Patients who Decline Blood Products:- Haematological Aspects of Care. Dr Catherine Flynn Consultant Haematologist CWIUH

Transcription

1 Patients who Decline Blood Products:- Haematological Aspects of Care Dr Catherine Flynn Consultant Haematologist CWIUH

2 Bloodless Labour and Delivery in CWIUH! % Total deliveries 2.5% 8500 deliveries in 2009, 2.5% transfused

3 Multidisciplinary Communication

4 Incidence of JW in Ireland 6.5 million Jehovah s Witnesses in 235 countries worldwide and about in Great Britain and Ireland. Estimated 5,000 Jehovah's Witnesses in Ireland

5 Maternal Morbidity in JW Mount Sinai study (Singla et al 2001) Netherlands Study (Van Wolfswinkel et al 2009)

6 2008 Report of Jehovah's Witnesses Worldwide Peak Witnesses in in 2007 (> ) Brazil Democratic Republic of Congo Germany Italy Japan Mexico Nigeria Philipines Russia Ukraine Zambia

7

8 Co existent Hb Disorders Van Wolfswinkel et al 2009 BJOG Netherlands study 1 JW patient with sickle cell disease

9 Meeting the clinical challenge of care for Jehovah s Witnesses Bodnaruk et al Trans Med Revs 2004 UNACCEPTABLE Whole Blood Red Cells White Cells Platelets Plasma Oxygen therapeutics* *Products in development Interferons* Interleukins* *Recombinant Products available PERSONAL DECISION Platelet Substitutes* *Products in development Platelets in additive solution Clotting Factor Concentrate* (*VIIa,VIII,IX available) Prothrombin Complex Concentrate Fibrinogen Albumin ± Immune Globulins

10 Optimisation of Haematological Status of Mother ANTEPARTUM INTRAPARTUM POSTPARTUM

11 Ante-partum Identify the patient early and discuss options Involve senior people Identify and investigate co-existent risk factors for anaemia/bleeding Consider stopping warfarin/aspirin/clopidrogel Minimise phlebotomy and use paediatric blood tubes for laboratory studies Estimate bleeding risk (placental position/previous pregnancies)

12 Define Acceptable Treatment for every Patient Pharmacological agents that do not contain blood products Transexamic acid/ DDAVP/ Recombinant factor concentrates Haematinics and Growth factors Iron/albumin free erythropoietin Synthetic oxygen carriers Non blood volume expanders

13 Transfusion Treatment Plan Treatment Accept Primary Blood Components Red Cells Yes No Apheresis Platelets Yes No Minor Fractions Solvent Detergent Plasma/ Octoplas Yes No Washed Platelets in Platelet Additive Solution Yes No Blood Products Fibrinogen Yes No Fibrin Glue Yes No Prothrombin Complex Yes No Immunoglobulin Yes No Recombinant Clotting Factors Factor VIIa Yes No Factor VIII or IX Yes No

14 Discuss Alternative Treatment Options Iron (PO or IV) Erythropoietin Tranexamic Acid Recombinant Blood Products

15 Erythropoietin and Blood Conservation Albumin free erythropoietin (rhuepo) enhances erythopoiesis NeoRecormon (Roche) epoetin beta Aranesp(Amgen) darbepoetin alfa Multiple case reports, few trials Time to start treatment Dosages Route of Administration Treatment Duration Variable Most reported cases use adjunctive iron/folic acid/vit B12

16 Erythropoiesis

17 Haematological Variables During admission Price, S. et al. Anesth Analg 2005;101: Copyright restrictions apply.

18 Intrapartum/Post Partum Anaesthetic/Surgical options Keep warm, normalise ph as platelets and coagulation factors less functional Consider position Prompt oxytoxics Antifibrinolytics (tranexamic acid/aprotonin) Topical Fibrin Glue (contains a blood fraction)

19 Antifibrinolytic agents Cyklokapron / Tranexamic acid Potent competitive inhibitor of the activation of plasminogen to plasmin. No evidence in animal studies of a teratogenic effect. Use in pregnant woman is limited/ crosses the placenta A synthetic derivative of the amino acid lysine with antifibrinolytic activity. With strong affinity for the five lysine-binding sites of plasminogen, tranexamic acid competitively inhibits the activation of plasminogen to plasmin, resulting in inhibition of fibrinolysis Longer half-life/ ten times more potent and less toxic than aminocaproic acid

20

21 Tranexamic acid/ Cyclokapron Meta-analysis comparing tranexamic acid with no treatment. 3 major trials involving 461 participants Transexamic acid versus no treatment and blood loss post delivery No mortality data A single dose of 1 gram of tranexamic acid given intravenously Tranexamic acid may reduce blood loss in post partum haemorrhage Ferrer et al,bmc Pregnancy and Childbirth 2009

22 World Maternal Antifibrinolytic Trial The WOMAN trial is a large, international, randomised, placebo controlled trial. Tranexamic Acid for the Treatment of Postpartum Haemorrhage: An International Randomised, Double Blind, Placebo Controlled Trial

23 Recombinant Blood Products Benefix Advate Factor VIIa

24 Options Identification of the case and optimisation of haematological status of the mother Optimisation of 3 rd stage of labour Prompt surgical intervention if necessary Other agents haematinic support/erythropoiesis stimulants/antifibrinolytics/recombinant blood products

25 VIIa/Novoseven

26 VIIa/Novoseven Limited to the site of tissue injury and tissue factor exposure. Useful in the obstetric setting where there is often bleeding from a large raw area of exposed tissue. Action of rfviia is dependant on the presence of adequate numbers of circulating platelets and adequate fibrinogen concentration.

27 rfviia in major obstetric Haemorrhage rfviia should be considered in major obstetric haemorrhage A dose of 90 μg/kg is recommended Use of rfviia should not be seen as an alternative to surgical haemostasis or correction of coagulopathy with blood products. Before administration of rfviia, the following laboratory indices are desirable; Prothrombin time < 1.5 upper limit of normal Fibrinogen > 1.0 g/l Platelet count > /L A ph > 7.1 is also desirable for optimal effect. Bomken et al Obstet Gynecol Int. 2009:

28 Post Haemorrhage Oxygen and erythropoietin 300IU/kg x3 per week Shortens lag period of erythropoiesis and accelerates haemoglobin recovery Iron supplementation essential Oral iron is slow and unreliable IV iron (Iron Sucrose) (Venofer) 200mg x3/week Augment with B12 and folic acid Hyperbaric Oxygen

29 Novel Alternatives Haemoglobin-based oxygen carriers Perfluorocarbons, Hyperbaric oxygen