blood conservation

1. Blood Conservation Techniques & Practice :
In Cardiac Surgery
Ns. Dwi Sigit Shiamtafa, SKep

2. History
• Blood transfusion became a universal
practice in surgery
• 40-70% of heart surgery require blood
transfusion
• Efforts to reduce blood transfusions
began at the beginning of the
development of cardiac surgery
• Blood transfusions are associated with
several complications, including
transfusion related infectious risks,
hemolytic, anaphylactic reaction, acute
lung injury and become risk factor for
morbidity and mortality following cardiac
surgery

5. A Paradigm Shift in the Use of Blood Products
Can we have heart surgery without blood tranfusion?

6. Scope of Practice
Blood conservation is a group of techniques used to
minimize the need for blood used during treatment for a health
condition
Multidisciplinary Team
Multidisciplinary Approach
Commitment
Patient
Surgeon
anesthes
iologists
Ners
health care
profession
als
Labs Team
Blood
Bank
Family

7. Re-
Optimize Reduce Restrice

8. Pre-Operative
• Identify Patient Risk
Factor for Bleeding
• Identify Patient with
Previous transfusion
history
• Treatment pre-operatif
anemia
• Suspend anticoagulants
& antiplatelet
• Autologous Donation
• Preoperative planning
Intra- Operative
• Systemic hemostatic
agent & agent that
increase the coagulation
factor activity
• Topical Hemostatic agent
• Acute Normovolemic
Hemodelution
• Surgical techniques
• Blood Micro sampling
• Miniaturization of CPB
Circuit
• Retrograde Autologous
Priming
• Ultrafiltration
• Cellsavage
• Restrictive Tranfusion
Threshold
Post-Operatif
• Restrictive Tranfusion
Threshold
• Increase the cardiac
output with optimize
circulating volume
• Maintain
Normothermia
• Cellsavage
• Continue Systemic
hemostatic agent &
agent that increase
the coagulation factor
activity
Phase of Blood Conservative in Cardiac Surgery

9. Identify Patient
 Age
 Religion: Some religions, including Jehovah’s Witness, forbid or discourage blood
transfusions.
• Previous transfusion reaction
 Anemia: The patient who has a decreased level of red blood cells, regardless of the
reason, is more likely to require a transfusion during or after surgery.
 Patients on blood thinners: These medications prevent blood clots but also lead
to greater bleeding during surgery. They are often stopped prior to a planned
surgery.
 Returning to the OR: Patients who are having a second surgery to correct
complications after a recent procedure.
 Emergency surgery
 Severe or multiple medical conditions in addition to the reason for surgery.
 Patients with a clotting disorder (trombocytopenia).

10. PRE CPB
INTRA CPB
POST CPB
Intraoperative Blood Conservation
SURGICAL
ANESTHESIA
PERFUSIONIST

11. General Consideration
•Systemic hemostatic agent & agent that increase
the coagulation factor activity
(Tranecamic Acid Drip, Calsium Drip)
•Topical Hemostatic agent (Bonewax, Lyostypt, bio-glue)
•Acute Normovolemic Hemodelution (Plebotomy)
•Surgical techniques
•Blood Micro sampling
•Restrictive Tranfusion Threshold
•Cell savage

12. Acute Normovolemic Hemodelution
(Phlebotomy)
In the past, we do this for cyanotic cases (to get
optimal Hct intra CPB) and avoid blood trauma
Start 2013, we do for all patient that have
estimated hemoglobin above 8-9 gr/dL during
CPB after get minimal volume circuit

13. Support Factor in ANH
• Stable Hemodynamic
• Good Team Collaboration:
Anestesia, Surgeon-Scrub Nurse, Pharmacy, all
team in OT
• Short and small circuit
• RAP

14. Cell Savers/Autotranfusion Machine
Cell salvage is the process by which blood from the
surgical field is collected, filtered, and washed to produce
autologous blood for transfusion back to the patient.

15. Cell salvage
The following steps describe the cell
salvage process:
• Step 1 : Suction
• Step 2 : Filtration
• Step 3 : Separation
• Step 4 : Disposal
• Step 5 : Cell salvage
• Step 6 : Reinfusion

16. Cell salvage …cont’
Indication:
• Anticipated intraoperative blood
loss >1 litre or >20% of blood
volume.
• Preoperative anaemia or increased
risk factors for bleeding.
• Patients with rare blood group
type or antibodies.
• Patient refusal to receive
allogeneic blood transfusion.
• The American Association of
Blood Banks suggest cell salvage is
indicated in surgery where blood
would ordinarily be cross-matched
or where more than 10% of
patients undergoing the procedure
require transfusion.
Contraindication:
• Patients with the presence of
sickle-cell disease, sickle-cell
trait, and other RBC disorders.
• Patients undergoing surgery for
maglinancy.
• Patients undergoing bowel
surgery, penetrating abdominal
injury, or surgery where infection
is present.
• Patients undergoing surgery with
major obstetric haemorrhage.
16

17. If we use CPB

18. Pre CPB
1. Minimal Volume in Circuit
2. Retrograde Autologous
Priming
3. Update guideline in blood
priming
One of Our Goals is to reduce the
use of blood tranfusion in priming

19. 1. Minimal Volume
Reduce Length Tubing Circuit :
• Lower Arterial Pump and to close with outlet
Reservoir
• Placement of Blood Cardioplegia Pump beside the
arterial pump
• Not Use Alumunium Coil for blood CPG circuit in
small patient (use Myoterm or CSC 14-Sorin)
• Cut all unnecessary length of tubing
• Positioning the CPB machine as close as possible to
the patient
• Oxygenator with Integrated AF

20. Lower Arterial Pump and to close with
outlet Reservoar

21. • Cut all unnecessary length of tubing (CPG, suction)
• Positioning the CPB machine as close as possible to
the patient

22. Integrated Arterial Filter Oxygenator
Before 2008, we use all of non-
Integrated arterial Filter
Try to use in 2010
From 2015- now, we use 80%
Integrated AF in all cases

24. Change of CPB Circuit
Prime Volume
Body Weight (Kg) Before 2008 After 2008 Reduction
(%)
Neonate - 10 400 300 25
11 - 20 700 500 28.57
21 - 40 1000 700 30
> 40 1200 700 41.66

25. A technique used to displace the
crystalloid priming solution in
CPB circuit with the patient’s
own blood.
Patient’s blood is withdrawn
from aortic and venous cannulas
to displace priming fluid in CPB
circuit before starting bypass.

26. 3. Updated Priming Protocol
Large volume but low Htc,
Limited stock esp.during fasting month
Short lifetime
Small volume, high level Htc,
Available at anytime,
Longer lifetime
2008
Rapid Respon To Re stock-PRC

27. Intra Op
• Ultrafiltration (PBUF, CUF, MUF)
• Medication: Calsium level, tranexamid acid
• Cellsaver
• Restrictive Tranfusion Threshold

28. Since 2008 Hemoconcentrator is used in all cases
Conventional Ultrafiltration
(CUF)
Modified Ultrafiltration (MUF)
We also performed
aggressive hemofiltration during
bypass and
performed arterio venous MUF
after termination of CPB to
remove excessive intravascular
volume

29. Post CPB
MUF
We push back all residual blood pump until the
reservoir is empty
Need 10-20 minute
Cell saver  optimizing until patient is
transferred to the ICU

30. What can we do for save the blood?
Equipment and Technique Before 2008 After 2008
Modified the CPB circuit (to get minimum priming) √ √
Integrated Arterial Filter with oxygenator X √
Retrograde autologous Priming X √
Acute Normovolumic Hemodilution X √
New Guideline for Blood Priming X √
CUF X
(Not For Simple Cases)
√
MUF X
(Just TGA, DVR, IAA,
CoArch)
√
Cellsaver X √
Pediatric Perfusion Experiences, NCC Harapan Kita

31. • How efective??
• Reduce ratio of
blood priming?
• Reduce Blood
tranfusion??
Blood
conservation

33. Resume
• Successful blood
conservation involves a
combination of techniques
tailored to the individual
patient.
• It requires planning and a
multidisciplinary team
approach but usually little
technology.

34. Refferences..
Klein A.A etal. Association of Anaesthetists guidelines: cell salvage for
peri-operative blood conservation.2018. 73, 1141–1150
Saleh M (2020) Blood conservation protocol based on modifi ed ultrafi ltration towards
bloodless pediatric surgery. Arch Clin Hypertens 6(1): 001-012.
DOI: https://dx.doi.org/10.17352/ach.000023
WilkinsonKL, BrunskillSJ, DoreeC, TrivellaM, GillR, MurphyMF.Red cell transfusion management for
patients undergoing cardiac surgery for congenital heart disease.Cochrane Database of
Systematic Reviews 2014,
Singh SP. Strategies for blood conservation
in pediatric cardiac surgery. Ann Card Anaesth 2016;19:705-16
EACTS/EACTA Guidelines on patient blood management . Journal of Cardiothoracic
and Vascular Anesthesia 32 (2018) 88–120