Blood Product Waste

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bigdan

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Looking for a little help from the group here.

I've got an interest in transfusion medicine, and have found my way into being a member of the hospital's transfusion medicine team. One of the subcommittees is focusing on reducing blood product waste. I have a ton of great info from our blood bank about the amount of product waste, but would like to hear what others have done to help keep products from ending up in the garbage.

We waste more platelets than any other product, by far, mostly due to outdating; once platelets are pooled, we have to transfuse them within 4 hrs, or they get the heave-ho. My anecdotal experience is that a surgeon will look over the drape and say "He's pretty oozy - let's get some platelets in here", and then we do, and then for whatever reason, the platelets don't get transfused.

Have you guys focused on anything like this? Any strategies work for you?

Thanks in advance for the replies.

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All -

Looking for a little help from the group here.

I've got an interest in transfusion medicine, and have found my way into being a member of the hospital's transfusion medicine team. One of the subcommittees is focusing on reducing blood product waste. I have a ton of great info from our blood bank about the amount of product waste, but would like to hear what others have done to help keep products from ending up in the garbage.

We waste more platelets than any other product, by far, mostly due to outdating; once platelets are pooled, we have to transfuse them within 4 hrs, or they get the heave-ho. My anecdotal experience is that a surgeon will look over the drape and say "He's pretty oozy - let's get some platelets in here", and then we do, and then for whatever reason, the platelets don't get transfused.

Have you guys focused on anything like this? Any strategies work for you?

Thanks in advance for the replies.

You need to come up with some sort of mechanism where the surgeon gets penalized for ordering products and then requesting them not to be given.

TEG and poct platelets/inr are useless IMHO. You are better off sending blood to the lab which might take over 1 hr.
 
should be restrictions in general to what can be used. We had an 89 year old ruptured triple A that coded once prior to even getting to the OR, Surgeon used over 30 units of PRBCs during the 9+ hours they were in there. Not sure how many platelet packs and FFP were used but he literally evaporated our entire blood bank for a patient that had a <0.01% chance of surviving. I know the moral/ethical use of blood products wasnt probably what you had in mind but I think it is important in terms of waste/meaningful use. Also making sure your hospital has transfusion guidelines up to date. Really good article in NEJM about transfusion thresholds in GI bleed patients who are hemodynmaically stable. I find alot of older attendings transfusing at much higher levels than are probably needed.
 
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You need to come up with some sort of mechanism where the surgeon gets penalized for ordering products and then requesting them not to be given.

TEG and poct platelets/inr are useless IMHO. You are better off sending blood to the lab which might take over 1 hr.

TEG useless? Really? I find it quite helpful in some cases to give you a rapid and comprehensive view of their coagulation status.
 
TEG useless? Really? I find it quite helpful in some cases to give you a rapid and comprehensive view of their coagulation status.

I find it quite useless in the heart room. It always comes normal, no matter if you do a 2hr bypass run on a pt with Plavix, Coumadin,...Effient....you name it, or if you do a 6 hr bypass run on an old gomer.
 
There have been a couple European papers in anesthesiology (I think) looking at flow charts/algorithms for when/what to give for cardiac cases, and these were shown to reduce transfusion. Also, google arieh shander, an anesthesiologist who writes extensively on this. Find some papers on the Perioperative transfusion of asymptomatic anemia and you'll see not only waste. It worsened patient outcomes.
 
Is that a professional courtesy or does someone enforce that as a policy?

It is a mutual agreement between anesthesia, surgery, and transfusion support. It has cut down on the "Let's order FFP thawed just in case" type requests. If anyone "enforces" it, it would be anesthesia, but enforcement has not been necessary.

In practice, the change is just fewer prophylactic requests from the surgeons.


Is that what is best for the patient?

Yes. Because we don't order it unless we know we are going to give it. If you order it prophylactically, there is subconscious pressure on the surgeon and the anesthesiologist to give it. We would all like to believe that we are not susceptible to this pressure, but I wuold argue otherwise.

We have cut our waste significantly and it looks like transfusions are down a bit too, but our numbers are to small to draw a significant conclusion on that as of yet.

And I love TEG. In residency and fellowship I used it extensively and found it to be extremely helpful for targeted component therapy. I wish that I had it here.

- pod
 
Yes. Because we don't order it unless we know we are going to give it. If you order it prophylactically, there is subconscious pressure on the surgeon and the anesthesiologist to give it. We would all like to believe that we are not susceptible to this pressure, but I wuold argue otherwise.


- pod

I'm not talking about being on pump and ordering products for when you come off.

I'm talking about being off pump post protamine with the surgeon whining that the pt is coagulopathic and ordering platelets & ffp. But 20-30min later when we have them, then they don't want them.

From what you tell me, you would transfuse them because they were ordered.
 
I find it quite useless in the heart room. It always comes normal, no matter if you do a 2hr bypass run on a pt with Plavix, Coumadin,...Effient....you name it, or if you do a 6 hr bypass run on an old gomer.

I haven't done hearts yet, but I do remember getting burned by a TEG on a pt that had been on Effient when I was on CT surgery as a med student. TEG was normal so we proceeded with a CABG. As a side note we ended up crashing onto pump because she had an ischemic event when we were harvesting the vein and she likely would have died on the floor had we not been in the OR. During the case she was very oozy and we spent about 7 hours trying to control bleeding before we closed the chest. She dumped a lot of blood out of her chest tubes overnight but it eventually slowed down. She was still alive when I saw her a year an a half later as an intern on the CT service. n=1 case of a TEG being normal but pt still having a coagulopathy.

Edit: We have TEG here so I'm looking forward to gaining more experience with it on CT in a couple of months.
 
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Just to be clear, when you say that TEG was not helpful in detecting coagulopathy due to plavix/effient are you referring to the standard TEG assay or the platelet mapping TEG? Due to the overwhelming effects of thrombin, standard TEG cannot be reliably used to detect platelet inactivation from plavix, etc... With this caveat in mind, I find TEG to be helpful in the CT OR. We typically send labs (TEG, platelet count, and fibrinogen) as we are re-warming and it is often helpful in guiding subsequent therapy.
 
Just to be clear, when you say that TEG was not helpful in detecting coagulopathy due to plavix/effient are you referring to the standard TEG assay or the platelet mapping TEG? Due to the overwhelming effects of thrombin, standard TEG cannot be reliably used to detect platelet inactivation from plavix, etc... With this caveat in mind, I find TEG to be helpful in the CT OR. We typically send labs (TEG, platelet count, and fibrinogen) as we are re-warming and it is often helpful in guiding subsequent therapy.

Sounds like the rep has been to your hospital.

"TEG is great" "Only cost around $20 ...."But if you want to be certain, you need the platelet mapping option because TEG by itself is not that good". "Only cost around $250"

By now you have blown over $270 and still have a bleeding patient.
 
I'm talking about being off pump post protamine with the surgeon whining that the pt is coagulopathic and ordering platelets & ffp. But 20-30min later when we have them, then they don't want them.

From what you tell me, you would transfuse them because they were ordered.


No. It isn't a hard rule, just an agreement. However, it has cut down remarkably on the exact situation that you are talking about. The surgeons seem to be less quick on the draw in the post-protamine time period when they know that they have agreed to only order when they definitely plan on giving. Yes, it is a mind game, but it works.

- pod
 
Sounds like the rep has been to your hospital.

"TEG is great" "Only cost around $20 ...."But if you want to be certain, you need the platelet mapping option because TEG by itself is not that good". "Only cost around $250"

By now you have blown over $270 and still have a bleeding patient.

that costs less than transfusing a single unit of product into a patient and provides less exposure to transfusion reaction to an unnecessary product.
 
I'm impressed if any of this changes the mindset of your surgeons. I find in residency that we send labs (fibrinogen, platelets, coags) while rewarming, we do TEG, and yet none of it changes the surgeon's mindset. If they bleed they want the product regardless of the numbers, and if they're not bleeding they don't care what the numbers are.
 
I'm impressed if any of this changes the mindset of your surgeons. I find in residency that we send labs (fibrinogen, platelets, coags) while rewarming, we do TEG, and yet none of it changes the surgeon's mindset. If they bleed they want the product regardless of the numbers, and if they're not bleeding they don't care what the numbers are.

This.

What's the point of blowing over $250?
 
TEG useless? Really? I find it quite helpful in some cases to give you a rapid and comprehensive view of their coagulation status.

I've always gotten the impression that TEG is primarily an academic center tool that is rarely used in private practice. I've never seen one, including my moonlighting gig where they do lots of hearts, vascular, and trauma.
 
I've always gotten the impression that TEG is primarily an academic center tool that is rarely used in private practice. I've never seen one, including my moonlighting gig where they do lots of hearts, vascular, and trauma.

Yes... rarely used, but for some... much missed.

You do a lot of OB Jwk... when you get a 20 y/o with DIC how do you know if they are predominantly consumptive or not. What guides your antifibrinolytic therapy? Do you add heparin on top of that.. why or why not?

Poor mans teg and put some blood in a vial and see what happens? I prefer the real TEG.


Just saying... :)
 
I'm impressed if any of this changes the mindset of your surgeons. I find in residency that we send labs (fibrinogen, platelets, coags) while rewarming, we do TEG, and yet none of it changes the surgeon's mindset. If they bleed they want the product regardless of the numbers, and if they're not bleeding they don't care what the numbers are.

Sure, if they're not bleeding why give blood products? But if they are, TEG/plt count/fibrinogen level can give you some guidance as to what to give. Certainly, application of this data requires buy in from the surgeons.
 
Sounds like the rep has been to your hospital.

"TEG is great" "Only cost around $20 ...."But if you want to be certain, you need the platelet mapping option because TEG by itself is not that good". "Only cost around $250"

By now you have blown over $270 and still have a bleeding patient.

Platelet mapping isn't needed for most patients.
 
I've always gotten the impression that TEG is primarily an academic center tool that is rarely used in private practice. I've never seen one, including my moonlighting gig where they do lots of hearts, vascular, and trauma.

we use it in private practice. Not routinely, but in the right setting it is quick and easy and provides plenty of useful objective data other than just the surgeon telling us the patient is "oozy".
 
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