Bruce Cartwright: Blood Conservation
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Transcript of Bruce Cartwright: Blood Conservation
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BLOOD CONSERVATION Bruce Cartwright Royal Prince Alfred Hospital
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Status quo? • Cardiac surgery consumes 15-20% of blood product
supply • RBC transfusion rate 5-80%; platelets up to 40%
• Up to 20% of cardiac surgical patients have a preoperatively identified risk factor for bleeding
• Around 5% of patients return to the OR for investigation of bleeding • “Microvascular coagulopathy” is diagnosed in >50%
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The cardiac dilemma • Don’t transfuse
• Re-exploration for bleeding increases morbidity and mortality up to 3 to 4 times
• Acute bleeding causes haemorrhagic shock, tamponade and cardiac decompensation
• Return to ICU after re-exploration is associated with higher rates of infective complications, arrhythmias and prolonged pulmonary support and complications
• Do transfuse • Risk especially with platelets • TRALI, allergy, allommunisation, GVHD, renal failure, volume
overload (TACO), immunosuppresion/immunomodulation • Increasing COST
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Normal perioperative course
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Normal cardiac course HAEMODILUTION ACTIVATION CONSUMPTION CPB Prime - crystalloids/colloids
Contact Activation - XIIa, kallikrein and
bradykinin
Thrombin and Plasmin mediated
Cardioplegia Tissue factor activation - Tissue injury - Monocyte related - Pericardial blood
Inflammation mediated - Elastase - Complement - Leukocyte-platelet
complexes Cell Salvage - Loss of platelets and coagulation factors
Activation of fibrinolysis - Increased tPA via
endothelial cells and pericardial cavity
- Intrinsic activation - Heparin and
protamine effects
Mechanical (ECC) - Oxygenator - Cardiotomy suction
and vents - Filters - Centrifugal and roller
pumps
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Coating the Circuit
Edmunds, L. H. (2004). Cardiopulmonary bypass after 50 years. New England Journal of Medicine, 351(16), 1603–1606
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What do we do to address this? Key components
• Attentive preoperative assessment • Surgical approaches to limit periop bleeding • Strategies to limit haemodilution, activation and
consumption associated with extracorporeal circulation • Systemic and topical pharmacological agents • Point of care testing to target blood product therapy and
recently use of factor concentrates • Post operative fluid management and transfusion
thresholds to limit unnecessary blood product use
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Preoperative assessment • Current Strategies
• identification of at-risk patients • cessation of over the counter supplements and all herbal remedies • timing of surgery with clopidogrel cessation according to platelet
aggregometry threshold • investigation of preoperative anaemia
• Considerations for the future: • screening for anaemia in preop clinic with subsequent
administration of IV iron +/- erythropoietin
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Surgical Strategies • IMA bed haemostasis prior to retractor removal • immediate bandaging of vein harvest sites • attention to sternum, ITA bed, pericardial edges and aortic
adventitia prior to sternal closure • topical haemostatic agents • topical tranexamic acid on pericardium prior to closure • cell salvage especially for OPCAB and redo sternotomy • stratification to OPCAB where antiplatelet therapy
inappropriate for cessation if possible
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Perioperative Perfusion Strategies • Current strategies
• Pre bypass fluid limited to 500ml crystalloid • Retrograde autologous priming in all patients • Transfusion trigger based on DO2i rather than Haematocrit alone
together with supportive evidence of VCO2i, SvO2, lactate and adequacy of regional circulation where available such as NIRS
• Normovolaemic haemodilution in selected cases • Shear force and blood air interface management: pump sucker
activated only on demand, minimisation of air entrainment into vents
• Future considerations • biocompatible circuits, heparin alternatives, platelet anaesthesia • quarantining of cardiotomy blood • modified ultrafiltration
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Systemic pharmacological agents Current practise • Tranexamic acid • No routine use of starch solutions Future directions • Aprotinin returns? • Cangrelor platelet anaesthesia • Direct thrombin vs indirect thrombin inhibition
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Point of Care Testing Multifaceted approach • Viscoelastic testing
• Need to utilise full capacity of technology • Rapid TEG, heparinase TEG, functional fibrinogen, platelet
mapping where appropriate • ROTEM: ExTEM, FIbTEM, InTEM, hepTEM, ApTEM
• Platelet aggregometry • Multiple electrode aggregometry (Multiplate)
• Activated Clotting time • low range vs high range, heparinase
• Prothrombin complex assessment • Coagucheck with Quick estimation
• Rapid turnover platelet count and fibrinogen level
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Post operative management • Crystalloid resuscitation in preference to HES & 4%
Albumex • no fluid challenge use for treatment of isolated low CVP or
low urine output where all other signs point to adequate cardiac output
• no empiric blood product transfusion • red cell transfusion trigger: Hb <70 unless evidence of
cardiogenic shock, severe vasoplegia or end organ dysfunction
• protamine where heparin rebound has been documented • early take back where point of care testing rules out
microvascular coagulopathy
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Results • All case transfusion rate: steady fall from 65% to 35%
0
10
20
30
40
50
60
70
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
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Results – average usage
0
0.5
1
1.5
2
2.5
3
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Red Blood Cells
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Platelets
0
0.5
1
1.5
2
2.5
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Fresh Frozen Plasma
0 0.5
1 1.5
2 2.5
3 3.5
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Cryoprecipitate
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Results – cost reductions
0.00
0.02
0.04
0.06
0.08
0.10
0.12
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Activated Factor 7
$0
$500
$1,000
$1,500
$2,000
$2,500
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Total cost per patient
$0
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
$1,400,000
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
At 600 per year
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Elective Coronary Surgery
0
10
20
30
40
50
60
70
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
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Elective Surgery – other benefits
• average decrease in 4 hour blood loss of 31% • reductions in ICU length of day by 25 hours when not
transfused (vs transfused) • reduction in length of hospital stay by 1 day when not
transfused
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Current Challenges
0
10
20
30
40
50
60
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Non Elective Coronary
0 10 20 30 40 50 60 70 80 90
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Aortic Surgery
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Future directions • Preoperative Fe +/- EPO • Circuit Modifications
• biocompatible circuits, heparin alternatives, platelet anaesthesia • quarantining of cardiotomy blood, MECC • modified ultrafiltration
• Aprotinin or alternatives • Integrated electronic data collection • Tranfusion trigger assessment • Refining POC algorithms • State/Nationwide/International colloboration • Factor Concentrates