Modern Transfusion Management in Cardiovascular Surgery

Transcription

1 Modern Transfusion Management in Cardiovascular Surgery Linda Shore-Lesserson, M.D. Professor of Anesthesiology Albert Einstein School of Medicine Montefiore Medical Center Bronx, New York

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3 Patient Blood Management Multidisciplinary interaction Three pillars of management Preoperative optimization i i of red cell mass Perioperative reduction in red cell loss Perioperative optimal treatment of anemia

4 Patient Blood Management- CT Surgery Preop Blood Conservation Treat Anemia Anesth Surg Med/ Card Anesth Surg Perf Anesth Surg ICU

5 Patient Blood Management- CT Surgery Preop Blood Conservation Treat Anemia Anesth Surg Med/ Card Anesth Surg Perf Anesth Surg ICU

6 Annals of Thoracic Surgery 2007;83:S27-86

7 Transfusion Risks Public concern: transmissible diseases NAT Pre- NAT Post-NAT Hepatitis C 1:237,000 <1:1,000,000 Hepatitis B 1:137,000 HIV 1:1,326,300 1:1,930,000 HTLV I and II 1:641,000

8 Contamination ti Rates (1996 reported) Contamination RBC s (1:500,000) 1:38,565 Apheresis platelets 1:777 Random donor plt (1:12,000) 1:3254 Random donor /6-pack 1:542 Sandler SG: Clin Adv Hematol Oncol 2003;1:

9 Transfusion Risks Physician concerns: White Blood Cell Effects Antibody formation Febrile reactions GVHD Volume overload (TACO) Lung injury (1/5000) Graft survival Cancer recurrence Infection

10 Pre- Optimization i i of RBC Mass Erythropoietin is reasonable to restore red cell volume preop when PAD is used. Class IIa, Level A IIb Goldberg G MA: Perioperative i epo: results of randomized d clinical trials. Semin Hematol 1997;34:41 7 Alghamdi h AA: A systematic review and meta-analysis. J Card Surg 2006;21:320 6

11 Blood Conservation- Pharmacology Antifibrinolytics (aprotinin, EACA, TA) are indicated to reduce the # patients transfused, and to reduce blood loss after cardiac operations Class I, Level A Aprotinin- i Class 3, Level A Use of rviia is not unreasonable for the management of intractable nonsurgical bleeding unresponsive to routine hemostatic therapy after cardiac Class IIb, Level lb no change

12 Antifibrinolytic Agents- MOA Kallikrein Aprotinin Plt IIa XIII XIIIa XL fibrin

13 Meta-Analysis Transfusion Aprotinin EACA/TA Re-exploration Aprotinin EACA/TA Decreased Risk Increased Risk Levi et al: Lancet 1999;354:

14 Factor VIIa and Tube Drainage Karkouti: Transfusion 2005;45:26-34

15 rviia and Matched Controls All demo = rviia Controls P value RBCs (U) 14 (9,18) 7 (3,13) < Plts (U) 15 (10,20) 5 (0,15) < LOS ICU 6(3.5,11.5) 3.5 (1,10) <0.05 Renal dys (%) 15(29) 6 (12) <0.05 Karkouti: Transfusion 2005;45:26-34

16 Canadian Review: Off-Label LblUse Multicenter, observational, retrospective (n=503) Jan 1, 2003-December 31, 2006: cardiac surgery Blood bank, pharmacy, hospital records Use of rviia, response to rviia Transfusion before and after rviia Adverse outcomes Comparison cohort used (2004 data, 7 centers) Karkouti: Circulation 2008;118:

17 Results Variable Bf Before rviia After rviia p value RBCs 8(5,12) 2(1,5) < Plts 10(10,15) 5(0,10) < FFP 8(5,12) 2(0,6) < Total 33(22,50) 9(2,22) < Karkouti: Circulation 2008;118:

18 Independent Predictors Mortality Variable OR 95% CI p Preop shock ph<7.2 pre Rx RBCs >10 pre RBCs >10 post Renal dysfx, age unstable CPB dur <0.03 Karkouti: Circulation 2008;118:

19 Blood dconservation-pharmacology DDAVP is not unreasonable to attenuate excess bleeding and transfusion in certain patients with demonstrable platelet dysfunction known to respond to this agent Class IIb, Level B Routine use of prophylactic DDAVP is not recommended to reduce bleeding or blood transfusion after cardiac operations Class III, Level A

20 Blood Conservation- Pharmacology D/C thienopyridine agents 5-7d Class IIa, Level B D/C thienopyridines as short as 3 d Class I, Level B D/C aspirin i in purely elective cases Class IIa, Level A Heparin-protamine management Class IIb, Level B

21 CPB-Platelet Effects Thrombin receptor Thrombin ADP GpIIb/IIIa GpIIb/IIIa Aggregation Epinephrine Platelet vwf Adhesion Endothelium Exposed Collagen

22 What Can Be Done for CABG? Wait a few days! Measure plt inhibition* Do it off-pump! If you must proceed on CPB Measure preop plt inhibition* Use antifibrinolytic? i i POC coag testing for tx algorithm DDAVP esp if plts are transfused *Ranucci M et al: Ann Thorac Surg 2011;91:

23 Off Pump Cardiac Surgery Class IIa, Level A

24 Cheng et al: Anesthsiology 2005;102:

25 Clopidogrel and Off-Pump CABG Database OPCAB January 2000-June 2002 Excluded Emergency, salvage, mini-incision, other proc, preop anticoagulants, anti-gpiibiiia, TPA N=1572, clop (n=281), none (n=1291) Clopidogrel <7 days vs. none No baseline demographic differences exc MI Kapetanakis EI: Circulation 2006;113:

26 Clopidogrel and Off-Pump CABG Clop None p Intraop RBC % < Intraop Plts % <0.01 Postop RBC % <0.01 Reop % <0.01 LOS days Kapetanakis EI: Circulation 2006;113:

27 Blood Conservation- Technologic Red cell salvage Class I, Level A Centrifugal pumps Class IIb, Level B Heparin-coated circuits (+/- low heparin) Class IIb, Level B PRP with adequate ate plt yield Class III, Level A Class IIa

28 Perioperative Treatment t of fanemia Hb<6 g/dl: RBC tx is reasonable-can be lifesaving- Level IIa,ClassC C Hb<7g/dL: RBC tx is reasonable in most postop patients but no high-level h levidence Level IIa, Class C Hb>10g/dL: RBC tx is not unreasonable in patients with critical noncardiac end-organ ischemia (eg, CNS and gut) Level IIb, Class C

29 Transfusion Triggers During CPB Hb<6 g/dl: RBC tx is reasonable-except in pts at risk for decreased cerebral oxygen delivery Hb>6g/dL: RBC tx is reasonable depending on patient factors, SVO2, etc. Level IIa, Class C Hb<7g/dL: RBC tx is not unreasonable in patients with critical noncardiac end-organ ischemia (eg, CNS and gut) Level liib, Class C

30 Non-RBC Transfusion It is reasonable to transfuse non red cell hemostatic ti blood products based on clinical evidence of bleeding and preferably guided by point-of-care tests that assess hemostatic function in a timely and accurate manner. Class IIa, Level C Nuttall et al: JCTVA 1997;11:

31 Transfusion Algorithms: The Response to Bleeding

32 POC Platelet Function Testing TEG PlateletWorks Multiplate VerifyNow Use the Right Instrument! t!

33 Plt Tx or Rx Microvascular Bleeding Coag tests s and TEG Plt ct <102K PT >16.6 Fib <144mg/dl MA <48mm FFP aptt >57 Cryo Nuttall et al: JCTVA 1997;11:

34 Percent Transfused in OR nts % Patie Control Algorithm P< Plts+FFP Plts only FFP only None Nuttall: Anesthesiology 2001;94:773-81

35 TEG GGuided dalgorithm ih Plt Ct cteg Fib w/wout hepnase R>2X hteg R Plt Ct<100K MA<45mm hteg R>20mm LY30>7.5% Fib<100mg/dl Protamine Plts FFP EACA Cryo Shore-Lesserson et al: Anesth Analg 1999;88:312 5

36 Standard d Algorithm P value Pts tx ed 17/52 7/53 < non-rbc Pts tx ed 34/52 22/ Platelets (U) 6.2±13 1.3± CTD 4hr (ml) 262± ±138 NS CTD 24 hr 659± ± (ml) Shore-Lesserson et al: Anesth Analg 1999;88:312

37 Clopidogrel Patients Plt Count >100, <50,000 Nl PFA Abnl PFA Nl PFA Abnl PFA Assess PT 6 U Plts 6U Plts 12 U Plts Chen L: J Thorac FFP Cardiovasc Surg 2004;128: Assess PT Assess PT

38 Transfusions Prosp-Clop Control Retro-Clop Control PLT 9.0±1.7* 1.2±0.5 # 12.5±2.1* 2.3±0.3 PRBC 4.3±0.6* 2.3± ±0.8*^ 2.3±0.1 FFP 10±06 1.0±0.6 05±03# 0.5±0.3 29±10* 2.9±1.0* 10±01 1.0±0.1 Chen L: J Thorac Cardiovasc Surg 2004;128:425-31

39 Plasma + t-pa Whole Blood (aprotinin) Tanaka et al: Anesth Analg 2008;106:

40 Class I Recommendation A multi-disciplinary approach involving multiple stakeholders, institutional support, enforceable transfusion algorithms supplemented with point-of-care testing, and all of the already mentioned efficacious blood conservation interventions limits blood transfusion and provides optimal blood conservation for cardiac operations. (Level of Evidence A)

41 In Conclusion Cost effective hemostasis care involves a combination i of strategies and disciplines i The tenets of patient blood management include prevention of anemia, blood conservation, and optimal treatment of anemia with a multidisciplinary approach

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