Transfusion and Blood Conservation

Transcription

1 Transfusion and Blood Conservation Kenneth G. Shann, CCP Assistant Director, Perfusion Services Senior Advisor, Performance Improvement Department of Cardiovascular and Thoracic Surgery Montefiore Medical Center New York

2 Disclosures No Relationships to Disclose

3 Overview Risks of anemia and transfusion Concept of balancing hemodilutionand oxygen delivery: opreserve red cell mass o Avoid low nadir hematocrits o Modify CPB flow according to hematocrit Salvage the patient s blood at the end of the procedure Participate in the creation and management of a multidisciplinary blood management team at your center

4 J Thorac Cardiovasc Surg 2003;125:

5 Anemia is Bad! Does Transfusion Mitigate that? SwaminathanM et al. The asscoiationof lowest hematocritduring cardiopulmonary bypass with acute renal injury after coronary artery bypass surgery. Ann Thorac Surg. 2003;76: KarkoutiK et al. Hemodilutionduring cardiopulmonary bypass is an independent risk factor for acute renal failure in adult cardiac surgery. J Thorac Cardiovasc Surg. 2005;129: Ranucci M et al. Lowest hematocrit on cardiopulmonary bypass impairs the outcome in coronary surgery: an Italian multicenter study from the National Cardiothoracic Database. Tex Heart Inst J 2006; 33: KarkoutiK et al. Low hematocrit during cardiopulmonary bypass is associated with increased risk of perioperative stroke in cardiac surgery. Ann Thorac Surg 2005; 80: DeFoe GR et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg :

6 Surgenor SD, Kramer RS, Olmstead EM, et al

7 Outcome Tx. and Heart Surgery Banbury MK et al. Transfusion increases the risk of postoperative infection after cardiac surgery. J Am Col Surg 2006;202: Septicemia/bacteremia -pneumonia >4 Severe Infection Mediastinitis Pneumonia Sepsis Afib Prolonged ventilation Bleeding Renal Failure Quality of Life Mortality (short and long term) Leal-Noval et al. Chest 2001;119:1461

8 Relative Odds of Receiving Packed Red Blood Cells Transfusion Odds Ratio Adjusted* Low HCT 15.5 Use of pump 7.91 Female Gender 2.37 Lower Body Weight 2.18 Older Age 1.99 p value <0.001 Which of these is modifiable by the operative team? 2003;97:958-63

9 Body size is related to low nadir hematocrit during CPB DeFoe GR, Ross CS, Olmstead EM, et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg 2001;71: SwaminathanM, Phillips-ButeBG, Conlon PJ, et al. The association of lowest hematocritduring cardiopulmonary bypass with acute renal injury after coronary artery bypass surgery. Ann Thorac Surg 2003;76: HabibRH, Zacharias A, Schwann TA, et al. Adverse effects of low hematocritduring cardiopulmonary bypass in the adult: should current practice be changed? J Thorac Cardiovasc Surg 2003;125: RanucciM, Conti D, CastelvecchioS, et al. Hematocriton cardiopulmonary bypass and outcome after coronary surgery in nontransfused patients. Ann Thorac Surg 2010;89: We can t change the size of our patients, but we can customize our strategy to accommodate their size

10 Ann Thorac Surg 2011;91: Strategies to Minimize Hemodilution Minicircuits (Class I Level of evidence A) Retrograde autologous priming (Class IIb Level B) Vacuum-assisted venous drainage (Class IIb Level of evidence C) Biocompatible CPB circuits (Class IIb Level of evidence A)

11 Matching the Circuit to the Size of the Patient Mrs. Nussbaum Oxygenator with integrated arterial filter 140mL prime 3/8 inch venous line All circuit tubing length minimized Biocompatible surface coating Retrograde and antegrade autologous priming Net prime 400mL

12 Retrograde and Antegrade Autologous Priming The passive displacement of crystalloid solution from the CPB circuit using the patient s blood volume via the arterial and venous lines of the CPB circuit. Perceived benefits: Less hemodilutionduring the initiation of CPB Hemoglobin, COP, plasma and platelets dilu on of circula ng pharmacologic agent Reduced blood transfusions on CPB Inexpensive RosengartTK, DeBoisW, O'Hara M, et al. Retrograde autologouspriming for cardiopulmonary bypass: a safe and effective means of decreasing haemodilutionand transfusion requirements. J Thorac Cardiovasc Surg 1998;115:

13 Post DilutionalHCT vsbody Weight With Different Hemodilution Strategies 30% First HCT in OR 35% 28% Post Dilutiona alhct % 26% 24% 22% 20% Old Circuit Customized + RAP Customized + RAP + Fluid Restriction 18% 16% Weight (kg)

14 Ann Thorac Surg 2005;80:

15 Oxygen Delivery vs. HCT At Different Flow Rates. DO 2 = Q(indexed)*10*(HGB*1.36*SaO 2 + po 2 *0.003) O ml/min/m 2 2 Delivery (m ) 272 ml/min/m 2 Cardiac Index HCT (%)

16 Ann Thorac Surg 2011;91: Blood Salvage and Collaboration Pump salvage (Class IIa Level of evidence C) Centrifugationinstead of direct infusion (Class IIa Level of evidence A) Modified ultrafiltration(muf) (Class I Level of evidence A) Multidisciplinary blood management teams (Class IIa Level of evidence B)

17 Modified Ultrafiltration Using the cardioplegia pump, blood is pumped retrograde out of aorta, hemoconcentrated, and returned to right atrium Performed for 10 to 20 minutes 10-15mL/kg/min up to 500ml/min Volume removed through ultrafiltration is replaced with volume from CPB circuit Substances less than 65,000 daltons are removed Ann Thorac Surg 1994;58:573-4

18 Blood Conservation Saves Lives? Risk score matched patients!

19 Summary Anemia is bad Transfusion is not the answer Balance hemodilution and oxygen delivery Match CPB circuit to size of patient Retrograde and antegrade autologous prime Modifying CPB flow rate will modify oxygen delivery and should be considered prior to transfusion Centrifugation and modified ultrafiltration should be considered for salvaging residual blood Perfusionists should actively participate in blood management efforts Collect and report transfusion data Report variation in blood loss