Bruce Cartwright: Blood Conservation
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Bruce Cartwright: Blood Conservation

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Bruce Cartwright speaks about surgical, peri and post-op methods blood conservation for patients undergoing surgery.

Bruce Cartwright speaks about surgical, peri and post-op methods blood conservation for patients undergoing surgery.

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Bruce Cartwright: Blood Conservation Bruce Cartwright: Blood Conservation Presentation Transcript

  • BLOOD CONSERVATION Bruce Cartwright Royal Prince Alfred Hospital
  • 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%
  • 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
  • Normal perioperative course
  • 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
  • Coating the Circuit Edmunds, L. H. (2004). Cardiopulmonary bypass after 50 years. New England Journal of Medicine, 351(16), 1603–1606
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Results •  All case transfusion rate: steady fall from 65% to 35% 70 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
  • Results – average usage Red Blood Cells Platelets 3 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 2.5 2 1.5 1 0.5 0 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q1 Q9 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Cryoprecipitate Fresh Frozen Plasma 3.5 2.5 3 2 2.5 2 1.5 1.5 1 1 0.5 0.5 0 Q1 0 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q9
  • Results – cost reductions Activated Factor 7 Total cost per patient 0.12 0.10 $2,500 0.08 $2,000 0.06 $1,500 0.04 $1,000 0.02 $500 $0 0.00 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q1 Q9 Q2 Q3 At 600 per year $1,400,000 $1,200,000 $1,000,000 $800,000 $600,000 $400,000 $200,000 $0 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q4 Q5 Q6 Q7 Q8 Q9
  • Elective Coronary Surgery 70 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
  • 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
  • Current Challenges Non Elective Coronary 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q8 Q9 Aortic Surgery 90 80 70 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q5 Q6 Q7
  • 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