Bruce Cartwright: Blood Conservation

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

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Bruce Cartwright: Blood Conservation

  1. 1. BLOOD CONSERVATION Bruce Cartwright Royal Prince Alfred Hospital
  2. 2. 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%
  3. 3. 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
  4. 4. Normal perioperative course
  5. 5. 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
  6. 6. Coating the Circuit Edmunds, L. H. (2004). Cardiopulmonary bypass after 50 years. New England Journal of Medicine, 351(16), 1603–1606
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. Elective Coronary Surgery 70 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
  18. 18. 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
  19. 19. 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
  20. 20. 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

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