterprises
Aurora, CO
DISCLOSURE OF RELATIONSHIPS WITH COMMERCIAL ENTITIES FOR THOSE IN A POSITION TO
CONTROL CONTENT FOR THIS ACTIVITY
Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control content
for an educational activity. Information listed below is provided to the learner, so that a determination can be made if
identified external interests or influences pose a potential bias of content, recommendations or conclusions. The intent is
full disclosure of those in a position to control content, with a goal of objectivity, balance and scientific rigor in the activity. Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be
presented in this educational activity. “Relevant financial relationships” are those in any amount, occurring within the
past 12 months that create a conflict of interest. A “commercial interest” is any entity producing, marketing, reselling, or
distributing health care goods or services consumed by, or used on, patients.
Activity Planning Committee/Authors/Reviewers:
Elizabeth Deroian, RN, BA
No conflicts of interest
Judith Pfister, RN, BSN, MBA
Co-owner of company that receives grant funds from commercial entities
Julia A. Kneedler, RN, MS, EdD
Co-owner of company that receives grant funds from commercial entities
Page 2
PRIVACY AND CONFIDENTIALITY POLICY
Pfiedler Enterprises is committed to protecting your privacy and following industry best practices and regulations regarding
continuing education. The information we collect is never shared for commercial purposes with any other organization. Our
privacy and confidentiality policy is covered at our website, www.pfiedlerenterprises.com, and is effective on March 27,
2008.
To directly access more information on our Privacy and Confidentiality Policy, type the following URL address into your
browser: http://www.pfiedlerenterprises.com/privacy-policy
In addition to this privacy statement, this Website is compliant with the guidelines for internet-based continuing education
programs.
The privacy policy of this website is strictly enforced.
CONTACT INFORMATION
If site users have any questions or suggestions regarding our privacy policy, please contact us at:
Phone: 720-748-6144
Email:
[email protected]
Postal Address: 2101 S. Blackhawk Street, Suite 220
Aurora, Colorado 80014
Website URL:
http://www.pfiedlerenterprises.com
Page 3
Introduction
The first known human blood transfusion was performed in 1795 by Dr. Philip Syng Physick although he did not publish
the information.1 In 1818, Dr. James Blundell performed the first successful transfusion of human blood to a patient for
the treatment of postpartum hemorrhage. He used the patient’s husband as the donor extracting a small amount of blood
by syringe and then transfusing the wife. In the early 1900s at the University of Vienna, Karl Landsteiner and associates
discovered the ABO blood types while trying to learn why blood transfusions sometimes caused a patient’s death and at
other times saved the patient’s life. In 1930 he received the Nobel Prize for Medicine recognizing his discovery. Between
1939 and 1940, he and his associates also discovered the Rhesus (Rh) system. Identification of the Rh factor took its
place next to the discovery of ABO as one of the most important breakthroughs in the field of blood banking. Today, blood
transfusions are common in the hospital setting. Allogenic (donor-donated) transfusions refer to blood transfused to
someone other than the donor. Autologous (self-donated) transfusions refer to those transfusions in which the blood donor
and transfusion recipient are the same.
According to the America’s Blood Centers:2
• One in 20 Americans will require a blood transfusion at some point in their lives.
• About 12 million units of red blood cells and whole blood, 8 million platelet units and 3 million plasma units are
transfused annually.
• More than 90% of transfusion complications have been attributed to the presence of leukocytes in allogenic blood.
• Every 3 seconds someone needs blood. Blood and blood products are used to treat accident and burn victims,
cancer patients and other patients undergoing surgeries and medical treatments.
• People older than 65 use 43% of all donated blood. The demand for blood will increase as the population ages.
• Approximately 40, 000 units of blood are used each day in the United States.
Examples of Blood Use
Average # of Units Required
Automobile Accident
50 units of blood
Heart Surgery
6 units of blood
6 units of platelets
Organ Transplant
40 units of blood
30 units of platelets
20 bags of cryoprecipitate
25 units of fresh frozen plasma
Bone Marrow Transplant
120 units of platelets
20 units of blood
Burn
20 units of platelets
Blood and Blood Components3,4
Blood is the only fluid tissue in the body. Although blood appears to be a thick, homogenous liquid, blood has both cellular
and liquid components. Blood is a specialized type of connective tissue. Living blood cells, the formed elements, are
suspended in a nonliving fluid matrix called plasma. The living cellular components are red blood cells (erythrocytes), white
blood cells (leukocytes) and platelets (thrombocytes). The major components of whole blood break down as 45% red blood
cells, 1% white blood cells and platelets, and 55% plasma. Blood plasma is a straw-colored, sticky fluid which is about 90%
water, but plasma contains 100 different dissolved solutes. These solutes include nutrients, gases, hormones, wastes and
products of cell activity, ions and proteins. The average adult volume of blood is 4-5L that accounts for 7-8% of the human
body weight. Factors such as body size, amount of adipose tissue, and electrolyte concentrations can all affect blood
volume. Blood performs a number of functions that are related to substance distribution, regulating blood levels of particular
substances and body protection.
Page 4
Distribution functions:
• Delivering oxygen from the lungs and nutrients to the digestive tract to all body cells.
• Transporting metabolic waste products from cells to elimination sites i.e., lungs and kidneys.
• Transporting hormones from endocrine organs to their target organs.
Regulation functions:
• Maintaining appropriate body temperature.
• Maintaining normal pH in body tissues.
• Maintaining adequate fluid volume in the circulatory system.
Protection functions:
• Preventing blood loss; platelets and plasma proteins initiate clot formation, halting blood loss.
• Preventing infection. Red Blood Cells
Erythrocytes or red blood cells (RBCs) are small cells without nuclei, about 7.5µm in diameter and are shaped like
biconcave discs (a flattened disc with a depressed center). The essential role of red blood cells is to transport oxygen from
the lungs to the body’s cells and return to the lungs with carbon dioxide. They are essentially little bags of hemoglobin (Hb),
the RBC protein that functions in gas transport. RBCs have an approximate life span of about 100 to 120 days. The body
must produce two million red blood cells every second to replace those that are being retired. Erythrocytes are the major
factor contributing to blood viscosity. Red blood cell production (erythropoiesis) can be increased when needed to up to 10
times the usual production rate.
White Blood Cells
Leukocytes or white blood cells (WBCs) are the only formed elements that are complete cells, having a nuclei and
organelles. Organelles are smaller cellular structures that perform specific metabolic functions for the cell as a whole. Leukocytes exist in variable numbers and types but account for less than 1% of total blood volume in a healthy person. Leukocytes are crucial to the body’s disease defense protecting against bacteria, viruses, parasites, toxins and tumor
cells. Although red blood cells are confined to the bloodstream, white blood cells are able to move out of the capillary blood
vessels and can be found elsewhere in the body as the spleen, liver and lymph glands. White blood cells generally last only
18-36 hours before they are removed, though some types may live as long as a year. Platelets
Thrombocytes or platelets are cell fragments without nuclei that work with blood clotting chemicals at wound sites. Platelets
are tiny oval shaped discs about one third the size of a red blood cell. Platelets are essential for the clotting process that
occurs in plasma when blood vessels are ruptured or their lining is injured. When such an injury occurs, platelets come
in contact with substances in the vessel wall which activate platelets to change shape, enlarge and become sticky. By
sticking to the injury site, platelets then form an initial plug that assists in sealing the break. Platelets will degenerate in
approximately 9 to10 days if they are not involved in blood clotting because they are enucleate.
Plasma
Plasma is a pale yellowish fluid with a total volume of 2-3L in a normal adult. It is a complex solution containing more
than 90% water. 8% of plasma is plasma proteins, of which 60% is albumin, 36%are globulins and 4% is fibrinogen. The
remaining 2% of plasma is made up of by products of cellular metabolism, nutrients, electrolytes, and hormones, such as
cortisol and thyroxine. The composition of plasma varies continuously as cells remove or add substances to the blood.
However, in a healthy adult with a healthy diet, plasma composition is kept relatively constant by various hemostatic
mechanisms. After platelets respond and form the initial plug on a damaged blood vessel, a chain reaction of various
chemicals in the plasma begins. Plasma forms a network of fibers binding the initial plug into a strong clot. This chain
Page 5
reaction until fibrinogen is converted into an insoluble, thread like substance called fibrin. This coagulation process involving
platelets and plasma becomes an important factor in blood management.
Why Consider A Blood Management Program?
Reasons to consider a blood management program include:
•
•
•
•
•
•
•
•
Minimizes the risk of the wrong blood to the wrong patient.
Decreases the risk of contracting blood-borne infections.
Decreases the risk of developing transfusion reactions.
Decreases the risk of suppressing a patient’s own immune system.
Religious beliefs may prohibit receiving blood transfusions.
Minimizes the use of blood from blood banks, blood that is an increasingly scarce resource.
Honors requests by patients who do not wish to receive transfusions of donor blood.
Reduces the risk of developing post-operative infections.
Blood transfusion alternatives have shown to lead to faster patient recovery, fewer infections and complications, reduced
hospital stays and lower healthcare costs. Traditional blood transfusions do save lives, but millions of patients needing
transfusions may not have timely access to safe blood or available blood. In times of blood shortages, even elective
surgeries may be cancelled. Although blood banks take strict precautions and safety measures to ensure a safe blood
supply, blood transfusions during surgery can weaken patients and make them more susceptible to allergic reactions and
postoperative infections. Patients who do not require blood products tend to recover faster with shorter stays in the hospital. A blood management program requires a team approach to determine a patient’s blood management needs. This team
consists of physicians, nurses and other health care professionals from surgical, medical and ancillary departments working
together to develop an appropriate plan of care. This plan of care should incorporate the latest medications, strategies and
techniques to include:
•
•
•
•
The prevention and treatment of anemia
Minimizing blood loss
Enhancing the patient’s own blood supply
Reducing or eliminating the need for a blood transfusion
According to the AABB, formerly known as the American Association of Blood Banks, the following are some alternative
considerations to blood transfusion.5
Preoperative Autologous Donation
The most common autologous donation is the preoperative donation of blood for possible transfusion back to the donor
during elective surgery. This collection and storage of a patient’s own blood usually occurs from 3 to 4 weeks before
surgery, but can be donated until 72 hours prior to surgery and stored for up to 42 days. Autologous donation usually occurs
when the surgery will be orthopedic, vascular, urologic, or cardiac and the likelihood of transfusion is high. If blood loss
during surgery is less than anticipated, transfusion of autologous blood may not be medically necessary. 40% of autologous
donations are unused by the autologous donor. Although the risk of a complication from autologous blood is low, some
residual risks remain and automatic transfusion of autologous blood should be evaluated. Autologous blood can be subject
to the same complications as stored allogenic blood and include:
•
•
•
•
Decreased ability to release oxygen
Resultant breakdown products
Quickly loses its clotting factors
Risk of bacterial infection
Page 6
Autologous blood does require special handling and storage requirements and are therefore more costly to process.
In addition, the patient’s blood count can be evaluated before surgery. Based on the surgical procedure, the patient can be
assessed for preoperative anemia or the risk of anemia during and after the surgical procedure. The expected and tolerable
RBC loss can be estimated to eliminate the necessity for an allogenic transfusion. Circulating RBCs can also be expanded
by administration of iron, folic acid, vitamin B12 and erythropoietin up to 10 to 21 days before surgery. Erythropoietin (EPO)
is a hormone produced by the kidneys that promotes the formation of RBCs in the bone marrow.
Hemodilution (Blood Dilution)
Hemodilution, or blood dilution, is the removal of one or more units of blood just before surgery for transfusion to the patient
during or at the end of the surgery. Hemodilution is used to decrease the loss of red blood cells during the procedure.
Blood is drawn from the patient prior to surgery and immediately replaced by intravenous fluids to compensate for the
amount of blood removed and maintain blood volume. The maintenance of blood volume is important for the heart to work
effectively and for oxygen to be delivered to the body’s cells. This procedure dilutes the number of red blood cells in the
patient’s circulatory system resulting in fewer red blood cells lost as a result of bleeding during the surgery. After surgery,
the patient’s own blood is reinfused, but the patient must be able to tolerate the anemia the procedure causes.
Perioperative Blood Collection
Blood lost by the patient during surgery is recovered and recycled throughout the surgery. Intraoperative cell salvage is
accomplished with a machine most likely referred to as the “cell saver”. The patient’s blood is collected and red blood
cells are concentrated, washed and returned to the patient. It is a procedure that is widely used for cardiac, vascular,
orthopedic, urologic, trauma, gynecologic and transplant surgeries where blood loss is anticipated to by 20% or more of the
patient’s estimated blood volume. The goals of this procedure are to minimize blood loss, maximize oxygen delivery and
maximize the body’s ability to produce blood. This procedure is generally not used in cancer surgery or surgery of the lower
gastrointestinal tract where the presence of cancer cells or bacteria are present.
Postoperative Blood Collection
Blood that is lost in the early postoperative period is collected from a drainage tube at the surgical site and transfused to the
patient, either washed or unwashed. Postoperative collection is used primarily in cardiac and orthopedic surgeries, and in
most cases, the recovered volume of salvaged red blood cells is small.
Blood Component Management
Autologous transfusion can be advantageous for the patient during the perioperative and postoperative surgical period.
However, because salvaged blood is washed, this mechanism removes both plasma and platelets in replaced blood. This
disadvantage may be only evident when very large blood loss occurs. Therefore, it is imperative that salvaged blood is
monitored and the recommendation for the administration of fresh frozen plasma (FFP), platelets, and cryoprecipitate may
be necessary.
Additional Strategies for Blood Management
• The use of surgical devices to minimize blood loss, i.e., electrosurgery, elctrocautery, argon beam coagulation,
ultrasonic scalpel, laser surgery, etc.
• Surgical and anesthesia techniques to limit blood loss, i.e., controlled hypotension, maintaining normothermia,
meticulous hemostasis, preoperative planning, minimally invasive surgery, etc.
• Volume expanders that are non-blood fluids administered intravenously to increase blood volume, i.e., crystalloids,
colloids, etc.
• Autologous tissue adhesives such as platelet gel and fibrin glue made from fractions of a patient’s own blood that are
used to control bleeding and promote healing.
Page 7
• Devices and techniques that limit iatrogenic blood loss, i.e., pulse oximeter, microsampling equipment, only essential
tests, multiple tests per sample, smaller samples (pediatric-sized tubes), etc.
The word iatrogenic comes from the Greek roots “iatros” meaning “the healer or physician” and “gennan” meaning “as a
product of” which equates to “due to the doctor”. Iatrogenic is a term applied to any adverse patient outcome resulting from
treatment by a physician or by a medical or surgical treatment or diagnostic procedure. Large, sometimes unnecessary
quantities of blood are often drawn from critically ill patients, including adults, neonates and children, particularly those in
intensive care units. Several studies have convincingly shown that iatrogenic blood loss due to lab testing, including arterial
blood sampling, can result in increased morbidity due to stress on the cardiovascular and respiratory systems and the
need for allogenic blood transfusion.6 Anemia commonly occurs in critically ill patients, affecting more than 90% of patients
admitted to intensive care units (ICUs) by the third day. The reason for anemia in critically ill patients are multifactorial and
include acute blood loss, (e.g., from trauma, surgery or gastrointestinal bleeding), iatrogenic blood loss from diagnostic
testing and blunted red blood cell production.7 An effective and simple blood management strategy for critically ill patients
may infact be the reduction in unneeded diagnostic testing.
Summary
A blood transfusion may be necessary when the body cannot produce blood fast enough due to major blood loss,
destruction of red blood cells, and/or decreased production of red blood cells. Blood management programs advocate and
advance the use of alternative treatments to the fullest extent possible and minimize the use of blood transfusion. Medical
and surgical care should allow for personal choices. Patients may request transfusion alternatives because of personal
convictions or to minimize the risk of adverse reactions to blood transfusion. If a blood management program is developed
and effectively used then ultimately, “If you don’t lose blood, you don’t have to use blood.”
Page 8
references
1. Advancing Transfusion and Cellular Therapies Worldwide. The Highlights of Transfusion Medicine History page.
Available at: http://www.aabb.org/Content/About_BloodHighlights_of_Transfusion_Medicine_History/ Accessed on April
22, 2014.
2. America’s Blood Centers. The What is Blood page. http://www.americasblood.org/go.cfm Accessed on April 22, 2014.
3. Anthro Palomar. The Human Blood: Blood Components page. http://www.bloodtransusion.com/facts.asp Accessed on
April 22, 2014.
4. Advancing Transfusion and Cellular Therapies Worldwide. The Whole Blood and Blood Components page. http://www.
aabb.org/Content/About_Blood/Facts_About_Blood_and_Blood_Banking/fabloodwhole.htm Accessed on April 22,
2014.
5. Advancing Transfusion and Cellular Therapies Worldwide. The Autologous (self-donated) Blood as an Alternative to
Allogeneic (donor donated) Blood Transfusion page. http://www.aabb.org/Content/About_Blood/Facts_About_Blood_
and_Blood_Banking/fabloofwhole.htm Accessed on April 22, 2014.
6. Find Articles.com. The complications of critical care: Lab testing and iatrogenic anemia-Brief Article page. http://
findarticles.com/p/articles/mi_m3230/is_10_33/ai_79790104 Accessed on April 22, 2014.
7. PubMed Central. The Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill
patients page. http://www.ncbi.nlm.nih.gov/pubmed/18166731 Accessed on April 22, 2014.
Page 9
Please Click Here for the Post-Test and
Evaluation
Page 10