The Management of Massive Blood Loss and Resuscitation during Redo Sternotomy in a Patient Supported with a Ventricular Assist Device
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1 The Management of Massive Blood Loss and Resuscitation during Redo Sternotomy in a Patient Supported with a Ventricular Assist Device Elyse Parchmont RN MSN, CRNA Pediatric Anesthesiology
2 No financial disclosures No conflicts of interest xxx00.#####.ppt 2/13/2015 4:16:02 PM
3 Objectives Address preoperative concerns and make effective preparations for caring for the patient with a VAD at risk for massive blood loss. Discuss the assessment and required communication and intervention in the exsanguinating patient with a VAD. Recognize the endpoints for volume and blood product administration, including laboratory study and monitor data. Be familiar with the complications of massive blood loss and transfusion in this setting. xxx00.#####.ppt 2/13/2015 4:16:02 PM
4 Case Study Patient History 15 y/o presenting to CVOR for orthotopic heart transplant Severe TR/MR; Mod-severe LA dilation DCM, decreased myocardial function/congestive heart failure (mildly depressed RV function) S/p HeartMate II LVAD placement xxx00.#####.ppt 2/13/2015 4:16:02 PM
5 Case Study - Medications Aspirin Enalapril Warfarin Furosemide Metoprolol Lansoprozole xxx00.#####.ppt 2/13/2015 4:16:02 PM
6 Increased Risk with Redo Sternotomy Staged or multiple cardiac procedures Presence of bioprosthetic conduits Dissection of adhesions Risk may be higher in older, teenage patients Decreased risk of injury over the recent decades Andropoulos, et al. (2002) Fabrizio, et al. (1999) George, et al. (2012) Kirshbom, et al Morales, et al Russell, et al xxx00.#####.ppt 2/13/2015 4:16:02 PM
7 Redo Sternotomy Preparation Surgery, anesthesia, and OR staff experienced in pediatric congenital heart disease Appropriate blood products ordered and delivered to the CVOR Femoral bypass available CT evaluations Andropoulos, et al. (2002 Hamid, et al. (2014 xxx00.#####.ppt 2/13/2015 4:16:02 PM
8 Pediatric Ventricular Assist Devices Use and challenges VADs in pediatric patients VADs vs ECMO Need for sedation Mechanical ventilation Anticoagulation/risk of thromboembolic phenomena Lack of mobility Risk of renal failure and/or stroke Risk of mortality > 2 weeks Davies, et al. (2014) George, et al. (2012) O Connor & Rossano (2014) Sharma, et al. (2012) xxx00.#####.ppt 2/13/2015 4:16:03 PM
9 Pediatric Ventricular Assist Devices Who gets a VAD? - Cardiogenic shock and/or progressive decline due to: End stage cardiomyopathy Myocarditis Univentricular failure Congenital heart disease/post cardiotomy VAD contraindications Irreversible end organ dysfunction Recent stroke Significant life limiting neurological disability O Connor & Rossano 2014 Sharma, et al xxx00.#####.ppt 2/13/2015 4:16:03 PM
10 Pediatric Ventricular Assist Devices Hematologic Prolonged ventilator dependence Device change/reoperation Infection/sepsis Neurologic complications Davies, et al O Connor & Rossano 2014 Sharma, et al xxx00.#####.ppt 2/13/2015 4:16:03 PM
11 Types of VADs for Pediatric Patients Device Type Indication HeartMate II Continuous-flow BTT,DT Berlin Heart EXCOR pediatric Pulsatile paracorporeal BTT Thorotec pvad Pulsatile paracorporeal BTT, PC Debakey VAD Child Continuous-flow BTT TandemHeart Centrifugal ECS < 6 h HeartWare Ventricular Assist System Centrifugal BTT SynCardia Total Artificial Heart Artificial heart BTT Impella Continuous-flow ECS < 6 h Centrimag Centrifugal ECS < 6 h O Connor & Rossano 2014 xxx00.#####.ppt 2/13/2015 4:16:03 PM
12 Increased Risk with Redo Sternotomy/VAD HeartMate II xxx00.#####.ppt 2/13/2015 4:16:03 PM
13 Increased Risk with Redo Sternotomy/VAD HeartMate II xxx00.#####.ppt 2/13/2015 4:16:03 PM
14 xxx00.#####.ppt 2/13/2015 4:16:03 PM
15 xxx00.#####.ppt 2/13/2015 4:16:03 PM diseasemanagement/cardiology/heart-failure/ J Am Coll Cardiol. 2009;54(18): doi: /j.jacc
16 xxx00.#####.ppt 2/13/2015 4:16:03 PM
17 Case Study Intraoperative Course xxx00.#####.ppt 2/13/2015 4:16:04 PM
18 Case Study Intraoperative Course xxx00.#####.ppt 2/13/2015 4:16:04 PM
19 Case Study Intraoperative Course xxx00.#####.ppt 2/13/2015 4:16:04 PM
20 Case Study Intraoperative Course/Post Bypass xxx00.#####.ppt 2/13/2015 4:16:04 PM
21 Monitoring During Massive Transfusion Monitoring during blood transfusion Access Volume Miller (2010) xxx00.#####.ppt 2/13/2015 4:16:04 PM
22 Blood Transfusion - Pediatrics Products: Packed red blood cells (PRBCs) Fresh frozen plasma (FFP) Cryoprecipitates of clotting factors (Cryo) xxx00.#####.ppt 2/13/2015 4:16:04 PM
23 Blood Transfusion for Pediatric Patients Age Estimated Blood Volume, ml/kg Premature infant Term infant to 3 months Children older than 3 months 70 Obese Children 65 Dehmer & Adamson (2010) xxx00.#####.ppt 2/13/2015 4:16:04 PM
24 Blood Transfusion ABO Compatability Donor O A B AB Recipient O,A,B,AB A,AB B,AB AB Miller (2010) xxx00.#####.ppt 2/13/2015 4:16:04 PM
25 Massive Transfusion Definition Adult The loss of one or more circulating blood volumes in 24 hours Loss of 50% of blood volume in 3 hours An ongoing loss of 150 ml/hour Pediatrics Weight based Dehmer & Adamson (2010) xxx00.#####.ppt 2/13/2015 4:16:04 PM
26 TCH Massive Transfusion Protocol PRBC Units/Kg Weight Total Blood Volume Patient s Weight (Kg) Number of Red Cell Units to Equal Total Blood Volume < > xxx00.#####.ppt 2/13/2015 4:16:04 PM
27 Massive Transfusion Age of Blood Older PRBC units: May be depleted in 2,3 diphosphoglycerate and adenosine triphosphate May have elevated levels of potassium xxx00.#####.ppt 2/13/2015 4:16:04 PM Dehmer & Adamson (2010) Miller, R.D. (2010) Pizzini & Pizzini (2014)
28 Systemic oxygen delivery Three main factors Cardiac output Oxygen saturation Hemoglobin levels O 2 content = 1.39 x (Hgb) x SaO 2 + (0.003 x PaO 2 ) Dehmer & Adamson (2010) Hall & Chantigian (2010) Pizzini & Pizzini (2014) xxx00.#####.ppt 2/13/2015 4:16:04 PM
29 Massive Transfusion Protocol A Starting Point Initiation of massive transfusion protocol in traumatic hemodynamic instability Blood component ratios Maintenance of temperature, calcium, and ph FVIIa Dehmer & Adamson (2010) xxx00.#####.ppt 2/13/2015 4:16:05 PM
30 TCH Massive Transfusion Protocol - Purpose xxx00.#####.ppt 2/13/2015 4:16:05 PM
31 TCH Massive Transfusion Protocol Pack Contents - Massive pack consists of up to 4 units of group O Rh negative RBC (<14 days old). When massive pack requested, 2 units of group AB FFP will be started to thaw. - Standard pack consists of 2 units of group O Rh negative RBC (<14 days old). xxx00.#####.ppt 2/13/2015 4:16:05 PM
32 Objectives Address preoperative concerns and make effective preparations for caring for the patient with a VAD at risk for massive blood loss. Discuss the assessment and required communication and intervention in the exsanguinating patient with a VAD. Recognize the endpoints for volume and blood product administration, including laboratory study and monitor data. Be familiar with the complications of massive blood loss and transfusion in this setting. xxx00.#####.ppt 2/13/2015 4:16:05 PM
33 References Andropoulos, D.B., Stayer, S.A, Skjonsby, B.S., East, D.L., McKenzie, E.D., Fraser, C.D. (2002). Anesthetic and Perioperative Outcomes of Teenagers and Adults with Congenital Heart Disease. Journal of Cardiothoracic and Vascular Anesthesia. Vol. 16 (6): Davies, R.R., Hadleman, S., McCulloch M.A., Pizzaro, C. (2014). Ventricular assist devices as a bridge to transplant improve early post-transplant outcomes in children. The Journal of Heart and Lung Transplantation. Vol. 33 (7): Dehmer, J.J & Adamson, W.T. (2010) Massive Transfusion and Blood Product Use in the Pediatric Trauma Patient. Seminars in Pediatric Surgery. Vol. 19: Fabrizio, M.F., Pett, S.B., Miller, K.B., Wong, R.S., Temes, R.T., Wernly, J.A. (1999) Catastrophic Hemorrhage on Sternal Reentry: Still a Dreaded Complication? Annals of Thoracic Surgery. Vol. 68: George, T.J., Beaty, C.A., Ewald, G.A., Russell, S.D., Shah, A.S., Conte, J.V., and Whitman, G.J. (2012) Reoperative Sternotomy is Associated with Increased Mortality. Annals of Thoracic Surgery. Vol. 94(6): xxx00.#####.ppt 2/13/2015 4:16:05 PM
34 References Hamid, U. I., Digney, R., Soo, L., Leung, S., and Graham, A.N.J. (2014). Incidence and Outcome of Reentry Injury in Redo Cardiac Surgery: Benefits of Preoperative Planning. European Journal of Cardio-Thoracic Surgery. doi: /ejcts/ezu261 Kishbom, P.M., Myung, R.J., Simsic, J.M., Kramer, Z.B., Leong, T., Kogon, B.E., and Kanter, K.R. (2009) One Thousand Repeat Sternotomies for Congenital heart surgery: Risk Factors fro Reentry Injury. Annals of Thoracic Surgery. Vol. 88(1): Miller, R.D. (2010) Miller s anesthesia: Seventh ed. Philadelphia:Churchill Livingstone Morales, D.L.S., Zafar, F., Arrington, K.A., Gonzalez, S.M., McKenzie, E.D., Heinle, J.S., Fraser, C.D. (2008) Repeat Sternotomy in Congenital Heart Surgery: No Longer a Risk Factor. Annals of Thoracic Surgery. Vol. 86: O Connor, M.J., Rossano, J.W. (2014) Ventricular assist devices in children. Obtained from Vol 29(1). xxx00.#####.ppt 2/13/2015 4:16:05 PM
35 References Russell, J.L., LeBlanc, J.G., Sett, S.S., Potts, J.E. (1998) Risks of Repeat Sternotomy in Pediatric Cardiac Operations. Annals of Thoracic Surgery. Vol. 66:575-8 Sesok-Pizzini, D., Pizzini, M.A. (2014) Hyperkalemic Cardiac Arrest in Pediatric Patients Undergoing Massive Transfusion: Unplanned Emergencies. DOI: /trf Transfusion Vol. 54(1):4-7. Sharma, M. S., Forbess, M.J., & Guleserian, K. J. (2012) Ventricular Assist Device Support in Children and Adolescents with Heart Failure: The Children s Medical Center of Dallas Experience Artificial Organs. Vol. 36 (7): xxx00.#####.ppt 2/13/2015 4:16:05 PM
36 xxx00.#####.ppt 2/13/2015 4:16:05 PM
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