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Transfusion and Blood Conservation
Kenneth G. Shann, CCP
Assistant Director, Perfusion Services
Senior Advisor, Performance Improvement
Department of Cardiovascular and Thoracic Surgery
Montefiore Medical Center
New York
Disclosures
No Relationships to Disclose
Overview
� Risks of anemia and transfusion
� Concept of balancing hemodilution and oxygen
delivery:
o Preserve red cell mass
Avoid low nadir hematocritso Avoid low nadir hematocrits
o Modify CPB flow according to hematocrit
� Salvage the patient’s blood at the end of the procedure
� Participate in the creation and management of a
multidisciplinary blood management team at your
center
J Thorac Cardiovasc Surg 2003;125: 1438-50
Anemia is Bad!
Does Transfusion Mitigate that?
� Swaminathan M et al. The asscoiation of lowest hematocrit during cardiopulmonary bypass with acute renal injury after coronary artery bypass surgery. Ann Thorac Surg. 2003;76:784-92
� Karkouti K et al. Hemodilution during cardiopulmonary bypass is an independent risk factor for acute renal failure in adult cardiac surgery. J Thorac Cardiovasc Surg. 2005;129:391-400
� Ranucci M et al. Lowest hematocrit on cardiopulmonary bypass impairs the � Ranucci M et al. Lowest hematocrit on cardiopulmonary bypass impairs the outcome in coronary surgery: an Italian multicenter study from the National Cardiothoracic Database. Tex Heart Inst J 2006; 33: 300-5.
� Karkouti K et al. Low hematocrit during cardiopulmonary bypass is associated with increased risk of perioperative stroke in cardiac surgery. Ann Thorac Surg 2005; 80: 1381-7.
� DeFoe GR et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg. 2001 71: 769-76.
Surgenor SD, Kramer RS, Olmstead EM, et al
Outcome Tx. and Heart Surgery
Banbury MK et al. Transfusion increases the
risk of postoperative infection after cardiac
surgery. J Am Col Surg 2006;202:131-138.
- Septicemia/bacteremia
- pneumonia
� Afib
� Prolonged ventilation
� Bleeding
� Renal Failure
� Quality of Life
� Mortality (short and long � Mortality (short and long
term)
0
2
4
6
8
10
12
14
16
18
1 2 3 >4
Severe Infection
Mediastinitis
Pneumonia
Sepsis
Leal-Noval et al. Chest 2001;119:1461
Relative Odds of Receiving Packed Red Blood Cells Transfusion
p value <0.001
Odds Ratio Adjusted*
Low HCT 15.5 Use of pump 7.91 Female Gender 2.37 Lower Body Weight 2.18 Older Age 1.99
2003;97:958-63
Which of these is modifiable by
the operative team?
Body size is related to low nadir
hematocrit during CPB
� DeFoe GR, Ross CS, Olmstead EM, et al. Lowest hematocrit
on bypass and adverse outcomes associated with coronary
artery bypass grafting. Northern New England
Cardiovascular Disease Study Group. Ann Thorac Surg
2001;71:769-76.11.
� Swaminathan M, Phillips-Bute BG, Conlon PJ, et al. The
association of lowest hematocrit during cardiopulmonary
bypass with acute renal injury after coronary artery bypass
surgery. Ann Thorac Surg 2003;76:784-92.12.
� Habib RH, Zacharias A, Schwann TA, et al. Adverse effects of � Habib RH, Zacharias A, Schwann TA, et al. Adverse effects of
low hematocrit during cardiopulmonary bypass in the adult:
should current practice be changed? J Thorac Cardiovasc
Surg 2003;125:1438- 50.
� Ranucci M, Conti D, Castelvecchio S, et al. Hematocrit on
cardiopulmonary bypass and outcome after coronary
surgery in nontransfused patients. Ann Thorac Surg
2010;89:11-17.
We can’t change the size of our patients,
but we can customize our strategy to
accommodate their size
Ann Thorac Surg 2011;91:944–82Ann Thorac Surg 2011;91:944–82
� Minicircuits
(Class I Level of evidence A)
� Vacuum-assisted venous drainage
(Class IIb Level of evidence C)
� Retrograde autologous priming
(Class IIb Level B)
� Biocompatible CPB circuits
(Class IIb Level of evidence A)
Strategies to Minimize Hemodilution
• Oxygenator with integrated arterial filter
• 140mL prime
• 3/8 inch venous line
• All circuit tubing length minimized
Matching the Circuit to the Size of the Patient
Mrs. Nussbaum
• All circuit tubing length minimized
• Biocompatible surface coating
• Retrograde and antegradeautologous priming
• Net prime 400mL
Retrograde and Antegrade Autologous Priming
� The passive displacement of crystalloid
solution from the CPB circuit using the
patient’s blood volume via the arterial
and venous lines of the CPB circuit.
� Perceived benefits:
� Less hemodilution during the � Less hemodilution during the
initiation of CPB
� ↑ Hemoglobin, COP, plasma and
platelets
� ↓ diluIon of circulaIng
pharmacologic agent
� Reduced blood transfusions on CPB
� Inexpensive
Rosengart TK, DeBois W, O'Hara M, et al. Retrograde
autologous priming for cardiopulmonary bypass: a safe
and effective means of decreasing haemodilution and
transfusion requirements. J Thorac Cardiovasc Surg
1998;115:426-38.
26%
28%
30%
Old Circuit
Customized + RAP
Dil
uti
on
al
HC
T %
First HCT in OR 35%
Post Dilutional HCT vs Body Weight With
Different Hemodilution Strategies
16%
18%
20%
22%
24%
50 55 60 65 70 75 80 85
Customized + RAP
Customized + RAP + Fluid
Restriction
Weight (kg)
Po
st D
ilu
tio
na
l
Ann Thorac Surg 2005;80:2213–20
De
live
ry (
ml/
min
/m2)
DO2 = Q(indexed)*10*(HGB*1.36*SaO2 + pO2*0.003)
Cardiac Index272 ml/min/m2
.
Oxygen Delivery vs. HCT At Different Flow Rates
O2
De
live
ry (
ml/
min
/m
HCT (%)
Ann Thorac Surg 2011;91:944–82
� Pump salvage
(Class IIa Level of evidence C)
� Centrifugation instead of direct infusion
(Class IIa Level of evidence A)
� Modified ultrafiltration (MUF)
(Class I Level of evidence A)
� Multidisciplinary blood management
teams
(Class IIa Level of evidence B)
Blood Salvage and Collaboration
Modified Modified Modified Modified UltrafiltrationUltrafiltrationUltrafiltrationUltrafiltration
•Using the cardioplegiapump, blood is pumped retrograde out of aorta, hemoconcentrated, and returned to right atrium•Performed for 10 to 20 minutes
Ann Thorac Surg 1994;58:573-4
minutes •10-15mL/kg/min up to 500ml/min•Volume removed through ultrafiltration is replaced with volume from CPB circuit•Substances less than 65,000 daltons are removed
Blood Conservation Saves Lives?
Risk score matched patients!
Summary
• Anemia is bad• Transfusion is not the answer• Balance hemodilution and oxygen delivery
– Match CPB circuit to size of patient– Retrograde and antegrade autologous prime– Modifying CPB flow rate will modify oxygen delivery and should be – Modifying CPB flow rate will modify oxygen delivery and should be considered prior to transfusion
• Centrifugation and modified ultrafiltration should be considered for salvaging residual blood
• Perfusionists should actively participate in blood management efforts� Collect and report transfusion data� Report variation in blood loss